Anthony Cavallerano

Stereo nonmydriatic digital-video color retinal imaging compared with Early Treatment Diabetic Retinopathy Study seven standard field 35-mm stereo color photos for determining level of diabetic retinopathy.

OBJECTIVE To evaluate the ability to determine clinical levels of diabetic retinopathy, timing of next appropriate retinal evaluation, and necessity of referral to ophthalmology specialists using stereoscopic nonmydriatic digital-video color retinal images as compared with Early Treatment Diabetic Retinopathy Study (ETDRS) seven standard field 35-mm stereoscopic color fundus photographs. DESIGN Prospective, clinic-based, comparative instrument validation study. PARTICIPANTS Fifty-four patients (108 eyes) with type 1 or type 2 diabetes mellitus selected after chart review from a single center to include the full spectrum of diabetic retinopathy. METHODS Nonsimultaneous 45 degrees -field stereoscopic digital-video color images (JVN images) were obtained from three fields with the Joslin Vision Network (JVN) system before pupil dilation. Following pupil dilation, ETDRS seven standard field 35-mm stereoscopic color 30 degrees fundus photographs (ETDRS photos) were obtained. Joslin Vision Network images and ETDRS photos were graded on a lesion-by-lesion basis by two independent, masked readers to assess ETDRS clinical level of diabetic retinopathy. An independent ophthalmology retina specialist adjudicated interreader disagreements in a masked fashion. MAIN OUTCOME MEASURES Determination of ETDRS clinical level of diabetic retinopathy, timing of next ophthalmic evaluation of diabetic retinopathy, and need for prompt referral to ophthalmology specialist. RESULTS There was substantial agreement (kappa = 0.65) between the clinical level of diabetic retinopathy assessed from the undilated JVN images and the dilated ETDRS photos. Agreement was excellent (kappa = 0.87) for suggested referral to ophthalmology specialists for eye examinations. Comparison of individual lesions between the JVN images and the ETDRS photos and for interreader comparisons were comparable to the prior ETDRS study. CONCLUSIONS Undilated digital-video images using the JVN system were comparable photographs for the determination of diabetic retinopathy level. The results validate the agreement between nonmydriatic JVN images and dilated ETDRS photographs and suggest that this digital technique may be an effective telemedicine tool for remotely determining the level of diabetic retinopathy, suggesting timing of next retinal evaluation and identifying the need for prompt referral to ophthalmology specialists. Thus, the JVN system would be an appropriate tool for facilitating increased access of diabetic patients into recommended eye evaluations, but should not be construed as a paradigm that would replace the need for comprehensive eye examinations.

Use of Joslin Vision Network digital-video nonmydriatic retinal imaging to assess diabetic retinopathy in a clinical program.

Purpose To incorporate a nonmydriatic, digital-video retinal imaging system into a Diabetes Outpatient Intensive Treatment Program and to evaluate the system’s ability to assess diabetic retinopathy (DR), determine follow-up, and appropriately refer to retinal specialist ophthalmologists. Methods Fundus images were obtained according to Joslin Vision Network (JVN) protocol and evaluated by certified JVN readers. Patients with significant retinal disease underwent evaluation by retinal specialists. Results A total of 268 (51.0%) of 525 imaged patients had comprehensive eye examination by a retinal specialist owing to referable JVN-assessed clinical level of DR, nondiabetic ocular disease, ungradeable images, last eye examination ≥12 months prior, or patient request for examination. JVN diagnosis of a clinical level of DR agreed exactly with clinical findings in 388 eyes (72.5%) or within one level in 478 eyes (89.3%). JVN referral based on most severe diagnosis in either eye matched retinal specialist-recommended follow-up in 248/268 of patients (92.5%). A total of 136/525 (25.9%) of JVN patients had nondiabetic ocular abnormalities requiring referral. Conclusions Recommended follow-up from JVN imaging compared favorably to clinical examination by a retinal specialist. Nondiabetic ocular pathology was identified. JVN assessment of DR level compares favorably to clinical practice, potentially improving access to eye care and enhancing diabetes management.

Racial differences in macular thickness in healthy eyes.

Purpose. The relationship between race and macular thickness remains unknown. This relationship may be important for early and accurate diagnosis of macular disease and glaucoma, and may also provide insight into disease mechanisms. In this study, we compared macular thickness in healthy eyes of black and white subjects using optical coherence tomography (Stratus OCT). Methods. This study used a matched, cross-sectional design. Subjects underwent OCT macular thickness map scanning in each eye, four-field, 45-degree digital retinal imaging in each eye, and blood pressure measurement. Retinal images were evaluated for absence of posterior pole disorders, including macular and optic nerve disease. Retinal thickness was evaluated in the central fovea, and in rings placed at 1, 3, and 6 mm from fixation. Results. Compared with whites (n = 7), blacks (n = 7) had significantly thinner total foveal thickness (TFT, retinal thickness in the central 1 mm diameter area; OD: p < 0.03; OS: p < 0.02; OU average: p < 0.02), and thinner total macular thickness (TMT, retinal thickness in 6mm diameter area excluding central foveal thickness; OS: p < 0.02; OU average: p < 0.03). There was a trend for central foveal thickness (retinal thickness at fixation) to be thinner in blacks than whites (OD: p = 0.12; OS: p = 0.08). There was no significant difference in macular thickness between right and left eyes. Conclusions. Retinal thickness as measured by Stratus OCT in the fovea and macula is significantly thinner in blacks compared with age-matched whites. Larger multiracial prospective studies are needed to confirm these results and to evaluate the need for race-specific normative values.

Macular thickness and systemic markers for diabetes in individuals with no or mild diabetic retinopathy

Background:  The relationship between diabetic risk factors and macular thickness in individuals without clinically detectable diabetic macular oedema has yet to be formally explored. The purpose of this study was to assess the correlation between macular thickness and diabetes control and duration.

Nonmydriatic teleretinal imaging improves adherence to annual eye examinations in patients with diabetes.

We studied whether nonmydriatic digital retinal imaging with remote interpretation (teleretinal imaging) in the ambulatory care setting affected adherence to annual dilated eye examinations among patients with diabetes. We randomly assigned 448 patients to a teleretinal imaging group or a control group. We measured the number of patients who had dilated eye examinations within 12 months of group assignment and the agreement for level of diabetic retinopathy between teleretinal imaging and the eye examinations. The teleretinal imaging group (n = 223) had significantly more dilated eye examinations than the control group (n = 225). Teleretinal imaging and eye examination results showed significant correlation and moderate agreement. Cataract and smaller pupil size were significantly associated with ungradable retinal images. Two-thirds of patients with ungradable images had other ocular findings. Patients reported high satisfaction with nonmydriatic teleretinal imaging. Nonmydriatic teleretinal imaging improves diabetic retinopathy assessment rates.

Teleretinal Imaging to Screen for Diabetic Retinopathy in the Veterans Health Administration

Diabetes is the leading cause of adult vision loss in the United States and other industrialized countries. While the goal of preserving vision in patients with diabetes appears to be attainable, the process of achieving this goal poses a formidable challenge to health care systems. The large increase in the prevalence of diabetes presents practical and logistical challenges to providing quality care to all patients with diabetes. Given this challenge, the Veterans Health Administration (VHA) is increasingly using information technology as a means of improving the efficiency of its clinicians. The VHA has taken advantage of a mature computerized patient medical record system by integrating a program of digital retinal imaging with remote image interpretation (teleretinal imaging) to assist in providing eye care to the nearly 20% of VHA patients with diabetes. We describe this clinical pathway for accessing patients with diabetes in ambulatory care settings, evaluating their retinas for level of diabetic retinopathy with a teleretinal imaging system, and prioritizing their access into an eye and health care program in a timely and appropriate manner.

THE JOSLIN VISION NETWORK INNOVATIVE TELEMEDICINE CARE FOR DIABETES: Preserving Human Vision

Despite advances in understanding and treating diabetic retinopathy, diabetes remains a leading cause of new blindness in workingaged American~.~~ In the United States, current levels of eye care and laser surgery save 220 thousand person-years of sight and more than

Accuracy of a technology-assisted eye exam in evaluation of referable diabetic retinopathy and concomitant ocular diseases

471 million in federal dollars a n n ~ a l l y . ~ ~ ~ ~ If these levels of care are provided to everyone with diabetes in the United States, the savings rise to 400 thousand person-years of sight and 624 million federal dollars annually.21-23 Unfortunately, all persons with diabetes who would benefit from timely and appropriate retinal examination and sight-saving laser surgery do not have access to specialized eye care. Reasons for this lack of care and unnecessary loss of vision include3, 24:

Glaucoma medication adherence in veterans and influence of coexisting chronic disease.

Background/aims Digital retinal imaging using store-and-forward technology is used to screen for diabetic retinopathy (DR). Its usefulness in detecting non-diabetic eye diseases is uncertain. We determined the level of agreement between teleretinal imaging supplemented with visual acuity and intraocular pressure (IOP) measurements (ie, technology-assisted eye (TAE) exam) and a comprehensive eye exam in evaluation for DR and non-diabetic ocular conditions. Methods We conducted a prospective, observational study with two parallel evaluations. Patients with diabetes (n=317) had a TAE exam and a comprehensive eye exam on the same day. A subset of participants with normal baseline exams (n=72) had follow-up exams 1 year later. We measured the level of agreement for referable ocular findings. Results Agreement for referable ocular findings was moderate (n=389, agreement: 77%; κ: 0.55), due in part to ungradable exams (22%). However, about half of the ungradable exams had findings that warranted referral. There was substantial agreement for follow-up exams (n=72, agreement: 93%; κ: 0.63). Among all gradable exams (n=303), the TAE exam had 86% sensitivity and 84% specificity for referable ocular findings, with high agreement (≥94%) for DR and other major ocular diagnoses. Conclusions There was moderate-to-substantial agreement between a TAE exam and a comprehensive eye exam for referable ocular findings in patients with diabetes. Ungradable exams were a frequent marker of ocular pathology. Teleretinal imaging may be a useful evaluation for both diabetic and non-diabetic ocular conditions.

Nonmydriatic Digital Imaging Alternative for Annual Retinal Examination in Persons With Previously Documented No or Mild Diabetic Retinopathy

Background:The aim of this study was to characterize veterans’ adherence to glaucoma medications and follow-up eye care, and to examine the influence of coexisting chronic conditions such as posttraumatic stress disorder (PTSD)/anxiety. Patients and Methods:A retrospective review of computerized medical records was performed for 161 veterans taking topical glaucoma medications. Medication possession ratio (MPR) was calculated using pharmacy data. Mean follow-up ratio (FUR) was calculated using the number of days between visits. Results:Among the health conditions examined, the most prevalent was hearing loss (0.34), followed by arthritis (0.29), PTSD, or other anxiety disorder (0.27), and dementia or other memory disorder (0.09). The average rates of MPR and FUR were 0.69±0.20 and 0.84±0.19, respectively.Group comparisons found that patients with hearing loss had higher MPR compared with patients without hearing loss, and patients who were white had higher FUR than African American patients. When demographic and health characteristics were examined simultaneously in multiple linear regressions, hearing loss emerged as a significant predictor of MPR, and being older was significantly related to FUR. Younger age was also associated with MPR and being white (vs. African American) or having a PTSD/other anxiety disorder was related to FUR, although these findings did not reach statistical significance. Conclusions:FUR was better than MPR in a veteran population being treated for glaucoma.Hearing loss was significantly related to higher MPR, whereas being older was significantly associated with higher FUR. These characteristics should be taken into consideration in future programs to improve adherence to glaucoma care.