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Age-related Macular Degeneration (AMD) is an eye condition that affects the elderly. Further, the prevalence of AMD is rising because of the aging population in the society. Therefore, early detection is necessary to prevent vision impairment in the elderly. However, organizing a comprehensive eye screening to detect AMD in the elderly is laborious and challenging. To address this need, we have developed a fourteen-layer deep Convolutional Neural Network (CNN) model to automatically and accurately diagnose AMD at an early stage. The performance of the model was evaluated using the blindfold and ten-fold cross-validation strategies, for which the accuracy of 91.17% and 95.45% were respectively achieved. This new model can be utilized in a rapid eye screening for early detection of AMD in the elderly. It is cost-effective and highly portable, hence, it can be utilized anywhere.

Introduction Diabetes mellitus (DM) is common metabolic disorder that is characterized by increased circulating blood glucose levels. Long-term, continuous hyperglycemia leads to vasculature-related disorders, including those affecting the eyes, such as retinopathy. The objective of this study was to assess the awareness of diabetic complications, specifically diabetic retinopathy, among diabetic patients attending the Jeddah Eye Hospital. Methods This was a cross-sectional study targeting the outpatient clinics of Jeddah Eye Hospital for a period of 2 months. A total of 380 participants were randomly selected based on sample size calculations. A closed-ended questionnaire, generated after an extensive literature review, was distributed among the selected individuals. The questions focused on the participants’ clinical status of DM, socio-demographic characteristics, awareness of eye complications secondary to DM, eye screening, and eye care-seeking behavior. Results The mean age of the patients was 58.3 (standard deviation 10.9) years, and 52.4% of patients were female. The majority (89.7%) of participants had type II DM (T2DM). The level of awareness was satisfactory (92.4%); however, only 10.5% of participants knew the recommended frequency for eye check-ups. The level of awareness of related complications was directly influenced by education level, source of patient information, place of residence, and frequency of follow-up visits. Conclusion The results of this study indicate that although the awareness of diabetes-related eye complications was satisfactory in the patient population, eye care-seeking behavior and frequency of eye check-ups were not optimal. Efforts are needed to promote eye care-seeking behavior in this patient group. Electronic supplementary material The online version of this article (10.1007/s40123-018-0147-5) contains supplementary material, which is available to authorized users.

Lapam Panda,1 Taraprasad Das,1 Suryasmita Nayak,1 Umasankar Barik,2 Bikash C Mohanta,1 Jachin Williams,3 Vivekanand Warkad,4 Guha Poonam Tapas Kumar,5 Rohit C Khanna3 1Indian Oil Center for Rural Eye Health, GPR ICARE, L V Prasad Eye Institute, MTC Campus, Bhubaneswar, India; 2Naraindas Morbai Budhrani Eye Centre, L V Prasad Eye Institute, Rayagada, India; 3Gullapalli Pratibha Rao International Center for Advancement of Rural Eye Care, L V Prasad Eye Institute, KAR Campus, Hyderabad, India; 4Miriam Hyman Children Eye Care Center, L V Prasad Eye Institute, MTC Campus, Bhubaneswar, India; 5District Administration, Government of Odisha, Rayagada, India Purpose: To describe program planning and effectiveness of multistage school eye screening and assess accuracy of teachers in vision screening and detection of other ocular anomalies in Rayagada District School Sight Program, Odisha, India.Methods: This multistage screening of students included as follows: stage I: screening for vision and other ocular anomalies by school teachers in the school; stage II: photorefraction, subjective correction and other ocular anomaly confirmation by optometrists in the school; stage III: comprehensive ophthalmologist examination in secondary eye center; and stage IV: pediatric ophthalmologist examination in tertiary eye center. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of teachers for vision screening and other ocular anomaly detection were calculated vis-à-vis optometrist (gold standard).Results: In the study, 216 teachers examined 153,107 (95.7% of enrolled) students aged 5–15 years. Teachers referred 8,363 (5.4% of examined) students and 5,990 (71.6% of referred) were examined in stage II. After prescribing spectacles to 443, optometrists referred 883 students to stage III. The sensitivity (80.51%) and PPV (93.05%) of teachers for vision screening were high, but specificity (53.29%) and NPV (26.02%) were low. The specificity and NPV, in general, were higher in ocular anomaly detection but varied from disease to disease.Conclusion: Multistage school screening is rapid and comprehensive in a resource-limited community. Regular training and periodic reinforcement of teachers for vision assessment and other ocular anomaly identification are required for further success of the strategy. Keywords: vision screening, school children, sensitivity, specificity, tribal, ocular anomalies

We report key findings and lessons learned from a health equity audit (HEA) of six National Health Service Diabetic Eye Screening Programmes (NDESPs) in Cumbria and the North East of England. Uptake of diabetic eye screening was analysed in relation to demographic variables including age, sex, socioeconomic deprivation and geography and a combinationof these in each of the six NDESPs. A total of 196,275 records of patients with diabetes aged 12 years and over on the NDESP registers were analysed. The key finding was a lower than acceptable screening uptake (70%) in the last year among the working age population, especially those living in the most socioeconomically deprived areas. The HEA process also highlighted the need for improvements in collecting data on ethnicity and sex. It informed action plans which address inequities in uptake of screening in each of the six NDESPs, especially those targeting the working age populations and individuals who never attended screening or never responded to screening invitations. We established a method of extracting the patient data from the local systems, pseudonymising and linking to lower super outputarea. This will be important for HEAs to become embedded in routine practice.

IMPORTANCE The novel intervention was effective at improving compliance to appropriate tertiary eye care after community eye screening. BACKGROUND Elderly individuals from low socio-economic background with visual impairment (VI) often do not attend tertiary care, even if significant eye diseases are detected while in the community. We evaluate a novel incentive care scheme (ICS) to improve compliance to appropriate follow-up after community eye screening. DESIGN Randomized controlled trial in a population-based setting was conducted. PARTICIPANTS A total of 140 elderly individuals with VI (visual acuity 0.05). Identified barriers for tertiary healthcare access included patient attitudes and financial- and health-related barriers. CONCLUSION AND RELEVANCE Our pilot RCT found that ICS improved adherence to appropriate tertiary eye care referrals after community eye screening in elderly people with VI.

Introduction: Covid-19 pandemic has changed the way of delivering health services worldwide into telemedicine and drive-through examination. Most schools also shift into online learning, including in Greater Jakarta, Indonesia. It has been reported that myopia prevalence is high in Southeast Asia, and refractive errors if not corrected properly may lead to amblyopia. Therefore, a regular eye screening is important. This study aims to report an outdoor drive-thru children eye screening utilizing Plusoptix A12 in Indonesia. Methods: A case series of consecutive subjects aged 4 to 17 years that underwent drive-thru eye screening using digital Snellen chart at 4 feet distance and Plusoptix A12 autorefractor photoscreening at 3 feet distance while seated inside a car in a 1 month period of July 2020 are included in the study. Results: A total of 47 children (19 males), aged 4-16 years (mean, 8.5;median, 10) were screened. Of these, 29 (61.7%) underwent further eye examination for subjective refraction in the clinic, while 18 (38.3%) were either determined not subjected to further eye examination or had their eye examination performed in another health facility. Myopia requiring spectacle correction was found in as early as 5 years of age (10%). The incidence of myopia detected was highest in the >10 years age group (67%) Conclusion/Relevance: The use of Plusoptix A12 in conjunction with visual acuity testing in an outdoor, drive-thru setting is an effective and safe method of children eye screening. This method is useful for myopia detection in Indonesia while maintaining physical distance during COVID-19 pandemic.

Introduction: Individuals with Diabetes Mellitus (DM) are at increased risk for developing diabetic ocular complications. Materials and Methods: A systematic approach was applied to find the relevant topic regarding the said issue. This literature review aimed to determine the system of eye screening, reasons for seeking eye screening and their treatment. Results: A total of 22 papers and one guideline were reviewed in this study. There were four main barriers found in this study regarding with factor influencing decision for eye screening among diabetes patients. Those were diabetic eye screening, management issues on diabetic eye screening and barriers to uptake diabetic eye screening. The details of these finding results were discussed further in the discussion section. Conclusion: The health care system, health care provider and patients itself could provide a clear explanation of factors influencing the decision for diabetic eye screening. A further study is recommended to validate these review findings

We aimed to report the results of fundus photography ophthalmic examinations among older adults in a rural community in South Korea. We used data from the Korean Social Life, Health, and Aging Project cohort study, which was designed to examine the entire population of individuals aged 60 years or older and their spouses living in a rural Village K of Ganghwa Island, South Korea. At baseline, a total of 860 people was targeted as the study population. From December 2011 to January 2019, five health examinations were conducted, including baseline and follow-up tests. During the fifth wave of the study, we performed fundus photography to assess eye health. Ophthalmic and physical examinations were conducted for 387 people who participated in the fifth wave by trained researchers. Systemic factors were evaluated via blood and diagnostic tests. After excluding eight people who did not undergo follow-up fundoscopy, a total of 379 participants was included for analysis. We classified the participants into two groups with either no (zero) or one or more suspicious ophthalmic diseases. The abnormalities included media opacity, suspected glaucoma, and suspicion of retinal disease as diagnosed by a trained specialist. We further categorized ophthalmic conditions as clinically insignificant, follow-up needed, semi-urgent, and urgent conditions. We included 379 participants, of which 225 (59.4%) were women. The mean age of the participants was 76.4 ± 6.2 years. Among all participants, 81% (n=307) had one or more abnormalities on fundus screening. Older age, living alone, high blood pressure, and high fasting insulin were associated with an increased risk of having ≥ one eye disease. In terms of triage, 3.7% (n= 14) of the observed conditions were urgent, and 25.9% (n= 98) were semi-urgent. Therefore, we documented fundoscopy results among the elderly population in a rural community in South Korea. Elderly people living alone were more likely to have eye disease. Policies to improve eye health are needed to prevent vision loss in this population.

This chapter provides a summary of key landmark clinical trials in ophthalmology and guidelines from the Royal College of Ophthalmologists (RCOphth). Additionally, information on Creutzfeldt-Jakob disease (CJD) and laser safety in hospitals is provided. The principles of screening with reference to the NHS diabetic eye screening programme is also provided.

An effective automatic diagnosis and grading of diabetic retinopathy would be very useful in the management of the diabetic retinopathy within the national health system. The detection of the presence of diabetic retinopathy features in the eyes is a challenging problem. Therefore, highly efficient and accurate image processing and machine learning techniques must be used in order to produce an effective automatic diagnosis of diabetic retinopathy. This chapter presents an up-to-date review on diabetic retinopathy detection systems that implement a variety of image processing techniques, including fuzzy image processing, along various machine learning techniques used for feature extraction and classification. Some background on diabetic retinopathy, with a focus on the diabetic retinopathy features and the diabetic retinopathy screening process, is included for better understanding. The chapter also highlights the available public databases, containing eye fundus images, which can be currently used in the diabetic retinopathy research. As the development of an automatic diabetic retinopathy screening system is a very challenging task, some of these challenges together with a discussion pertaining the automatic diabetic retinopathy screening are also presented in this chapter.

Background: Cataracts are a major cause of visual impairment and blindness in the United States and worldwide. Introduction: Risk factors for cataracts include age over 40 years, smoking, diabetes,...

Purpose To determine the rates and develop an initial risk prediction model for nonadherence to post screening ophthalmic referral (PSOR) in type 2 diabetes mellitus (T2DM) patients attending a national diabetic retinopathy screening program in Singapore. Methods Data from 2387 patients with T2DM (mean [standard deviation] age: 66.5 [11] years; 52.5% female patients) who underwent teleophthalmic screening between 2010 and 2014 under the Singapore Integrated Diabetic Retinopathy Program were extracted from electronic medical records. All were referred for tertiary ophthalmic management at the Singapore National Eye Centre (SNEC). Nonadherence was defined as not attending the SNEC appointment within 6 months of the assigned appointment date. Regression analysis using traditional modified Poisson and conditional inference models was used to construct and evaluate the discriminative ability of the preliminary risk prediction model to identify nonadherent individuals. Results Nonadherence rates to PSOR was 12.7% (95% confidence interval, 11.4%-14.1%). In traditional multivariable models adjusted for sociodemographic, lifestyle, and ocular factors, nonadherent individuals had higher triglyceride levels and were less likely to have a referable eye condition (P < 0.05). This model was able to identify nonadherent individuals with an accuracy (area under the curve) of 84%. In contrast, the conditional inference model was able to achieve similar discriminative ability using only participants' ocular health characteristics. Conclusions The rates of nonadherence to PSOR in Singaporean individuals with T2DM is low, with better ocular health being strongly predictive of nonadherence in our Asian population. Translational Relevance Our results may inform interventions to decrease nonadherence to PSOR.

Background: We investigated whether specific appointments for quality-assured care could increase referral uptake, often low in China, in children's vision screening. Methods: We randomized children aged 4-7 years in Yudu, Jiangxi, China, by school to Control (free school-based eye screening, parents of children failing screening recommended for further examination [usual practice]) or Intervention (identical examinations, with parents additionally provided with specific appointments for further examinations by quality-assured doctors at a designated local hospital). Both groups could select any hospital for referral exams, which were not free. Six months after screening, parents were interviewed on referral compliance and potential determinants. Findings: Among 9936 children at 63 schools randomized to Intervention (32 schools, 5053 [50·9%] children) or Control (31 schools, 4883 [49·1%] children), 1114 children (11·2%) failed screening. Among 513 referred Intervention children (46·1%, 32 schools, mean age 5·36 years, 53·0% boys) and 601 referred Control children (53·9%, 31 schools, mean age 5·30 years, 57·7 % boys), 104 (20·3%) and 135 (22·5%) were lost to follow-up respectively. Under Intention to Treat analysis, assuming children lost to follow-up were non-compliant, Intervention children had significantly higher compliance than Controls (308/513=60·0 % vs. 225/601=37·4%, P

mTEH (mobile Tele-Eye Health), a decision support system for teleophthalmology provides coordination among collaborators to conduct eye-screening events in community settings at southern Wisconsin with a mission to prevent vision loss as well as to educate people about diabetes and eye health. This system allows the collaborators to work in a time-efficient manner from remote locations and to manage data of the eye-screening participants securely.

Aims To investigate the relationships between age at diagnosis of diabetes, age at diabetic eye screening and severity of diabetic retinopathy at first and subsequent screenings in children aged 12 or 13 years. Methods Data were extracted from four English screening programmes and from the Scottish, Welsh and Northern Irish programmes on all children with diabetes invited for their first and subsequent screening episodes from the age of 12 years. Retinopathy levels at first and subsequent screens, time from diagnosis of diabetes to first screening and age at diagnosis in years were calculated. Results Data were available for 2125 children with diabetes screened for the first time at age 12 or 13 years. In those diagnosed with diabetes at 2 years of age or less, the proportion with retinopathy in one or both eyes was 20% and 11%, respectively, decreasing to 8% and 2% in those diagnosed between 2 and 12 years (P < 0.0001). Only three children (aged 8, 10 and 11 years at diagnosis of diabetes) had images graded with referable retinopathy and, of these, two had non‐referable diabetic retinopathy at all subsequent screenings. Of 1703 children with subsequent images, 25 were graded with referable diabetic retinopathy over a mean follow‐up of 3.1 years, an incidence rate of 4.7 (95% confidence interval, 3.1–7.0) per 1000 per year. Conclusions In this large cohort of children, the low prevalence and incidence rates of referable diabetic retinopathy suggest that screening earlier than age 12 is not necessary., What's new? This is the largest reported study in the literature of baseline levels of diabetic retinopathy in the age group 12 or 13 years.This is the largest reported study showing the rate of progression of diabetic retinopathy in adolescents.Of 2125 children with diabetes screened for the first time at age 12 or 13 years, three were found to have referable disease.The absence of referable disease in subsequent screens in two of the children and of pre‐proliferative changes in the third child suggest that it is unlikely that any treatment is required.

In resource-poor countries, there is a reported lack of\ud quality and structured retinal laser training in residency\ud and hospital eye programs. This unmet training need has\ud been validated in current international diabetic retinopathy\ud screening centers.1 In our own experience, there is\ud a lack of specialist laser expertise that is a barrier to highquality\ud and competent laser treatment delivery for patients\ud in the developing world. Furthermore, with the introduction\ud of new pattern scan laser technology, clinicians in the\ud developing world have variable insights into new contemporary\ud laser settings. One of the critical issues for\ud a diabetic eye screening programs in the developing\ud world is the significant risk of loss of vision from inadequate\ud laser treatment despite successful eye screening\ud and detection of sight-threatening diabetic retinopathy.

PURPOSE OF REVIEW: We discuss opportunities to address key barriers to widespread implementation of teleophthalmology programs for diabetic eye screening in the United States (U.S.). RECENT FINDINGS: Teleophthalmology is an evidence-based form of diabetic eye screening. This technology has been proven to substantially increase diabetic eye screening rates and decrease blindness. However, teleophthalmology implementation remains limited among U.S. health systems. Major barriers include financial concerns as well as limited utilization by providers, clinical staff, and patients. Possible interventions include increasingly affordable camera technology, demonstration of financially sustainable billing models, and engaging key stakeholders. SUMMARY: Significant opportunities exist to overcome barriers to scale up and promote widespread implementation of teleophthalmology in the USA. Further development of methods to sustain effective increases in diabetic eye screening rates using this technology is needed. In addition, the demonstration of cost-effectiveness in a variety of billing models should be investigated to facilitate widespread implementation of teleophthalmology in U.S. health systems.

Background To document ocular abnormalities in healthy full-term newborn infants using wide-field digital imaging and to analyze factors associated with the findings. Methods A total of 1208 full-term newborn infants at a tertiary eye hospital (Cipto Mangunkusumo National Referral Hospital) and a district hospital in Jakarta (Koja Hospital) were enrolled to the study. All eligible newborns underwent fundus examination within 48 hours after birth using the RetCam shuttle (Natus Medical Incorporated, USA). All eye findings were documented and analyzed according to obstetric and neonatal risk factors. Results Of the 1208 newborn infants enrolled, ocular abnormalities were found in 150 infants (12.4%). Retinal hemorrhage (RH) was the most common findings (88%) in which 2.67% involved the macula, followed with chorioretinitis (4.67%). Univariate analysis showed caesarean section (C-section) (OR 0.27, 95% CI 0.18-0.41, p

Background Immigrants to Canada belonging to ethnocultural minority groups are at increased risk of developing diabetes and complications, including diabetic retinopathy, and they are also less likely to be screened and treated. Improved attendance to retinopathy screening (eye tests) has the potential to reduce permanent complications, including blindness. Objective This study aims to identify the barriers and enablers of attending diabetic retinopathy screening among ethnocultural minority immigrants living with diabetes in Quebec and Ontario, Canada, to inform the development of a behavior change intervention to improve diabetic retinopathy screening attendance. Methods The research question draws on the needs of patients and clinicians. Using an integrated knowledge translation approach, the research team includes clinicians, researchers, and patient partners who will contribute throughout the study to developing and reviewing materials and procedures, helping to recruit participants, and disseminating findings. Using a convenience snowball strategy, we will recruit participants from three target groups: South Asian and Chinese people, and French-speaking people of African descent. To better facilitate reaching these groups and support participant recruitment, we will partner with community organizations and clinics serving our target populations in Ontario and Quebec. Data will be collected using semistructured interviews, using topic guides developed in English and translated into French, Mandarin, Hindi, and Urdu, and conducted in those languages. Data collection and analysis will be structured according to the Theoretical Domains Framework (TDF), which synthesizes predominant theories of behavior change into 14 domains covering key modifiable factors that may operate as barriers or enablers to attending eye screening. We will use directed content analysis to code barriers and enablers to TDF domains, then thematic analysis to define key themes within domains. Results This study was approved for funding in December 2017, and the research ethics board approved the conduct of the study as of January 13, 2018. Data collection then began in April 2018. As of August 28, 2018, we have recruited 22 participants, and analysis is ongoing, with results expected to be published in 2020. Conclusions Findings from this study will inform the codevelopment of theory-informed, culturally- and linguistically-tailored interventions to support patients in attending retinopathy screening. International Registered Report Identifier (IRRID) DERR1-10.2196/15109

AIMS: To evaluate the refractive status of young Saudi schoolchildren with a “Spot Screener.” SUBJECTS AND METHODS: This cross-sectional study was conducted from January to July 2016 in Riyadh, Saudi Arabia. Children of kindergarten (3–5 years) and grades 1 and 2 (6–7 years) were screened for refractive error (RE) using the handheld Spot Screener (Welch Allyn, Skaneateles Falls, NY, USA). Data were collected on age, gender, and spectacle use. The pass/fail notation from the Spot Screener and the RE were documented. Children with a “fail” were re-tested with an autorefractor (AR). The rate of agreement was evaluated for the spherical equivalent (SE) from the Spot Screener and AR. RESULTS: We examined 300 schoolchildren and 114 preschool children. The prevalence of RE was 22% in schoolchildren and 25% in preschoolers. There were 183 (61%) hyperopes, 110 (36.7%) myopes, 6 (2%) emmetropes, and 29 (9.7%) astigmats (>2 D cylinder) in grade 1 and 2. There were 85 (74.6%) hyperopes, 22 (19.3%) myopes, 7 (6.1%) emmetropes, and 10 (8.8%) astigmats among preschoolers. The SE differed between the AR and the Spot Screener in 17 (28%) children of 61 failed Spot Screener tests. Accommodation (9, 53%) and high astigmatism (8, 47%) were the main underlying causes of the difference. The Spot Screener could identify RE for the first time in 51 (17%) schoolchildren and 26 (22%) preschoolers. End-users suggested that Spot Screener was child-friendly and quick to test RE. CONCLUSIONS: The Spot Screener could be a good initial screening tool for RE in young schoolchildren.

Purpose: To compare the measurement of intraocular pressure (IOP) of Icare rebound tonometer and Perkins applanation tonometer (PAT) during community eye screening and to assess the agreement between these 2 instruments. Design: A cross-sectional, non-interventional study. Methods: The IOP measurements by handheld Icare rebound tonometer (Finland) were first performed by a primary care physician. Then the IOP was measured using Perkins Mk3 applanation tonometer (Haag-Streit, UK) by an ophthalmologist who was masked to previous readings from the Icare rebound tonometer. The mean IOP measured by each tonometer was compared. Pearson correlation coefficient was used to explore the correlation between the IOP measurements of the 2 instruments. The level of agreement between them was assessed using the Bland and Altman method. Results: A total of 420 left eyes were examined. The mean age of subjects was 38.6 ± 18.2 years. Approximately 67% of subjects were female. The mean IOP was 16.3 ± 4.0 mm Hg using Icare and 13.4 ± 2.3 mm Hg using PAT. Pearson correlation coefficient showed a moderate positive correlation between the 2 methods (r = +0.524, P < 0.001). Linear regression analysis revealed a slope of 0.28 with R2 of 0.255. The mean difference between the 2 methods was 2.90 ± 3.5 mm Hg and the sample t-test revealed a statistically significant mean difference from 0 (P < 0.001). The 95% limits of agreement between the 2 methods were between −9.73 and 3.93 mm Hg. Conclusions: The handheld Icare rebound tonometer is a reasonably acceptable screening tool in community practices. However, Icare overestimated IOP with a mean of 2.90 mm Hg higher than the PAT. Thus, using Goldmann applanation tonometer as a confirmatory measurement tool of IOP is suggested.

We have developed a novel technique to explain results of an AI system and demonstrate its ability in explaining the EyeArt AI eye screening system for DR. Besides providing clinically consistent and accurate results, AI systems in healthcare must be explainable (be able to provide reasons for their decisions). This is paramount in making them trustworthy. The EyeArt system is intended for use by healthcare providers to screen for referable DR using color fundus photographs from 18 years or older diabetic patients who do not have persistent visual impairment. It is designed to provide screening results in under a minute and enable DR screening at point of care in endocrinology and primary care clinics. Figure shows that the explainability technique highlights image regions that most significantly contribute to the EyeArt system’s results. These highlighted regions correspond to lesions marked by an expert human grader. In a previous study on 107,001 consecutive patient visits, the EyeArt system has been shown to achieve sensitivity of 91.3% (95% CI: 90.9%-91.7%), specificity of 91.1% (95% CI: 90.9%-91.3%), NPV of 97.6% (95% CI: 97.5%-97.7%), and PPV of 72.5% (95% CI: 71.9%-73.0%). The work presented here provides evidence that the EyeArt system is explainable and has been designed to report DR screening results based on lesions considered important by the ophthalmology community for DR severity grading. Disclosure N. Parekh: Employee; Self; Eyenuk Inc. M. Bhaskaranand: Employee; Self; Eyenuk Inc. C. Ramachandra: Employee; Self; Eyenuk Inc. S. Bhat: Employee; Self; Eyenuk Inc. K. Solanki: Employee; Self; Eyenuk Inc. Stock/Shareholder; Self; Eyenuk Inc. Funding National Institutes of Health

A prospective study (NCT03112005) evaluated DR screening using the EyeArt AI eye screening system against the ETDRS clinical reference standard (CRS). A total of 893 subjects with diabetes were enrolled at 15 U.S. clinical centers and completed 2-field fundus photography for analysis by the EyeArt system and dilated 4-wide field stereo fundus photography for adjudicated expert grading to establish CRS. The EyeArt system provided eye-level results for referable DR (rDR) [moderate non-proliferative DR (NPDR) or higher on the International Clinical DR (ICDR) severity scale or clinically significant diabetic macular edema (CSDME)] and for vision-threatening DR (vtDR) [severe NPDR or higher on the ICDR scale or CSDME]. Out of 1718 eyes with gradable CRS for rDR, 1392 eyes were negative and 326 were positive. Out of 1702 eyes with gradable CRS for vtDR, 1588 were negative and 114 were positive. The EyeArt system was evaluated against CRS for identifying rDR and vtDR under an undilated protocol and a dilate-if-needed protocol (where dilated images were used for subjects with ungradable EyeArt results on undilated images). Results (Table) indicate that the EyeArt AI system compares favorably with the clinical reference standard and meets the predetermined study endpoints for the detection of referable and vision-threatening DR in people with diabetes. Disclosure B.W. Bode: Consultant; Self; ADOCIA, Lexicon Pharmaceuticals, Inc., Novo Nordisk Inc. Research Support; Self; Becton, Dickinson and Company, Dexcom, Inc., Diasome Pharmaceuticals, Inc., Eli Lilly and Company, Eyenuk Inc., Insulet Corporation, National Institutes of Health, Novo Nordisk Inc., Sanofi Research & Development, Senseonics, Xeris Pharmaceuticals, Inc. Speaker’s Bureau; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi US, Senseonics. Stock/Shareholder; Self; AgaMatrix, Glytec, LLC. E. Ipp: Research Support; Self; Eyenuk Inc., Novartis Pharmaceuticals Corporation. V.N. Shah: Advisory Panel; Self; Sanofi US. Consultant; Self; Dexcom, Inc. S.R. Sadda: Consultant; Self; Carl Zeiss Meditec, Centervue, Heidelberg Engineering, Optos. Other Relationship; Self; Nidek. Other Relationship; Spouse/Partner; Topcon. Funding National Institutes of Health (EY027241, EY026864)

A prospective study (NCT03112005) evaluated DR screening using the EyeArt AI eye screening system and dilated ophthalmoscopy by board-certified ophthalmologists against the ETDRS clinical reference standard (CRS) of adjudicated expert grading of 4-wide field stereoscopic fundus photographs. A total of 497 subjects with diabetes from 10 U.S. clinical centers underwent undilated 2-field fundus photography for analysis by the EyeArt system, dilated ophthalmoscopy, and dilated 4-wide field stereo fundus photography for the CRS. Performance (Table) of dilated ophthalmoscopy against CRS for identifying referable DR [moderate non-proliferative or higher on the International Clinical Diabetic Retinopathy severity scale or clinically significant macular edema] indicates significant variability across retina specialists and general ophthalmologists. In a previous study, this AI system has been shown to achieve sensitivity 89.0% [95% CI: 87.7-90.2%] and specificity 91.6% [95% CI: 91.0-92.2%] against 7-field ETDRS reference standard. We await the results of the EyeArt system in this multicenter study to verify its ability to provide a more consistent performance for detection of referable DR to facilitate DR screening in primary care and endocrinology clinics. Disclosure E. Ipp: Research Support; Self; Eyenuk Inc., Novartis Pharmaceuticals Corporation. V.N. Shah: Advisory Panel; Self; Sanofi US. Consultant; Self; Dexcom, Inc. B.W. Bode: Consultant; Self; ADOCIA, Lexicon Pharmaceuticals, Inc., Novo Nordisk Inc. Research Support; Self; Becton, Dickinson and Company, Dexcom, Inc., Diasome Pharmaceuticals, Inc., Eli Lilly and Company, Eyenuk Inc., Insulet Corporation, National Institutes of Health, Novo Nordisk Inc., Sanofi Research & Development, Senseonics, Xeris Pharmaceuticals, Inc. Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi US, Senseonics. Stock/Shareholder; Self; AgaMatrix, Glytec, LLC. S.R. Sadda: Consultant; Self; Carl Zeiss Meditec, Centervue, Heidelberg Engineering, Optos. Other Relationship; Self; Nidek. Other Relationship; Spouse/Partner; Topcon. Funding Eyenuk Inc.

Background Children and young people (CYP) living with diabetes require integrated child-centered care. We hypothesized that suboptimal uptake to diabetic retinopathy screening in CYP may be partly related to the degree of services integration. We investigated the structure of the current pediatric diabetic eye care pathway and associations between service-level characteristics and screening uptake. Methods A quality improvement project between January and May 2017 comprising a survey of practice of all 158 pediatric diabetes services (pediatric diabetes units, PDUs) across England and secondary data analysis of routinely collected service data. Generalized linear models for proportional responses were fitted to investigate associations between reported PDU characteristics and screening uptake. Results 124 PDUs (78%) responded. In 67% (n = 83), patients could be referred directly to screening programs; the remainder relied on primary care for onward referral. 97% (n = 120) considered eye screening results useful for counseling patients but only 65% (n = 81) reported it was "easy" to obtain them. Factors independently associated with higher screening uptake were a higher proportion of patients referred from primary care (OR = 1.005; 95%CI = 1.004-1.007 per 1% of increase), absence of "out-of-catchment area" patients (OR = 1.13; 95%CI = 1.04-1.22), and easy access to eye screening results (OR = 1.45; 95%CI = 1.34-1.56). Conclusions There is limited direct communication between the services involved in diabetic eye care for CYP in England. This risks reducing the effectiveness of diabetic retinopathy screening. Similar vulnerabilities are likely to exist in other countries where retinopathy screening for CYP has been "bolted on" to provision for adults.

To correlate the clinico-cytological features of dry eye among diabetic patients attending Lagos University Teaching Hospital, Lagos. This was a cross-sectional, comparative study among 104 diabetic and 104 age-/sex-matched non-diabetic participants. Demographics were obtained using interviewer-administered questionnaire. Ocular Surface Disease Index (OSDI) questionnaire was used for subjective assessment of dry eye. All participants underwent ocular examination and dry eye assessment including Schirmer I test, tear film break-up time (TBUT) and ocular surface staining. In addition, conjunctival impression cytology (CIC) samples were taken for histological assessment. Data were analysed using IBM Statistical Package for the Social Sciences version 20.0 (IBM Corp., Armonk, NY USA). The mean age was 58.5 ± 10.05 years and 58.32 ± 10.48 years among the diabetics and non-diabetics, respectively (p = 0.856). The male/female ratio was 1:1.4. Three hundred and ninety-seven (199 diabetic and 198 non-diabetic) eyes were assessed. Diabetics had a significantly higher median OSDI score and ocular surface staining grade compared to non-diabetics (p = 0.002 and 0.005, respectively). The TBUT was slightly lower, while the Schirmer test was slightly higher among the diabetics, but not significant (p = 0.058 and 0.033, respectively). The diabetics had a significantly higher CIC grade (p

One of the key factors to be looked at during design of an automated eye screening system is to find the optic disc and optic cup. Objective: In eye screening of diabetic patients, the feature such as hard exudates and cotton wool spots can be noticed which share similar properties with optic disc In certain diseases like glaucoma ophthalmologist look at the ratio of optic cup with optic disc to detect the presence or absence of glaucoma Currently, the process is manual performed by ophthalmologist, which a time consuming and tedious job. This fact motivated to design a fully automated procedure to detect optic cup and optic disc. Method: In the current paper a multilevel active contour technique is used that generates the snake to detect boundaries of optic cup and optic disc using intensity of the border pixels which are tested using 3σ control limits. The algorithm works in two parts. In part-1, optic disc boundary is detected and in part-2, the optic cup is marked by concentrating inside the area marked as optic disc in part-1. Findings: This approach reduces processing area and hence improves computational time A local database to carry out this work was created by collecting images from Karnataka Institute of Diabetology, Bangalore The results obtained by the proposed procedure are encouraging and have yielded 100% results with the fundus images containing full optic disc Improvement: The method is fully automatic and no user intervention is required

In the Netherlands, youth-healthcare (YHC) physicians screen children 7 times for vision disorders between the ages of 1 and 60 months. Examination consists of inspection of the external structures of the eye, fundus red reflex, Hirschberg test, pupillary reflexes, cover-uncover test, alternating-cover test, eye motility, monocular pursuit, and, from 36 months onwards, visual acuity (VA). We observed how well these tests are done.Screening test performance was assessed with semistructured observations. Two orthoptic students developed a semistructured observation form. In addition to extensive instructions from an orthoptist and YHC-physicians instructor, they attended 2 one-day courses for YHC physicians. Tests were assessed using criteria based on the Dutch Child Vision Screening Guideline version 2010 and the Dutch Manual for Orthoptic Examination. Type of chart, testing distance, and starting eye were recorded for VA measurements. The observations in the first week were done simultaneously by the two observers and checked for concordance.Concordance between the two observers was good. Twenty-five YHC physicians were observed during 100 days in total. Two physicians were excluded because they examined few children. The remaining 23 physicians examined 329 children, of whom 82 were aged 1-4 months, 157 aged 6-24 months, and 90 aged 36-45 months of age. Fundus red reflex was performed in 89% of children, Hirschberg test in 88%, pupillary reflexes in 14%, cover-uncover test in 65%, alternating-cover test in 62%, eye motility in 68%, monocular pursuit in 23%, and VA at 36-45 months in 94%. Forty-eight percent of cover-uncover tests, 36% of alternating-cover tests, and 7% of eye motility tests were performed correctly. VA was measured at 3 meters in 2%, others at 5 meters in accordance with the guideline. A picture chart was used instead of the Landolt-C at the age of 45 months in 23%. VA measurements were performed correctly in 89%, fundus red reflex in 89%, and Hirschberg test in 87%.Hirschberg test, fundus red reflex, and VA were adequately tested in most cases. Cover-uncover test, alternating-cover test, and eye motility were often performed inadequately. Pupillary reflexes were skipped often as room lights could not be dimmed.

Objective: To describe the role of Clinical Pharmacists in the Medication Refill Clinic area as a part of a multidisciplinary team in which he/she can provide education to patients and caregivers on the safe and appropriate use of medications, counsel on medication compliance, monitor and manage medication side effects, as well as screen for dangerous drug interactions. Methods: The data of this prospective, single-centered, chart review based study have been collected since the clinic launched in June 2011 till December 2013 in King Khalid Eye Specialist Hospital which is a Tertiary Hospital in KSA. Types of interventions documented during the patient–pharmacist visit are categorized as medication review and patient compliance. Key findings: Out of the total 16,417 patients, 3641 (22.2%) are noncompliant. The Clinical Pharmacist identified 18 intervention types. The most frequent interventions are as follows: Eye screening (24.8%), Counseling (13%), Physician/ER referral (12.4%), Therapeutic substitution/switch (10.8%), and Frequency changed (7%). Summary: This prospective analysis is a document evidence showing Clinical Pharmacist positive outcomes in the management of ophthalmic patients. Dissemination of this information would be valuable because it could raise the awareness of other Healthcare Professionals regarding Pharmacist as effective clinicians in care of ophthalmic patients.

Telemedicine has been used worldwide in several medical specialties including Ophthalmology. However, its use in infant eye screening especially for Retinopathy of Prematurity (ROP) has been more limited. Ironically, it is for this disease entity wherein telemedicine promises possibly the highest benefit. A short time window of screening, a standard classification of the disease, specially designed infant retinal cameras and lossless image transfer tools make this feasible. Furthermore, the lack of trained experts and the large number of infants that require screening in the outreach make “tele-ROP” an attractive prospect. Yet, its relatively poor adoption can be attributed to several real-world challenges like the cost of the technology, cost of implementation, cost benefit, and medicolegal concerns. Drawing from the experience of over 150,000 infant screening sessions in the “KIDROP- Tele-ROP” program in India, this chapter addresses these challenges and suggests possible solutions for a wider expansion.

Digital retinal imaging is a challenging screening method for which effective, robust and cost-effective approaches are still to be developed. Regular screening for diabetic retinopathy and diabetic maculopathy diseases is necessary in order to identify the group at risk of visual impairment. This paper presents a novel automatic detection of diabetic retinopathy and maculopathy in eye fundus images by employing fuzzy image processing techniques. The paper first introduces the existing systems for diabetic retinopathy screening, with an emphasis on the maculopathy detection methods. The proposed medical decision support system consists of four parts, namely: image acquisition, image preprocessing including four retinal structures localisation, feature extraction and the classification of diabetic retinopathy and maculopathy. A combination of fuzzy image processing techniques, the Circular Hough Transform and several feature extraction methods are implemented in the proposed system. The paper also presents a novel technique for the macula region localisation in order to detect the maculopathy. In addition to the proposed detection system, the paper highlights a novel online dataset and it presents the dataset collection, the expert diagnosis process and the advantages of our online database compared to other public eye fundus image databases for diabetic retinopathy purposes.

The aim of this study was to assess the socioeconomic inequalities in the use of preventive eye screening services among individuals with diabetes in Korea.Using nationally representative survey data, the concentration index (CI) and decomposition of the CI were used to capture and quantify income-related inequalities.The results show income-related inequality in the use of eye screening services among individuals with diabetes, suggesting that services were concentrated among individuals with higher incomes. After adjusting for need factors, such as sex, age and self-rated health, the inequality still persisted as observed horizontal inequity in the services, indicating that unequal care was provided for equal need. The decomposition approach revealed that the largest contributions to the observed inequality were higher education and higher income levels. Having private insurance and residing in non-Seoul metro areas also contributed to the observed pro-rich inequality.These findings suggest that income- and education-related barriers to the use of preventive eye screening services for individuals with diabetes should be targeted for removal at the national level to achieve the goal of equal care for equal need in diabetes management.

Universal newborn eye screening is gaining increased interest as a potential way to reduce long-term visual impairment through early identification of ocular abnormalities. The number of skilled healthcare providers available to provide bedside examinations for a universal newborn eye screening program is inadequate, but advances in retinal fundus imaging and telemedicine systems have enabled the execution of several pilot studies in India, China and the United States.1, 2, 3 In the study by Goyal and colleagues, they report on fundus image screening of 1152 newborn infants in an Eastern Indian hospital from March 2014 to October 2015.4

BackgroundThe provision of eye care services is currently insufficient to meet the requirements of eye care. Many people remain unnecessarily visually impaired or at risk of becoming so because of treatable or preventable eye conditions. A lack of access and awareness of services is, in large part, a key barrier to handle this unmet need.ObjectiveThis study aimed to assess whether utilizing novel smartphone-based clinical algorithms can task-shift eye screening to community volunteers (CVs) to accurately identify and refer patients to primary eye care services. In particular, we developed the Peek Community Screening app and assessed its validity in making referral decisions for patients with eye problems.MethodsWe developed a smartphone-based clinical algorithm (the Peek Community Screening app) using age, distance vision, near vision, and pain as referral criteria. We then compared CVs’ referral decisions using this app with those made by an experienced ophthalmic clinical officer (OCO), which was the reference standard. The same participants were assessed by a trained CV using the app and by an OCO using standard outreach equipment. The outcome was the proportion of all decisions that were correct when compared with that of the OCO.ResultsThe required sensitivity and specificity for the Peek Community Screening app were achieved after seven iterations. In the seventh iteration, the OCO identified referable eye problems in 65.9% (378/574) of the participants. CVs correctly identified 344 of 378 (sensitivity 91.0%; 95% CI 87.7%-93.7%) of the cases and correctly identified 153 of 196 (specificity 78.1%; 95% CI 71.6%-83.6%) cases as not having a referable eye problem. The positive predictive value was 88.9% (95% CI 85.3%-91.8%), and the negative predictive value was 81.8% (95% CI 75.5%-87.1%).ConclusionsDevelopment of such an algorithm is feasible; however, it requires considerable effort and resources. CVs can accurately use the Peek Community Screening app to identify and refer people with eye problems. An iterative design process is necessary to ensure validity in the local context.

Introduction: sickle cell disease can result in visually threatening eye disease (proliferative sickle cell retinopathy). This can be prevented with timely eye screening. It is important for patients to understand their role. Our research is to determine the knowledge, beliefs and practices (KBP) regarding eye disease of Sickle Cell patients and the impact of genotype, demographic and socio-economic status. Methods: cross-sectional study at the Sickle Cell Unit, Jamaica during May 2016. Consecutive non-pregnant adults (>18 years of age) attendees, who were not acutely unwell, were invited to participate. A 26-item single interviewer administered questionnaire was used to obtain socio-demographic data, highest level of education completed, employment status, sickle cell genotype, if known, frequency of clinic attendance and patients' knowledge, beliefs and practices. Ten of these were yes/no questions, whereas eight required that they choose correct answers from four choices. Results: one hundred subjects were recruited, 72% had homozygous SS disease. Their ages ranged from 18-63 years (mean 34.1 years, SD11.3). Fifty six percent were female. Most (75%) had achieved at least secondary education. The majority (62%) were unemployed. The mean belief score was 3.6/6(60%) and the mean knowledge and practice scores were 3.3/7(47%) and 2.2/5(44%) respectively. Milder genotypes had higher knowledge scores vs the more severe genotypes (4.0 vs 3.2, P=0.013). Only 28% had regular eye examinations; less than 50% had seen an ophthalmologist in the past year. Practice scores were higher in employed than in unemployed patients (2.6 vs 1.9, (P=0.04)). Employed patients were more likely than the unemployed to see their eye doctor for regular eye "examinations" (42.1% vs 19.4%, χ2=6.0, P=0.02). The practice and knowledge scores correlated (r2=0.363, P

Systematic or national screening programs for diabetic retinopathy (DR) and diabetic macular edema (DME), using digital fundus photography and optical coherence tomography (OCT), are currently implemented at primary care level, aiming to provide timely referral for vision-threatening DR and DME to ophthalmologists for timely treatment and vision loss prevention. However, interpretation of retinal images requires specialized knowledge and expertise in diabetic eye disease. Furthermore, current DR screening programs are capital- and labor-intensive, which makes it difficult to rapidly scale up and expand diabetic eye screening to meet the needs of this growing global epidemic. Deep learning (DL), a new branch of machine learning technology under the broad term of artificial intelligence (AI), has made remarkable breakthrough in medical imaging in particular for pattern recognition and image classification. In ophthalmology, AI and DL technology has been developed from big image datasets in assessment of retinal photographs for detection and screening of DR as well as the segmentation and assessment of OCT images for diagnosis and screening of DME. This review aimed to summarize the current progress and the development of using AI and DL technology for diabetic eye disease screening as well as current challenges in the actual implementation of DL in screening programs, and translating DL research into direct clinical applications of screening in a community setting.

Purpose Previous studies on the association between choroidal thickness (CT) and severity of diabetic retinopathy (DR) gave conflicting results. The aim of this study was to evaluate the CT changes in diabetic patients and associated factors in a large sample of Chinese patients with diabetes. Methods Type 2 diabetes mellitus patients without history of ocular treatment were recruited from the community health system in Guangzhou, China. The swept source OCT instrument was used to obtain high-definition retina and choroid images. The diabetic retinopathy (DR) status was graded based on the guidelines of the United Kingdom National Diabetic Eye Screening Programme. Univariate and multivariate linear regression analyses was used to explore the association of CT with DR severity, diabetic macular edema (DME), hemoglobin A1c, and vision function. Results A total of 1347 patients were included in the final analysis. After adjusting for other factors, the patients with stage R3 DR had significantly thinner CT (β = –29.1 µm, 95% CI –53.8 to –4.4, P = 0.021) in comparison in those with R0. After adjusting for other factors, the CTs were thicker than those in R0 patients with difference of 15.6 µm (95% CI 4.3-26.9, P = 0.007) for outer nasal sector, 15.7 µm (95% CI 3.8-25.5, P = 0.008) for outer inferior, and 12.2 µm (95% CI 0.4-24.0, P = 0.042) for inner inferior sector. The presence of DME and hemoglobin A1c levels did not significantly affect average CT. Higher average CT was significantly associated with better best corrected visual acuity, with a –0.02 LogMAR unit per 100 µm increase in average CT (95% CI –0.03 to –0.01, P < 0.001). Conclusions CT increased in the early stage of DR, and further decreased with DR progression. DME was not significantly associated with CT. These findings provide more clues to suggest that choroid alterations play a role in the pathogenesis of DR.

OBJECTIVE: To compare the accuracy of infrared (IR)-reflex assessment using a prototype imaging device to standard non-mydriatic red-reflex screening with direct ophthalmoscope (DO) in the diagnosis of neonatal and childhood cataract. METHODS: The comparison of the techniques was made in two distinct cohorts: in the first, newborns underwent IR and red-reflex testing by a medical student, with results compared to a reference red-reflex examination by an experienced midwife. In the second, an enriched cohort of children attending a specialist paediatric ophthalmology clinic had IR and red-reflex testing by a medical student to reference examination by a paediatric ophthalmologist. The medical students were considered inexperienced screeners due to their limited exposure to ophthalmology. The sensitivity and specificity of the IR and red-reflex assessments in respect to reference examination were calculated. Diagnostic accuracy was compared in Caucasian and non-Caucasian eyes. RESULTS: IR and red-reflex imaging were possible in all 180 neonatal eyes examined. A total of 5% of newborn eyes were found to have embryological remnants in the anterior segment of the eye with IR-reflex imaging which were not detected on reference red-reflex examination. IR-reflex assessment had significantly better sensitivity (100 vs 71%, p