Nonmydriatic Ultrawide Field Retinal Imaging Reduces Ungradable Rate, Increases Retinopathy Detection and Reduces Image Evaluation Time in an Ocular Telehealth Program for Diabetic Retinopathy

Abstract

Purpose: To compare efficiency of image analysis and diabetic retinopathy (DR) identification between nonmydriatic ultrawide field (UWF) retinal imaging and nonmydriatic multifield fundus photography (NMFP) in a diabetic retinopathy (DR) ocular telehealth program.

Methods: The analysis included all patients having Joslin Vision Network (JVN) retinal imaging at the Joslin Diabetes Center from Nov 1, 2011 to Nov 1, 2012. The validated protocol used identical color calibrated LCD high resolution monitors and certified graders to evaluate all images for DR and diabetic macular edema (DME). Lowlight adapted NMFP (stereoscopic pairs of 3 45°, 2 30° retinal fields, and 1 external image) was compared to UWF imaging (stereoscopic pairs of Optos P200MA 100° & 200° images).

Results: From Nov 1, 2011 to Mar 31, 2012, 1649 subjects were imaged using NMFP and 2154 subjects were then imaged from Apr 1, 2012 to Nov 1, 2012 using UWF imaging. There was no statistically significant difference between groups in age, gender, ethnicity or insulin use. The rate of ungradable eyes for DR and DME was lower with UWF compared to NMFP (DR: 2.2% vs 9.9%, p<0.001; DME: 3.9% vs 8.8%, p<0.0001). Identification of eyes with DR and vision threatening DR increased using UWF from 30.7% to 37.2% (p<0.001) and from 10.8% to 14.1% (p=0.002), respectively. In a subgroup of 1622 (38%) eyes, the distribution of peripheral retinal changes outside ETDRS fields was evaluated. There were 304 (37%) subjects (604 eyes) with DR in this subgroup and hemorrhage/microaneurysms, venous beading, IRMA and new vessels elsewhere were present in the periphery in 24%, 0.6%, 2% and 0.6%, respectively. Peripheral lesions led to diagnosis of more severe DR in 15% (46 patients).The median time per patient to evaluate retinal images was reduced by 28% (12.8 minutes [NMFP] to 9.2 minutes [UWF], P<0.0001).

Conclusions: In a standardized DR ocular telehealth program, nonmydriatic UWF imaging reduced the rate of ungradable eyes by 78% to less than 3%. DR was identified 17% more frequently and DR peripheral lesions led to diagnosis of a more severe DR level in 15%. Image evaluation time was reduced substantially. These data suggest that UWF imaging may improve ability of ocular telehealth programs to efficiently evaluate DR and DME.

Keywords: 499 diabetic retinopathy • 552 imaging methods (CT, FA, ICG, MRI, OCT, RTA, SLO, ultrasound) • 688 retina