Damian McNamara

May 29, 2013

SEATTLE, Washington — An app-based telemedicine program significantly increases screening for diabetic retinopathy at community health clinics, according to a multicenter randomized controlled trial.

This is a more convenient form of screening than traditional surveillance by an ophthalmologist, and it is "done right in the clinic," Steven Mansberger, MD, director of glaucoma services at the Devers Eye Institute in Portland, Oregon, told Medscape Medical News.

The strategy is also efficient. "The majority of patients did not have levels of retinopathy requiring an eye care provider," Dr. Mansberger said. Only about 10% required physician attention.

"The nice thing is that about 90% can be followed with just this technology," he said here at the Association for Research in Vision and Ophthalmology 2013 Annual Meeting.

Dr. Mansberger and his team randomly assigned 567 patients with diabetes to telemedicine or traditional screening. They studied patients at 2 healthcare clinics: one in Wichita, Kansas; the other in Pendelton, Oregon. They chose these settings because they have a large Native American population that often experiences difficulty getting eye examinations, he said.

The nice thing is that about 90% can be followed with just this technology.

After a trained technician takes clinical images using a nonmydriatic camera, the app developed by Dr. Mansberger and his team automatically uploads the photos to a cloud, where information is stored on a remote computer server for online retrieval.

An email alert is sent to participating ophthalmologists notifying them that new images are ready for review. They grade retinopathy on a validated scale from stage 0 for none to stage 4 for proliferative diabetic retinopathy.

Overall, the technicians took good images, said Dr. Mansberger. "Unable to determine" was the result in only 7% of patient photos and was the most common reason patients were referred for ophthalmologist evaluation.

After 2 years, all participants were offered telemedicine screening. When the randomization phase ended, the difference between strategies was no longer statistically significant.

"This is a staged intervention showing that telemedicine improves the rate of adherence to annual eye examinations," Dr. Mansberger said. However, "it doesn't stay up at 90%, as we'd like." The rate drops to approximately 50% after the first year, "so there are other factors" acting as barriers to effective diabetic retinopathy screening, he said.

Table. Proportion of Patients Screened for Diabetic Retinopathy*

Year Telemedicine, % (n = 296) Traditional, % (n = 271)
1 91.9 43.9
2 53.0 33.2
3 44.3 39.5
4 45.9 46.1
5 47.6 51.3
*Based on an intent-to-treat analysis.


During the 5 years of follow-up, the proportion of patients with moderate diabetic retinopathy or worse — those recommended for referral — remained below 10%.

Asked to comment by Medscape Medical News, Barbara Klein, MD, from the University of Wisconsin School of Medicine and Public Health in Madison, said that "there are many such programs around the globe. In most, diabetic retinopathy that is less than the most severe cases is often missed at the time of grading. This is problematic because healthcare intervention early in the course of diabetic retinopathy might prevent progression to later vision-threatening stages."

Dr. Klein noted that "drop out after the first screening examination is very common. This suggests that efforts might be best spent in determining factors that could be improved to increase compliance."

This study was supported by the Centers for Disease Control and Prevention. Dr. Mansberger reports receiving honoraria from Merck; being a consultant for Alcon, Allergan, Santen, and Glaukos; and receiving funding from Allergan and Merck. Dr. Klein has disclosed no relevant financial relationships.

Association for Research in Vision and Ophthalmology 2013 Annual Meeting. Abstract C0030. Presented May 6, 2013.


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