ABSTRACT
Purpose : The most common cause of blurry vision in the United States is refractive error. Despite being a correctable condition, over 8.2 million people are estimated to have their refractive error go undiagnosed or untreated. Minorities and low-income groups in particular have significantly increased odds of inadequate correction and double the rates of near-vision impairment. We aimed to address this gap in care through the provision of refractive glasses during community-based tele-ophthalmology screenings. Methods : Eight free eye screening events were held in Newark and West New York, NJ. Demographic information, intraocular pressure, visual acuity, auto-refraction, retinal imaging, and optical coherence tomography were obtained from each subject as part of a comprehensive tele-ophthalmology protocol. Reading glasses were provided as needed based on the recommendation of a certified telemedicine reader. Eligible recipients completed surveys on site regarding access to eye care. They were surveyed again by phone after one month to assess degree of satisfaction and vision improvement. Results : 38 subjects (mean age 53, 47% male) qualified for presbyopia correction and received reading glasses. 97% were Hispanic and 3% were African American. Of the 33 that returned surveys, 88% reported not seeing an eye doctor annually. The most common reason was lack of insurance or inability to pay (71%). Others included having no need to see an eye doctor (10%), disliking eye doctors (7%), not knowing the importance of regular eye exams (3%), and COVID-19 (3%). Of the 25 subjects that were reached for follow-up, 92% reported using the glasses daily. Those that did not reported the power was too strong or they did not feel they needed them. Subjects noted an average improvement in vision of 4.4 out of 5 and an average satisfaction of 4.7 out of 5 (Figure 1). Conclusions : Glasses distribution is an effective way to address refractive error in underserved communities. Given the gaps in knowledge and utilization of eye care identified in our study, there is an obvious need for continued outreach to these areas. Further studies will include larger populations and evaluate mobile refraction devices to increase ease and reach of glasses provision.
ABSTRACT
Purpose : Vision Threatening Diseases (VTD) (age-related macular degeneration [AMD], cataract, diabetic retinopathy [DR], and glaucoma) account for 37% of all blindness. Screening and follow-up are crucial in preserving vision. During COVID-19, clinics reduced access, using telemedicine for diagnosis and follow-ups. The efficacy of remote screening and triage in the management of single or multiple VTDs was evaluated. Methods : We screened 41 subjects (19-85 years, 37% male, 17% Caucasian) (20 controls, 21 subjects). Demographics, 45-degree retinal photos, ganglion cell complex (GCC), and optic nerve head (ONH) images were collected using a non-contact puff-tonometer, nonmydriatic retinal camera, and an OCTA. Demographics and images were transmitted to two readers (onsite telemedicine screener [TS] and remote ophthalmologist [RO]) for triage. Triage was categorized: immediate referral to specialist, follow-up in person via clinic or telemedicine visit, or no follow-up necessary during COVID. Results : TS made 19 referrals (46%), 6 in person follow-ups (15%), 15 no follow-ups (37%);RO made 17 referrals (41%), 2 in person follow-ups (5%), 22 no follow-ups (54%). TS identified 12 subjects as possible VTD(s) while RO identified 11 subjects. TS and RO agreed on 8 glaucoma, 7 cataract, 3 DR, and 3 and 2 AMD cases, respectively. Glaucoma was identified using IOPs, retinal fundoscopy, and OCT imaging. Mean intraocular pressures were 12.9 and 15.7 (OD, OS) in glaucoma and 14.2 and 14.0 in controls. Fundoscopy was used for overall retinal health while OCT images were used to analyze GCC, ONH, nerve fiber layer, cup to disc ratio, and anterior chamber angles. AMD and DR were identified by fundoscopy and OCT imaging. 11 of the subjects were known clinic patients;both RO and TS referred all 11 to specialty clinics, matching the in-person clinic management. Conclusions : During the COVID pandemic, triaging patients can minimize person-toperson contact and help control the spread of the virus. Both readers agreed on the management and triage of a variety of patients with TS and RO differing only on 2 referrals and 4 in person follow-ups. Telemedicine is a promising alternative to in-person patient care for management and triage of vision threatening diseases. Further enrollment and follow-up are needed to increase robustness.
ABSTRACT
Purpose : The Centers for Disease Control reports 28.2% of surveyed US adults had reduced access to medical care (June/August 2020) due to the COVID-19 pandemic, with 8.9% reporting reduced access to vision care. A non-mydriatic digital retinal camera was piloted for deployment to the Emergency Department (ED) to help address this gap in vision care. Referrals for clinical follow-up in vision threatening diseases (VTDs) such as age-related macular degeneration, cataracts, diabetic retinopathy (DR), and glaucoma were assessed with human readers. Artificial Intelligence (AI) deep learning software was evaluated in known DR cases. Methods : 33 patients with known VTDs (48.48% male, avg 59.33 years) and 36 control subjects (41.67% male, avg 31.33 years) were included in tele-ophthalmology screening. A Canon CR-2 Plus AF non-mydriatic retinal camera captured 45-degree angle color and auto-fluorescence images of the eyes. Images (136 eyes) were graded by a certified telemedicine reader on site and an off-site clinical ophthalmologist following International Clinical Diabetic Retinopathy Disease Severity Scale (ICDRSS). Intergrader agreement between readers was evaluated with Cohen's kappa. An automated deep learning screening software optimized for DR (SELENA+, EyRIS Pte Ltd, Singapore) performed independent validation of readable color fundus images (17 eyes). Results : 5.07% of images were deemed unreadable by graders due to poor quality. Intergrader agreement for subject referral was κ = 0.710 (95% CI 0.545-0.875, p<.0005), with the clinical ophthalmologist generating more referrals than the telemedicine reader. Readers had 96.97% sensitivity (95% CI 91.12-1.028) and 72.22% specificity (95% CI 57.59- 86.85) in detecting referable disease. Positive predictive value was 76.19% (CI 63.31%- 89.07%) and negative predictive value was 96.30% (CI 89.17%- 1.034%). Of the 10 false positives, 6 were referred for rule out of glaucoma. Four had early stage cataracts that were deemed nonurgent. SELENA+ referred 100% of the known 9 DR patients. Conclusions : Tele-ophthalmology deployment in the ED helps limit patient and staff exposure to SARS-CoV-2 without sacrificing evaluation for VTDs. Tele-ophthalmology readers err on the side of caution to avoid missing VTD in a given patient. Use of AI can help keep strict adherence to referral guidelines.
ABSTRACT
Purpose : To test and identify diagnostic accuracy of a single OCTA in Central Asians for differentiating among normal subjects, POAG suspects and POAG compared to clinical examination. Methods : Data from Central Asians (Kazakh, Korean, N=59) with confirmed POAG, POAG suspects and healthy subjects age 27 -76 yr were collected. Patients with different stages of glaucoma were included. Visual acuity, refraction, IOP (non contact tonometer, ShinNippon NCT -200), slit lamp and fundus examination, ultrasound biometry of lens and vitreous (Alcon Ultrascan B-Scan + A-scan),visual field (HFI 750i, Carl Zeiss), anterior segment (AngioVue OCTA ,Optovue Inc.) were obtained. Anterior chamber parameters were measured. The optic nerve was measured and analyzed in all patients with OCTA (AngioVue, Optovue Inc.). Parameters included RNFL analysis, ONH analysis, GCC analysis, TSNIT NDB Reference. OCTA images interpretation with a single-page report were exported and analyzed by independent, experienced glaucoma imaging expert, according to a specified grading protocol. The OCTA reader was blinded to any clinical patient information, such as the patient's medical history, visual acuity, IOP, fundus examination, etc. The OCTA reader assessment was compared to the standard of care clinical examination which had access to exam and all ancillary testing. Results : An OCTA analysis gave an overall classification rate of 85%. With two outputs (normal subject, POAG suspect) of OCTA analysis the specificity was 87% and sensitivity 91.4%. The specificity of OCTA for the detection of POAG was 86.6% with sensitivity of 92.5% Conclusions : A single OCTA assessment demonstrated good diagnostic accuracy when compared to comprehensive exam in its ability to differentiate glaucoma patients from glaucoma suspect and normal subjects in Central Asians. This findings demonstrates that OCTA is a valuable adjunctive tool to assist in glaucoma diagnosis and may provide a method for diagnosis remotely which has value during the COVID pandemic.
ABSTRACT
Purpose : In this pilot study, we compared the efficacy of drive-through intraocular pressure (IOP) checks in combination with E-health visits to E-health visits alone in the management of glaucoma patients during the COVID-19 pandemic. Methods : We performed a retrospective chart review for visits from April 2020 - November 2020 to compare subjects that received E-health visits (Group 1) versus subjects that received E-health visits with a drive-through IOP check (Group 2). Drive-through visits consisted of temperature screening with a non-contact infrared thermometer, near visual acuity check, and IOP measurements using a Tono-Pen XL Tonometer (Reichert, Depew, NY) followed by a video E-health visit with a glaucoma specialist. Group 1 patients only attended a video visit. We compared the proportion of interventions done at the visit as well as changes in visual acuity (VA) and IOP after the tele-visits between the 2 groups. The 4 types of interventions were: change in drop type, change in drop frequency, change in number of drops, and recommending surgical or laser intervention. Results : 28 subjects were included in our pilot study (mean age 74.9 +/- 3.8 years, 57.1% female). There was no significant difference in baseline characteristics between group 1 (n=15) and group 2 (n=13, Table 1). 6.7% of Group 1 patients had an intervention done compared to 38.5% of group 2 patients. Fisher exact probability testing showed a significant increase in the proportion of interventions done in group 2 subjects compared to group 1 subjects (p=.041), with the most common interventions being changing number of drops and drop frequency. There was no significant difference in changes in VA or IOP between the 2 groups (Table 1). Conclusions : Drive-through IOP checks in combination with virtual visits resulted in more interventions than virtual visits alone in the care of glaucoma patients during the COVID-19 pandemic. This novel healthcare modality can address the mismatch between capacity and demand for glaucoma care both during a pandemic and can further expand access to sub-specialized care.
ABSTRACT
Purpose : Coronavirus-19 (COVID-19) has had immense effects on access to medical care. Loss of medical care is alarming for individuals with pre-existing conditions like Type 1 Diabetes Mellitus (T1DM) which require uninterrupted care for best outcomes. Consistent care and medication use can reduce risk of developing diabetic retinopathy (DR) by 76% or progression by 54%. Healthy habits have also been linked to reduced risk of DR. The purpose of this study is to assess the effect of COVID-19 on care access and health habits in individuals with T1DM Methods : Surveys were administered from July-November of 2020 to multinational groups including the Children with Diabetes Conference (USA) and online groups, the American Diabetes Association and Connected in Motion Canadian Conference for T1DM. Data was collected from 125 patients from the USA, UK, Canada, and Bolivia. Age range was 5-81, and average years with T1DM was 17.9. The survey was online so responder rate is unclear, though response rates from previous surveys with similar groups averaged less than 10%. Results : While 73.6% of respondents saw an ophthalmologist within 1 year and 98.4% had medication without rationing, 40% postponed medical visits. Reasons for postponement included lack of appointments or transportation, financial issues and safety concerns. The majority (86.4%) were from the US where private insurance is prevalent, 12% were from Europe and Canada, where socialized medicine is common. Of respondents, 90.4% are willing to use telemedicine as an alternative. For most, diet remained the same (48.8%);25.6% stated their diet was healthier and 20% stated their diet was less healthy. 16.8% had problems accessing their usual foods due to the pandemic. A majority (55.2%) reported decreased exercise with 18.4% reporting more exercise. These overall trends were consistent across countries, and gender trends remained the same as pre-COVID, with women having better lifestyle and medical care adherence. Conclusions : Though patients delayed appointments, most were able to see an ophthalmologist and access medication. Physical activity levels decreased, though diets were mostly unchanged. In individuals with T1DM, disruptions in medical care and health habits can have negative long-term outcomes on overall and eye health. Telemedicine offers a promising solution for mitigating this risk.