Elsevier

Ophthalmology

Volume 124, Issue 7, July 2017, Pages 970-976
Ophthalmology

Original article
Hemorrhage and/or Microaneurysm Severity and Count in Ultrawide Field Images and Early Treatment Diabetic Retinopathy Study Photography

https://doi.org/10.1016/j.ophtha.2017.02.012Get rights and content

Objective

To evaluate detection of hemorrhage and/or microaneurysm (H/Ma) using ultrawide field (UWF) retinal imaging as compared with standard Early Treatment Diabetic Retinopathy Study (ETDRS) 7-field photographs (ETDRS photos).

Design

Single-site comparative study of UWF images and ETDRS photos.

Participants

One hundred twenty-six eyes of 69 patients with no diabetic retinopathy (DR) or mild or moderate nonproliferative DR (NPDR).

Methods

Stereoscopic 200° UWF images and stereoscopic 35mm 30° 7-field color photographs were acquired on the same visit. Images were graded for severity and distribution of H/Ma. H/Mas were counted in ETDRS fields 2 to 7 in both ETDRS photos and UWF images. H/Mas in the UWF peripheral fields were also counted.

Main Outcome Measures

Kappa (κ) and weighted κ statistics for agreement. Number of H/Ma within and outside ETDRS fields identified in UWF images and ETDRS photos.

Results

Distribution of DR severity by ETDRS photos was 24 (19.0%) no DR, 48 (38.1%) mild NPDR, and 54 (42.9%) moderate NPDR. A total of 748 of 756 fields (98.9%) were gradable for H/Mas on ETDRS photos and UWF images. Simple κ/weighted κ statistics for severity of H/Ma: all fields 0.61/0.69, field 2 0.70/0.77, field 3 0.62/0.73, field 4 0.50/0.62, field 5 0.54/0.65, field 6 0.64/0.70, and field 7 0.58/0.63 with overall exact agreement in 81.3% and within 1 step in 97.9% of fields. A greater proportion of fields was graded a more severe H/Ma level in UWF images than in the corresponding ETDRS photos (UWF: 12.7% vs. ETDRS: 6.5%). Evaluating comparable areas in UWF images and ETDRS photos (fields 2–7), a mean of 42.8 H/Mas were identified using ETDRS photos and 48.8 in UWF images (P = 0.10). An additional mean of 21.3 H/Mas (49.8% increase, P < 0.0001) were identified in the peripheral fields of the UWF images.

Conclusions

There is good to excellent agreement between UWF images and ETDRS photos in determining H/Ma severity, with excellent correlation of H/Ma counts within ETDRS photo fields. UWF peripheral fields identified 49.8% more H/Ma, suggesting a more severe H/Ma in 12.7% of eyes. Given the additional lesions detected in peripheral fields and the known risks associated with H/Ma and peripheral lesions, quantification of H/Ma using UWF images may provide a more accurate representation of DR disease activity and potential greater accuracy in predicting DR progression.

Section snippets

Methods

Retinal images were reviewed from a previously completed single-site, prospective, clinic-based, comparative-instrument validation study7, 14 that was specifically conducted to evaluate the agreement in assessing severity of DR at the retinal lesion level between stereoscopic mydriatic 200° UWF images and mydriatic ETDRS 7-field 35mm slide film photography (ETDRS photos). Both UWF imaging (stereoscopic 200° pairs of each eye, acquired using an Optos P200Tx, Optos plc, Dunfermline, Scotland, UK)

Results

Retinal images from 126 eyes of 69 patients were evaluated. Based on ETDRS photos, the distribution of DR severity of the eyes was as follows: no DR = 24 (19.0%), mild NPDR = 48 (38.1%), and moderate NPDR = 54 (42.9%). Both UWF and ETDRS photos were gradable for H/Ma severity in 748 of 756 (98.9%) fields. Only 4 (0.5%) and 5 (0.7%) fields were ungradable for H/Ma severity based on ETDRS photos and UWF images, respectively.

Discussion

This study utilizes standardized methods for measuring H/Ma counts that are essential to provide the foundation and rationale for future studies evaluating potentially important parameters that include MA distribution, ratio, and other yet-to-be-determined endpoints. These data demonstrate 2 key aspects of H/Ma identification in UWF images. First, when evaluating similar retinal fields both ETDRS photos and UWF images identify similar numbers of H/Mas. Second, there are up to 50% more H/Mas

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    Financial Disclosure(s):

    Supported in part by grant funding from the Massachusetts Lions Eye Research Fund to the Joslin Diabetes Center.

    P.S.S.: Grant funding – Balik Scientist Program, Department of Science and Technology, Republic of the Philippines.

    P.S.S. and L.P.A.: Supported by the Massachusetts Lions Eye Research Fund

    A.F. and J.v.H.: Employees of Optos, plc.

    L.P.A.: Travel funding only – Optos.

    Conflict of Interest Disclosures: Temporary loan of 2 ultrawide field imaging devices was provided to the Joslin Diabetes Center (Optos plc, Dunfermline, Scotland).

    Dr Silva had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    None of the sources of funding support had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Author Contributions:

    Conception and design: Silva, El-Rami, Barham, Gupta, Fleming, van Hemert, Cavallerano, Sun, Aiello

    Analysis and interpretation: Silva, El-Rami, Barham, Gupta, Fleming, van Hemert, Cavallerano, Sun, Aiello

    Data collection: Silva, El-Rami, Barham, Gupta, Fleming, van Hemert, Cavallerano, Sun, Aiello

    Obtained funding: Silva, Fleming, van Hemert, Aiello

    Overall responsibility: Silva, Aiello

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