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Dorrian D, Al-Janabi A, Gallagher K. Primary care optometry-based diabetic retinopathy review clinics - a new model of care and comparison with virtual diabetic retinopathy clinics. Eye (Lond) 2024:10.1038/s41433-024-03211-0. [PMID: 38951677 DOI: 10.1038/s41433-024-03211-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 06/06/2024] [Accepted: 06/21/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Given the increasing prevalence of diabetes and diabetic retinopathy (DR) in the UK, this study evaluates a novel primary care optometry-based DR review service against traditional hospital-based virtual DR clinics. METHODS In the hospital-based virtual DR service, patients attended for data capture (visual acuity, fundus photography, macular OCT scanning) with asynchronous review at a later data by a hospital clinician. In the primary care optometry DR review clinic, patients attended an optometry practice for a face-to-face(F2F) review (with imaging) by an optometrist with additional training in DR. Data from both clinic types were analysed. Metrics included DR grading, management plans, grading concordance between primary care optometrists and consultant ophthalmologists, and the assessment of "ungradable" retinopathy referrals. RESULTS One thousand seven hundred and sixty patients attended the virtual clinic between January 2021 and September 2023. 954 patients attended the primary care review clinic between August 2022 and September 2023. Grading agreements between primary care optometrists and hospital consultants on those patients referred for consultant opinion were significant with Weighted Kappa scores of 0.61(95% CI 0.52-0.69) for DR grade and 0.69(95% CI 0.56-0.82) for diabetic macular oedema (DMO) status. Additionally, the primary care optometry clinic reported a considerably reduced non-attendance rate of 5%, in contrast to 21% in virtual clinics. CONCLUSION The primary care optometry-based DR service emerges as an efficient, safe alternative to hospital services. It offers notable advantages over virtual clinics and addresses a care gap for those unsuitable for virtual consultations. The results highlight the potential of primary care-based models in managing DR.
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Affiliation(s)
- Dervla Dorrian
- Cwm Taf Morgannwg University Health Board, Royal Glamorgan Hospital, CF72 8XR, Pontyclun, UK
| | - Ahmed Al-Janabi
- Cwm Taf Morgannwg University Health Board, Royal Glamorgan Hospital, CF72 8XR, Pontyclun, UK
| | - Kevin Gallagher
- Cwm Taf Morgannwg University Health Board, Royal Glamorgan Hospital, CF72 8XR, Pontyclun, UK.
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2
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Patel D, Abdi S, Carmichael J, Balaskas K, Blandford A. What are the experiences of teleophthalmology in optometric referral pathways? A qualitative interview study with patients and clinicians. BMJ Open 2024; 14:e078161. [PMID: 38803257 PMCID: PMC11129051 DOI: 10.1136/bmjopen-2023-078161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/17/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE Implementing teleophthalmology into the optometric referral pathway may ease the current pressures on hospital eye services caused by over-referrals from some optometrists. This study aimed to understand the practical implications of implementing teleophthalmology by analysing lived experiences and perceptions of teleophthalmology in the optometric referral pathway for suspected retinal conditions. DESIGN Qualitative in-depth interview study SETTING: Fourteen primary care optometry practices and four secondary care hospital eye services from four NHS Foundation Trusts across the UK. PARTICIPANTS We interviewed 41 participants: patients (17), optometrists (18), and ophthalmologists (6) who were involved in the HERMES study. Through thematic analysis, we collated and present their experiences of implementing teleophthalmology. RESULTS All participants interviewed were positive towards teleophthalmology as it could enable efficiencies in the referral pathway and improve feedback and communication between patients and healthcare professionals. Concerns included setup costs for optometrists and anxieties from patients about not seeing an ophthalmologist face to face. However, reducing unnecessary visits and increasing the availability of resources and capacity were seen as significant benefits. CONCLUSIONS Overall, we report positive experiences of implementing teleophthalmology into the optometric referral pathway for suspected retinal conditions. Successful implementation will require appropriate investment to set up and integrate new technology and remunerate services, and continued evaluation to ensure timely feedback to patients and between healthcare professionals is received. TRIAL REGISTRATION NUMBER ISRCTN18106677.
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Affiliation(s)
- Dilisha Patel
- UCL Interaction Centre, University College London, London, UK
| | - Sarah Abdi
- UCL Interaction Centre, University College London, London, UK
| | - Josie Carmichael
- UCL Interaction Centre, University College London, London, UK
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Ann Blandford
- UCL Interaction Centre, University College London, London, UK
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3
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Ashrafkhorasani M, Habibi A, Nittala MG, Corradetti G, Emamverdi M, Sadda SR. Peripheral retinal lesions in diabetic retinopathy on ultra-widefield imaging. Saudi J Ophthalmol 2024; 38:123-131. [PMID: 38988777 PMCID: PMC11232752 DOI: 10.4103/sjopt.sjopt_151_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/03/2023] [Indexed: 07/12/2024] Open
Abstract
Peripheral retinal imaging plays a crucial role in the diagnosis, management, and prognosis of diabetic retinopathy (DR). Traditional fundus imaging techniques have limited coverage of the retina, resulting in missed peripheral lesions. The advent of ultra-widefield (UWF) imaging has revolutionized the assessment of the peripheral retina. UWF imaging modalities provide comprehensive visualization of the retina, enabling the detection of peripheral lesions without the need for mydriasis. Integration of UWF imaging with other modalities, including fluorescein angiography (FA), indocyanine green angiography, pseudocolor imaging, and fundus autofluorescence, further enhances our understanding of peripheral retinal lesions. UWF imaging has demonstrated improved detection of DR lesions and presumably more accurate management of DR compared to traditional fundus photography and dilated fundus examination. UWF-FA and UWF-optical coherence tomography angiography have emerged as valuable tools for assessing retinal and choroidal vascular abnormalities, nonperfusion areas, neovascularization, and microvascular abnormalities. The presence and increasing extent of predominantly peripheral lesions detected using UWF FA are associated with a higher risk of DR progression and proliferative DR. UWF imaging provides a comprehensive evaluation of DR severity, aiding in more accurate risk stratification and treatment decision-making. Overall, UWF imaging modalities have significantly advanced our understanding of peripheral retinal lesions in DR, facilitating early detection and targeted management for better visual outcomes.
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Affiliation(s)
- Maryam Ashrafkhorasani
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Abbas Habibi
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Muneeswar G. Nittala
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
| | - Giulia Corradetti
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mehdi Emamverdi
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Srinivas R. Sadda
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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4
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Veeramani P, Pilar Martin-Gutierrez M, Agorogiannis E, Hamilton R, Griggs T, Nicholson L, Heng LZ. Efficacy and Safety outcomes of a novel model to assess new medical retina referrals in a high-volume medical retina virtual clinic. Eye (Lond) 2024; 38:168-172. [PMID: 37491441 PMCID: PMC10764806 DOI: 10.1038/s41433-023-02653-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 05/12/2023] [Accepted: 06/21/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Ophthalmology outpatient attendances have significantly increased recently with rising pressure from backlogs arising from the pandemic. Medical retina digital surveillance clinics for stable follow-up appointments are well established. We present a model for assessing new referrals and evaluating clinical outcomes and long-term sustainability in a complex high-volume medical retina service. METHODS Suitable routine new patient referrals were identified from electronic referrals and referred to this new pathway. Structured history, visual acuities, and intraocular pressures were recorded, and widefield colour fundus and optical coherence tomography imaging were performed at a imaging hub for asynchronous consultant-led review. RESULTS 1458 patients were invited to attend over four months, with a 13.2% did-not-attend (DNA) rate. Common diagnoses included stable diabetic retinopathy (19.9%), early age-related macular degeneration (6.7%), central serous retinopathy (8.8%), and retinal vein occlusion (6.3%). 7 patients (0.05%) required urgent same-day review. 61 (5.0%) required urgent face-to-face (F2F) assessment within two weeks. A total of 727 (59.0%) were either discharged or remained in the virtual pathway following their first visit. CONCLUSION This study encourages the use of a digital model that efficiently assesses suitable newly referred medical retina patients in both complex and local eye unit settings. This decreased the need for F2F clinics and resources. Further patient satisfaction surveys for digital services are currently being evaluated to guide long-term sustainability of this model.
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Affiliation(s)
- P Veeramani
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - E Agorogiannis
- Manchester Royal Eye Hospital Manchester, Manchester, UK
| | - R Hamilton
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - T Griggs
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - L Nicholson
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - L Z Heng
- Moorfields Eye Hospital NHS Foundation Trust, London, UK.
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5
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Vofo BN, Yosef YB, Tiosano L, Levy J, Khateb S, Chowers I. Visualizing Vitreous Traction by Biomicroscopy versus OCT. Ophthalmol Retina 2023; 7:1116-1117. [PMID: 37673398 DOI: 10.1016/j.oret.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Brice N Vofo
- Department of Ophthalmology, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yair B Yosef
- Department of Ophthalmology, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Liran Tiosano
- Department of Ophthalmology, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jaime Levy
- Department of Ophthalmology, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Samer Khateb
- Department of Ophthalmology, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itay Chowers
- Department of Ophthalmology, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.
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6
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Valentim CCS, Muste JC, Iyer AI, Krause MA, Kalur A, Gendi SW, Ohlhausen M, Rachitskaya A, Singh RP, Talcott KE. Characterization of ophthalmology virtual visits during the COVID-19 pandemic. Eye (Lond) 2023; 37:332-337. [PMID: 35091708 PMCID: PMC8796604 DOI: 10.1038/s41433-022-01938-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 12/14/2021] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To characterize the use of virtual visits, as well as compare the characteristics to in-person visits during the pandemic period. METHODS This retrospective study included patients who had virtual and in-person ophthalmology visits from March 19, 2020, to July 31, 2020, in a large multispecialty ophthalmic center. Exclusion criteria included patients aged less than 18 years old; canceled, incomplete, mislabelled, and duplicated visits. 2943 virtual and 56,174 in-person visits were identified. A random sample of 3000 in-person visits was created. Each visit was analyzed as an individual data point. RESULTS 2,266 virtual visits (2,049 patients, 64.3% female, mean [SD] age 64.3 [16.6] years old) and 2590 in-person visits (2509 patients, 59.5% female, 65.9 [15.8] years old) were included. Most virtual visits were classified as comprehensive ophthalmology (34.6%), optometry-related (19.5%), and oculoplastics (13.0%). For in-person visits, the most common specialties were optometry (29.8%), comprehensive ophthalmology (23.9%), and retina and uveitis (17.3%). The most common diagnoses in the virtual group were from the eyelids, lacrimal system, and orbits group (26.9%), while in the in-person groups were choroid and retina conditions (19.3%). CONCLUSIONS Numerous ocular conditions were evaluated and managed through virtual visits, and external complaints and oculoplastic consults appear to be well-suited to the virtual format. Further studies focusing on visual outcomes and patient experience will be beneficial.
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Affiliation(s)
- Carolina C. S. Valentim
- grid.239578.20000 0001 0675 4725Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH USA
| | - Justin C. Muste
- grid.239578.20000 0001 0675 4725Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH USA
| | - Amogh I. Iyer
- grid.239578.20000 0001 0675 4725Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH USA
| | - Michael A. Krause
- grid.239578.20000 0001 0675 4725Cole Eye Institute, Cleveland Clinic, Cleveland, OH USA
| | - Aneesha Kalur
- grid.239578.20000 0001 0675 4725Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH USA
| | - Steve W. Gendi
- grid.67105.350000 0001 2164 3847Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Marc Ohlhausen
- grid.67105.350000 0001 2164 3847Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Aleksandra Rachitskaya
- grid.239578.20000 0001 0675 4725Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH USA
| | - Rishi P. Singh
- grid.239578.20000 0001 0675 4725Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH USA
| | - Katherine E. Talcott
- grid.239578.20000 0001 0675 4725Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH USA
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7
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Smith J, Hirst N, Yagan A. A Quality Assurance Audit of an Orthoptic-Led Virtual Neuro-Ophthalmology Clinic. Br Ir Orthopt J 2023; 19:7-14. [PMID: 36909675 PMCID: PMC10000316 DOI: 10.22599/bioj.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/14/2023] [Indexed: 03/12/2023] Open
Abstract
Introduction Neuro-ophthalmology is experiencing increasing demand. There is a lack of literature relating to how we deal with the capacity and demand issues, and the use of virtual clinics. Virtual clinics are well-recognised in other subspecialties to help deal with capacity and demand issues, with reports of non-medical-led clinics, and are supported by the National Health Services Long Term Plan and People Plan. We present a quality assurance audit of our orthoptic-led neuro-ophthalmology virtual clinic. Methods The virtual clinic was developed in October 2014 to help deal with capacity and demand issues, however, only since 2019 have orthoptists been trained to virtually review. This paper provides a summary of a quality assurance audit that was completed to determine concurrence between orthoptic and consultant virtual reviews. Results From January to August 2021, all patients attending the virtual clinic were reviewed by a trained orthoptist and then audited for concordance by a consultant neuro-ophthalmologist; 163 patients were identified. There was 100% agreement between orthoptic reviewers and consultants regarding visual function status and optical coherence tomography interpretation. Of the patients reviewed, 100% of patients were satisfied and 96% of patients would be happy to be seen in the virtual clinic again. Conclusions Current demands on the neuro-ophthalmology speciality mean that we need to explore new ways of working. Our outcomes demonstrate a high level of agreement between orthoptists and ophthalmologists, and excellent patient satisfaction results. We hope this highlights where orthoptists can play an invaluable role in the care of neuro-ophthalmic patients and help deal with capacity and demand issues.
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Affiliation(s)
| | | | - Ali Yagan
- Consultant Ophthalmologist - Neuro-Ophthalmology and Adult Strabismus, GB
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8
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Moon JY, Wai KM, Patel NS, Katz R, Dahrouj M, Miller JB. Visualization of retinal breaks on ultra-widefield fundus imaging using a digital green filter. Graefes Arch Clin Exp Ophthalmol 2022; 261:935-940. [PMID: 36350430 PMCID: PMC9643990 DOI: 10.1007/s00417-022-05855-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/07/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022] Open
Abstract
PURPOSE We compare the ability of resident physicians to identify retinal breaks on ultra-widefield color fundus photos using the traditional image compared to an image with a green filter overlay. METHODS Residents were shown fundus photos of 10 eyes with either a retinal tear or hole. Participants were shown each photo twice-once with traditional color settings and once with a green filter overlay. Participants were scored on whether the break was correctly identified and timed on how long it took to identify the pathology. RESULTS Residents were able to correctly identify more retinal breaks on fundus photos with a green filter overlay compared to photos with traditional settings (P = 0.02). Residents were also able to identify breaks on fundus photos more quickly on images with a green filter overlay compared to the traditional images (P < 0.001). CONCLUSIONS The application of a green filter overlay may help in identifying retinal breaks.
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Affiliation(s)
- Jade Y Moon
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, USA
| | - Karen M Wai
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, USA
| | - Neal S Patel
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, USA
| | - Raviv Katz
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, USA
| | - Mohammad Dahrouj
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, USA
| | - John B Miller
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA.
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, USA.
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Ong J, Tan G, Ang M, Chhablani J. Digital Advancements in Retinal Models of Care in the Post-COVID-19 Lockdown Era. Asia Pac J Ophthalmol (Phila) 2022; 11:403-407. [PMID: 36094383 DOI: 10.1097/apo.0000000000000533] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/14/2022] [Indexed: 11/25/2022] Open
Abstract
The coronavirus disease-2019 (COVID-19) pandemic introduced unique barriers to retinal care including limited access to imaging modalities, ophthalmic clinicians, and direct medical interventions. These unprecedented barriers were met with the robust implementation of digital advances to aid in monitoring and efficiency of retinal care while taking into the account of public safety. Many of these innovations have been successful in maintaining efficiency and patient satisfaction and are likely to stay to help preserve vision in the future. In this article we highlight these advances implemented during the pandemic including telescreening triage, virtual retinal imaging clinics, at-home optical coherence tomography, mobile phone self-monitoring, and virtual reality monitoring technology. We also discuss advancing innovations including Internet of Things and Blockchain technology that will be critical for further implementation and security of these digital advancements.
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Affiliation(s)
- Joshua Ong
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Gavin Tan
- Surgical Retinal Department of the Singapore National Eye Centre, Singapore
- Clinician Scientist, Singapore Eye Research Institute, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore
| | - Marcus Ang
- Duke-NUS Department of Ophthalmology and Visual Sciences, Singapore
| | - Jay Chhablani
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Blandford A, Abdi S, Aristidou A, Carmichael J, Cappellaro G, Hussain R, Balaskas K. Protocol for a qualitative study to explore acceptability, barriers and facilitators of the implementation of new teleophthalmology technologies between community optometry practices and hospital eye services. BMJ Open 2022; 12:e060810. [PMID: 35858730 PMCID: PMC9305899 DOI: 10.1136/bmjopen-2022-060810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Novel teleophthalmology technologies have the potential to reduce unnecessary and inaccurate referrals between community optometry practices and hospital eye services and as a result improve patients' access to appropriate and timely eye care. However, little is known about the acceptability and facilitators and barriers to the implementations of these technologies in real life. METHODS AND ANALYSIS A theoretically informed, qualitative study will explore patients' and healthcare professionals' perspectives on teleophthalmology and Artificial Intelligence Decision Support System models of care. A combination of situated observations in community optometry practices and hospital eye services, semistructured qualitative interviews with patients and healthcare professionals and self-audiorecordings of healthcare professionals will be conducted. Participants will be purposively selected from 4 to 5 hospital eye services and 6-8 affiliated community optometry practices. The aim will be to recruit 30-36 patients and 30 healthcare professionals from hospital eye services and community optometry practices. All interviews will be audiorecorded, with participants' permission, and transcribed verbatim. Data from interviews, observations and self-audiorecordings will be analysed thematically and will be informed by normalisation process theory and an inductive approach. ETHICS AND DISSEMINATION Ethical approval has been received from London-Bromley research ethics committee. Findings will be reported through academic journals and conferences in ophthalmology, health services research, management studies and human-computer interaction.
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Affiliation(s)
- Ann Blandford
- UCL Interaction Centre, University College London, London, UK
| | - Sarah Abdi
- UCL Interaction Centre, University College London, London, UK
| | | | - Josie Carmichael
- UCL Interaction Centre, University College London, London, UK
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Giulia Cappellaro
- School of Management, University College London, London, UK
- Department of Social and Political Sciences, Bocconi University, Milano, Italy
| | - Rima Hussain
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Institute of Ophthalmology, UCL, London, UK
| | - Konstantinos Balaskas
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Institute of Ophthalmology, UCL, London, UK
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11
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Patients views on a new surveillance pathway involving allied non-medical staff for people with treated diabetic macular oedema and proliferative diabetic retinopathy. Eye (Lond) 2022; 37:1155-1159. [PMID: 35523861 PMCID: PMC10102164 DOI: 10.1038/s41433-022-02050-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 03/22/2022] [Accepted: 03/22/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND/OBJECTIVE To explore acceptability by patients and health care professionals of a new surveillance pathway for people with previously treated and stable diabetic macular oedema (DMO) and/or proliferative diabetic retinopathy (PDR). SUBJECT/METHODS Structured discussions in 10 focus groups with patients; two with ophthalmic photographers/graders, and one with ophthalmologists, held across the UK as part of a large diagnostic accuracy study (EMERALD). RESULTS The most prominent issues raised by patients concerned (i) expertise of the various professionals within clinic, (ii) quality of interactions with clinic professionals, especially the flow of information from professionals to patients, and (iii) wish to be treated holistically. Ophthalmologists suggested such issues could be best dealt with via a programme of patient education and tended to overlook deeper implications of patient concerns for the organisation of services. CONCLUSION For patients, the clinical service should not only include the identification and treatment of disease but also exchange of information, reassurance, and mitigation of anxiety. Alterations in the standard care pathway need to take account of such concerns and their implications, in addition to any assessments of 'efficiency' that may flow from changes in diagnostic technology, or the division of professional labour.
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Nicholson L, Talks SJ, Amoaku W, Talks K, Sivaprasad S. Retinal vein occlusion (RVO) guideline: executive summary. Eye (Lond) 2022; 36:909-912. [PMID: 35301458 PMCID: PMC9046155 DOI: 10.1038/s41433-022-02007-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/24/2022] [Accepted: 02/21/2022] [Indexed: 12/30/2022] Open
Affiliation(s)
- Luke Nicholson
- grid.439257.e0000 0000 8726 5837Moorfields Eye Hospital, London, UK
| | - Stephen J. Talks
- grid.419334.80000 0004 0641 3236Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Winfried Amoaku
- grid.415598.40000 0004 0641 4263Queen’s Medical Centre, Nottingham, UK
| | - Katherine Talks
- grid.419334.80000 0004 0641 3236Department of Haematology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Sobha Sivaprasad
- grid.439257.e0000 0000 8726 5837Moorfields Eye Hospital, London, UK
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13
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Juaristi L, Irigoyen C, Chapartegui J, Guibelalde A, Mar J. Assessing the Utility and Patient Satisfaction of Virtual Retina Clinics During COVID-19 Pandemic. Clin Ophthalmol 2022; 16:311-321. [PMID: 35173410 PMCID: PMC8841596 DOI: 10.2147/opth.s349939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/13/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To explore whether the virtual retina clinic (VRC) has been a useful and safe platform for monitoring retinal diseases during the COVID-19 pandemic and assessing patient satisfaction. METHODS A prospective observational study was conducted for patients with stable retinal diseases in Donostia University Hospital's Ophthalmology Service during the pandemic. All patients were assessed in the VRC with optical coherence tomography of the macula and widefield retinography, plus visual field tests in hydroxychloroquine retinopathy screenings. The VRC´s effectiveness was evaluated with repeat blind assessments and patient satisfaction with an adapted SERVQUAL scale. RESULTS The most common diseases were diabetic retinopathy (30.3%) and age-related macular degeneration (21.8%). Most patients (74%) were eligible to continue in the VRC, 19.3% were referred to face-to-face (F2F) appointments and 6.6% were discharged. Patients underwent repeat blind assessments in F2F appointments to monitor VRC performance in 23.7% of the cases. The sensitivity to detect disease progression was 100%. The specificity was 80.1%. The VRC took half the time. The patient overall satisfaction rating was 9.8/10. CONCLUSION The VRC, as an additional platform, supports F2F appointments. Almost three-quarters of patients could continue being safely seen in the VRC. The virtual approach decreases SARS-CoV-2 exposure. Patient satisfaction is very good. TRANSLATIONAL RELEVANCE The VRC enables us to attend patients safely with decreased SARS-CoV-2 exposure.
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Affiliation(s)
- Leire Juaristi
- Department of Ophthalmology, Donostia Unibertsitate Ospitalea - Hospital Universitario Donostia (HUD), Donostia San-Sebastian, Gipuzkoa, Spain
- Biodonostia Health Research Institute, Donostia-San Sebastián, Gipuzkoa, Spain
| | - Cristina Irigoyen
- Department of Ophthalmology, Donostia Unibertsitate Ospitalea - Hospital Universitario Donostia (HUD), Donostia San-Sebastian, Gipuzkoa, Spain
- Biodonostia Health Research Institute, Donostia-San Sebastián, Gipuzkoa, Spain
- Department of Ophthalmology, University of the Basque Country, Basque Country, Spain
| | - Jaione Chapartegui
- Department of Ophthalmology, Donostia Unibertsitate Ospitalea - Hospital Universitario Donostia (HUD), Donostia San-Sebastian, Gipuzkoa, Spain
- Biodonostia Health Research Institute, Donostia-San Sebastián, Gipuzkoa, Spain
| | - Ane Guibelalde
- Department of Ophthalmology, Donostia Unibertsitate Ospitalea - Hospital Universitario Donostia (HUD), Donostia San-Sebastian, Gipuzkoa, Spain
- Department of Ophthalmology, University of the Basque Country, Basque Country, Spain
| | - Javier Mar
- Biodonostia Health Research Institute, Donostia-San Sebastián, Gipuzkoa, Spain
- Basque Health Service (Osakidetza), Debagoiena Integrated Healthcare Organisation, Research Unit, Arrasate-Mondragón, Gipuzkoa, Spain
- Kronikgune Institute for Health Service Research, Barakaldo, Bizkaia, Spain
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Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group. Eye (Lond) 2021; 34:1-51. [PMID: 32504038 DOI: 10.1038/s41433-020-0961-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.
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Lois N, Cook J, Wang A, Aldington S, Mistry H, Maredza M, McAuley D, Aslam T, Bailey C, Chong V, Ghanchi F, Scanlon P, Sivaprasad S, Steel D, Styles C, Azuara-Blanco A, Prior L, Waugh N. Multimodal imaging interpreted by graders to detect re-activation of diabetic eye disease in previously treated patients: the EMERALD diagnostic accuracy study. Health Technol Assess 2021; 25:1-104. [PMID: 34060440 DOI: 10.3310/hta25320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Owing to the increasing prevalence of diabetes, the workload related to diabetic macular oedema and proliferative diabetic retinopathy is rising, making it difficult for hospital eye services to meet demands. OBJECTIVE The objective was to evaluate the diagnostic performance, cost-effectiveness and acceptability of a new pathway using multimodal imaging interpreted by ophthalmic graders to detect reactivation of diabetic macular oedema/proliferative diabetic retinopathy in previously treated patients. DESIGN This was a prospective, case-referent, cross-sectional diagnostic study. SETTING The setting was ophthalmic clinics in 13 NHS hospitals. PARTICIPANTS Adults with type 1 or type 2 diabetes with previously successfully treated diabetic macular oedema/proliferative diabetic retinopathy in one/both eyes in whom, at the time of enrolment, diabetic macular oedema/proliferative diabetic retinopathy could be active or inactive. METHODS For the ophthalmic grader pathway, review of the spectral domain optical coherence tomography scans to detect diabetic macular oedema, and seven-field Early Treatment Diabetic Retinopathy Study/ultra-wide field fundus images to detect proliferative diabetic retinopathy, by trained ophthalmic graders. For the current standard care pathway (reference standard), ophthalmologists examined patients face to face by slit-lamp biomicroscopy for proliferative diabetic retinopathy and, in addition, spectral domain optical coherence tomography imaging for diabetic macular oedema. OUTCOME MEASURES The primary outcome measure was sensitivity of the ophthalmic grader pathway to detect active diabetic macular oedema/proliferative diabetic retinopathy. The secondary outcomes were specificity, agreement between pathways, cost-consequences, acceptability and the proportion of patients requiring subsequent ophthalmologist assessment, unable to undergo imaging and with inadequate quality images/indeterminate findings. It was assumed for the main analysis that all patients in whom graders diagnosed active disease or were 'unsure' or images were 'ungradable' required examination by an ophthalmologist. RESULTS Eligible participants with active and inactive diabetic macular oedema (152 and 120 participants, respectively) and active and inactive proliferative diabetic retinopathy (111 and 170 participants, respectively) were recruited. Under the main analysis, graders had a sensitivity of 97% (142/147) (95% confidence interval 92% to 99%) and specificity of 31% (35/113) (95% confidence interval 23% to 40%) to detect diabetic macular oedema. For proliferative diabetic retinopathy, graders had a similar sensitivity and specificity using seven-field Early Treatment Diabetic Retinopathy Study [sensitivity 85% (87/102), 95% confidence interval 77% to 91%; specificity 48% (77/160), 95% confidence interval 41% to 56%] or ultra-wide field imaging [sensitivity 83% (87/105), 95% confidence interval 75% to 89%; specificity 54% (86/160), 95% confidence interval 46% to 61%]. Participants attending focus groups expressed preference for face-to-face evaluations by ophthalmologists. In the ophthalmologists' absence, patients voiced the need for immediate feedback following grader's assessments, maintaining periodic evaluations by ophthalmologists. Graders and ophthalmologists were supportive of the new pathway. When compared with the reference standard (current standard pathway), the new grader pathway could save £1390 per 100 patients in the review of people with diabetic macular oedema and, depending on the imaging modality used, between £461 and £1189 per 100 patients in the review of people with proliferative diabetic retinopathy. CONCLUSIONS For people with diabetic macular oedema, the ophthalmic grader pathway appears safe and cost saving. The sensitivity of the new pathway to detect active proliferative diabetic retinopathy was lower, but may still be considered acceptable for patients with proliferative diabetic retinopathy previously treated with laser. Suggestions from focus group discussions should be taken into consideration if the new pathway is introduced to ensure its acceptability to users. LIMITATIONS Lack of fundus fluorescein angiography to confirm diagnosis of active proliferative diabetic retinopathy. FUTURE WORK Could refinement of the new pathway increase its sensitivity to detect proliferative diabetic retinopathy? Could artificial intelligence be used for automated reading of images in this previously treated population? TRIAL REGISTRATION Current Controlled Trials ISRCTN10856638 and ClinicalTrials.gov NCT03490318. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology AssessmentVol. 25, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Noemi Lois
- The Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Jonathan Cook
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Ariel Wang
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | | | - Hema Mistry
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mandy Maredza
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Danny McAuley
- The Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.,The Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Tariq Aslam
- The Manchester Academic Health Science Centre, Manchester Royal Eye Hospital and Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Victor Chong
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Faruque Ghanchi
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Bradford, UK
| | - Peter Scanlon
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Sobha Sivaprasad
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
| | - David Steel
- Sunderland Eye Infirmary, Sunderland, UK.,Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Lindsay Prior
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Norman Waugh
- Warwick Medical School, University of Warwick, Coventry, UK
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Sodhi SK, Golding J, Trimboli C, Choudhry N. Feasibility of peripheral OCT imaging using a novel integrated SLO ultra-widefield imaging swept-source OCT device. Int Ophthalmol 2021; 41:2805-2815. [PMID: 33830372 PMCID: PMC8289804 DOI: 10.1007/s10792-021-01837-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/29/2021] [Indexed: 11/25/2022]
Abstract
Purpose To describe the feasibility of peripheral OCT imaging in retinal diseases using a novel full-field device. Methods A total of 134 consecutive eyes were referred and imaged on the Optos Silverstone swept-source OCT (SS-OCT) (Optos PLC; Dunfermline, UK). Scanning laser ophthalmoscope (SLO) images and the associated SS-OCT images were obtained in the posterior pole, mid-periphery or far periphery based on the nature of the referral and on new areas of interest observed in the optomap images at the time of imaging. Results A total of 134 eyes (96 patients) were enrolled in the study. One hundred and twenty-five eyes (91 patients) with 38 retinal pathologies were prospectively assessed and 9 eyes (5 patients) were excluded due to incomplete image acquisition. The average age of the subjects was 54 years (range 21–92 years). Thirty-nine out of 125 eyes (31%) had macular pathologies. Eighty-six out of 125 eyes (69%) had peripheral only pathologies, an area which cannot be visualized by standard OCT devices with a 50 degree field-of-view. Conclusions The ability to capture peripheral pathologies using an integrated SLO-UWF imaging with full-field swept-source provided high-grade anatomical insight that confirmed the medical and surgical management in a majority of cases. Its use in the mid- and far periphery provides a holistic clinical picture, which can potentially aid in the understanding of various retinal pathologies. Supplementary Information The online version contains supplementary material available at 10.1007/s10792-021-01837-7.
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Affiliation(s)
| | - John Golding
- Vitreous Retina Macula Specialists of Toronto, 3280 Bloor St. West. Suite 310, Etobicoke, ON, M8X 2X3, Canada
| | - Carmelina Trimboli
- Vitreous Retina Macula Specialists of Toronto, 3280 Bloor St. West. Suite 310, Etobicoke, ON, M8X 2X3, Canada
| | - Netan Choudhry
- Vitreous Retina Macula Specialists of Toronto, 3280 Bloor St. West. Suite 310, Etobicoke, ON, M8X 2X3, Canada.
- Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, ON, Canada.
- Cleveland Clinic Canada, Toronto, ON, Canada.
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Hanumunthadu D, Adan K, Tinkler K, Balaskas K, Hamilton R, Nicholson L. Outcomes following implementation of a high-volume medical retina virtual clinic utilising a diagnostic hub during COVID-19. Eye (Lond) 2021; 36:627-633. [PMID: 33824508 PMCID: PMC8023775 DOI: 10.1038/s41433-021-01510-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/05/2021] [Accepted: 03/10/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To describe the clinical outcomes following implementation of a high-volume medical retina virtual clinic utilising a diagnostic hub. METHODS Retrospective consecutive case-series of all patients attending the medical retina virtual clinics at Moorfields Eye Hospital (City Road) for 6 weeks from September 21, 2020. RESULTS In 6 weeks, 1006 patients attended the medical retina virtual clinics, which included an appointment in the diagnostic hub followed by an assessment asynchronously the following working day. The vast majority of patients were follow-up attendances (969, 96.3%) with much fewer new patient attendances (37, 3.7%). The most common diagnoses made overall were diabetic retinopathy (457, 45.4%), age-related macular degeneration (208, 20.7%) and retinal vein occlusion (80, 8.0%). The majority of patient (643, 63.9%) outcomes were follow-up in the medical retina virtual clinics including 313 (31.1%) with OCT-only pathway and 330 (32.8%) with OCT and widefield fundus imaging. Routine follow-up requested after virtual assessment included 320 (31.8%) with a 3-4 month review and 267 (26.5%) with a 6 months assessment. Only 62 patients (6.2%) were asked to return for face-to-face assessment within 2 weeks. CONCLUSIONS We describe a new high-volume medical retina virtual clinic utilising a diagnostic hub in which more than 1000 patients were seen and assessed asynchronously. Most patients were assessed as suitable for routine follow-up in this virtual pathway and only a small proportion required urgent reviews (within 2 weeks). In the COVID-19 era, this form of high-volume virtual clinic has the potential to review patients efficiently and safely.
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Affiliation(s)
| | - Khadra Adan
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Kerry Tinkler
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Robin Hamilton
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Luke Nicholson
- Moorfields Eye Hospital NHS Foundation Trust, London, UK.
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18
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Sim SS, Yip MY, Wang Z, Tan ACS, Tan GSW, Cheung CMG, Chakravarthy U, Wong TY, Teo KYC, Ting DS. Digital Technology for AMD Management in the Post-COVID-19 New Normal. Asia Pac J Ophthalmol (Phila) 2021; 10:39-48. [PMID: 33512827 DOI: 10.1097/apo.0000000000000363] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The COVID-19 pandemic has put strain on healthcare systems and the availability and allocation of healthcare manpower, resources and infrastructure. With immediate priorities to protect the health and safety of both patients and healthcare service providers, ophthalmologists globally were advised to defer nonurgent cases, while at the same time managing sight-threatening conditions such as neovascular Age-related Macular Degeneration (AMD). The management of AMD patients both from a monitoring and treatment perspective presents a particular challenge for ophthalmologists. This review looks at how these pressures have encouraged the acceptance and speed of adoption of digitalization. DESIGN AND METHODS A literature review was conducted on the use of digital technology during COVID-19 pandemic, and on the transformation of medicine, ophthalmology and AMD screening through digitalization. RESULTS In the management of AMD, the implementation of artificial intelligence and "virtual clinics" have provided assistance in screening, diagnosis, monitoring of the progression and the treatment of AMD. In addition, hardware and software developments in home monitoring devices has assisted in self-monitoring approaches. CONCLUSIONS Digitalization strategies and developments are currently ongoing and underway to ensure early detection, stability and visual improvement in patients suffering from AMD in this COVID-19 era. This may set a precedence for the post COVID-19 new normal where digital platforms may be routine, standard and expected in healthcare delivery.
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Affiliation(s)
- Shaun Sebastian Sim
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Michelle Yt Yip
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Zhaoran Wang
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Anna Cheng Sim Tan
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Gavin Siew Wei Tan
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Chui Ming Gemmy Cheung
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Usha Chakravarthy
- Queen's University of Belfast Royal Victoria Hospital, Belfast, Ireland
| | - Tien Yin Wong
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Kelvin Yi Chong Teo
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Daniel Sw Ting
- Singapore National Eye Centre
- Singapore Eye Research Institute
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
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Evaluation of a New Model of Care for People with Complications of Diabetic Retinopathy: The EMERALD Study. Ophthalmology 2020; 128:561-573. [PMID: 33130144 PMCID: PMC7980088 DOI: 10.1016/j.ophtha.2020.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 01/21/2023] Open
Abstract
Purpose The increasing diabetes prevalence and advent of new treatments for its major visual-threatening complications (diabetic macular edema [DME] and proliferative diabetic retinopathy [PDR]), which require frequent life-long follow-up, have increased hospital demands markedly. Subsequent delays in patient's evaluation and treatment are causing sight loss. Strategies to increase capacity are needed urgently. The retinopathy (EMERALD) study tested diagnostic accuracy, acceptability, and costs of a new health care pathway for people with previously treated DME or PDR. Design Prospective, multicenter, case-referent, cross-sectional, diagnostic accuracy study undertaken in 13 hospitals in the United Kingdom. Participants Adults with type 1 or 2 diabetes previously successfully treated DME or PDR who, at the time of enrollment, had active or inactive disease. Methods A new health care pathway entailing multimodal imaging (spectral-domain OCT for DME, and 7-field Early Treatment Diabetic Retinopathy Study [ETDRS] and ultra-widefield [UWF] fundus images for PDR) interpreted by trained nonmedical staff (ophthalmic graders) to detect reactivation of disease was compared with the current standard care (face-to-face examination by ophthalmologists). Main Outcome Measures Primary outcome: sensitivity of the new pathway. Secondary outcomes: specificity; agreement between pathways; costs; acceptability; proportions requiring subsequent ophthalmologist assessment, unable to undergo imaging, and with inadequate images or indeterminate findings. Results The new pathway showed sensitivity of 97% (95% confidence interval [CI], 92%–99%) and specificity of 31% (95% CI, 23%–40%) to detect DME. For PDR, sensitivity and specificity using 7-field ETDRS images (85% [95% CI, 77%–91%] and 48% [95% CI, 41%–56%], respectively) or UWF images (83% [95% CI, 75%–89%] and 54% [95% CI, 46%–61%], respectively) were comparable. For detection of high-risk PDR, sensitivity and specificity were higher when using UWF images (87% [95% CI, 78%–93%] and 49% [95% CI, 42%–56%], respectively, for UWF versus 80% [95% CI, 69–88%] and 40% [95% CI, 34%–47%], respectively, for 7-field ETDRS images). Participants preferred ophthalmologists’ assessments; in their absence, they preferred immediate feedback by graders, maintaining periodic ophthalmologist evaluations. When compared with the current standard of care, the new pathway could save £1390 per 100 DME visits and between £461 and £1189 per 100 PDR visits. Conclusions The new pathway has acceptable sensitivity and would release resources. Users’ suggestions should guide implementation.
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Lim WS, Grimaldi G, Nicholson L, Basheer K, Rajendram R. Widefield imaging with Clarus fundus camera vs slit lamp fundus examination in assessing patients referred from the National Health Service diabetic retinopathy screening programme. Eye (Lond) 2020; 35:299-306. [PMID: 33082533 PMCID: PMC7574390 DOI: 10.1038/s41433-020-01218-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To compare diabetic retinopathy (DR) grading and management plan between virtual review using widefield Clarus imaging and macular optical coherence tomography (OCT) versus slit lamp clinical examination and macular OCT. METHOD New referrals over 3 months from the National Diabetic Eye Screening programme (DESP) were screened. Patients who had both Clarus widefield imaging and macular OCT were included. All patients underwent slit lamp examination in clinic. Data obtained from electronic patient records included referral reason, DR grading and management plan. Two graders retrospectively reviewed imaging and formulated a management plan blinded to results from patients' clinic visit. Results from virtual examination were compared with those from slit lamp examination. RESULTS One-hundred and two eyes of 51 patients were assessed. 11 fundus photos from 7 patients and 15 fundus photos from 10 patients were deemed inadequate by grader G1 and G2, respectively. Eighteen (35%) patients and 11 (22%) patients from virtual assessment by G1 and G2, respectively were found to need a face a face appointment to aid diagnosis. Compared to slit lamp examination, 15% and 7.5% of patients from G1 and G2's virtual assessment respectively had different proposed management plan. Agreement of DR grading between both virtual graders and slit lamp examination was fair (Kappa's coefficient = 0.56). One case of slit lamp noted retinal neovascularization, which was graded as background retinopathy by DESP was also graded as such on virtual assessment. CONCLUSION Widefield Clarus and OCT imaging allowed two-thirds of DESP referrals to be safely managed virtually.
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Affiliation(s)
- Wei Sing Lim
- Moorfields Eye Hospital NHS Foundation Trust, London, UK.
| | | | - Luke Nicholson
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
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21
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de Araujo AL, Rados DRV, Szortyka AD, Falavigna M, Moreira TDC, Hauser L, Gross PB, Lorentz AL, Maturro L, Cabral F, Costa ALFDA, Martins TGDS, da Silva RS, Schor P, Harzheim E, Gonçalves MR, Umpierre RN. Ophthalmic image acquired by ophthalmologists and by allied health personnel as part of a telemedicine strategy: a comparative study of image quality. Eye (Lond) 2020; 35:1398-1404. [PMID: 32555520 DOI: 10.1038/s41433-020-1035-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES This study evaluates the quality of ophthalmic images acquired by a nurse technician trained in teleophthalmology as compared with images acquired by an ophthalmologist, in order to provide a better understanding of the workforce necessary to operate remote care programs. METHODS A cross-sectional study was performed on 2044 images obtained from 118 participants of the TeleOftalmo project, in Brazil. Fundus and slit-lamp photography were performed on site by an ophthalmologist and by a nurse technician under the supervision of a remote ophthalmologist. Image quality was then evaluated by masked ophthalmologists. Proportion of suitable images in each group was compared. RESULTS The proportion of concordant classification regarding quality was 94.8%, with a corrected kappa agreement of 0.94. When analyzing each type of photo separately, there was no significant difference in the proportion of suitable images between on-site ophthalmologist and nurse technician with remote ophthalmologist assistance for the following: slit-lamp views of the anterior segment and anterior chamber periphery, and fundus photographs centered on the macula and on the optic disc (P = 0.825, P = 0.997, P = 0.194, and P = 0.449, respectively). For slit-lamp views of the lens, the proportion of suitable images was higher among those obtained by an ophthalmologist (99.6%) than by a technician (93.8%, P < 0.01). CONCLUSIONS Ophthalmic photographs acquired by a trained technician consistently achieved >90% adequacy for remote reading. Compared with ophthalmologist-acquired photos, the proportion of images deemed suitable achieved a high overall agreement. These findings provide favorable evidence of the adequacy of teleophthalmological imaging by nurse technicians.
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Affiliation(s)
- Aline Lutz de Araujo
- Núcleo de Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. .,Department of Ophthalmology and Visual Sciences, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | | | | | | | | | - Lisiane Hauser
- Núcleo de Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Paula Blasco Gross
- Núcleo de Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Andrea Longoni Lorentz
- Núcleo de Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | - Ana Luiza Fontes de Azevedo Costa
- Department of Ophthalmology and Visual Sciences, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Rodolfo Souza da Silva
- Núcleo de Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Paulo Schor
- Department of Ophthalmology and Visual Sciences, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Erno Harzheim
- Programa de Pós-Graduação em Epidemiologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo Rodrigues Gonçalves
- Núcleo de Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Epidemiologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Roberto Nunes Umpierre
- Núcleo de Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Amoaku W, Bailey C, Downey L, Gale RP, Ghanchi F, Hamilton R, Mahmood S, Menon G, Nosek J, Pearce I, Yang Y. Providing a Safe and Effective Intravitreal Treatment Service: Strategies for Service Delivery. Clin Ophthalmol 2020; 14:1315-1328. [PMID: 32546938 PMCID: PMC7239611 DOI: 10.2147/opth.s233061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/03/2020] [Indexed: 11/23/2022] Open
Abstract
An aging population leads to increasing demand for medical retina services with chronic diseases being managed in long-term care pathways. Many hospital services struggle to deliver efficient and effective MR care due, at least in part, to infrastructure that does not expand responsively enough to meet the increased demand. A steering committee of retinal specialists from a variety of UK NHS hospital ophthalmology departments with experience of leading and managing NHS retinal services in the intravitreal era came together for the generation of this document to review and compile key aspects that should be considered when optimising intravitreal treatment capacity within MR services. This article aims to provide a useful collation and signposting of key published evidence, consensus and insights on aspects of delivering an intravitreal service, including treatment regimens, virtual clinics, staff training and governance, telemedicine and information technology, and data collection and key performance indicators. The objective is to equip ophthalmologic healthcare professionals with the necessary tools to develop and adapt their local service in the face of current and projected increased demand.
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Affiliation(s)
- Winfried Amoaku
- Academic Ophthalmology, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Clare Bailey
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Louise Downey
- Hull and East Yorkshire Eye Hospital, Hull University Teaching Hospital, Hull, UK
| | | | - Faruque Ghanchi
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Sajjad Mahmood
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Geeta Menon
- Frimley Health NHS Foundation Trust, Frimley, UK
| | | | - Ian Pearce
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Yit Yang
- Wolverhampton Eye Infirmary, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
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Patel SN, Shi A, Wibbelsman TD, Klufas MA. Ultra-widefield retinal imaging: an update on recent advances. Ther Adv Ophthalmol 2020; 12:2515841419899495. [PMID: 32010879 PMCID: PMC6971964 DOI: 10.1177/2515841419899495] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/10/2019] [Indexed: 11/23/2022] Open
Abstract
The development of ultra-widefield retinal imaging has accelerated our understanding of common retinal diseases. As we continue to validate the diagnostic and prognostic significance of pathology in the retinal periphery, the ability to visualize and evaluate these features in an efficient and patient-friendly manner will become more important. Current interest in ultra-widefield imaging includes the development of potential biomarkers of disease progression and indicators of preclinical disease development. This article reviews the current ultra-widefield imaging systems and recent advances in their applications to clinical practice with a focus on diabetic retinopathy, retinal vein occlusion, uveitis, and pediatric retina.
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Affiliation(s)
- Samir N Patel
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Angell Shi
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Turner D Wibbelsman
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael A Klufas
- Assistant Professor of Ophthalmology, Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, Suite 1020, Philadelphia, PA 19107, USA
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24
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Giardini ME, Livingstone IAT. Extending the Reach and Task-Shifting Ophthalmology Diagnostics Through Remote Visualisation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1260:161-174. [DOI: 10.1007/978-3-030-47483-6_9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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