Background: Diabetic retinopathy (DR) is a leading cause of low vision and blindness. We evaluated the feasibility of using a handheld, noncontact digital retinal camera, Pictor, to obtain retinal images in dilated and undilated eyes for DR screening. We also evaluated the accuracy of ophthalmologists with different levels of training/experience in grading these images to identify eyes with vision-threatening DR. Methods: A prospective study of diabetic adults scheduled to have dilated eye exams at Duke Eye Center from January to May 2014 was conducted. An imager acquired retinal images pre- and postdilation with Pictor and selected 1 pre- and 1 postdilation image per eye. Five masked ophthalmologists graded images for gradability (based on image focus and centration) and the presence of no, mild, moderate, or severe nonproliferative DR (NPDR) or proliferative DR (PDR). Referable disease was defined as moderate or severe NPDR or PDR on image grading. We evaluated feasibility based on the graders’ evaluation of image gradability. We evaluated accuracy of identifying vision-threatening disease (severe NPDR or PDR documented on dilated clinical examination) based on the graders’ sensitivity and specificity of grading referable disease. Results: Images were gradable in 86-94% of predilation and 94-97% of postdilation photos. Compared to the dilated clinical exam, overall sensitivity for identifying vision-threatening DR was 64-88% and specificity was 71-90%. Conclusions: Pictor can capture retinal images of sufficient quality to screen for DR with and without dilation. Single retinal images obtained using Pictor can identify eyes with vision-threatening DR with high sensitivity and acceptable specificity compared to clinical exam.

BACKGROUND AND OBJECTIVES: Retinopathy of prematurity (ROP) is the leading avoidable and treatable cause of childhood blindness in the United States. The objective of this study was to evaluate trends of ROP screening, incidence, and treatment in US NICUs over the last 11 years. METHODS: Using standardized data submitted by NICUs from US Vermont Oxford Network member hospitals from 2008 to 2018 on very low birth weight infants hospitalized at the recommended age for ROP screening, we assessed trends in the proportion of eligible infants who received ROP screening, incidence, and treatment of ROP using logistic regression models. RESULTS: This study included 381 065 very low birth weight infants at 819 US NICUs participating in Vermont Oxford Network. Over time, more eligible infants received ROP screening (89% in 2008 to 91% in 2018, trend P < .001). Among those screened, overall ROP (stages 1–5, 37% in 2008 to 32% in 2018), severe ROP (stages 3–5, 8% in 2008 to 6% in 2018), and retinal ablation (6% in 2008 to 2% in 2018) declined and anti–vascular endothelial growth factor injections (1% in 2012 to 2% in 2018) increased (all trend P < .001). CONCLUSIONS: Among US hospitals from 2008 to 2018, the proportion of ROP screening among infants hospitalized at the recommended age increased, less overall and severe ROP were reported, less retinal ablation was performed, and more anti–vascular endothelial growth factor treatment was used. Despite increased ROP screening over time, 10% of infants were not screened, representing an opportunity for improvement in health care delivery.

Importance Progression of retinopathy of prematurity (ROP) to stage 4 may require surgical intervention. The partial retinal detachment of stage 4 ROP may involve the fovea (stage 4B ROP) or may not (stage 4A ROP). This determination has heretofore been based on indirect ophthalmoscopy and documented with color fundus photography. Objective To investigate optical coherence tomography (OCT) features of eyes with stage 4 ROP and compare them with indirect ophthalmoscopy findings and grading of photographs. Design, Setting, and Participants In this study, research and clinical medical records of 15 infants with clinically diagnosed stage 4 ROP were retrospectively reviewed. Infants were treated at an academic center from May 2011 to January 2018. Main Outcomes and Measures Review of OCT images for the presence and foveal involvement of retinoschisis, retinal detachment, and/or vitreomacular traction masked to indirect ophthalmoscopy findings. Results Of the 15 included infants, 9 (60%) were male, the mean (SD) gestational age at birth was 23.9 (1.1) weeks, and the mean (SD) postmenstrual age at surgery was 42.4 (4.9) weeks. A total of 21 eyes were analyzed, of which 19 had adequate OCT imaging. Optical coherence tomography imaging extended to the retinal midperiphery but did not cover the entire region of possible detachment in each eye. Among these eyes, 7 eyes had peripheral retinoschisis without retinal detachment or foveal involvement, 5 eyes had peripheral retinoschisis and retinal detachment without foveal involvement, 7 eyes had either retinoschisis or retinal detachment involving the fovea, and 2 eyes had poor OCT signal owing to high retinal detachment. Conclusions and Relevance Handheld OCT imaging is useful in clinical evaluation of stage 4 ROP to determine foveal involvement and differentiate retinal detachment and retinoschisis. Many infants diagnosed as having stage 4A ROP had retinoschisis without OCT evidence of retinal detachment. This group of infants may represent a substage of stage 4A ROP, ie, stage 4A–schisis by OCT. These findings suggest handheld OCT imaging may be useful in the clinical evaluation of stage 4 ROP. Further investigations are needed to determine if this subgroup portends a different prognosis and if this observation should alter future clinical practice.