microangiopathic abnormalities and the optic nerve [10, 11]. A total of 6.999 volunteers took part in the ongoing study from August 2007 until January 2010. This population consisted of 3,275 women and 3,717 men. The mean age of the population was 54.2 years with a standard deviation of 15.9 years. The participants were recruited from private medical institutions. There were no inclusion or exclusion criteria, and volunteers were examined on a first come first serve basis. The examinations took place in the private practice area of cooperating physicians with mobile digital fundus cameras.

The study was conducted in accordance with the Declaration of Helsinki on Biomedical Research Involving Human Subjects. The Clinical Investigation Ethics Committee of the University of Erlangen-Nürnberg approved the study protocol. Written informed consent was obtained from all participants.

10.5Results

10.5.1 Medical History

The average systolic/diastolic arterial blood pressure was reported with 132/82 mmHg in average; the mean body mass index was 27.5 ± 6.7 kg/cm2. 13.6% of the examined subjects were smokers. The prevalences of reported systemic diseases in percent of the whole group were arterial hypertension in 40%, angina pectoris in 8.2%, diabetes in 11.1%, stroke in 2.9%, and cardiac infarction in 3.0%. Table 10.1 gives the numbers separated for male and female subjects.

10.5.2Telemedical Evaluation of Retinal Vessels

10.5.2.1 Prevalence of Retinal Microangiopathy

We found focal narrowing in 28.1%, generalized narrowing in 26.6%, dilated veins in 19.0%, arteriovenous crossings in 9.0%, tortuositas vasorum in 8.2%, retinal bleedings in 0.9%, microaneurysm in 0.5%, and retinal microinfarcts in 0.4% of all evaluated patients. Most

frequently, focal narrowing of the retinal arteries was observed. Very seldom retinal microinfarctions (0.4%) or microaneurysms (0.5%) were noticed.

10.5.2.2 Arteriovenous Ratio

Mean arteriovenous ratio indicating the diameter of retinal arterioles in relation to the diameter of retinal veins was 0.82 ± 0.09. The arteriovenous ratio decreased significantly with age and with degree of retinal microangiopathy. Figure 10.6 shows the percentiles of the mean AV ratio of OD and OS as a function of age. Figure 10.7 depicts the mean of AV ratio of OD and OS as a function of the degree of retinal microangiopathy.

10.5.2.3 PROCAM-Index

The mean PROCAM-index was 4.9 ± 9.9% in male subjects and 1.9 ± 6.9% in female subjects. In 2% of patients, we found PROCAM-values >5%, indicating a high risk for cardiovascular events within the next 10 years. With increasing microangiopathic alterations of retinal vessels, the percentage of subjects with a high vascular heart risk (PROCAM-index >5%) increased significantly. Figure 10.8 showed the prevalence of patients with a high PROCAM-index in relation to the degree of retinal microangiopathy.

In 55 out of 6,999 patients (0.8%), we found relevant retinal microangiopathic changes (e.g., retinal bleedings or microaneurysms or retinal infarcts) and simultaneously a PROCAM-index indicating no or a small vascular heart risk.

10.6Discussion and Perceptive

It is validated that the caliber of the retinal vessels is associated with stroke and cardiovascular events.

AV ratio in quintiles as a function of age

0.96

0.94

0.92

0.90

0.88

0.86

0.84

0.82

0.80

0.78

0.76

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0.72

0.70

Age in decades

Mean

1.Quintile (20%)

2.Quintile (40%)

3.Quintile (60%)

4.Quintile (80%)

10.6.1Estimation of “Stroke Risk” Estimated by the Stage of Retinal Microangiopathy

According to ARIC studies [4], the incident stroke risk within 3 years is coupled with the degree of retinal microangiopathy. Thus, we calculated the 3-year stroke risk prevalence as a function of visible retinal microangiopathic changes. In our study, 97% of the examined subjects have a 3-year risk of “incident stroke” of lower than 2%, 0.8% of the examined subjects have a 3-year risk of “incident stroke” of between 2% and 5%, and 0.5% of the examined subjects have a 3-year risk of “incident stroke” of higher

than 2%. We found that in patients with AV crossing, retinal bleedings, microaneurysms, or microinfarcts, the prevalence of reported stroke or heart infarction was increased by a factor of 10, compared to patients with no relevant retinal signs.

Interdisciplinary prevention of vascular diseases might become very important to reduce the number of patients with manifest stroke or heart infarction. It was evidenced that one-third of chronic vascular diseases like diabetes, stroke, heart infarction, dementia, macular degeneration, and others are preventable by appropriate weight, no smoking, moderate alcohol consumption, sufficient exercise, and normal blood pressure and

Anteriovenous ratio (mean OD & OS)

R2 Linear = 0.08

1.500

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1.000

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Stage of retinal microangiopathy

blood sugar. For the prevention of vascular diseases, it is necessary to detect early signs to begin early treatment.

In our opinion, a successful vascular screening program should consist of measuring indicators like the condition of retinal microvessels, blood pressure, body mass index, smoking, alcohol consumption, and blood markers. These factors provide important information to predict vascular health. The observation of retinal microangiopathy in a patient should be regarded as a sign of an altered microcirculation in end organs. Thus, evaluation of the retinal vessels in patients visiting general practitioners by a tele- medicine-based, on-site screening system might be a very efficient tool to find cases with an increased vascular risk.

Our approach, named “talkingeyes®,” consists of (1) on-site photography of the retina by a nonmydriatic fundus camera, (2) a telemedicinebased evaluation of retinal vessels and optic nerve by eye doctors, (3) an automated generation of an individual medical report, and (4) a follow-up of high-risk patients.

We found that patients with retinal microangiopathy showed a higher prevalence of reported stroke and heart infarction.

In about 1% of the group, we detected patients with severe microangiopathy and no increased PROCAM-risk. These patients might need a more intensive internal therapy to reduce the stroke probability.

The web-based documentation system used in this program allowed a prospective, standardized