Rebecca & Andrew sit down 16.4.18

Rebecca & Andrew sit down 16.4.18
From Unit 21 Observation Checklist

Question 1 (AC 1.3)
Describe feature based grading in Diabetic Retinal Screening?
offering a measure of specificity when assessing a fundus for diabetic eye disease, allows for the monitoring of progression / treatment response of pathology. Most commonly these days digital images have the potential to be processed by automatic analysis systems (AI), as well as the human eye (optometrist / ophthalmologist / lay persons)

What could be the consequence if features were not entered onto the software accurately?
Can you give an example of when incorrect recording of features could give an adverse outcome for a patient?
thankfully i cant personally offer an example but the best theoretical example is the wrong information was recorded for a patient & no secondary checks done (ie if we have seen the px before, do the photos look similar) and thus leading to pathology being missed
id like to think in the latter instance though an optometrist would physically see the fundus & act accordingly
Good example is px whom is lax with DRS, last exam 7 years ago, it maybe another seven years before they attend again. There is potentially one chance to help save this patient’s sight.
In a hypothetical case if the wrong photos were taken / incorrectly inputted then there is the extra cost (chair time / admin fees / px time / lost confidence in the service). One could also consider the extra costs for retraining the photographer / grader.

Question 2 (AC1.4)
You are grading a set of images; an error message comes on the screen. What would you do?
depends on the nature of the error message -
most common is software crash, where Microsoft offers to send off an error report, usually after attempting to take a first retinal image. After this, when i need to review a photo or resume taking photos after the software crash it will prompt me to make sure NO-ONE else is reviewing said photos (system will prompt to NOT do unless certain no-one else has a session open for the same patient elsewhere).
“Vector cannot access the database and has closed” - in this case, re-check VPN is working by attempting a second log in and then if the same message crops up after this, it probably means that the server is off-line (expect email from head of team citing server is down).

Question 3 (AC 2.1, 2.2, 2.3)
What are the definitions of gradability for both the macular centre and disc centred images?
Macular image: centre of fovea >2DD from edge of image  & vessels visible within 1DD of centre of fovea
Disc image: all of optic disc >2DD from edge of image  & fine vessels visible on surface of disc
No obstructions to the view, (can see small vasculature after 3 branches without excessive zoom / post capture image modification)
In what circumstances would an unassessable image become assessable?
If any referable pathology is seen (e.g. R2, M1 and R3), it’s automatically considered assessable & referred to HES (irrespective of urgent / routine) else px is referred to slit lamp bio clinic

What reasons are there for unassessable images both ocular and non-ocular?
Ocular -
Field position unacceptable (refer to centration of mac / ONH)
Difficulty obtaining correct position due to Nystagmus
Lack of Clarity posterior (media opacity / high astigmatism)
Anterior anomalies - Iris trauma, corneal dystrophies, scarring

Non-Ocular -
Head posotion (neck . back . head posture prohibit a picture being taken on a desk mounted camera) only seen in a hand full of cases.
Poor communication - language/deafness/dementia providing an inability to obey the instructions required for photography
Px reluctance, patient’s who are unwilling to adhere
Lens artefacts from a dirty camera lens.
What should be done to overcome obstacles to obtaining assessable images?
lid tape or mechanical movement of lid ptosis
pupils dilated
hair out the way
ensure good fixation target / fixation target is visible
Ensure given instructions are as clear as possible
double up on dilation drops
use alternate photos (should software be unavailable)
small pupil setting on the camera
Take numerous photos to move floaters out of position
Ensure anterior photos are taken of those with anterior opacities to help second graders identify reasons for unclear images or low VAs.

What is the correct pathway for patients with unassessable images?
Any referral pathology, automatically refer & bypass ungradeable status
Field position unacceptable refer to S/L biomicroscopy
Clarity unacceptable refer to S/L biomicroscopy
if physical limitation (ie px cant reach head rest for camera / slit lamp - consider removal from system) only had one where px was wheel chair bound & had a head in head band

Are all patients with unassessable images sent to Slit lamp clinics?
No, there are instances where Px cant reach a slit lamp (posture / tremor) and px should be discharged from the service as they would have the same problem with slitlamps as they would fundus camera - which unfortunately means most things that can be done medically would also counter-indicated due to excessive risk of surgery
Additionally, any referral pathology, automatically refer & bypass ungradeable status

Question 4 (AC 4.1)
Can you describe the internal quality assurance process for grading?
Step one - all photos are second graded and in occasions of urgent referral because straight to an ROG (which is a referral outcome grader) and I high proportion of cases.
In cases where a photo has been graded as routine referral, the second grader is blind to this previous grading and so the images are graded independently. If both graders agree, this referral moves forward. If there is a discrepancy between the first and second grader, this is sent to a ROG, who makes the final call.
1/10 of all routine, no retinopathy photos are sent for full quality assurance checks to ensure the graders have graded accordingly.

Can you describe the national grading pathway? difference between R0/R1/R2/R3 ?
Non referable retinopathy: Patients who are found to have no referable retinopathy (grades R0, R1, M0) will be listed for routine recall in the future 12/12.
Routine referral retinopathy: Patients with retinopathy (grades R2, M1) are referred routinely to the Hospital Eye Service. In Greater Manchester the graded photos are sent directly to ophthalmology to be triaged by the Diabetic Consultant Ophthalmologist before any referral letter is issued to the patient. Upon agreeing the patient needs to be seen the details of the patient are made available to the HES and an appointment is made and sent to the patient to be seen. Usual waiting time should be <10 weeks routine.
Urgent referral retinopathy: Patients with urgent retinopathy (grade R3) are once again referred to HES, but they will appear top of the triage file and are flagged with an urgent message. The images are seen within one day and upon the ophthalmologist agreeing that an urgent appointment is required, the HES once again contact the patient to issue an appointment within 2 weeks.

Ungradeable Images: are referred for Slit lamp biomicroscopy.
-R0 and M0 are classed as non-referable, and px can be reassured and recalled in another 12/12
-R1 is described as (benign) background changes (scattered dot/blot haemorrhages and exudates CWS in the presence of non-referable features and outside of the macula area)
-R2 consists of more significant change in the blood vessels, like beading, Deep round blot haemorrhages and IRMA.
-R3 changes are urgent and significant changes such as new vessels, vitreous haemorrhage and pre retinal fibrosis.

Question 5 (AC 4.4)
Why is timely grading important?
In the event of a dangerous pathology (ie ret detach) would lead to serious complications if left untreated or ungraded for a significant period of time. I, personally when seen in practice, have phoned the HES even though px there for DRS in the presence of “dangerous” pathology.

What should be done to ensure timely grading is delivered in a Screening Programme?
Ideally grade the photos there & then to avoid any data transmission errors / system failures (software crashing is the main issued though it usually BEFORE photos are taken)

What are the necessary conditions for grading?
Adequately positioned and clear photos and the ability and knowledge of the grader needed to identify and correctly grade the various levels of retinopathy. A transparent grading software program is also required to minimise risk of human error.

What measures should be done to prevent fatigue of graders?
In clinic allowing for a reasonable but not excessive number of patients to be seen, so that patient experience is not compromised and so that the grader has time to adequately assess and grade their photos. targets are important for graders to ensure their knowledge and skills are up to date, however these targets should be achievable in normal practice.

Question 6 (AC 5.1, 5.2)
List the features that compose the varies levels of diabetic retinopathy (including advanced proliferative retinopathy)
Retinopathy (R) Action
Level R0 None = Annual photographic screen
Level R1 Background Retinopathy = Annual photographic screen
Any of:  MAs or intra-retinal haemorrhages anywhere  Any exudate(s) in the presence of other features of DR and not falling into the definition of maculopathy  Venous loop  Any number of CWS in the presence of other non-referrable features of DR
Level R2 Pre-proliferative Retinopathy = Routine referral to HES
Any of:  Venous beading  Venous reduplication  Multiple large, deep, round blot haemorrhages  IRMA
Level R3a Active Proliferative Retinopathy = Urgent referral to HES
Any of:  NVD  NVE  New pre-retinal or vitreous haemorrhage  New pre-retinal fibrosis +/- tractional retinal detachment  Rubeosis iridis  Reactivation in a previous stable R3s eye
Level R3s Stable Proliferative Retinopathy = Annual photographic screen
Evidence of peripheral scatter laser AND a photograph taken at or shortly after discharge from the HES plus any of the following:  Stable pre-retinal fibrosis  Stable fibrous proliferation  Stable R2 features  R1 features

Maculopathy (M)
Level M0 None
Level M1  Routine referral to HES
Any of:  hard exudates (single or multiple)  within 1 disc diameter (DD) of the centre of the fovea.  group of hard exudates within the macular area (see overleaf)  Retinal thickening within 1DD of the centre of the fovea (if stereo available)  any MA or haemorrhage within 1DD of the centre of the fovea only if associated with unexplained best VA of  6/12 or less (if no stereo)

Photocoagulation (P)
Level P0 None
Level P1  Previous macular or peripheral laser treatment.

What are the surrogate markers for diabetic macular oedema? Anything that grades as "M1"
As macular oedema is not directly visible on two dimensional digital photographs such that surrogate markers need to be used. In the English National Screening Programme these are exudate within one optic disc diameter (DD) of the fovea, group of exudates within two DD of the fovea and haemorrhages or microaneurysms (HMA) within one DD of the fovea WITH best corrected visual acuity (VA) worse than 6/9. All patients who present with any of these surrogate markers at screening are referred to an ophthalmology clinic for slit lamp examination.

Which surrogate marker is most sensitive in predicting the presence of macular oedema ?
Exudates
In a recent article http://publications.aston.ac.uk/17027/
Maculopathy by exudates: Of 155 patients 45 (29%) showed thickening on the OCT of these 12 required laser.
Those who also had pre-proliferative retinopathy (n=20) were more likely to have macular oedema (75%) than those with background diabetic retinopathy.
Maculopathy by HMA and VA worse than 6/9: Of 66 patients 11 (16.7%) showed thickening on the OCT. 5 (7.6%) of these had macular oedema, 5 (7.6%) epi-retinal membrane, and 1 (1.5%) age related macular degeneration. None of these patients required laser.
CONCLUSIONS. The likelihood of the presence of macular oedema and requiring laser treatment is greater with macular exudation than HMA within one DD and reduced VA. Overall the surrogate markers used show low specificity for macular oedema, however combining OCT with photography does identify those with macular oedema who require a true referral for an ophthalmological slit lamp examination.

Question 7 (AC 5.3)
What are the confounders for diabetic maculopathy?
A confounder is a retinal feature e.g. drusen / amd / csr which may be mistaken for a diabetic change.
Name 3 confounders for diabetic retinopathy and for each one explain how you distinguish it from true diabetic retinopathy
Venkatramani J, Mitchell P: Ocular and systemic causes of retinopathy in patients without diabetes mellitus. BMJ 328:625–629, 2004 [PMC free article = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC381138/ ]
Radiation retinopathy: a mistaken diagnosis of hypertensive retinopathy
Vignesh Raja MRCS MRCOphth
Sripriya Rajagopalan MRCS
Tarek Kashab MRCOphth
Brendan Moriarty FRCOphth https://onlinelibrary.wiley.com/doi/full/10.1111/j.1444-0938.2007.00133.x
Ocular = Retinal vein occlusion / Radiation retinopathy / Ocular ischaemic syndrome
Systemic = Diabetes / Hypertension / Sickle cell disease / Aplastic anaemia / AIDS related microangiopathy / Leukaemia / Systemic lupus erythematosis / Collagen vascular diseases

Question 8 (AC 6.2)
Who receives the retinal screening results?
Digital pictures stored locally (and anonymously) & at the server farm owned by manchester diabetic screening program "VECTOR" in Salford.
Outcome of the screening results when routine review - to px & to GP - a letter is received within 3 weeks.
Outcome of the screening results when further referral required (urgent / routinely) - to the HES, to px & to GP

What are timings for the results in order to conform to national Retinal Screening Quality Standards?
URGENT 1. 90%  <2 weeks
ROUTINE 2. 70% <10 weeks
NO REFERRAL - The national targets state that 70% of patients (and their GPs) should receive their results by letter within three weeks of attending their screening appointment and that 100% of patients should receive results within 6 weeks.
The best screening programmes will aim for 95% within 3 weeks.

What are the advantages and disadvantages of giving the patient a result at the time of screening?
PRO -
-Px can relax & stop worrying when its R0M0 or R1M0.
-Or we can explain WHY we want a doctor to look at R0M1 or R2M0 or R2M1 cases.
-Additionally, If the patient is shown their images and shown potential pathology it makes the diagnosis more real, and may encourage them to better their lifestyles in the presence of retinopathy.
-Saves the grader time having to grade the images later.
CON
-what if we get it wrong - px loses confidence in us when miss something / over refer as Px has to handle an over zealous ophthalmologist
-in the presence of more concerning pathology, Px may become anxious and worried in practice, presenting the grader with additional challenges of offering emotional support.