Teleophthalmology image-based navigated retinal laser therapy for diabetic macular edema: a concept of retinal telephotocoagulation

Assessment of a Telehealth Platform in Evaluating the Urgency of Ophthalmical Consultation in the Middle East and North Africa Region: The Red Flags of Retinal Detachment

Background: The availability and utilization of telehealth services have been rapidly increasing in the past decade, which paved the way for ophthalmological care to be offered more easily and conveniently. However, the proficiency of telehealth in the context of ophthalmical care still requires further studies to prove its effectiveness. This study examined the proficiency of general practitioners in a telemedicine platform in identifying red flag symptoms, suggestive of retinal detachment, and devising optimal management strategies. Methods: Our cross-sectional study used chat-based consultations on Altibbi Telemedicine platform (2018-2023) to study ophthalmical patients presenting with "blurred vision" or "blindness." Those endorsing red flag symptoms were categorized as having "positive symptomatology" and those reporting none as having "negative symptomatology." Management plans were classified as referral or reassuring. Statistical analysis was performed using IBM's Statistical Package for Social Sciences to examine associations between symptomatology and other variables. p values below 0.05 were considered statistically significant. Results: Five hundred and fifty (n = 550) patients with a mean age 22.5 ± 13 years were included. Patients expressing positive symptomatology were more likely to be referred relative to those expressing negative symptomatology (81% vs. 61%, p < 0.001). No significant difference was found between genders and referral (p = 0.053) or age and referral (p = 0.231). Multivariate regression showed a significant correlation between positive symptoms and referral (adjusted odds ratio [aOR]: 2.0; 95% confidence interval [95% CI]: 1.3-3.3), none between gender (aOR: 1.5; 95% CI: 0.9-2.2) or age (aOR: 1.0; 95% CI: 0.9-1.1) and referral odds. Conclusion: The telemedicine platform studied is effective in referring cases with red flag symptoms to urgent care, regardless of age and gender.

Teleophthalmology and retina: a review of current tools, pathways and services

Telemedicine, the use of telecommunication and information technology to deliver healthcare remotely, has evolved beyond recognition since its inception in the 1970s. Advances in telecommunication infrastructure, the advent of the Internet, exponential growth in computing power and associated computer-aided diagnosis, and medical imaging developments have created an environment where telemedicine is more accessible and capable than ever before, particularly in the field of ophthalmology. Ever-increasing global demand for ophthalmic services due to population growth and ageing together with insufficient supply of ophthalmologists requires new models of healthcare provision integrating telemedicine to meet present day challenges, with the recent COVID-19 pandemic providing the catalyst for the widespread adoption and acceptance of teleophthalmology. In this review we discuss the history, present and future application of telemedicine within the field of ophthalmology, and specifically retinal disease. We consider the strengths and limitations of teleophthalmology, its role in screening, community and hospital management of retinal disease, patient and clinician attitudes, and barriers to its adoption.

Teleophthalmology in Saudi Arabia

Teleophthalmology is the provision of ophthalmic care using digital medical equipment and telecommunications technology. While teleophthalmology has been practiced since the 1990s, it became a crucial medical service during the COVID-19 pandemic when doctors were required to make diagnoses from a distance. This was certainly the case in Saudi Arabia, a relatively large country with limited medical workforce to meet demands, yet a high prevalence of diseases such as diabetes, glaucoma, and cataracts which are considered leading causes of visual impairment. In response to the pandemic, Saudi Arabia's Ministry of Health issued scientific instruction manuals and guidelines for health-care providers which paved the way for increased use of digital technologies and solutions to mitigate the health and economic impacts of COVID-19. The pandemic served to accelerate the use of virtual ophthalmology in Saudi Arabia with the most common teleophthalmology applications being teleconsultation and disease-specific applications such as diabetic retinopathy and retinopathy of prematurity. Although some challenges relating to implementing teleophthalmology in Saudi Arabia remain, it is felt that there are great opportunities to expand the use of telemedicine in ophthalmology in this country.

Teleophthalmology and Artificial Intelligence As Game Changers in Ophthalmic Care After the COVID-19 Pandemic

The current COVID-19 pandemic has boosted a sudden demand for telemedicine due to quarantine and travel restrictions. The exponential increase in the use of telemedicine is expected to affect ophthalmology drastically. The aim of this review is to discuss the utility, effectiveness and challenges of teleophthalmological new tools for eyecare delivery as well as its implementation and possible facilitation with artificial intelligence. We used the terms: “teleophthalmology,” “telemedicine and COVID-19,” “retinal diseases and telemedicine,” “virtual ophthalmology,” “cost effectiveness of teleophthalmology,” “pediatric teleophthalmology,” “Artificial intelligence and ophthalmology,” “Glaucoma and teleophthalmology” and “teleophthalmology limitations” in the database of PubMed and selected the articles being published in the course of 2015-2020. After the initial search, 321 articles returned as relevant. A meticulous screening followed and eventually 103 published manuscripts were included and used as our references. Emerging in the market, teleophthalmology is showing great potential for the future of ophthalmological care, benefiting both patients and ophthalmologists in times of pandemics. The spectrum of eye diseases that could benefit from teleophthalmology is wide, including mostly retinal diseases such as diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration but also glaucoma and anterior segment conditions. Simultaneously, artificial intelligence provides ways of implementing teleophthalmology easier and with better outcomes, contributing as significant changing factors for ophthalmology practice after the COVID-19 pandemic.

Application of 5G Technology to Conduct Real-Time Teleretinal Laser Photocoagulation for the Treatment of Diabetic Retinopathy

Question

How feasible is fifth-generation (5G) real-time telemedicine-mediated laser photocoagulation as a treatment for diabetic retinopathy?

Findings

In this study, a retinal specialist in Beijing, China, performed an online 5G real-time navigated retinal laser photocoagulation procedure on 6 participants (9 eyes) with diabetic retinopathy located in Huzhou, China. All procedures were able to be completed without noticeable delay, and no safety issues were identified.

Meaning

The combination of a 5G high-speed network and navigated retinal laser photocoagulation may enable a novel teleophthalmology paradigm that can provide essential remote health care to patients with diabetic retinopathy.

Importance

Interest in teleophthalmology has been growing, especially during the COVID-19 pandemic. The advent of fifth-generation (5G) wireless systems has the potential to revolutionize teleophthalmology, but these systems have not previously been leveraged to conduct therapeutic telemedicine in the ophthalmology field.

Objective

To assess the feasibility of 5G real-time laser photocoagulation as a telemedicine-based treatment for diabetic retinopathy (DR).

Design, Setting, and Participants

This was a prospective study involving a retinal specialist from the Peking Union Medical College Hospital in Beijing, China, who performed online 5G real-time navigated retinal laser photocoagulation to treat participants with proliferative or severe nonproliferative DR who had been recruited in the Huzhou First People’s Hospital in Zhejiang Province, China, located 1200 km from Beijing from October 2019 to July 2020.

Interventions

These teleretinal DR and laser management procedures were conducted using a teleophthalmology platform that used the videoconference platform for teleconsultation, after which telelaser planning and intervention were conducted with a laser system and a platform for remote computer control, which were connected via 5G networks.

Main Outcomes and Measures

Diabetic eye prognosis and the real-time laser therapy transmission speed were evaluated.

Results

A total of 6 participants (9 eyes) were included. Six eyes were treated via panretinal photocoagulation alone, while 1 eye underwent focal/grid photocoagulation and 2 eyes underwent both panretinal photocoagulation and focal/grid photocoagulation. The mean (SD) age was 53.7 (13.6) years (range, 32-67 years). The mean (SD) duration of diabetes was 14.3 (6.4) years (range, 3-20 years). The mean (SD) logMAR at baseline was 0.32 (0.20) (20/30 Snellen equivalent). Retinal telephotocoagulation operations were performed on all eyes without any noticeable delay during treatment. The mean (SD) number of panretinal photocoagulation laser spots per eye in 1 session was 913 (243).

Conclusions and Relevance

This study introduces a novel teleophthalmology paradigm to treat DR at a distance. Applying novel technologies may continue to ensure that remote patients with DR and other conditions have access to essential health care. Further studies will be needed to compare this approach with the current standard of care to determine whether visual acuity or safety outcomes differ.

The Role of Telemedicine, In-Home Testing and Artificial Intelligence to Alleviate an Increasingly Burdened Healthcare System: Diabetic Retinopathy

In the presence of the ever-increasing incidence of diabetes mellitus (DM), the prevalence of diabetic eye disease (DED) is also growing. Despite many improvements in diabetic care, DM remains a leading cause of visual impairment in working-age patients. So far, prevention has been the best way to protect vision. The sooner we diagnose DED, the more effective the treatment is. Thus, diabetic retinopathy (DR) screening, especially with imaging techniques, is a method of choice for vision protection. To alleviate the burden of diabetic patients who need ophthalmic care, telemedicine and in-home testing are used, supported by artificial intelligence (AI) algorithms. This is why we decided to evaluate current image teleophthalmology methods used for DR screening. We searched the PubMed platform for papers published over the last 5 years (2015–2020) using the following key words: telemedicine in diabetic retinopathy screening, diabetic retinopathy screening, automated diabetic retinopathy screening, artificial intelligence in diabetic retinopathy screening, smartphone diabetic retinopathy testing. We have included 118 original articles meeting the above criteria, discussing imaging diabetic retinopathy screening methods. We have found that fundus cameras, stable or mobile, are most commonly used for retinal photography, with portable fundus cameras also relatively common. Other possibilities involve the use of ultra-wide-field (UWF) imaging and even optical coherence tomography (OCT) devices for DR screening. Also, the role of smartphones is increasingly recognized in the field. Retinal fundus images are assessed by humans instantly or remotely, while AI algorithms seem to be useful tools facilitating retinal image assessment. The common use of smartphones and availability of relatively cheap, easy-to-use adapters for retinal photographs augmented by AI algorithms make it possible for eye fundus photographs to be taken by non-specialists and in non-medical setting. This opens the way for in-home testing conducted on a much larger scale in the future. In conclusion, based on current DR screening techniques, we can suggest that the future practice of eye care specialists will be widely supported by AI algorithms, and this way will be more effective.

Teleophthalmology and its evolving role in a COVID-19 pandemic: A scoping review

ABSTRACT Introduction: Teleophthalmology may assist the healthcare sector in adapting to limitations imposed on clinical practice by a viral pandemic. A scoping review is performed in this study to assess the current applications of teleophthalmology for its suitability to diagnose, monitor or manage ophthalmological conditions with accuracy. Methods: A search of PubMed was conducted for teleophthalmology-related articles published from 1 January 2018 to 4 May 2020. Only articles that focused on the use of teleophthalmology in terms of diagnosis and management, as well as its benefits and detriments, were included. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the included articles. Results: A total of 38 articles were assessed at the full-text level. There were 2 qualitative studies and 1 quantitative randomised controlled trial, while the majority were either quantitative descriptive studies (19, 50.0%) or quantitative non-randomised studies (16, 42.1%). Overall, 8 studies described reducing manpower requirements, 4 described reducing direct patient–doctor contact, 17 described storage of medical imaging and clinical data, and 9 described real-time teleconferencing. The MMAT analysis revealed limitations in appropriate sampling strategy in both quantitative non-randomised studies (9 of 16, 56.3%) and quantitative descriptive studies (9 of 19, 47.4%). Cost-effectiveness of teleophthalmology was not performed in any included study. Conclusion: This current review of the various aspects of teleophthalmology describes how it may potentially assist the healthcare sector to cope with the limitations imposed by a viral pandemic through technology. Further research is required to evaluate the cost-effectiveness of the various strategies. Keywords: Artificial intelligence, health informatics, ophthalmology, teleconsultation, telemedicine

The Role of Imaging in Planning Treatment for Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a controversial disease both in terms of clinical classification and choice of therapeutic strategy. Choroidal layers, retinal pigment epithelium (RPE), photoreceptors, and retina are involved to varying degrees. Beyond well-known symptoms raising the clinical suspect of CSC and slit-lamp fundus examination, multimodal imaging plays a key role in assessing the extent of chorioretinal structural involvement. Subretinal fluid (SRF) originating from the choroid leaks through one or multiple RPE defects and spreads into the subretinal space. Spontaneous fluid reabsorption is quite common, but in some eyes, resolution can be obtained only after treatment. Multiple therapeutic strategies are available, and extensive research identified the most effective procedures. Imaging has carved a significant role in guiding the choice of the most appropriate strategy for each single CSC eye. Multiple biomarkers have been identified, and all of them represent a diagnostic and prognostic reference point. This review aims to provide an updated and comprehensive analysis of the current scientific knowledge about the role of imaging in planning the treatment in eyes affected by CSC.

Informed consent in refractive surgery: in-person vs telemedicine approach

Purpose

The aim of this study was to compare the quality of consent process in refractive surgery between patients who had a preoperative consent discussion with the surgeon using a telemedicine approach and those who had a face-to-face discussion.

Methods

Patients treated between January and December 2017 (8,184 laser vision correction [LVC] and 3,754 refractive lens exchange [RLE] patients) that attended day 1 and 1-month postoperative visit were retrospectively reviewed. Preoperative consent preparation included a consultation with an optometrist, observation of an educational video, and written information. Patients then selected either a face-to-face appointment with their surgeon (in-clinic group) or a telemedicine appointment (remote group) for their consent discussion, according to their preference. Patient experience questionnaire and clinical data were included in a multivariate model to explore factors associated with consent quality.

Results

Prior to surgery, 80.1% of LVC and 47.9% of RLE patients selected remote consent. Of all LVC patients, 97.5% of in-clinic and 98.3% of remote patients responded that they were adequately consented for surgery (P=0.04). Similar percentages in the RLE group were 97.6% for in-clinic and 97.9% for remote patients (P=0.47). In a multivariate model, the major predictor of patient's satisfaction with the consent process was postoperative satisfaction with visual acuity, responsible for 80.4% of variance explained by the model. Other significant contributors were postoperative visual phenomena and dry eyes, difficulty with night driving, close-up and distance vision, postoperative uncorrected distance visual acuity, change in corrected distance visual acuity, and satisfaction with the surgeon's approach. The type of consent (remote or in-clinic) had no impact on patient's perception of consent quality in the regression model.

Conclusion

The majority of patients opted for telemedicine-assisted consent. Those who chose it were equally satisfied as those who had a face-to-face meeting with their surgeon. Dissatisfaction with surgical outcome was the major factor affecting patient's perception of consent quality, regardless of the method of their consent.