Original Paper

Ophthalmologica

Ophthalmologica 2014;231:172–176 DOI: 10.1159/000356695

Received: August 7, 2013 Accepted after revision: September 9, 2013 Published online: December 12, 2013

Age-Related Macular Degeneration Screening Using a Nonmydriatic Digital Color Fundus Camera and Telemedicine F. De Bats a C. Vannier Nitenberg b B. Fantino c, d P. Denis a L. Kodjikian a a Department of Ophthalmology, Croix-Rousse University Hospital, University of Lyon and b Health Examination Centers of French Health Insurance Rhône, Lyon, c Department of Internal Medicine and Clinical Gerontology, University Hospital of Angers, Angers, and d Regional Health Agency of Lorraine, Nancy, France

Key Words Age-related macular degeneration · Screening · Telemedicine

Abstract Purpose: To investigate the use of a nonmydriatic digital color fundus camera and telemedicine as screening tools for age-related macular degeneration (AMD). Methods: Nonmydriatic color fundus photography was performed on patients consulting health examination centers and transmitted by telemedicine to an ophthalmology department. Rates for different grades of AMD were calculated and also statistically related to the presence or absence of risk factors. Results: Among the 1,022 patients screened, a total of 1,363 color fundus photographs were interpreted, with 80% gradable images, allowing a diagnosis of AMD in 178 photographs. Among all the gradable images, 83.7% had no AMD (grade 0). The rates of AMD at grades 1, 2, 3 and 4 were 8%, 5.6%, 2.3% and 0.4%, respectively. A statistical odds ratio was found between the presence of AMD on fundus photographs and age, familial history of AMD or prior cataract surgery. Conclusions: Nonmydriatic color fundus photography and telemedicine succeeded in screening for AMD. © 2013 S. Karger AG, Basel

© 2013 S. Karger AG, Basel 0030–3755/13/2313–0172$38.00/0 E-Mail [email protected] www.karger.com/oph

Introduction

Age-related macular degeneration (AMD) is the leading cause of irreversible central visual loss in industrialized countries [1]. The prevalence of AMD increases in patients older than 65 years and will increase in the future with the rise in numbers of the elderly population. The limited number of retinal specialists does not allow optimal management of all the patients needing timely access to treatment. Thus, an efficient method of large-scale screening with decentralized photographic units is needed for detecting patients who are at risk of visual loss. Color fundus photographs are used to document the presence and to grade the severity of AMD in clinical practice, in epidemiological studies and also in the context of screening [2–9]. To our knowledge, it is the first time that a nonmydriatic color fundus camera was used as an AMD screening tool in a decentralized nonophthalmological team, with photographs taken by a nonophthalmologist and analyzed for its diagnostic rentability. Health examination centers of French health insurance are developing

This study was presented at the 2013 ARVO (Association for Research in Vision and Ophthalmology) congress, Seattle. F. De Bats and C. Vannier Nitenberg contributed equally to this work.

Prof. Laurent Kodjikian, MD, PhD Croix Rousse University Hospital, Department of Ophthalmology 103, Grande rue de la Croix-Rousse FR–69004 Lyon (France) E-Mail laurent.kodjikian @ chu-lyon.fr

preventive programs in order to detect several diseases. In this case a medical cooperation, enhanced by telemedicine, was developed between clinical ophthalmologists (Department of Ophthalmology, Croix-Rousse University Hospital, Lyon, France) and health examination centers (Baraban and Mermoz Units, Lyon) of the French health insurance in order to screen patients with AMD. The purpose of this study was to evaluate (1) the clinical rentability of nonmydriatic digital color fundus photography in AMD screening when performed by a nonophthalmological team on a population older than 65 years, and (2) the use of telemedicine to connect decentralized photographic centers and ophthalmological departments. Methods This prospective, interventional multicenter study included consecutive patients older than 65 years consulting 2 health examination centers of the French health insurance between February 1 and December 31, 2012. Subjects were excluded if the photograph could not be taken, if they were not able to sign the informed consent form, or if they were already known or treated for prior AMD. The study adhered to the tenets of the Declaration of Helsinki. The patients gave their written informed consent before inclusion, and the study was in compliance with French legislation and approved by the ethics committee. Systemic and ocular risk factors were recorded using standardized questionnaires and were assessed for association with AMD. No clinical ophthalmic examination and no pharmacologic mydriasis were performed, because the photographs were taken by nurses and mydriatic drops could be instilled only by doctors. At both centers, the same type of nonmydriatic digital fundus camera was used: a TRC-NW6S (Topcon, Tokyo, Japan), with a Nikon D7000 digital camera (16-megapixel resolution). It was combined with an IMAGEnet 2000 computer system (Topcon). It was possible to take nonstereoscopic, 45-degree photographs of the posterior pole of each eye. Color fundus photographs were taken by nurses not working in ophthalmological units but trained before the study began. The images were transmitted weekly by telemedical communication systems from the health examination centers for grading by an ophthalmologist. After telemedical transmission, the images were interpreted each week on a Sony PCG-791M monitor (Sony Electronics Inc., Park Ridge, N.J., USA). The screen resolution was 1,600 × 1,200 pixels. All the images were displayed on a monitor using the IMAGEnet 2000 viewer. The definitions of the different stages of AMD were based on an international classification system and were graded for druse size, pigmentary abnormalities, geographic atrophy and neovascular lesions [10]. The signs of AMD were stratified, using the Rotterdam staging system [11], into 5 exclusive stages (0– 4) to facilitate analysis. Grade 0 was defined as no AMD with no drusen or the presence of small drusen (

Age-related macular degeneration screening using a nonmydriatic digital color fundus camera and telemedicine.

To investigate the use of a nonmydriatic digital color fundus camera and telemedicine as screening tools for age-related macular degeneration (AMD)...
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