[10 June 2018, The STAR]

UTP scientists develop a portable easy-to-use system that puts mass screening for diabetic retinopathy in the line of sight

IT'S a menacing irony – the retina at the back of the eye is technically out of sight, and therefore out of mind. That's why the least talked about aspect of diabetes is diabetic retinopathy, the damage high blood sugar does to the retina leading to blindness. Malaysians are familiar with other diabetic associations, like amputation, nerve damage, obesity and unhealthy lifestyles but retinopathy rarely enters everyday discourse.

It shows up in eye exams – which diabetics are advised to do annually – and images taken by a specialised camera capture the damage done to blood vessels on the retina. The image needs to be studied by a doctor, preferably an ophthalmologist, who grades the severity of the retinopathy and then advises the patient on the next step.

 That's where the problem lies. Given Malaysia's large number of diabetics and the rapidly rising number of newly diagnosed diabetics, the backlog in image reading can sometimes be overwhelming. Delays like that usually cause patients to lose the sense of urgency. Couple that with a woeful lack of concern to keep their diabetes under control.

That administrative mountain was the motivation for scientists at Universiti Teknologi PETRONAS (UTP) who looked into ways to quickly screen diabetics, have their retinopathy graded (mild, moderate, severe, proliferative) and then immediately directed to the right doctor.

In 2007, they collaborated with doctors at Hospital Selayang, Selangor, home of the national eye database. Working with software and clever algorithms, the UTP team led by Prof Ir Dr Ahmad Fadzil Mohamad Hani created a novel way to send the same image direct to a computer that could analyse it and grade the severity of the retinopathy. The computer creates a preliminary report and the patient can be directed to his regular doctor or if necessary, to an ophthalmologist.

To establish the reliability of the grading system, patients in the clinical trial were asked to do a fundus fluorescein angiography (FFA). The FFA is a hospital procedure that involves injecting dye into the bloodstream to highlight the blood vessels on the retina. An image of that is taken for doctors to get a highly detailed report of retinopathy. In particular, the scientists used the FFA, the gold standard in ophthalmology, to view and measure the FAZ, or foveal avascular zone (where capillaries are located on the fovea, the centre and visually the most important part of the retina). This provided the information they needed to develop the algorithm.

By 2010, the trial at Hospital Selayang concluded that this could really work – screening takes about three minutes, and patients could be quickly sorted for who really needs the attention of an eye specialist. It would shorten queues, and fast-track the patient to the next step. Best of all, retinopathy could be caught as early as possible and the patient strongly counselled. But, because the fundus camera and its companion computer were big and clunky, the test would still have to be done in a hospital.

The Selayang doctors offered valuable feedback: to make it uber cool, this diabetic retinopathy grading system needs to be portable, so it can go out into the community and do mass screening even in the most rural of places.

That was when Associate Professor Dr Fawnizu Azmadi Hussin of UTP's Faculty of Engineering was asked to take a look. With a multinational team on campus and funding from UTP's Centre for Intelligent Signal and Imaging Research, he got to work with more software and algorithms. By 2013, he and his team had developed the portable version and filed a patent for it.

"Our goal was to make the apparatus smaller, portable and easy to use," says Fawnizu. "It can be operated by a trained technician, paramedic or nurse who can go anywhere and conduct tests in the community. This makes mass screening truly possible and early detection more likely. This is the game-changer."

Their portable diabetic retinopathy grading system is called RetinoGo. It works with a much smaller fundus camera which takes photos in colour, attached to a smartphone with an app that sends data to the cloud for processing. The results – it grades the severity of retinopathy – are filed for a specialist to study and the patient can be counselled appropriately.

The portable system is in its final fine-tuning phase to ensure that it can work anywhere in the world. Fawnizu and his team are also studying the best model for commercialisation.

With the fundus camera shrinking further, portability is really expanding. "Someday the smartphone may even take over the role of the fundus camera. I'm looking forward to that. For now, we know our system can save time, shorten queues and can reach people quickly. It certainly overcomes the universal fear of needles and injections."

No looking back once you get it

DIABETIC retinopathy occurs when high blood glucose levels damage the blood vessels of the retina. Uncontrolled diabetes will escalate retinopathy, eventually affecting vision and lead to blindness. All diabetics will have retinopathy of some degree. "In the early stages, there are no symptoms so the patient doesn't see the need for an eye exam," says Dr Nor Fariza Ngah, the national head of ophthalmology services based in Hospital Shah Alam. "When a diabetic begins to complain about his or her vision, it's actually already advanced."

About 10% of blindness in Malaysia is caused by diabetic retinopathy, thanks to our high prevalence of diabetes and the rising number of undiagnosed diabetics. It is the leading cause of vision loss among working adults.

There is no treatment at the early stage but strict control of blood sugar can arrest retinopathy. "But compliance is the big issue," says Dr Nor Fariza. "There are some helpful medical procedures for the advanced stage but the patient still needs to control the diabetes, and technically the patient is already blind."

Dr Nor Fariza was one of the clinicians involved in the first trial of UTP's Diabetic Retinopathy Grading System at Hospital Selayang. "It would mean so much to the nation to have our own portable system for screening. During the trial, we found that it can simplify the screening process. I'm looking forward to its next phase. For a clinician, the most important thing is getting 100% accuracy in every reading when the system is being used in the community."

Klang Valley-based ophthalmologist Dr Tara Mary George, who was also part of the clinical trial at Hospital Selayang, says all diabetics need an eye check annually. "Sadly, not all will do that, and certainly many won't make a trip to hospital just for an eye test. The portable grading system will be a game changer because it goes to the patient in the community and gets a preliminary report. This means access to healthcare. I would target people in rural locations and any group with limited understanding of diabetes and the seriousness of this disease."

In 2017, in an effort to improve access to patients, pilot diabetic resource centres were created at Hospital Putrajaya and the Jeram Health Clinic. Here, diabetics who were in the hospital for other reasons could swing by the centre (where there are no queues) for a preliminary eye check with a fundus camera. And, if needed, they were referred to the ophthalmology department. "This helps reduce unnecessary visits to the eye clinic," says Dr Nor Fariza. "It's working well and we hope to expand to other places together with awareness programmes."

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