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Original Investigation |

Comparison of Prevalence of Diabetic Macular Edema Based on Monocular Fundus Photography vs Optical Coherence Tomography

Yu T. Wang, BS1; Mongkol Tadarati, MD2,3; Yulia Wolfson, MD3; Susan B. Bressler, MD3; Neil M. Bressler, MD3,4
[+] Author Affiliations
1Johns Hopkins University School of Medicine, Baltimore, Maryland
2Retina Division, Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
3Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
4Editor, JAMA Ophthalmology
JAMA Ophthalmol. 2016;134(2):222-228. doi:10.1001/jamaophthalmol.2015.5332.
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Importance  Diagnosing diabetic macular edema (DME) from monocular fundus photography vs optical coherence tomography (OCT) central subfield thickness (CST) can yield different prevalence rates for DME. Epidemiologic studies and telemedicine screening typically use monocular fundus photography, while treatment of DME uses OCT CST.

Objective  To compare DME prevalence from monocular fundus photography and OCT.

Design, Setting, and Participants  Retrospective cross-sectional study of DME grading based on monocular fundus photographs and OCT images obtained from patients with diabetic retinopathy at a single visit between July 1, 2011, and June 30, 2014, at a university-based practice and analyzed between July 30, 2014, and May 29, 2015. Presence of DME, including clinically significant macular edema (CSME), on monocular fundus photographs used definitions from the Multi-Ethnic Study of Atherosclerosis (MESA) and the National Health and Nutrition Examination Survey (NHANES). Presence of DME on OCT used Diabetic Retinopathy Clinical Research Network eligibility criteria thresholds of CST for trials evaluating anti–vascular endothelial growth factor treatments.

Main Outcomes and Measures  Prevalence of DME based on monocular fundus photographs or OCT.

Results  A total of 246 eyes of 158 participants (mean [SD] age, 65.0 [11.9] years; 48.7% women; 60.8% white) were included. Among the 246 eyes, the prevalences of DME (61.4%) and CSME (48.5%) based on MESA definitions for monocular fundus photographs were greater than the DME prevalence based on OCT (21.1%) by 40.2% (95% CI, 32.8%-47.7%; P < .001) and 27.2% (95% CI, 19.2%-35.3%; P < .001), respectively. Using NHANES definitions, DME and CSME prevalences from monocular fundus photographs (28.5% and 21.0%, respectively) approximated the DME prevalence from OCT (21.1%). However, among eyes without DME on OCT, 58.2% (95% CI, 51.0%-65.3%) and 18.0% (95% CI, 12.9%-24.2%) were diagnosed as having DME on monocular fundus photographs using MESA and NHANES definitions, respectively, including 47.0% (95% CI, 39.7%-54.5%) and 10.3% (95% CI, 6.3%-15.7%), respectively, with CSME. Among eyes with DME on OCT, 26.9% (95% CI, 15.6%-41.0%) and 32.7% (95% CI, 20.3%-47.1%) were not diagnosed as having either DME or CSME on monocular fundus photographs using MESA and NHANES definitions, respectively.

Conclusions and Relevance  These data suggest that many eyes diagnosed as having DME or CSME on monocular fundus photographs have no DME based on OCT CST, while many eyes diagnosed as not having DME or CSME on monocular fundus photographs have DME on OCT. While limited to 1 clinical practice, caution is suggested when extrapolating prevalence of eyes that may benefit from anti–vascular endothelial growth factor therapy based on epidemiologic surveys using photographs to diagnose DME.

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Figure.
Enrollment Data of All Reviewed Eyes

DME indicates diabetic macular edema; OCT, optical coherence tomography.

aConcurrent conditions included choroidal neovascularization, retinal vein occlusion, postsurgical macular edema, central serous retinopathy, macular retinal detachment, and epiretinal membrane or vitreomacular traction within 1 disc diameter of the fovea as determined on OCT.

bTen of the eyes with ungradable-quality fundus photographs also had ungradable OCT images.

cReasons eyes had ungradable OCT images included 3 scans with extreme decentration errors, 10 scans with poor signal strength, and 2 scans with dense preretinal hemorrhage shadowing and obscuring identification of the internal limiting membrane.

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