title: Telemedicine diagnosis of cytomegalovirus retinitis by nonophthalmologists.
abstract: OBJECTIVE
  Cytomegalovirus (CMV) retinitis continues to be a leading cause of blindness in many developing countries. Telemedicine holds the potential to increase the number of people screened for CMV retinitis, but it is unclear whether nonophthalmologists could be responsible for interpreting fundus photographs captured in a telemedicine program.
  
  
  OBJECTIVE
  To determine the accuracy of nonophthalmologist photographic graders in diagnosing CMV retinitis from digital fundus photographs.
  
  
  METHODS
  Fifteen nonexpert graders each evaluated 182 mosaic retinal images taken from the eyes of patients with AIDS who were evaluated at the Ocular Infectious Diseases Clinic at Chiang Mai University in Chiang Mai, Thailand.
  
  
  METHODS
  Graders diagnosed each image as CMV retinitis present, CMV retinitis absent, or unknown. The results from each grader were compared with those of an indirect ophthalmoscopic examination from an experienced on-site ophthalmologist as well as with the consensus grade given by a panel of CMV retinitis experts.
  
  
  RESULTS
  Relative to the on-site ophthalmologist, the sensitivity of remote CMV retinitis diagnosis by nonexpert graders ranged from 64.0% to 95.5% (mean, 84.1%; 95% CI, 78.6%-89.6%)), and the specificity ranged from 65.6% to 92.5% (mean, 82.3%; 95% CI, 76.6%-88.0%)). Agreement between nonexpert and expert graders was high: the mean sensitivity and specificity values of nonexpert diagnosis using expert consensus as the reference standard were 93.2% (95% CI, 90.6%-95.8%) and 88.4% (95% CI, 85.4%-91.1%), respectively. Mean intrarater reliability also was high (mean Cohen κ, 0.83; 95% CI, 0.78-0.87).
  
  
  CONCLUSIONS
  The sensitivity and specificity of remote diagnosis of CMV retinitis by nonexpert graders was variable, although several nonexperts achieved a level of accuracy comparable to that of CMV retinitis experts. More intensive training and periodic evaluations would be required if nonexperts are to be used in clinical practice.
authors.affiliation: Francis I. Proctor Foundation, University of California, San Francisco2medical student, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Michael
authors.initials: M
authors.lastname: Yen
authors.affiliation: Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
authors.forename: Somsanguan
authors.initials: S
authors.lastname: Ausayakhun
authors.affiliation: Francis I. Proctor Foundation, University of California, San Francisco.
authors.forename: Jenny
authors.initials: J
authors.lastname: Chen
authors.affiliation: Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
authors.forename: Sakarin
authors.initials: S
authors.lastname: Ausayakhun
authors.affiliation: Department of Ophthalmology, Nakornping Hospital, Chiang Mai, Thailand.
authors.forename: Choeng
authors.initials: C
authors.lastname: Jirawison
authors.affiliation: Department of Ophthalmology and Pacific Vision Foundation, California Pacific Medical Center, San Francisco.
authors.forename: David
authors.initials: D
authors.lastname: Heiden
authors.affiliation: Department of Ophthalmology, University of California, Los Angeles.
authors.forename: Gary N
authors.initials: GN
authors.lastname: Holland
authors.affiliation: Francis I. Proctor Foundation, University of California, San Francisco7Department of Ophthalmology, University of California, San Francisco.
authors.forename: Todd P
authors.initials: TP
authors.lastname: Margolis
authors.affiliation: Francis I. Proctor Foundation, University of California, San Francisco7Department of Ophthalmology, University of California, San Francisco.
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Keenan
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis; D000488:Allied Health Personnel / Q000592:standards*; D000998:Antiviral Agents / Q000627:therapeutic use; D017726:Cytomegalovirus Retinitis / Q000175:diagnosis*; D003906:Developing Countries; D005189:False Positive Reactions; D006801:Humans; D008297:Male; D008875:Middle Aged; D009885:Ophthalmology / Q000592:standards*; D009887:Ophthalmoscopy; D010781:Photography / Q000145:classification*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D012160:Retina / Q000473:pathology*; D012680:Sensitivity and Specificity; D017216:Telemedicine / Q000592:standards*; D013785:Thailand; D014792:Visual Acuity
chemical_list: D000998:Antiviral Agents