Impact of Field Selection in Nonmydriatic Retinal Imaging

1
Impact of Field Selection in Nonmydriatic Retinal
Imaging for Diabetic Retinopathy in the Joslin
Vision Network

• Lloyd M. Aiello, MD Sharon Eagan, OD Nigel
  Timothy, MD Ann Tolson, BA
• Kristen, Hock, BS Jerry Cavallerano, OD, PhD
• Joslin Vision Network Team

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Hypotheses

• Single field nonmydriatic 45-degree JVN field
  (NM-1) will permit Category 1 and Category 2
  assessment of diabetic retinopathy (DR)
• Single field nonmydriatic 45-degree JVN field
  (NM-1) will not permit Category 3 assessment of
  diabetic retinopathy compared with JVN protocol
  of three 45-degree stereoscopic fields (NM-1,
  NM-2, NM-3) and two 30-degree stereoscopic fields
  (optic disc centered and macula centered)

3
Background
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ATA Position Statement Standards and Guidelines
in Telehealth for DR

• Goals
• Promote informed and reasonable patient and
  provider expectations
• Address clinical, technical and administrative
  issues
• ETDRS 30-degree seven-standard field color slides
  chosen as the standard for validating retinal
  images for DR telehealth

1.Telehealth Practice Recommendations for
Diabetic Retinopathy. Telemedicine Journal and
e-Health. 200410469-482.
5
Validation

• Category 1 no (or minimal) DR vs. more than
  minimal DR.
• Category 2 no sight-threatening DR vs.
  potentially sight-threatening DR present (severe
  or worse NPDR, any PDR, and DME)
• Category 3 management to match clinical
  recommendations based on clinical retinal
  examination through dilated pupils
• Category 4 can replace ETDRS photos in any
  clinical or research program

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Joslin Vision Network
Screening
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JVN Diabetes Eye Care

• Validation JVN vs. 35 mm slides. Bursell S-E,
  Cavallerano JD, Cavallerano AA, Aiello LP, Aiello
  LM. Stereo nonmydriatic digital-video color
  retinal imaging compared with Early Treatment
  Diabetic Retinopathy Study seven standard field
  35-mm stereo color photos for determining level
  of diabetic retinopathy. Ophthalmology
  2001108572-585.
• Validation JVN vs. clinical exam. Cavallerano
  AA, Cavallerano JD, Aiello LP, Aiello LM. Use of
  Joslin Vision Network digital-video nonmydriatic
  retinal imaging to assess diabetic retinopathy in
  a clinical program. Retina 2003 23215 223.

• Validation JVN for annual f/u exam. Cavallerano
  J, Aiello LP, Cavallerano AA, Aiello LM. Joslin
  Vision Network Digital-Video Imaging as an
  Alternative for Subsequent Annual Retinal
  Examination in Persons with Previously Documented
  Mild Nonproliferative or No Diabetic Retinopathy.
  American Journal of Ophthalmology 2005
  140667-673.
• Validation Nondiabetic eye disease. Chow SP,
  Cavallerano J, Hock K, Aiello LM, Aiello LP,
  Bursell S. Comparison of nonmydriatic digital
  retinal imaging with dilated clinical eye exam
  for detecting non-diabetes-related pathology in
  diabetic patients. Accepted for publication
  Ophthalmology 2006.

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JVN FieldsRight Eye
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Methods

• N 233 patients (466 eyes)
• Nonmydriatic retinal images per JVN protocol
• Reader performs Category 1, Category 2, and
  Category 3 grading
• 2nd masked reader performs Category 1 and
  Category 2 grading

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Comparison

• Category 3Joslin Vision Network
• Determines clinical level of DR
• Validated to clinical exam
• Validated to 35mm ETDRS 7 standard field
  photography

• Category 1DR present vs. no DR
• Category 2 Sight-threatening DR vs. no
  sight-threatening DR
• Any PDR or Macular Edema
• Severe/Very Severe NPDR

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Comparison of No Retinopathy and Ungradable
Studies by Category (n 466 eyes)
No sight-threatening diabetic retinopathy
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Results

• Category 117 eyes (13 patients) had DR not
  identified by Category 1 evaluation
• Category 210 eyes (8 patients) had
  sight-threatening DR not identified by Category 2
  evaluation
• Discrepancy due to lesions lying outside Category
  1 and Category 2 field

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35-year-old male Type 1 DM-19 years Insulin
TID A1C 10.8
Field NM-1
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Field NM-2
15
Field NM-3
16
33-year-old male Type 1 DM-23 years Insulin
TID A1C 9.5
Field NM-1
17
Field NM-2
18
Field NM-3
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Discussion

• Category 3 JVN protocol identifies more eyes with
  any DR (Category 1) and more eyes with
  sight-threatening DR (Category 2) as compared
  with single-field (NM-1)
• This discrepancy in all cases was due to lesions
  lying outside Category 1 and Category 2 field
  (NM-1)
• JVN protocol reduced the rate of ungradable
  studies

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Summary and Conclusion

• The JVN has been previously validated to identify
  level of diabetic retinopathy and diabetic
  macular edema
• JVN single field (NM-1) alone does not allow the
  same degree of diagnosis of clinical level of DR
• JVN field NM-1 has the potential to provide ATA
  Category 1 and Category 2 evaluations
• Telemedicine programs for DR should clearly
  define patient and care provider expectations

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Thank You