Maximizing Visible Retinal Area May Optimize Diabetic Retinopathy Risk Assessment


Pupillary dilation and manual eyelid lifting were shown to substantially increase visible retinal area and PLL-HMA detection using fully automated algorithms.

Paolo S. Silva, MD, PhD

Paolo S. Silva, MD, PhD

Maximizing visible retina area (VRA) may be important for optimal risk assessment in determining risk of diabetic retinopathy progression, according to new findings.

Study data show fully automated VRA and hemorrhage and/or microaneurysm (HMA) detection algorithms, pupillary dilation, and eyelid lifting were shown to substantially increase detection of VRA and predominantly peripheral lesions (PPL).

“Given the importance of HMAs and PPLs for determining risk of DR progression, these findings emphasize the potential importance of maximizing VRA in addition to image quality for optimal risk assessment in clinical trials and teleophthalmology programs,” said study author Paolo S. Silva, MD, PhD, Beetham Eye Institute, Joslin Diabetes Center.

The retrospective, comparative case-control study evaluated the association of dilation and manual eyelid lifting with ultra-wide field visible retina area and additionally assessed the association of VRA with detection of clinically relevant lesions and grading of diabetic retinopathy severity.

Retinal images were acquired at the Beetham Eye Institute (BEI) of the Joslin Diabetes Center from November 2017 - November 2019.

All nonmydriatic teleophthalmology images were with manual eyelid lifting and evaluated at a central reading center for diabetic retinopathy severity and predominantly peripheral lesion (PPLs) in the Joslin Vision Network (JVN).

Fully automated algorithms determined VRA and hemorrhage and/or microaneurysm (HMA) counts. Additionally, predominantly peripheral lesions and HMAs were defined as present when ≥1 field had a greater number in the peripheral retina, than the corresponding Early Treatment Diabetic Retinopathy Study field.

A total of 3014 consecutive patients (n = 5919 eyes) undergoing retinal imaging at the centers were included in the study. From this population, the mean age was 56.1 years, 1302 (43.2%) were female, 2450 (81.3%) were White, and the mean diabetes duration was 15.9 years.

Investigators noted all images from 5919 eyes with ultra-widefield imaging were analyzed. The mean VRA for all eyes was 665.1 mm2, consisting of:

  • 550.8 mm2 for non mydriatic JVN with manual eyelid lifting (1418 eyes; 24.0%)
  • 688.1 mm2 for mydriatic BEI images (3650 eyes; 61.7%)
  • 757.0 mm2 for all mydriatic and manual eyelid lifting BEI images (851 eyes; 14.4%)

Data show dilation increased VRA by 25% (P <.001) and manual eyelid lifting increased VRA an additional 10% (P <.001), while nonmydriatic manual eyelid lifting increased VRA by 11.0%.

Moreover, manual eyelid lifting increased the mean number of HMAs identified overall by 16.0% (from 8.1 to 9.4; P <.001) and those in ultra-widefield imaging fields by 41.7% (from 4.8 to 6.8; P <.001).

Visible retina area was further moderately associated with increasing PPL-HMA overall and in each cohort (all, r = .33; BEI, r = .29; JVN, r = .36; P <.001). Then, in JVN images, increasing VRA was associated with more PPL-HMAs detected (all P <.001).

  • Q1, 23.7%
  • Q2, 45.8%
  • Q3, 60.6%
  • Q4, 69.2%

The study, “Association of Maximizing Visible Retinal Area by Manual Eyelid Lifting With Grading of Diabetic Retinopathy Severity and Detection of Predominantly Peripheral Lesions When Using Ultra-Widefield Imaging,” was published online in JAMA Ophthalmology.

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