Validation of the Electronic Mailing of Retinographs of Diabetic Patients in Order to Detect Retinopathy in Primary Care
Validación de la transmisión por correo electrónico de la retinografía de pacientes diabéticos para detectar retinopatía en atención primaria
Eduardo Molina Fernándeza, M Sacramento Valero Mollb, Miguel Pedregal Gonzáleza, José Calvo Lozanoc, José Luis Sánchez Ramosd, Eusebio Díaz Rodríguezb, Rosario Uceda Torresb
a Family and Community Medicine, UDMFyC Huelva, Huelva-Costa Health District. Huelva, Spain.
b Ophthalmology Department, Juan Ramón Jiménez FEA Hospital, Huelva, Spain.
c Family and Community Medicine, Primary Care Service, Molino de la Vega Health Centre, Huelva-Costa Health District, Huelva, Spain.
d Professor of Statistics, University of Huelva, Huelva, Spain
Read
6241
Timeswas read the article
963
Total PDF
5278
Total HTML
Share statistics
array:22 [ "pii" => "13116626" "issn" => "02126567" "doi" => "10.1157/13116625" "estado" => "S300" "fechaPublicacion" => "2008-03-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Aten Primaria. 2008;40:119-23" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4329 "formatos" => array:3 [ "EPUB" => 51 "HTML" => 3808 "PDF" => 470 ] ] "Traduccion" => array:1 [ "es" => array:18 [ "pii" => "13116625" "issn" => "02126567" "doi" => "10.1157/13116625" "estado" => "S300" "fechaPublicacion" => "2008-03-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Aten Primaria. 2008;40:119-23" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4336 "formatos" => array:3 [ "EPUB" => 48 "HTML" => 3810 "PDF" => 478 ] ] "es" => array:11 [ "idiomaDefecto" => true "titulo" => "Validación de la transmisión por correo electrónico de la retinografía de pacientes diabéticos para detectar retinopatía en atención primaria" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "119" "paginaFinal" => "123" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Validation of the Electronic Mailing of Retinographs of Diabetic Patients in Order to Detect Retinopathy in Primary Care" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eduardo Molina Fernández, M Sacramento Valero Moll, Miguel Pedregal González, José Calvo Lozano, José Luis Sánchez Ramos, Eusebio Díaz Rodríguez, Rosario Uceda Torres" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Molina Fernández" ] 1 => array:2 [ "nombre" => "M Sacramento" "apellidos" => "Valero Moll" ] 2 => array:2 [ "nombre" => "Miguel" "apellidos" => "Pedregal González" ] 3 => array:2 [ "nombre" => "José" "apellidos" => "Calvo Lozano" ] 4 => array:2 [ "nombre" => "José Luis" "apellidos" => "Sánchez Ramos" ] 5 => array:2 [ "nombre" => "Eusebio" "apellidos" => "Díaz Rodríguez" ] 6 => array:2 [ "nombre" => "Rosario" "apellidos" => "Uceda Torres" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "13116626" "doi" => "10.1157/13116625" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13116626?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13116625?idApp=UINPBA00004N" "url" => "/02126567/0000004000000003/v0_201307091235/13116625/v0_201307091235/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "13116625" "issn" => "02126567" "doi" => "10.1157/13116625" "estado" => "S300" "fechaPublicacion" => "2008-03-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Aten Primaria. 2008;40:119-23" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4336 "formatos" => array:3 [ "EPUB" => 48 "HTML" => 3810 "PDF" => 478 ] ] "es" => array:11 [ "idiomaDefecto" => true "titulo" => "Validación de la transmisión por correo electrónico de la retinografía de pacientes diabéticos para detectar retinopatía en atención primaria" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "119" "paginaFinal" => "123" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Validation of the Electronic Mailing of Retinographs of Diabetic Patients in Order to Detect Retinopathy in Primary Care" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eduardo Molina Fernández, M Sacramento Valero Moll, Miguel Pedregal González, José Calvo Lozano, José Luis Sánchez Ramos, Eusebio Díaz Rodríguez, Rosario Uceda Torres" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Molina Fernández" ] 1 => array:2 [ "nombre" => "M Sacramento" "apellidos" => "Valero Moll" ] 2 => array:2 [ "nombre" => "Miguel" "apellidos" => "Pedregal González" ] 3 => array:2 [ "nombre" => "José" "apellidos" => "Calvo Lozano" ] 4 => array:2 [ "nombre" => "José Luis" "apellidos" => "Sánchez Ramos" ] 5 => array:2 [ "nombre" => "Eusebio" "apellidos" => "Díaz Rodríguez" ] 6 => array:2 [ "nombre" => "Rosario" "apellidos" => "Uceda Torres" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "13116626" "doi" => "10.1157/13116625" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13116626?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13116625?idApp=UINPBA00004N" "url" => "/02126567/0000004000000003/v0_201307091235/13116625/v0_201307091235/es/main.assets" ] "itemAnterior" => array:17 [ "pii" => "13116624" "issn" => "02126567" "doi" => "10.1157/13116624" "estado" => "S300" "fechaPublicacion" => "2008-03-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Aten Primaria. 2008;40:115-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 13988 "formatos" => array:3 [ "EPUB" => 58 "HTML" => 11986 "PDF" => 1944 ] ] "es" => array:9 [ "idiomaDefecto" => true "titulo" => "Aportaciones de la atención primaria y la salud pública al desarrollo de la salud comunitaria" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "115" "paginaFinal" => "117" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Contributions of Primary Care and Public Health to the Development of Community Health" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M Isabel Pasarín Rua, Rick Miller, Andreu Segura Benedicto" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M Isabel" "apellidos" => "Pasarín Rua" ] 1 => array:2 [ "nombre" => "Rick" "apellidos" => "Miller" ] 2 => array:2 [ "nombre" => "Andreu" "apellidos" => "Segura Benedicto" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13116624?idApp=UINPBA00004N" "url" => "/02126567/0000004000000003/v0_201307091235/13116624/v0_201307091235/es/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Validation of the Electronic Mailing of Retinographs of Diabetic Patients in Order to Detect Retinopathy in Primary Care" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "119" "paginaFinal" => "123" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Eduardo Molina Fernández, M Sacramento Valero Moll, Miguel Pedregal González, José Calvo Lozano, José Luis Sánchez Ramos, Eusebio Díaz Rodríguez, Rosario Uceda Torres" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Molina Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "M Sacramento" "apellidos" => "Valero Moll" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Miguel" "apellidos" => "Pedregal González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "José" "apellidos" => "Calvo Lozano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 4 => array:3 [ "nombre" => "José Luis" "apellidos" => "Sánchez Ramos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] 5 => array:3 [ "nombre" => "Eusebio" "apellidos" => "Díaz Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 6 => array:3 [ "nombre" => "Rosario" "apellidos" => "Uceda Torres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Family and Community Medicine, UDMFyC Huelva, Huelva-Costa Health District. Huelva, Spain." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Ophthalmology Department, Juan Ramón Jiménez FEA Hospital, Huelva, Spain." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Family and Community Medicine, Primary Care Service, Molino de la Vega Health Centre, Huelva-Costa Health District, Huelva, Spain." "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Professor of Statistics, University of Huelva, Huelva, Spain" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Validación de la transmisión por correo electrónico de la retinografía de pacientes diabéticos para detectar retinopatía en atención primaria" ] ] "textoCompleto" => "<p class="elsevierStylePara"> Introduction</p><p class="elsevierStylePara">Diabetic retinopathy (DR) is a highly prevalent, chronic and progressive disease. It is the second cause of blindness in Spain and the second in people of working age.<span class="elsevierStyleSup">1</span> Even in its most aggressive forms, loss of acute vision symptoms are not normally present, so when there is a decrease it is usually too late for effective treatment. For this reason early detection is vital.</p><p class="elsevierStylePara">Laser photocoagulation prevents or delays vision loss in a good number of patients.<span class="elsevierStyleSup">2</span> Photographs of the back of the eye are more reliable than ophthalmoscope for diagnosis.<span class="elsevierStyleSup">3</span> Studies have validated the digital image as the most ideal method for DR screening.<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">In the Andalusian Health System the diagnosis and follow-up of type 2 diabetic patients is carried out in primary care centres. In those centres, the health network allows digital images taken, to be sent by e-mail to a reference centre to be stored and studied by ophthalmologists for classification and treatment of DR.</p><p class="elsevierStylePara">Studies are required to assess the real use of this method and, its practicality in providing full cover for the diabetic population, and its direct relationship at the 2 care levels and, its potential to reduce costs with a greater benefit for patients and the system.</p><p class="elsevierStylePara">To achieve this, we proposed the following objectives:</p><p class="elsevierStylePara">to evaluate the concordance of biomicroscopy between ophthalmologists. To analyse the validity of digital photographs (received by e-mail) read by ophthalmologists and family doctors to detect DR, and to look at the benefits for patients.</p><p class="elsevierStylePara"><img src="27v40n03-13116626tab01.gif"></img></p><p class="elsevierStylePara">General Scheme of the Study. Observational, descriptive. Parallel, blind assessment, for observers of the degree of diabetic retinopathy by means of a study with a biomicroscope and by comparing this with a digital photograph image (retinography).</p><p class="elsevierStylePara"> Methods</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Design</span></p><p class="elsevierStylePara">Observational, descriptive. Parallel blind assessment, of the degree of DR measured with a biomicroscope and comparing this with a digital photographic image.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Population and Sample</span></p><p class="elsevierStylePara">Type 2 diabetic patients, who had not received photocoagulation, consecutively selected on arriving at a clinic.</p><p class="elsevierStylePara">The sample size for the kappa index is N=196 (15% disagreement ratio, precision 5%, and a 95% confidence level).<span class="elsevierStyleSup">5</span> For validation, for a 95% negative predictive value, precision 5% and a 95% confidence level, N=73.</p><p class="elsevierStylePara">It was increased to Na=91, according to Na=N [1/(1­R)], for losses.<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Measured Variables</span></p><p class="elsevierStylePara">Degree of DR in the digital photograph and biomicroscopy, according to the modified Early Treatment Diabetic Research Study (ETDRS) classification,<span class="elsevierStyleSup">7</span> measured by an ophthalmologist. Macular oedema was excluded as stereoscopic photographs could not be taken.</p><p class="elsevierStylePara">Diagnosis of DR in the photograph by the family doctor.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Data Collection and Variable Measurement Techniques</span></p><p class="elsevierStylePara">In a first group of participants, a family doctor, previously trained in ophthalmology, took 3 photographs (JPEG format) of each eye with a Topcon® TRC-50 EX mydriatic retinograph, under mydriasis with tropicamide with or without phenylephrine, and of the, macular, nasal and upper temporal fields.<span class="elsevierStyleSup">8</span> With the second group, a Topcon® NW100 non-mydriatic retinograph was used, with first ones always without dilation and the following ones dilated with tropicamide when, in their opinion, the quality of the photograph was not good. In both cases, 3 photographs, nasal, central, and temporal (immovable fixed points in this retinograph), were taken.</p><p class="elsevierStylePara">The photographs were sent by e-mail to the Juan Ramón Jiménez Hospital, using the program Outlook 2000®, over the Andalusia Regional Government Corporate network.</p><p class="elsevierStylePara">The eye fundus (3 photos) was divided into 6 fields: papilla, macula, upper, lower, temporal, and nasal; it was considered "not assessable" when more than 3 were of poor quality.</p><p class="elsevierStylePara">The patients were sent to the ophthalmologist with 3 weeks to avoid any progression of the DR causing discordances.</p><p class="elsevierStylePara">Biomicroscopy was performed independently by 2 ophthalmologists with a slit lamp and a non-contact lens (VOLK Super 66)® or a contact lens (Ocular MAINSTER Standard Focal/Grid®), if the version was inappropriate.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Data Analysis</span></p><p class="elsevierStylePara">Weighted linear and quadratic kappa index, was used to assess the agreement of the biomicroscopy between ophthalmologists. For the strength of the agreement the Landis and Koch<span class="elsevierStyleSup">9</span> scale was used. To test the validity, sensitivity (Se), specificity (Sp), the positive predictive value (PPV), and the negative predictive value (NPV), for all the standards and confidence intervals (CI) were measured.</p><p class="elsevierStylePara">Version 11.0 of the SPSS program and version 6.0 of EpiInfo program was used.</p><p class="elsevierStylePara"> Results</p><p class="elsevierStylePara">There were 352 retinal photographs performed; 99 with a mydriatic retinograph (MYD), 247 non-mydriatic (NOMYD): 112 always with no dilation (NOMYD-ND) and 135 with elective dilation (NOMYD-D). Six eyes (1.7%) eyes were lost, 4 due to storage errors and 2 due to duplication of the examination in the same eye. There were no losses in the electronic transmission.</p><p class="elsevierStylePara">The mean age and standard deviation of the patients was 65.4±9.9 years.</p><p class="elsevierStylePara">The ophthalmologist considered 28% of the examinations non-assessable (17.2% of those performed with MYD, 38.4% of the NOMYD-ND, and 27.4% of the NOMYD-D) (<span class="elsevierStyleItalic">P</span>=.0027). Cataracts were more common in the non-assessables (63.42%) than in the assessables (15.32%) (<span class="elsevierStyleItalic">P</span><.001).</p><p class="elsevierStylePara">Similarly with other problems of transparency (5.8% compared to 4.9%; <span class="elsevierStyleItalic">P</span>=.005). A family doctor made 291 examinations, of which 23.71% were non-assessable compared with 50.9% which made 55 (<span class="elsevierStyleItalic">P</span>=.004).</p><p class="elsevierStylePara">Of the retinal photographs read by ophthalmologists, 25.7% had DR: 10.4% mild (MiDR), 12% moderate (MoDR), and 3.2% severe (SDR).</p><p class="elsevierStylePara">The family doctor considered 13.6% of the retinal photographs non-assessable. Of the assessable ones, 36.5% had DR.</p><p class="elsevierStylePara">Overall, 328 biomicroscopies were performed, as 12 of the patients (24 eyes) did not turn up, 3 of them had lesions in both eyes, and in 1 the lesion was MoDR. Four were non-assessable (1 due to a detached retina, 2 due to cataracts, and 1 with no diagnosis). Of the 28.7% who had a lesion: 12.65% were MiDR; 13.9%, MoDR; 1.8%, SDR; and 0.3% very severe (VSDR). The mean time between the retinograph and the biomicroscopy was 15.6 days, and ranged between 2 and 68 days.</p><p class="elsevierStylePara">The agreement in biomicroscopy between ophthalmologist was "very good" (linear weighted kappa =0.80; 95% CI, 0.73-0.88, and quadratic weighted kappa =0.88; 95% CI, 0.65-0.95).</p><p class="elsevierStylePara">Table 1 shows the validity results of digital photographs read by the ophthalmologists and family doctors as a method for detecting DR and referable DR (grade ≥MoDR), and in Table 2, that of the ophthalmologists differentiated by retinal photographs. Significant differences were found in sensitivity in favour of MYD (<span class="elsevierStyleItalic">P</span>=.009), compared to NOMYD-ND.</p><p class="elsevierStylePara"><img src="27v40n03-13116626tab02.gif"></img></p><p class="elsevierStylePara"><img src="27v40n03-13116626tab03.gif"></img></p><p class="elsevierStylePara"> Discussion</p><p class="elsevierStylePara">The agreement in biomicroscopy was "very good." It enables the examination by an ophthalmologist to be like a reference test.</p><p class="elsevierStylePara">The time between the 2 tests was not seen to influence the differences, since it was too short for the lesions to progress.</p><p class="elsevierStylePara">We found the sensitivity to be slightly less than the 80% recommended by the British Diabetic Association<span class="elsevierStyleSup">10</span> and a specificity slightly higher than the recommended 95%. With NOMYD-SD, the sensitivity is clearly lower, although specificity is maintained. This decrease in sensitivity is found by the majority of authors. When the eyes which had had poor quality photographs were subsequently dilated, we found a great improvement in the sensitivity, although lower than MYD dilating to 100% and with higher temporal field. In this case, the sensitivity and specificity are similar to those of Baeza Díaz et al,<span class="elsevierStyleSup">11</span> using 3 fields and dilation if the examination quality was poor, or Murgatroyd et al,<span class="elsevierStyleSup">12</span> who used 3 fields with dilation, and somewhat higher than that of other authors such as Harding et al<span class="elsevierStyleSup">13</span> and Lawrence,<span class="elsevierStyleSup">14</span> with 3 fields, or Scanlon et al,<span class="elsevierStyleSup">15,16</span> Olson et al<span class="elsevierStyleSup">17</span>, or Stellingwerf et al,<span class="elsevierStyleSup">18</span> with 2.</p><p class="elsevierStylePara">The negative predictive value was taken as a reference for the sample size, since, on having an effective treatment for DR, it is important to avoid the patients with a lesion being diagnosed as healthy. In our case it was very good and similar to that found by Stellingwerf et al<span class="elsevierStyleSup">18</span> and lower than that of Baeza Díaz et al.<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">Although 28% of the examinations were non-assessable, it would be 5.8% if we discard those who had cataracts or opacities, which is around the 5% recommended by the British Diabetic Association.<span class="elsevierStyleSup">10</span> If we analyse by methods, the losses decrease with dilation, and this difference is statistically significant. Murgatroyd et al,<span class="elsevierStyleSup">12</span> achieved a reduction in non-assessables from 26% to 5% by dilating the eyes to 100%. The difference found between the MYD and NOMYD could be due to 3 different causes: the first could be the dilation of the eyes to 100% instead of 50.74% and, also a higher dilation by using 2 drops of tropicamide and phenylephrine if 1 was not sufficient. The second could be the greater temporal field which cannot be done with NOMYD. This would have less influence because, although some authors, such as Baeza et al,<span class="elsevierStyleSup">11</span> found slight improvements in the sensitivity for retinopathy, others, such as Perrier et al<span class="elsevierStyleSup">19</span> and Baeza et al themselves, did not find any when they studied referable retinopathy. Also, the third field does not reduce the losses. The third reason could be the difference in technical quality of the retinal photographs. That from the MYD was higher than the NOMYD used, which was a portable apparatus with poorer software.</p><p class="elsevierStylePara">On the other hand, many disadvantages were observed: MYD required much more time to learn than NOMYD and it resulted in one of the 3 doctors refusing to use it; the time required, 12 examinations were made with NOMYD for every 5 with MYD, with the need for more health staff, and lastly, the inconvenience for the patients, longer waiting time in clinic and then a much longer and uncomfortable pupil dilation.</p><p class="elsevierStylePara">The reading of the digital photograph by a family doctor is very safe when detecting a significant DR. Good sensitivity was found, 95.2%, and a very good NPV of 99% when MoDR or higher was assessed, which ensures that patients with DR are not diagnosed as healthy. However, the specificity of 81.5% and a PPV of 47.6% to detect MoDR or higher, raises doubts on if the high number of false positives in a disease like DR, which could mean telling patients that they do not have it, counteracts the benefits that practically no lesion escaped. In any case, it is clear that training in reading, the only objective difference between these and the ophthalmologist, is essential.</p><p class="elsevierStylePara">As regards benefits to the patients (and for the health system), half of them would have avoided going to the ophthalmologist and almost all of them that had to go had a DR (16.8%≥MoDR) or opacities.</p><p class="elsevierStylePara">To send the digital photograph of the back of the eye of type 2 diabetics by e-mail, as a method of detecting and monitoring DR, is viable and on setting it up the following recommendations should be taken into account:</p><p class="elsevierStylePara">­ The retinal photograph should be the non-mydriatic type, since the management of mydriatic is too complex and slow</p><p class="elsevierStylePara">­ The retinal photograph should be taken by photographing at least 2 retinal fields of 45° (a single field has been rejected by several authors due to its insufficient validity,<span class="elsevierStyleSup">11,12,14,16,20,21</span> and dilating with tropicamide, as it significantly improves sensitivity and the percentage of assessable photographs</p><p class="elsevierStylePara">­ If the family doctor is going to read the photographs in the health centre, training must be improved to avoid the high number of false positives found</p><p class="elsevierStylePara">­ The person who performs the retinal photographs should do the highest number possible, since the percentage of non-assessables significantly decreases with practice</p><p class="elsevierStylePara">With these recommendations, it would mean that only between 30% and 40 % of patients would have to be seen by the ophthalmologist in the first visit, and given the high percentage of opacities in the non-assessables, it is likely that in the following reviews the percentage of referrals would be even less on this problem being controlled.</p><p class="elsevierStylePara">Project financed by the Health Research Fund (FIS 01/0708) of the Ministry of Health, which made the acquisition of the retinal photographs possible.</p><p class="elsevierStylePara">The project received assistance from the Andalusian Society of Family and Community Medicine.</p><p class="elsevierStylePara">What Is Known About the Subject</p><p class="elsevierStylePara">• Diabetic retinopathy is highly prevalent disease which does not usually present with loss of acute vision; its early detection is essential.<br></br> • Back of the eye photographs are more reliable than ophthalmoscope for the diagnosis of diabetic retinopathy.<br></br> • The health service internet allows digital images taken in primary care health centres to be sent, stored and studied by ophthalmologists.</p><p class="elsevierStylePara">What This Study Contributes</p><p class="elsevierStylePara">• Retinal photographs of type 2 diabetic patients sent by e-mail is feasible as a method for the detection and monitoring of retinopathy.<br></br> • The retinograph must be the non-mydriatic type and the photos taken dilated with tropicamide.<br></br> • The person taking the retinal photographs should do as many as possible and be trained well to avoid losses and the high number of false positives.</p><hr></hr><p class="elsevierStylePara">Correspondence:<br></br> Dr. E. Molina Fernández.<br></br> Unidad Docente de Medicina.<br></br> Familiar y Comunitaria de Huelva.<br></br> Servicio Andaluz de Salud.<br></br> Hospital Vázquez Díaz. 4.<span class="elsevierStyleSup">a</span> planta.<br></br> Ronda Norte, s/n. 21005 Huelva.<br></br> España.<br></br> E-mail: <a href="mailto:udhuelva@tiscali.es" class="elsevierStyleCrossRefs"> udhuelva@tiscali.es</a></p><p class="elsevierStylePara">Manuscript received February 26, 2007.<br></br> Manuscript accepted for publication October 8, 2007.</p><p class="elsevierStylePara">Spanish version available<br></br><a href="http://www.doyma.es/197.924" class="elsevierStyleCrossRefs">www.doyma.es/197.924</a></p>" "pdfFichero" => "27v40n03a13116626pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec193443" "palabras" => array:5 [ 0 => "Diabetes mellitus tipo 2" 1 => "Retinopatía diabética" 2 => "Técnicas diagnósticas oftalmológicas" 3 => "Estándares de referencia" 4 => "Estudios de evaluación" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec193442" "palabras" => array:5 [ 0 => "Diabetes mellitus type 2" 1 => "Diabetic retinopathy" 2 => "Diagnostic thechniques ophthalmological" 3 => "Reference standard" 4 => "Evaluation studies" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Objective. Evaluate concordance in biomicroscopy evaluation of diabetic retinopathy degree among ophthalmologists. Validation of e-mail transmission of digital fundus photographs of type 2 diabetes patients as a method of diabetic retinopathy detection. Design. Descriptive study. Setting. Urban, primary health centre, and hospital. Participants. Type 2 diabetic patients selected of consecutive form when going to the primary health center (n=352). Main measurements. Parallel observer-blind evaluation of degree of retinopathy through biomicroscopy performed by ophthalmologists, against digital photographic images sent by e-mail taken by the family doctors. Concordance in the biomicroscopy among ophthalmologists was previously tested. Results. Retinopathy was revealed in 25.70% of the retinographs; 10.44% was mild, 12.05% moderate, and 3.21% severe. Weighted kappa was 0.876 for biomicroscopy concordance. Sensitivity in detecting retinopathy is 76.6% and specificity 95.2%; 92.7% and 99.5% for ophthalmologist-derivable retinopathy. Sensitivity was 66.7% for non-mydriatic retinograph without dilation, 76.9% with elective dilation, and 85% with the mydriatic. Conclusions. Concordance in evaluation of retinopathy degree through biomicroscopy was "very good." This allows using a single ophthalmologist's exploration as a reference model. E-mail transmission of the photograph of the back of the eye in type 2 diabetic patients as a retinopathy detection method is feasible. Regardless of the type of retinograph used, the photographs should be taken on the dilated eye, as this significantly improves sensitivity." ] "es" => array:1 [ "resumen" => "Objetivo. Evaluar la concordancia de la biomicroscopia de los pacientes diabéticos tipo 2 entre oftalmólogos, y analizar la validez de la transmisión por correo electrónico de la fotografía del fondo de ojo de pacientes diabéticos tipo 2, para detectar retinopatía diabética. Diseño. Observacional, descriptivo. Emplazamiento. Centro de salud y hospital urbanos. Participantes. Pacientes diabéticos tipo 2 seleccionados de forma consecutiva al acudir al centro de salud (n = 352). Mediciones principales. Valoración en paralelo, de forma ciega para los observadores, del grado de retinopatía mediante biomicroscopia realizada por oftalmólogos, frente a imagen fotográfica digital realizada por el médico de familia enviada por correo electrónico. Previamente se comprobó la concordancia entre oftalmólogos en la biomicroscopia. Resultados. El 25,70% de las retinografías mostraron retinopatía: el 10,44%, leve; el 12,05%, moderada, y el 3,21%, severa. El análisis de la concordancia en la biomicroscopia mostró un valor kappa ponderado de 0,876. La sensibilidad para detectar retinopatía es del 76,6% y la especificidad del 95,2%; que son del 92,7% y el 99,5%, respectivamente, para retinopatía derivable al oftalmólogo. La sensibilidad fue del 66,7% con el retinógrafo no midriático sin dilatación, del 76,9% con dilatación electiva y del 85% con el retinógrafo midriático. Conclusiones. La concordancia, mediante biomicroscopia, ha sido «muy buena» y permite utilizar la exploración de un solo oftalmólogo como patrón de referencia. Es factible la transmisión telemática de la fotografía del fondo de ojo de pacientes diabéticos tipo 2 como método para detectar retinopatía. Las fotografías deberían realizarse dilatando, independientemente del tipo de retinógrafo empleado, ya que mejora significativamente la sensibilidad." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v40n03-13116626tab01.gif" "imagenAlto" => 1299 "imagenAncho" => 945 "imagenTamanyo" => 59858 ] ] ] ] ] "descripcion" => array:1 [ "en" => "General Scheme of the Study. Observational, descriptive. Parallel, blind assessment, for observers of the degree of diabetic retinopathy by means of a study with a biomicroscope and by comparing this with a digital photograph image (retinography)." ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "TABLE 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v40n03-13116626tab02.gif" "imagenAlto" => 355 "imagenAncho" => 1144 "imagenTamanyo" => 33268 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Analysis of the Digital Photograph Assessments Made by Ophthalmologists and Family Doctors as a Method of Detecting Retinopathy in General and Referable in Particular (Degree Equal to or Greater Than Moderate)" ] ] 2 => array:8 [ "identificador" => "tbl3" "etiqueta" => "TABLE 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v40n03-13116626tab03.gif" "imagenAlto" => 318 "imagenAncho" => 1149 "imagenTamanyo" => 28054 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Analysis of the Validity of Digital Photography Read by Ophthalmologists by Retinograph Type (Mydriatic, Non-Mydriatic With Elective Dilation and Non-Mydriatic With No Dilation)" ] ] 3 => array:5 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 4 => array:5 [ "identificador" => "tbl5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 5 => array:5 [ "identificador" => "tbl6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Consideraciones oftalmológicas sobre la evolución de la ceguera en España." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Lalaurie Dubernet F" 1 => "Martín Hernández E." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Integración" "fecha" => "1999" "volumen" => "29" "paginaInicial" => "12" "paginaFinal" => "6" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Early photocoagulation for diabetic retinopathy: ETDRS report number 9." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Early Treatment Diabetic Retinopathy Study Research Group." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "1991" "volumen" => "98" "paginaInicial" => "766" "paginaFinal" => "85" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2062512" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Sensibility and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Harding SP" 1 => "Broadbent DM" 2 => "Neoh C" 3 => "White MC" 4 => "Vora J." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "BMJ" "fecha" => "1995" "volumen" => "311" "paginaInicial" => "1131" "paginaFinal" => "5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7580708" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Screening for diabetic retinopathy in the 21st century." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Ryder REJ." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/(SICI)1096-9136(199809)15:9<721::AID-DIA694>3.0.CO;2-B" "Revista" => array:6 [ "tituloSerie" => "Diabet Med" "fecha" => "1998" "volumen" => "15" "paginaInicial" => "721" "paginaFinal" => "2" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9737799" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "Muestreo para la investigación en ciencias de la salud. Madrid: Díaz de Santos; 1993." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Muestreo para la investigación en ciencias de la salud. Madrid: Díaz de Santos; 1993." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Silva Ayçaguer LC." ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "Métodos de investigación clínica y epidemiológica. Madrid: Harcourt; 2000." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Métodos de investigación clínica y epidemiológica. Madrid: Harcourt; 2000." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Argimon Pallás JM" 1 => "Jiménez Villa J." ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Grading diabetic retinopathy from stereoscopic colour fundus photographs. An extension of the modified Airlie House Classification. ETDRS report no. 10." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Early Treatment Diabetic Retinopathy Study Research Group." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "1991" "volumen" => "98" "paginaInicial" => "786" "paginaFinal" => "806" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2062513" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Methodology for retinal photography and assessment of diabetic retinopathy: the EURODIAB IDDM Complications Study." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Aldington SJ" 1 => "Kohner EM" 2 => "Meuer S" 3 => "Sjolie A-K" 4 => "The EURODIAB IDDM Complications Study Group." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Diabetologia" "fecha" => "1995" "volumen" => "38" "paginaInicial" => "437" "paginaFinal" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7796984" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The measurement of observer agreement for categorical data." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Landis JR" 1 => "Koch GG." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Biometrics" "fecha" => "1977" "volumen" => "33" "paginaInicial" => "159" "paginaFinal" => "74" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/843571" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "A British Diabetic Association Report. 1997." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "A British Diabetic Association Report. 1997." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Working Party of the British Diabetic Association." ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Validez de la cámara no midriática en el cribado de la retinopatía diabética y análisis de indicadores de riesgo de la retinopatía." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Baeza Díaz M" 1 => "Gil Guillén V" 2 => "Orozco Beltrán D" 3 => "Pedrera Carbonell V" 4 => "Ribera Montes C" 5 => "Pérez Pons LI" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Soc EspOftalmol" "fecha" => "2004" "volumen" => "79" "paginaInicial" => "433" "paginaFinal" => "42" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Effect of mydriasis and different field strategies on digital image screening of diabetic eye disease." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Murgatroyd H" 1 => "Ellingford A" 2 => "Cox A" 3 => "Binnie M" 4 => "Ellis JD" 5 => "MacEwen CJ" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bjo.2003.026385" "Revista" => array:6 [ "tituloSerie" => "Br J Ophthalmol" "fecha" => "2004" "volumen" => "88" "paginaInicial" => "920" "paginaFinal" => "4" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15205238" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Sensibility and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Harding SP" 1 => "Broadbent DM" 2 => "Neoh C" 3 => "White MC" 4 => "Vora J." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "BMJ" "fecha" => "1995" "volumen" => "311" "paginaInicial" => "1131" "paginaFinal" => "5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7580708" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The accuracy of digital-video retinal imaging to screen for diabetic retinopathy: an analysis of two digital-video retinal imaging systems using standard stereoscopic seven-field photography and dilated clinical examination as reference standards." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Lawrence MG." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Trans Am Ophthalmol Soc" "fecha" => "2004" "volumen" => "102" "paginaInicial" => "321" "paginaFinal" => "40" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15747766" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Comparison of two reference standards in validating two field mydriatic digital photography as a method of screening for diabetic retinopathy." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Scanlon PH" 1 => "Malhotra R" 2 => "Greenwood RH" 3 => "Aldington SJ" 4 => "Foy C" 5 => "Flatman M" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Ophthalmol" "fecha" => "2003" "volumen" => "87" "paginaInicial" => "1258" "paginaFinal" => "63" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14507762" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The effectiveness of screening for diabetic retinopathy by digital imaging photography and technician ophthalmoscopy." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Scanlon PH" 1 => "Malhotra R" 2 => "Thomas G" 3 => "Foy C" 4 => "Kirkpatrick JN" 5 => "Lewis-Barned N" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Diabet Med" "fecha" => "2003" "volumen" => "20" "paginaInicial" => "467" "paginaFinal" => "74" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12786681" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "A comparative evaluation of digital imaging, retinal photography and optometrist examination in screening for diabetic retinopathy." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Olson JA" 1 => "Strachan FM" 2 => "Hipwell JH" 3 => "Goatman KA" 4 => "McHardy KC" 5 => "Forrester JV" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Diabet Med" "fecha" => "2003" "volumen" => "20" "paginaInicial" => "528" "paginaFinal" => "34" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12823232" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Two-field photography can identify patients with vision-threatening diabetic retinopathy: a screening approach in the primary care setting." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Stellingwerf C" 1 => "Hardus PL" 2 => "Hooymans JM." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Diabetes Care" "fecha" => "2001" "volumen" => "24" "paginaInicial" => "2086" "paginaFinal" => "90" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11723088" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Comparison of two, three and four 45 degrees image fields obtained with the Topcon CRW6 non-mydriatic camera for screening for diabetic retinopathy." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Perrier M" 1 => "Boucher MC" 2 => "Angioi K" 3 => "Gresset JA" 4 => "Olivier S." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Can J Ophthalmol" "fecha" => "2003" "volumen" => "38" "paginaInicial" => "569" "paginaFinal" => "74" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14740798" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Moller F" 1 => "Hansen M" 2 => "Sjolie AK." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "degrees fundus photograph sufficient for screening of proliferative diabetic retinopathy? Diabetes Care" "fecha" => "2001" "volumen" => "24" "paginaInicial" => "2083" "paginaFinal" => "5" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Herbert HM" 1 => "Jordan K" 2 => "Flanagan DW." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Is screening with digital imaging using one retinal view adequate? Eye" "fecha" => "2003" "volumen" => "17" "paginaInicial" => "497" "paginaFinal" => "500" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02126567/0000004000000003/v0_201307091235/13116626/v0_201307091235/en/main.assets" "Apartado" => array:4 [ "identificador" => "14695" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Originales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02126567/0000004000000003/v0_201307091235/13116626/v0_201307091235/en/27v40n03a13116626pdf001.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13116626?idApp=UINPBA00004N" ]
Article information
ISSN: 02126567Original language: English
DOI:10.1157/13116625
The statistics are updated each day
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 2 | 6 |
| 2024 October | 11 | 11 | 22 |
| 2024 September | 25 | 8 | 33 |
| 2024 August | 22 | 6 | 28 |
| 2024 July | 19 | 12 | 31 |
| 2024 June | 20 | 5 | 25 |
| 2024 May | 13 | 3 | 16 |
| 2024 April | 17 | 6 | 23 |
| 2024 March | 27 | 7 | 34 |
| 2024 February | 29 | 15 | 44 |
| 2024 January | 27 | 5 | 32 |
| 2023 December | 28 | 5 | 33 |
| 2023 November | 38 | 8 | 46 |
| 2023 October | 26 | 15 | 41 |
| 2023 September | 22 | 3 | 25 |
| 2023 August | 20 | 12 | 32 |
| 2023 July | 14 | 10 | 24 |
| 2023 June | 26 | 5 | 31 |
| 2023 May | 19 | 6 | 25 |
| 2023 April | 45 | 24 | 69 |
| 2023 March | 26 | 12 | 38 |
| 2023 February | 23 | 5 | 28 |
| 2023 January | 9 | 8 | 17 |
| 2022 December | 27 | 3 | 30 |
| 2022 November | 30 | 6 | 36 |
| 2022 October | 36 | 9 | 45 |
| 2022 September | 22 | 9 | 31 |
| 2022 August | 35 | 10 | 45 |
| 2022 July | 25 | 11 | 36 |
| 2022 June | 28 | 8 | 36 |
| 2022 May | 40 | 7 | 47 |
| 2022 April | 41 | 14 | 55 |
| 2022 March | 23 | 5 | 28 |
| 2022 February | 17 | 10 | 27 |
| 2022 January | 39 | 3 | 42 |
| 2021 December | 18 | 11 | 29 |
| 2021 November | 37 | 10 | 47 |
| 2021 October | 51 | 9 | 60 |
| 2021 September | 31 | 11 | 42 |
| 2021 August | 31 | 23 | 54 |
| 2021 July | 38 | 9 | 47 |
| 2021 June | 24 | 5 | 29 |
| 2021 May | 16 | 6 | 22 |
| 2021 April | 65 | 24 | 89 |
| 2021 March | 26 | 9 | 35 |
| 2021 February | 27 | 10 | 37 |
| 2021 January | 32 | 11 | 43 |
| 2020 December | 13 | 4 | 17 |
| 2020 November | 31 | 8 | 39 |
| 2020 October | 13 | 6 | 19 |
| 2020 September | 17 | 12 | 29 |
| 2020 August | 25 | 8 | 33 |
| 2020 July | 14 | 7 | 21 |
| 2020 June | 21 | 4 | 25 |
| 2020 May | 22 | 5 | 27 |
| 2020 April | 15 | 1 | 16 |
| 2020 March | 21 | 4 | 25 |
| 2020 February | 20 | 11 | 31 |
| 2020 January | 16 | 5 | 21 |
| 2019 December | 29 | 8 | 37 |
| 2019 November | 24 | 5 | 29 |
| 2019 October | 18 | 3 | 21 |
| 2019 September | 27 | 2 | 29 |
| 2019 August | 12 | 2 | 14 |
| 2019 July | 19 | 12 | 31 |
| 2019 June | 43 | 6 | 49 |
| 2019 May | 83 | 3 | 86 |
| 2019 April | 40 | 11 | 51 |
| 2019 March | 8 | 16 | 24 |
| 2019 February | 11 | 11 | 22 |
| 2019 January | 14 | 5 | 19 |
| 2018 December | 10 | 8 | 18 |
| 2018 November | 11 | 2 | 13 |
| 2018 October | 31 | 12 | 43 |
| 2018 September | 11 | 6 | 17 |
| 2018 August | 6 | 1 | 7 |
| 2018 July | 2 | 1 | 3 |
| 2018 June | 8 | 4 | 12 |
| 2018 May | 6 | 2 | 8 |
| 2018 April | 4 | 2 | 6 |
| 2018 March | 8 | 1 | 9 |
| 2018 February | 7 | 0 | 7 |
| 2018 January | 4 | 0 | 4 |
| 2017 December | 4 | 0 | 4 |
| 2017 November | 7 | 0 | 7 |
| 2017 October | 6 | 3 | 9 |
| 2017 September | 11 | 4 | 15 |
| 2017 August | 8 | 2 | 10 |
| 2017 July | 7 | 3 | 10 |
| 2017 June | 16 | 4 | 20 |
| 2017 May | 17 | 2 | 19 |
| 2017 April | 20 | 1 | 21 |
| 2017 March | 13 | 26 | 39 |
| 2017 February | 27 | 5 | 32 |
| 2017 January | 20 | 2 | 22 |
| 2016 December | 27 | 10 | 37 |
| 2016 November | 17 | 5 | 22 |
| 2016 October | 45 | 6 | 51 |
| 2016 September | 19 | 4 | 23 |
| 2016 August | 21 | 4 | 25 |
| 2016 July | 26 | 2 | 28 |
| 2016 June | 49 | 26 | 75 |
| 2016 May | 42 | 12 | 54 |
| 2016 April | 21 | 9 | 30 |
| 2016 March | 16 | 7 | 23 |
| 2016 February | 23 | 8 | 31 |
| 2016 January | 24 | 20 | 44 |
| 2015 December | 41 | 16 | 57 |
| 2015 November | 34 | 7 | 41 |
| 2015 October | 42 | 5 | 47 |
| 2015 September | 39 | 10 | 49 |
| 2015 August | 41 | 4 | 45 |
| 2015 July | 46 | 9 | 55 |
| 2015 June | 25 | 3 | 28 |
| 2015 May | 29 | 4 | 33 |
| 2015 April | 23 | 9 | 32 |
| 2015 March | 31 | 6 | 37 |
| 2015 February | 37 | 4 | 41 |
| 2015 January | 45 | 2 | 47 |
| 2014 December | 83 | 21 | 104 |
| 2014 November | 46 | 3 | 49 |
| 2014 October | 77 | 4 | 81 |
| 2014 September | 79 | 3 | 82 |
| 2014 August | 69 | 5 | 74 |
| 2014 July | 62 | 5 | 67 |
| 2014 June | 68 | 8 | 76 |
| 2014 May | 43 | 2 | 45 |
| 2014 April | 36 | 5 | 41 |
| 2014 March | 41 | 4 | 45 |
| 2014 February | 41 | 6 | 47 |
| 2014 January | 24 | 2 | 26 |
| 2013 December | 48 | 3 | 51 |
| 2013 November | 31 | 7 | 38 |
| 2013 October | 52 | 4 | 56 |
| 2013 September | 33 | 8 | 41 |
| 2013 August | 48 | 3 | 51 |
| 2013 July | 48 | 2 | 50 |
| 2008 March | 1497 | 0 | 1497 |
Show all
