A technological approach to “Reaching the Unreached” – Leveraging teleophthalmology services in Rural Gujarat

Purpose: Early detection of sight?threatening disorders by technological applications like teleophthalmology and prompt treatment can help decrease visual impairment. This study evaluated the role of teleophthalmology in underserved rural areas along with cost?saving estimates for the end user. Methods: A prospective, observational, cross?sectional hospital?based study was conducted over 3 months. First 1000 teleconsultations were included. None of the patients denied providing informed consent. The patients were consulted at the eight vision centers and three satellite centers of the hospital in the nearby rural and tribal regions closer to their residential places. These vision and satellite centers were connected to the base hospital like a hub and spoke model with a teleophthalmology network. Results: Cataract (n = 301, 30.1%) and refractive error (n = 290, 29%) were the most common diagnosis. 42.1% of patients were referred to base hospital for further evaluation. Thus, a total of 57.9% of patients were not required to visit the base hospital for initial consultation, saving time and money. Furthermore, 15.1% of patients were provided medical treatment at the vision center and satellite center, which helped in making teleophthalmology cost?saving for the patients. An average of Rs. 621/? were saved per patient for the community in our study. Conclusion: Networked teleophthalmology model can be an affordable and feasible tool for providing eye care delivery services in rural and tribal regions of Gujarat and the whole country, especially for the end user. Thus, it may be a workable model in ophthalmology practice with substantial cost saving to the community.

Smartphone for retinal imaging – Case series in resource-limited rural settings

Purpose: There is a clinical need for a cost?effective, reliable, easy?to?use, and portable retinal photography. The use of smartphone fundus photography for documentation of retinal changes in resource?limited settings, where retinal imaging was not previously possible, is studied here. The introduction of smartphone?based retinal imaging has resulted in the increase in available technologies for fundus photography. On account of the cost, fundus cameras are not readily available in ophthalmic practice in developing countries. Because smartphones are readily available, easy to use, and also portable, they present a low?cost alternative method in resource?limited settings. The aim is to explore the use of smartphones (iphones) for retinal imaging in resource?limited settings. Methods: A smartphone (iphone) was used to acquire retinal images with the use of +20 D lens in patients with dilated pupils by activating the video mode of the camera. Results: Clear retinal images were obtained in different clinical conditions in adults and children, including branch retinal vein occlusion with fibro?vascular proliferation, choroidal neo?vascular membranes, presumed ocular toxoplasmosis, diabetic retinopathy, retinoblastoma, ocular albinism, and hypertensive retinopathy. Conclusion: New inexpensive, portable, easy?to?operate cameras have revolutionized retinal imaging and screening programs and play an innovative role in research, education, and information sharing

Is it time to consider teleophthalmology as a game-changer in the management of diabetic retinopathy? / É hora de se considerar a teleoftalmologia como um agente de mudança no manejo da retinopatia diabética?

ABSTRACT Currently the "pandemic" of diabetes mellitus is noted. The incidence and prevalence of diabetes and diabetic retinopathy, the most common microvascular complications of diabetes, are exponentially growing due to increased life expectancy in many parts of the world. The increasing number of people suffering from diabetic retinopathy not only highlights medical issues, but also an economic burden, representing a medical and social challenge. It is extremely important to identify a disease as soon as possible and successfully treat it. Technological progress results in developing Artificial Intelligence systems capable of detecting diabetic retinopathy. Current screening will be cost effectively based on the use of advanced digital technologies, in particular teleretinal screening systems. At present, we may consider teleophthalmology and Artificial Intelligence with automatic analysis of fundus photos as a Millennium-minded impactful tool for increasing discoverability and manageability of diabetic retinopathy, especially in filling the gap of inaccessibility to hard-to-reach areas, which enforces highly professionally effective time- and cost-saving care everywhere to provide the best possible care for the patients.

RESUMO Atualmente, observa-se a "pandemia" do diabetes mellitus. A incidência e a prevalência do diabetes e da retinopatia diabética, as complicações microvasculares mais comuns do diabetes, estão crescendo exponencialmente devido ao aumento da expectativa de vida em muitas partes do mundo. O número cada vez maior de pessoas que sofrem de retinopatia diabética não apenas destaca problemas médicos, mas também um ônus econômico, representando um desafio médico e social. É extremamente importante identificar uma doença o mais rápido possível e tratá-la com sucesso. O progresso tecnológico resulta no desenvolvimento de sistemas de Inteligência Artificial capazes de detectar a retinopatia diabética. A triagem atual será econômica com base no uso de tecnologias digitais avançadas, em especial os sistemas de triagem telerretiniana. No momento, podemos considerar a teleoftalmologia e a Inteligência Artificial com análise automática de fotos de fundo de olho como uma ferramenta de impacto do milênio para aumentar a capacidade de descoberta e de manejo da retinopatia diabética, especialmente para preencher a lacuna da inacessibilidade a áreas de difícil acesso, o que impõe um atendimento altamente profissional e eficaz, com economia de tempo e de custos, em todos os lugares, para oferecer o melhor atendimento possível aos pacientes.

Demographic profile of patients seeking teleophthalmology consultations through e-Sanjeevani: Retrospective analysis of 5138 patients from North India

Purpose: To report the demographic profile of patients registered through e?Sanjeevani OPD seeking teleophthalmology services. Methods: This was a cross?sectional data analysis of patients with ocular complaints registered through the e?Sanjeevani platform at a tertiary care center. It was a doctor?to?doctor consultation, where teleophthalmology consultants provided teleconsultation services at subcenters (SCs), primary health centers (PHCs), and community health centers (CHCs). Data regarding the patient’s age, gender, residential address, provisional diagnosis, and treatment prescribed were recorded from May 2021 to February 2022 (9 months). Results: In total, 5138 patients were teleconsulted from the mean age of the patients was 37.64 ± 19.34 years. Among these patients, 44% were males and 56% were females. Most of the teleconsultation calls were made from Palwal district (19.8%), followed by Hisar (14.5%) and Sonipat. The most common provisional diagnosis was dry eyes (21%), followed by allergic conjunctivitis (18%), refractive error (15%), and cataract (14%). These constituted approximately 70% of the diagnosis made through teleconsultations. The rest of the eye problems were diagnosed as stye, blepharitis, nasolacrimal duct obstruction, pterygium, subconjunctival hemorrhage, etc., The majority of the patients were managed medically (56.6%) and approximately 11.6% of the patients were referred for surgical intervention. Conclusion: e?Sanjeevani is an effective way to provide teleconsultations to patients in remote locations. The majority of the patients seeking ophthalmology consultations can be managed conservatively. Patients requiring surgical intervention can be referred timely, thus avoiding any delay in treatment

Trends in teleconsultations for uveitis during the COVID-19 lockdown

Purpose: To study the use of teleophthalmology as a tool to manage patients with uveitis and to describe the experience of teleconsultation for uveitis at a tertiary eye care hospital in India during the two waves of the COVID?19 pandemic. Methods: A prospective observational case series of uveitis patients seeking teleconsultations during the first (March 25–May 2020) and second lockdown (April 27 to June 21, 2021) in a tertiary eye care center were analyzed. Results: There were 79 teleconsultations in the first and 89 teleconsultations in the second lockdown. A majority of the patients presented in the age group of 41– 60 years in both the lockdowns. There were both new or primary consultations and follow?up patients (6% vs. 94%) in the first lockdown, and similarly in the second lockdown (8% new vs. 92% follow?up). The majority of patients resided in Bengaluru city (78% in the first and 76% in the second lockdown). After evaluation through video consultation, only 15% required a hospital referral in the first lockdown, whereas in the second lockdown, 21.3% were referred to the hospital. During the second lockdown, 20% presented with COVID?19 infection?related ailments. Conclusion: Based on our preliminary experience using a customized smartphone?based application for teleconsultation, we found it to be an alternative option to provide continuation of ophthalmic care to uveitis patients. Given the current COVID?19 situation, it can help avoid physical visits of uveitis patients to the hospital

Research advances in telemedicine program for diabetic retinopathy screening / 国际眼科杂志(Guoji Yanke Zazhi)

@#Diabetic retinopathy(DR)remains a major cause of worldwide preventable blindness among working-age adults. DR screening programs are challenged by the rising burden of diabetes, unbalancing distribution of health resources and poor compliance with regular fundus examination. Teleophthalmology provide a viable method for rural remotely diabetic patients evaluated and monitored by the ophthalmologist at far location by exchange of medical data through electronic telecommunications technology. This review apply Wilson and Jungner's all 10 criteria of screening for chronic diseases to evaluate telemedicine screening program, summarizes and compares telemedicine screening programs according to American Telemedicine Association validation level.

Avaliação Econômica de um Serviço de Telemedicina para ampliação da Atenção Primária à Saúde no Rio Grande do Sul: o microcusteio do Projeto TeleOftalmo / Economic Evaluation of a Telemedicine Service to expand Primary Health Care in Rio Grande do Sul: TeleOftalmo's microcosting analysis

Resumo Este estudo avaliou o custo de um serviço público de telediagnóstico em oftalmologia. O método de custeio baseado em atividades e tempo (TDABC) foi adotado para examinar os componentes de custos relacionados à teleoftalmologia. Com este método, também foi possível estabelecer o custo unitário padrão que o telediagnóstico deveria ter, dada a capacidade instalada e utilização de profissionais. Dados de um ano de telediagnósticos foram considerados, e avaliou-se a mudança do custo por telediagnóstico ao longo do período de adaptação da tecnologia no sistema. O custo padrão calculado por diagnóstico oftalmológico a distância foi de R$ 119, considerando a emissão de 1.080 laudos de telediagnóstico oftalmológico por mês. Foi identificado um desequilíbrio entre as atividades que sugere a capacidade do método TDABC orientar ações de gestão e melhoria na alocação dos recursos. Ao longo de um ano, o custo unitário real passou de R$ 783 para R$ 283, ainda havendo espaço para se aproximar do custo padrão estimado. Avaliações econômicas parciais possuem importante aporte para subsidiar a incorporação de novas tecnologias. O TDABC merece destaque nesse sentido, pois permite obter informações mais precisas sobre custo da tecnologia, melhorando a capacidade de dimensionamento e gerenciamento da organização de saúde.

Abstract This study evaluated the cost of public telediagnostic service in ophthalmology. The time-driven activity-based costing method (TDABC) was adopted to examine the cost components related to teleophthalmology. This method allowed us to establish the standard unit cost of telediagnosis, given the installed capacity and utilization of professionals. We considered data from one year of telediagnoses and evaluated the cost per telediagnosis change throughout technology adaptation in the system. The standard cost calculated by distance ophthalmic diagnosis was approximately R$ 119, considering the issuance of 1,080 monthly ophthalmic telediagnostic reports. We identified an imbalance between activities, which suggests the TDABC method's ability to guide management actions and improve resource allocation. The actual unit cost fell from R$ 783 to R$ 283 over one year - with room to approach the estimated standard cost. Partial economic evaluations contribute significantly to support the incorporation of new technologies. The TDABC method deserves prominence, as it enables us to retrieve more accurate information on the cost of technology, improving the scalability and management capacity of the healthcare system.

Role of teleophthalmology to manage anterior segment conditions in vision centres of south India: EyeSmart study-I

Purpose: To study the role of teleophthalmology (TO) in the diagnosis and treatment of anterior segment conditions (including adnexal conditions) in rural areas. Methods: This is a pilot study of 5,604 patients, who visited primary vision centres (VCs) for 1 week from 1-7 September 2018. The patients were examined by a vision technician (VT) to identify those who may need teleconsultation. The centres were located in 16 districts of four Indian states of Andhra Pradesh, Telangana, Odisha, and Karnataka. The demographic profile, along with the role of teleconsultation was reviewed. Results: Teleconsultation was advised in 6.9% of the patients, out of which 59.6% were referred to a higher level of care, and 40.4% were treated directly at the VC. Teleconsultations were higher among males (7.0% as compared to 6.6% in females), though not statistically significant (P = 0.55). Teleconsultation was higher in the older population, that is, 60 years and above (14.5%); those with severe visual impairment (VI) (21%) and blindness (31.1%); and in the states of Telangana (11%) and Andhra Pradesh (6.3%). It was noted that 45% of the patients who underwent teleconsultation had pathologies related to ocular surface, cornea and lid, and adnexa-related conditions. Conclusion: Teleconsultation has a significant role in the management of anterior segment conditions in bridging the gap between the patients and ophthalmologists in rural India. TO can also play an important role in the diagnosis and management of anterior segment, lid, and adnexa-related pathologies.

Knowledge, attitudes, and practices of telemedicine in Ophthalmology in a Tertiary Hospital: A cross-sectional survey

Objective@#The purposes of this study were to (1) describe the perceptions and practices of telemedicine among ophthalmologists in a tertiary hospital; and (2) evaluate knowledge, satisfaction, and perceived patient outcomes in using telemedicine to provide eye care in a time of a global pandemic.@*Methods@#This was a descriptive, cross-sectional study using a self-administered online survey. Thirty-two (32) ophthalmology consultants and residents-in-training in a single tertiary, private hospital who practiced telemedicine participated in this study. Descriptive statistics was used to summarize the data. Responses to open-ended questions were analyzed thematically@*Results@#The respondents were somewhat knowledgeable (75%) and somewhat confident (72%) in using telemedicine. Respondents strongly conveyed their satisfaction with telemedicine outcomes (56%). Majority also believed that their patients were satisfied with teleconsults (69%). Majority agreed that telemedicine can be effective for select types of care [i.e., chronic condition management (66%), follow- up care (62%), and acute non-emergency care (53%)]. Telemedicine also proved to be a boon during a pandemic due to its convenience (59%) and efficiency (63%). However, it is limited by the imperative need for face-to-face consults (69%) and technological constraints (44%).@*Conclusions@#Telemedicine was perceived to be a valuable solution during the present pandemic due to its convenience, safety, and ability to provide remote diagnosis and management of urgent and non-urgent cases. Although the current practice of telemedicine still has plenty of room for improvements in the standardization of training, connectivity and technological constraints, and addressing liability concerns, it can serve as an adjunct to face-to face consultations to provide optimal care for patients.

Trash to treasure Retcam

Digital fundus imaging is being used in diagnosis, documentation, and sharing of many retinal diseases and hence forms an essential part of ophthalmology. The use of smartphones for the same has been ever increasing. There is a need for simpler devices to couple the 20D lens and smartphone so as to take fundus photographs which can help in fundus documentation. This article describes a simple inexpensive technique of preparing a smartphone fundus photography device (Trash To Treasure (T3) Retcam) from the used materials in the clinics within minutes. This article will also review the optical principles of the T3 Retcam and describe the step–by–step method to record good-quality retinal image/videos. This inexpensive device is made by recycling and modifying the plastic hand sanitizer bottle in the clinics/hospitals which can be used for documenting, diagnosing, screening, and academic purposes.

Curious case of retrolental mass: An unusual tele-screening artifact

We are presenting a case of premature baby born at 32 weeks of gestation who was under regular follow-up with our retinopathy of prematurity (ROP) tele-screening team. During final follow-up at 41 weeks of postconceptional age, anterior segment image captured with RetCam showed a retrolental mass lesion in right eye resembling retinoblastoma or medulloepithelioma. The baby was referred to our base hospital for further evaluation, where a detailed examination showed no retrolental lesion or intraocular mass. This is the first case where imaging artifact, despite use of high-quality imaging system by well-trained staff, during ROP tele-screening appeared like a retrolental mass lesion and resulted in false-positive referral.

A novel smartphone ophthalmic imaging adapter: User feasibility studies in Hyderabad, India.

Aim of Study: To evaluate the ability of ancillary health staff to use a novel smartphone imaging adapter system (EyeGo, now known as Paxos Scope) to capture images of sufficient quality to exclude emergent eye findings. Secondary aims were to assess user and patient experiences during image acquisition, interuser reproducibility, and subjective image quality. Materials and Methods: The system captures images using a macro lens and an indirect ophthalmoscopy lens coupled with an iPhone 5S. We conducted a prospective cohort study of 229 consecutive patients presenting to L. V. Prasad Eye Institute, Hyderabad, India. Primary outcome measure was mean photographic quality (FOTO‑ED study 1–5 scale, 5 best). 210 patients and eight users completed surveys assessing comfort and ease of use. For 46 patients, two users imaged the same patient’s eyes sequentially. For 182 patients, photos taken with the EyeGo system were compared to images taken by existing clinic cameras: a BX 900 slit‑lamp with a Canon EOS 40D Digital Camera and an FF 450 plus Fundus Camera with VISUPAC™ Digital Imaging System. Images were graded post hoc by a reviewer blinded to diagnosis. Results: Nine users acquired 719 useable images and 253 videos of 229 patients. Mean image quality was ≥ 4.0/5.0 (able to exclude subtle findings) for all users. 8/8 users and 189/210 patients surveyed were comfortable with the EyeGo device on a 5‑point Likert scale. For 21 patients imaged with the anterior adapter by two users, a weighted κ of 0.597 (95% confidence interval: 0.389–0.806) indicated moderate reproducibility. High level of agreement between EyeGo and existing clinic cameras (92.6% anterior, 84.4% posterior) was found. Conclusion: The novel, ophthalmic imaging system is easily learned by ancillary eye care providers, well tolerated by patients, and captures high‑quality images of eye findings.

The KIDROP model of combining strategies for providing retinopathy of prematurity screening in underserved areas in India using wide-field imaging, tele-medicine, non-physician graders and smart phone reporting.

Aim: To report the Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP) program for retinopathy of prematurity (ROP) screening in underserved rural areas using an indigenously developed tele-ROP model. Materials and Methods: KIDROP currently provides ROP screening and treatment services in three zones and 81 neonatal units in Karnataka, India. Technicians were trained to use a portable Retcam Shutt le (Clarity, USA) and validated against ROP experts performing indirect ophthalmoscopy. An indigenously developed 20-point score (STAT score) graded their ability (Level I to III) to image and decide follow-up based on a three-way algorithm. Images were also uploaded on a secure tele-ROP platform and accessed and reported by remote experts on their smart phones (iPhone, Apple). Results: 6339 imaging sessions of 1601 infants were analyzed. A level III technician agreed with 94.3% of all expert decisions. The sensitivity, specifi city, positive predictive value and negative predictive value for treatment grade disease were 95.7, 93.2, 81.5 and 98.6 respectively. The kappa for technicians to decide discharge of babies was 0.94 (P < 0.001). Only 0.4% of infants needing treatment were missed.The kappa agreement of experts reporting on the iPhone vs Retcam for treatment requiring and mild ROP were 0.96 and 0.94 (P < 0.001) respectively. Conclusions: This is the fi rst and largest real-world program to employ accredited non-physicians to grade and report ROP. The KIDROP tele-ROP model demonstrates that ROP services can be delivered to the outreach despite lack of specialists and may be useful in other middle-income countries with similar demographics.

Evaluation of the effectiveness of diagnostic & management decision by teleophthalmology using indigenous equipment in comparison with in-clinic assessment of patients.

Background & objectives: There is a concern on the quality and the usefulness of teleophthalmology images, particularly those using indigenous equipment, in making a diagnosis and treatment decisions in ophthalmology. The present study was done to compare the level of agreement and sensitivity and specificity of diagnosis and management decisions of various eye diseases by teleophthalmology using indigenous equipment, compared to the in-clinic assessment. Methods: Patients having different eye diseases were evaluated by two ophthalmologists – one ophthalmologist examined the patient in clinic setting while the other ophthalmologist made the diagnosis and management decision based on images sent by teleophthalmology. The images were taken by the ophthalmic technician using digital imaging system and fundus camera. The clinical findings and management decisions by the two ophthalmologists were masked to each others. Results: In diagnosis of anterior segment eye diseases such as cataract and corneal diseases there was good to very good agreement (kappa values of 0.68 and 0.91 for cataract and corneal diseases respectively) between in-clinic assessment and assessment by teleophthalmology. There was moderate agreement (kappa values of 0.52 and 0.48 for glaucoma and retinal diseases respectively) between in-clinic assessment and assessment by teleophthalmology for the diagnosis of glaucoma and retinal diseases. For the management decisions of patients, there was moderate level of agreement in all groups of eye diseases. Interpretation & conclusions: Teleophthalmology, using indigenous equipment was found to be effective in diagnosis and management decision of anterior segment eye diseases such as cataract and cornea, and with some modification and continuous training to the technicians could become an effective tool for screening and referral of glaucoma and retinal diseases.

Best practice eye care models.

Since the launching of Global Initiative, VISION 2020 “the Right to Sight” many innovative, practical and unique comprehensive eye care services provision models have evolved targeting the underserved populations in different parts of the World. At places the rapid assessment of the burden of eye diseases in confined areas or utilizing the key informants for identification of eye diseases in the communities are promoted for better planning and evidence based advocacy for getting / allocation of resources for eye care. Similarly for detection and management of diabetes related blindness, retinopathy of prematurity and avoidable blindness at primary level, the major obstacles are confronted in reaching to them in a cost effective manner and then management of the identified patients accordingly. In this regard, the concept of tele-ophthalmology model sounds to be the best solution. Whereas other models on comprehensive eye care services provision have been emphasizing on surgical output through innovative scales of economy that generate income for the program and ensure its sustainability, while guaranteeing treatment of the poorest of the poor.

Application of tele-ophthalmology in remote diagnosis and management of adnexal and orbital diseases.

Purpose: To assess the feasibility of making a diagnosis of adnexal and orbital diseases by Tele-ophthalmological means. Materials and Methods: Tele-consultation for eye diseases was done for 3497 patients from remote areas of Tamilnadu as part of the rural tele-ophthalmology project of a tertiary eye care hospital during a period of nine months from October 2004 to June 2005. These patients were comprehensively examined on-site by optometrists. Using digitized images sent by store and forward technique and videoconferencing, the ophthalmologist made a diagnosis and advised treatment. Results: Adnexal or orbital diseases were detected in 101 out of 3497 patients (2.88%). Medical treatment was advised to 13 of 101 patients (12.8%). Surgery was advised in 62 of 101 patients (61.28%) whereas 18 of 101 patients (17.8%) required further investigations at a tertiary center. Conclusion: It was feasible to apply the satellite based tele-ophthalmology set-up for making a presumptive diagnosis and planning further management of adnexal and orbital diseases based on live interaction and digital still images of the patients.