Accuracy and reliability of teleophthalmology for diagnosing diabetic retinopathy and macular edema: a review of the literature

Implementation of a pilot teleretinal screening protocol for hydroxychloroquine retinopathy in a Los Angeles County safety net clinic

INTRODUCTION

This study aimed to determine whether teleretinal screening for hydroxychloroquine retinopathy (HCQR) improves clinical efficiency and adherence to recommended screening guidelines compared to face-to-face screening among patients in a large safety net medical system.

METHODS

In this retrospective cohort study of a consecutive sample of 590 adult patients with active HCQ prescriptions seen in the outpatient ophthalmology clinic at Los Angeles County + University of Southern California Medical Center from 1 September 2018 to 25 November 2019, 203 patients underwent technician-only tele-HCQR screening (THRS), and 387 patients underwent screening with traditional face-to-face visits (F2FV) with an eye-care provider. Data on clinic efficiency measures (appointment wait time and encounter duration) and adherence to recommended screening guidelines were collected and compared between the two cohorts.

RESULTS

Compared to F2FV, the THRS cohort experienced significantly shorter median (interquartile range) time to appointment (2.5 (1.5-4.6) vs. 5.1 (2.9-8.4) months; p < 0.0001), shorter median encounter duration (1 (0.8-1.4) vs. 3.7 (2.5-5.2) hours; p < 0.0001) and higher proportion of complete baseline screening (102/104 (98.1%) vs. 68/141 (48.2%); p < 0.001) and complete chronic screening (98/99 (99%) vs. 144/246 (58.5%); p < 0.001).

DISCUSSION

A pilot THRS protocol was successfully implemented at a major safety net eye clinic in Los Angeles County, resulting in a 50.9% reduction in wait times for screening, 72.9% reduction in encounter duration and 49.9% and 40.5% increases in proportions of complete baseline and chronic screening, respectively. Tele-HCQ retinal screening protocols may improve timeliness to care and screening adherence for HCQR in the safety net setting.

Risk assessment of diabetic retinopathy with machine and deep learning models with PPG signals and PWV

Retinopathy is one of the most common micro vascular impairments in diabetic subjects. Elevated blood glucose leads to capillary occlusion, provoking the uncontrolled increase in local growth of new vessels in the retina. When left untreated, it can lead to blindness. Traditional approaches for retinopathy detection require expensive devices and high specialized personnel. Being a microvascular complication, the retinopathy could be detected using the photoplethysmography (PPG) technology. In this paper we investigate the predictive value of the pulse wave velocity and PPG signal analysis with machine and deep learning approaches to detect retinopathy in diabetic subjects. PPG signals and pulse wave velocity (PWV) showed promising results in assessing the diabetic retinopathy. The best performances were scored by a LightGBM based model trained over a subset of the available dataset obtaining 80% of specificity and sensitivity.Clinical relevance- PPG based retinopathy detection could make the retinopathy detection more accessible since it does not need neither expensive devices for signal acquisition nor highly specialized personnel to be interpreted.

Is your vision blurry? A systematic review of home-based visual acuity for telemedicine

INTRODUCTION

Visual acuity (VA) testing is a vital screening tool for the assessment of ocular function. The coronavirus 2019 pandemic has caused an immediate need for synchronous telemedicine in all specialties, including ophthalmology. While a plethora of mobile VA applications exist, there is no consensus as to what technology can accurately and reproducibly measure a patient's vision at home.

METHODS

A systematic literature search was performed in April 2020 using PubMed, Embase and Medline, identifying English publications from 2010 to 2020 on remote VA tests: 4338 articles were identified and 14 were ultimately included in the review.

RESULTS

Of those 14, the highest quality studies, best reproducibility and correlation with in-clinic acuities measured were found using the Peek Acuity application. The studies included patients throughout the world aged 3-97, with and without correction, with known ocular pathology.The Peek Acuity studies measured distance vision on a Samsung Galaxy S3 with a mean difference of 0.055 Logarithm of the Minimum Angle of Resolution (LogMAR) for home testing compared with the Early Treatment Diabetic Retinopathy Study (ETDRS). Test-retest variability was ±0.029 LogMAR for 95% confidence interval limits.

DISCUSSION

There can be one or more lines of variability in vision testing in a clinical setting using reference standard ETDRS and clinical standard Snellen charts. Test-retest reliability is not perfect even on standard clinical charts (variation up to 0.48 LogMAR). Of the technologies reviewed, Peek Acuity home testing had the greatest correlation with ETDRS clinical vision and high test-retest reliability. Peek Acuity performed no worse than Snellen and ETDRS charts.

Teleophthalmology research: Where do we stand?

PURPOSE

To identify global research trends in teleophthalmology, as well as productivity and its association with Human development index (HDI).

METHODS

A cross-sectional study. The main outcome measures were publication count, citation count, and publications count per million populations. Bibliographic data were derived from the Web of Science website. HDI data were derived from Human Development Report [2020]. One-way ANOVA test was used to examine the association between HDI and the outcome measures. We studied the correlation between continuous variables using Spearman's. Bibliometric analysis software's VOSviewer and Citspace were used to analyse results and creating visualizing maps.

RESULTS

The results retrieved 355 publications, one-third of them have been published in the year of the COVID-19 pandemic; (2020). The USA has contributed to one-half of all publications, and just five countries have contributed to about 90% of all records. Very high HDI countries had significantly more publications count per million populations, than high (p-value = 0.0047), medium (p-value = 0.0081) or low HDI countries (p-value = 0.002). The main themes are screening programmes, reliability, photography, COVID-19, access, artificial intelligence, and cost-effectiveness. The leading countries in terms of both publications and citation count are the USA and India. In terms of publications count per million populations, the leading countries are Singapore and Australia.

CONCLUSION

Most of the contribution in teleophthalmology research was confined to a small number of countries. More effort is needed to expand the global contribution. The hotspots in this field are artificial intelligence applications and COVID-19 impact.

Applications of Telemedicine in the Middle East and North Africa Region: Benefits Gained and Challenges Faced

Information and communication technology has left a print on all fields of life, including medicine and the health care system. Telemedicine is the perfect way to ensure adequate healthcare delivery to all people at any time, particularly during pandemics, regardless of any geographic or economic considerations. This article investigates the different types, categories, and benefits in addition to the barriers to telemedicine implementation, especially in the Middle East and North Africa (MENA) region. After a thorough review of medical literature related to telemedicine using PubMed, Google Scholar, and some other gray literature, it has been found that telemedicine has been involved in almost all medical specialties with a positive influence on healthcare delivery and medical education and research. It had a major role during the COVID-19 pandemic. However, many obstacles prevent its proper application and need to be addressed carefully by the government and relevant authorities. Due to the rapidly growing population, unequal distribution of healthcare services, and social distancing of the COVID-19 pandemic, the role of telemedicine has become increasingly essential. Regarding medical education and research, telemedicine facilitates the exchange of information and ideas between physicians and professionals from all over the world, bringing these various minds together on a single platform.

Cost-Utility Analysis of Screening for Diabetic Retinopathy in China

Background. Diabetic retinopathy (DR) has been primarily indicated to cause vision impairment and blindness, while no studies have focused on the cost-utility of telemedicine-based and community screening programs for DR in China, especially in rural and urban areas, respectively.Methods. We developed a Markov model to calculate the cost-utility of screening programs for DR in DM patients in rural and urban settings from the societal perspective. The incremental cost-utility ratio (ICUR) was calculated for the assessment.Results. In the rural setting, the community screening program obtained 1 QALY with a cost of $4179 (95% CI 3859 to 5343), and the telemedicine screening program had an ICUR of $2323 (95% CI 1023 to 3903) compared with no screening, both of which satisfied the criterion of a significantly cost-effective health intervention. Likewise, community screening programs in urban areas generated an ICUR of $3812 (95% CI 2906 to 4167) per QALY gained, with telemedicine screening at an ICUR of $2437 (95% CI 1242 to 3520) compared with no screening, and both were also cost-effective. By further comparison, compared to community screening programs, telemedicine screening yielded an ICUR of 1212 (95% CI 896 to 1590) per incremental QALY gained in rural setting and 1141 (95% CI 859 to 1403) in urban setting, which both meet the criterion for a significantly cost-effective health intervention.Conclusions. Both telemedicine and community screening for DR in rural and urban settings were cost-effective in China, and telemedicine screening programs were more cost-effective.

Evaluation of a Telemedicine Model for Following Keratoconus Patients in the Era of COVID-19 Pandemic

Purpose: To evaluate the diagnostic accuracy and reliability of a telemedicine approach for detecting keratoconus patients' progression in the era of coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: A retrospective study, comparing the office and telemedicine evaluations in determining whether keratoconus patients were at risk of progression and indicated for further treatment of corneal crosslinking, was conducted. The clinic examination included best spectacle corrected visual acuity measurement and manifest refraction, full ophthalmic examination, and corneal topography, which provided with the gold-standard diagnosis. The remote assessment included two decisions of keratoconus progression or stability: the first evaluation after revealing patient demographics and topography images, and the second with the manifest refraction and clinical findings as documented in the outpatient clinic visit. Results: Two-hundred and four eyes of 102 keratoconus patients were included. There was an agreement of assessment between the in-person and the remote diagnostic decisions in 192 (94%) of the eyes. Among the remaining 12 eyes, a false-positive diagnosis was made in 8 (3.9%) eyes, whereas a false-negative diagnosis was made in 4 (1.9%) eyes. The remote assessment showed a sensitivity and specificity of 69% and 96%, respectively. In no case was remote diagnostic decision 2 different from remote decision 1. Conclusions: The telemedicine model yielded high specificity, but low sensitivity values, therefore, not suitable as an alternative for keratoconus patient follow-up (Clinical trial number TLV-0363-20).

Evidence-based Canadian guidelines for tele-retina screening for diabetic retinopathy: recommendations from the Canadian Retina Research Network (CR2N) Tele-Retina Steering Committee

OBJECTIVE

The purpose of this report is to develop a consensus for Canadian national guidelines specific to a tele-medicine approach to screening for diabetic retinopathy (DR) using evidence-based and clinical data.

METHODS

Canadian Tele-Screening Grading Scales for DR and diabetic macular edema (DME) were created primarily based on severity grading scales outlined by the International Clinical Diabetic Retinopathy Disease Severity Scale (ICDR) and the Scottish DR Grading Scheme 2007. Other grading scales used in international screening programs and the clinical expertise of the Canadian Retina Research Network members and retina specialists nationwide were also used in the creation of the guidelines.

RESULTS

National Tele-Screening Guidelines for DR and DME with and without optical coherence tomography (OCT) images are proposed. These outline a diagnosis and management algorithm for patients presenting with different stages of DR and/or DME. General guidelines detailing the requirements for imaged retina fields, image quality, quality control, and follow-up care and the role of visual acuity, pupil dilation, OCT, ultra-wide-field imaging, and artificial intelligence are discussed.

CONCLUSIONS

Tele-retina screening can help to address the need for timely and effective screening for DR, whose prevalence continues to rise. A standardized and evidence-based national approach to DR tele-screening has been proposed, based on DR/DME grading using two 45° image fields or a single widefield or ultra-wide-field image, preferable use of OCT imaging, and a focus on local quality control measures.

Sociodemographics Associated With Risk of Diabetic Retinopathy Detected by Tele-Ophthalmology: 5-Year Results of the Toronto Tele-Retinal Screening Program

OBJECTIVES

Our aim in this study was to describe screening outcomes and sociodemographic characteristics of patients in an urban tele-ophthalmology screening program for diabetic retinopathy (DR).

METHODS

A prospective cohort study was conducted on adults with diabetes type 1 or type 2 enrolled in the Toronto Tele-Retinal Screening Program between September 2013 and March 2019.

RESULTS

A total of 1,374 screenings were completed, of which 344 (25%) detected DR. Of all participants, 17% did not have provincial health coverage and 21% never had an eye exam. Of the 587 patients who completed sociodemographic questionnaires, the majority (84%) were born outside of Canada, and only 62% preferred English as their spoken language. Forty percent reported a household income of <$25,000, with these participants having an increased likelihood of detectable DR (odds ratio [OR], 1.83; p<0.01).

CONCLUSIONS

Participants with low income are more likely to screen positive for DR. Tele-ophthalmologic screening can be effective in an urban, culturally diverse and socioeconomically disadvantaged population.

Assessment of Training Outcomes of Nurse Readers for Diabetic Retinopathy Telescreening: Validation Study

BACKGROUND

With the high prevalence of diabetic retinopathy and its significant visual consequences if untreated, timely identification and management of diabetic retinopathy is essential. Teleophthalmology programs have assisted in screening a large number of individuals at risk for vision loss from diabetic retinopathy. Training nonophthalmological readers to assess remote fundus images for diabetic retinopathy may further improve the efficiency of such programs.

OBJECTIVE

This study aimed to evaluate the performance, safety implications, and progress of 2 ophthalmology nurses trained to read and assess diabetic retinopathy fundus images within a hospital diabetic retinopathy telescreening program.

METHODS

In this retrospective interobserver study, 2 ophthalmology nurses followed a specific training program within a hospital diabetic retinopathy telescreening program and were trained to assess diabetic retinopathy images at 2 levels of intervention: detection of diabetic retinopathy (level 1) and identification of referable disease (level 2). The reliability of the assessment by level 1-trained readers in 266 patients and of the identification of patients at risk of vision loss from diabetic retinopathy by level 2-trained readers in 559 more patients were measured. The learning curve, sensitivity, and specificity of the readings were evaluated using a group consensus gold standard.

RESULTS

An almost perfect agreement was measured in identifying the presence of diabetic retinopathy in both level 1 readers (κ=0.86 and 0.80) and in identifying referable diabetic retinopathy by level 2 readers (κ=0.80 and 0.83). At least substantial agreement was measured in the level 2 readers for macular edema (κ=0.79 and 0.88) for all eyes. Good screening threshold sensitivities and specificities were obtained for all level readers, with sensitivities of 90.6% and 96.9% and specificities of 95.1% and 85.1% for level 1 readers (readers A and B) and with sensitivities of 86.8% and 91.2% and specificities of 91.7% and 97.0% for level 2 readers (readers A and B). This performance was achieved immediately after training and remained stable throughout the study.

CONCLUSIONS

Notwithstanding the small number of trained readers, this study validates the screening performance of level 1 and level 2 diabetic retinopathy readers within this training program, emphasizing practical experience, and allows the establishment of an ongoing assessment clinic. This highlights the importance of supervised, hands-on experience and may help set parameters to further calibrate the training of diabetic retinopathy readers for safe screening programs.

Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition

Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.

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.

Use of Telemedicine Technologies in Diabetes Prevention and Control in Resource-Constrained Settings: Lessons Learned from Emerging Economies

Telemedicine is a promising strategy that utilizes telecommunication to provide health care in remote areas, facilitating beneficial interaction between the health care provider and people in rural areas and making affordable and accessible medical care available to remote, inaccessible areas of the world. This article provides an overview of some of the ways telemedicine is improving diabetes care outcomes at the community level. Telemedicine can play a number of roles in moving quality diabetes care forward. It is currently being used to create awareness among urban and rural population about the risk factors and prevention of diabetes; to facilitate patient monitoring; for remote diabetic retinopathy screening; and in diabetes prevention at the primary, secondary, and tertiary level. We also highlight the use of automated artificial intelligence software combined with telemedicine to conduct efficient real-time screening of complications such as diabetic retinopathy in remote areas where such facilities are currently unavailable.

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.

Telemedicine in long-term care of glaucoma patients

Introduction

This manuscript describes data from an original study, simulating a tele-glaucoma programme in an established clinic practice with an interdisciplinary team. This is a ‘real life’ trial of a telemedicine approach to see a follow-up patient. The goal is to evaluate the accuracy of such a programme to detect worsening and/or unstable disease. Such a programme is attractive since in-clinic time could be reduced for both the patient and provider. This study evaluates agreement between in-person and remote assessment of glaucoma progression.

Methods

A total of 200 adult glaucoma patients were enrolled at a single institution. The in-person assessment by an optometrist or glaucoma specialist at time of enrolment was used as the gold standard for defining progression. Collated clinical data were then reviewed by four masked providers who classified glaucoma as progression or non-progression in each eye by comparing data from enrolment visit to data from the visit immediately prior to enrolment. Agreement of glaucoma progression between the masked observer and the in-person assessment was determined using Kappa statistics. Intra-observer agreement was calculated using Kappa to compare in-person to remote assessment when both assessments were performed by the same provider (n = 279 eyes).

Results

A total of 399 eyes in 200 subjects were analysed. Agreement between in-person versus remote assessment for the determination of glaucoma progression was 63%, 62%, 69% and 68% for each reader 1–4 (kappa values = 0.19, 0.20, 0.35 and 0.33, respectively). For intra-observer agreement, reader 1 agreed with their own in-person assessment for 65% of visits (kappa = 0.18).

Discussion

Intra-observer agreement was similar to the agreement for each provider who did not see the patient in person. This similarity suggests that telemedicine may be equally effective at identifying glaucomatous disease progression, regardless of whether the same provider performed both in-clinic and remote assessments. However, fair agreement levels highlight a limitation of using only telemedicine data to determine progression compared with clinical detail available during in-patient assessment.

Clinical Application of a Smartphone-Based Ophthalmic Camera adapter in Under-Resourced Settings in Nepal

Background

The ability to obtain high quality ocular images utilizing smartphone technology is of special interest in under-resourced parts of the world where traditional ocular imaging devices are cost-prohibitive, difficult to transport, and require a trained technician for operation.

Purpose

The purpose of this study was to explore potential anterior and posterior segment ocular imaging use cases for a smartphone-based ophthalmic camera adapter (Paxos Scope, Digisight Technologies, San Francisco, CA, USA) in under-resourced settings in Nepal.

Methods

From September to November of 2015 we utilized the Paxos Scope smartphone camera adapter coupled with an iPhone 5 to explore anterior and posterior segment clinical applications for this mobile technology. We used the device at a tertiary eye care facility, a rural eye hospital and a rural cataract outreach camp. We tested the device's capability for high quality photo-documentation in clinic, in the operating room, and in the outreach camp setting. Images were automatically uploaded to a secure, cloud-based electronic medical record system that facilitated sharing of images with other providers for telemedicine purposes.

Results

Herein we present 17 ocular images documenting a wide variety of anterior and posterior segment pathology using the Paxos Scope from clinical cases seen in a variety of settings in Nepal.

Conclusions

We found the quality of both the anterior and posterior segment images to be excellent in the clinic, the operating room, and the outreach camp settings. We found the device to be versatile and user-friendly, with a short learning curve. The Paxos Scope smartphone camera adapter may provide an affordable, high-quality, mobile ocular imaging option for under-resourced parts of the world.

Can Commercially Available Handheld Retinal Cameras Effectively Screen Diabetic Retinopathy?

Organizations that care for people with diabetes have increasingly adopted telemedicine-based diabetic retinopathy screening (TMDRS) as a way to increase adherence to recommended retinal exams. Recently, handheld retinal cameras have emerged as a low-cost, lightweight alternative to traditional bulky tabletop retinal cameras. Few published clinical trials have been performed on handheld retinal cameras. Peer-reviewed articles about commercially available handheld retinal cameras have concluded that they are a usable alternative for TMDRS, however, the clinical results presented in these articles do not meet criteria published by the United Kingdom Diabetic Eye Screening Programme and the American Academy of Ophthalmology. The future will likely remedy the shortcomings of currently available handheld retinal cameras, and will create more opportunities for preventing diabetic blindness.

Evidence for Telemedicine for Diabetic Retinal Disease

According to current projections, the number of Americans with diabetes mellitus will increase from 27.8 million in 2007 to 60.7 million in 2030. With the increasing gap between demand for eye care and supply of ophthalmologists and optometrists, and the non-uniform distribution of eye care providers in US counties, barriers to eye examinations will likely increase. Telemedicine assessment of diabetic retinal disease through remote retinal imaging and diagnosis has the potential to meet these growing demands. To establish evidence for a telemedicine program as an effective modality for diabetic retinopathy (DR) assessment, the interpretation of teleretinal images should compare favorably with Early Treatment Diabetic Retinopathy Study film or digital photographs. We review the current evidence on the critical features and characteristics of ocular telehealth programs for DR in the following categories: image gradability, mydriasis, sensitivity and specificity, cost-effectiveness, long-term effectiveness, patient comfort and satisfaction, and improvement of patient related outcomes.

Real-time teleophthalmology versus face-to-face consultation: A systematic review

Introduction Advances in imaging capabilities and the evolution of real-time teleophthalmology have the potential to provide increased coverage to areas with limited ophthalmology services. However, there is limited research assessing the diagnostic accuracy of face-to-face teleophthalmology consultation. This systematic review aims to determine if real-time teleophthalmology provides comparable accuracy to face-to-face consultation for the diagnosis of common eye health conditions. Methods A search of PubMed, Embase, Medline and Cochrane databases and manual citation review was conducted on 6 February and 7 April 2016. Included studies involved real-time telemedicine in the field of ophthalmology or optometry, and assessed diagnostic accuracy against gold-standard face-to-face consultation. The revised quality assessment of diagnostic accuracy studies (QUADAS-2) tool assessed risk of bias. Results Twelve studies were included, with participants ranging from four to 89 years old. A broad number of conditions were assessed and include corneal and retinal pathologies, strabismus, oculoplastics and post-operative review. Quality assessment identified a high or unclear risk of bias in patient selection (75%) due to an undisclosed recruitment processes. The index test showed high risk of bias in the included studies, due to the varied interpretation and conduct of real-time teleophthalmology methods. Reference standard risk was overall low (75%), as was the risk due to flow and timing (75%). Conclusion In terms of diagnostic accuracy, real-time teleophthalmology was considered superior to face-to-face consultation in one study and comparable in six studies. Store-and-forward image transmission coupled with real-time videoconferencing is a suitable alternative to overcome poor internet transmission speeds.

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.

Eye Care Quality and Accessibility Improvement in the Community (EQUALITY) for adults at risk for glaucoma: study rationale and design

Background

Primary open angle glaucoma is a chronic, progressive eye disease that is the leading cause of blindness among African Americans. Glaucoma progresses more rapidly and appears about 10 years earlier in African Americans as compared to whites. African Americans are also less likely to receive comprehensive eye care when glaucoma could be detected before irreversible blindness. Screening and follow-up protocols for managing glaucoma recommended by eye-care professional organizations are often not followed by primary eye-care providers, both ophthalmologists and optometrists. There is a pressing need to improve both the accessibility and quality of glaucoma care for African Americans. Telemedicine may be an effective solution for improving management and diagnosis of glaucoma because it depends on ocular imaging and tests that can be electronically transmitted to remote reading centers where tertiary care specialists can examine the results. We describe the Eye Care Quality and Accessibility Improvement in the Community project (EQUALITY), set to evaluate a teleglaucoma program deployed in retail-based primary eye care practices serving communities with a large percentage of African Americans.

Methods/Design

We conducted an observational, 1-year prospective study based in two Walmart Vision Centers in Alabama staffed by primary care optometrists. EQUALITY focuses on new or existing adult patients who are at-risk for glaucoma or already diagnosed with glaucoma. Patients receive dilated comprehensive examinations and diagnostic testing for glaucoma, followed by the optometrist’s diagnosis and a preliminary management plan. Results are transmitted to a glaucoma reading center where ophthalmologists who completed fellowship training in glaucoma review results and provide feedback to the optometrist, who manages the care of the patient. Patients also receive eye health education about glaucoma and comprehensive eye care. Research questions include diagnostic and management agreement between providers, the impact of eye health education on patients’ knowledge and adherence to follow-up and medication, patient satisfaction, program cost-effectiveness, and EQUALITY’s impact on Walmart pharmacy prescription rates.

Discussion

As eye-care delivery systems in the US strive to improve quality while reducing costs, telemedicine programs including teleglaucoma initiatives such as EQUALITY could contribute toward reaching this goal, particularly among underserved populations at-risk for chronic blinding diseases.

Recent Directions in Telemedicine: Review of Trends in Research and Practice

Objectives

Healthcare is now routinely delivered by telecommunications-based services in all developed countries and an increasing number of developing countries. Telemedicine is used in many clinical specialities and across numerous healthcare settings, which range from mobile patient-centric applications to complex interactions amongst clinicians in tertiary referral hospital settings. This paper discusses some recent areas of significant development and progress in the field with the purpose of identifying strong trends in both research and practice activities.

Methods

To establish the breadth of new ideas and directions in the field, a review of literature was made by searching PubMed for recent publications including terms (telemedicine OR telehealth) AND (challenge OR direction OR innovation OR new OR novel OR trend), for all searchable categories. 3,433 publications were identified that have appeared since January 1, 2005 (2,172 of these since January 1, 2010), based on a search conducted on June 1, 2015.

Results

The current interest areas in these papers span both synchronous telemedicine, including intensive care, emergency medicine, and mental health, and asynchronous telemedicine, including wound and burns care, dermatology and ophthalmology.

Conclusions

It is concluded that two major drivers of contemporary tele medicine development are a high volume demand for a particular clinical service, and/or a high criticality of need for clinical exper tise to deliver the service. These areas offer promise for further study and enhancement of applicable telemedicine methods and have the potential for large-scale deployments internationally, which would contribute significantly to the advancement of healthcare.

Global teleophthalmology with iPhones for real-time slitlamp eye examination

PURPOSE

To evaluate the image resolutions in global teleophthalmology using 2 smartphones.

METHODS

A standard resolution test card and two human eyes (one eye wearing a contact lens) were imaged with an iPhone 4S adapted for slitlamp biomicroscopy in Hangzhou, Zhejiang, China. An iPhone 5 was used as a receptor on the other side of the world (Miami, FL). The real-time images and still images were transferred through Skype from Hangzhou to Miami during slitlamp eye examination. The real-time resolutions captured and displayed on the both phones at different places were measured. There was vocal communication concurrent between two parties during image transference and the examination by the slitlamp biomicroscopy performed in Hangzhou.

RESULTS

The real-time and still images were transferred between two cities while two operators talked with each other smoothly and without difficulty. The viewer in Miami was able to instruct the operator in Hangzhou to thoroughly examine the eye using the slitlamp microscopy with different magnification settings and illumination settings. The resolution of the still images recorded in the iPhone in Hangzhou was higher than that of the real-time images on the screen. The main features of the eye were recognizable in real-time.

CONCLUSIONS

The study demonstrated that global teleophthalmology is feasible using two smartphones. The system is simple, portable, and affordable, and the image quality in still and real-time images is acceptable for real-time teleophthalmology.

A survey of Alabama eye care providers in 2010-2011

BACKGROUND

State level information regarding eye care resources can provide policy makers with valuable information about availability of eye care services. The current study surveyed ophthalmologists, optometrists and vision rehabilitation providers practicing in Alabama.

METHODS

Three mutually exclusive provider groups were identified, i.e., all ophthalmologists, optometrists, and vision rehabilitation providers working in Alabama in 2010. Eligible providers were contacted in 2010 and 2011 and information was requested regarding provider demographics and training, practice type and service characteristics, and patient characteristics. Descriptive statistics (e.g., means, proportions) were used to characterize provider groups by their demographic and training characteristics, practice characteristics, services provided and patients or clients served. In addition, county level figures demonstrate the numbers and per capita ophthalmologists and optometrists.

RESULTS

Ophthalmologists were located in 24 of Alabama's 67 counties, optometrists in 56, and 10 counties had neither an ophthalmologist nor an optometrist. Overall, 1,033 vision care professionals were identified as eligible to participate in the survey: 217 ophthalmologists, 638 optometrists, and 178 visual rehabilitation providers. Of those, 111 (51.2%) ophthalmologists, 246 (38.6%) optometrists, and 81 (45.5%) rehabilitation providers participated. Most participating ophthalmologists, optometrists, and vision rehabilitation providers identified themselves as non-Hispanic White. Ophthalmologists and optometrists estimated that 27% and 22%, respectively, of their patients had diabetes but that the proportion that adhered to eye care guidelines was 61% among ophthalmology patients and 53% among optometry patients.

CONCLUSIONS

A large number of Alabama communities are isolated from eye care services. Increased future demand for eye care is anticipated nationally given the aging of the population and decreasing numbers of providers; however, Alabama also has a high and growing prevalence of diabetes which will result in greater numbers at risk for diabetic retinopathy, glaucoma, and cataracts.

"Think different": a qualitative assessment of commercial innovation for diabetes information technology programs

BACKGROUND

This study reviews the state of diabetes information technology (IT) initiatives and presents a set of recommendations for improvement based on interviews with commercial IT innovators.

MATERIALS AND METHODS

Semistructured interviews were conducted with 10 technology developers, representing 12 of the most successful IT companies in the world. Average interview time was approximately 45 min. Interviews were audio-recorded, transcribed, and entered into ATLAS.ti for qualitative data analysis. Themes were identified through a process of selective and open coding by three researchers.

RESULTS

We identified two practices, common among successful IT companies, that have allowed them to avoid or surmount the challenges that confront healthcare professionals involved in diabetes IT development: (1) employing a diverse research team of software developers and engineers, statisticians, consumers, and business people and (2) conducting rigorous research and analytics on technology use and user preferences.

CONCLUSIONS

Because of the nature of their respective fields, healthcare professionals and commercial innovators face different constraints. With these in mind we present three recommendations, informed by practices shared by successful commercial developers, for those involved in developing diabetes IT programming: (1) include software engineers on the implementation team throughout the intervention, (2) conduct more extensive baseline testing of users and monitor the usage data derived from the technology itself, and (3) pursue Institutional Review Board-exempt research.

Telehealth practice recommendations for diabetic retinopathy, second edition

Ocular telemedicine and telehealth have the potential to decrease vision loss from DR. Planning, execution, and follow-up are key factors for success. Telemedicine is complex, requiring the services of expert teams working collaboratively to provide care matching the quality of conventional clinical settings. Improving access and outcomes, however, makes telemedicine a valuable tool for our diabetic patients. Programs that focus on patient needs, consider available resources, define clear goals, promote informed expectations, appropriately train personnel, and adhere to regulatory and statutory requirements have the highest chance of achieving success.

Comparison of dilated fundus examinations with seven-field stereo fundus photographs in the Veterans Affairs Diabetes Trial

OBJECTIVE

The Veterans Affairs Diabetes Trial (VADT) is a 20-medical center, prospective, randomized study of 1792 Type 2 diabetic individuals primarily aimed at determining whether intensive glycemic control prevents macrovascular events. We report a comparison of fundus photographs and ophthalmologic examination at baseline, permitting an evaluation of multiple settings similar to common clinical practice.

RESEARCH DESIGN AND METHODS

A 340-patient subset had both local dilated fundus examinations and centrally read seven-field stereo fundus photographs completed within 60 days of each other (median 28 days). Local examiners were unaware of the stereo photographs.

RESULTS

Overall, agreement within one step was 76% and exact agreement between ophthalmoscopy and central gradings of fundus photographs on a five-step retinopathy severity scale was 43% (weighted kappa 0.42, CI 0.35-0.48). In about 90% of disagreements the severity level was higher by photographic grading. The sensitivity for ophthalmoscopy compared to grading of fundus photographs for the detection of any retinopathy was 51% and specificity was 91%. For proliferative diabetic retinopathy (PDR), sensitivity was 61% and specificity 98%. Only one eye was high-risk PDR, and it was detected by both methods. For clinically significant macular edema, these measures were 24% and 98%, respectively. The disagreements were of possible clinical importance in three cases (<1%).

CONCLUSION

Most disagreements occurred in eyes rated near the milder end of a category and/or resulted from small differences between the ophthalmoscopic and photographic definitions used in classifying severity. There were reasonably few disagreements of possible clinical significance.

Ocular telehealth initiatives in diabetic retinopathy

Diabetic retinopathy (DR) is a common complication of diabetes mellitus and a leading cause of new-onset vision loss in adults worldwide. Current medical and surgical evidence-based care, including laser photocoagulation, is effective in preserving vision. This care is most effective prior to the onset of ocular or visual symptoms, but many diabetic persons do not receive the recommended annual eye examination for the evaluation of the retina for level of DR. With diabetes incidence and prevalence increasing at epidemic rates and the prediction that 370 million people worldwide will have diabetes by the year 2030, human and fiscal resources will be unable to meet the visual needs with current acute care methods. Appropriate and validated telemedicine programs for DR hold the promise of both enrolling patients into appropriate eye care programs and, more importantly, providing more effective, high-quality diabetes eye care based on current and developing technology.

EyePACS: an adaptable telemedicine system for diabetic retinopathy screening

BACKGROUND

Annual retinal screening of patients with diabetes is the standard clinical practice to prevent visual impairment and blindness from diabetic retinopathy. Telemedicine-based diabetic retinopathy screening (DRS) in primary care settings can effectively detect sight-threatening retinopathy and significantly increase compliance with annual retinal exams. EyePACS is a license-free Web-based DRS system designed to simplify the process of image capture, transmission, and review. The system provides a flexible platform for collaboration among clinicians about diabetic retinopathy.

METHODS

Primary clinic personnel (i.e., nursing, technical, or administrative staff) are trained and certified by the EyePACS program to acquire retinal images from standard digital retinal cameras. Relevant clinical data and eight high-resolution images per patient (two external and six retinal images) are encrypted and transmitted to a secure Internet server, using a standard computer and Web browser. Images are then interpreted by certified EyePACS reviewers or local eye care providers who are certified through the EyePACS Retinopathy Grading System. Reports indicating retinopathy level and referral recommendations are transmitted back to primary care providers through the EyePACS Web site or through interfaces between EyePACS and Health Level 7-compliant electronic medical records or chronic disease registries.

RESULTS

The pilot phase of the EyePACS DRS program in California (2005-2006) recorded 3562 encounters. Since 2006, EyePACS has been expanded to over 120 primary care sites throughout California and elsewhere recording over 34,000 DRSs. The overall rate of referral is 8.21% for sight-threatening retinopathy and 7.83% for other conditions (e.g., cataract and glaucoma).

CONCLUSION

The use of license-free Web-based software, standard interfaces, and flexible protocols has allowed primary care providers to adopt retinopathy screening with minimal effort and resources.

Accuracy of digital images for assessing diabetic retinopathy

BACKGROUND

To determine the accuracy of diabetic retinopathy status assessments with and without pupil dilation using digital fundus photographs acquired by a clinic staff person and interpreted remotely by ophthalmologists.

METHOD

Using early treatment diabetic retinopathy study (EDTRS) grading criteria, diabetic retinopathy status assessments were made by an experienced (nonphysician) retinal grader (NPG) based on seven standard field 35-mm stereoscopic slides acquired by an experienced ophthalmic photographer. These assessments were compared with those of the same eyes made by two ophthalmologists and the NPG using digital photographs acquired by a clinic staff person using a high-resolution (800 x 600) digital color camera system.

RESULTS

Based on 35-mm slides, 38% of 244 diabetic patients had ETDRS > or =35 in at least one eye and 5% had vision-threatening diabetic retinopathy (ETDRS > or =53 or macular edema). The proportion of ungradable images was significantly greater for nonmydriatic than mydriatic assessments (30% versus 10% ungradable as determined by the NPG). For ETDRS level > or =35, specificity ranged from moderate to high (0.70 to 0.96) for the three graders, while sensitivity was poor to moderate (0.38 to 0.71), and the area under the receiver-operating characteristic curves was less than satisfactory (0.67 to 0.71).

CONCLUSIONS

The low sensitivity of the digital assessments indicates a significant proportion of patients in need of referral would not have been referred. These findings suggest that implementation of a simplified screening system using nonphotographer clinic staff acquiring nonmydriatic images, with interpretation by an ophthalmologist, should take place with an understanding of potential limitations.