Teleophthalmology

Teleophthalmology is a branch of telemedicine that delivers eye care through digital medical equipment and telecommunications technology. Today, applications of teleophthalmology encompass access to eye specialists for patients in remote areas, ophthalmic disease screening, diagnosis and monitoring; as well as distant learning.

Teleophthalmology enables health professionals to take ocular images and attend to patients who have limited access to ocular health care. These images allow the ophthalmologist or optometrist, health care professionals and researchers to carry out the aforementioned applications. The required equipment includes a camera that can take ocular images and a computer terminal with network capabilities, which can transfer the images. There has been a significant increase in teleophthalmology research over the past decade. However, differences in health information exchange standards, data security, liability issues, and cost of equipment are other major challenges in teleophthalmology.

Implementation

Although ocular photography has been present since the early 1980s, the transfer of digital images from one location to another for assessment is a relatively recent phenomenon. The rise of digital imaging in the early 1990s allowed ophthalmologists and optometrists to capture images and store them on computers for future assessment. The advent of the Internet allowed for the digital transfer of these ocular images from one location to another.

Current teleophthalmological solutions are generally focused on a particular eye problem, such as diabetic retinopathy, retinopathy of prematurity,
macular degeneration, strabismus and adnexal eye diseases. Less common conditions that can be revealed using retinal images are arterial and vein occlusions, chorioretinitis, congenital anomalies, and tapetoretinal abitrophy. Several population-based studies have used retinal imaging to relate ophthalmic abnormalities to general conditions, including hypertension, renal dysfunction, cardiovascular mortality, subclinical and clinical stroke, and cognitive impairment.

Mobile applications are widely available in ophthalmology and optometry as tools for eye tests (visual acuity, colour test, and viewing eye images) and for educational purposes. Technological advancements in digital ocular imaging devices are perceived by many as key drivers for teleophthalmology. Recently, emerging retinal imaging modalities such as optical coherence tomography are capable of producing digital images of the retina with a micrometer resolution, which can be transmitted for research or diagnostic purposes. Along with systems designed for health care professionals, patient-centred systems such a
Eye-File
for use by the general public are emerging.

Process

Fundus photography is performed by a fundus camera, which basically consists of a specialized low power microscope with an attached camera.

Teleophthalmology services can be provided primarily in two ways synchronously or asynchronously:

*Synchronous teleophthalmology enables real-time interaction between participants (using standard telemedicine technologies e.g. video-conferencing), synchronous to supervise the removal of corneal foreign bodies and for consultations.
*Asynchronous teleophthalmology in a "store-and-forward" method, where data is captured and transmitted for review at a later time.

Images of the eye can be captured non-invasively through various methods, generally by a technician or non-physician health care professional.
*External eye: standard digital stills or video camera
*Anterior segment: slit lamp connected to a camera
*Posterior segment
Mydriasis (pupil dilation, e.g. using tropicamide) may be required to obtain an image of sufficient quality.

Stereoscopy may be used to detect retinal thickening.

The image can then be transferred, over the Internet or dedicated network to a physician for immediate examination, or for storage and later review. Ideally, the image is encrypted or anonymized for transmission, to protect patient confidentiality. Between image capture and viewing, image processing may be done, including compression, enhancement and edge-detection.
Image evaluation, to detect various pathologies in the case of asynchronous evaluation, is often done by an ophthalmologist, optometrist or primary care physician, though it is also performed by specially trained staff. Image evaluation may also be automated to provide pathology detection or grading.

Automated image recognition

Computer software applications have been tasked with the automated assessment of retinal images to recognize lesions associated with an ocular disease of interest. The clinical process entails initially discriminating retinal lesions from non-factor artifacts, subsequently distinguishing lesions associated with the disease in question from other types of lesions, and finally grading the disease according to guideline-endorsed severity scales set by medical authorities.

Dedicated research in artificial intelligence drives the underlying technology in automated image recognition. Specific approaches involve pattern recognition using trained artificial neural networks; feature extraction using edge-detection and region-growing techniques; and content-based comparison with previously adjudicated samples.

Advantages

*Improved patient care
*Strengthened referral patterns
*Extended patient care and expertise to remote areas
*Education of hospital staff, clinicians and the community
*Cost-effectiveness
*More effective planning and administrative meetings with point-and-click sharing of content
*Use of videoconferencing to members of the human resources department has helped to resolve emergency staffing issues
*Community nurses, ophthalmologists or optometrists in training can attend teaching sessions at the main hospital via a live video teleopthamological feed, thereby enhancing their knowledge and skills.

Implemented projects by country

Australia

A 100-case audit of retinal screening by optometrists was performed in the remote areas of Western Australia. Projects are now being started base on this pilot experience.

Canada

A number of teleophthalmology programs exist in Canada, including those in the provinces of Alberta, British Columbia, Manitoba, Newfoundland, Ontario, and Quebec.

The cost of taking the images and of the ophthalmologist to interpret the images is covered by public-funded health care insurance. Typically a registered nurse or registered practical nurse is trained to dilate the patient's pupils and take the images.

Key challenges to providing teleophthalmology services in Canada are likely: 1) the high staff turnover in remote areas; 2) the lack of an inexpensive mobile imaging device that takes diagnostic quality images; and 3) the difficulty securing public funds where the costs are incurred and savings are realized from separate funding envelopes.

Alberta

Teleophthalmology has been provided in Alberta since 2003, and is supported by Alberta Health Services, using their proprietary teleophthalmology softwar
Secure Diagnostic Imaging
Approximately six ophthalmologists from the University of Alberta review the images. As of January 2014, approximately 15,000 patients had been screened for diabetic retinopathy, across 15 community-hospital-based stationary locations, 44 First Nations communities and five primary care practices. Approximately 130 patients are screened per month across these locations. The teleophthalmology program also facilitates approximately 55 optometrist-to-ophthalmologist referrals per month.

British Columbia

Teleophthalmology is provided by ophthalmologists from the University of British Columbia, and is supported by Alberta Health Service's proprietar
Secure Diagnostic Imaging
software.

Manitoba

In Manitoba, teleophthalmology is provided by ophthalmologists at the University of Manitoba

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