Dataset Information

Diabetic retinopathy screening in urban primary care setting with a handheld smartphone-based retinal camera.

ABSTRACT: AIMS:To evaluate diabetic retinopathy (DR) screening with a portable handheld smartphone-based retinal camera and telemedicine in an urban primary healthcare setting and to evaluate the learning curve for image acquisition, performed by healthcare personnel without previous experience in retinal imaging. METHODS:This was a prospective study that enrolled patients with type 2 diabetes mellitus (T2DM) followed at a primary healthcare unit in São Paulo, Brazil. After a brief training in image acquisition, there was further continuous feedback given by a retina specialist during the remote image reading process. Each patient underwent two fundus and one anterior ocular segment images per eye, after mydriasis. Patients were classified according to the need of referral. RESULTS:A total of 627 adult individuals with T2DM underwent retinal evaluation. The population was composed by 63.2% female individuals, age median of 66 years, diabetes duration 10.7?±?8.2 years and HbA1c 7.7?±?1.9% (61?+?20.8 mmol/mol). The most prevalent associated comorbidities were arterial hypertension (80.3%) and dyslipidemia (50.2%). Referral decision was possible in 81.2% patients. Most patients had absent or non-referable DR; the main ocular media opacity detected was cataract. After the 7th day of image acquisition, the daily rate of patients whose images allowed clinical decision was maintained above 80%. A higher HbA1c was associated with referable DR. CONCLUSIONS:A low-cost DR screening strategy with a handheld device and telemedicine is feasible and has the potential to increase coverage of DR screening in underserved areas; the possibility of mobile units is relevant for DR screening in the context of COVID-19 pandemic. Daily rate of patients whose examinations allowed clinical decision. X-axis: day of examination; Y-axis: rate (%) of patients whose examinations allowed a clinical decision.

SUBMITTER: Queiroz MS

PROVIDER: S-EPMC7398859 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Diabetic retinopathy screening in urban primary care setting with a handheld smartphone-based retinal camera.

Queiroz Márcia Silva MS de Carvalho Jacira Xavier JX Bortoto Silvia Ferreira SF de Matos Mozania Reis MR das Graças Dias Cavalcante Cristiane C Andrade Elenilda Almeida Silva EAS Correa-Giannella Maria Lúcia ML Malerbi Fernando Korn FK

Acta diabetologica 20200804 12

<h4>Aims</h4>To evaluate diabetic retinopathy (DR) screening with a portable handheld smartphone-based retinal camera and telemedicine in an urban primary healthcare setting and to evaluate the learning curve for image acquisition, performed by healthcare personnel without previous experience in retinal imaging.<h4>Methods</h4>This was a prospective study that enrolled patients with type 2 diabetes mellitus (T2DM) followed at a primary healthcare unit in São Paulo, Brazil. After a brief training ...[more]

PMID: 32748176

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Project description:Diabetic Retinopathy (DR) may result in various degrees of vision loss and even blindness if not diagnosed in a timely manner. Therefore, having an annual eye exam helps early detection to prevent vision loss in earlier stages, especially for diabetic patients. Recent technological advances made smartphone-based retinal imaging systems available on the market to perform small-sized, low-powered, and affordable DR screening in diverse environments. However, the accuracy of DR detection depends on the field of view and image quality. Since smartphone-based retinal imaging systems have much more compact designs than a traditional fundus camera, captured images are likely to be the low quality with a smaller field of view. Our motivation in this paper is to develop an automatic DR detection model for smartphone-based retinal images using the deep learning approach with the ResNet50 network. This study first utilized the well-known AlexNet, GoogLeNet, and ResNet50 architectures, using the transfer learning approach. Second, these frameworks were retrained with retina images from several datasets including EyePACS, Messidor, IDRiD, and Messidor-2 to investigate the effect of using images from the single, cross, and multiple datasets. Third, the proposed ResNet50 model is applied to smartphone-based synthetic images to explore the DR detection accuracy of smartphone-based retinal imaging systems. Based on the vision-threatening diabetic retinopathy detection results, the proposed approach achieved a high classification accuracy of 98.6%, with a 98.2% sensitivity and a 99.1% specificity while its AUC was 0.9978 on the independent test dataset. As the main contributions, DR detection accuracy was improved using the deep transfer learning approach for the ResNet50 network with publicly available datasets and the effect of the field of view in smartphone-based retinal imaging was studied. Although a smaller number of images were used in the training set compared with the existing studies, considerably acceptable high accuracies for validation and testing data were obtained.

Project description:BackgroundThe evidence on diagnostic test accuracy (DTA) of diabetic retinopathy (DR) screening utilising photographic studies by non-ophthalmologist personnel in low and middle-income country (LMIC) settings is scarce. We aimed to assess DTA of DR screening using a nonmydriatic hand-held digital camera by trained general physicians in a non-ophthalmic setting.MethodsThis study is a validation of a screening intervention. We selected 700 people with diabetes (PwDM) > 18 years of age, not previously screened or treated for DR, presenting at a tertiary medical clinic in Sri Lanka. Two-field retinal imaging was used to capture fundus images before and after pupil dilatation, using a hand-held non-mydriatic (Visuscout 100®-Germany) digital retinal camera. The images were captured and graded by two trained, masked independent physician graders. The DTA of different levels of DR was assessed comparing physician's grading with a retinologist's clinical examination by mydriatic bio-microscopy, according to a locally adopted guideline.ResultsSeven hundred eligible PwDM were screened by physician graders. The mean age of participants was 60.8 years (SD ±10.08) and mean duration of DM was 9.9 years (SD ±8.09). Ungradable image proportion in non-mydriatic imaging was 43.4% (either eye-31.3%, both eyes 12.1%). This decreased to 12.8% (either eye-11.6%, both eyes-1.2%) following pupil dilatation. In comparison to detection of any level of DR, a referable level DR (moderate non-proliferative DR and levels above) showed a higher level of DTA. The sensitivity of the defined referable DR was 88.7% (95% CI 81.7-93.8%) for grader 1 (positive predictive value [PPV] 59.1%) and 92.5% (95% CI 86.4-96.5%) for grader 2 (PPV 68%), using mydriatic imaging, after including ungradable images as screen positives. The specificity was 94.9% (95% CI 93.6-96.0%) for grader 1 (negative predictive value [NPV] 99%) and 96.4% (95% CI 95.3-97.3%) for grader 2 (NPV 99.4%).ConclusionsThe Physicians grading of images from a digital hand-held non-mydriatic camera at a medical clinic, with dilatation of pupil of those who have ungradable images, provides a valid modality to identify referable level of DR. This could be a feasible alternative modality to the existing opportunistic screening to improve the access and coverage.Trial registrationCurrent Controlled Trials ISRCTN47559703 . Date of Registration 18th March 2019, Retrospectively registered.

Project description:BackgroundDespite recent incentives through Medicare (Australia's universal health insurance scheme) to increase retinal screening rates in primary care, comprehensive diabetic retinopathy (DR) screening has not been reached in Australia. The current study aimed to identify key factors affecting the delivery of diabetic retinopathy (DR) screening in Australian general practices.MethodsA descriptive qualitative study involving in-depth interviews was carried out from November 2019 to March 2020. Using purposive snowballing sampling, 15 general practitioners (GPs) were recruited from urban and rural general practices in New South Wales and Western Australia. A semi-structured interview guide was used to collect data from participants. All interviews were conducted over the phone by one facilitator, and each interview lasted up to 45 min. The Socio-Ecological Model was used to inform the content of the interview topic guides and subsequent data analysis. Recorded data were transcribed verbatim, and thematic analysis was conducted to identify and classify recurrent themes.ResultsOf 15 GPs interviewed, 13 were male doctors, and the mean age was 54.7 ± 15.5 years. Seven participants were practising in urban areas, while eight were practising in regional or remote areas. All participants had access to a direct ophthalmoscope, but none owned retinal cameras. None of the participants reported performing DR screening. Only three participants were aware of the Medicare Benefits Schedule (MBS) items 12,325 and 12,326 that allow GPs to bill for retinal screening. Seven themes, a combination of facilitators and barriers, emerged from interviews with the GPs. Despite the strong belief in their role in managing chronic diseases, barriers such as costs of retinal cameras, time constraints, lack of skills to make DR diagnosis, and unawareness of Medicare incentives for non-mydriatic retinal photography made it difficult to conduct DR screening in general practice. However, several enabling strategies to deliver DR screening within primary care include increasing GPs' access to continuing professional development, subsidising the cost of retinal cameras, and the need for a champion ace to take the responsibility of retinal photography.ConclusionThis study identified essential areas at the system level that require addressing to promote the broader implementation of DR screening, in particular, a nationwide awareness campaign to maximise the use of MBS items, improve GPs' competency, and subsidise costs of the retinal cameras for small and rural general practices.

Project description:BackgroundDiabetic eye complications are the leading cause of visual loss among working-aged people. Pharmacy-based teleophthalmology has emerged as a possible alternative to in-person examination that may facilitate compliance with evidence-based recommendations and reduce barriers to specialized eye care. The objective of this study was to estimate the cost-effectiveness of mobile teleophthalmology screening compared with in-person examination (primary care) for the diabetic population residing in semiurban areas of southwestern Ontario.MethodsA decision tree was constructed to compare in-person examination (comparator program) versus pharmacy-based teleophthalmology (intervention program). The economic model was designed to identify patients with more than minimal diabetic retinopathy, manifested by at least 1 microaneurysm at examination (modified Airlie House classification grade of ≥ 20). Cost-effectiveness was assessed as cost per case detected (true-positive result) and cost per case correctly diagnosed (including true-positive and true-negative results).ResultsThe cost per case detected was $510 with in-person examination and $478 with teleophthalmology, and the cost per case correctly diagnosed was $107 and $102 respectively. The incremental cost-effectiveness ratio was $314 per additional case detected and $73 per additional case correctly diagnosed. Use of pharmacologic dilation and health care specialists' fees were the most important cost drivers.InterpretationThe study showed that a compound teleophthalmology program in a semiurban community would be more effective but more costly than in-person examination. The findings raise the question of whether the benefits of pharmacy-based teleophthalmology in semiurban areas, where in-person examination is still available, are equivalent to those observed in remote communities. Further study is needed to investigate the impact of this program on the prevention of severe vision loss and quality of life in a semiurban setting.

Dataset Information

Diabetic retinopathy screening in urban primary care setting with a handheld smartphone-based retinal camera.

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Diabetic retinopathy screening in urban primary care setting with a handheld smartphone-based retinal camera.

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