The Influence of Ultra-Widefield Fluorescein Angiography on the Diagnosis and Management of Diabetic Retinopathy

Abstract

Purpose: To study the influence of ultra-widefield fluorescein angiography (FA) on the diagnosis and management of diabetic retinopathy (DR). Methods: Ten experts in DR completed an online survey in which they were asked to diagnose and manage DR cases using different imaging modalities. Experts independently reviewed 20 cases of DR and provided a diagnosis and management plan for each case, first based on ultra-widefield color-free and red-free images alone and again with the corresponding ultra-widefield FA images. Experts were polled on their diagnostic confidence, use of FA in clinical practice, and opinions on the value of ultra-widefield FA. Based on the reference standard diagnosis, primary outcomes included diagnostic sensitivity and specificity with and without ultra-widefield FA. Secondary outcomes included intergrader agreement, expert confidence, management outcomes, and an analysis of experts’ opinions on the clinical use of ultra-widefield FA. Results: Diagnostic sensitivity (95% CI) increased from 36% (29%-43%) to 69% (62%-75%) (P < .05) with ultra-widefield FA. Intergrader agreement (Fleiss kappa statistic, 0.29 [95% CI, 0.21-0.27] vs 0.44 [95% CI, 0.40-0.47]; P < .05) and expert confidence (38% vs 65%) also improved. In 39% of responses, management was changed from observation to treatment. Although 40% of experts did not request FA with the initial ultra-widefield color-free/red-free images, 80% found ultra-widefield FA clinically useful when provided. Conclusions: Diagnosis, treatment, and expert opinions on the use of FA all changed when a corresponding ultra-widefield FA was available. Incorporating FA into routine clinical practice may facilitate more accurate clinical decision-making.