A recent Ophthalmic Technology Assessment (OTA) by the American Academy of Ophthalmology (AAO) evaluated the effectiveness of conventional teleretinal screening (TS) in detecting diabetic retinopathy (DR) and diabetic macular edema (DME).
Give me some background.
The AAO periodically publishes OTAs in the Academy’s clinical journal Ophthalmology to investigate new and existing procedures, drugs, and diagnostic and screening tests for safety and clinical effectiveness.
Note: DR is an ocular complication observed in patients with diabetes mellitus (DM) secondary to damaged retinal vasculature and ischemia.
Nonadherence to annual diabetic eye exams due to insurance status and lack of education on DR are some of the ongoing challenges eyecare professionals (ECPs) encounter when treating these patients.
How does this connect to teleretinal screening?
Previous studies have shown that telemedicine DR screening has a high overall diagnostic accuracy, with sensitivity exceeding 80% and specificity of 90% or higher.
Consequently, TS offers ECPs an opportunity to significantly expand screening capacity as well as increase engagement for these vulnerable patient populations.
Now talk about the OTA.
Investigators performed a literature search of the PubMed database to identify data published between 2006 and 2023 on:
- The accuracy of TS in detecting DR or DME compared with traditional ophthalmic screening with dilated fundus examination or 7-standard field Early Treatment Diabetic Retinopathy Study (ETDRS) photography,
- The impact of TS on DR screening compliance rates or other patient behaviors
- Cost-effectiveness and patient satisfaction of TS compared with traditional DR screening
How did they compare these studies?
Identified studies were rated based on the Oxford Center for Evidence-Based Medicine (OCEBM) grading system.
Note: The OCEBM Levels of Evidence is a tool to help clinicians and researchers compare study designs to appraise evidence for:
- Prevalence
- Accuracy of diagnostic tests
- Prognosis
- Therapeutic effects
- Rare harms
- Common harms
- Usefulness of early screening
Findings?
In total researchers identified:
- Eight Level I studies
- 14 Level II studies
- Two Level III studies
Further, two Level I studies, five Level II studies, and one Level III study supported that TS had a positive impact on overall DR screening compliance—even increasing it by more than 2-fold in one study.
Tell me more.
While cross-study comparison was challenging due to differences in reference standards and grading methods, the research team found:
- TS demonstrated acceptable sensitivity and good specificity in detecting DR
- Moderate to good agreement between TS and reference-standard DR grading
TS performance was not as robust in detecting DME, though this may be attributed to the limited number of studies evaluating DME specifically.
What about cost-effectiveness and patient satisfaction?
Studies assessing cost-effectiveness and patient satisfaction were not graded formally, but they generally showed that TS was cost-effective and preferred by patients over traditional DR screening.
Expert opinion?
“Some evidence suggests that patient education, which often is integrated into the teleretinal screening visits, may impact future likelihood to seek repeat DR screening positively,” explained the study authors.
Although further studies are required to validate this, they also noted the possibility that TS may have benefits on DM-related medical outcomes, including lowering glycated hemoglobin and cholesterol levels.
Tie it all together for me.
These findings suggest that conventional TS is an effective approach to DR screening not only for its accuracy in detecting referable-level disease but also for improving screening compliance in a cost-effective manner that patients may prefer.
Next steps?
Further research is warranted to understand the optimal approach of TS—which may involve the integration of artificial intelligence (AI) or other imaging technologies in the future.