Five-year experience of tele-ophthalmology for diabetic retinopathy screening in a rural population

Implementation of a Teleophthalmology Screening Program for Diabetic Retinopathy in New York City

Purpose: To examine the implementation of a teleophthalmology program for diabetic retinopathy (DR) screening at a metropolitan hospital system and identify the challenges that the clinical teams encountered using the program. Methods: The study was conducted in 2 parts. The first was a pilot retrospective chart review of 300 consecutive patients screened for DR by the teleophthalmology screening program. The baseline variables, DR capture rate and staging, and continuity of care for those diagnosed with DR were analyzed. The second was a web-based survey identifying the barriers encountered by 36 physicians and clinical staff as they participated in the teleophthalmology screening program. Results: Part 1: Of the patients evaluated, 57 (19.0%) were diagnosed with DR; 42 (73.7%) had mild nonproliferative DR (NPDR), 7 (12.3%) had moderate NPDR, none had severe NPDR, and 8 (14.0%) had PDR. Thirty-one patients (54.4%) with retinopathy diagnoses were referred for an in-person follow-up at the clinic while the rest continued monitoring via the program. Of this subset, 22 (71.0%) completed the follow-up visit. Part 2: The survey respondents comprised 28 physicians (77.8%), 6 licensed nurse practitioners (16.7%), and 2 medical assistants (5.6%). Twenty-two providers (71.0%) preferred initiating referrals for in-person annual examinations over teleophthalmology screening referrals. The most common barriers described were related to workflow interruption, time constraints, and staff shortages. Conclusions: The teleophthalmology DR screening program allowed identification of early or absent DR at clinics in an urban setting (New York City). The findings suggest areas for targeted improvement in the screening program to better complement internal referral practices' workflows.

Changes in the Epidemiology of Diabetic Retinopathy in Spain: A Systematic Review and Meta-Analysis

Background. The aim of the present study was to determine the prevalence and incidence of diabetic retinopathy (DR) and its changes in the last 20 years in type 2 diabetes mellitus (T2DM) patients in Spain. Methods. A systematic review with a meta-analysis was carried out on the studies published between 2001–2020 on the prevalence and incidence of DR and sight-threatening diabetic retinopathy (STDR) in Spain. The articles included were selected from four databases and publications of the Spanish Ministry of Health and Regional Health Care System (RHCS). The meta-analysis to determine heterogeneity and bias between studies was carried out with the MetaXL 4.0. Results. Since 2001, we have observed an increase in the detection of patients with DM, and at the same time, screening programs for RD have been launched; thus, we can deduce that the increase in the detection of patients with DM, many of them in the initial phases, far exceeds the increased detection of patients with DR. The prevalence of DR was higher between 2001 and 2008 with values of 28.85%. These values decreased over the following period between 2009 and 2020 with a mean of 15.28%. Similarly the STDR prevalence decrease from 3.67% to 1.92% after 2008. The analysis of the longitudinal studies determined that the annual DR incidence was 3.83%, and the STDR annual incidence was 0.41%. Conclusion. In Spain, for T2DM, the current prevalence of DR is 15.28% and 1.92% forSTDR. The annual incidence of DR is 3.83% and is 0.41% for STDR.

Assessment of image quality on color fundus retinal images using the automatic retinal image analysis

Image quality assessment is essential for retinopathy detection on color fundus retinal image. However, most studies focused on the classification of good and poor quality without considering the different types of poor quality. This study developed an automatic retinal image analysis (ARIA) method, incorporating transfer net ResNet50 deep network with the automatic features generation approach to automatically assess image quality, and distinguish eye-abnormality-associated-poor-quality from artefact-associated-poor-quality on color fundus retinal images. A total of 2434 retinal images, including 1439 good quality and 995 poor quality (483 eye-abnormality-associated-poor-quality and 512 artefact-associated-poor-quality), were used for training, testing, and 10-ford cross-validation. We also analyzed the external validation with the clinical diagnosis of eye abnormality as the reference standard to evaluate the performance of the method. The sensitivity, specificity, and accuracy for testing good quality against poor quality were 98.0%, 99.1%, and 98.6%, and for differentiating between eye-abnormality-associated-poor-quality and artefact-associated-poor-quality were 92.2%, 93.8%, and 93.0%, respectively. In external validation, our method achieved an area under the ROC curve of 0.997 for the overall quality classification and 0.915 for the classification of two types of poor quality. The proposed approach, ARIA, showed good performance in testing, 10-fold cross validation and external validation. This study provides a novel angle for image quality screening based on the different poor quality types and corresponding dealing methods. It suggested that the ARIA can be used as a screening tool in the preliminary stage of retinopathy grading by telemedicine or artificial intelligence analysis.

Ophthalmic Telesurgery with a Low-Cost Smartphone Video System for Surgeon Self-Reflection and Remote Synchronous Consultation: A Qualitative and Quantitative Study

SUMMARY

More than a third of the global burden of blindness is due to cataracts, yet cataract surgery is one of the most cost-effective surgical treatments in medicine. Poor surgical outcomes in many settings remain a major challenge, raising concerns about the quality and efficacy of surgical training. Reflective learning from video recordings of a trainees' surgical performance has a high educational impact and is available routinely for surgical training within high-resource institutions. However, the prohibitive cost and limited portability of current surgical video recording systems make its use problematic in low-resource settings and outreach environments.

OBJECTIVE

The study's aim was to evaluate the potential of smartphone-captured surgical videos for surgeon learning via self-recording and self-review as well as the potential to support live telesurgical consultation.

METHODOLOGY

A quantitative and qualitative methodology was used to explore and describe the utility and acceptance of smartphone videos in two training facilities in Nepal. Twenty surgeries were recorded on the smartphone for surgeon self-review, to assess image quality, and its application to measure performance against the International Council of Ophthalmology (ICO) Ophthalmology Surgical Competency Assessment Rubrics (OSCAR) SICS Rubric. The same system was used to transmit 15 different surgeries live via Skype from Nepal to an ophthalmologist surgical trainer in South Africa to evaluate the feasibility of live consultation.

FINDINGS

Overall video quality was described as high in 65% and moderate in 35% for the videos recorded for self-review. In the surgeries streamed via Skype, quality was described as high in 92.9% and moderate in 7.1%. There were no instances where the video quality was described as poor. The video quality was good enough that the surgeons could measure against ICO-OSCAR rubric in all cases.

DISCUSSION

The video quality of smartphone-captured surgical videos was found to be high and gained acceptance for reflective teaching and learning purposes. The extended telesurgical potential and portability of the smartphone enables use across many settings. More studies over a longer period are needed to determine how they can support training and learning in cataract surgery.

Utilization of Remote Diabetic Retinal Screening in a Suburban Healthcare System

Purpose

We conducted a cross-sectional study to assess the utilization of a tele-ophthalmology screening program in a low-risk, suburban population of patients with diabetes.

Methods

A total of 214 diabetic patients without previously documented diabetic retinopathy (DR) underwent point-of-care non-mydriatic fundus photography through their primary care providers at five Beth Israel Lahey Health locations. The characteristics of the patients who received remote screening were compared with those patients who were eligible for screening but did not take part in the program. Time-driven activity-based costing (TDABC) was implemented to examine the cost of screening by tele-ophthalmology compared with in-person examinations.

Results

Tele-ophthalmology screening was more likely to be provided for patients who were younger (OR 0.985; 95% CI 0.973–0.997, p=0.016), who were obese (OR 2.04; 95% CI: 1.47–2.84, p=0.008), who had an HbA1c above 8.0% (OR 1.60; 95% CI: 1.13–2.26, p=0.031), or who had an eye examination in the past year (OR 5.55; 95% CI: 3.89–7.92, p<0.001). Those patients newly diagnosed with DR because of the program were more likely to have diabetic nephropathy (OR 7.79; 95% CI: 1.73–35.05, p=0.007). TDABC identified a health system cost-savings of between $8 and $29 per patient screened by tele-ophthalmology compared with the cost of in-person eye examinations.

Conclusion

Tele-ophthalmology presents an opportunity to reduce the costs of screening patients without prior evidence of DR, especially those who have completed a comprehensive eye examination within the prior year.

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.

Teleophthalmology Service: Organization, Management, Actual Current Applications, and Future Prospects

Teleophthalmology (TO) consists of the clinical and therapeutic approach to the patient (e-Health) using informatic and telecommunication systems. Already widespread worldwide, it aims to improve patient care, expand the healthcare offer, and access to medical care by reducing overall costs. Despite the organizational, legal, and management difficulties, the substantial economic investments necessary for the start-up of equipped structures and efficient territorial services are amply rewarded by economic results and optimal services for professionals and patients. This review specifically analyses the current scenario of teleophthalmology, the points for and against its application in different sociodemographic realities, and in particular, the current and future fields of use.

A summary of eye-related visits to a tertiary emergency department

Timely ophthalmologic consultation is important to ensure patients receive high quality ophthalmologic care in the Emergency Department (ED). Tele-ophthalmology may prove useful in safely and efficiently managing ED eye-related complaints. Prior to implementing such a solution, current consultation patterns must be understood. We aimed to assess case-mix acuity and consultation workflow patterns in the ophthalmology consult service at a tertiary emergency department in New York City. The medical records of patients with eye-related complaints who presented to the ED between January 1, 2015 and December 31, 2015 were reviewed. Visits were retrospectively assigned acuities and the ophthalmologic subspecialty involved in the case was recorded. The number of ophthalmologic consultations ordered and consultant response times were analyzed. Patients who were transferred to the ED for eye-related complaints were included. The ED received 1090 eye-related complaints in this period. 60% were retrospectively assigned low acuity, 27% were assigned medium acuity, and 13% were assigned high acuity. Ophthalmology was consulted on 19% of low, 18% of medium, and 48% of high acuity cases. 44% of complaints involved the anterior segment and 30% involved oculoplastics. 2/3 of transfer patients initially assigned high acuity were downgraded to low acuity upon examination. On average, the consult note was created and signed within 109 and 153 min, respectively, after consult order. ED consults are heavily weighted towards pathology of low-to-medium acuity affecting the anterior segment and ocular adnexa. Currently available tele-ophthalmology technology can potentially address a large volume of eye-related visits.

Telemedicine for Diabetic Retinopathy Screening in an Urban, Insured Population Using Fundus Cameras in a Primary Care Office Setting

BACKGROUND AND OBJECTIVE

This study examines the rate of adherence to recommended ophthalmology follow-up after primary care-based telemedicine diabetic retinopathy (DR) screening.

PATIENTS AND METHODS

Retrospective observational study of 5,764 insured diabetic patients undergoing telemedicine DR screening between May 2015 and April 2017 in an urban primary care setting. Patients underwent non-mydriatic fundus photography for telemedicine DR screening. The main outcome measure was the "capture rate."

RESULTS

Of the patients studied, 31.7% were found to have any retinal pathology, and 20% were found to have DR. In the 11.8% percent of patients with sight-threatening retinopathy who were recommended to have a retinal examination, the capture rate was 81.9%.

CONCLUSION

The authors' study demonstrated higher capture rate than has been previously reported, indicating that telemedicine DR screening in an urban, insured population may be a useful method for triaging high-risk patients without losing patients to follow-up. [Ophthalmic Surg Lasers Imaging Retina. 2019;50: e274-e277.].

[Prevalence and risk factors associated with diabetic retinopathy in Santander. Northern Spain]

OBJETIVE

To assess the prevalence and risk factors associated with diabetic retinopathy (DR) in Cantabria.

DESIGN

ross-sectional population based study.

LOCATION

Health center of Cantabria.

PARTICIANTS

A random sample of 442 patients with type 2 diabetes.

MAIN MEASUREMENTS

Non-mydiatric retinography, classifying them according to the International Clinical Diabetic Retinopathy Disease Severity Scale. The analyzed risk factors were: age, gender, age at diabetes onset, duration of diabetes, glycated haemoglobin levels (A1C), treatment of diabetes, blood pressure (systolic and diastolic), serum lipids concentration, body mass index, smoking status, hematocrit, pregnancy, serum vitamin D (25 OH D) levels, nephropathy and cardiovascular events.

RESULTS

The prevalence of DR was 8.56% (CI: 5.81-11.32): Mild non-proliferative DR: 5.07% (CI: 2.89-7.25); Moderate non-proliferative DR: 1.38% (CI: 0.17-2.60); Severe non-proliferative DR: 0.27% (CI: 0.006-1.28); proliferative DR: 1.84% (CI: 0.46-3.22). Diabetic macular oedema: 2.30% (CI: 0.77-3.83). Mean age: 70 years, mean diagnostic age: 58.97 years, mean body mass index 29.86, 78.40% patients with hypertension, 67.30% dyslipidemia and median A1C: 6.7%. A deficit of 25 (OH) D was identified in 77% of patients. In the multivariate analysis, treatment of type 2 diabetes, body mass index, duration of diabetes and metabolic control of glycaemia were identified as independent risk factors.

CONCLUSIONS

The prevalence of DR, compared with former studies, has decreased to 8.56%; this decrease is associated with the improvement in the control of modifiable risk factors. The associated independent risk factors were: treatment, body mass index, duration and control of diabetes. The variables antihypertensive treatment, cardiovascular events and nephropathy showed predictive value for DR.

Teleophthalmology through handheld mobile devices: a pilot study in rural Nepal

Background

To compare screening referral recommendations made by remotely located ophthalmic technicians with those of an ophthalmologist examining digital photos obtained by a portable ophthalmic camera system powered by an iOS handheld mobile device (iPod Touch).

Methods

Dilated screening eye exams were performed by ophthalmic technicians in four remote districts of Nepal. Anterior and posterior segment photographs captured with a Paxos Scope ophthalmic camera system attached to an iPod Touch 6^th generation device were uploaded to a secure cloud database for review by an ophthalmologist in Kathmandu. The ophthalmic technicians' referral decisions based on slit-lamp exam were compared to the ophthalmologist's recommendation based on the transmitted images.

Results

Using the transmitted images, the ophthalmologist recommended referral for an additional 20% of the 346 total subjects screened who would not have been referred by the ophthalmic technician. Of those subjects, 34% were referred to the retina clinic. Conversely, among the 101 patients referred by the technician, the ophthalmologist concurred with the appropriateness of referral in more than 97% of cases but thought eight (2.8%) of those patients had variants of normal eye pathology.

Conclusion

An ophthalmologist who reviewed data and photos gathered with the mobile device teleophthalmology system identified a significant number of patients whose need for referral was not identified by the screening technician. Posterior segment pathology was most frequently found by the remote reader and not by the technician performing dilated slit lamp examinations. These results are promising for further clinical implementation of handheld mobile devices as tools for teleophthalmic screening in resource-limited settings.

[Screening for diabetic retinopathy by non-mydriatic fundus photography: First national campaign in Lebanon]

INTRODUCTION

Diabetic retinopathy (DR) is a leading cause of blindness worldwide. Non-mydriatic fundus photography (NMFP) has been adopted as a screening tool for this disease. We aim to determine the prevalence of DR through this method in Lebanese diabetic patients and to evaluate the impact of such screening in this population.

MATERIALS AND METHODS

This study explores data from an awareness and screening campaign conducted in Lebanon. Diabetic patients from multiple regions were referred by their endocrinologists to undergo NMFP using the Optomed SmartScope^® handheld fundus camera. Photographs were interpreted by a remote observer, and recommendations were given accordingly. The prevalence of DR was calculated, and statistical analyses were performed on the clinical characteristics, fundus findings and number of referrals to ophthalmologists.

RESULTS

The campaign lasted 11 months, during which 2205 patients were examined in 37 screening locations. Out of the 97.41% of patients with type 2 diabetes mellitus, 12.56% had signs of DR, with no significant difference between the regions. 6.28% of the photos were uninterpretable. Positive results were associated with a longer duration of diabetes (P<0.01), treatment with insulin (P<0.01), as well as the presence and chronicity of systemic hypertension (P=0.01). 25% of patients with positive testing were retrospectively asked about their follow-up; only one third had an ophthalmologic examination as per the recommendation, among whom 68.18% underwent treatment for proliferative DR and/or diabetic macular edema.

CONCLUSION

Tele-ophthalmology is useful in mass screening for DR. The importance of dilated fundus examinations still needs to be highlighted for diabetic patients, and better collaboration between endocrinologists and ophthalmologists is required to improve screening outcomes.

A systematic review of teleophthalmological studies in Europe

A systematic review of the recent literature regarding a series of ocular diseases involved in European telemedicine projects was performed based on the PubMed, Google Scholar and Springer databases in June 2017. Literature review returned 44 eligible studies; among them, emergency ophthalmology, diabetic retinopathy, glaucoma, age-related macular disease, cataract and retinopathy of prematurity. The majority of studies indicate teleophthalmology as a valid, reliable and cost-efficient method for care-provision in ophthalmology patients which delivers comparable outcomes to the traditional examination methods.

Models of care in tele-ophthalmology: A scoping review

The objective of this review was to identify and describe telehealth models of care for ophthalmic services. We conducted a scoping review of the literature to identify how ophthalmic care can be delivered by telehealth. We searched the PubMed database to identify relevant articles which were screened based on pre-defined inclusion criteria. For included articles, data were extracted, categorised and analysed. Synthesis of findings was performed narratively. The scoping review included 78 articles describing 62 discrete tele-ophthalmic models of care. Tele-ophthalmic models of care can be used for consultative service, screening, triage and remote supervision. The majority of services were for general eye care and triage ( n = 17; 26%) or emergency services ( n = 8; 12%). The most common conditions for disease-specific models of care were diabetic retinopathy ( n = 14; 21%), and glaucoma ( n = 8; 12%). Most models of care involved local clinicians capturing images and transmitting them to an ophthalmologist for assessment. This scoping review demonstrated tele-ophthalmology to be feasible for consultation, screening, triage and remote supervision applications across a broad range of ophthalmic conditions. A large number of models of care have been identified and described in this review. Considerable collaboration between patient-end clinicians and substantial infrastructure is typically required for tele-ophthalmology.

Predictors of Photographic Quality with a Handheld Nonmydriatic Fundus Camera Used for Screening of Vision-Threatening Diabetic Retinopathy

PURPOSE

To analyze predictors of image quality for a handheld nonmydriatic fundus camera used for screening of vision-threatening diabetic retinopathy.

METHODS

An ophthalmic photographer at an Aravind Eye Hospital obtained nonmydriatic and mydriatic fundus images from 3 fields in 275 eyes of 155 participants over 13 months using a Smartscope camera (Optomed, Oulu, Finland) and a Topcon tabletop fundus camera (Topcon, Tokyo, Japan). Two fellowship-trained retina specialists graded the images. Repeated-measures logistic regression assessed predictors of the main outcome measure: gradability of the fundus images.

RESULTS

Of 2,475 images, 76.2% of the Smartscope nonmydriatic images, 90.1% of the Smartscope mydriatic images, and 92.0% of the Topcon mydriatic images were gradable. Eyes with vitreous hemorrhage (OR = 0.24, p < 0.0001) or advanced cataract (OR = 0.08, p < 0.0001) had decreased odds of image gradability. Excluding eyes with cataract or vitreous hemorrhage, nonmydriatic macular image gradability improved from 68.4% in the first set of 55 eyes to 94.6% in the final set of 55 eyes.

CONCLUSION

With sufficient training, paraprofessional health care staff can obtain high-quality images with a portable nonmydriatic fundus camera, particularly in patients with clear lenses and clear ocular media.