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      Diabetic maculopathy: multicolour and SD-OCT versus fundus photography


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          The English Diabetic Eye Screening (DES) programme recommends patients with M1 diabetic maculopathy to be referred to hospital eye services. DES uses flash fundus photography as the reference standard for maculopathy grading. We compared multicolour versus non-stereoscopic fundus photography at identifying M1 maculopathy, with spectral domain optical coherence tomography (SD-OCT) identifying macular thickening.

          Methods and analysis

          This cross-sectional study included 345 patients with R1M1 referred from DES and reviewed in secondary care with fundus photographs, multicolour and SD-OCT. Maculopathy was graded based on DES exudate criteria on both multicolour and fundus photography in a blind fashion by two independent graders. Macular thickness was ascertained on SD-OCT.


          Intergrader agreement on grading maculopathy using fundus photography (Cohen’s κ=0.91) and multicolour (Cohen’s κ=0.82) was ‘almost perfect’. Agreement between fundus photography and multicolour on grading maculopathy (Cohen’s κ=0.76) was ‘substantial’. Compared with fundus photography, multicolour had sensitivity of 87% (95% CI 81% to 93%) and specificity of 90% (95% CI 87% to 94%) in detecting M1 maculopathy. SD-OCT identified 84 eyes with macular thickening, 47 of which were graded as M0 by fundus photography. 5 eyes with exudates and severe macular oedema requiring urgent intervention were also missed on fundus photography but not on multicolour. Multicolour, when complemented by SD-OCT, did not miss any clinically significant macular oedema.


          Multicolour integrates synergistically in a single platform with SD-OCT providing effective monitoring of M1 diabetic maculopathy. The need for fundus photography is eliminated by multicolour/SD-OCT in dedicated R1M1 virtual clinics not requiring parallel diabetic retinopathy grading.

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          Most cited references24

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          The Measurement of Observer Agreement for Categorical Data

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            Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Early Treatment Diabetic Retinopathy Study research group.

            Data from the Early Treatment Diabetic Retinopathy Study (ETDRS) show that focal photocoagulation of "clinically significant" diabetic macular edema substantially reduces the risk of visual loss. Focal treatment also increases the chance of visual improvement, decreases the frequency of persistent macular edema, and causes only minor visual field losses. In this randomized clinical trial, which was supported by the National Eye Institute, 754 eyes that had macular edema and mild to moderate diabetic retinopathy were randomly assigned to focal argon laser photocoagulation, while 1,490 such eyes were randomly assigned to deferral of photocoagulation. The beneficial effects of treatment demonstrated in this trial suggest that all eyes with clinically significant diabetic macular edema should be considered for focal photocoagulation. Clinically significant macular edema is defined as retinal thickening that involves or threatens the center of the macula (even if visual acuity is not yet reduced) and is assessed by stereo contact lens biomicroscopy or stereo photography. Follow-up of all ETDRS patients continues without other modifications in the study protocol.
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              Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema.

              The relative efficacy and safety of intravitreous aflibercept, bevacizumab, and ranibizumab in the treatment of diabetic macular edema are unknown.

                Author and article information

                BMJ Open Ophthalmol
                BMJ Open Ophthalmol
                BMJ Open Ophthalmology
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                19 February 2021
                : 6
                : 1
                [1 ]departmentDepartment of Ophthalmology , Ninewells Hospital , Dundee, UK
                [2 ]departmentDepartment of Ophthalmology , Free University of Brussels , Brussels, Belgium
                [3 ]departmentDepartment of Biomedical and Clinical Science , Luigi Sacco University Hospital , Milano, Lombardia, Italy
                [4 ]departmentEye Clinic, Department of Biomedical and Clinical Science , Luigi Sacco University Hospital , Milano, Lombardia, Italy
                [5 ]departmentDepartment of Ophthalmology , University Hospitals Coventry and Warwickshire NHS Trust , Coventry, UK
                Author notes
                [Correspondence to ] Dr Obaid Kousha; okousha@ 123456gmail.com
                © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

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