Eyelid Lifting Maneuver During UWF Imaging May Assist in Diabetic Retinopathy Monitoring

Fluorescence angiogram of retina showing severe case of diabetic retinopathy, associated with diabetes mellitus. The angiogram shows distinct, multiple microaneurysms and hemorrhages
Using specific algorithms, pupillary dilation and manual eyelid lifting ‘substantially increase’ visible retina area, help detect lesions, hemorrhage and/or microaneurysm in diabetic retinopathy.

The visible retinal area can be substantially increased using automated detection algorithms and ultra-widefield imaging (UWFI) technology, according to a study published in JAMA Ophthalmology. This process, which requires dilation and manual eyelid lifting (MLL), can assist in the detection of predominantly peripheral lesions (PPL), hemorrhage and microaneurysms (HMA), and in determining diabetic retinopathy (DR) severity. 

“Given the importance of HMAs and PPLs for determining risk of DR progression, these findings emphasize the potential importance of maximizing VRA in addition to image quality for optimal risk assessment in clinical trials and teleophthalmology programs,” researchers report.

The retrospective, comparative case-control study examined 3014 consecutive patients (5919 eyes) undergoing nonmydriatic UWFI with MLL at the DR teleophthalmology program at Joslin Vision Network and in a second cohort of mydriatic UWFI from an academic retina practice (Beetham Eye Institute). Results were collected from November 2017 to November 2018, and MLL was performed until November 6, 2019. 

The fully automated algorithms determined counts for VRA and HMA. Researchers defined PPL and HMAs as present when “at least 1 field had greater HMA number in the peripheral retina than within the corresponding Early Treatment Diabetic Retinopathy Study field.” The main outcomes and measures were: Visible retinal area, DR severity, and presence of PPLs.

They found mean VRA was 665.1±167.6 mm2 for all eyes (theoretical maximal VRA, 923.9 mm2), 550.8±240.7 mm2 for nonmydriatic JVN with MLL (1418 eyes [24.0%]), 688.1±119.9 mm2 for mydriatic BEI images (3650 eyes [61.7%]), and 757.0±69.7 mm2 for mydriatic and MLL BEI images (851 eyes [14.4%]). 

“Dilation increased VRA by 25% (P <.001) and MLL increased VRA an additional 10% (P <.001). Nonmydriatic MLL increased VRA by 11.0%,” according to researchers. “With MLL, HMA counts in UWFI fields increased by 41.7% (from 4.8 to 6.8; P <.001). Visible retinal area was moderately associated with increasing PPL-HMA overall and in each cohort (all, r=0.33; BEI, r=0.29; JVN, r=0.36;P <.001).” 

For the images obtained through the JVN, increasing VRA was associated with more PPL-HMA (quartile 1 [Q1], 23.7%; Q2, 45.8%; Q3, 60.6%; and Q4, 69.2%; P <.001), investigators report.

The study did have limitations, including how it evaluated 2 cohorts, 1 of which was a teleophthalmology program, whose results might not extrapolate to other populations and instruments. In addition, the study’s eyelid artifacts and palpebral fissure width might differ by confounding effects.


Jacoba CMP, Ashraf M, Cavallerano JD, et al. Association of maximizing visible retinal area by manual eyelid lifting with grading of diabetic retinopathy severity and detection of predominantly peripheral lesions when using ultra-widefield imaging. JAMA Ophthalmol. Published online February 24, 2022. doi:10.1001/jamaophthalmol.2021.6363