Teleophthalmology link between a primary health care centre and a reference hospital

Evaluating the Efficacy of Teleophthalmology in Delivering Ophthalmic Care to Underserved Populations: A Literature Review

Technological advancement has brought commendable changes in medicine, advancing diagnosis, treatment, and interventions. Telemedicine has been adopted by various subspecialties including ophthalmology. Over the years, teleophthalmology has been implemented in various countries, and continuous progress is being made in this area. In underserved populations, due to socioeconomic factors, there is little or no access to healthcare facilities, and people are at higher risk of eye diseases and vision impairment. Transportation is the major hurdle for these people in obtaining access to eye care in the main hospitals. There is a dire need for accessible eye care for such populations, and teleophthalmology is the ray of hope for providing eye care facilities to underserved people. Numerous studies have reported the advantages of teleophthalmology for rural populations such as being cost-effective, timesaving, reliable, efficient, and satisfactory for patients. Although it is being practiced in urban populations, for rural populations, its benefits amplify. However, there are certain obstacles as well, such as the cost of equipment, lack of steady electricity and internet supply in rural areas, and the attitude of people in certain regions toward acceptance of teleophthalmology. In this review, we have discussed in detail eye health in rural populations, teleophthalmology, and its effectiveness in rural populations of different countries.

Telemedicine for neuro-ophthalmology: challenges and opportunities

PURPOSE OF REVIEW

Telemedicine for neuro-ophthalmology (tele-neuro-ophthalmology) has the potential to increase access to neuro-ophthalmic care by improving efficiency and decreasing the need for long-distance travel for patients. Requirements for decreased person-to-person contacts during the COVID-19 pandemic accelerated adoption of tele-neuro-ophthalmology. This review highlights the challenges and opportunities with tele-neuro-ophthalmology.

RECENT FINDINGS

Tele-neuro-ophthalmology programs can be used for triage, diagnostic consultation, and long-term treatment monitoring. Formats include telephone appointments, interprofessional collaborations, remote data interpretation, online asynchronous patient communication, and video visits. Barriers to long-term implementation of tele-neuro-ophthalmology arise from data quality, patient engagement, workflow integration, state and federal regulations, and reimbursement. General neurologists may collaborate with local eye care providers for ophthalmic examination, imaging, and testing to facilitate efficient and effective tele-neuro-ophthalmology consultation.

SUMMARY

Tele-neuro-ophthalmology has tremendous potential to improve patient access to high-quality cost-effective neuro-ophthalmic care. However, many factors may impact its long-term sustainability.

Design, Development, and Evaluation of a Teleophthalmology System Using a Low-Cost Fundus Camera

Introduction:

The increasing prevalence of diabetic retinopathy in developing countries has become a worldwide concern. This problem is preventable by timely diagnosis and treatment; however, in the majority of cases, patients attend the eye clinics very late because of a lack of specialists and travel difficulties. Running a teleophthalmology system would significantly help to manage this disease.

Aim:

This study seeks to assess the accuracy of the teleophthalmology system and its effect on reducing unnecessary referrals in Iran.

Methods:

This study was conducted on 125 diabetic patients. First, the patients were examined by a retina specialist using a slit lamp and, then, single-field digital photos were captured by a portable, low-cost fundus camera. The images were uploaded onto a website and, after two months, were assessed by two retina specialists and two general practitioners (GPs). Finally, the diagnoses based on the digital photos were contrasted with the diagnoses established through face-to-face visits as a gold standard.

Results:

Out of 125 diabetic patients, eight (6.4%) were removed because of low-quality images and a total of 117 were evaluated. The sensitivity and specificity of each retina specialist presented with the photographs produced success rates of 90% and 97% respectively when judged against the gold standard of face-to-face visits. The rates of sensitivity for retinopathy referrals from the retina specialists were 92% and 85%. The sensitivity and specificity of their diagnoses of clinically significant macular edema (CSME) were calculated at 93% and 100%. The rates of sensitivity for each GP were 95% and 93% and the level of specificity was estimated to be approximately 98% for both GPs. The diagnosis rate for GPs when viewing the photographs as opposed to hosting face-to-face visits was more than 90%. Generally, with the implementation of this system, between 40% and 55% of referrals were calculated to have been avoidable.

Conclusion:

Our results from the first-ever research conducted on this topic in Iran showed that the teleophthalmology system is extremely accurate, that it can prevent unnecessary referrals and that it is useful for locating treatable patients. The results of this study could be of assistance in the running and expansion of such systems throughout Iran and Kerman Province to reduce eye damage arising from diabetes, decrease avoidable referrals to clinics, increase the availability of specialist visits for people in remote and rural areas and optimize the use of clinical infrastructures for patients in emergencies.

Age and gender influence on foveal avascular zone in healthy eyes

The foveal avascular zone (FAZ) is the capillary-free area in the central macula with high photoreceptor density and metabolic activity. In the present study we measured the superficial and deep macular foveal avascular zone (sFAZ, dFAZ) in the eyes of healthy adults of both sexes of various ages ranging from 10 to 69 years using optical coherence tomography angiography (OCT-A) in order to evaluate the influence of gender and age on FAZ size. A cross-sectional study was carried out in 240 eyes of 120 healthy subjects, OCT-A was performed by means of a Topcon swept source OCT. sFAZ and dFAZ areas were measured using the IMAGEnet6 software package. Subjects were grouped by age (six groups) and gender. The mean ± sd age of the subjects was 39.2 ± 17.4 years (50% women, 50% men), ranging from 10 to 69 years. The overall mean sFAZ size in women (0.297 ± 0.110 mm²) was significantly larger (p = 0.002) than in men (0.254 ± 0.098 mm²). Similarly, the overall mean dFAZ in women (0.322 ± 0.111 mm²) was significantly larger (p < 0.001) than in men (0.273 ± 0.099). However, when analyzed by age group, these gender differences appeared only in groups younger than 20 years old and older than 50 years old. Men did not show differences among the six age groups. In women, for both sFAZ and dFAZ, the 20-29 year old group had a smaller FAZ size than the 50-59 year old group. In conclusion for both sFAZ and dFAZ, women have larger areas than men, but this occurs only in the young and old age groups. In men, age does not seem to influence the size of the FAZ, but in women, both sFAZ and dFAZ were significantly smaller in younger than in older ages. These results suggest that retinal changes in retinal structure caused by aging may be different in woman than in men, probably reflecting the more hormonal variations known to exist with age in women.

Tele-glaucoma versus clinical evaluation: The New Jersey Health Foundation Prospective Clinical Study

INTRODUCTION

Glaucoma, the second most common cause of blindness, is normally detected in clinic. With technological improvements, tele-glaucoma exams can identify these changes off-site. The quality of tele-glaucoma exams needs to be compared with that of traditional exams. This study's purpose was to validate the tele-glaucoma programme, which allows a physician comprehensive access to patients' data, by comparing results to clinical examinations.

METHODS

A prospective study of 107 subjects evaluated in clinic and then tele-glaucoma stations, which consisted of non-mydriatic fundus photography, puff-tonometry, auto-refraction and Optical Coherence Tomography (OCT). The OCT captured central corneal thickness, angle anatomy, cup-to-disc ratio (CDR), retinal nerve fibre layer distribution and posterior-pole ganglion cell complex data.

RESULTS

Intraocular pressure (IOP) comparisons between clinical and tele-glaucoma exams had strong positive Pearson correlation coefficients (0.8248 OD, 0.8672 OS). Strong positive correlations were seen for CDR (0.7835 OD, 0.8082 OS) as well as diagnosis (glaucoma, no glaucoma or glaucoma suspect). A moderate positive correlation was seen for return to clinic time (RTC). Tele-glaucoma had an average lower RTC (2.7 vs 3.9 months). Tele-glaucoma was more likely to elicit a non-glaucomatous diagnosis not found in clinic vs a diagnosis found only in clinic (18% vs 5% of subjects).

DISCUSSION

Tele-glaucoma allows for detecting glaucoma remotely. These advancements alleviate patient difficulties with obtaining adequate glaucoma screenings and helps ophthalmologists triage patients with more severe pathology. Our study indicates that our tele-glaucoma protocol is comparable to a clinical exam in its ability to detect glaucoma. Further studies will be needed for off-site testing and transferring data separately for analysis.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Analysis of Unreadable Fundus Images

PURPOSE

The purpose of this study was to ascertain determinants of unreadable fundus images for participants enrolled in the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study.

METHODS

Individuals were screened for glaucoma at 7 primary care practices and 4 Federally Qualified Health Centers using telemedicine. Screening (visit 1) included fundus photography, assessing family history of glaucoma, and intraocular pressure (IOP) measurements. Participants with an unreadable image in at least one eye were deemed unreadable and invited to return for a confirmatory eye examination (visit 2).

RESULTS

A total of 906 participants completed the visit 1 eye screening and 17.1% (n=155/906) were "unreadable." In the multivariable logistic regression analysis, older age, male sex, smoking, and worse visual acuity were significantly associated with an unreadable fundus image finding at the eye screening (P<0.05). Of the 89 participants who were invited for the confirmatory eye examination solely for unreadable images and attended visit 2, 58 (65.2%) were diagnosed with at least one ocular pathology. The most frequent diagnoses were cataracts (n=71; 15 visually significant, 56 nonvisually significant), glaucoma suspects (n=27), and anatomical narrow angle (n=10).

CONCLUSIONS

Understanding the causes of unreadable fundus images will foster improvements in telemedicine techniques to optimize the predictive accuracy, efficiency, and cost in ophthalmology. A high proportion of participants with unreadable images (65.2%) in our study were diagnosed with some ocular pathology, indicating that the finding of an unreadable fundus image warrants a referral for a comprehensive follow-up eye examination.

Review of economic evaluations of teleophthalmology as a screening strategy for chronic eye disease in adults

BACKGROUND/AIMS

Teleophthalmology is well positioned to play a key role in screening of major chronic eye diseases. Economic evaluation of cost-effectiveness of teleophthalmology, however, is lacking. This study provides a systematic review of economic studies of teleophthalmology screening for diabetic retinopathy (DR), glaucoma and macular degeneration.

METHODS

Structured search of electronic databases and full article review yielded 20 cost-related articles. Sixteen articles fulfilled the inclusion criteria and were retained for a narrative review: 12 on DR, 2 on glaucoma and 2 on chronic eye disease.

RESULTS

Teleophthalmology for DR yielded the most cost savings when compared with traditional clinic examination. The study settings varied among urban, rural and remote settings, community, hospital and health mobile units. The most important determinant of cost-effectiveness of teleophthalmology was the prevalence of DR among patients screened, indicating an increase of cost savings with the increase of screening rates. The required patient pool size to be screened varied from 110 to 3500 patients. Other factors potentially influencing cost-effectiveness of teleophthalmology were older patient age, regular screening and full utilisation of the equipment. Teleophthalmology for glaucoma was more cost-effective compared with in-person examination. Similarly, increasing number of glaucoma patients targeted for screening yielded more cost savings.

CONCLUSIONS

This economic review provides supportive evidence of cost-effectiveness of teleophthalmology for DR and glaucoma screening potentially increasing screening accessibility especially for rural and remote populations. Special selection of the targeted screening population will optimise the cost-effectiveness of teleophthalmology.

Telephone consultation in primary care

Purpose

The purpose of this paper is to describe and analyze a teleconsultation modality based on a simple telephone call, using either landline or mobile phone, made available to more than two million people. Telecommunication systems are an increasingly common feature in modern healthcare. However, making teleconsultations available to the entire population covered by a public health system is a challenging goal.

Design/methodology/approach

This retrospective longitudinal observational study analyzed how this modality was used at the primary care level in Galicia, a region in the Northwest of Spain, in 2014 and 2015, focusing on demand, gender and age preferences, rural vs urban population and efficiency.

Findings

Of 28,472,852 consultations requested in this period, 9.0 percent were telephone consultations. Women requested more telephone consultations (9.9 percent of total consultations) than men (7.7 percent of total consultations). The highest demand occurred for the over 85 age group for both men and women. In both years, 2014 and 2015, the number of telephone consultations per inhabitant was higher in urban (0.53 and 0.69) than in rural areas (0.34 and 0.47). In 10.9 percent of cases, the telephone consultations required further face-to-face consultation.

Originality/value

Conventional voice telephone calls can efficiently replace conventional face-to-face consultations in primary healthcare in roughly 10 percent of cases. Women are more likely than men to use primary care services in both face-to-face and telephone consultation modalities. Public healthcare systems should consider implementing telephone consultations to deliver their services.

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.

Teleophthalmology: improving patient outcomes?

Teleophthalmology is gaining importance as an effective eye care delivery modality worldwide. In many developing countries, teleophthalmology is being utilized to provide quality eye care to the underserved urban population and the unserved remote rural population. Over the years, technological innovations have led to improvement in evidence and teleophthalmology has evolved from a research tool to a clinical tool. The majority of the current teleophthalmology services concentrate on patient screening and appropriate referral to experts. Specialty care using teleophthalmology services for the pediatric group includes screening as well as providing timely care for retinopathy of prematurity (ROP). Among geriatric eye diseases, specialty teleophthalmology care is focused toward screening and referral for diabetic retinopathy (DR), glaucoma, age-related macular degeneration (ARMD), and other sight-threatening conditions. Comprehensive vision screening and refractive error services are generally covered as part of most of the teleophthalmology methods. Over the past decades, outcome assessment of health care system includes patients' assessments on their health, care, and services they receive. Outcomes, by and large, remain the ultimate validators of the effectiveness and quality of medical care. Teleophthalmology produces the same desired clinical outcome as the traditional system. Remote portals allow specialists to provide care over a larger region, thereby improving health outcomes and increasing accessibility of specialty care to a larger population. A high satisfaction level and acceptance is reported in the majority of the studies because of increased accessibility and reduced traveling cost and time. Considering the improved quality of patient care and patient satisfaction reported for these telemedicine services, this review explores how teleophthalmology helps to improve patient outcomes.

The effectiveness of teleglaucoma versus in-patient examination for glaucoma screening: a systematic review and meta-analysis

Background

Glaucoma is the leading cause of irreversible visual impairment in the world affecting 60.5 million people worldwide in 2010, which is expected to increase to approximately 79.6 million by 2020. Therefore, glaucoma screening is important to detect, diagnose, and treat patients at the earlier stages to prevent disease progression and vision loss. Teleglaucoma uses stereoscopic digital imaging to take ocular images, which are transmitted electronically to an ocular specialist. The purpose is to synthesize literature to evaluate teleglaucoma, its diagnostic accuracy, healthcare system benefits, and cost-effectiveness.

Methods

A systematic search was conducted to help locate published and unpublished studies. Studies which evaluate teleglaucoma as a screening device for glaucoma were included. A meta-analysis was conducted to provide estimates of diagnostic accuracy, diagnostic odds ratio, and the relative percentage of glaucoma cases detected. The improvements to healthcare service quality and cost data were assessed.

Results

Of 11237 studies reviewed, 45 were included. Our results indicated that, teleglaucoma is more specific and less sensitive than in-person examination. The pooled estimates of sensitivity was 0.832 [95% CI 0.770, 0.881] and specificity was 0.790 [95% CI 0.668, 0.876]. The relative odds of a positive screen test in glaucoma cases are 18.7 times more likely than a negative screen test in a non-glaucoma cases. Additionally, the mean cost for every case of glaucoma detected was $1098.67 US and of teleglaucoma per patient screened was $922.77 US.

Conclusion

Teleglaucoma can accurately discriminate between screen test results with greater odds for positive cases. It detects more cases of glaucoma than in-person examination. Both patients and the healthcare systems benefit from early detection, reduction in wait and travel times, increased specialist referral rates, and cost savings. Teleglaucoma is an effective screening tool for glaucoma specifically for remote and under-services communities.

A comparative cost analysis of digital fundus imaging and direct fundus examination for assessment of diabetic retinopathy

The objective of this study was to compare the cost between two procedures for fundus examination in patients with diabetes. In our setting, two alternatives for fundus examination are available for patients with diabetes. In the first alternative, a digital image is taken with a nonmydriatic fundus camera when the patient is at the endocrinology consultation, and the image is then examined by an ophthalmologist. In the second alternative, a direct fundus examination is made by an ophthalmologist. We calculated the costs of both procedures from both Public Healthcare System (PHS) and patient perspectives using the official scales to compute personnel, consumables, capital cost of equipment, travel expenses, and time loss of the patient caused by attending the consultation. The first alternative (digital fundus image) required 2.69, 0.03, and 1.62 Euros per patient for personnel, consumables, and capital cost of the equipment, respectively. A direct fundus examination was needed in 31% of patients that had an additional cost of 0.97 Euros per patient for the PHS plus 14.97 Euros per patient because of travel cost and loss of income. The second alternative (direct fundus examination) required 2.69, 0.11, and 0.33 Euros per patient for personnel, consumables, and capital cost, respectively. All patients in this second alternative had to attend a consultation that implied travel and loss of income costs. Attending a consultation represented a cost of 48.29 Euros per patient. From the PHS perspective, direct fundus examination is less costly than using digital fundus images. The higher cost of the digital fundus option is a consequence of the higher capital costs required by the equipment needed to obtain the digital image. However, from a global perspective, the digital image alternative is more convenient because the travel cost and loss of income of the patient are lower.

Evaluation of retinal digital images by a general practitioner

Diabetes and systemic hypertension are among the most prevalent diseases in developed countries. Since both can produce retinal involvement, they often cause long waiting lists for ophthalmologist consultation. The inspection of digital eye fundus images by a general practitioner would help to divert only those cases with retinal involvement. To evaluate this possibility we studied the agreement between the assessment of digital fundus images made by a general practitioner and an ophthalmologist. A total of 776 fundus images of 194 patients were inspected by both observers looking for retinal lesions consistent with diabetic or hypertensive retinopathy. Contingency tables were made, and the agreement between both observers was assessed by using the kappa index. We found good agreement between the findings reported by the general practitioner and those reported by the ophthalmologist (kappa = 0.80 for patients with only diabetes, 1.00 for patients with only hypertension, and 0.79 for patients with both diseases). Our results suggest that the inspection of digital retinal images by a general practitioner could reduce the number of referred patients for specialist consultation.

Telemedicine for eye care

Tele-ophthalmology has been employed mainly for patients in under-served rural areas in need of specialty care, but other applications such as telementoring have also been used. In certain populations, cost containment is a significant issue and telemedicine is a solution. Tele-ophthalmology can be performed in realtime, by store-and-forward mode, or by hybrid techniques. After appropriate modification, a range of peripherals may be used for tele-ophthalmology, including the direct ophthalmoscope, indirect ophthalmoscope, slit lamp or retinal camera. Tele-ophthalmology applications include: detecting, screening and diagnosing diabetic retinopathy; anterior segment imaging; glaucoma screening; low vision consultation; telementoring. Tele-ophthalmology shows great promise for improving patient care and increasing access to specialty care not available in under-served areas. In developing countries tele-ophthalmology may be a cost-effective method by which richer countries can assist them.

Measurements of the Periocular Facial Area with Web-Based Software

We developed a simple Web-based program to make measurements on displayed photographs between several ocular and periocular landmarks. The measurements were: (1) vertical distance between the margin of the upper and lower eyelids (palpebral aperture), (2) distance between the lower eyelid margin and the inferior corneal margin (palpebro-limbar distance); (3) interpupillary distance; (4) ocular proptosis. We measured the distances using the Web program and compared them with manual measurements on the subject's face. The measurements involved 102 eyes of 51 patients with a variety of ophthalmic conditions. There was good agreement between manual and computer measurements. For example, for manual measurements in 49 patients, we obtained interpupillary distances ranging from 45 to 69 mm (mean 61, SD 6), whereas for computer measurements we found values ranging from 42 to 49 mm (mean 59, SD 6). The mean of the differences between manual and computer measurements was -2.0 mm (SD 4.3) and the 95% limits of agreement were -6.5 to 10.5 mm. Thus, computer measurements tended to give a higher reading by between 0.8 and 3.2 mm (95% confidence interval for the difference). Web-based software may be used to perform measurements on two-dimensional pictures and the technique appears to be suitable for telemedical purposes.

Digital retinal images and teleophthalmology for detecting and grading diabetic retinopathy

OBJECTIVE

Detecting and grading of diabetic retinopathy (DR) by means of digital retinal images sent via the Internet.

RESEARCH DESIGN AND METHODS

Four nonstereoscopic digital retinal images (45 degrees field each) of 126 eye fundus images from 70 diabetic patients were obtained with a nonmydriatic camera at two peripheral units. The images were sent via the Internet using a web-based system to a reference center, where they were diagnosed and graded by one ophthalmologist. These results were compared with those obtained by two other ophthalmologists, one at each peripheral unit, after direct examination of the patients. A modified severity scale of Airlie House was used for grading DR in all cases. Agreement between observers was assessed using unweighted kappa for categorical data and the intraclass correlation coefficient (ICC) for continuous data.

RESULTS

Presence of DR was detected in 69 eyes (55%). All eyes with DR (69 of 69, 100%) were correctly identified (kappa = 1) by inspecting the digital images. In 118 eyes (118 of 126, 94%), 57 with no DR and 61 with DR, there was an agreement between the gradation made after the direct examination and the gradation made after the inspection of the images (ICC = 0.92). In eight eyes with DR (8 of 126, 6%), there was disagreement in the grading made with both techniques.

CONCLUSIONS

Inspection of digital retinal images sent via the Internet allowed diagnosis and grading of DR. The presence or absence of DR was correctly assessed by inspection of the images in all instances. We also found agreement, in most cases, between retinopathy gradation made from the images and the gradation made by direct examination of the eyes. These findings suggest that this technique is suitable for screening procedures.