title: Telemedicine screening for cytomegalovirus retinitis using digital fundus photography.
abstract: BACKGROUND
  Screening for cytomegalovirus retinitis (CMVR) is important in patients with acquired immune deficiency syndrome and low CD4(+) counts. However, many human immunodeficiency virus (HIV) patients lack access to specialist ophthalmological care. Telemedicine screening is a cost-effective method for screening these patients. We aimed to report the use of composite nine-field digital fundus photography (DFP) images for CMVR screening. We report its sensitivity and specificity in detecting CMVR and the level of agreement with gold-standard binocular indirect ophthalmoscopy.
  
  
  METHODS
  An audit was performed on our national CMVR screening program that screened all HIV patients referred to the Ophthalmology Department at Tan Tock Seng Hospital, Singapore. All patients underwent retinal screening with DFP. Images were categorized as CMVR-positive, CMVR-negative, suspicious, or unreadable by blinded retinal specialists. Patients subsequently underwent dilated gold-standard indirect ophthalmoscopy by a different retinal specialist. Diagnoses were categorized as CMVR-positive, CMVR-negative, or unreadable. Sensitivity and specificity of retinal findings on DFP and kappa values for level of agreement between the two screening methods were calculated.
  
  
  RESULTS
  Three hundred seventy screenings on 188 patients were performed. Twenty-three eyes diagnosed with CMVR on indirect ophthalmoscopy were also identified on DFP (100% sensitivity). A 99.9% specificity was achieved. The fundus photograph of one eye without CMVR was read as CMVR-positive because of an artifact, accounting for a false-positive. Kappa values ranged from 0.739 to 0.987.
  
  
  CONCLUSIONS
  DFP is a sensitive and specific method of screening HIV patients for CMVR and has a high level of agreement with indirect ophthalmoscopy.
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Jinesh M
authors.initials: JM
authors.lastname: Shah
authors.forename: Seo W
authors.initials: SW
authors.lastname: Leo
authors.forename: James C
authors.initials: JC
authors.lastname: Pan
authors.forename: Vernon K
authors.initials: VK
authors.lastname: Yong
authors.forename: Elizabeth P
authors.initials: EP
authors.lastname: Wong
authors.forename: Tock H
authors.initials: TH
authors.lastname: Lim
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Teoh
mesh_terms: D000328:Adult; D017726:Cytomegalovirus Retinitis / Q000175:diagnosis*; D005260:Female; D015658:HIV Infections / Q000150:complications; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D009887:Ophthalmoscopy / Q000379:methods; D010781:Photography / Q000379:methods*; D012680:Sensitivity and Specificity; D012846:Singapore; D017216:Telemedicine