evaluation of retinal vessels in a high number of cases. Interdisciplinary prevention of vascular diseases should be a worthwhile goal in modern societies to reduce the number of vascular impaired persons.

References

1. Wong TY, Klein R, Klein BE, Tielsch JM, Hubbard L, Nieto FJ (2001) Retinal microvascular abnormalities and their relationship with hypertension, cardiovascular disease, and mortality. Surv Ophthalmol 46:59–80

2. Tso MO, Jampol LM (1982) Pathophysiology of hypertensive retinopathy. Ophthalmology 89:1132–1145

3. Patton N, Aslam T, Macgillivray T, Pattie A, Deary IJ, Dhillon B (2005) Retinal vascular image analysis as a potential screening tool for cerebrovascular disease: a rationale based on homology between cerebral and retinal microvasculatures. J Anat 206:319–348

4. Wong TY, Klein R, Couper DJ et al (2001) Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities study. Lancet 358:1134–1140

5. Wong TY, Klein R, Nieto FJ et al (2003) Retinal microvascular abnormalities and 10-year cardiovascular mortality: a population-based case-control study. Ophthalmology 110:933–940

6. Mitchell P, Wang JJ, Wong TY, Smith W, Klein R, Leeder SR (2005) Retinal microvascular signs and risk of stroke and stroke mortality. Neurology 65: 1005–1009

7.Michelson EL, Morganroth J, Nichols CW, MacVaugh H 3rd (1979) Retinal arteriolar changes as an indica-

tor of coronary artery disease. Arch Intern Med 139: 1139–1141

8. Duncan BB, Wong TY, Tyroler HA, Davis CE, Fuchs FD (2002) Hypertensive retinopathy and incident coronary heart disease in high risk men. Br J Ophthalmol 86:1002–1006

9. Wong TY, Klein R, Sharrett AR et al (2002) Retinal arteriolar narrowing and risk of coronary heart disease in men and women. The Atherosclerosis Risk in Communities study. JAMA 287:1153–1159

10. Wong TY, Rosamond W, Chang PP et al (2005) Retinopathy and risk of congestive heart failure. JAMA 293:63–69

11. Wong TY, Coresh J, Klein R et al (2004) Retinal microvascular abnormalities and renal dysfunction: the atherosclerosis risk in communities study. J Am Soc Nephrol 15:2469–2476

12. Cuspidi C, Meani S, Salerno M et al (2004) Retinal microvascular changes and target organ damage in untreated essential hypertensives. J Hypertens 22: 2095–2102

13. Saitoh M, Matsuo K, Nomoto S et al (1998) Relationship between left ventricular hypertrophy and renal and retinal damage in untreated patients with essential hypertension. Intern Med 37:576–580

14. McGeechan K, Liew G, Macaskill P, Irwig L, Klein R, Klein BE, Wang JJ, Mitchell P, Vingerling JR, Dejong PT, Witteman JC, Breteler MM, Shaw J, Zimmet P, Wong TY (2009) Meta-analysis: retinal vessel caliber and risk for coronary heart disease. Ann Intern Med 151(6):404–413

15. McGeechan K, Liew G, Macaskill P, Irwig L, Klein R, Klein BE, Wang JJ, Mitchell P, Vingerling JR, de Jong PT, Witteman JC, Breteler MM, Shaw J, Zimmet P, Wong TY (2009) Prediction of incident stroke events based on retinal vessel caliber: a systematic review and individual-participant meta-analysis. Am J Epidemiol 170(11):1323–1332

16. Williams B, Poulter NR, Brown MJ et al (2004) British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 328:634–640

17.Chobanian AV, Bakris GL, Black HR et al (2003) The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 289:2560–2572

18. Assmann G, Cullen P, Schulte H (2002) A simple scoring scheme for calculating the risk of acute

coronary events based on the 10-year follow-up of the prospective cardiovascular Münster (PROCAM) study. Circulation 105(3):310–315

19. Adler W, Wärntges S, Lausen B, Michelson G (2010) Prevalence of glaucomatous optic nerve atrophy among a working population in Germany diagnosed by a telemedical approach. Klin Monbl Augenheilkd 227(11):905–911

20. Michelson G, Laser M, Müller S, Weber F, Wärntges S (2011) Validation of telemedical fundus images from patients with retinopathy. Klin Monbl Augenheilkd 228(3):234–238

21. Paulus J, Meier J, Bock R, Hornegger J, Michelson G (2010) Automated quality assessment of retinal fundus photos. Int J Comput Assist Radiol Surg 5(6): 557–564

22. Bock R, Meier J, Nyúl LG, Hornegger J, Michelson G (2010) Glaucoma risk index: automated glaucoma detection from color fundus images. Med Image Anal 14(3):471–481

23.Michelson G (2005) TalkingEyes-and-more. Biomed Tech (Berl) 50(7–8):218–226

24. Chrástek R, Wolf M, Donath K, Niemann H, Paulus D, Hothorn T, Lausen B, Lämmer R, Mardin CY, Michelson G (2005) Automated segmentation of the optic nerve head for diagnosis of glaucoma. Med Image Anal 9(4):297–314

25.Michelson G, Groh M, Groh MJ, Baleanu D, Harazny J, Horstmann R, Kolominsky-Rabas P (2005) Telemedicalsupported screening of retinal vessels (“talking eyes”). Klin Monbl Augenheilkd 222(4):319–325

11.1Introduction

A major unresolved challenge in clinical ophthalmology is the elimination of avoidable vision loss due to diabetic retinopathy. Despite wellestablished guidelines for periodic retinal examinations in patients with diabetes, poor compliance with these recommendations still results in missed opportunities for management of treatable disease in a timely manner. In the past decade, numerous telemedicine diabetic retinopathy assessment programs have been established as a potential alternative strategy to assess patients who would not otherwise undergo a periodic dilated retinal examination. With increasing frequency, these telemedicine diabetic retinopathy surveillance programs are occurring outside of the traditional eye care setting in the primary care or general health arena. Because most patients with diabetes visit their primary care physicians with some regularity, this has been postulated as an ideal environment in which to assess for retinopathy [1]. This chapter describes the approach used by a primary care–based telemedicine diabetic retinopathy assessment program which has

I.E. Zimmer-Galler, M.D.

Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University Medical Institutions, Maumenee 738, 600 N Wolfe Street, Baltimore,

MD 21287, USA

e-mail: izimmerg@jhmi.edu

been successfully implemented on a wide-scale and long-term basis.

11.2System Requirements

Practical implementation of a diabetic retinopathy assessment system in the primary care setting requires special considerations. Although the incidence of diabetes is rising at an alarming rate, the typical primary care medical practice still may see only a few patients with diabetes on any given day. Since it is estimated that at least half of these patients are already under the care of an ophthalmologist, the volume of patients requiring a screening retinal imaging procedure is likely to be relatively small in individual primary care practices. This implies that the cost of instrumentation for diabetic retinopathy assessment in this setting also needs to be low in order to remain cost-effec- tive. Additionally, the imaging procedure must be easy to administer by any non-eye care office personnel including physician’s assistants or technicians. The images obtained must be of adequate resolution to detect the small microvascular abnormalities seen in diabetic retinopathy. Another system requirement is the capability to transfer the data to a remote reading center in a secure manner as mandated by the Health Insurance Portability and Accountability Act (HIPAA). Finally, the remote reading center must have qualified personnel to analyze and grade the images as well as software for image analysis and a robust reporting and archiving platform.