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UMass Chan, AEYE Health researching use of AI-based retinal camera screenings in primary care practice

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By Pat Sargent February 09, 2023

Juan Ding, OD, PhD, and James Ledwith, MD

UMass Chan Medical School faculty members Juan Ding, OD, PhD, and James Ledwith, MD, are working with Israeli-based AEYE Health on a pilot study testing a handheld, AI-assisted retinal camera to improve screening for diabetic retinopathy in a primary care setting.

For the pilot study, patients with diabetes seeing their physician or nurse practitioner at the UMass Memorial Health family medicine practice in Fitchburg may also be screened for retinopathy by a medical assistant or resident using an AI-assisted retinal camera. The technology is based on an algorithm developed by AEYE Health that received FDA clearance last fall. The retinal images of each eye will be quickly uploaded to an integrated cloud-based service with a corresponding report available to the physician in under a minute. The physician can then discuss the results of the screening with the patient and decide whether they need to return in one year or will need to be referred to Dr. Ding, assistant professor of ophthalmology & visual sciences, and her colleagues at the UMass Memorial Eye Center for further reevaluation.

The current screening process requires primary care physicians to refer patients to have an eye exam with an eye doctor. Dr. Ledwith, assistant professor of family medicine & community health, and Ding anticipate that the convenience of the AI camera will allow primary care practices to screen more patients.

“Only one-third of our patients consistently get their eye exam done every year and the others are going without their annual screening,” said Ledwith. “Increasing the number of patients not only requires testing in this pilot project that we’re doing, but also seeing the benefit of it in a relatively small sample of one practice and getting a camera like this into each primary care practice that’s providing care for people with diabetes.”

“Most patients know that they are supposed to have the exam done each year. Their primary care doctors and their diabetes doctors keep telling them you should go for eye exams, but they just don’t,” said Ding. “Sometimes we make an appointment, but the patient doesn’t show.”

UMass Chan and AEYE Health received an $800,000 grant for the study from the Israeli-U.S. Binational Industrial Research and Development Foundation. The study is also receiving the Herman G. Berkman Diabetes Clinical Innovation Fund grant from the UMass Diabetes Center of Excellence to help complete the pilot project after the BIRD grant expires.

The pilot study is expected to include 500 patients and launch in April.

Floaters- hate them, hate them

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This video talks about a common and very annoying eye condition- floaters. I describe my own experience with floaters and talk about risk factors of having floaters. If you suddenly see new floaters or flashes of light, don’t delay, call you eye doctor and have your eyes checked, because 15% of cases may be associated with retinal tears and detachment. Check out my previous post about floaters: https://bostoneyeblink.com/2019/11/28… One of the risk factors of having floaters early is myopia, here is the list of videos that talk about myopia prevention and control. https://www.youtube.com/playlist?list…

Diabetic Retinopathy Screening Using Artificial Intelligence in a Primary Care Setting

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https://www.umassmed.edu/ophthalmology/education/seminar-news/2022/11/juan-ding-od-phd-and-james-ledwith-md-faafp/

Diabetic retinopathy remains the number 1 cause of vision loss in working-age adults in America. Key to prevent this vision loss is early screening and detection. However, the screening rate remains low world-wide as well as in the US. For many Americans, there are several barriers to accessing quality eye care which include income, distance to the nearest clinic, and health insurance among other factors. Due to these barriers, it is important to improve the methods of screening for diabetic retinopathy, as well as the adherence to recommended follow up.  Recent studies have identified AI-based algorithms as promising tools for the screening and early identification of DR in at-risk individuals. Many different algorithms are being developed and the sensitivity and specificity of these algorithms needs to be evaluated before they can be clinically implemented. Further, there are limitations for the currently available AI that prevent them from being widely used clinically.

Our research aims to implement a novel AI that overcomes these limitations and improve diabetic retinal screening. We have partnered with the digital health company AEYE Health to test the diagnostic accuracy of a hand-held AI-assisted non-mydriatic funduscopic camera to be used in the primary care setting to screen at-risk individuals for retinal changes indicative of diabetic retinopathy. AEYE AI algorithm just received FDA clearance and we are in the final stage of implementing this technology in the primary care setting.

Freckle in the wrong place

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Juan Ding, OD, PhD

Choroidal nevus is a collection of pigmented cells in the choroid, a thin layer of tissue just underneath retina. In layman’s term we often refer nevus to a ‘freckle’. Traditionally choroidal nevus is considered a benign condition. True, only about 1 in 8000 of nevi will turn into a melanoma. So the vast majority of choroidal nevus is benign. But does that mean that they don’t cause a problem? The answer is it depends. For some unfortunate people, it does cost their vision.

I recently had the pleasure of meeting a gentleman in his 60s who had vision loss in his right eye for 20+ years. The cause? A choroidal nevus that happened to be in the worst location, under the fovea. This is where our central vision is, so as a result of a nevus growing there his visual acuity was 20/400. He used to see a renowned ocular oncologist for many years and it remained stable for years, meaning it’s not turning into a melanoma. However, due to the unfortunate location of this freckle, his right eye cannot see details at all.

So given that this is chronic and stable, he was in the clinic actually complaining about something else. He has developed double vision and had to pull over while driving because of seeing two roads. Important to note, even though the nevus took away his central vision, his peripheral vision was quite normal and he relied on peripheral vision of both eyes to drive. I measured and found that he had a mild esophoric deviation, this means that his eyes are converging a little bit too much towards each other. But normally this is a small misalignment and most people compensate for this well. In his situation though, because his right eye does not see too well, it is not able to send a clear signal to the brain which then in turn is not able to feed back to both eyes to fuse the images into single vision. 

Solution to this double vision issue? A small amount of prism made it go away.

So how does this freckle that has such a big impact on his vision look? Figure 1 below is a color photo of this freckle, which was in the center of the eye.

Figure 1. Fundus image of a choroidal nevus at fovea. The arrow points to a black blob which is the nevus.

Figure 2 below shows the cross section showing how thick this freckle is.

Figure 2. Cross section view of the fovea with nevus under the retina.

So are choroidal nevi good or bad? It appears that they may not be as benign as we often believe. A retrospective medical review looked at more than 3000 eyes with stable choroidal nevi and found that of those that had nevi under the fovea, 26% developed vision loss over 15 years [1]. And it is not even that rare to have nevi under fovea, about 6% of choroidal nevus patients in this review series had their nevi right under the fovea [1]. So what is the mechanism for reduced vision if the nevi are stable? It appears that even though the size and thickness of the nevi may not change over time, they may cause edema of the retina, detachment of the RPE and thinning of the photoreceptors. If these changes occur at the fovea, then you get reduced central vision; if in the periphery as in most cases, there may be a peripheral visual field defect. It is not rare to have visual field defects from choroidal nevi; in fact, it is quite common to have field defects, ranging from 38% to 85% depending on the population analyzed [2, 3]. 

In my patient’s case, you can see that it is not even a large or thick nevus. However, it is right in the fovea and there is a thin layer of fluid between RPE and the retina, and the foveal region looks significantly thinned out (Figure 2).

It is easy to overlook choroidal nevus, because it is so commonly seen in an eye doctor’s office, and it rarely converts to melanoma. However, it is important to realize that even though it is not a cancer, it is a tumor all the same. It is not just an inert growth under the retina, but rather can often slowly but actively cause changes to the retina, affecting its function. If it happens to be under the fovea, significant vision loss can happen to patients. 

References

[1] Shields CL, Furuta M, Mashayekhi A, et al. Visual Acuity in 3422 Consecutive Eyes With Choroidal Nevus. Arch Ophthalmol. 2007;125(11):1501–1507. doi:10.1001/archopht.125.11.1501

[2] Tamler  EMaumenee  AE A clinical study of choroidal nevi.  AMA Arch Ophthalmol 1959;62 (2) 196- 202

[3] Flindall  RJDrance  SM Visual field studies of benign choroidal melanomata.  Arch Ophthalmol 1969;81 (1) 41- 44