Age-related macular degeneration screening using a nonmydriatic digital color fundus camera and telemedicine

Stakeholder perceptions affecting the implementation of teleophthalmology

PURPOSE

Teleophthalmology has become the subject of heightened interest and scrutiny in the wake of the SARS-CoV-2 global pandemic. A streamlined implementation framework becomes increasingly important as demand grows. This study identified obstacles to teleophthalmology implementation through summative content analysis of key stakeholders' perceptions.

DESIGN

Summative content analysis of transcribed interviews with key stakeholders (including patients, technicians, ophthalmic readers, staff, nurses, and administrators at two teleophthalmology clinic sites).

METHODS

Keyword Were counted and compared to examine underlying meaning. Two analysts coded text independently using MAXQDA for summative qualitative content analysis to derive themes and hierarchical relationships as a basis for future refinement of TECS implementation. xMind ZEN was used to map conceptual relationships and overarching themes that emerged to identify perceived facilitators and barriers to implementation RESULTS: Analysis revealed two themes common to perceptions: (1) benefits of care, and (2) ease of implementation. Perceived benefits included efficiency, accessibility, and earlier intervention in disease course. The quality and quantity of training was heavily weighted in its influence on stakeholders' commitment to and confidence in the program, as were transparent organizational structure, clear bidirectional communication, and the availability of support staff.

CONCLUSION

Using a determinant framework of implementation science, this report highlighted potential hindrances to teleophthalmology implementation and offered solutions in order to increase access to screening, improve the quality of care provided, and facilitate sustainability of the innovation.

Evaluation of a remote telemedicine platform using a novel handheld fundus camera: Physician and patient perceptions from real-world experience

BACKGROUND

Although teleophthalmology has gained traction in recent years, it is at the center of the coronavirus disease pandemic. However, most hospitals are not ready owing to a severe lack of real-world experience. Furthermore, a limited number of studies have evaluated telemedicine applications on remote islands. This study aimed to evaluate real-world clinical and referral accuracy, image quality, physician-perceived diagnostic certainty, and patient satisfaction with telemedicine eye screening using a novel handheld fundus camera in a rural and medically underserved population.

METHODS

This prospective study included 176 eyes from a remote island. All participants underwent a comprehensive ophthalmic examination. Nonmydriatic retinal images obtained using a handheld fundus camera were reviewed by two retinal specialists to determine image quality, diagnosis, and need for referrals. The agreement of diagnosis between image-based assessments was compared with that of binocular indirect ophthalmoscopic assessments.

RESULTS

Image quality of fundus photographs was considered acceptable or ideal in 97.7% and 95.5% of eyes assessed by two reviewers, respectively. There was considerable agreement in diagnosis between the indirect ophthalmoscopic assessment and image-based assessment by two reviewers (Cohen's kappa = 0.80 and 0.78, respectively). Likewise, substantial agreement was achieved in the referrals. The sensitivity for referable retinopathy from the two reviewers was 78% (95% confidence interval [CI], 57%-91%) and 78% (95% CI, 57%-91%), whereas specificity was 99% (95% CI, 95%-99%] and 98% (95% CI, 93%-99%), respectively. For physicians' perceived certainty of diagnosis, 93.8% and 90.3% were considered either certain or reliable. Overall, 97.4% of participants were satisfied with their experiences and greatly valued the telemedicine services.

CONCLUSION

Novel fundus camera-based telemedicine screening demonstrated high accuracy in detecting clinically significant retinopathy in real-world settings. It achieved high patient satisfaction and physician-perceived certainty in diagnosis with reliable image quality, which may be scaled internationally to overcome geographical barriers under the global pandemic.

Telemedicine for the Diagnosis and Management of Age-Related Macular Degeneration: A Review

Use of ophthalmic telemedicine for patients with age-related macular degeneration (AMD) has shown remarkable advances over recent years. The recent COVID pandemic accelerated this transition since in-person evaluation of elderly patients at high risk for advanced AMD and severe vision loss were also at higher risk for complications from COVID infection. To date, ophthalmic telemedicine has been successfully used in remote retinal consultation by general ophthalmologists for AMD management, hybrid testing visits with both in-office testing and remote evaluation, as well as early successes in home-based remote monitoring of patients with high-risk AMD. We therefore review the current literature and evidence base related to ophthalmic telemedicine for AMD.

Impact of illumination spectrum and eye pigmentation on image quality from a fundus camera using transscleral illumination

SIGNIFICANCE

The use of the transscleral illumination approach has the potential to simplify the optical design of fundus cameras. In particular, this approach could allow the use of smaller and cheaper cameras that are easier to use by non-specialists, thereby facilitating a wider spread of eye disease screening programs.

AIM

Our aim was to investigate the suitability of transscleral illumination in a fundus camera system. In particular, we explored the impact of the illumination spectrum and the eye pigmentation on the quality of the image. These factors have never been systematically investigated before in the literature on transscleral illumination.

APPROACH

A fundus camera was constructed using transscleral illumination. We studied the influence of eye pigmentation and choice of illumination spectra on the image quality for a group of 10 individuals with varied skin pigmentation, ranging from pale white (North-European) to darkest brown (African). The influence of the light source spectrum on the image quality was assessed using wavelength filters.

RESULTS

There was a difference of a factor of 100 in the signal level of retinal images between individuals with low and high skin pigmentation. The image contrast was highest using illumination wavelengths of 500 to 600 nm. The illumination level can be adjusted to obtain high-quality images for highly pigmented eyes while keeping the system eye-safe.

CONCLUSIONS

We have demonstrated that a fundus camera with transscleral illumination can provide high-quality images. However, the variations observed in scleral and retinal pigmentation in a practical setting require a system that must be able to adapt illumination and/or exposure to the individual patient.

Teleophthalmology as a Model for Detecting Ocular Diseases in Tribal Areas of a North West State in India

Background

Lahaul and Spiti district of Himachal Pradesh, a high altitude tribal district, situated at altitudes varying from 10,000 to 15, 000 ft. above mean sea level is cut off from the rest of the country for nearly 6 months due to heavy snowfall in the mountain passes. In the absence of any ophthalmologist and ophthalmic technician, the provision of eye care is virtually absent. The current study (part of a research project funded by the Indian Council of Medical Research) was conducted with the aim to explore teleophthalmology as a model for detecting posterior segment eye diseases in tribal and inaccessible areas.

Materials and Methods

Fundus images (taken through fundus photography) of 1000 individuals above 5 years of age with no improvement in vision to 6/6 on refraction and individuals with known history of diabetes mellitus, systemic hypertension, or long standing headache with features of raised intracranial tension irrespective of whether their vision improved to 6/6 or not were sent to tertiary care center (base hospital) from regional hospital (field hospital). Transmitted images (through internet after attaching the details and patient particulars on the excel sheet) were analyzed by the ophthalmologists and the final diagnosis along with the line of management if any was transmitted back.

Results

Eighty-five percent of the images transmitted were of good quality. Retinal, vitreous, optic nerve head, and choroidal diseases could be detected.

Conclusions

In the present situation, where trained workforce is unavailable in these areas, teleophthamology is an appropriate tool by which a number of eye diseases can be detected at early stages. Most of them can be treated in these early stages by lifestyle modification and medical management.

Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic

BACKGROUND

We introduced a video consultation (VC) during the coronavirus (COVID-19) pandemic in an ophthalmology practice with eight doctors to ensure continuous ophthalmological care, infection prophylaxis and to compensate a decreased number of patient presentations.

OBJECTIVE

Evaluation of the most common reasons for patient presentations in the VC, the proportion of re-presentations in the practice despite VC, practical challenges associated with the introduction of VC and patient satisfaction.

MATERIAL AND METHODS

Patients with a recent acute visual deterioration and severe eye pain were excluded from the VC. The VC were carried out by a trained specialist in ophthalmology. A questionnaire with eight questions was completed after the VC appointment in order to evaluate the proportion of completed VC and patient satisfaction.

RESULTS

We included 29 (13 male, Ø 52.6 years, 16 female, Ø 64.7 years) patients in this analysis. The VC could be performed with 68.97% of the participants who rated their overall experience with an average grade of 1.6 (1 very good to 6 insufficient) and all of them indicated that they would recommend the VC. Of presentations in VC 70% were related to the symptoms of the anterior eye segment. In 70% of the cases no re-presentations took place in the unit.

CONCLUSION

Our study represents a significant practical application of VC for the management of non-urgent ocular conditions with maximum infection prophylaxis. The introduction of VC was severely limited by technological or user-related issues by the establishment of video connections. Patient satisfaction with VC was high to very high.

Optical coherence tomography and color fundus photography in the screening of age-related macular degeneration: A comparative, population-based study

Purpose

To analyze the individual value and the contribution of color fundus photography (CFP) and optical coherence tomography (OCT) in the screening of age-related macular degeneration (AMD) of an unselected population.

Methods

CFP and OCT images of 15957 eyes of 8069 subjects older than 55 years, obtained during a population-based screening for AMD using a single diagnostic non-mydriatic imaging device, were analyzed by a blinded examiner. The two techniques were preliminary evaluated considering the dichotomous parameter "gradable/ungradable", then gradable images were classified. CFP were graded according to the standardized classification of AMD lesions. OCT images were also categorized considering the presence of signs of early/intermediate AMD, late AMD, or other retinal diseases. Another blinded operator re-graded 1978 randomly selected images (for both CFP and OCT), to assess test reproducibility.

Results

Of the 15957 eyes, 8356 CFP (52.4%) and 15594 (97.7%) OCT scans were gradable. Moreover, most of the eyes with ungradable CFP (7339, 96.6%) were gradable at OCT. AMD signs were revealed in 7.4% of gradable CFP and in 10.4% of gradable OCT images. Moreover, at OCT, AMD signs were found in 1110 (6.9%) eyes whose CFP were ungradable or without AMD (847 and 263 eyes, respectively). The inter-operator agreement was good for the gradable versus ungradable parameter, and optimal for the AMD grading parameter of CFP. The agreement was optimal for all OCT parameters.

Conclusions

OCT provided gradable images in almost all examined eyes, compared to limited CFP efficiency. Moreover, OCT images allowed to detect more AMD eyes compared to gradable photos. OCT imaging appears to significantly improve the power of AMD screening in a general, unselected population, compared to CFP alone.

[Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic]

BACKGROUND

We introduced a video consultation (VC) during the coronavirus (COVID-19) pandemic in an ophthalmology practice with eight doctors to ensure continuous ophthalmological care, infection prophylaxis and to compensate a decreased number of patient presentations.

OBJECTIVE

Evaluation of the most common reasons for patient presentations in the VC, the proportion of re-presentations in the practice despite VC, practical challenges associated with the introduction of VC and patient satisfaction.

MATERIAL AND METHODS

Patients with a recent acute visual deterioration and severe eye pain were excluded from the VC. The VC were carried out by a trained specialist in ophthalmology. A questionnaire with eight questions was completed after the VC appointment in order to evaluate the proportion of completed VC and patient satisfaction.

RESULTS

We included 29 (13 male, Ø 52.6 years, 16 female, Ø 64.7 years) patients in this analysis. The VC could be performed with 68.97% of the participants who rated their overall experience with an average grade of 1.6 (1 very good to 6 insufficient) and all of them indicated that they would recommend the VC. Of presentations in VC 70% were related to the symptoms of the anterior eye segment. In 70% of the cases no re-presentations took place in the unit.

CONCLUSION

Our study represents a significant practical application of VC for the management of non-urgent ocular conditions with maximum infection prophylaxis. The introduction of VC was severely limited by technological or user-related issues by the establishment of video connections. Patient satisfaction with VC was high to very high.

Tele-ophthalmology: Need of the hour

Telemedicine and tele-ophthalmology have been in existence since many years, but have recently gained more importance in the present scenario of pandemic COVID-19. The attitude and perception of the doctors and patients has been changing gradually. Telemedicine has many advantages including providing care in inaccesible areas.In the present scenario, tele-ophthalmology gives an oppurtunity to patient for seeking consultation while also protecting against the contagion. There are many barriers faced by the patients and doctors that have restricted use of this technology in the past. However, with a systematic approach to designing the best suited technology, these barriers can be overcome and user friendly platforms can be created. Furthermore, the demand and use of teleconsulation had increased presently in this area of pandemic. Recent survey conducted by the All India Ophthalmological Society also reveals that many ophthalmologists who have not used tele-ophthalmology in the past are more keen to use it presently. In this article, we have reviewed telemedicine and tele-ophthalmology literature on Google and PubMed to get a holistic idea towards teleconsultation, its advantages, increased importance and prefrence during COVID-19 pandemic and various barriers faced so that the known challenges can be understood, which can pave way for better understanding and future incorporation into practice.

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.

Telemedicine for Age-Related Macular Degeneration

Background: As the leading cause of vision loss in the United States, age-related macular degeneration (AMD) would seem to be amenable to interventions that increase access to screening and management services for patients. AMD poses several unique challenges for telemedicine, however. The disease lacks clinical consensus on the effectiveness and cost-effectiveness of screening the general population, and more complex imaging modalities may be required than for what has traditionally been used for diabetic retinopathy telehealth systems. Methods: The current literature was reviewed to find clinical trials and expert consensus documents on the state-of-the-art of telemedicine for AMD. Results: A range of feasibility studies have reported success with telemedicine strategies for AMD. Several investigators have reported experience with AMD screening and remote-monitoring systems as well as artificial intelligence applications. Conclusions: There are currently no large-scale telemedicine programs for either screening or managing AMD, but new approaches to screening and managing the condition may allow for expansion of high-quality convenient care for an increasing patient population.

Artificial Intelligence to Identify Retinal Fundus Images, Quality Validation, Laterality Evaluation, Macular Degeneration, and Suspected Glaucoma

Purpose

To assess the performance of deep learning algorithms for different tasks in retinal fundus images: (1) detection of retinal fundus images versus optical coherence tomography (OCT) or other images, (2) evaluation of good quality retinal fundus images, (3) distinction between right eye (OD) and left eye (OS) retinal fundus images,(4) detection of age-related macular degeneration (AMD) and (5) detection of referable glaucomatous optic neuropathy (GON).

Patients and Methods

Five algorithms were designed. Retrospective study from a database of 306,302 images, Optretina’s tagged dataset. Three different ophthalmologists, all retinal specialists, classified all images. The dataset was split per patient in a training (80%) and testing (20%) splits. Three different CNN architectures were employed, two of which were custom designed to minimize the number of parameters with minimal impact on its accuracy. Main outcome measure was area under the curve (AUC) with accuracy, sensitivity and specificity.

Results

Determination of retinal fundus image had AUC of 0.979 with an accuracy of 96% (sensitivity 97.7%, specificity 92.4%). Determination of good quality retinal fundus image had AUC of 0.947, accuracy 91.8% (sensitivity 96.9%, specificity 81.8%). Algorithm for OD/OS had AUC 0.989, accuracy 97.4%. AMD had AUC of 0.936, accuracy 86.3% (sensitivity 90.2% specificity 82.5%), GON had AUC of 0.863, accuracy 80.2% (sensitivity 76.8%, specificity 83.8%).

Conclusion

Deep learning algorithms can differentiate a retinal fundus image from other images. Algorithms can evaluate the quality of an image, discriminate between right or left eye and detect the presence of AMD and GON with a high level of accuracy, sensitivity and specificity.

Retinal Pathologic Features on OCT among Eyes of Older Adults Judged Healthy by Color Fundus Photography

PURPOSE

OCT has revealed many details of retinal disease that were not available with older imaging technologies. In eyes of adults older than 60 years with healthy maculas as determined by color fundus photography (CFP) and a validated grading system, we screened for pathologic features using OCT. We also tested visual function to assess potential impact of the observed pathologic features on patients.

DESIGN

Cross-sectional study.

PARTICIPANTS

Persons recruited from primary ophthalmology care clinics.

METHODS

Color fundus photographs were assessed by the 9-step Age-Related Eye Disease Study scale. OCT macular volumes of participants at step 1 on the Age-Related Eye Disease Study scale, considered healthy, were reviewed by a retina specialist masked to other participant characteristics. Participants were tested for 6 different cone- and rod-mediated visual functions.

MAIN OUTCOME MEASURES

Percentage of participants with disorders detected on OCT review and visual function measures.

RESULTS

In 138 of 984 eyes (14%) considered healthy by CFP, pathologic features were detectable by OCT, with 8.4% having vitreomacular interface disorders. Among the low-prevalence disorders found, 5 eyes (0.5%) showed macular telangiectasia type 2. Relative to eyes lacking detectable chorioretinal pathologic features, eyes with any pathologic features were associated with poorer low-luminance visual acuity and rod-mediated dark adaptation. In eyes with epiretinal membranes, the largest single entity identified (n = 61 [6.2%]), significantly worse visual functions were best-corrected visual acuity (P = 0.0444), low-luminance visual acuity (P = 0.0151), and light sensitivity (central 3° and 9°; P = 0.0035 and P = 0.0097, respectively).

CONCLUSIONS

Macular pathologic features with functional visual implications not identified by clinical examination or CFP are detectable with OCT. Vitreomacular interface disorders often are visually significant and treatable conditions that are visible on OCT, but are easily missed on CFP and clinical examination. Another such condition best seen on OCT is macular telangiectasia type 2, an untreatable disorder for which a clinical trial is in progress. OCT has a potential role in primary eye care clinics to screen for retinal pathologic features, especially in eyes with decreased visual acuity and otherwise normal examination results.

Detection of Age-Related Macular Degeneration by Portable Optical Coherence Tomography Operated by Nonexpert Personnel: Potential Use for Screenings

Purpose

The purpose of this study is to determine the sensitivity and specificity of detecting age-related macular degeneration (AMD) using portable optical coherence tomography (OCT) operated by nonexpert photographers on undilated patients.

Methods

In this case-control study, 92 individuals were recruited from the glaucoma and retina clinics at the Wilmer Eye Institute (Johns Hopkins University, Baltimore, MD). Using the portable iVue (Optovue, Inc, Fremont, CA) spectral-domain OCT (SD-OCT), 2 nonexpert photographers acquired retina map scans on undilated eyes of all participants. In total, 33 AMD eyes and 105 control eyes were evaluated and graded by ophthalmologists masked to the diagnoses.

Results

Detection of AMD on the portable OCT by ophthalmologists exhibited sensitivities of 0.91 and 0.94 and specificities of 0.88 and 0.89, for graders 1 and 2, respectively. A strong intergrader agreement was observed (κ = 0.87).

Conclusions

Nonexpert photographers can use a portable OCT on undilated eyes to acquire images for the detection of AMD. These findings present the potential utility of implementing a portable OCT in community screenings for earlier detection and treatment of disease.

Smartphones, tele-ophthalmology, and VISION 2020

Telemedicine is an emerging field in recent medical achievements with rapid development. The "smartphone" availability has increased in both developed and developing countries even among people in rural and remotes areas. Tele-based services can be used for screening ophthalmic diseases and also monitoring patients with known diseases. Electronic ophthalmologic records of the patients including captured images by smartphones from anterior and posterior segments of the eye will be evaluated by ophthalmologists, and if patients require further evaluations, they will be referred to experts in the relevant field. Eye diseases such as cataract, glaucoma, age-related macular degeneration, diabetic retinopathy, and retinopathy of prematurity are the most common causes of blindness in many countries and beneficial use of teleophthalmology with smartphones will be a good way to achieve the aim of VISION 2020 all over the world. Numerous studies have shown that teleophthalmology is similar to the conventional eye care system in clinical outcomes and even provides more patient satisfaction as it saves time and cost. This review explains how teleophthalmology helps to improve patient outcomes through smartphones.

Quality and learning curve of handheld versus stand-alone non-mydriatic cameras

Purpose

Nowadays, complex digital imaging systems allow detailed retinal imaging without dilating patients’ pupils. These so-called non-mydriatic cameras have advantages in common circumstances (eg, for screening or emergency purposes) but present limitations in terms of image quality and field of view. We compare the usefulness of two non-mydriatic camera systems (ie, a handheld versus a stand-alone device) for fundus imaging. The primary outcome was image quality. The secondary outcomes were learning effects and quality grade-influencing factors.

Methods

The imaging procedures followed standard protocol and were all performed by the same investigator. Camera 1 (DRS^®) was a stand-alone system, while Camera 2 (Smartscope^® PRO) was a mobile system. In order to evaluate possible learning effects, we selected an examiner with no prior training in the use of these systems. The images were graded separately by two experienced and “blinded” ophthalmologists following a defined protocol.

Results

In total, 211 people were enrolled. Quality grade comparisons showed significantly better grades for Camera 1. Both systems achieved better quality grades for macular images than for disc-centered images. No remarkable learning effects could be demonstrated.

Conclusions

Both camera systems are useful for fundus imaging. The greater mobility of Camera 2 was associated with lower image quality. For screening scenarios or telemedicine, it must be determined whether image quality or mobility is more important.

Telemedicine screening of retinal diseases with a handheld portable non-mydriatic fundus camera

Background

We modified and reconstructed a high image quality portable non-mydriatic fundus camera and compared it with the tabletop fundus camera to evaluate the efficacy of the new camera in detecting retinal diseases.

Methods

We designed and built a novel portable handheld fundus camera with telemedicine system. The image quality of fundus cameras was compared to that of existing commercial tabletop cameras by taking photographs of 364 eyes from the 254 patients. In all 800 fundus images taken by two camera types, 400 images per camera, were graded with the four image clarity classifications.

Results

Using the portable fundus camera, 63% (252/400) images were graded as excellent overall quality, 20.5% (82/400) were good, 11.75% (47/400) were fair, and 4.75% (19/400) were inadequate. Using the tabletop fundus camera, 70.75% (283/400) images were graded as excellent overall quality, 20.4% (51/400) were good, 13.25% (53/400) were fair, and 3.25% (13/400) were inadequate. Common retinal diseases were easily identified from fundus images obtained from the portable fundus camera.

Conclusion

The new type of non-mydriatic portable fundus camera was qualified to have professional quality of fundus images. The revolutionary screening camera provides a foundational platform which can potentially improve the accessibility of retinal screening programmes.

Telemedicine Applications in Pediatric Retinal Disease

Teleophthalmology is a developing field that presents diverse opportunities. One of its most successful applications to date has been in pediatric retinal disease, particularly in screening for retinopathy of prematurity (ROP). Many studies have shown that using telemedicine for ROP screening allows a remote ophthalmologist to identify abnormal findings and implement early interventions. Here, we review the literature on uses of telemedicine in pediatric retinal disease and consider future applications.

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.

Teleretinal imaging for detection of referable macular degeneration

PURPOSE

The purpose of this study was to determine the sensitivity and specificity for detection of referable age-related macular degeneration (AMD) using an existing nonmydriatic telemedicine pathway for diabetic retinopathy screening with comparison to same-day face-to-face examination by a retina specialist.

METHODS

Subjects in this study underwent nonmydriatic and mydriatic digital retinal imaging on the same day as stereoscopic dilated examination of the macula by a retina specialist and the level of AMD was recorded for each eye. Images were graded by two trained readers as nonreferable or referable (AREDS [Age-Related Eye Disease Study] grading of level 3 or greater). Sensitivity and specificity were calculated by comparing referral recommendations between each reader and the retina specialist ("gold standard").

RESULTS

There were 47 subjects (94 eyes) enrolled in the study. Sensitivity for nonreferable AMD with nonmydriatic imaging was 1.0 (reader 1) and 1.0 (reader 2), whereas specificity was 0.75 (reader 1) and 0.91 (reader 2). Sensitivity for referable AMD with nonmydriatic imaging was 0.84 (reader 1) and 0.88 (reader 2), whereas specificity was 0.81 (reader 1) and 0.81 (reader 2).

CONCLUSIONS

Our study showed that nonmydriatic digital retinal imaging had excellent sensitivity and specificity in identifying referable and nonreferable AMD using an existing validated telemedicine pathway for diabetic retinopathy screening.