Ben Szirth

Ocular telehealth screenings in an urban community.

The current U.S. economic recession has resulted in a loss of income, housing, and healthcare coverage. Our major goal in this socioeconomic setting was to provide ophthalmic remote health screenings for urban soup kitchen and homeless populations in order to identify and refer undetected vision-threatening disease (VTD). We assessed visual acuity, blood pressure, pulse/oxygen saturation, body mass index, and intraocular pressure for 341 participants at soup kitchens as part of the homeless outreach program in Newark, NJ. History of diabetes, hypertension, and smoking, last ocular examination, and ocular history were noted. Imaging was performed with an 8.2 megapixel non-mydriatic retinal camera with high-speed Internet ready for off-site second opinion image evaluation. Positive VTD findings were identified in 105 participants (31%) (mean age, 53.6 years), of whom 78% were African American, 73% males, and 62% smokers. We detected glaucoma in 34 participants (32%), significant cataract in 22 (21%), diabetic retinopathy in 5 (5%), optic atrophy in 1 (1%), age-related macular degeneration in 1 (1%), and other retinal findings in 43 (41%). The incidence of VTDs was higher among this cohort than among study groups in previous screenings (31% vs. 12%). This finding shows an increase in ocular morbidity in a younger, at-risk population with elevated rates of hypertension, diabetes, and smoking. Functional visual impairment was 2.5 times higher than the national average (16% vs. 6.4%). Comprehensive, community-based screenings can provide more sensitive detection of VTDs in high-risk groups with low access to ophthalmic care and can be an integral part of recession solutions for improving healthcare.

Type 1 Diabetic and Hypertensive Retinopathy: Case Presentation and Review of Literature

Background: Type 1 Diabetes (T1D) Mellitus is a complex, chronic illness that affects half a million children under the age of 15 years. Complications associated with diabetic retinopathy can be prevented with continued self-management of Blood Glucose (BG) and Blood Pressure (BP) into adulthood. In this case, we present a 20-year-old man with a 15 year history of T1D who loses control of his BG and BP for 2 years. Methods: Blood pressure, visual acuity and intraocular pressures were measured at the time of visit. Non-mydriatic retinal imaging was performed using a Canon CR-2 Plus AF with a resolution of 18 megapixel. A Spectral Domain (SD)-OCT provided a 5 micron resolution of the posterior pole including the macula/fovea. Optical Coherence Tomography Angiography (OCTA) (Optovue, Inc., Fremont, CA, USA) captured 6*6 mm angiograms centered on macula. TeamViewerTM was used to perform remote tele-presence tele-ophthalmology. Results: Color Fundus Photo (CFP) of the subject in 2013 showed few hemorrhages with virtually no signs of retinopathy although his BP, last Glycated hemoglobin (HbA1c) and BG were uncontrolled (130/91 mm Hg, 13+, 421 mg/dL, respectively). Two years later, after 15 years of diabetes, his BP, last HbA1c, and BG are still uncontrolled (142/62 mm Hg, 13.5%, and 319 mg/dL, respectively). CFP and tele-consultation confirms severe Non-proliferative diabetic retinopathy (NPDR), after 131 days since last annual eye examination, with 259 retinal hemorrhages and 12 Intraretinal microvascular abnormalities (IRMAs) in his left eye. OCT was normal, but OCTA identified areas of retinal telangiectasia and micro-aneurysm formation. 21 days following NPDR diagnosis, he reduced BP to 122/78 mm Hg, HbA1c to 10%, and BG to 115 mg/dL. CFP showed 80 fewer hemorrhages and 10 IRMAs. 57 days following NPDR diagnosis, subject had BP of 107/72 mm Hg and BG of 124 mg/dL. CFP showed 180 fewer hemorrhages and 13 IRMAs. Conclusions: As BG and BP were decreased and maintained within normal levels, the subject benefited from reduction in retinopathy findings. This case identifies the role non-mydriatic retinal imaging, OCT, and OCTA may play in the assessment and follow-up of patients with long duration type 1 diabetes. Tele-ophthalmology can be an important tool in the follow-up and second opinion of screened patients. An emphasis on BP monitoring can play an important role in the better management of patients with type I diabetes. Close monitoring and maintenance of BP below 130/80, fasting BG under 120 mg/dL, and HbA1c<10% can help reduce NPDR microvascular complications and save vision.

Feasibility of Spectral Domain Optical Coherence Tomography Acquisition Using a Handheld Versus Conventional Tabletop Unit.

Purpose: Patients afflicted with ocular complications of diabetes represent a diverse demographic who often cannot undergo spectral-domain optical coherence tomography (SD-OCT) imaging of the retina due to postural restraints. Our pilot study compared imaging acquisition methods using SD-OCT in the handheld (HH) mode versus the conventional tabletop (TT) method. Methods: Our study included 22 undilated eyes of 22 subjects (mean ± SD age, 35.8 ± 16.8 years) imaged using HH and TT iVue SD-OCT (Optovue, Fremont, CA). Statistical analysis was performed using Microsoft Excel 12.2.7 (Microsoft Corporation, Redmond, WA) software with an accepted significance of P < .05. Results: Strong intraclass correlation coefficient was observed for (1) overall (.97), superior (.93), and inferior (.94) ganglion cell complex thickness, and (2) central (.98), inferior (.90), superior (.92), nasal (.94), and temporal (.93) macular retinal thickness. Mean scan quality index was adequate but lower in HH versus TT SD-OCT (62.8 vs 68.1, respectively; P < .0001). Multiple attempts for adequate imaging were required more frequently in HH versus TT SD-OCT (34% vs 5%, respectively; P < .001). Conclusion: HH SD-OCT may be a feasible alternative to TT SD-OCT in select situations, especially in patients suffering from diabetic complications with limited mobility.

Software-Assisted Depth Analysis of Optic Nerve Stereoscopic Images in Telemedicine

Background. Software guided optic nerve assessment can assist in process automation and reduce interobserver disagreement. We tested depth analysis software (DAS) in assessing optic nerve cup-to-disc ratio (VCD) from stereoscopic optic nerve images (SONI) of normal eyes. Methods. In a prospective study, simultaneous SONI from normal subjects were collected during telemedicine screenings using a Kowa 3Wx nonmydriatic simultaneous stereoscopic retinal camera (Tokyo, Japan). VCD was determined from SONI pairs and proprietary pixel DAS (Kowa Inc., Tokyo, Japan) after disc and cup contour line placement. A nonstereoscopic VCD was determined using the right channel of a stereo pair. Mean, standard deviation, t-test, and the intraclass correlation coefficient (ICCC) were calculated. Results. 32 patients had mean age of 40 ± 14 years. Mean VCD on SONI was 0.36 ± 0.09, with DAS 0.38 ± 0.08, and with nonstereoscopic 0.29 ± 0.12. The difference between stereoscopic and DAS assisted was not significant (p = 0.45). ICCC showed agreement between stereoscopic and software VCD assessment. Mean VCD difference was significant between nonstereoscopic and stereoscopic (p < 0.05) and nonstereoscopic and DAS (p < 0.005) recordings. Conclusions. DAS successfully assessed SONI and showed a high degree of correlation to physician-determined stereoscopic VCD.

Use of High Resolution Digital Retinal Imaging in the Early Detection of Retinopathy in Type 1 Diabetes

Background: Type 1 Diabetes Mellitus is one of the most common endocrine and metabolic conditions worldwide, affecting nearly half a million children under the age of 15 years with an anticipated rise in incidence of 4%. The ocular complications of type 1 diabetes can be blind- ing and thus, inflicting catastrophic consequences on quality of life. In this disease, the greatest impact in the prevention of vision loss comes from early detection and treatment. Methods: Retinal screening was performed to capture both right and left eyes of children as young as 5 years of age. A Canon CR-2 Plus AF (Tokyo, Japan) non-mydriatic retinal camera with a CMOS chip, a resolution of 18 megapixel and an ISO setting of 400 (range available is from 200 to 6400 ISO) in sensitivity was used for these images. Image management used was image SPECTRUM V5 (Canon USA, Irvine, CA), a postcapture imaging software that automat- ically separated a color image into three (3) monochromatic images; namely blue, green and red, to help visualize the nerve fiber layer, the retinal layers as well as the choroid, respectively. Results: In subjects with positive findings (mild diabetic retinopathy), retinal pathology was noted on digital imaging and involved retinal hemorrhages and vascular changes consistent with microaneurysms. Severe nonproliferative diabetic retinopathy was detected in one 20-year-old subject. One subject presented with cataract. Subjects with a positive finding were counseled and a referral to an ophthalmologist was recommended. Conclusions: Non-mydriatic retinal imaging used in mass screenings can help identify the ear- ly retinal changes and advance the management and care of patients with diabetic retinopathy. Improvements in digital imaging software and the ability to perform telemedicine from remote locations, can aid eye health care providers in the detection and isolation associated with vari- ous levels of retinopathy.