Modeling a National Telemedicine Screening Program for Diabetic Retinopathy in Iran and Implementing a Pilot Project

To model a national telemedicine screening program for diabetic retinopathy (DR) in Iran, and to implement a pilot project at a branch of the Iranian Diabetes Society (IDS) at the southern border of Tehran.Methods: This study was performed in three phases. Firstly, a DR screening referral pathway and a web application called Iranian Retinopathy Teleophthalmology Screening (IRTOS) was designed. Secondly, an educational course was established for general practitioners (GPs). Thirdly, the registered patients at an IDS branch were recalled for fundus photography. The images and patients data were sent to the reading center at the Ophthalmic Research Center via IRTOS and two GPs entered their interpretations into the application. Images were independently reviewed by a retina specialist as the gold standard. Finally, patients and the IDS branch were informed of the results via mobile text messages.Results: Overall, 604 patients with type 1 and type 2 diabetes were screened; of these, 68.7% were female. The retinal image quality was good in 93.5% of cases; cataract was the main cause of ungradable images. Half of the screened subjects were referred for clinical examination. Overall, the rate of sight-threatening DR was 15.5%. Of 229 patients who underwent clinical evaluation, 21.4% required treatment. The sensitivity, specificity, positive and negative predictive values for diagnosis of any stage of DR by trained GPs were 82.8, 86.2, 80.1 and 88.2%, respectively. Corresponding values were 63.5, 96.6, 60.8 and 96.9% for DME diagnosis.Conclusion: Telescreening was an effective method for detecting DR, especially in women in Iran. GPs’ grading showed high sensitivity in any stage of DR. This method made follow-up of 50% of diabetic patients possible at a primary care center. This screening model will be presented to the Ministry of Health to promote the diabetic eye care services at the national level.