Photographic Screening Research Articles

Article Commentary: The English national screening programme for sight-threatening diabetic retinopathy

The main objective of the national screening programme is to reduce the risk of sight loss among people with diabetes due to diabetic retinopathy (DR). Offering two-field mydriatic digital photographic screening to all people with diabetes in England over the age of 12 years. The programme is in its infancy, receiving the first year's annual reports from approximately 96 screening programmes, each of which have developed to offer screening to a minimum number of 12,000 people with diabetes, which would cover a population of 350,000 people with 3.4% diabetes prevalence. The national programme has commenced the External quality assurance (QA) programme in order to achieve and sustain the highest possible standards. England has a population of two million people with diabetes over the age of 12 and it is believed that there is a prevalence of blindness of 4200 and an annual incidence of blindness of 1280 people with diabetes. This programme has the potential to reduce the prevalence of blindness in England from 4200 people to 1000 people and a conservative estimate of reducing the annual incidence of DR blindness by one-third would save 427 people per annum from blindness. These figures are based on the UK certification of blindness but if World Health Organization (WHO) definitions are used the prevalence, incidence and potential reductions in blindness are much greater.

Evolution of Retinal Detachment in Posterior Retinopathy of Prematurity: Impact on Treatment Approach

To provide insight into the course of retinal detachment in eyes with aggressive posterior retinopathy of prematurity (APROP). Prospective, multicenter, masked clinical trial. Multicenter trial based on serial digital photographic imaging detailing five infants (in the Photographic Screening for Retinopathy of Prematurity [PHOTO-ROP] Study) in whom bilateral retinal detachment developed during the course of the study. Retinal detachment developed in both eyes (n=10) of all five infants despite peripheral retinal laser ablation. The mean birth weight was 651.4+/-45.30 g (range, 601 to 718 g), and the mean gestation was 26.75+/-0.96 weeks (range, 24 to 26 weeks). APROP (flat neovascularization) was present in all eyes at the time of treatment. Laser treatment was performed at a mean postconceptual age of 37.25+/-1.8 weeks (range, 35 to 39.57 weeks). Plus disease resolved initially and then recurred (mean, 9.5 days) with progression to retinal detachment; the mean postconceptual age at the time of retinal detachment was 41.42+/-3.6 weeks (range, 36 to 47.29 weeks). Untreated avascular retina became visible with regression of flat preretinal neovascularization. All 10 eyes showed preretinal vitreous organization (most prominent nasally) along the retinal surface without significant transvitreal components. Eyes with APROP may follow an atypical course after laser ablation. Such eyes may still fare poorly, even when plus disease wanes. Additional laser to avascular retina may be necessary after the overlying flat stage 3 neovascularization regresses. The absence of obvious fibrosis at the time of laser should provide no reassurance as to reduced probability of progression to retinal detachment.

Medicare to Cover Skin Screening Photography

Medicare to Cover Skin Screening Photography

Systematic screening for diabetic retinopathy with a digital fundus camera following pupillary dilatation in a university diabetes department

Screening for diabetic retinopathy (DR) is highly inadequate in France because of insufficient infrastructure and increasing disease prevalence. We describe the results of the first systematic DR screening programme established in a university diabetes department. In this cross-sectional study conducted over 1 year, consecutive adult patients underwent three-field retinal photography with the Topcon TRC NW6S digital fundus camera following pupillary dilatation with Tropicamide 1%. A questionnaire provided information on patients' systemic and ocular history. Glycated haemoglobin (HbA1c) was measured at the screening visit. Two ophthalmologists graded the retinal photographs in a masked fashion. Of 1157 patients attending the diabetes department, 1153 (99.7%)underwent photographic screening. Images were gradable in 96% patients. Diabetic retinopathy was detected in 522 (45%) patients and sight-threatening DR in 167 (14%). Of 704 (61%) patients previously believed to have no DR,254 (34%) screened positive. The presence of DR was associated with age,insulin use and non-Caucasian ethnicity in Type 2 patients, and with duration of diabetes and HbA1c in Type 1 and Type 2 patients. Associated ocular pathologies were diagnosed in 612 (53%) patients. Our photographic screening programme using pharmacological mydriasis provided a high screening coverage feasible in a hospital setting. We obtained information regarding prevalence and associated risk factors of DR inpatients attending a tertiary care centre. Screening was well accepted by patients and met with no protest from city ophthalmologists. It generated considerable interest among endocrinologists and feedback of results is expected to improve optimization of glycaemic control.

THE PHOTOGRAPHIC SCREENING FOR RETINOPATHY OF PREMATURITY STUDY (PHOTO-ROP)

The Photographic Screening for Retinopathy of Prematurity Study (Photo-ROP) sought to evaluate the utility of digital wide-angle photographic fundus screening for retinopathy of prematurity (ROP) as compared to bedside indirect ophthalmoscopy. This article describes the study design and presents baseline characteristics of the subjects. Prospective, multicenter, masked, Internet-based clinical trial. Premature infants <31 weeks postmenstrual age at birth and <1000 g birthweight. Examinations began at 31 weeks postmenstrual age or 4 weeks postnatal age, whichever was later. Both eyes of all infants were imaged with a panoramic fundus imaging system followed by indirect ophthalmoscopic fundus examination. Images were transmitted via Internet to the Reading Center for interpretation by masked graders. Clinical interpretations based on indirect ophthalmoscopy were recorded for comparison with the Reading Center determinations. Examinations were performed weekly for 10 weeks or until an infant was discharged from the hospital. Sensitivity, specificity, and positive and negative predictive values of Reading Center image interpretations were compared to clinical impressions based on bedside indirect ophthalmoscopy. Enrollment began in February 2001 and was completed in February 2002. The target number of infants was 50, and 62 were enrolled. Of those enrolled, 51 infants (102 eyes) were considered eligible, and are the subject of this article. Mean postmenstrual age (+/- SD) at time of delivery was 26.80 +/- 1.73 weeks (median = 26.86 weeks, interquartile range [IQR] = 2.43 weeks). Mean postmenstrual age at first examination (+/- SD) was 32.19 +/- 2.86 weeks (median = 31.71 weeks, IQR = 2.29 weeks). Mean birthweight (+/- SD) was 830.51 +/- 219.57 g (median = 817 g, IQR = 225 g). Female infants comprised 49.02% of the patients. Race distribution was as follows: white 45.10%, African or black 39.22%, Hispanic 3.92%, Asian 9.80%, and other races 1.96%. Mean follow-up (+/- SD) was 5.73 +/- 3.22 weeks (median = 6 weeks, IQR = 5, range = [1, 15]). The Photo-ROP Study Cooperative Group successfully recruited and enrolled at-risk premature infants into a longitudinal, prospective clinical trial comparing two different diagnostic approaches. Technology employed in this study is comparable to that currently available. Design issues for this trial included establishing the information technology infrastructure for an ROP study based on digital imaging, defining the study endpoints, estimating event rates, defining a standardized imaging protocol, and defining standards for interpretation of image quality and clinical findings.

The influence of age, duration of diabetes, cataract, and pupil size on image quality in digital photographic retinal screening

This study was performed in order to evaluate the effect of age, duration of diabetes, cataract, and pupil size on the image quality in digital photographic screening. Randomized groups of 3650 patients had one-field, non-mydriatic, 45 degrees digital retinal imaging photography before mydriatic two-field photography. A total of 1549 patients were then examined by an experienced ophthalmologist. Outcome measures were ungradable image rates, age, duration of diabetes, detection of referable diabetic retinopathy, presence of early or obvious central cataract, pupil diameter, and iris color.

Monoscopic Versus Stereoscopic Photography in Screening for Clinically Significant Macular Edema

The purpose of the study was to determine whether monoscopic photography could serve as an accurate tool when used to screen for clinically significant macular edema. In a masked randomized fashion, two readers evaluated monoscopic and stereoscopic retinal photographs of 100 eyes. The photographs were evaluated first individually for probable clinically significant macular edema based on the Early Treatment Diabetic Retinopathy Study criteria and then as stereoscopic pairs. Graders were evaluated for sensitivity and specificity individually and in combination. Individually, reader one had a sensitivity of 0.93 and a specificity of 0.77, and reader two had a sensitivity of 0.88 and a specificity of 0.94. In combination, the readers had a sensitivity of 0.91 and a specificity of 0.86. They correlated on 0.76 of the stereoscopic readings and 0.92 of the monoscopic readings. These results indicate that the use of monoscopic retinal photography may be an accurate screening tool for clinically significant macular edema.

Screening for retinopathy of prematurity-a comparison between binocular indirect ophthalmoscopy and RetCam 120

To compare the photographic screening for retinopathy of prematurity (ROP) using RetCam 120 with binocular indirect ophthalmoscope (BIO), which is the current gold standard. Prospective, comparative study. A total of 87 RetCam examinations were performed on 27 premature babies. They were stored in a separate file after deleting the identifying information. At the same visit using the BIO with scleral depression, an experienced vitreoretinal surgeon evaluated the fundus in detail. A masked examiner then evaluated the RetCam photographs for presence or absence of ROP, the stage and zone of the disease and the presence or absence of plus disease. These data were then compared with the BIO findings to determine the sensitivity, specificity and the positive and negative predictive values of the method. ROP was detected in 63 of 87 examinations by BIO and in 56 of 87 RetCam examinations. Nine RetCam examinations were false-negative and two were false-positive. Sensitivity of RetCam was 85.71% (54/63) and specificity was 91.66% (22/24). The positive and negative predictive values were 96.43% and 70.97% respectively. Nine cases having ROP were missed by the RetCam. All these cases were either in zone 3 or the outer part of zone 2, which later regressed. These were missed mostly because of the restricted mobility of the camera head caused by its size and the barrier caused by the lid speculum arms. No case of threshold ROP was missed. RetCam may replace BIO for screening of ROP.

Managing ‘suspicious glaucomatous discs’ identified during digital‐photography‐based diabetic retinopathy screening

An audit to demonstrate the outcome of patients identified with suspicious glaucomatous discs within a digital-photography-based diabetic retinopathy screening programme. Primary care based digital photographic screening was performed utilising mydriasis and two-field digital photography for all patients with diabetes. Patients identified with discs suspicious of glaucomatous optic neuropathy (GON) were initially referred to an accredited community-based optometrist for further assessment. Some patients were then referred to secondary care where appropriate. From 1st April 2002 to 31st March 2003 a total of 3868 patients were screened for diabetic retinopathy. This audit revealed that 55 subjects were identified by retinal screeners as having discs suspicious of glaucoma. A total of 29 were already under glaucoma clinic review. A total of 23/26 remaining were referred for an assessment by an accredited optometrist. Of these 13 were normal, 6 were referred to secondary care and 4 failed to attend. The three remaining were referred directly to secondary care. All nine referrals to secondary care were deemed appropriate by a glaucoma specialist. This suggests that the system described does not lead to over-referral of suspicious discs - although the issue of how many glaucomatous discs are missed during screening (false negatives) will only be answered in the longer term.

An evaluation of photographic screening for neovascular age-related macular degeneration

Bursell SE, 2001, OPHTHALMOLOGY, V108, P572, DOI 10.1016-S0161-6420(00)00604-7; Maberley DAL, 2005, EYE, V19, P611, DOI 10.1038-sj.eye.6701584; MERRIN LM, 2004, J OPHTHALM PHOTOGRAP, V26, P59; van Leeuwen R, 2003, OPHTHALMOLOGY, V110, P1540, DOI 10.1016-S0161-6420(03)00501-3

Screening for Diabetic Retinopathy by Ophthalmologists and Endocrinologists With Pupillary Dilation and a Nonmydriatic Digital Camera

To assess the effects of pupillary dilation on image quality and certitude of screening diabetic retinopathy by trained endocrinologists using a digital nonmydriatic camera. Prospective, comparative, observational case series. One hundred fifty patients with diabetes attending a hospital-based photographic screening clinic had five-field (45 degree) digital retinal imaging and mosaic construction, first through dark-adapted pupils, then after a single application of tropicamide 1%. The 600 sets of images (150 patients, 300 eyes, before and after dilation) were graded independently and in a blinded manner by two endocrinologists and two ophthalmologists, with the consensual opinion on dilated images of the latter serving as the gold standard. The criteria of evaluation were assessment of image quality and certitude of detecting and grading retinopathy. Of 300 eyes, pharmacological mydriasis improved image quality, with an increase in the number of eyes with five good images from seven to 160 and good-quality mosaics from 99 to 233. Dilation allowed better identification of maculopathy in the second eye because there was a decrease in ungradeable central images from 127 to 15 eyes. Dilation increased the number of eyes having retinopathy detected with certainty from 153 to 252 and graded with certainty from 173 to 277. No adverse effects were recorded. Single application of tropicamide 1% significantly improves image quality and certitude of screening diabetic retinopathy with nonmydriatic camera by endocrinologists.

The Influence of Age, Duration of Diabetes, Cataract, and Pupil Size on Image Quality in Digital Photographic Retinal Screening

To evaluate the effect of age, duration of diabetes, cataract, and pupil size on the image quality in digital photographic screening. Randomized groups of 3,650 patients had one-field, non-mydriatic, 45 degrees digital retinal imaging photography before mydriatic two-field photography. A total of 1,549 patients were then examined by an experienced ophthalmologist. Outcome measures were ungradable image rates, age, duration of diabetes, detection of referable diabetic retinopathy, presence of early or obvious central cataract, pupil diameter, and iris color. The ungradable image rate for non-mydriatic photography was 19.7% (95% CI 18.4-21.0) and for mydriatic photography was 3.7% (3.1-4.3). The odds of having one eye ungradable increased by 2.6% (1.6-3.7) for each extra year since diagnosis for nonmydriatic, by 4.1% (2.7-5.7) for mydriatic photography irrespective of age, by 5.8% (5.0-6.7) for non-mydriatic, and by 8.4% (6.5-10.4) for mydriatic photography for every extra year of age, irrespective of years since diagnosis. Obvious central cataract was present in 57% of ungradable mydriatic photographs, early cataract in 21%, no cataract in 9%, and 13% had other pathologies. The pupil diameter in the ungradable eyes showed a significant trend (P < 0.001) in the three groups (obvious cataract 4.434, early cataract 3.379, and no cataract 2.750). The strongest predictor of ungradable image rates, both for non-mydriatic and mydriatic digital photography, is the age of the person with diabetes. The most common cause of ungradable images was obvious central cataract.

Screening for Diabetic Retinopathy by One-Field, Non-Mydriatic, 45° Digital Photography Is Inadequate

Purpose: To evaluate the sensitivity and specificity of one-field, non-mydriatic, 45° digital photography for screening for diabetic retinopathy compared to indirect ophthalmoscopy using a slit-lamp, the reference standard. Methods: A total of 100 consecutive diabetic patients (200 eyes) who underwent digital fundus photography and ocular examinations from June 2002 to November 2002 were included in this retrospective study. The patients, recruited from a hospital-based, retina referral practice, underwent 45°, non-mydriatic, digital fundus photography using a non-mydriatic fundus camera. One image was obtained focusing the mid fundus between the optic disc and the macula. The fundus images were printed and graded by endocrinologists and a retinal specialist separately. The patients also underwent complete standard ocular examinations as the reference method for determining diabetic retinopathy, including dilation of their pupils and slit-lamp biomicroscopy done by ophthalmologists. The sensitivity and specificity of the digital photographic method were calculated by comparison to the reference method. Results: The sensitivity and specificity of the retinal specialist’s diabetic retinopathy grades were 53.8 and 89.0%, respectively. The sensitivity and specificity of the endocrinologists’ grades were 45 and 75.3%, respectively. The false negative rates were 22 and 21.5% for endocrinologists and the retinal specialist, respectively. Conclusions: Screening for diabetic retinopathy using one-field, non-mydriatic, 45° digital photography is inadequate.

Detection of Associated Ocular Lesions During Screening of Diabetic Retinopathy

Diabetic retinopathy is the foremost cause of blindness in the working-age population in France (1). An increased incidence of diabetes combined with the lack of ophthalmologists and absence of optometrists makes screening inaccessible to the vast majority. In this setting, the digital fundus camera provides a rapid, sensitive, and cost-effective option (2). Since its installation in our hospital diabetes clinic, patients now routinely undergo photographic screening. Dilated multifield photography allowed good quality imaging of the posterior fundus, which enabled detection of other coexisting pathologies in addition to diabetic retinopathy. Fundus photographs of 1,153 consecutive patients attending our screening clinic between November 2003 and October 2004 were recorded with the Topcon TRC NW6S camera …

Persuading Sanity: Magic Lantern Images and the Nineteenth‐Century Moral Treatment in America

In first half of nineteenth century, while Western institutions reorganized themselves according to philosophies of Enlightenment, doctors, alienists, and reformers adopted new attitudes toward the mad.1 Abandoning chains and cages for mentally ill in jails and almshouses, they began creating therapeutic models of confinement. In 1820s, they founded asylum. Through surroundings and activities that uplifted spirits and rebuilt fiber, new superintendents of these new American institutions sought to drive out madness with good conduct. After 1839, another new American professional group, photographers, introduced photographic reproduction and better projection technologies that also incorporated ideas of Enlightenment. For these new specialists, mission expanded to all citizens equal opportunities for seeing images that would educate, morally uplift, and amuse. During 1840s, two Philadelphia photographers, William and Frederick Langenheim, worked to make photographic images more accessible, even to those confined to a new insane asylum in Philadelphia. Dr. Thomas Kirkbride, who had been appointed to head Pennsylvania Hospital for Insane in 1840, sought to combine his new ideas about moral of mental illness with his scientific interests in new image projection technology. In 1844, he asked his friends Langenheims to provide him with a magic lantern projector and their prepackaged illustrative slides. From then until he retired in 1883, Kirkbnde scheduled three magic lantern slide shows a week as part of his program of treatment at Pennsylvania Hospital for Insane (Layne 189). After 1850, Langenheims acquired nation's first patent for photographic collodion process, which replaced daguerreotype process and allowed better photographic detail and reproductions. Kirkbride also made available to his patients literally thousands of life-sized photographic images (Hamilton and Hargreaves 37). Kirkbride announced in 1844 that he expected magic lantern shows to amuse patients, and more to persuade them to shift their mental state from insanity to sanity. Specifically, he expected - and he never deviated from these expectations - shows to exert subtle control over patients' conduct and sense of responsibility. Framing shows so as to induce persuasive guilt, Kirkbride also said in his announcement that he hoped they would instill physical calmness, alter moods of sadness and depression to cheerfulness, enhance a sense of social position and cultivation, and evoke gratitude toward hospital's trouble and expense. Kirkbride's unusual strategy of using commercially manufactured images as tools for curing the mad brings together early history of American institutional psychiatry with early history of a photographic screening practice that became a model for early US cinema (Musser 16). Slides and papers documenting shows at Pennsylvania Hospital for Insane, which are housed at Philadelphia's Atwater Kent Museum, offer a unique chance to investigate how this new nineteenth-century screening practice was received within hopeful context of a new, sophisticated form of therapeutic confinement for middle- and upper-class mental patients. While public magic lantern screenings had been taking place since late 160Os, when use of photographic lantern show slides began, it was one of those of profound transformation m precmema history of screening practices, Charles Musser explains in The Emergence of Cinema (16). Musser argues that such moments allow for new possibilities, for an influx of new personnel, and for disruption and considerable discontinuity (16). This was year that the screen enters a period of flux, as also happened when motion picture inventors transferred images onto screens. The screening practice then became receptive to new influences from other cultural forms; it is at such times that its cultural interconnectedness becomes most apparent and perhaps important, Musser says (16). …

The incidence of visual impairment due to diabetic retinopathy in Leeds

A key aim of the photographic screening model for diabetic retinopathy advocated by the National Screening Committee is a reduction in new blindness due to diabetic retinopathy within 5 years. This study determines the incidence of visual impairment due to diabetic retinopathy in Leeds in 2002 and provides a benchmark against which the success of the retinopathy screening programme in Leeds will be judged. A retrospective review of all blind and partially sighted registrations for 2002 was conducted. The 2001 Census data and the diabetes prevalence model developed by the Yorkshire and Humber Public Health Observatory were used to determine the total and diabetic populations of Leeds. Diabetic retinopathy was the primary cause of registration in 24 of the 398 completed records obtained; seven patients were registered blind and 17 partially sighted. For the total population in 2002, the incidence of blind and partially sighted registration due to diabetic retinopathy was 10 per million and 24 per million per year, respectively. For the diabetic population of Leeds in 2002, the incidence of blind and partial sighted registration due to diabetic retinopathy was 337 and 817 per million per year, respectively. The incidence of blind registration due to diabetic retinopathy in Leeds in 2002 is similar to the estimate provided by the National Screening Committee but higher than the figure from other UK centres.

This Issue of Acta

This Issue of Acta

Man versus machine: is technology a blessing or a barrier in screening for diabetic eye disease?

Man versus machine: is technology a blessing or a barrier in screening for diabetic eye disease?

Concentration of Circulating Rhodopsin mRNA in Diabetic Retinopathy

Diabetes mellitus is a major health problem throughout the world, and retinopathy is a serious and common complication of diabetes (1). Most individuals with diabetes will eventually develop diabetic retinopathy (DR). In the United States, up to 24 000 patients with diabetes become legally blind each year, and DR is the leading cause of blindness in adults 20–74 years of age (2). The United Kingdom Prospective Diabetes Study (UKPDS) showed that 39% of men and 35% of women had some degree of retinopathy at the time of diagnosis (3). With the incidence of diabetes mellitus increasing in many countries, the prevalence of DR as a major cause of blindness or visual impairment is also likely to increase. Factors influencing the development of retinopathy include type and duration of diabetes, degree of glycemic control, blood pressure, and serum lipids (3)(4)(5). Of these, duration of diabetes is the major factor related to the incidence of retinopathy. Clinical trials such as the Diabetic Retinopathy Study (DRS) (6) and the Early Treatment Diabetic Retinopathy Study (ETDRS) (7) have shown that effective laser photocoagulation could reduce the loss of vision by 90%. To be effective, regular screening for DR is required. Current recommendations are for annual screening for DR (8). Although recent studies suggest that in the absence of risk factors such as insulin use or duration of diabetes >20 years, screening every 2 or 3 years is adequate in type 2 diabetes (9). Despite these guidelines, 30–50% of patients with diabetes still do not get any eye examinations (10). Screening for DR includes visual acuity assessment as well as fundal photographs through dilated pupils. This involves cooperation between various healthcare professionals, such as diabetologists, optometrists, general practitioners, and photographic screening clinics. Patient eye status is classified according to a scale …

Cost-effectiveness of digital photographic screening for retinopathy of prematurity in the United Kingdom.

To compare the cost-effectiveness of alternative methods of screening for retinopathy of prematurity (ROP) in the United Kingdom, including the existing method of indirect ophthalmoscopy by ophthalmologists and digital photographic screening by nurses. A decision tree model was used to compare five screening modalities for the UK population of preterm babies, using a health service perspective. Data were taken from published sources, observation at a neonatal intensive care unit (NICU), and expert judgment. We estimated that use of standard digital cameras by nurses in NICUs would cost more than current methods (pound 371 compared with pound 321 per baby screened). However, a specialist nurse visiting units with a portable camera would be cheaper (pound 172 per baby). These estimates rely on nurses capturing and interpreting the images, with suitable training and supervision. Alternatively, nurses could capture the images then transmit them to a central unit for interpretation by ophthalmologists, although we estimate that this would be rather more expensive (pound 390 and pound 201, respectively, for NICU and visiting nurses). Sensitivity analysis was used to examine the robustness of estimates. It is likely that there is an opportunity to improve the efficiency of the ROP screening program. We estimate that screening by specialist nurses trained in image capture and interpretation using portable digital cameras is a cost-effective alternative to the current program of direct visualization by ophthalmologists. This option would require the development of a suitable portable machine. Direct comparative research is strongly needed to establish the accuracy of the various screening options.