A screening approach to the surveillance of patients with diabetes for the presence of vision-threatening retinopathy
A screening approach to the surveillance of patients with diabetes for the presence of vision-threatening retinopathy
复制标题
DOI：
10.1016/s0161-6420(99)00010-x
复制
发表时间：
2000-01-01
期刊：
影响因子：
13.7
通讯作者：
Cole, DR
中科院分区：
文献类型：
--
作者：
Bresnick, GH;Mukamel, DB;Cole, DR
目的：为初级保健机构提供科学的筛查规则，旨在通过对规定的和有限的后眼底部分的评估，识别那些严重到需要转诊给眼科专家的糖尿病视网膜病变患者。设计：对早期治疗糖尿病视网膜病变研究（ETDRS）摄影数据库进行回顾性分析。研究对象：纳入ETDRS的3711例糖尿病患者眼底摄影分级数据。方法：采用多元回归技术识别在摄影区1、2、3或其组合中的视网膜病变病变，这些病变可预测7个标准视域内的增散性糖尿病视网膜病变（PDR）或临床显著性黄斑水肿（CSME）。这些被用来构建一个家族的筛选规则与最佳的综合敏感性和特异性的基础上转介到眼科保健专家。主要观察指标：分级眼底照片中是否存在中度至重度非增殖性糖尿病视网膜病变（NPDR）、PDR或CSME。结果:黄斑颞部出血和微动脉瘤（h/ma）（摄影视场3），与ETDRS标准照片1 （h/ma 3大于或等于3）一样严重或更严重，87%至89%的PDR眼睛和92%至93%的中度至重度NPDR眼睛具有发生PDR的高风险，使用来自一般老年发病糖尿病人群的流行病学研究的视网膜病变患病率数据来推断结果。单次检测PDR的计算灵敏度为87%，特异性为80%；对于中度及更严重的NPDR，敏感性为81%，特异性为93%。将h/ ma3≥3作为筛查规则应用于年龄较大的发病人群，26.5%的患者会转诊，73.5%的患者不会转诊。黄斑中心一个圆盘直径范围内的任何硬渗出物检测CSME的敏感性为94%，特异性为54%，黄斑区域（2区）任何中度或更严重的硬渗出物预测CSME的敏感性为89%，特异性为58%。结论：基于评估后眼底视网膜病变严重程度的筛查方案有可能识别大多数糖尿病患者的视力威胁视网膜病变。如果该方案能够在初级保健环境中有效实施，需要转诊专科护理的患者就可以可靠地识别出来，需要转诊专科护理的患者总数就可以从目前的指南中大大减少。眼科2000;107:19-24 (C) 2000由美国眼科学会。
Objective: To provide scientifically based screening rules for the primary care setting designed to identify, through evaluation of a prescribed and limited portion of the posterior fundus, those patients with diabetes who have retinopathy severe enough to need referral to eye care specialists.Design: Retrospective analysis of the Early Treatment Diabetic Retinopathy Study (ETDRS) photographic data base.Participants: The fundus photographic grading data from 3711 patients with diabetes enrolled in the ETDRS,Methods: Multivariate regression techniques were used to identify retinopathy lesions in photographic fields 1, 2, 3, or a combination thereof that predict proliferative diabetic retinopathy (PDR) or clinically significant macular edema (CSME) within the seven standard fields. These were used to construct a family of screening rules with optimal combined sensitivity and specificity on which to base referrals to eye care specialists.Main Outcome Measures: Presence of moderate to severe nonproliferative diabetic retinopathy (NPDR), PDR, or CSME in graded fundus photographs.Results: Hemorrhages and microaneurysms (h/ma) temporal to the macula (photographic field 3), as severe as or more severe than ETDRS standard photograph 1 (h/ma 3 greater than or equal to 3), identified 87% to 89% of eyes with PDR and 92% to 93% of eyes with moderately severe to severe NPDR, which are at high risk for developing PDR, Extrapolating the results using retinopathy prevalence data from epidemiologic studies for the general older onset diabetic population, the calculated sensitivity for detecting PDR on a single examination is 87%, the specificity 80%; for moderate NPDR or worse, the sensitivity is 81%, specificity 93%, Applying the presence of h/ma 3 greater than or equal to 3 asa screening rule to the older onset population, 26.5% of patients would be referred and 73.5% would not be referred. Any hard exudate within one disc diameter of the macular center detects CSME with sensitivity 94%, specificity: 54%, Hard exudate of moderate or worse severity anywhere in the macular region (field 2) predicts CSME with sensitivity 89%, specificity 58%.Conclusions: Screening protocols based on assessing retinopathy lesion severity in the posterior fundus have the potential to identify most diabetic patients with vision-threatening retinopathy. If the protocols can be implemented effectively in a primary care setting, patients requiring referral for specialty care could be reliably identified, and the total number of patients needing specialty referral could be substantially reduced from current guidelines. Ophthalmology 2000;107:19-24 (C) 2000 by the American Academy of Ophthalmology.