Screening For Diabetic Eye Disease Research Articles

What are the perceptions and concerns of people living with diabetes and National Health Service staff around the potential implementation of AI-assisted screening for diabetic eye disease? Development and validation of a survey for use in a secondary care screening setting

IntroductionThe English National Health Service (NHS) Diabetic Eye Screening Programme (DESP) performs around 2.3 million eye screening appointments annually, generating approximately 13 million retinal images that are graded by humans...

Is diabetic retinopathy screening worthwhile among people first diagnosed with diabetes at older ages? A cohort study of Norfolk diabetic retinopathy screening programme.

England's Diabetic Eye Disease Screening Programme offers screening to every resident over age 12 with diabetes, starting as soon as possible after diagnosis and repeated annually. People first diagnosed with diabetes at older ages have shorter life expectancy and therefore may be less likely to benefit from screening and treatment. To inform decisions about whether diabetic eye screening policy should be stratified by age, we investigated the probability of receiving treatment according to age at first screening episode. This was a cohort study of participants in the Norfolk Diabetic Retinopathy Screening Programme from 2006 to 2017, with individuals' programme data linked to hospital treatment and death data recorded up to 2021. We estimated and compared the probability, annual incidence and screening costs of receiving retinal laser photocoagulation or intravitreal injection and of death, in age groups defined by age at first screening episode. The probability of death increased with increasing age at diagnosis, while the probability of receiving either treatment decreased with increasing age. The estimated cost of screening per person who received either or both treatments was £18,608 among all participants, increasing with age up to £21,721 in those aged 70-79 and £26,214 in those aged 80-89. Diabetic retinopathy screening is less effective and less cost-effective with increasing age at diagnosis of diabetes, because of the increasing probability of death before participants develop sight-threatening diabetic retinopathy and can benefit from treatment. Upper age limits on entry into screening programmes or risk stratification in older age groups may, therefore, be justifiable.

Effectiveness of Non-mydriatic Ultra-widefield Retinal Imaging to Screen for Diabetic Eye Disease: A Randomized Controlled Trial (Clearsight)

Suboptimal diabetic eye disease screening is a major cause of preventable vision loss. Screening barriers include mydriasis and need for dedicated screening appointments. The Clearsight trial assessed whether non-mydriatic ultra-widefield (NM UWF) screening on the day of a diabetes clinic visit improved detection of clinically important eye disease vs usual screening. This single-centre, randomized, parallel-group controlled trial was conducted at St. Joseph’s Health Care, London, Canada. Adults with diabetes due for screening were randomized to same-day On-Site Screening (NM UWF imaging) on the day of a scheduled diabetes clinic visit or Usual Screening (encouraged to arrange optometric screening).

Analysis of Health System Size and Variability in Diabetic Eye Disease Screening in Wisconsin

This cohort study uses statewide claims data to assess variability in diabetic eye disease screening across Wisconsin health systems and to examine the association between patient health system and screening receipt.

Telemedical Diabetic Retinopathy Screening in a Primary Care Setting: Quality of Retinal Photographs and Accuracy of Automated Image Analysis

ABSTRACT Background Screening for diabetic eye disease (DED) and general diabetes care is often separate, which leads to delays and low adherence to DED screening recommendations. Thus, we assessed the feasibility, achieved image quality, and possible barriers of telemedical DED screening in a point-of-care general practice setting and the accuracy of an automated algorithm for detection of DED. Methods Patients with diabetes were recruited at general practices. Retinal images were acquired using a non-mydriatic camera (CenterVue, Italy) by medical assistants. Images were quality assessed and double graded by two graders. All images were also graded automatically using a commercially available artificial intelligence (AI) algorithm (EyeArt version 2.1.0, Eyenuk Inc.). Results A total of 75 patients (147 eyes; mean age 69 years, 96% type 2 diabetes) were included. Most of the patients (51; 68%) preferred DED screening at the general practice, but only twenty-four (32%) were willing to pay for this service. Images of 63 patients (84%) were determined to be evaluable, and DED was diagnosed in 6 patients (8.0%). The algorithm’s positive/negative predictive values (95% confidence interval) were 0.80 (0.28–0.99)/1.00 (0.92–1.00) and 0.75 (0.19–0.99)/0.98 (0.88–1.00) for detection of any DED and referral-warranted DED, respectively. Overall, the number of referrals was 18 (24%) for manual telemedical assessment and 31 (41%) for the artificial intelligence (AI) algorithm, resulting in a relative increase of referrals by 72% when using AI. Conclusions Our study shows that achieved overall image quality in a telemedical GP-based DED screening was sufficient and that it would be accepted by medical assistants and patients in most cases. However, good image quality and integration into existing workflow remain challenging. Based on these findings, a larger-scale implementation study is warranted.

Artificial Intelligence in Diabetic Eye Disease Screening.

Systematic or national screening programs for diabetic retinopathy (DR) and diabetic macular edema (DME), using digital fundus photography and optical coherence tomography (OCT), are currently implemented at primary care level, aiming to provide timely referral for vision-threatening DR and DME to ophthalmologists for timely treatment and vision loss prevention. However, interpretation of retinal images requires specialized knowledge and expertise in diabetic eye disease. Furthermore, current DR screening programs are capital- and labor-intensive, which makes it difficult to rapidly scale up and expand diabetic eye screening to meet the needs of this growing global epidemic. Deep learning (DL), a new branch of machine learning technology under the broad term of artificial intelligence (AI), has made remarkable breakthrough in medical imaging in particular for pattern recognition and image classification. In ophthalmology, AI and DL technology has been developed from big image datasets in assessment of retinal photographs for detection and screening of DR as well as the segmentation and assessment of OCT images for diagnosis and screening of DME. This review aimed to summarize the current progress and the development of using AI and DL technology for diabetic eye disease screening as well as current challenges in the actual implementation of DL in screening programs, and translating DL research into direct clinical applications of screening in a community setting.

A randomised trial of non-mydriatic ultra-wide field retinal imaging versus usual care to screen for diabetic eye disease: rationale and protocol for the Clearsight trial

IntroductionSuboptimal screening for diabetic eye disease is a major cause of preventable vision loss. Screening barriers include mydriasis and the extra time patients need to attend dedicated eye screening appointments....

Screening for Diabetic Eye Disease among Samoan Adults: A Pilot Study.

IntroductionThe purpose of this study was to determine the prevalence of diabetic retinopathy in Samoa by piloting a retinal photography screening programme.MethodsWe performed a cross-sectional study of patients with diabetes who presented to the Tupua Tamasese Meaole eye clinic in Apia, Samoa, between May 2011 and September 2011. Study approval was granted by the National Health Service Board of Samoa, the Monash University Human Research Ethics Committee, and the study adhered to the Tenets of the Declaration of Helsinki. Following informed consent, data collection included patient demographics [age, area of residence (rural or urban)], type of diabetes, length of time since diagnosis, most recent random blood sugar and blood pressure levels. The subjects had three 45-degree retinal photographs taken in each eye with the Canon CR6-45NM camera. All gradable photographs were assessed for the presence of diabetic retinopathy or macular oedema using the International Clinical Diabetic Retinopathy Severity Scale and the International Clinical Diabetic Macular Oedema Severity scale, respectively.ResultsTwo hundred and fourteen eyes from 107 subjects were examined during the study period, all of whom had type 2 diabetes mellitus. Diabetic retinopathy was present in 53.3% (114/214) of eyes, with 14.5% having proliferative retinopathy and 7.5% with severe non-proliferative retinopathy. Also, 25.2% (54/214) had some evidence of macular oedema with 11.7% (25/214) requiring treatment. A statistically significant relationship existed between the length of time since diagnosis and the severity of both retinopathy (p < 0.001) and macular oedema (p = 0.031). Blood pressure more than 150/85 mmHg was associated with higher levels of diabetic retinopathy (p = 0.03) and macular oedema (p = 0.02).ConclusionA comprehensive diabetic retinopathy screening programme is much needed in Samoa given the high prevalence of diabetic eye disease.

Tele-ophthalmology for diabetic retinopathy screening: 8 years of experience

Purpose To describe the results of a diabetic retinopathy screening program implemented in a primary care area. Methods A retrospective study was conducted using data automatically collected since the program began on 1 January 2007 until 31 December 2015. Results The number of screened diabetic patients has progressively increased, from 7,173 patients in 2007 to 42,339 diabetic patients in 2015. Furthermore, the ability of family doctors to correctly interpret retinographies has improved, with the proportion of retinal images classified as normal having increased from 55% in 2007 to 68% at the end of the study period. The proportion of non-evaluable retinographies decreased to 7% in 2015, having peaked at 15% during the program. This was partly due to a change in the screening program policy that allowed the use of tropicamide. The number of severe cases detected has declined, from 14% with severe non-proliferative and proliferativediabetic retinopathy in the initial phase of the program to 3% in 2015. Conclusions Diabetic eye disease screening by tele-ophthalmology has shown to be a valuable method in a growing population of diabetics. It leads to a regular medical examination of patients, helps ease the workload of specialised care services and favours the early detection of treatable cases. However, the results of implementing a program of this type are not immediate, achieving only modest results in the early years of the project that have improved over subsequent years.

Advances in retinal imaging for diabetic retinopathy and diabetic macular edema.

Diabetic retinopathy and diabetic macular edema (DME) are leading causes of blindness throughout the world, and cause significant visual morbidity. Ocular imaging has played a significant role in the management of diabetic eye disease, and the advent of advanced imaging modalities will be of great value as our understanding of diabetic eye diseases increase, and the management options become increasingly varied and complex. Color fundus photography has established roles in screening for diabetic eye disease, early detection of progression, and monitoring of treatment response. Fluorescein angiography (FA) detects areas of capillary nonperfusion, as well as leakage from both microaneurysms and neovascularization. Recent advances in retinal imaging modalities complement traditional fundus photography and provide invaluable new information for clinicians. Ultra-widefield imaging, which can be used to produce both color fundus photographs and FAs, now allows unprecedented views of the posterior pole. The pathologies that are detected in the periphery of the retina have the potential to change the grading of disease severity, and may be of prognostic significance to disease progression. Studies have shown that peripheral ischemia may be related to the presence and severity of DME. Optical coherence tomography (OCT) provides structural detail of the retina, and the quantitative and qualitative features are useful in the monitoring of diabetic eye disease. A relatively recent innovation, OCT angiography, produces images of the fine blood vessels at the macula and optic disc, without the need for contrast agents. This paper will review the roles of each of these imaging modalities for diabetic eye disease.

Image-quality standardization for diabetic retinopathy screening

Screening for diabetic eye disease in the UK relies on the correct interpretation of a digital retinal image to identify pathological features in the retina. The lesions that mark the early stages of disease are small, and a number of nonharmful features of similar appearance may confound detection. Early recognition of pathology and prompt treatment can preserve sight. It is, therefore, essential that each component of the digital imaging system is of a sufficient standard to maximize the probability of early detection. The imaging pathway between the patient’s eye and a final diagnostic outcome is discussed in this article, with reference to appropriate national standards for equipment and processes.

Biennial eye screening in patients with diabetes without retinopathy: 10-year experience

Aims:To evaluate the safety of every-other-year eye screening for patients with diabetes without retinopathy.Methods:Since 1994, patients with diabetes without retinopathy in Iceland have received eye screening every other year. 296...

Patients’ attitudes towards mydriasis for diabetic eye disease screening

The purpose of the questionnaire was to explore attitudes of patients towards mydriasis for diabetic retinopathy screening. Two groups of patients were invited to take part: group 1 comprised patients attending the diabetic clinic and had previous experience of mydriasis, group 2 patients attending the mobile screening unit for non-mydriatic digital retinal photograph and who were not previously used to receiving mydriatic eye drops. Basic demographic data was recorded and the volunteers invited to complete a questionnaire. 292 patients were recruited into group 1 (median age 63 years range 20-94) and 103 into group 2 (median age 68 years range 29-96). 42% of patients in group 2 indicated that they were unhappy with the use of dilating eye drops and 26% of this group reported that they may be discouraged from attending screening for diabetic retinopathy if drops were introduced. These figures were statistically lower in group 1 at 8% and 1-8% respectively (p < 0.001). Blurring of vision was identified as the most troublesome feature of the use of mydriasis for patients. A large proportion of patients drove themselves to their last screening appointment; 58% in group 2 and 39% in group 1. A third of all patients (33%) indicated that they worked outside the home. Many patients attending diabetic eye screening return to driving and work immediately after the appointment. Introduction of the use of routine drops may discourage attendance. Education and experience may have an important role in improving acceptability of mydriatic eye drops. Retinal screeners need to have clear guidelines with which to advise patients.

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?

Ambulatory photographic screening for diabetic retinopathy in nursing homes.

To evaluate the feasibility and cost of screening for diabetic eye disease in homebound nursing home residents not attending a systematic screening programme. Postal survey identification of residents with diabetes in all nursing homes in Liverpool. An ophthalmologist and nurse performed Bailey-Lovie logmar visual acuity (VA), portable slit-lamp examination, fundus photography, and subjective assessment of ability to cooperate with treatment in a sample of homes. Modified Wisconsin photographic grading was performed. Screen-positive patients were invited to a dedicated assessment clinic. Sight-threatening diabetic eye disease (STED) was defined as any of: moderate preproliferative retinopathy or worse, circinate maculopathy, or exudate within 1 disc diameter of fixation. A total of 54 (78%) nursing homes responded reporting 199/2427 (8.2%) residents with diabetes. Of these, 64/80 (80%) residents in 17 homes were examined: VA possible in 50 (78%); slit-lamp examination in 56 (88%); gradable photographs in at least one eye in 34 (53%); STED in 12 (35%) patients. In all, 35 (70%) patients had Snellen-equivalent VA worse than 6/12 in the better eye, of whom 13 (26%) were worse than 6/60. Of 29 screen positive patients, 12 attended the assessment clinic: one was unable to cooperate outside the home; 11 continue under ophthalmic review, four for previously undetected STED of which one listed for laser photocoagulation. Total cost pound 16,980; cost per screen event pound 60.30. Systematic eye screening in homebound patients with diabetes detects disease but follow-up and treatment is only feasible in a small proportion and at high cost. Alternative targeted assessment is recommended.

Does direct ophthalmoscopy improve retinal screening for diabetic eye disease by retinal photography?

To identify whether after performing retinal photography, direct ophthalmoscopy can improve the yield of screening for the detection of sight-threatening diabetic eye disease (STDED). Patients (n = 408) who had previously received both dilated direct ophthalmoscopy by a diabetologist and retinal photography graded by a diabetologist within 3 months of each other were included. The results of the other screening modality were not available to the grader/screener. The first 308 patients were consecutive attendees at the clinic who fulfilled the study criteria and 100 were selected because they were identified as having potential STDED by either one of these modalities. An ophthalmologist using slit lamp biomicroscopy then examined patients identified with potential STDED. In 357 (88%) patients there was agreement between the two modalities about whether referral to an ophthalmologist was required (kappa 0.62). Retinal photography identified 38 patients for referral to ophthalmology which ophthalmoscopy missed. Of these, the ophthalmologist agreed that STDED was present in 32 (84%) and four patients required early laser. Ophthalmoscopy identified 13 patients for referral who were not identified by photography. Of these, the ophthalmologist agreed with the diabetologist that STDED was present in seven (54%) and one patient required early laser. Ophthalmoscopy may identify the occasional patient with diabetes who has STDED which is missed by retinal photography. For a systematic retinal screening programme, adding ophthalmoscopy to retinal photography will increase false-positive referrals and is likely to detect only a few extra patients requiring laser.

Characteristics of those registered blind as a result of diabetes in Fife over a ten year period

AbstractFife is a geographically defined area of Scotland with a stable population of about 350 000. Screening for diabetic eye disease is performed annually with a hand held ophthalmoscope by doctors in hospital clinics and by trained optomotrists in those attending primary care. The standards for screening and management are those recommended by the Scottish Intercollegiate Guideline Network.Over the ten year period 1990–1999 41 people were registered blind where diabetes was considered to be the main cause of blindness. The hospital and primary care records of all 41 patients were examined.Eight of the 41 people were under 60 years old and six had type 1 diabetes. Three had serious mental health problems, 13 were people who had chronically defaulted and five had been geographically mobile.No patient with type 1 diabetes who regularly attended a clinic became blind. There was a very high prevalence of microvascular disease and by the end of the study 29 patients had died of macrovascular complications.The organisation of screening is more important than the method of screening used and the development of strategies to improve the outcome in those who fail to keep appointments and those who are geographically mobile is very important in preventing blindness. Copyright © 2002 John Wiley &amp; Sons, Ltd.

Screening and prevention of diabetic blindness.

Diabetic eye disease remains a major cause of blindness in the world. Laser treatment for proliferative diabetic retinopathy and diabetic macular edema became available more than two decades ago. The outcome of treatment depends on the timing of laser treatment. The laser treatment is optimally delivered when high-risk characteristics have developed in proliferative retinopathy or diabetic macular edema and before this has significantly affected vision. Laser treatment is usually successful if applied during this optimal period whereas the treatment benefit falls sharply if the treatment is applied too late. In order to optimize the timing of laser treatment in diabetic eye disease screening programs have been established. The oldest screening program is 20 years old and several programs have been established during the last decade. In this paper the organisation and methods of screening programs are described including direct and photographic screening. The incidence and prevalence of blindness is much lower in populations where screening for diabetic eye disease has been established compared to diabetic populations without screening. Technical advantages may allow increased efficiency and telescreening. From a public health standpoint screening for diabetic eye disease is one of the most cost effective health procedures available. Diabetic eye disease can be prevented using existing technology and the cost involved is many times less than the cost of diabetic blindness.

Cost effectiveness analysis of screening for sight threatening diabetic eye disease

Objective: To measure the cost effectiveness of systematic photographic screening for sight threatening diabetic eye disease compared with existing practice.Design: Cost effectiveness analysisSetting: Liverpool.Subjects: A target population of 5000 diabetic...

The implementation of prompted retinal screening for diabetic eye disease by accredited optometrists in an inner-city district of North London: a quality of care study

The implementation of prompted retinal screening for diabetic eye disease by accredited optometrists in an inner-city district of North London: a quality of care study