Clinical examination and fundus photography in diabetic retinopathy screening

Year 2021, , 444 - 448, 01.05.2021

Erol Erkan , Sema Dündar , Ayşe İpek Akyüz Ünsal

https://doi.org/10.28982/josam.871584

Abstract

Background/Aim: An increasing number of patients and an ophthalmologist shortage in some areas necessitate reaching more patients in a shorter time to decrease the burden of devastating visual complications of diabetic retinopathy (DR). Screening and diagnosing DR using fundus photographs may save time and effort. In this study, we aimed to report the results of DR screening in a Turkish treatment-naive diabetes mellitus (DM) patient group by examining fundus photographs taken with ETDRS protocol and compare them with clinical examination and optical coherence tomography (OCT) findings.
Methods: Two hundred and ninety-two eyes of 150 DR treatment-naive DM patients were included in this cross-sectional study. Complete ophthalmic examination was performed by a single examiner. Fundus photograph acquisition according to ETDRS protocol and OCT were performed by an experienced technician. Fundus photographs were evaluated by the same examiner who was blinded to patient names, at the end of the study period.
Results: Two hundred and ninety-two eyes of 150 DR treatment-naive DM patients’ findings were evaluated. According to stereoscopic fundus examination, 76 (26%) eyes showed no signs of DR, 76 (26%) eyes showed mild non-proliferative diabetic retinopathy (NPDR) signs, 44 eyes (15.1%) showed moderate NPDR signs, 78 eyes (26.7%) showed severe NPDR signs, and 18 eyes (6.2%) showed PDR signs. According to images acquired with the ETDRS protocol, 79 (27.1%) eyes showed no signs of DR, 81 (27.7%) eyes showed mild NPDR signs, 50 eyes (17.1%) showed moderate NPDR signs, 68 eyes (23.3%) showed severe NPDR signs, and 14 eyes (4.8%) showed PDR signs. Clinical examination and fundus photography showed substantial agreement in detecting DR severity (Kappa value: 0.78 P<0.001). Diabetic macular edema (DME) was present in 106 and 68 eyes according to OCT and ETDRS fundus photographs, respectively. These two methods showed moderate agreement in detecting DME (Kappa value: 0.57, P<0.001). ETDRS fundus photography is an effective method for screening DR severity in a Turkish DR population. When patients with no evident DR findings were excluded, we found a statistically significant negative correlation (P<0.001, Spearman Rho coefficient: -0.306) between central retinal thickness and best-corrected visual acuity, as expected.
Conclusion: For screening DR severity, ETDRS fundus photography is an effective method in a Turkish DR population.

Keywords

Diabetic retinopathy, Optical coherence tomography, Clinical examination, Fundus Photography

Project Number

YOK

References

• 1. Satman İ, İmamoğlu Ş, Yılmaz C, Akalın S, Salman S, Dinççağ N. Turkey Endocrinology and Metabolism Association Diabetes Mellitus Complications, Diagnosis, Treatment and Monitoring Guide 2016. Ankara: 2016; Section 1: 15.
• 2. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2009;32(Suppl 1):S62-7.
• 3. Klein BE. Overview of epidemiologic studies of diabetic retinopathy. Ophthalmic Epidemiology. 2007;14:179-83.
• 4. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye and Vision. 2015;2:17.
• 5. Zhang X, Saaddine JB, Chou CF, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA 2010;304:649-56.
• 6. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy. III. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. Arch Ophthalmol. 1984Apr;102(4):527-32.
• 7. Davis MD, Fisher MR, Gangnon RE, et al. Risk factors for high-risk proliferative diabetic retinopathy and severe visual loss: Early Treatment Diabetic Retinopathy Study report number 18. Invest Ophthalmol Vis Sci. 1998;39:233-52.
• 8. Kilpatrick ES, Rigby AS, Atkin SL, Frier BM. Does severe hypoglycaemia influence microvascular complications in Type 1 diabetes? An analysis of the Diabetes Control and Complications Trial database. Diabet Med. 2012;29:1195-8.
• 9. Klein R, Klein BE, Moss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol. 1984;102:520-6.
• 10. Wu L, Fernandez-Loaiza P, Sauma J, Hernandez-Bogantes E, Masis M. Classification of diabetic retinopathy and diabetic macular edema. World J Diabetes. 2013;4(6):290-4
• 11. Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA. 2009;301(20):2129-40.
• 12. Congdon NG, Friedman DS, Lietman T. Important causes of visual impairment in the world today. JAMA .2003;290(15):2057-60.
• 13. Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet. 2010;376(9735):124-36.
• 14. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013 Apr;36(4):1033-46.
• 15. Alcubierre N, Rubinat E, Traveset A, Martinez-Alonso M, Hernandez M, Jurjo C, Mauricio D. A prospective cross-sectional study on quality of life and treatment satisfaction in type 2 diabetic patients with retinopathy without other major late diabetic complications. Health Qual Life Outcomes. 2014 Aug 20;12:131.
• 16. National Institute for Clinical Excellence. Management of Type 2 Diabetes: Retinopathy—Screening and Early Management. London, UK: Inherited Clinical Guideline;2002.
• 17. Grading diabetic retinopathy from stereoscopic color fundus photographs—an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991;98(5 suppl):786-806.
• 18. Goh JK, Cheung CY, Sim SS, Tan PC, Tan GS, Wong TY. Retinal Imaging Techniques for Diabetic Retinopathy Screening. J Diabetes Sci Technol. 2016 Feb 1;10(2):282-94.
• 19. Rasmussen ML, Broe R, Frydkjaer-Olsen U, Olsen BS, Mortensen HB, Peto T, et al. Comparison between Early Treatment Diabetic Retinopathy Study 7-field retinal photos and non-mydriatic, mydriatic and mydriatic steered widefield scanning laser ophthalmoscopy for assessment of diabetic retinopathy. J Diabetes Complications. 2015 Jan-Feb;29(1):99-104.
• 20. Vujosevic S, Benetti E, Massignan F, Pilotto E, Varano M, Cavarzeran F, et al. Screening for diabetic retinopathy: 1 and 3 nonmydriatic 45-degree digital fundus photographs vs 7 standard early treatment diabetic retinopathy study fields. Am J Ophthalmol. 2009 Jul;148(1):111-8.
• 21. Browning DJ, Glassman AR, Aiello LP, et al. Relationship between optical coherence tomography-measured central retinal thickness and visual acuity in diabetic macular edema. Ophthalmology. 2007;114:525-36.
• 22. Sim DA, Keane PA, Zarranz-Ventura J, Fung S, Powner MB, Plateau E, et al. The effects of macular ischemia on visual acuity in diabetic retinopathy. Invest Ophthalmol Vis Sci. 2013 Mar28; 54(3):2353-60.
• 23. Olsen TW, Adelman RA, Flaxel CJ, Folk JC, Pulido JS, Regillo CD, et al. Diabetic Retinopathy Preferred Practice Pattern. https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2016 17.12.2016).
• 24. Nunes S, Pereira I, Santos A, Bernardes R, Cunha-Vaz J. Central retinal thickness measured with HD-OCT shows a weak correlation with visual acuity in eyes with CSME. Br J Ophthalmol. 2010 Sep;94(9):1201-4.
• 25. Özdek SC, Erdinç MA, Gürelik G, Aydin B, Bahçeci U, Hasanreisoğlu B. Optical coherence tomographic assessment of diabetic macular edema: comparison with fluorescein angiographic and clinical findings. Ophthalmologica. 2005;219:86–92.
• 26. Wong TY, Liew G, Tapp RJ, et al. Relation between fasting glucose and retinopathy for diagnosis of diabetes: three population-based cross-sectional studies. Lancet 2008;371:736-43.
• 27. Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopathy: a systematic review. JAMA. 2007;298(8):902–16.
• 28. Browning DJ, Fraser CM, Clark S. The relationship of macular thickness to clinically graded diabetic retinopathy severity in eyes without clinically detected diabetic macular edema. Ophthalmology. 2008 Mar 1; 15(3):533-9.
• 29. García-Serrano JL, Serrano-Laborda D, López-Pozas M, Cabello-Aparicio C, Castro-Rosales L. (The Granada Diabetic Retinopathy Study. Direct screening of 8,244 patients. I). Arch Soc Esp Oftalmol. 2007 Nov;82(11):681-9.
• 30. Javitt JC, Aiello LP. Cost-effectiveness of detecting and treating diabetic retinopathy. Ann Inter Med. 1996;124:164-9.