Mobile technology brings the eye exam home
More than half of the world’s population is now online. According to 2018 data, the number of unique mobile subscribers around the world has surpassed 5 billion. North America and Europe still have the highest rate of internet penetration, but Southern Asia and Central Africa are rapidly catching up and are currently seeing the fastest growth in internet adoption.
In this scenario, telemedicine, portable devices and mobile applications have the potential to revolutionize eye care, making high-quality services sustainable and accessible to all.
“Even in the United States, one of the most developed countries in the world, less than half of the patients with diabetes get their recommended annual eye examinations. Teleophthalmology gives us the opportunity to reach them in their communities and in primary care settings to screen and diagnose eye diseases earlier and improve referral,” OSN Retina/Vitreous Board Member Judy E. Kim, MD, said.
Kim is a member of the American Telemedicine Association and professor at the Medical College of Wisconsin, an academic institution with a strong focus on community health initiatives. She is involved in several community-based teleophthalmology programs that provide diabetic retinopathy screening to the economically disadvantaged, ethnic minorities and low-income, impaired-mobility persons who have limited or no access to eye care and those with language, educational and cultural barriers.
“We have trained bilingual community members and public health department employees in our city so that they can set up mobile screenings in locations such as churches, health fairs, food pantries and community centers. As a result, we have been able to reach African-American, Hispanic and Hmong communities and also improved the screening of men, who are less likely to attend screening programs,” Kim said.
With the aging of the population, chronic diseases such as diabetes, glaucoma and macular degeneration are dramatically on the rise in the Western world. Teleophthalmology can be a valuable resource for screening, early diagnosis and monitoring, reaching more patients, and reducing the burden of overcrowded clinics and shortage of specialists. According to Kim, while her work has been in the community, teleophthalmology has been incorporated in many different settings, including as a part of wellness exams, internist and endocrinology offices, neonatal intensive care units, rural and remote settings, emergency rooms and homes. Her research has shown that teleophthalmology is well accepted by the participants.
Teleophthalmology relies on internet connectivity, and portable technologies are improving its potential and utilization. Several portable cameras are becoming available and can be linked for transferring the images to specialists and reading centers.
“When it comes to cameras for teleophthalmology, there are a number of considerations. These include cost, ease of use with automation, portability, field of view and image quality through undilated pupils affecting gradable rates. Fortunately, many of these aspects are being addressed by camera companies and groups of inventors. We also need good software to evaluate images and results, and to integrate findings into electronic medical record systems to have everything in one digital space for each patient. Eventually, we should aim for interconnecting EMRs to access and exchange information across clinics throughout the country and around the world. Advances in artificial intelligence and machine learning in the coming years hold significant promise for rapid and accurate resulting of high volume of images in a cost-effective manner,” Kim said.
Reimbursement issues with telemedicine are also a limitation.
“The current reimbursement system for teleophthalmology is inadequate and ill-defined in our country. Successful systems have been driven by internal uses in large health care systems, veterans hospital systems and some for-profit companies. We need policies and a financial model for teleophthalmology at a national level,” Kim said.
In the United Kingdom and Canada, the implementation of national teleophthalmology diabetic screening programs resulted in a significant decrease in the prevalence of diabetic retinopathy and diabetic retinopathy-related blindness, she said.
Portable devices, such as the ForeseeHome AMD monitoring program (Notal Vision), allow patients to test themselves at home. Data are transmitted directly to the reading center, and worsening of metamorphopsia, a sign of AMD progression, is detected by comparing to previous test results. An alert is sent to patients or the physicians to get the patient in for an examination.
“This device is already FDA approved and used in the U.S. The same company is now working on a home optical coherence tomography device. Many retinal diseases are being assessed by OCT, and if patients could test themselves at home with the reading center evaluating for any worsening, we could detect recurrences and disease progression earlier and monitor treatment response, while reducing visits to the doctor’s office,” Kim said.
Mobile technology is used as a way to make eye testing and examinations available to patients directly or to doctors via internet communication.
“There is a myriad of mobile apps, such as testing for metamorphopsia, stereopsis, visual acuity and even prescription for glasses,” Kim said. “As technology, instrumentation and deep learning algorithms improve, I predict that we will see a huge revolution in delivery of eye and medical care in the future.”
Hand-held adaptive optics SLO
A new hand-held adaptive optics scanning laser ophthalmoscope (HAOSLO), which measures 4 inches by 2 inches by 5.5 inches and weighs less than half a pound, has been developed by researchers at Duke University. The SLO system, enhanced by adaptive optics technology, is compacted into a hand-held probe, which allows the capture of high-resolution images of the retina with the patient in the supine position.
“Physicians can take the device directly to their patients, and images can be collected quickly, even if there is movement. This allows us to widen the access to this technology,” Sina Farsiu, PhD, associate professor of biomedical engineering and ophthalmology at Duke, said.
The fundamental difference with the classic SLO, besides portability, is the addition of a deformable mirror in the light pathway, which dynamically compensates for higher-order aberrations.
“Static defocus and astigmatism are more or less constant in large areas in the retina, but [higher-order aberrations] change quickly from one small region of the retina to the next. Adaptive optics allows us to capture images of individual photoreceptors with extreme clarity and to visualize individual nerve fiber bundles of the ganglion cell axons,” Joseph A. Izatt, PhD, who co-leads the project with Farsiu, said.
The primary focus of this project was pediatric ophthalmology. Tabletop SLO systems are designed for adult patients who are able to sit upright and fixate on a target for several minutes. The combination of portability and adaptive optics makes the new system suitable for noncooperative patients, patients with limited mobility and infants. Cynthia A. Toth, MD, a vitreoretinal surgeon at Duke, was the first to use this device for imaging the eyes of newborns at risk for developing retinal diseases.
“In a longitudinal clinical trial, we will be testing if this system can be used as a surrogate to image the changes of the brain based on the association between the development of retinal photoreceptors and the brain. We will be also testing the possibility to use it as a means to assess brain trauma in athletes, like football players. The effects of head injuries might show in the retina and could be immediately assessed by adaptive optics. Another area of interest is the relationship between Alzheimer’s disease and changes in the retina,” Farsiu said.
Finally, this new modality will allow imaging of the retina in large animals in a noninvasive way, without the need for anesthesia, heading in the direction of noninvasive tests in animal models.
“Another good news is that we have made the software for HAOSLO freely available online. Other research centers can download this system and replicate it for their own research,” Farsiu said.
Taking the clinic into the home
Five years ago, Iordanis I. Chatziangelidis, MD, MBA, FEBO, presented at the winter European Society of Cataract and Refractive Surgeons meeting his prototype of a remote-controlled slit lamp. The project was entirely self-financed. Chatziangelidis purchased a slit lamp on eBay and the hardware for motorized back-forth and left-right movements and slit angulation. He used an Apple iPhone, a 4G internet connection, and Skype HD or Apple FaceTime to capture and stream videos. The purpose of this new tool was to make teleophthalmological examinations possible between Athens, Greece, and remote, underserved Greek islands.
In the following years, he also created a complete portable “teleophthalmological clinic in a suitcase,” containing a Vision Screener VS100 autorefractor (Welch Allyn), a Tono-Pen Avia (Reichert), an indirect ophthalmoscope (Keeler), a portable slit lamp (Shin Nippon), a portable lens meter (Opto Hellas), 124 piece trial lenses and frame, and an iPad and iPhone with slit lamp and fundus camera adapter.
“I invested in whatever was commercially available in a portable and compact size and completed my armamentarium with a series of apps, including optotype (Konan Medical Acuity), Amsler grid (Konan Medical Amsler grid recorder), color testing (Konan Medical Color Dx) and visual field (Melbourne Rapid Fields). Finally, I created my own electronic medical record system for iPad. With all this equipment to complement the remote-controlled slit lamp, I had created the first teleophthalmological clinic,” Chatziangelidis said.
He personally presented his project to two ministers of health and two ministers of development in his country. They warmly congratulated him, but nothing was done to implement the project. He did not give up and started his own service of home visits. Finally, he got to know and joined SOS Doctors, an organization of freelance medical specialists dedicated to providing home medical services.
A great need
“You have a completely different perception of patients and diseases if you go out there. You see the people who would never come to the clinic who are getting blind with wet AMD but would not get out of bed and out of home to get an injection. Many of them have other serious health problems, are clinically depressed and just waiting to die,” Chatziangelidis said.
There may be little to do for these patients from a medical standpoint, but a sympathetic doctor and simple solutions can sometimes change their lives.
“I had a 90-year-old patient with cataract,” Chatziangelidis said. “She had about 20/50 vision, not so bad for someone who lives in bed, but she could not see the television. She refused to be operated, so my therapy was to help her get a new and bigger screen.”
In the future, there will be an increasingly bigger demand for this kind of service, he said. With the aging of the population in Europe, health issues correlated with older age are bound to increase, while isolation, limited mobility, cost of transportation and lack of family support will make access to health services more difficult and burdensome for individuals and the system.
“Many of these patients need an ambulance to move out of their home with two people to take care of them. Home visits and mobile ophthalmology are likely to be a more cost-effective option and more comfortable for the patient. The need is already much greater than we think. In many areas in most countries there are forgotten people in rural but also in highly urbanized areas,” Chatziangelidis said.
Digitized networks in India
The LV Prasad Eye Institute (LVPEI) is a comprehensive eye health facility with its main campus located in Hyderabad, India. Its entire network of 200 tertiary and secondary centers across four states in India and 176 primary vision centers in rural areas is completely digitized, interconnected and able to offer a broad range of teleophthalmology services.
“Our digitization project at LVPEI started 8 years ago in 2010. We see close to 4,500 consultations per day across the network on the eyeSmart EMR system, with over 1,000 patients being treated at the rural vision center level, and all of these analytics is real time,” Anton Vipin Das, MD, said.
This huge project utilized the possibilities offered by relatively inexpensive, simple technologies.
The first challenge was the lack of connectivity and power in rural villages, which included the 176 primary vision centers.
“We met that challenge by creating the eyeSmart EMR app from the EMR system that we have in our bigger centers. It is built on Android, can be used offline and syncs the data whenever you have the connectivity. After testing the app, we had two teams going across our 176 vision centers, in four states of India, and within 3 months, from January to March 2017, the entire network of rural centers went digital in 90 days,” Das said.
Everyone in the LVPEI centers was given a tablet, “a very powerful, extremely versatile, multipurpose tool at a very low cost,” Das said. “Each tablet is about 16,000 Indian rupees, the equivalent of US$200, plus the cost of a 3G SIM card, which is another $5 to $6, which is a recurring expenditure every month.”
Skype Lite, a Skype app designed for low internet bandwidth connectivity in India, is used to send clinical data and images to the command center, where an ophthalmologist and an optometrist analyze the individual cases. Through Skype Lite, they can also directly connect via video call with the vision technician and the patient, talking to them, answering questions, giving advice and organizing referrals in real time.
“We designed a very fast, dynamic system through which optometrists and ophthalmologists who are stationed at the command center are able to answer calls within 2 minutes. We have done so far 17,000 consultations, about 80 to 100 per day,” Das said.
Every day at 10 p.m., a teleophthalmology deficiency report is shared with all members of staff, showing how many consultations have been answered on that day and how many have not. The deficiency rate is 0% every day because the progress is able to be tracked in real time.
Digitally integrated devices
A special adapter, called the eyeSmart Cyclops, has also been developed to physically connect the tablet to the slit lamp and transmit live slit lamp videos anywhere in the word at no cost. Remotely, the ophthalmologists in the command center can see the patient’s eye while asking the technicians in the vision centers to change the magnification, illumination and specific area they want to focus on.
“We went another step further on integration,” Das said. “We created a portable mydriatic fundus camera, called OWL or OIO (open indirect ophthalmoscope), and integrated this device with the app. We are also working at integrating these devices into our tablets.”
An automated image analysis system is underway and soon will allow identification of pathological signs even before the images are sent to the command center.
Another innovative project is the Drone slit lamp, first developed at Bascom Palmer Eye Institute as a pilot research project and replicated at LVPEI. The slit lamp is remotely controlled via computer and allows ophthalmologists at the command center to do teleconsultations for patients in distant locations. Three-dimensional stereo viewing is obtained through the use of 3-D spectacles.
“The patient sits at the remote center, and you can operate the slit lamp while talking and asking him or her to fixate, to change eye position and so on. It is an expensive technology but has great potential for use in underserved regions. We have eight of these Drones, and eventually we might be able to put them in all our centers,” Das said.
Mixed reality is another future goal, with holograms that will give patients in remote areas the full experience of a consultation room in the tertiary centers. The Holo Eye Anatomy app developed by LVPEI on the HoloLens (Microsoft) is available to download for free.
“We are evolving with the technology that is evolving. We think simple, use the solutions that are there and have a high impact,” Das said. “We are very excited that we have taken the leap of getting into digital rural eye health in a very strong way. Our network is one of the largest rural eye health network systems worldwide, completely real time, and we have been able to overcome challenges by the way of simple, inexpensive solutions.” – by Michela Cimberle
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- For more information:
- Iordanis I. Chatziangelidis, MD, MBA, FEBO, can be reached at iC.Today, Dimitriou Basiliou 22, 15451 Athens Greece; email: email@example.com.
- Anton Vipin Das, MD, can be reached at Department of eyeSmart EMR & AEye, LV Prasad Eye Institute, KAR Campus, Road No 2, Banjara Hills, Hyderabad, Telangana – 500034, India; email: firstname.lastname@example.org.
- Sina Farsiu, PhD, can be reached at Departments of Biomedical Engineering and Ophthalmology, Duke University, 101 Science Drive, Durham, NC 27708-0281; email: email@example.com.
- Joseph A. Izatt, PhD, can be reached at Departments of Biomedical Engineering and Ophthalmology, Duke University, 101 Science Drive, Durham, NC 27708-0281; email: firstname.lastname@example.org.
- Judy E. Kim, MD, can be reached at the Medical College of Wisconsin, 925 N. 87th St., Milwaukee, WI 53226; email: email@example.com.
Disclosures: Izatt and Duke University have licensed technology to and have a financial interest (including royalty/milestone payments) in Bioptigen/Leica Microsystems, which manufactures hand-held and intrasurgical OCT systems. Kim reports she is a consultant for Notal Vision. Chatziangelidis, Das and Farsiu report no relevant financial disclosures.
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