This retrospective medical chart review consisted of collecting data regarding diabetic patients 18 years and older who have participated in the teleophthalmology program offered throughout the state of WV between January 2017 and June 2019. The WVU institutional review board approved the study protocol. The Volk Pictor (Volk Optical, Inc., Mentor, OH, USA) nonmydriatic cameras used by trained nurses and staff acquired 45-degree fundus images from patients at various primary care and endocrinology clinic settings. In these settings, patients waited in rooms with the lights turned off to maximize pupillary dilation sans mydriatic drop administration. Staff would use the handheld fundus cameras to take photographs that were then uploaded and subsequently reviewed by retina specialists. Both eyes were photographed when possible with hopes of acquiring at least one viable image per eye. The number of attempts made was contingent on the judgment of the trained staff acquiring the images and the tolerance demonstrated by the patients being screened for repeated attempts.
Images were graded by a retina specialist at the WVU Eye Institute. These specialists included three WVU board-certified retina faculty and one vitreoretinal fellow—all patients were assigned to have their set of acquired images evaluated by one of these four specialists. Images were noted as gradable or ungradable, and the extent of DR (absent, mild, moderate, severe, or proliferative) and/or DME (absent, mild, moderate, or severe) was described in accordance to the International Classification of DR scale [24 (link)]. Care plan recommendations and suspicion of other pathologies were also noted. The results with their accompanying care plan recommendations were uploaded to the Epic electronic medical record (EMR) for the use of primary care physicians (PCPs) in their advising of diabetic patients in accordance to the American Academy of Ophthalmology’s guidelines for DR follow-up (Fig.1 ). Referral recommendations were made in accordance to those proposed by the International Council of Ophthalmology (ICO) and American Diabetes Association (ADA) [25 (link)]—albeit with the decision to recommend referral for suspected DR of any severity. Recommendations could also be made on the basis of other ocular pathologies that were remarked by reviewing ophthalmologists (e.g., age-related macular degeneration, choroidal nevi, colobomas, hypertensive retinopathy, glaucomatous optic nerves). For the purpose of this study, we exclusively followed patients whose screening findings indicated suspicion for diabetic retinopathy of any severity in at least one eye.![]()
Images were graded by a retina specialist at the WVU Eye Institute. These specialists included three WVU board-certified retina faculty and one vitreoretinal fellow—all patients were assigned to have their set of acquired images evaluated by one of these four specialists. Images were noted as gradable or ungradable, and the extent of DR (absent, mild, moderate, severe, or proliferative) and/or DME (absent, mild, moderate, or severe) was described in accordance to the International Classification of DR scale [24 (link)]. Care plan recommendations and suspicion of other pathologies were also noted. The results with their accompanying care plan recommendations were uploaded to the Epic electronic medical record (EMR) for the use of primary care physicians (PCPs) in their advising of diabetic patients in accordance to the American Academy of Ophthalmology’s guidelines for DR follow-up (Fig.
Teleophthalmology flow chart
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