Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition

Integrating Nursing-Teleophthalmology Improves Diabetic Retinopathy Screening in Primary Healthcare, Reducing Unnecessary Referrals to Specialist Healthcare

AIM

This work aimed to evaluate the use of teleophthalmology by a primary healthcare nursing team for the diagnosis and referral for diabetic retinopathy to specialized healthcare in relation to numbers referred for specialized healthcare.

METHODS

In this quantitative, cross-sectional service evaluation study, participants with type 2 diabetes mellitus underwent a fundoscopy examination between February and June 2020. Using a portable retinal camera attached to a smartphone, nurses acquired fundus images that were stored on a cloud platform, enabling remote reading by a retinal specialist. The study was conducted at a primary healthcare urban centre on the outskirts of São Paulo, Brazil.

RESULTS

The study enrolled 779 participants, of whom 150 were identified as having diabetic retinopathy present; in another 434, evidence of diabetic retinopathy was absent, and 195 individuals (25%) were classified as having ungradable images. In total, 345 participants were referred for specialized appraisal, 150 of whom due to evidence of diabetic retinopathy and for another 195 participants owing to ungradable images. Thus, more than half of the imaged participants (56%) were not eligible for referral to specialist healthcare and remained treated in primary care.

CONCLUSIONS

Nursing-teleophthalmology integration reduced specialized healthcare referral numbers by more than half. This approach contributed to better triage with a more robust evaluation for diabetic retinopathy diagnostic suspicion, reducing unnecessary referral.

Stakeholder-driven multi-stage adaptive real-world theme-oriented (SMART) telehealth evaluation framework: a scoping review

Telehealth has revolutionized healthcare delivery by integrating cutting-edge technologies, yet evaluations of its services and programs often lack comprehensive frameworks, resulting in unclear standards for quality assurance. To address this gap, we conducted a scoping review of telehealth evaluation frameworks applicable to the United States healthcare system, following the Joanna Briggs Institute methodology and a published protocol. Twelve telehealth evaluation frameworks published between 2019 and 2023 were identified, focusing on four key themes: program implementation, clinical impact, economic impact, and equity. Guided through two auxiliary frameworks, we further developed a stakeholder-driven multi-stage adaptive real-world theme-oriented (SMART) conceptual framework for telehealth evaluation. We illustrated this framework through a use case on a remote patient monitoring program. This comprehensive telehealth evaluation framework not only facilitates stakeholders in developing tailored evaluation plans but also contributes to the standardization and enhancement of telehealth services, ultimately improving health outcomes and promoting greater equity across society.

Exploring retinal conditions through blue light reflectance imaging

Blue light reflectance (BLR) imaging offers a non-invasive, cost-effective method for evaluating retinal structures by analyzing the reflectance and absorption characteristics of the inner retinal layers. By leveraging blue light's interaction with retinal tissues, BLR enhances visualization beyond the retinal nerve fiber layer, improving detection of structures such as the outer plexiform layer and macular pigment. Its diagnostic utility has been demonstrated in distinct retinal conditions, including hyperreflectance in early macular telangiectasia, hyporeflectance in non-perfused areas indicative of ischemia, identification of pseudodrusen patterns (notably the ribbon type), and detection of peripheral retinal tears and degenerative retinoschisis in eyes with reduced retinal pigment epithelial pigmentation. Best practices for image acquisition and interpretation are discussed, emphasizing standardization to minimize variability. Common artifacts and mitigation strategies are also addressed, ensuring image reliability. BLR's clinical utility, limitations, and future research directions are highlighted, particularly its potential in automated image analysis and quantitative assessment. Different BLR acquisition methods, such as fundus photography, confocal scanning laser ophthalmoscopy, and broad line fundus imaging, are evaluated for their respective advantages and limitations. As research advances, BLR's integration into multimodal workflows is expected to improve early detection and precise monitoring of retinal diseases.

Narrative review of comprehensive management strategies for diabetic retinopathy: interdisciplinary approaches and future perspectives

This review examines the epidemiological trends, pathophysiologic mechanisms, and current and future therapeutic strategies for diabetic retinopathy (DR), focusing on innovative management countermeasures in the face of this global public health challenge. As the number of patients with diabetes continues to increase, DR, as one of its major complications, poses a significant threat to global visual health. This review not only summarises the latest advances in personalised treatment and emerging therapeutic modalities (such as anti-vascular endothelial growth factor therapy, laser treatment, surgical procedures and cutting-edge gene and stem cell therapies) but also emphasises the revolutionary potential of telemedicine technologies and digital health platforms to improve DR screening and adherence among people with diabetes. We show how these technological innovations, especially in resource-limited settings, can achieve early diagnosis and effective treatment, thereby significantly reducing the public health burden of DR. In addition, this article highlights the critical role of interdisciplinary teamwork in optimising the comprehensive management of DR, involving close collaboration among physicians, researchers, patient education specialists and policy-makers, as well as the importance of implementing these innovative solutions through societal engagement and policy support. By highlighting these innovative strategies and their specific impact on improving public health practices, this review offers new perspectives and strategies for the future management of DR, with the goal of promoting the prevention, diagnosis and treatment of DR worldwide, improving patient prognosis and enhancing quality of life.

Improving Access to Specialist Eye Care for Indigenous Australians via Telehealth: An Observational Cohort Study

Background: Indigenous people are often neglected in eye health research and service delivery programs, despite having a greater burden of vision loss, most of which is avoidable. The objective of this work was to improve access to specialist eye care for Indigenous Australians living in rural and remote areas, by providing direct access to expert diagnostic services based in metropolitan areas through a tele-ophthalmology system. Methods: Over a four-year study period, 13 remote communities in Queensland and the Northern Territory were identified that had limited or no access to eye screening services. Relationships with health service providers in the communities were established to codesign a sustainable model of service delivery and referral pathways to ensure that patients identified with eye issues received appropriate treatment. Results: Over the course of the study, screening records from 378 patients were uploaded to a web-based telehealth system and diagnosed by ophthalmologists. From these examinations, 64 new cases of diabetic retinopathy (DR) were identified (including 2 cases of proliferative DR and 4 cases of severe nonproliferative DR), and diabetic macular edema was noted in 18 patients. The majority of participants screened had no eye problems, which enables the removal of these patients from the queues of overwhelmed specialist lists, improving service efficiency. The study also demonstrates capacity building of healthcare workers to perform eye screening and improved patient health awareness where the retinal cameras were used as an educational tool. Conclusions: A valuable screening service has been established in the target areas, where access to ophthalmic services has been improved for residents of the study screening locations. Routine eye examination (instead of opportunistic eye examination) is feasible for early detection of some eye diseases for remote and rural patients.

Comprehensive insights into a decade-long journey: The evolution, impact, and human factors of an asynchronous telemedicine program for diabetic retinopathy screening in Pennsylvania, United States

Diabetic Retinopathy stands as a leading cause of irreversible blindness, necessitating frequent examinations, especially in the early stages where effective treatments are available. However, current examination rates vary widely, ranging from 25-60%. This study scrutinizes the Point-of-Care Diabetic Retinopathy Examination Program at the University of Pittsburgh/UPMC, delving into its composition, evolution, challenges, solutions, and improvement opportunities. Employing a narrative approach, insights are gathered from key stakeholders, including ophthalmologists and staff from primary care clinics. A quantitative analysis from 2008 to 2020 provides a comprehensive overview of program outcomes, covering 94 primary care offices with 51 retinal cameras. Program components feature automated non-mydriatic 45° retinal cameras, a dedicated coordinator, rigorous training, and standardized workflows. Over this period, the program conducted 21,960 exams in 16,458 unique individuals, revealing a diverse population with an average age of 58.5 and a balanced gender distribution. Average body mass index (33.96±8.02 kg/m2) and hemoglobin A1c (7.58%±1.88%) surpassed normal ranges, indicating prevalent risk factors for diabetes-related complications. Notably, 24.2% of patients underwent more than one exam, emphasizing program engagement. Findings indicated that 86.3% of exams were gradable, with 59.0% within normal limits, 12.1% showing some evidence of diabetic retinopathy, and 6.4% exhibiting vision-threatening diabetic retinopathy. Follow-up appointments with ophthalmologists were recommended in 31.5% of exams due to indeterminate results, positive diabetic retinopathy (≥moderate or macular exudate), or other findings like age-related macular degeneration or suspected glaucoma. The program demonstrated high reproducibility across diverse healthcare settings, featuring a sustainable model with minimal camera downtime, standardized workflows, and financial support from grants, health systems, and clinical revenues. Despite COVID-19 pandemic challenges, this research emphasizes the program's reproducibility, user-friendly evolution, and promising outcomes. Beyond technical contributions, it highlights human factors influencing program success. Future research could explore adherence to follow-up ophthalmological recommendations and its associated factors.

Disparities Between Teleretinal Imaging Findings and Patient-Reported Diabetic Retinopathy Status and Follow-up Eye Care Interval: A 10-Year Prospective Study

OBJECTIVE

To assess self-reported awareness of diabetic retinopathy (DR) and concordance of eye examination follow-up compared with findings from concurrent retinal images.

RESEARCH DESIGN AND METHODS

We conducted a prospective observational 10-year study of 26,876 consecutive patients with diabetes who underwent retinal imaging during an endocrinology visit. Awareness and concordance were evaluated using questionnaires and retinal imaging.

RESULTS

Awareness information and gradable images were available in 25,360 patients (94.3%). Severity of DR by imaging was as follows: no DR (n = 14,317; 56.5%), mild DR (n = 6,805; 26.8%), or vision-threatening DR (vtDR; n = 4,238; 16.7%). In the no, mild, and vtDR groups, 96.7%, 88.5%, and 54.9% of patients, respectively, reported being unaware of any prior DR. When DR was present, reporting no prior DR was associated with shorter diabetes duration, milder DR, last eye examination >1 year before, no dilation, no scheduled appointment, and less specialized provider (all P < 0.001). Among patients with vtDR, 41.2%, 58.1%, and 64.2% did not report being aware of any DR and follow-up was concordant with current DR severity in 66.7%, 41.3%, and 25.4% (P < 0.001) of patients when prior examination was performed by a retinal specialist, nonretinal ophthalmologist, or optometrist (P < 0.001), respectively.

CONCLUSIONS

Substantial discrepancies exist between DR presence, patient awareness, and concordance of follow-up across all DR severity levels. These discrepancies are present across all eye care provider types, with the magnitude influenced by provider type. Therefore, patient self-report should not be relied upon to reflect DR status. Modification of medical care and education models may be necessary to enhance retention of ophthalmic knowledge in patients with diabetes and ensure accurate communication between all health care providers.

Telehealth Evaluation in the United States: Protocol for a Scoping Review

BACKGROUND

The rapid expansion of telehealth services, driven by the COVID-19 pandemic, necessitates systematic evaluation to guarantee the quality, effectiveness, and cost-effectiveness of telehealth services and programs in the United States. While numerous evaluation frameworks have emerged, crafted by various stakeholders, their comprehensiveness is limited, and the overall state of telehealth evaluation remains unclear.

OBJECTIVE

The overarching goal of this scoping review is to create a comprehensive overview of telehealth evaluation, incorporating perspectives from multiple stakeholder categories. Specifically, we aim to (1) map the existing landscape of telehealth evaluation, (2) identify key concepts for evaluation, (3) synthesize existing evaluation frameworks, and (4) identify measurements and assessments considered in the United States.

METHODS

We will conduct this scoping review in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). This scoping review will consider documents, including reviews, reports, and white papers, published since January 1, 2019. It will focus on evaluation frameworks and associated measurements of telehealth services and programs in the US health care system, developed by telehealth stakeholders, professional organizations, and authoritative sources, excluding those developed by individual researchers, to collect data that reflect the collective expertise and consensus of experts within the respective professional group.

RESULTS

The data extracted from selected documents will be synthesized using tools such as tables and figures. Visual aids like Venn diagrams will be used to illustrate the relationships between the evaluation frameworks from various sources. A narrative summary will be crafted to further describe how the results align with the review objectives, facilitating a comprehensive overview of the findings. This scoping review is expected to conclude by August 2024.

CONCLUSIONS

By addressing critical gaps in telehealth evaluation, this scoping review protocol lays the foundation for a comprehensive and multistakeholder assessment of telehealth services and programs. Its findings will inform policy makers, health care providers, researchers, and other stakeholders in advancing the quality, effectiveness, and cost-effectiveness of telehealth in the US health care system.

TRIAL REGISTRATION

OSF Registries osf.io/aytus; https://osf.io/aytus.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55209.

Telemedicine for Cornea and External Disease: A Scoping Review of Imaging Devices

OBJECTIVE

The objective of this scoping review is to understand the extent and type of evidence in relation to telemedicine imaging devices for cornea and external segment conditions.

INTRODUCTION

The coronavirus pandemic has emphasized the benefits of telemedicine in diagnosing and managing ocular diseases. With the rapid advancement of technology in slit lamp biomicroscopes, smartphones and other ocular surface imaging modalities, telemedicine applications for cornea and external diseases have become an active area of research.

INCLUSION CRITERIA

For studies to be included, they had to discuss the concept of imaging devices for cornea and external diseases in the context of telemedicine. There was no restriction on the studied population or participants.

METHODS

A scoping review was conducted according to an a priori protocol. Documents written in English were identified from the PubMed and Embase databases and searches. Anterior segment imaging devices were then classified into different categories.

RESULTS

Anterior segment imaging devices identified in this review included 19 slit lamp-based devices, 17 smartphone-based devices and 15 other devices. These tools can detect a wide variety of cornea and external diseases (e.g., pterygium, conjunctivitis, corneal opacity, corneal ulcer, and blepharitis). Fewer than half of the devices (24/51) were assessed for diagnostic performance. Their diagnostic accuracy varied greatly from condition to condition and from device to device. The inter-rater reliability of different photo-graders assessing images was assessed in only a few studies.

CONCLUSIONS

Anterior segment imaging devices are promising tools for remote diagnosis and management of patients with cornea and external disease. However, there are significant gaps in the literature regarding the diagnostic accuracy and inter-rater reliability of several devices. Future research with rigorous methods is required to validate the use of these devices in telemedicine settings.

Telemedicine in Elderly Hypertensive and Patients with Chronic Diseases during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

BACKGROUND

One aspect of the distancing measures imposed in response to the COVID-19 pandemic is that telemedicine consultations have increased exponentially. Among these consultations, the assessment and follow-up of patients with chronic diseases in a non-presential setting has been strengthened considerably. Nevertheless, some controversy remains about the most suitable means of patient follow-up.

OBJECTIVE

To analyze the impact of the telemedicine measures implemented during the COVID-19 period on chronic patients.

MATERIAL AND METHODS

A systematic review was carried out using the following databases: PubMed, Pro-Quest, and Scopus. The systematic review followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search equation utilized descriptors sourced from the Medical Subject Headings (MeSH) thesaurus. The search equation was: "hypertension AND older AND primary care AND (COVID-19 OR coronavirus)" and its Spanish equivalent.

RESULTS

The following data were obtained: 14 articles provided data on 6,109,628 patients and another 4 articles focused on a study population of 9684 physicians. Telemedicine was less likely to be used by elderly patients (OR 0.85; 95% C.I. 0.83-0.88; p = 0.05), those of Asian race (OR 0.69; 95% C.I. 0.66-0.73; p = 0.05), and those whose native language was not English (OR 0.89; 95% C.I. 0.78-0.9; p = 0.05). In primary care, lower use of telemedicine was associated with residents of rural areas (OR 0.81; p = 0.05), patients of African American race (OR 0.65, p = 0.05), and others (OR 0.64; p = 0.05). A high proportion (40%) of physicians had no prior training in telemedicine techniques. The highest quality in terms of telephone consultation was significantly associated with physicians who did not increase their prescription of antibiotherapy during the pandemic (OR = 0.30, p = 0.05) or prescribe more tests (OR 0.06 p = 0.05), i.e., who maintained their former clinical criteria despite COVID-19.

CONCLUSIONS

Telemedicine is of proven value and has been especially useful in the COVID-19 pandemic. A mixed remote-presential model is most efficient. Appropriate training in this area for physicians and patients, together with correct provision, is essential to prevent errors in implementation and use.

Artificial intelligence for telemedicine diabetic retinopathy screening: a review

PURPOSE

This study aims to compare artificial intelligence (AI) systems applied in diabetic retinopathy (DR) teleophthalmology screening, currently deployed systems, fairness initiatives and the challenges for implementation.

METHODS

The review included articles retrieved from PubMed/Medline/EMBASE literature search strategy regarding telemedicine, DR and AI. The screening criteria included human articles in English, Portuguese or Spanish and related to telemedicine and AI for DR screening. The author's affiliations and the study's population income group were classified according to the World Bank Country and Lending Groups.

RESULTS

The literature search yielded a total of 132 articles, and nine were included after full-text assessment. The selected articles were published between 2004 and 2020 and were grouped as telemedicine systems, algorithms, economic analysis and image quality assessment. Four telemedicine systems that perform a quality assessment, image preprocessing and pathological screening were reviewed. A data and post-deployment bias assessment are not performed in any of the algorithms, and none of the studies evaluate the social impact implementations. There is a lack of representativeness in the reviewed articles, with most authors and target populations from high-income countries and no low-income country representation.

CONCLUSIONS

Telemedicine and AI hold great promise for augmenting decision-making in medical care, expanding patient access and enhancing cost-effectiveness. Economic studies and social science analysis are crucial to support the implementation of AI in teleophthalmology screening programs. Promoting fairness and generalizability in automated systems combined with telemedicine screening programs is not straightforward. Improving data representativeness, reducing biases and promoting equity in deployment and post-deployment studies are all critical steps in model development.

Considerations of COVID-19 in Ophthalmology

Since its emergence in early 2020, the SARS-CoV-2 infection has had a significant impact on the entire eye care system. Ophthalmologists have been categorized as a high-risk group for contracting the virus due to the belief that the eye may be a site of inoculation and transmission of the SARS-CoV-2 infection. As a result, clinical ophthalmologists, optometrists, and eyecare professionals have had to familiarize themselves with the ocular manifestations of COVID-19, as well as its treatments and vaccines. The implementation of measures to prevent the transmission of the virus, such as restrictions, lockdowns, telemedicine, and artificial intelligence (AI), have led to substantial and potentially irreversible changes in routine clinical practice, education, and research. This has resulted in the emergence of a new mode of managing patients in a routine clinical setting. This brief review aims to provide an overview of various aspects of COVID-19 in ophthalmology, including the ocular manifestations related to the disease, the modes of transmission of SARS-CoV-2 infection, precautions taken in ophthalmic practice to prevent the spread of the virus, drugs, and vaccines used in the treatment of COVID-19, the impact of the pandemic on patients, clinicians, and the eye care system as a whole, and the future of ophthalmology conditioned by this global pandemic experience.

Diabetic Retinopathy Screening at the Point of Care (DR SPOC): detecting undiagnosed and vision-threatening retinopathy by integrating portable technologies within existing services

INTRODUCTION

The aim of this study was to determine the prevalence of diabetic retinopathy (DR) in a low socioeconomic region of a high-income country, as well as determine the diagnostic utility of point-of-care screening for high-risk populations in tertiary care settings.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of patients with diabetes attending foot ulcer or integrated care diabetes clinics at two Western Sydney hospitals (n=273). DR was assessed using portable, two-field, non-mydriatic fundus photography and combined electroretinogram/ pupillometry (ERG). With mydriatic photographs used as the reference standard, sensitivity and specificity of the devices were determined. Prevalence of DR and vision-threatening diabetic retinopathy (VTDR) were reported, with multivariate logistic regression used to identify predictors of DR.

RESULTS

Among 273 patients, 39.6% had any DR, while 15.8% had VTDR, of whom 59.3% and 62.8% were previously undiagnosed, respectively. Non-mydriatic photography demonstrated 20.2% sensitivity and 99.5% specificity for any DR, with a 56.7% screening failure rate. Meanwhile, mydriatic photography produced high-quality images with a 7.6% failure rate. ERG demonstrated 72.5% sensitivity and 70.1% specificity, with a 15.0% failure rate. The RETeval ERG was noted to have an optimal DR cut-off score at 22. Multivariate logistic regression identified an eGFR of ≤29 mL/min/1.73 m2, HbA1c of ≥7.0%, pupil size of <4 mm diameter, diabetes duration of 5-24 years and RETeval score of ≥22 as strong predictors of DR.

CONCLUSION

There is a high prevalence of vision-threatening and undiagnosed DR among patients attending high-risk tertiary clinics in Western Sydney. Point-of-care DR screening using portable, mydriatic photography demonstrates potential as a model of care which is easily accessible, targeted for high-risk populations and substantially enhances DR detection.

Factors Associated with Follow-Up Adherence After Teleophthalmology for Diabetic Eye Screening Before and During the COVID-19 Pandemic

Abstract Background: Follow-up adherence with in-person care is critical for achieving improved clinical outcomes in telemedicine screening programs. We sought to quantify the impact of the COVID-19 pandemic upon follow-up adherence and factors associated with follow-up adherence after teleophthalmology for diabetic eye screening. Methods: We retrospectively reviewed medical records of adults screened in a clinical teleophthalmology program at urban and rural primary care clinics between May 2015 and December 2020. We defined follow-up adherence as medical record documentation of an in-person eye exam within 1 year among patients referred for further care. Regression models were used to identify factors associated with follow-up adherence. Results: Among 948 patients, 925 (97.6%) had health insurance and 170 (17.9%) were referred for follow-up. Follow-up adherence declined from 62.7% (n = 52) prepandemic to 46.0% (n = 40) during the pandemic (p = 0.04). There was a significant decline in follow-up adherence among patients from rural (p < 0.001), but not urban (p = 0.72) primary care clinics. Higher median household income (odds ratio [OR] 1.68, 95% confidence interval [CI]: 1.19-2.36) and obtaining care from an urban clinic (OR 5.29, 95% CI: 2.09-13.43) were associated with greater likelihood of follow-up during the pandemic. Discussion: Follow-up adherence remains limited after teleophthalmology screening even in a highly insured patient population, with a further decline observed during the COVID-19 pandemic. Our results suggest that rural patients and those with lower socioeconomic status experienced greater barriers to follow-up eye care during the COVID-19 pandemic. Conclusions: Addressing barriers to in-person follow-up care is needed to effectively improve clinical outcomes after teleophthalmology screening.

Incidence and Progression of Diabetic Retinopathy in American Indian and Alaska Native Individuals Served by the Indian Health Service, 2015-2019

Importance

Estimates of diabetic retinopathy (DR) incidence and progression in American Indian and Alaska Native individuals are based on data from before 1992 and may not be informative for strategizing resources and practice patterns.

Objective

To examine incidence and progression of DR in American Indian and Alaska Native individuals.

Design, Setting, and Participants

This was a retrospective cohort study conducted from January 1, 2015, to December 31, 2019, and included adults with diabetes and no evidence of DR or mild nonproliferative DR (NPDR) in 2015 who were reexamined at least 1 time during the 2016 to 2019 period. The study setting was the Indian Health Service (IHS) teleophthalmology program for diabetic eye disease.

Exposure

Development of new DR or worsening of mild NPDR in American Indian and Alaska Native individuals with diabetes.

Main Outcomes and Measures

Outcomes were any increase in DR, 2 or more (2+) step increases, and overall change in DR severity. Patients were evaluated with nonmydriatic ultra-widefield imaging (UWFI) or nonmydriatic fundus photography (NMFP). Standard risk factors were included.

Results

The total cohort of 8374 individuals had a mean (SD) age of 53.2 (12.2) years and a mean (SD) hemoglobin A1c level of 8.3% (2.2%) in 2015, and 4775 were female (57.0%). Of patients with no DR in 2015, 18.0% (1280 of 7097) had mild NPDR or worse in 2016 to 2019, and 0.1% (10 of 7097) had PDR. The incidence rate from no DR to any DR was 69.6 cases per 1000 person-years at risk. A total of 6.2% of participants (441 of 7097) progressed from no DR to moderate NPDR or worse (ie, 2+ step increase; 24.0 cases per 1000 person-years at risk). Of patients with mild NPDR in 2015, 27.2% (347 of 1277) progressed to moderate NPDR or worse in 2016 to 2019, and 2.3% (30 of 1277) progressed to severe NPDR or worse (ie, 2+ step progression). Incidence and progression were associated with expected risk factors and evaluation with UWFI.

Conclusions and Relevance

In this cohort study, the estimates of DR incidence and progression were lower than those previously reported for American Indian and Alaska Native individuals. The results suggest extending the time between DR re-evaluations for certain patients in this population, if follow-up compliance and visual acuity outcomes are not jeopardized.

Teleophthalmology Using Remote Retinal Imaging During the COVID-19 Pandemic

Introduction: Lower insurance reimbursements have limited the financial sustainability of remote eye screening programs. Greater utilization and insurance coverage for teleophthalmology screening during the coronavirus disease 2019 (COVID-19) pandemic in 2020 may enhance awareness and expand remote retinal imaging services. This retrospective cross-sectional study evaluates utilization and insurance coverage for remote retinal imaging in the United States in 2020. Methods: We analyzed teleretinal imaging utilization and insurance payments from January 1 to December 31, 2020, using the Optum Labs Data Warehouse, a comprehensive national database of deidentified administrative claims for commercial and Medicare Advantage enrollees in the United States. We evaluated frequency of claims and insurance payment for services using the Current Procedural Terminology codes 92227 and 92228 for remote eye imaging by any provider, and 92250 for fundus photography by non-eye care providers. Results: The use of remote retinal imaging in the United States declined rapidly during the initial COVID-19 lockdown from 3,627 claims in February 2020 to 1,414 claims in April 2020, but returned to 3,133 claims by December 2020, similar to mean prepandemic levels in 2019 (2,841 ± 174.8 claims). The proportion of insurance payments for remote imaging increased temporarily from 47.4% in February to 56.7% in April, and then returned to 45.9% in December of 2020. Discussion: Utilization of remote retinal imaging declined steeply, while the insurance coverage increased during the initial COVID-19 lockdown in 2020, but returned to prepandemic levels by end of the year. Changes in utilization and relaxed restrictions on insurance reimbursements for teleophthalmology during the COVID-19 pandemic were not sustained.

Digital innovations for retinal care in diabetic retinopathy

AIM

The purpose of this review is to examine the applications of novel digital technology domains for the screening and management of patients with diabetic retinopathy (DR).

METHODS

A PubMed engine search was performed, using the terms "Telemedicine", "Digital health", "Telehealth", "Telescreening", "Artificial intelligence", "Deep learning", "Smartphone", "Triage", "Screening", "Home-based", "Monitoring", "Ophthalmology", "Diabetes", "Diabetic Retinopathy", "Retinal imaging". Full-text English language studies from January 1, 2010, to February 1, 2022, and reference lists were considered for the conceptual framework of this review.

RESULTS

Diabetes mellitus and its eye complications, including DR, are particularly well suited to digital technologies, providing an ideal model for telehealth initiatives and real-world applications. The current development in the adoption of telemedicine, artificial intelligence and remote monitoring as an alternative to or in addition to traditional forms of care will be discussed.

CONCLUSIONS

Advances in digital health have created an ecosystem ripe for telemedicine in the field of DR to thrive. Stakeholders and policymakers should adopt a participatory approach to ensure sustained implementation of these technologies after the COVID-19 pandemic. This article belongs to the Topical Collection "Diabetic Eye Disease", managed by Giuseppe Querques.

Prevalence of Diabetic Eye Diseases in American Indians and Alaska Natives (AI/AN) as Identified by the Indian Health Service's National Teleophthalmology Program Using Ultrawide Field Imaging (UWFI)

PURPOSE

Estimates of diabetic eye disease in American Indian and Alaska Natives (AI/AN) vary over time, region, and methods. This article reports recent prevalence of diabetic retinopathy (DR) and diabetic macular edema (DME) in AI/AN served by the Indian Health Services' (IHS) teleophthalmology program, as identified using ultrawide field imaging (UWFI).

METHODS

This was a retrospective analysis of 2016-2019 clinical data (n = 53,900). UWF images were acquired by certified imagers using a validated protocol, and graded by licensed, certified optometrists supervised by an ophthalmologist. Graders evaluated the extent/severity of retinal lesions in comparison to standard photographs. DR lesions predominantly in any peripheral field were considered "predominantly peripheral lesions" (PPL). The analyses calculated prevalence of any DR, any DME, DR and DME severity, sight-threatening disease, and PPL.

RESULTS

Patients averaged 56 years of age with a 68 mmol/mol A1c and 55% had had diabetes for 5+ years. Prevalence of any DR, any DME, and sight-threatening disease was 28.6%, 3.0%, and 3.0%. In patients with mild nonproliferative DR, PPL was seen in 25.3%. PPL suggested a more severe level of DR in 8.7% of patients. DR increased with age. DME decreased with age. Males and patients in the Nashville IHS area had more diabetic eye disease.

CONCLUSION

AI/AN have a high burden of diabetes and its complications. The IHS is resource-constrained, making accurate disease estimates necessary for resource allocation and budget justifications to Congress. These data update the estimates of diabetic eye disease in Indian Country and suggest that UWFI identifies early DR.

Effect of health system on the association of rurality and level of disadvantage with receipt of diabetic eye screening

INTRODUCTION

Rural versus urban disparities have been observed in diabetic eye screening, but whether the level of disadvantage in rural versus urban areas is related to these disparities is unclear. Our goal was to determine the role of level of disadvantage in explaining the effect of health systems on rural and urban disparities in diabetic eye screening.

RESEARCH DESIGN AND METHODS

This is a retrospective cohort study using an all-payer, state-wide claims database covering over 75% of Wisconsin residents. We included adults with diabetes (18-75 years old) who had claims billed throughout the baseline (2012-2013) and measurement (2013-2014) years. We performed multivariable regressions to assess factors associated with receipt of diabetic eye screening. The primary exposure was the primary care clinic's combined level of rurality and disadvantage. We adjusted for the health system as well as patient-level variables related to demographics and comorbidities. Health system was defined as an associated group of physicians and/or clinics.

RESULTS

A total of 118 707 adults with diabetes from 698 primary care clinics in 143 health systems met the inclusion criteria. Patients from urban underserved clinics were less likely to receive screening than those from rural underserved clinics before adjusting for health system in the model. After adjusting for health system fixed effects, however, the directionality of the relationship between clinic rurality and screening reversed: patients from urban underserved clinics were more likely to receive screening than those from rural underserved clinics. Similar findings were observed for both Medicare and non-Medicare subgroups.

CONCLUSIONS

The effect of health system on receipt of diabetic eye screening in rural versus urban areas is most pronounced in underserved areas. Health systems, particularly those providing care to urban underserved populations, have an opportunity to increase screening rates by leveraging health system-level interventions to support patients in overcoming barriers from social determinants of health.

Developing and evaluating a SAFER model to screen for diabetes complications among people experiencing homelessness: a pilot study protocol

Background

Diabetes management combined with housing instability intersects, forcing individuals to triage competing needs and critical stressors, such as safety and shelter, with fundamental diabetes self-management tasks like attending healthcare appointments to screen for the complications of diabetes, leaving individuals overwhelmed and overburdened. We aim to address this disjuncture found within our current healthcare delivery system by providing point-of-care screening opportunities in a more patient-centered approach.

Method

We describe a pilot study of a novel clinical intervention which provides timely, comprehensive, and accessible screening for diabetes complications to people experiencing homelessness. We will assess the reach, effectiveness, adoption, implementation, and maintenance, as per the RE-AIM framework, of a SAFER model of care (i.e., screening for A1C, feet, eyes, and renal function). A trained nurse will provide this screening within a homeless shelter. During these encounters, eligible participants will be screened for microvascular complications (neuropathy, nephropathy, retinopathy) and have their A1C measured, all at the point of care, using bedside tools and novel technology. Effectiveness, our primary objective, will be evaluated using a pre-post design, by comparing the rate of completion of full microvascular screening during the study period with individuals’ own historical screening in the 2-year period prior to enrollment. The other domains of the RE-AIM framework will be assessed using process data, chart reviews, patient surveys, and qualitative semi-structured interviews with service providers and participants. This study will be conducted in a large inner-city homeless shelter within a major urban Canadian city (Calgary, Canada).

Discussion

Currently, screening for diabetes complications is often inaccessible for individuals experiencing homelessness, which places heavy burdens on individuals and, ultimately, on already strained emergency and acute care services when complications go undetected at earlier stages. The SAFER intervention will modify the current standard of care for this population in a way that is less fragmented, more person-focused, and timely, with the goal of ultimately improving the rate of screening in an acceptable fashion to identify those requiring specialist referral at earlier stages.

Telehealth Screening for Diabetic Retinopathy: Economic Modeling Reveals Cost Savings

Introduction: The use of telehealth screening (TS) for diabetic retinopathy (DR) consists of fundus photography in a primary care setting with remote interpretation of images. TS for DR is known to increase screening utilization and reduce vision loss compared with standard in-person conventional diabetic retinal exam (CDRE). Anti-vascular endothelial growth factor intravitreal injections have become standard of care for the treatment of DR, but they are expensive. We investigated whether TS for DR is cost-effective when DR management includes intravitreal injections using national data. Materials and Methods: We compared cost and effectiveness of TS and CDRE using decision-tree analysis and probabilistic sensitivity analysis with Monte Carlo simulation. We considered the disability weight (DW) of vision impairment and 1-year direct medical costs of managing patients based on Medicare allowable rates and clinical trial data. Primary outcomes include incremental costs and incremental effectiveness. Results: The average annual direct cost of eye care was $196 per person for TS and $275 for CDRE. On average, TS saves $78 (28%) compared with CDRE and was cost saving in 88.9% of simulations. The average DW outcome was equivalent in both groups. Discussion: Although this study was limited by a 1-year time horizon, it provides support that TS for DR can reduce costs of DR management despite expensive treatment with anti-VEGF agents. TS for DR is equally effective as CDRE at preserving vision. Conclusions: Annual TS for DR is cost saving and equally effective compared with CDRE given a 1-year time horizon.

A Virtual Reading Center Model Using Crowdsourcing to Grade Photographs for Trachoma: Validation Study (Preprint)

BACKGROUND

As trachoma is eliminated, skilled field graders become less adept at correctly identifying active disease (trachomatous inflammation-follicular [TF]). Deciding if trachoma has been eliminated from a district or if treatment strategies need to be continued or reinstated is of critical public health importance. Telemedicine solutions require both connectivity, which can be poor in the resource-limited regions of the world in which trachoma occurs, and accurate grading of the images.

OBJECTIVE

Our purpose was to develop and validate a cloud-based "virtual reading center" (VRC) model using crowdsourcing for image interpretation.

METHODS

The Amazon Mechanical Turk (AMT) platform was used to recruit lay graders to interpret 2299 gradable images from a prior field trial of a smartphone-based camera system. Each image received 7 grades for US $0.05 per grade in this VRC. The resultant data set was divided into training and test sets to internally validate the VRC. In the training set, crowdsourcing scores were summed, and the optimal raw score cutoff was chosen to optimize kappa agreement and the resulting prevalence of TF. The best method was then applied to the test set, and the sensitivity, specificity, kappa, and TF prevalence were calculated.

RESULTS

In this trial, over 16,000 grades were rendered in just over 60 minutes for US $1098 including AMT fees. After choosing an AMT raw score cut point to optimize kappa near the World Health Organization (WHO)-endorsed level of 0.7 (with a simulated 40% prevalence TF), crowdsourcing was 95% sensitive and 87% specific for TF in the training set with a kappa of 0.797. All 196 crowdsourced-positive images received a skilled overread to mimic a tiered reading center and specificity improved to 99%, while sensitivity remained above 78%. Kappa for the entire sample improved from 0.162 to 0.685 with overreads, and the skilled grader burden was reduced by over 80%. This tiered VRC model was then applied to the test set and produced a sensitivity of 99% and a specificity of 76% with a kappa of 0.775 in the entire set. The prevalence estimated by the VRC was 2.70% (95% CI 1.84%-3.80%) compared to the ground truth prevalence of 2.87% (95% CI 1.98%-4.01%).

CONCLUSIONS

A VRC model using crowdsourcing as a first pass with skilled grading of positive images was able to identify TF rapidly and accurately in a low prevalence setting. The findings from this study support further validation of a VRC and crowdsourcing for image grading and estimation of trachoma prevalence from field-acquired images, although further prospective field testing is required to determine if diagnostic characteristics are acceptable in real-world surveys with a low prevalence of the disease.

Inter-observer agreement in grading severity of diabetic retinopathy in wide-field fundus photographs

OBJECTIVE

To examine the inter-observer agreement between two retina specialists in grading diabetic retinopathy (DR) severity in ultra-wide-field fundus photographs.

METHODS

Two hundred and seventy patients with diabetes, who visited the vitreoretinal specialty at a tertiary eye care hospital, with or without DR underwent comprehensive ophthalmic examination, dilated retinal exam and Optos ultra-wide-field (UWF) retinal photography. Optos images were graded for DR severity based on the International Clinical Diabetic Retinopathy Disease Severity Scale by two retina specialists with same number of years of experience, masked to the clinical details of the participants.

RESULTS

The two graders showed agreement in 229/270 images (84.8%) and disagreement in 41/270 images (15.2%). The unweighted kappa for agreement between graders was k = 0.715, SE = 0.037 and the weighted kappa was k = 0.838, SE = 0.022. No DR was identified in 170/270 (62.9%) patients, mild NPDR in 15/270 (5.6%) patients, moderate NPDR in 35/270 (12.9%) patients, severe NPDR in 4/270 (1.48%) patient and PDR in 5/270 (1.85%) patients by both graders. Disagreement was neither related to the learning curve of graders nor with the patient's age (p = 0.574), gender (p = 0.169), duration of diabetes (0.660) or the lens being phakic or pseudophakic (p = 0.171) on logistic regression.

CONCLUSIONS

The impact of disagreement noted between observers in grading DR on UWF fundus photographs should be considered when utilizing UWF system in clinical studies.

Telemedicine Curriculum in an Ophthalmology Residency Program

Background The COVID-19 pandemic has accelerated the adoption of telemedicine in the field of ophthalmology. Despite the increasing utilization of telemedicine, there is a lack of formal training in ophthalmology residency programs to ensure ophthalmologists are prepared to conduct virtual eye exams.

Objective This article aims to assess the impact of an ophthalmic telemedicine curriculum on ophthalmology residents' self-reported knowledge acquisition in conducting telemedicine eye exams, perceived ability to diagnose, manage, and triage common eye diseases, and evaluate their attitudes toward the current and future use of teleophthalmology.

Methods This single-center study at Massachusetts Eye and Ear used a nonvalidated pre- and postcurriculum survey conducted during the 2020 to 2021 academic year among ophthalmology residents. Participants engaged in an ophthalmic telemedicine curriculum that consisted of interactive didactic lectures and electronic postdidactic assessments.

Results Twenty-four residents (100%) completed a precurriculum survey, while 23 of 24 (95.8%) residents completed both the telemedicine curriculum and a postcurriculum survey. On a five-point Likert scale, the median interquartile range (IQR) scores for confidence with setup/logistics, history taking, examination, documentation, and education increased from 2.5 (2.0–4.0) to 4.0 (3.5–4.5) (p = 0.001), 3.0 (3.0–4.0) to 5.0 (4.0–5.0) (p < 0.001), 2.0 (1.8–2.0) to 4.0 (3.5–4.0) (p < 0.001), 2.0 (1.0–2.0) to 4.0 (3.0–4.0) (p < 0.001), and 2.5 (2.0–3.0) to 4.0 (4.0–4.0) (p < 0.001), respectively. The median (IQR) scores for comfort with ethics/professionalism, disparities and conducting patient triage, diagnosis, and management increased from 2.0 (2.0–2.3) to 4.0 (3.0–4.0) (p < 0.001), 2.0 (2.0–2.0) to 3.0 (3.0–4.0) (p < 0.001) and 3.0 (2.0–3.0) to 4.0 (3.0–4.0) (p = 0.001), 2.0 (2.0–3.0) to 3.0 (3.0–4.0) (p < 0.001), and 3.0 (2.0–3.0) to 3.0 (3.0–4.0) (p = 0.008), respectively.

Conclusion The implementation of an ophthalmic telemedicine curriculum increased resident confidence and self-reported knowledge across all logistical and clinical components of virtual ophthalmic care. Formal telehealth curricula can address an unmet educational need of resident trainees in an era of rapid uptake and utilization of telehealth services.

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.

Current status and future possibilities of retinal imaging in diabetic retinopathy care applicable to low- and medium-income countries

Diabetic retinopathy (DR) is a leading cause of blindness among adults and the numbers are projected to rise. There have been dramatic advances in the field of retinal imaging since the first fundus image was captured by Jackman and Webster in 1886. The currently available imaging modalities in the management of DR include fundus photography, fluorescein angiography, autofluorescence imaging, optical coherence tomography, optical coherence tomography angiography, and near-infrared reflectance imaging. These images are obtained using traditional fundus cameras, widefield fundus cameras, handheld fundus cameras, or smartphone-based fundus cameras. Fluorescence lifetime ophthalmoscopy, adaptive optics, multispectral and hyperspectral imaging, and multicolor imaging are the evolving technologies which are being researched for their potential applications in DR. Telemedicine has gained popularity in recent years as remote screening of DR has been made possible. Retinal imaging technologies integrated with artificial intelligence/deep-learning algorithms will likely be the way forward in the screening and grading of DR. We provide an overview of the current and upcoming imaging modalities which are relevant to the management of DR.

Telemedicine in diabetic retinopathy screening in India

With ever-growing prevalence of diabetes mellitus and its most common microvascular complication diabetic retinopathy (DR) in Indian population, screening for DR early for prevention of development of vision-threatening stages of the disease is becoming increasingly important. Most of the programs in India for DR screening are opportunistic and a universal screening program does not exist. Globally, telemedicine programs have demonstrated accuracy in classification of DR into referable disease, as well as into stages, with accuracies reaching that of human graders, in a cost-effective manner and with sufficient patient satisfaction. In this major review, we have summarized the global experience of telemedicine in DR screening and the way ahead toward planning a national integrated DR screening program based on telemedicine.

Telemedicine Use by Oculoplastic Surgeons During the COVID-19 Pandemic

Background: Telemedicine use expanded dramatically during the COVID-19 pandemic, including to surgical fields that had limited prior adoption of telehealth such as oculoplastic surgery. To assess telemedicine usage patterns, barriers to implementation, and satisfaction with telemedicine, we conducted a survey among members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Methods: We performed a Web-based, anonymous survey of ASOPRS members from November to December 2020. Statistical analyses were performed by using Fisher's exact and Chi-squared tests. Results: We received 196 unique survey responses from 963 invited participants (20.5% response rate). Among the 192 ASOPRS members who participated, the majority (79%) reported currently using telemedicine. Very few of those currently using telemedicine (14%) had used telemedicine before March 15, 2020 and a significant proportion (36%) were unsure or did not plan to use telemedicine post-pandemic. Telemedicine use was more common among participants with fewer years in practice (p < 0.01) and those who were university- versus self-employed (p < 0.01). The most common barriers to telemedicine use were technological issues, reimbursement concerns, and a perceived lack of patient acceptance. Nearly half of the surgeons reported being satisfied with telemedicine (48%), and the majority reported perceived patient satisfaction with telemedicine (74%). Discussion: Telemedicine adoption increased significantly among oculoplastic surgeons during the COVID-19 pandemic. However, many current users reported that they were unsure or did not plan to use telemedicine post-pandemic. Conclusions: Further research is needed to design sustainable telemedicine programs to enhance patient access to oculoplastic specialty care in the long term.

Automated Detection and Diagnosis of Diabetic Retinopathy: A Comprehensive Survey

Diabetic Retinopathy (DR) is a leading cause of vision loss in the world. In the past few years, artificial intelligence (AI) based approaches have been used to detect and grade DR. Early detection enables appropriate treatment and thus prevents vision loss. For this purpose, both fundus and optical coherence tomography (OCT) images are used to image the retina. Next, Deep-learning (DL)-/machine-learning (ML)-based approaches make it possible to extract features from the images and to detect the presence of DR, grade its severity and segment associated lesions. This review covers the literature dealing with AI approaches to DR such as ML and DL in classification and segmentation that have been published in the open literature within six years (2016-2021). In addition, a comprehensive list of available DR datasets is reported. This list was constructed using both the PICO (P-Patient, I-Intervention, C-Control, O-Outcome) and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2009 search strategies. We summarize a total of 114 published articles which conformed to the scope of the review. In addition, a list of 43 major datasets is presented.

Welcoming teleretinography into diabetes integrated care

Integrated Care (IC) is a perfect fit for people with diabetes. Fundus examination (FE) is a disease marker for diabetologists and identifies potentially blinding complications (Diabetic Retinopathy, DR). In our Diabetes Clinic (DC) in Pescara, Italy, FE is possibly provided with telemedicine in same day as other exams, avoiding it to be a standalone clinical one; images taken with a retinal digital camera are graded by a remote ophthalmologist within a shared Electronic Health Record (EHR), immediately readable by other stakeholders; a dedicated care path to the Eye Clinic, University of Chieti-Pescara is provided for urgent cases. Personnel's worktime shortening allows gaining time for ophthalmologists' eye examinations in outpatient settings and other stakeholders' work in the DC. The need for a DR digital screening system is growing worldwide: our experience confirms the ease of implementation, and the advantage of sharing clinical data with all stakeholders when working within an EHR, aiming to optimize an IC effective system.

The Role of Telemedicine, In-Home Testing and Artificial Intelligence to Alleviate an Increasingly Burdened Healthcare System: Diabetic Retinopathy

In the presence of the ever-increasing incidence of diabetes mellitus (DM), the prevalence of diabetic eye disease (DED) is also growing. Despite many improvements in diabetic care, DM remains a leading cause of visual impairment in working-age patients. So far, prevention has been the best way to protect vision. The sooner we diagnose DED, the more effective the treatment is. Thus, diabetic retinopathy (DR) screening, especially with imaging techniques, is a method of choice for vision protection. To alleviate the burden of diabetic patients who need ophthalmic care, telemedicine and in-home testing are used, supported by artificial intelligence (AI) algorithms. This is why we decided to evaluate current image teleophthalmology methods used for DR screening. We searched the PubMed platform for papers published over the last 5 years (2015–2020) using the following key words: telemedicine in diabetic retinopathy screening, diabetic retinopathy screening, automated diabetic retinopathy screening, artificial intelligence in diabetic retinopathy screening, smartphone diabetic retinopathy testing. We have included 118 original articles meeting the above criteria, discussing imaging diabetic retinopathy screening methods. We have found that fundus cameras, stable or mobile, are most commonly used for retinal photography, with portable fundus cameras also relatively common. Other possibilities involve the use of ultra-wide-field (UWF) imaging and even optical coherence tomography (OCT) devices for DR screening. Also, the role of smartphones is increasingly recognized in the field. Retinal fundus images are assessed by humans instantly or remotely, while AI algorithms seem to be useful tools facilitating retinal image assessment. The common use of smartphones and availability of relatively cheap, easy-to-use adapters for retinal photographs augmented by AI algorithms make it possible for eye fundus photographs to be taken by non-specialists and in non-medical setting. This opens the way for in-home testing conducted on a much larger scale in the future. In conclusion, based on current DR screening techniques, we can suggest that the future practice of eye care specialists will be widely supported by AI algorithms, and this way will be more effective.

Anterior Segment Imaging Devices in Ophthalmic Telemedicine

Obtaining a clear assessment of the anterior segment is critical for disease diagnosis and management in ophthalmic telemedicine. The anterior segment can be imaged with slit lamp cameras, robotic remote controlled slit lamps, cell phones, cell phone adapters, digital cameras, and webcams, all of which can enable remote care. The ability of these devices to identify various ophthalmic diseases has been studied, including cataracts, as well as abnormalities of the ocular adnexa, cornea, and anterior chamber. This article reviews the current state of anterior segment imaging for the purpose of ophthalmic telemedical care.

Application of Telemedicine in Diabetes Care: The Time is Now

The utilization of telemedicine solutions to reduce outpatient clinic visits and visits to physicians' offices, thus saving financial and personal resources as well as time, has gained substantial importance in recent years. The COVID19 pandemic has made it necessary to abruptly adjust outpatient care methods in various medical settings that needlessly require consultations in person to monitor and change the disease management of patients in specific risk groups. People with diabetes represent a vulnerable population who need to be protected from avoidable outpatient clinic visits, particularly in times of influenza or other pandemic outbreaks. However, the treatment and care of patients with diabetes and its comorbidities require careful and regular monitoring and therapy adjustments by medical staff. Advanced age or cognitive impairment and insufficient access to the health care system due to low socioeconomic status can complicate the use of possible alternatives to in-person consultations in outpatient clinics or physicians' offices. Telemedicine solutions may offer suitable alternatives to standard face-to-face consultations in outpatient settings and provide sufficient access to appropriate diabetes care. Nevertheless, telemedicine methods for monitoring diabetes issues are yet to find widespread use due to numerous barriers, such as a lack of acceptance and doubt about its time- and cost-effectiveness, availability, and potential technical and regulatory issues. This article offers an overview of existing applications that provide telemedicine diabetes care. Furthermore, it discusses potential ways to restructure and revolutionize diabetes outpatient care.

Using Public Datasets to Identify Priority Areas for Ocular Telehealth

Purpose: Telemedicine can expand access to ocular services, but barriers include restrictive policies and poor reimbursement. A tool to identify priority regions for interventions is needed. Methods: Eye care provider (ECP) density, self-reported visual disability, and demographics were calculated using census data and professional registries. The relationship between visual disability and ECP density was explored in fractional regression models. These data were compared with state telemedicine policy favorability. Results: For each additional ECP per 100,000 population, there was 0.0111% less disability in the county (95% confidence interval -0.0150% to -0.00719%) in an adjusted model. Of 3,142 counties, 1,078 (34%) were in the worst population-weighted quartile for ECP density and visual disability. Conclusions: Low ECP density is associated with higher visual disability, suggesting an opportunity for ocular telehealth. Counties with favorable policy climates should be prioritized for telemedicine implementation. Public datasets can be used to survey wide geographic areas to identify areas worthy of detailed needs assessments.

The Ideal Patient for Teleconsultation and Saving Resources

Objectives: The main objectives of the study were to evaluate the level of patients' acceptance of teleconsultation (TC) and to define the ideal patient profile for this type of service. The secondary objectives were to estimate the impact in time and financial resources for the patient in relation to face-to-face medicine. Materials and Methods: This is a prospective, nonprobabilistic, and random sampling study using an uncontrolled selection process consisting of a 19-question survey for health care users in the general population, in which the patients' acceptance of TC was analyzed through the question: "If your doctor suggested that you have a video conference consultation, how attractive would the proposal be for you?" Results: Of the 400 patients, 73.8% were in favor of a TC service. The variables that were associated with the acceptance of TC were health care users who had previously purchased on the internet (odds ratio [OR] = 2.6 confidence interval [CI] 95% 1.31; 5.05) and whether they were willing to assume the economic cost for a TC (OR = 7.8 CI 95% 3.26; 18.6). In terms of face-to-face consultations per year, 50% of the patients spent 5 h (standard deviation [SD] 10.7) going to see the doctor, and on average they requested 8.9 h (SD 16.1) of time off work permission and assumed an economic cost of €29.8 (SD 82.9) on journey time. Conclusion: A high number of health care users accept the use of TC, and this percentage increases in patients who had previously purchased online and were willing to assume an economic cost for this service.

Artificial Intelligence Segmented Dynamic Video Images for Continuity Analysis in the Detection of Severe Cardiovascular Disease

In this paper, an artificial intelligence segmented dynamic video image based on the process of intensive cardiovascular and cerebrovascular disease monitoring is deeply investigated, and a sparse automatic coding deep neural network with a four layers stack structure is designed to automatically extract the deep features of the segmented dynamic video image shot, and six categories of normal, atrial premature, ventricular premature, right bundle branch block, left bundle branch block, and pacing are achieved through hierarchical training and optimization. Accurate recognition of heartbeats with an average accuracy of 99.5%. It provides technical assistance for the intelligent prediction of high-risk cardiovascular diseases like ventricular fibrillation. An intelligent prediction algorithm for sudden cardiac death based on the echolocation network was proposed. By designing an echolocation network with a multilayer serial structure, an intelligent distinction between sudden cardiac death signal and non-sudden death signal was realized, and the signal was predicted 5 min before sudden death occurred, with an average prediction accuracy of 94.32%. Using the self-learning capability of stack sparse auto-coding network, a large amount of label-free data is designed to train the stack sparse auto-coding deep neural network to automatically extract deep representations of plaque features. A small amount of labeled data then introduced to micro-train the entire network. Through the automatic analysis of the fiber cap thickness in the plaques, the automatic identification of thin fiber cap-like vulnerable plaques was achieved, and the average overlap of vulnerable regions reached 87%. The overall time for the automatic plaque and vulnerable plaque recognition algorithm was 0.54 s. It provides theoretical support for accurate diagnosis and endogenous analysis of high-risk cardiovascular diseases.

The Indian Health Service Primary Care-Based Teleophthalmology Program for Diabetic Eye Disease Surveillance and Management

Background: Historically, fewer than half of American Indians and Alaska Natives (AI/AN) with diabetes received the annual diabetic retinopathy (DR) examination that is considered the minimum standard of care; this rate is similar to that of the general United States (U.S.) population with diabetes. Solution: The Indian Health Service-Joslin Vision Network (IHS-JVN) Teleophthalmology Program in 2000 to increase compliance with DR standards of care among AI/AN through validated, primary care-based telemedicine. The IHS-JVN provides remote diagnosis of DR severity, with a report including management recommendations that is returned to the patient's primary care provider. The program conforms with the American Telemedicine Association (ATA) Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. Outcomes: The IHS-JVN has been expanding incrementally since the first patients were recruited in 2000; this expansion coincides with large improvements in the annual DR examination rates reported as part of local, regional, and national regulatory compliance under the Government Performance and Results Act (GPRA). Currently, with 99 clinical implementations in 23 states, IHS-JVN is the largest primary care-based ATA validation category three telemedicine program in the U.S. Summary: This article describes the program's workflow, imaging and reading technologies, diagnostic protocols, reports to providers, training, quality assurance processes, and geographical distribution. In addition to its clinical use, the program has been utilized in research on utilization of diabetic eye care, cost-effectiveness, technology development, and DR epidemiology of the AI/AN population. Potential next steps for this program are discussed.

Hybrid Telehealth Medical Retina Clinic Due to Provider Exposure and Quarantine During COVID-19 Pandemic

Objective

To present our hybrid telehealth medical retina clinic service with intravitreal injections (IVI) treatment as a safe alternative to in-person visits and examination during COVID-19 pandemic disease.

Methods

Due to exposure to a COVID-19 positive retina fellow, our retina service, in quarantine, evaluated patients’ medical files and retinal scans using a telemedicine approach. A different protocol for patients coming for IVI during the COVID-19 pandemic was established for IVI administration.

Results

During the 14-day quarantine period (between March 18th and March 31st 2020), the hybrid telehealth medical retina clinic performed 523 IVI to 394 patients with a mean age ± SD 70.96 ± 14.4 years. IVI were administered for neovascular age-related macular degeneration in 50.5% of the cases (199 patients), diabetic macular edema in 21.3% (84 patients), retinal vein occlusion in 17.5% (69 patients), and 10.7% for other retinal pathologies (42 patients). No ocular or systemic complications were observed.

Conclusion

During disasters and pandemics, IVI can be provided safely using a hybrid telehealth medical retina clinic approach but only in the appropriate patient and health care system.

Open-care telemedicine in ophthalmology during the COVID-19 pandemic: a pilot study

Objetivo

Reportar una experiencia piloto de atención por telemedicina en la especialidad de oftalmología, en el periodo de confinamiento por la pandemia por COVID-19.

Métodos

Estudio descriptivo. Se describen características demográficas y clínicas de pacientes atendidos en periodo de confinamiento de 10 semanas. Se evalúa la satisfacción de los pacientes y médicos participantes mediante una encuesta en línea.

Resultados

En las primeras 10 semanas, se realizaron 291 atenciones de telemedicina oftalmológica. Los principales motivos de consulta fueron afecciones inflamatorias de la superficie ocular y párpados (79,4%), seguido de requerimientos administrativos (6,5%), afecciones no inflamatorias de la superficie ocular (5,2%), sospecha de estrabismo (3,4%) y síntomas vitreorretinales (3,1%); 22 pacientes (7,5%) fueron derivados a atención presencial inmediata. El nivel de satisfacción con la prestación fue alto, tanto en médicos (100%), como en pacientes (93,4%).

Conclusiones

La atención oftalmológica por telemedicina en periodo de pandemia es un instrumento de utilidad para realizar un filtro de potenciales consultas presenciales, ya sea electivas o de urgencia, y para reducir potencialmente el riesgo de contagio por COVID-19.

The Role of Telemedicine to Alleviate an Increasingly Burdened Healthcare System: Retinopathy of Prematurity

Telemedicine-based remote digital fundus imaging (RDFI-TM) offers a promising platform for the screening of retinopathy of prematurity. RDFI-TM addresses some of the challenges faced by ophthalmologists in examining this vulnerable population in both low- and high-income countries. In this review, we studied the evidence on the use of RDFI-TM and analyzed the practical framework for RDFI-TM systems. We assessed the novel technological advances that can be deployed within RDFI-TM systems including noncontact imaging systems, smartphone-based imaging tools, and deep learning algorithms.

Telemedicine in ophthalmology in view of the emerging COVID-19 outbreak

Purpose

Technological advances in recent years have resulted in the development and implementation of various modalities and techniques enabling medical professionals to remotely diagnose and treat numerous medical conditions in diverse medical fields, including ophthalmology. Patients who require prolonged isolation until recovery, such as those who suffer from COVID-19, present multiple therapeutic dilemmas to their caregivers. Therefore, utilizing remote care in the daily workflow would be a valuable tool for the diagnosis and treatment of acute and chronic ocular conditions in this challenging clinical setting. Our aim is to review the latest technological and methodical advances in teleophthalmology and highlight their implementation in screening and managing various ocular conditions. We present them as well as potential diagnostic and treatment applications in view of the recent SARS-CoV-2 virus outbreak.

Methods

A computerized search from January 2017 up to March 2020 of the online electronic database PubMed was performed, using the following search strings: “telemedicine,” “telehealth,” and “ophthalmology.” More generalized complementary contemporary research data regarding the COVID-19 pandemic was also obtained from the PubMed database.

Results

A total of 312 records, including COVID-19-focused studies, were initially identified. After exclusion of non-relevant, non-English, and duplicate studies, a total of 138 records were found eligible. Ninety records were included in the final qualitative analysis.

Conclusion

Teleophthalmology is an effective screening and management tool for a range of adult and pediatric acute and chronic ocular conditions. It is mostly utilized in screening of retinal conditions such as retinopathy of prematurity, diabetic retinopathy, and age-related macular degeneration; in diagnosing anterior segment condition; and in managing glaucoma. With improvements in image processing, and better integration of the patient’s medical record, teleophthalmology should become a more accepted modality, all the more so in circumstances where social distancing is inflicted upon us.

Telemedicine for Retinopathy of Prematurity

Background: Retinopathy of prematurity (ROP) is a disease of the retinal vasculature that remains a leading cause of childhood blindness worldwide despite improvements in the systemic care of premature newborns. Screening for ROP is effective and cost-effective, but in many areas, access to skilled examiners to conduct dilated examinations is poor. Remote screening with retinal photography is an alternative strategy that may allow for improved ROP care. Methods: The current literature was reviewed to find clinical trials and expert consensus documents on the state-of-the-art of telemedicine for ROP. Results: Several studies have confirmed the utility of telemedicine for ROP. In addition, several clinical studies have reported favorable long-term results. Many investigators have reinforced the need for detailed protocols on image acquisition and image interpretation. Conclusions: Telemedicine for ROP appears to be a viable alternative to live ophthalmoscopic examinations in many circumstances. Standardization and documentation afforded by telemedicine may provide additional benefits to providers and their patients. With continued improvements in image quality and affordability of imaging systems as well as improved automated image interpretation tools anticipated in the near future, telemedicine for ROP is expected to play an expanding role for a uniquely vulnerable patient population.