Internet based ophthalmology service: impact assessment

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

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

Telemedicine and delivery of ophthalmic care in rural and remote communities: Drawing from Australian experience

Rural and remote communities in Australia are characterised by small but widely dispersed populations. This has been proven to be a major hurdle in access to medical care services with screening and treatment goals repeatedly being missed. Telemedicine in ophthalmology provides the opportunity to increase the availability of high quality and timely access to healthcare within. Recent years has also seen the introduction of artificial intelligence (AI) in ophthalmology, particularly in the screening of diseases. AI will hopefully increase the number of appropriate referrals, reduce travel time for patients and ensure timely triage given the low number of qualified optometrists and ophthalmologists. Telemedicine and AI has been introduced in a number of countries and has led to tremendous benefits and advantages when compared to standard practices. This paper summarises current practices in telemedicine and AI and the future of this technology in improving patient care in the field of ophthalmology.

Tele-refraction in tele-eye care settings

Refraction is an important part of a comprehensive eye examination, and when performed remotely through information and communication technology or when its results are transmitted for remote analysis, this procedure is called tele-refraction. Uncorrected refractive errors are the main reason for consultation in primary eye care, and an increasing number of eye care providers offer tele-refraction services in response to the global demand. Even so, very little literature exists on how the correction of refractive errors can be managed through tele-eye care. The objectives of this review are to examine the integration of tele-refraction in different eye care models and to report the existing findings regarding patient satisfaction towards tele-refraction and the efficacy of tele-refraction. Searches were undertaken on Medline, Embase, EBM Reviews, CINAHL and Web of Science to identify relevant articles. All original studies describing a clinical tele-refraction service and its outcomes were included. Out of 1322 articles, 15 were retained for analysis and have shown that tele-refraction has been provided for general eye care (n = 10; 67%), refractive-only examinations (n = 3; 20%) or disease-specific screening (n = 2; 13%). Ten (67%) had a hybrid telemedicine modality. Given the small number of included studies and the lack of outcomes comparing refractive errors between face-to-face and remote refraction, it is concluded that the current scientific literature does not reflect the increasing availability of tele-refraction in clinical practice. More studies on remote refraction should be conducted to better understand its efficacy, cost-effectiveness and impacts on patient satisfaction and management.

A Systematic Review of Current Teleophthalmology Services in New Zealand Compared to the Four Comparable Countries of the United Kingdom, Australia, United States of America (USA) and Canada

Background

Over 700,000 New Zealanders (NZ), particularly elderly and Māori, live without timely access to specialist ophthalmology services. Teleophthalmology is a widely recognised tool that can assist in overcoming resource and distance barriers. Teleophthalmology gained unprecedented traction in NZ during the COVID-19 pandemic and subsequent lockdown. However, its provision is still limited and there are equity issues. The aim of this study was to conduct a systematic review identifying, describing and contrasting teleophthalmology services in NZ with the comparable countries of Australia, USA, Canada and the United Kingdom.

Methods

The electronic databases Embase, PubMed, Web of Science, Google Scholar and Google were systemically searched using the keywords: telemedicine, ophthalmology, tele-ophthalmology/teleophthalmology. The searches were filtered to the countries above, with no time constraints. An integrative approach was used to synthesise findings.

Results

One hundred and thirty-two studies were identified describing 90 discrete teleophthalmology services. Articles spanned from 1997 to 2020. Models were categorised into general eye care (n=21; 16%); emergency/trauma (n=6; 4.5%); school screening (n=25; 19%); artificial intelligence (AI) (n=23; 18%); and disease-specific models of care (MOC) (n=57; 43%). The most common diseases addressed were diabetic retinopathy (n=23; 17%); retinopathy of prematurity (n=9; 7%); and glaucoma (n=8; 6%). Programs were mainly centred in the US (n=72; 54.5%), followed by the UK (n=29; 22%), then Canada (n=16; 12%), Australia (n=13; 10%), with the fewest identified in NZ (n=3; 2%). Models generally involved an ophthalmologist consultative service, remote supervision and triaging. Most models involved local clinicians transmitting fed-forward or live images.

Conclusion

Teleophthalmology will likely play a crucial role in the future of eye care. COVID-19 has offered a unique opportunity to observe the use of teleophthalmology services globally. Feed-forward and, increasingly, live-based teleophthalmology services have demonstrated feasibility and cost-effectiveness in similar countries internationally. New Zealand’s teleophthalmology services, however, are currently limited. Investing in strategic partnerships and technology at a national level can advance health equities in ophthalmic care.

Ophthalmic Virtual Visit Utilization and Patient Satisfaction During the COVID-19 Pandemic

Background: Due to the COVID-19 pandemic, there was a surge in synchronous ophthalmic telehealth visits. The purpose of this study is to analyze the utilization and patient satisfaction of synchronous ophthalmic video visits over the course of the COVID-19 pandemic. Methods: In this retrospective, single-center cross-sectional study, 1,756 patients seen through synchronous video visits between March 1, 2020, and March 31, 2021, were identified using billing codes. E-mails containing a validated, 11-item, telehealth satisfaction scale were sent to patients who had at least one video visit within the study period. Questions were scored on a 1-4 scale, corresponding to poor, fair, good, and excellent. Main outcome measures included patient satisfaction scores, frequency of repeat video visits, and primary visit diagnoses. Results: The top 3 subspecialties by virtual visit volume were oculoplastic surgery (999 visits, 42.9%), neuro-ophthalmology (331 visits, 17.0%), and cornea (254 visits, 14.2%). The top 3 diagnoses seen were chalazion/hordeolum, dry eye, and meibomian gland dysfunction. The overall survey response rate was 14.3% (252 participants). The mean patient satisfaction score was 3.67 ± 0.63, with no significant difference in scores between specialties. A total of 380 (21%) patients had repeat virtual visits. Mean survey response scores were significantly higher for patients with repeat visits than those without (3.82 ± 0.42 vs. 3.62 ± 0.68, p = 0.03). Patients undergoing oculoplastic services were more likely to have repeat visits (odds ratio 2.58, 95% confidence interval 2.18-3.06, p < 0.001). Multivariate regression analysis found that provider thoroughness/skillfulness was the most predictive feature of the patient returning to a telehealth encounter (p = 0.01). Conclusions: Our study suggests that synchronous videoconferencing for ophthalmology is a highly satisfactory delivery method and will likely find continued success in select subspecialties as the pandemic fades.

Integrating Telemedicine Services in Ophthalmology: Evaluating Patient Interest and Perceived Benefits

PURPOSE

The purpose of this study was to assess patient interest and willingness to pay (WTP) for teleophthalmology services, whose benefits include improved healthcare access and potential cost savings.

PATIENTS AND METHODS

Cross-sectional study of 215 patients attending a single tertiary center to assess their interest in teleophthalmology. Comparisons between those interested and those not interested were conducted; logistic regression was used to evaluate the effect of price on interest.

RESULTS

Two thirds (66.5%) of patients were interested in teleophthalmology instead of in-person clinic visits. Those interested were significantly younger than uninterested patients (48.8±22.7 vs 62.4±18.3 years) and were more likely to miss work to attend clinic, own both a computer and smartphone, have experience with video conferencing, and use the internet frequently (all P<0.05). Interested patients were also more likely to indicate time and cost savings, as well as improved follow-up testing, compared to uninterested patients (both P<0.001). Overall, 70.4% of interested patients expressed WTP out-of-pocket for teleservices, especially at low (<$14 US dollars) and moderate-high (>$28) price points. Higher level of education was associated with WTP (OR=2.31, 95% CI 1.05-5.06; P=0.037).

CONCLUSION

Most patients were interested in teleophthalmology services, especially if they were young, would otherwise miss work, and were familiar with electronics, video conferencing, and internet use. Most interested patients expressed WTP out-of-pocket. Targeting factors related to teleophthalmology interest may increase patient use and enhance communication, thereby improving healthcare access and follow-up.

Tele-ophthalmology: Need of the hour

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

Perception Among Diabetic Patients of Telescreening for Diabetic Retinopathy

Purpose: To evaluate the satisfaction of diabetic patients and its determinants of telescreening for diabetic retinopathy (DR) in Saudi Arabia. Methods: This cross-sectional survey was conducted in December 2018 in a diabetes center of Riyadh, Saudi Arabia. Ten questions were asked by the interviewer. A 5-point Likert scale was used to grade patient responses for each question. Rasch analysis was conducted to evaluate the response of the participants. The main outcome variable was the sum of the Logit values of the responses. The Rasch score was also compared among subgroups. Results: Two hundred (n = 200) diabetic patients were interviewed. The median Rasch score of client-perceived benefit of DR telescreening was +14.6 (25% quartile +3.09, minimum; -23.2, maximum; +35.7). A positive attitude of patients regarding DR telescreening was recorded in 159 (79.5%) participants. The perception of telescreening was better in younger diabetic patients than in older diabetic patients (Friedman p < 0.001). The perception was similar in both genders (Mann-Whitney p = 0.3). Diabetic patients from Riyadh and the southern region of Saudi Arabia had significantly more positive perception than those from north and eastern regions (Freedman p < 0.001). Conclusion: Diabetic patients have positive attitude toward tele-DR screening. Their cooperation is likely to be high if large scale tele-DR screening is implemented in the Kingdom.

A novel telemedicine technique for evaluation of ocular exam findings via smartphone images

In this study, we compared the assessment of remote smartphone photographs to in-office exams in the diagnosis of two groups of external eye diseases, red-eye pathology and post-operative eyelid surgery complications. Participants were examined and received an in-office diagnosis by either a corneal or oculoplastic specialist. After viewing an educational video on smartphone photography, the patient's companion then took a series of standardized photographs. Two additional corresponding specialists then made a separate diagnosis via the interpretation of only smartphone images and the patient's history. 'Remote' and in-office diagnoses were compared using a kappa test for agreement. The remote and in-office diagnoses were in agreement for 27 of 28 eyes, representing a chance-corrected Kappa agreement rate of 93% (95% confidence interval: 79-99%). Among the 16 red eyes, the diagnoses were in agreement for 15 of 16 red eyes, representing a chance-corrected Kappa agreement rate of 92% (95% confidence interval: 77-99%). Among the 12 eyes with post-operative eyelid surgery complications, the diagnoses were in perfect agreement. Our results suggest that the diagnosis of 1) red-eye pathology and 2) post-operative eyelid surgery complications based on smartphone images may be comparable to in-office exams.

Smartphones, tele-ophthalmology, and VISION 2020

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

Models of care in tele-ophthalmology: A scoping review

The objective of this review was to identify and describe telehealth models of care for ophthalmic services. We conducted a scoping review of the literature to identify how ophthalmic care can be delivered by telehealth. We searched the PubMed database to identify relevant articles which were screened based on pre-defined inclusion criteria. For included articles, data were extracted, categorised and analysed. Synthesis of findings was performed narratively. The scoping review included 78 articles describing 62 discrete tele-ophthalmic models of care. Tele-ophthalmic models of care can be used for consultative service, screening, triage and remote supervision. The majority of services were for general eye care and triage ( n = 17; 26%) or emergency services ( n = 8; 12%). The most common conditions for disease-specific models of care were diabetic retinopathy ( n = 14; 21%), and glaucoma ( n = 8; 12%). Most models of care involved local clinicians capturing images and transmitting them to an ophthalmologist for assessment. This scoping review demonstrated tele-ophthalmology to be feasible for consultation, screening, triage and remote supervision applications across a broad range of ophthalmic conditions. A large number of models of care have been identified and described in this review. Considerable collaboration between patient-end clinicians and substantial infrastructure is typically required for tele-ophthalmology.

Teleophthalmology: improving patient outcomes?

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

A pilot trial of tele-ophthalmology services in north Wales

We identified the need for a tele-ophthalmology service at the Tywyn hospital in Wales. During a two-year period, 22 emergency patients were managed by telemedicine, thereby reducing the need for ambulance transfer. We expect that there will be increased use of tele-ophthalmology in north Wales as the technology improves and the equipment becomes easier to use.

A pilot teleconsultation network for retinal diseases in ophthalmology

A store-and-forward teleconsultation network was developed as a web application in order to provide second opinions on retinal diseases. The system provided automatic notification messages to the referring doctor and the consulted ophthalmologist by mobile phone message (SMS) and email. Images in the electronic medical record (EMR) could be examined in detail using special magnification software. Of the 19 ophthalmologists who agreed to participate, 17 used the teleconsultation network during the pilot trial (89%). During the four-week study period, a total of 52 EMRs containing 82 images were uploaded by the participating ophthalmologists. In 46 cases (89%), a second opinion was provided by the consulted ophthalmologist. Thirty-three of the cases (72%) were related to macular diseases and anti-VEGF (vascular endothelial growth factor) ophthalmology drugs. At the end of the study period, 18 of the participating ophthalmologists evaluated the cases, using a three-point score (poor, good, very good) for Access, Acceptability, Image Quality and Medical Efficacy. Most cases were rated as very good or good for all four variables. Successful use of the network in future will depend on various technical, policy and human factors. The latter is particularly important and appropriate motivations need to be found in order to promote teleconsultations.

A survey of the state of telemedicine in Western Australia

To provide a baseline for future planning we conducted a survey of the use of telemedicine in the state of Western Australia. A questionnaire was designed, validated and posted to all public and private health-care facilities in Western Australia (metropolitan hospitals, country hospitals and nursing posts). Of the 132 questionnaires sent out, 102 were returned (77% response rate). Seven of the responding hospitals (all public) were classified as mainly providers of telehealth services and 95 (both public and private) were mainly receivers. Of these 95 receivers of services, 58 facilities (61%) reported that they had access to videoconferencing for telehealth purposes. The most common purposes for which videoconferencing was used were reported to be education (76% of those using videoconferencing), wound care (55%) and psychiatry (53%). The most common store-and-forward application was tele-ECG, which was reported by more than half (54%) of respondents. Eighty-five percent of public health-care facilities reported the use of telehealth (either videoconferencing or store-and-forward) in comparison with 24% of those in the private sector. There was a tendency for facilities further away from Perth to be users of more telehealth services: the correlation between distance and the number of telehealth services received was significant (Spearman's rho = 0.54, P < 0.001). The survey showed that about 73% of responding health-care facilities in Western Australia were using telemedicine.

Impact of direct electronic optometric referral with ocular imaging to a hospital eye service

AIMS

A study to assess the feasibility, safety, and clinical effectiveness of electronic referral--with and without images--of patients directly from optometrists in primary care to the hospital eye service (HES) in contrast to the traditional paper-based referral, through the general practitioner (GP).

METHODS

Three optometry practices sent consecutive referrals with images through the NHS Net to the HES. The standard General Ophthalmic Service form was electronically redesigned with additional information on patient choice for advice, appointment, or surgery. All paper referrals to the HES from the same three optometry practices before the study period were analysed (control group A) as were all paper referrals from the remaining optometrists in Fife (control group B).

RESULTS

A total of 346 electronic referrals were received over 18 months. 218 (63%) were classified as requiring and 128 (37%) as not requiring a HES appointment. The latter were subsequently examined with unexpected pathology found in three cases (glaucoma, macular pigment epithelial detachment, and possible peripheral retinal tear). In both groups, the major pathologies reported were macular degeneration, cataract, glaucoma, diabetic retinopathy, and abnormal retinal appearances. A total of 17 (15%) patients in group A and 26 (8.4%) patients in group B were classified as not requiring HES appointment. These control groups indicate that approximately 10-15% of paper referrals are not seen in the HES. To summarise, therefore, 63% of people referred by the optometrist directly using electronic referral (with or without images) were given a HES appointment compared to 85% of people referred through the traditional paper method (without images) through their GP.

CONCLUSION

Electronic referral with images to the HES is safe, speedy, efficient, and clinically accurate given some limitations and avoids unnecessary consultation in 37% of referrals.

Automated determination of distance visual acuity: towards teleophthalmology services

PURPOSE

The aim of this study was to evaluate the visual acuity scores of a computer-based visual function testing (CVFT) system. The automated chart uses logMAR notation (logarithm of the minimum angle of resolution) and randomised tilting E as optotype. The test was conducted using a laptop computer.

METHODS

This prospective, clinic-based, test validation study was based on a model of repeatability in two observations. The right eyes of a total of 104 participants were randomly tested with both CVFT and the manual, gold standard Early Treatment of Diabetic Retinopathy Study (ETDRS) chart.

RESULTS

The mean difference between CVFT and ETDRS was -0.01+/-0.11 (SD) logMAR units. The Spearman Rank correlation coefficient (r) between the absolute difference and the average was 0.35. The average time for testing one eye was 54.7+/-11.89 seconds. The mean difference between two consecutive, repeated CVFT tests in the same eye was 0.02+/-0.07 logMAR units (paired t-test p=0.046).

CONCLUSIONS

A novel, automated visual acuity testing application is reported. This automated system should be a useful tool for mass screening of visual impairment in rural and remote regions with its ease of use and shorter testing time.

Glaucoma screening: analysis of conventional and telemedicine-friendly devices

PURPOSE

Portable, telemedicine-friendly devices offer novel opportunity for screening and monitoring glaucoma in the remote and rural regions of the world. This study examines the effective combination of telemedicine-friendly screening devices for detection of glaucoma in relation with conventional, hospital-based devices.

METHODS

A total of 399 eyes were screened with telemedicine-friendly devices and conventional, hospital-based devices such as ophthalmoscope, tonometer and perimeter.

RESULTS

Combination of age and family history of glaucoma alone has a sensitivity of 35.6% (specificity 94.2%, area under the curve 0.81, correctly classified 81.1%) and an addition of telemedicine-friendly or conventional visual field tests optimized the sensitivity to 91.1% (specificity 93.6%, area under the curve 0.95, correctly classified 93%). Analysis indicates good agreement between vertical cup-to-disc ratio by ophthalmoscopy and digital image reading. An addition of intraocular pressure test does not change sensitivity (35.6%) and specificity (94.2%).

CONCLUSION

This study indicates that evaluations of cup-to-disc ratio and visual field, using telemedicine-friendly devices, are most useful tools in screening for glaucoma. When used together these devices may be an alternative for conventional glaucoma screenings.

Telemedicine-friendly, portable tonometers: an evaluation for intraocular pressure screening

PURPOSE

To evaluate the intraocular pressure (IOP) readings from two portable, telemedicine-friendly tonometers for suitability in glaucoma screening.

METHODS

213 eyes of 107 consenting patients attending an eye clinic were tested with an I-care tonometer and a Pulsair-Easy Eye puff-air tonometer. Gold standard IOP was measured with a Goldmann applanation tonometer (GAT). Effect of central corneal thickness, anterior chamber depth and refractive errors on IOP measurements were also analysed.

RESULTS

The mean difference of IOP by GAT and both the portable tonometers was +/- 2.2 mmHg. The analysis indicates minimal difference between IOP readings of both the portable tonometers. The mean difference between two consecutive readings by I-care was 0.01 mmHg. Using 21 mmHg as a threshold for suspected glaucoma, both the portable digital tonometers reported a sensitivity of 38% and specificity of >95%. In the subjects studied, central corneal thickness had statistically significant influence on IOP measurements while refractive errors and anterior chamber depth had no significant influence on IOP measurements with any tonometry.

CONCLUSION

The IOP readings by both portable tonometers are comparable and were within clinically acceptable range from GAT. These portable tonometers are useful tools for IOP screening.