incident stroke events were recorded. They found that wider retinal venular caliber predicted stroke and including retinal venular caliber in prediction models containing traditional stroke risk factors reassigned 10.1% of people who were in intermediate risk category into different, mostly lower, risk categories.

Various guidelines for management of hypertension recommend assessment of retinopathy to enable risk stratification [16, 17]. Patients with mild retinopathy will probably only need routine care, whereas patients with moderate signs might benefit from further assessment of blood-pressure control (24-h blood-pressure monitoring), assessment of other vascular risk (cholesterol levels, CRP), and if clinically indicated, appropriate risk reduction therapy (cholesterol-lowering agents). In patients with borderline arterial hypertension, physicians could interpret mild or moderate signs of retinopathy as evidence for end-organ damage. The visible retinopathy is an indication that antihypertensive therapy could aid in treatment. In patients with established hypertension, signs of hypertensive retinopathy could suggest a need for close observation of blood pressure and improvement of antihypertensive therapy, or both. Patients with severe retinopathy need urgent antihypertensive management.

10.2Purpose

To estimate the grade of hypertensive retinopathy by using telemedicine to process images of the retinal vasculature and embed the medical results in a quality-assured, interdisciplinary prevention framework.

10.3Method

10.3.1 Medical Approach

The telemedical screening program of the retinal vasculature by mobile fundus cameras – named “talkingeyes®” – comprised six medical steps:

1.Gather general patient information about vascular diseases.

2.Mobile medical examination (photography of retinal vessels, blood pressure, blood marker,

body mass index) by a technician in the rooms of cooperating general practitioners, saving all data in a web-based patient chart.

3.Perform telemedicine-based standardized evaluation of the retinal images by eye doctors to assess the risk of incident stroke given retinal microangiopathy, blood markers, and calculation of an individual risk profile.

4.Recommendations regarding the findings.

5.Automated generation of a medical report.

6.Follow-up and feedback.

Step 1 Patient information: General patient information about vascular diseases and medical prevention is offered through the online journal “talkingeyes&more” at the web address [www. talkingeyes.de].

Step 2 Retinal screening: In the rooms of the cooperating general practitioner, the retinal screening procedure was performed by a medical technician using a mobile, non-mydriatic digital fundus camera. After a standardized documentation of the medical history, measurement of arterial blood pressure, blood markers like cholesterol, LDL, and HDL, a digital 45°- image of the retina was performed by a non-mydriatic fundus camera (Kowa non-myd alpha). The images and data were saved in a web-based patient chart system. Figure 10.1 shows the mobile, non-mydriatic camera documenting the retinal vessels.

Step 3 Evaluation performed via telemedicine: The analysis of the retinal vessels was performed remotely in a standardized way by specialized ophthalmologists. The evaluation consisted of a computer-assisted calculation of the arteriovenous ratio of retinal vessels and a medical evaluation of the retinal vessels, the optic nerve head, and the macula following a standardized protocol. The calculation of the arteriovenous ratio was performed by the method of Parr and Hubbard. Figure 10.2 shows the screen capture of the electronic form for the telemedical fundus image evaluation. The evaluation protocol is visible at the right border of the screen. The results of the medical evaluation were stored in a webbased patient chart. A retinal vessel-driven risk for incident stroke and incident cardiac disease was calculated according to the data of [4] and [5]. In addition, the PROCAM-score was calculated by using blood markers, blood pressure, and

other factors [18]. The PROCAM-score calculates for each total score the corresponding global risk for suffering a heart attack or dying from an acute coronary event within the next 10 years. The score was derived from the PROCAM-study. Independent variables were age, systolic blood pressure, LDL-C, HDL-C, triglycerides, diabetes mellitus, smoking, and family history of MI.

Thus, two “vascular event-risk indexes” were calculated. One “vascular event-risk index” was calculated by the degree of visible retinal microan-

giopathy, and a second “vascular event-risk index” was estimated by blood markers using the PROCAM-calculation. Both “vascular event-risk indexes” were presented in the medical report using a graphic representation.

Step 4 Recommendation: Based on the medical results, an individual diagnostic and therapeutic summary was compiled. If necessary, further diagnostics were suggested:

•24 h ambulatory blood pressure

•ECG

•Blood inflammation parameter CRP

•Blood sugar

•Vessel wall thickness carotid artery, IMT

Step 5 Medical report: After assessment of the individual risk profile, by using all information and images, a medical report was automatically generated. The medical report consisted of the results of all blood markers, the blood pressure, the medical evaluation of the retina, the vascular risk estimation, and the retinal images. Figure 10.3 depicts the automatically generated electronic report. With PIN and TAN, the report was electronically available with downloadable retina images in a good resolution.

Step 6 “Follow-up and feedback”: The followup of subjects with an increased vascular risk is important. Within follow-up examinations or interviews, the outcome parameters like body mass index, exercise per week, smoking, arterial blood pressure, and new cardiovascular events were documented and correlated with medical data. Thus, over time, the success of the prevention program will be evaluated by traditional outcome parameters. The prospective and stan-

dardized documentation allows an analysis with respect to optimization of the prevention concept. The complete longitudinal documentation facilitates a quality management with respect to structural, procedural, and medical quality.

10.3.2 Technical Approach

The technical setup was described in detail elsewhere [19–25]. Briefly, all data and images of the telemedical screening program were documented in one secure web-based system, using a “smart” adobe-formular. This adobe-formular – named “Cardio-Vascular-Prevention-Plan” (CVPP) – was sent as a pdf to the cooperating physicians, allowing data input after login with ID and password. Only the regular adobe reader was necessary. The adobe-formular coupled itself actively with the medical server, showing all data of the selected patient. The adobe-formular, CVPP, acted as a “medical navigator” for past and future medical examinations of the individual patient.

Input of medical data: All medical data and images were stored within the “Cardio-Vascular- Prevention-Plan” formular. The smart formular,

CVPP, could take data and images from one patient from several physicians at different points in time. The medical report could be edited or printed out.