Enhancing diabetic retinopathy screening: Non-mydriatic fundus photography-assisted telemedicine for improved clinical management

Abstract

The utilization of non-mydriatic fundus photography-assisted telemedicine to screen patients with diabetes mellitus for diabetic retinopathy provides an accurate, efficient, and cost-effective method to improve early detection of disease. It has also been shown to correlate with increased participation of patients in other aspects of diabetes care. In particular, patients who undergo teleretinal imaging are more likely to meet Comprehensive Diabetes Care Healthcare Effectiveness Data and Information Set metrics, which are linked to preservation of quality-adjusted life years and additional downstream healthcare savings.

Key Words: Diabetes; Diabetic retinopathy; Telemedicine; Tele-ophthalmology; Non-mydriatic fundus photography-assisted telemedicine; Vision screening; Preventative health services; Health policy

Core Tip: Point-of-care screening for diabetic retinopathy by means of teleretinal imaging provides an effective and economical method to improve early detection of eye disease in at-risk populations. Non-mydriatic fundus photography (NMFP)-assisted telemedicine allows critical ophthalmic examinations to reach individuals when resources for eye care are limited or difficult to access. As technology continues to evolve, further research efforts should focus on refining NMFP-assisted telemedicine protocols and evaluating its long-term impact on patient outcomes across the spectrum of healthcare settings.

TO THE EDITOR

Telemedicine screening for eye disease is key to making eye care more available to the growing numbers of individuals with diabetes mellitus (DM) worldwide[1,2]. We read with great interest the paper by Zhou et al[3], which validated the effectiveness of screening patients with DM for diabetic retinopathy (DR) at a major university-based medical center located in Hefei, Anhui Province, China. The authors compared non-mydriatic fundus photography (NMFP)-assisted telemedicine screening with fundus fluorescein angiography as the gold standard for diagnosis and staging of DR. The authors present compelling evidence for the efficacy of NMFP-assisted telemedicine in detecting and staging DR, finding a high degree of consistency between the two modalities. This study has significant implications for improving the early detection of DR, thereby allowing for earlier referrals to ophthalmologists for interventions capable of improving patient outcomes.

We agree with the authors that point-of-care screening for DR incorporating teleretinal imaging (TRI) offers an accurate and cost-effective means for improving early detection of disease in at-risk populations[4-7]. It also has the advantage of increasing patient participation in the care of their DM[8-12] and allows optimal resource allocation within healthcare systems that are at risk of becoming overextended[13-16]. For a comprehensive review of the diagnostic accuracy of telemedicine screening protocols for the detection of DR in various settings see the meta-analysis by Mehraban Far et al[17]. However, there is an equal, if not a greater, value derived from the use of TRI to screen lower-risk populations. In this context, its introduction could also reduce the costs associated with diabetic eye examinations, especially for patients without prior evidence of DR or who have completed a comprehensive eye examination within the prior year[18,19]. We particularly want to commend the authors for including in their discussion due attention to how the use of a hand-held NMFP allows for increased accessibility for certain patients who would otherwise be unable to avail themselves of traditional fixed ocular imaging or fundus examining devices. This flexibility, combined with their generally lower acquisition costs and portability, is one of the most compelling reasons for advocating for the expanded use of hand-held fundus cameras.

Though the authors highlighted several significant advantages of NMFP-assisted telemedicine screening, we feel that further discussion is warranted encompassing a broader view of the full extent of their potential benefits for comprehensive diabetes care. Our own recent study examined the factors associated with the utilization of point-of-care TRI for DR screening in a primary care setting in the United States[20]. The patients screened in our study were well-insured, suburban patients. They included both sexes, spanned a broad range of ages, types of health insurance, and, to a lesser extent, races. In this population, we found that participation in TRI was closely associated with the completion of other Comprehensive Diabetes Care Healthcare Effectiveness Data and Information Set (HEDIS) metrics. In particular, those patients screened were more likely to have had their hemoglobin A1c and microalbumin levels measured[21]. This combination of earlier and more regular DR screening, as well as the completion of HEDIS metrics, has the potential to improve more than just the ocular health of these patients. Furthermore, the detection of DR and other diabetes-associated complications may allow for the timely initiation of treatments that may preserve or prevent loss of quality-adjusted life years[22]. Finally, a more complete analysis of the cost-effectiveness of these technologies ought to take into consideration additional indirect economic benefits brought about by the earlier detection and treatment of diabetes-associated complications, as well as the costs linked to downstream healthcare service utilization[23].

One of the features of the manuscript by Zhou et al[3] that may cause difficulties for some readers is the use of non-standard abbreviations and nomenclature for certain aspects of diabetic eye disease. For example, the use of the acronym “NDR” to describe patients with “no” DR is very similar to the clinical acronym in common use for nonproliferative diabetic retinopathy, NPDR, and may potentially cause confusion. There is also use of some less common terminology for features associated with DR. For example, in place of the term “microhemangioma” in the context of DR, we recommend using more established terminology to describe small vascular abnormalities such as “microaneurysms” or “intraretinal microvascular abnormalities”. The study also does not utilize the most current definition of DR staging. The authors mention relying on the International Federation of Ophthalmological Societies’ guidelines for DR screening and staging established in 2002. We urge consultation of more up-to-date standards on diagnosis, management, and treatment of diabetic eye disease such as those published by the American Academy of Ophthalmology and American Diabetes Association[1,2]. Finally, the discussion would have benefited from a more comprehensive examination of the potential limitations and challenges associated with NMFP-assisted telemedicine. These issues include acknowledgement of the barriers related to patient and provider acceptance of TRI technology, the need to put in place robust data security to protect patient privacy, and the requirement for an adequate referral system to ophthalmologists and retina specialists to assure timely monitoring and treatment of any patients identified to have DR. By addressing these needs, researchers can refine NMFP-assisted telemedicine protocols and increase their implementation in clinical practice.

These issues aside, we want to emphasize that the authors deserve to be recognized for their forward-thinking approach to the introduction of TRI in an underserved population in a major urban center in a Chinese province that has undergone rapid development. Teleophthalmology has been successfully employed in China for many years[24,25]. Elsewhere in Asia, Singapore’s Integrated Diabetic Retinopathy Program has also demonstrated significant cost savings, without sacrificing health outcomes in an urban population[4]. Importantly, countries that have established universal DR screening programs supported by registries, such as in the United Kingdom, have achieved considerably higher screening rates among eligible patients with DM and have successfully reduced the incidence of blindness associated with DR[22].

Our own research, as well as many others, focused on the use of TRI in primary medical care settings[21]. It is exciting to see this technology extended for use in an endocrinology department by Zhou et al[3]. Endocrinologists see a larger proportion of patients with DM that is often more challenging to control or of longer duration[26]. Many of the patients in this study by Zhou et al[3] would, therefore, not likely be considered low-risk for DR. Including additional demographic details such as age and sex distribution, duration of DM, and socioeconomic status would help readers better assess the generalizability of their findings to other populations. Nevertheless, this setting may explain the very high rate of DR encountered in their study population, which is well above the rate expected in the overall diabetic population, including in China[24,25]. In the United States, most of those patients would not generally be monitored by means of NMFP-assisted telemedicine to screen for vision-threatening eye disease.

In conclusion, the study by Zhou et al[3] contributes significantly to the literature on DR screening, and it underscores the potential of NMFP-assisted telemedicine in improving early detection and management of DR. As technology continues to evolve, further research efforts should focus on refining NMFP-assisted telemedicine protocols, integrating them into current healthcare practice standards, and evaluating their long-term impact on patient outcomes.

ACKNOWLEDGEMENTS

The authors thank Dr. Shiyoung Roh, Dr. Jeffrey L. Marx, and Dr. John T. Ramsey, as well as Carol Spencer, Lahey Hospital Librarian, for research support. This work was performed as part of regular employment duties at the Lahey Hospital & Medical Center, Beth Israel Lahey Health.