International Conference on Ophthalmic Photography

Organized by
Australian Institute of Medical and Biological Illustration
Japanese Ophthalmic Photographers' Society
Ophthalmic Imaging Association
Ophthalmic Photographers' Society

Thursday, 18 May 2006
Plenary Session 1
Diabetic Retinopathy Screening I
1.75 OPS Continuing Education Credits
10:15 Introduction by Moderator
Chris J. Barry
Lions Eye Institute
Perth, Western Australia, Australia
10:20 Diabetic Retinopathy Screening Utilizing Telehealth: A Working Program In The Veterans Health Administration
Gary S. Michalec, Mary G. Lawrence, Sandra K. Schmunk
Veterans Administration Medical Center
Minneapolis, Minnesota, USA
Purpose: To validate and establish a program utilizing Telehealth to screen patients with diabetes for diabetic retinopathy in a large, integrated healthcare system.
Materials and Methods: The U.S. Department of Veterans Affairs is the largest health care provider in the United States, performing 55 million medical appointments to some 5.4 million veterans in 2005. With 20% of this patient population afflicted with diabetes, the VA has made detection, education, and treatment of this disease a high priority. With a grant through the VA’s Office of Care Coordination, the Minneapolis Veterans Administration Medical Center has validated and established a working program to identify and screen diabetic patients for diabetic retinopathy. This program uses a non-mydriatic retinal camera with digital imaging capability that interfaces with the VA’s Computerized Patient Record System This allows a patient’s images as well as consult information and medical record be transmitted between a remote image capture site and a centralized reading center.
Results: Since the programs’ inception in 2001, over 9000 imaging procedures have been performed across four sites within the VA’s Midwest Health Care Network. Using components of the Minneapolis program, the Department of Veterans Affairs has committed to a full scale expansion of the Tele-Retinal Screening program, with plans to add over 100 new imaging sites at VA Medical facilities nationwide in 2006.
Conclusions: Through the use of retinal imaging and Telehealth, diabetic patients within the Veterans Health Administration System are receiving the care needed to prevent blindness. It is hoped that the VA can act as a role model to other health organizations in the United States in establishing similar programs to assist their diabetic populations.

10:35 High Throughput Retinal Screening Using Telemedicine
Gerry Skews, Nick Nightingale, Stuart McIntyre, Matthew Adams
Digital Healthcare
Owings Mills, Maryland, USA
Purpose: The large scale screening of patients for retinopathy presents a unique set of challenges for both the technology and the industry. Prevalence of Diabetes in the US now exceeds 20 Million people and they all need to be photographed and their images graded.
After four years of developing and deploying technology for high throughput imaging it seems an ideal time to present a review showing the differences between the principle and the practice.
Materials and Methods: Where once clever analytical algorithms were thought to hold the key to efficient triaging, we actually found that the rather mundane business of administration, security, encryption, digital messaging and electronic referrals are the determinant factors in successful screening programs. As more and more schemes evolve and more methodologies emerge, the role of the skilled imaging specialist and photographer becomes focused on quality of service and management of standards in order to achieve success.
Results: The technical applications and services developed to link primary care to the advanced diagnostic services found in the specialist clinic are critical to the future of retinal imaging. Although the techniques may appear somewhat boring, each patient who has their eyesight saved or prolonged by timely intervention would no doubt disagree.
Conclusions: This review shows how technology is used to follow patients through a defined care pathway in a methodical and coordinated fashion. It shows how literally thousands of patients can be managed and tracked, and how physicians and technicians can all have access to the information that is required to manage a complete sight-saving service.
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10:50 Probing The Morbidity Rate And The Degree Of Diabetic Retinopathy According To Fundus Fluorescein Angiography
Zhangying Wang
Hospital of Inner Mongolia
Zhaowudalu, China
Methods: Heidelberg retinal fluorescein angiography was performed on 857 patients (1714 eyes).
Results: In 1714 eyes there were 811 (47.3%) without DR, 903(52.7%) with DR,.365 (51.50%) with DR I, 213 (23.59%) with DR II, 184 (11.52%) with DR III, 96 (10.63%) with DR IV, 96 (10.63%) with DR V, and 12 (1.33%) with DR VI. In 903 eyes there were 253 (28%) with macular edema, including 94 (37.15%) with focal macular edema, 76(30%) with diffused macular edema, 52 (20.55%) with cystoid macular edema, 22 (8.69%) with ischemia macular edema, and 9 (3.55%) with proliferative macular edema.

11:05 Photographic Retinal Screening For Diabetic Retinopathy - The Experiences Of A New Program In North Carolina (A Preliminary Report)
Marshall E. Tyler, Ramon Velez
Wake Forest University Medical Center
Winston-Salem, North Carolina, USA
Purpose: After many years creating a team to execute a retinal screening program – "I See in NC" – we received funding for a pilot study for a two year program to screen the under-served ophthalmic patients, who are the known diabetics aged 12 and over.
Materials and Methods: We used two semi-portable digital non-mydriatic cameras. One camera was located at a remote location, a four hour drive away, near the coast of the state. The camera was used in a 50+ mile radius from the home clinic. The other camera was moved around over a six county area near our University. Screening locations are typically in hospitals or local public health clinics.
We established the "I See in NC" Diabetic Retinal Screening Reading Center in a dedicated room in the same building as the Ophthalmology Department.
Scheduling of clinic location and patients was done at the remote location using customized software. Trained nurses or other healthcare personnel were responsible for patient education, noting a brief health history focused on the patient's diabetes, recording visual acuity and, of course, retinal photographs.
Results: Images and the appropriate patient demographic information are sent to the reading center via the internet or removable media in encrypted files.
We graded the images in the center and locations in the Department of Ophthalmology as well as at remote locations via secure internet lines.
Letters are sent to the patient's primary care physician. Any other pathology which was seen is also noted in the letter. Reports of the pathology findings by the graders and the cost to benefits balance of the program are of a prime concern. Conclusions: As with any new system of this complexity, strengths and weaknesses arrive with time. These will be discussed with the knowledge that such a service offers valuable eyecare to underserved populations.

11:20 Developing An Accredited Qualification For Diabetic Retinal Screeners
Steve J Aldington
Imperial College Faculty of Medicine
London, England, UK
Purpose: To design, develop, obtain accreditation for, test and implement an educational evaluation package and qualification for staff working in diabetic retinopathy screening in the UK.
Materials and Methods: The UK National Health Service, National Service Framework for Diabetes, effective from 2003, incorporates a requirement to offer systematic screening for diabetic eye disease to 100% of eligible persons with diabetes by the end of 2007. It is a key requirement that all staff members are suitably trained, qualified and/or accredited. What was acutely lacking however was a definitive list of essential skills and knowledge for staff, a formalised and accredited route for assessment and ultimately a recognised qualification. The first stage was one whereby we agreed exactly what comprised and how to classify diabetic retinopathy (the grading algorithms). Next we formulated a list of key skills, attributes, knowledge and characteristics which make up the essential toolkit of a screener/grader. These raised more questions: how were we to ensure people already held or could gain these skills and abilities; what were the most appropriate methods of assessment for each element; who was going to assess and validate the elements; how do the key skills relate to those found in other working areas and what can we learn from them; how and what should we prioritise; what potential benefits would accrue to a person who gained all the necessary skills and competencies; how transferable are the skills? It has been our intention to address these and other key issues through the development of a recognised and accredited formal qualification for diabetic retinopathy screeners, the outcome of which will be illustrated.
Results: A Level 3 City and Guilds of London Institute Diploma qualification has been developed and rolled out to eight pilot sites across the UK. The qualification covers both mandatory and optional elements, includes an MCQ exit exam and requires no less than 300 notional learning hours. Evaluation of the results of the pilot will have been completed by early May 2006.
Conclusions: An accredited qualification has been developed and pilot tested. Full roll-out of the assessment methodology and qualification is planned for the 3rd quarter of 2006 with a view to achieving availability to all by end 2007.

11:35 Panel Discussion: Diabetic Retinopathy Screening

ICOP Home Page | Schedule of Events

Thursday, 18 May 2006 Plenary Session 1 Diabetic Retinopathy Screening I 1.75 OPS Continuing Education Credits
10:15	Introduction by Moderator Chris J. Barry Lions Eye Institute Perth, Western Australia, Australia
10:20	Diabetic Retinopathy Screening Utilizing Telehealth: A Working Program In The Veterans Health Administration Gary S. Michalec, Mary G. Lawrence, Sandra K. Schmunk Veterans Administration Medical Center Minneapolis, Minnesota, USA Purpose: To validate and establish a program utilizing Telehealth to screen patients with diabetes for diabetic retinopathy in a large, integrated healthcare system. Materials and Methods: The U.S. Department of Veterans Affairs is the largest health care provider in the United States, performing 55 million medical appointments to some 5.4 million veterans in 2005. With 20% of this patient population afflicted with diabetes, the VA has made detection, education, and treatment of this disease a high priority. With a grant through the VA’s Office of Care Coordination, the Minneapolis Veterans Administration Medical Center has validated and established a working program to identify and screen diabetic patients for diabetic retinopathy. This program uses a non-mydriatic retinal camera with digital imaging capability that interfaces with the VA’s Computerized Patient Record System This allows a patient’s images as well as consult information and medical record be transmitted between a remote image capture site and a centralized reading center. Results: Since the programs’ inception in 2001, over 9000 imaging procedures have been performed across four sites within the VA’s Midwest Health Care Network. Using components of the Minneapolis program, the Department of Veterans Affairs has committed to a full scale expansion of the Tele-Retinal Screening program, with plans to add over 100 new imaging sites at VA Medical facilities nationwide in 2006. Conclusions: Through the use of retinal imaging and Telehealth, diabetic patients within the Veterans Health Administration System are receiving the care needed to prevent blindness. It is hoped that the VA can act as a role model to other health organizations in the United States in establishing similar programs to assist their diabetic populations.
10:35	High Throughput Retinal Screening Using Telemedicine Gerry Skews, Nick Nightingale, Stuart McIntyre, Matthew Adams Digital Healthcare Owings Mills, Maryland, USA Purpose: The large scale screening of patients for retinopathy presents a unique set of challenges for both the technology and the industry. Prevalence of Diabetes in the US now exceeds 20 Million people and they all need to be photographed and their images graded. After four years of developing and deploying technology for high throughput imaging it seems an ideal time to present a review showing the differences between the principle and the practice. Materials and Methods: Where once clever analytical algorithms were thought to hold the key to efficient triaging, we actually found that the rather mundane business of administration, security, encryption, digital messaging and electronic referrals are the determinant factors in successful screening programs. As more and more schemes evolve and more methodologies emerge, the role of the skilled imaging specialist and photographer becomes focused on quality of service and management of standards in order to achieve success. Results: The technical applications and services developed to link primary care to the advanced diagnostic services found in the specialist clinic are critical to the future of retinal imaging. Although the techniques may appear somewhat boring, each patient who has their eyesight saved or prolonged by timely intervention would no doubt disagree. Conclusions: This review shows how technology is used to follow patients through a defined care pathway in a methodical and coordinated fashion. It shows how literally thousands of patients can be managed and tracked, and how physicians and technicians can all have access to the information that is required to manage a complete sight-saving service. M.td<
10:50	Probing The Morbidity Rate And The Degree Of Diabetic Retinopathy According To Fundus Fluorescein Angiography Zhangying Wang Hospital of Inner Mongolia Zhaowudalu, China Methods: Heidelberg retinal fluorescein angiography was performed on 857 patients (1714 eyes). Results: In 1714 eyes there were 811 (47.3%) without DR, 903(52.7%) with DR,.365 (51.50%) with DR I, 213 (23.59%) with DR II, 184 (11.52%) with DR III, 96 (10.63%) with DR IV, 96 (10.63%) with DR V, and 12 (1.33%) with DR VI. In 903 eyes there were 253 (28%) with macular edema, including 94 (37.15%) with focal macular edema, 76(30%) with diffused macular edema, 52 (20.55%) with cystoid macular edema, 22 (8.69%) with ischemia macular edema, and 9 (3.55%) with proliferative macular edema.
11:05	Photographic Retinal Screening For Diabetic Retinopathy - The Experiences Of A New Program In North Carolina (A Preliminary Report) Marshall E. Tyler, Ramon Velez Wake Forest University Medical Center Winston-Salem, North Carolina, USA Purpose: After many years creating a team to execute a retinal screening program – "I See in NC" – we received funding for a pilot study for a two year program to screen the under-served ophthalmic patients, who are the known diabetics aged 12 and over. Materials and Methods: We used two semi-portable digital non-mydriatic cameras. One camera was located at a remote location, a four hour drive away, near the coast of the state. The camera was used in a 50+ mile radius from the home clinic. The other camera was moved around over a six county area near our University. Screening locations are typically in hospitals or local public health clinics. We established the "I See in NC" Diabetic Retinal Screening Reading Center in a dedicated room in the same building as the Ophthalmology Department. Scheduling of clinic location and patients was done at the remote location using customized software. Trained nurses or other healthcare personnel were responsible for patient education, noting a brief health history focused on the patient's diabetes, recording visual acuity and, of course, retinal photographs. Results: Images and the appropriate patient demographic information are sent to the reading center via the internet or removable media in encrypted files. We graded the images in the center and locations in the Department of Ophthalmology as well as at remote locations via secure internet lines. Letters are sent to the patient's primary care physician. Any other pathology which was seen is also noted in the letter. Reports of the pathology findings by the graders and the cost to benefits balance of the program are of a prime concern. Conclusions: As with any new system of this complexity, strengths and weaknesses arrive with time. These will be discussed with the knowledge that such a service offers valuable eyecare to underserved populations.
11:20	Developing An Accredited Qualification For Diabetic Retinal Screeners Steve J Aldington Imperial College Faculty of Medicine London, England, UK Purpose: To design, develop, obtain accreditation for, test and implement an educational evaluation package and qualification for staff working in diabetic retinopathy screening in the UK. Materials and Methods: The UK National Health Service, National Service Framework for Diabetes, effective from 2003, incorporates a requirement to offer systematic screening for diabetic eye disease to 100% of eligible persons with diabetes by the end of 2007. It is a key requirement that all staff members are suitably trained, qualified and/or accredited. What was acutely lacking however was a definitive list of essential skills and knowledge for staff, a formalised and accredited route for assessment and ultimately a recognised qualification. The first stage was one whereby we agreed exactly what comprised and how to classify diabetic retinopathy (the grading algorithms). Next we formulated a list of key skills, attributes, knowledge and characteristics which make up the essential toolkit of a screener/grader. These raised more questions: how were we to ensure people already held or could gain these skills and abilities; what were the most appropriate methods of assessment for each element; who was going to assess and validate the elements; how do the key skills relate to those found in other working areas and what can we learn from them; how and what should we prioritise; what potential benefits would accrue to a person who gained all the necessary skills and competencies; how transferable are the skills? It has been our intention to address these and other key issues through the development of a recognised and accredited formal qualification for diabetic retinopathy screeners, the outcome of which will be illustrated. Results: A Level 3 City and Guilds of London Institute Diploma qualification has been developed and rolled out to eight pilot sites across the UK. The qualification covers both mandatory and optional elements, includes an MCQ exit exam and requires no less than 300 notional learning hours. Evaluation of the results of the pilot will have been completed by early May 2006. Conclusions: An accredited qualification has been developed and pilot tested. Full roll-out of the assessment methodology and qualification is planned for the 3rd quarter of 2006 with a view to achieving availability to all by end 2007.
11:35	Panel Discussion: Diabetic Retinopathy Screening