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

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

2. 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

4. 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

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

7. 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 2001;108:572-585. 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; 23:215 – 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; 140:667-673. 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.

8. JVN Fields—Right Eye

9. 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

10. Comparison

11. Comparison of No Retinopathy and Ungradable Studies by Category (n = 466 eyes)

12. Results Category 1—17 eyes (13 patients) had DR not identified by Category 1 evaluation Category 2—10 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

19. 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

20. 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