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Paolo S. Silva, Jerry D. Cavallerano, Jennifer K. Sun, Ahmed Z. Soliman, Jerald Wisdom, Abumare Akinwale, Lloyd M. Aiello, Lloyd P. Aiello; Identification of Additional Diabetic Retinopathy Lesions using Mydriatic Wide-field Fundus Imaging: distribution & agreement with ETDRS photography and dilated retinal examination. Invest. Ophthalmol. Vis. Sci. 2012;53(14):2069.
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© ARVO (1962-2015); The Authors (2016-present)
To determine if mydriatic ultrawide-field fundus imaging identifies diabetic retinopathy (DR) lesions not observed w/ ETDRS film fundus photography (ETDRS photos) or dilated fundus exam (DFE).
Mydriatic Optos® 200 degree (D200), ETDRS photos and masked retina specialist DFE were obtained. Two masked readers graded images for presence/extent of DR lesions and clinical DR severity. Distribution of H/MA, venous beading (VB), IRMA, and NVE on D200 were compared to ETDRS photos. A 3rd masked retina specialist adjudicated discrepancies. Unweighted (K) and weighted (KW) kappa statistics (linear scale) assessed agreement.
206 eyes (103 diabetic patients) were evaluated. By ETDRS photos there was no DR in 23 eyes (12%), mild NPDR in 36 (18%), moderate NPDR in 72 (36%), severe/very severe NPDR in 17 (9%), & PDR in 51 (26%). DR severity between D200 & ETDRS photos matched in 67% (KW=0.74, K=0.57) and was within 1 level in 91%. D200 & DFE matched in 58% (KW=0.67, K=0.45), and was within 1 level in 87%. When D200 did not match DFE (N=86), higher agreement occurred between D200 & ETDRS photos (KW=0.70, K=0.50) than DFE & ETDRS photos (KW=0.33, K=0.08). Retinal lesions distribution on D200 in relation to ETDRS photo coverage (within ETDRS fields; outside ETDRS fields; both) was HMA (68%, 30%, 2%), VB (61%, 13%, 26%), IRMA (69%, 27%, 4%), NVE (66%, 34%, 0%). NVEs were seen in 29 eyes by ETDRS photos or DFE. NVEs in 12 (41%) eyes were seen by both ETDRS photos & DFE, 11 (38%) by ETDRS photos and 6 (21%) by DFE. All NVE seen on ETDRS photos were seen on D200. NVE in 11 (38%) eyes were seen on ETDRS & D200 and not on DFE. NVE in 5 (17%) eyes seen by DFE were not seen in either D200 or ETDRS photos. NVE in 9 (31%) additional eyes were seen on D200 that were not observed on either ETDRS photos or DFE. Of these, 4 (44%) were within ETDRS fields and did not increase DR severity. The 5 additional D200 detected NVEs outside ETDRS fields led to PDR detection in 3 of 9 (33%) eyes. Considering all retinal lesions detected outside ETDRS fields, 29 eyes (14.5%) would have been graded as more severe DR than ETDRS photos and none graded as less severe.
D200 images had substantial agreement with ETDRS photos and DFE in determining DR severity (>91% within 1 step). Agreement was less for DFE, but validity of DFE findings by ETDRS photos only occurred in 26%. Nearly 1/3 of DR lesions were located outside the ETDRS image area. Ultrawide imaging increased NVE identification >30% and DR severity grade in >14%. Ultrawide field imaging may identify more DR lesions than ETDRS photos or DFE (and perhaps more accurately than DFE), with potential implications for disease progression.
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