How accurate is the diagnosis of diabetic retinopathy on telescreening? The Indian scenario

Abstract

Context: Diabetes mellitus is a healthcare burden in India. Seventy-four percent of India's population lives in rural areas with limited access to healthcare resources. Telemedicine can play a big role in screening people with diabetes at grassroots level. In the telescreening model, single field 45-degree photographs are used for detecting diabetic retinopathy. The American Academy of Ophthalmology does not recommends single-field fundus photography as an adequate substitute for a comprehensive ophthalmic examination because it may lead to a higher rate of underdiagnosis. We conducted a telescreening project using single-field fundus photography to determine its accuracy compared to the traditional camp-based screenings. Issues: In this project we compared the prevalence of diabetic retinopathy between an ophthalmologist-based and an ophthalmologist-led model on two different samples of people self-reporting with diabetes in rural South India. Between 2004 and 2005 in rural South India, 3522 people with diabetes mellitus underwent ophthalmologist-based diabetic retinopathy screening and 4456 people with diabetes underwent ophthalmologist-led (telescreening) diabetic retinopathy screening. The two population groups were randomly separated. In the ophthalmologist-based program, a trained retina specialist travels along with the camp team and screens patients at the camp site for diabetic retinopathy. In the ophthalmologist-led program (telescreening), fundus photographs are transmitted to the base hospital for further evaluation and grading. A total of 519 people (14.7%) were diagnosed to have diabetic retinopathy in the ophthalmologist-based model, and 853 people (19.1%) in the ophthalmologist-led model (p<0.0001). More sight-threatening retinopathies were found in the ophthalmologist-led model than in the ophthalmologist-based model (6.3% vs 5%). Lessons learned: The ophthalmologist-led (telescreening) model did not underestimate the prevalence of diabetic retinopathy. Therefore, because it obviates the need for travel by an ophthalmologist, it is a good method for diabetic retinopathy screening in rural areas of India.