The influence of ultra-wide field fluorescein angiography on the diagnosis and management of diabetic retinopathy

Abstract

Purpose : To study the influence of ultra-wide field (UWF) fluorescein angiography (FA) on the diagnosis and management of diabetic retinopathy (DR) when presented in addition to UWF color fundus and red free (CF/RF) images.

Methods : This cohort study was an online survey completed by experts who were asked to diagnose and manage DR cases based on different imaging modalities provided. Ten DR experts participated in the online survey. Experts independently reviewed 20 DR cases on a secure website and provided a diagnosis and management plan for each case, first based on UWF CF/RF images alone and again with the UWF CF/RF images and a corresponding UWF FA. Experts were also polled on their diagnostic confidence, their use of FA in clinical practice, and their opinions on the value of UWF FA in the cases presented. Primary outcomes included diagnostic sensitivity and specificity with and without the UWF FA based on the reference standard diagnosis. Secondary outcomes included intergrader agreement, expert confidence, management outcomes, and an analysis of experts’ opinions on the clinical utility of UWF FA.

Results : Diagnostic sensitivity (95%CI) increased from 36% (29-43%) to 69% (62-75%, p<0.05) with the UWF FA. Intergrader agreement (Fleiss kappa statistic 0.29 [CI 0.21-0.27] vs. 0.44 [CI 0.40-0.47], p<0.05) and expert confidence (38% vs. 65%) also improved. Management changed from observation to treatment in 39% of responses. While 40% of experts did not request an FA when presented with UWF CF/RF images alone, 80% found the UWF FA clinically useful when it was provided.

Conclusions : Diagnosis, treatment, and experts’ opinions on the utility of FA all changed when a corresponding UWF FA was available. Incorporating UWF FA into clinical practice may improve DR grading accuracy, intergrader agreement, and expert confidence compared to diagnosis with UWF CF/RF images alone.

This abstract was presented at the 2022 ARVO Annual Meeting, held in Denver, CO, May 1-4, 2022, and virtually.

 

This figure displays the 10 expert responses to each of the 20 cases. The cases are subdivided into different graphs based on their consensus reference standard diagnosis. The figure demonstrates the frequency at which experts selected each category of diabetic retinopathy based on the ultra-wide field (UWF) color fundus and red-free images alone compared to the addition of the corresponding UWF fluorescein angiography (FA). Increased diagnostic accuracy was more frequently associated with the use of UWF FA.