'Teleglaucoma’ is feasible and can play a major role in blindness prevention. Telemedicine and teleglaucoma are going to be an important part of how physicians take care of patients in the United States and worldwide.
Telemedicine is not a new concept. Physicians in Australia were using two-way radio to treat patients in rural Australia in the 1920s. Almost a century later, glaucoma is going remote.
“In the glaucoma clinic of the future, patients will be checking their own eye pressure,” predicted Louis Pasquale, MD, professor of ophthalmology, Harvard Medical School, and director of Glaucoma Service and Teleretinal Program, Massachusetts Eye and Ear Infirmary, Boston. “They will be doing their own visual fields and imaging their own discs. This will convert the glaucoma clinic to focus on the patients who really need to be seen.”
Dr. Pasquale moderated “New Horizons in Telemedicine” session and set the scene for changes that are already underway. The session was part of the New Horizons Forum at the 2017 Glaucoma 360 meeting.
“‘Teleglaucoma’ is feasible and can play a major role in blindness prevention,” said Lama A. Al-Aswad, MD, MPH, associate professor of ophthalmology, Columbia University College of Physicians and Surgeons, New York. “Telemedicine and teleglaucoma are going to be an important part of how we take care of patients in the United States and worldwide.”
Telemedicine is practicing medicine over a spatial or temporal distance by using electronic communications, Dr. Aswad explained. Glaucoma is an ideal candidate for telemedicine because patients tend to be older and less mobile. The disease is chronic and the technology exists for remote screening, diagnosis, and treatment.
The Edward S. Harkness Eye Institute at Columbia University is testing “tele-ophthalmology” to screen for the four leading causes of blindness–cataracts, glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy. Screening for visual acuity, non-contact tonometry, frequency doubling technology (FDT) perimetry, fundus imaging, and optical coherence tomography are loaded into a small truck that travels to screening sites.
“We don’t have an ophthalmologist on the truck,” Dr. Al-Aswad said. “We send results to a central reading center. If the doctor decides the patient has potential for eye disease, we teleconference on the spot. It is a highly efficient use of resources to screen for eye disease and raise awareness.”
In London, Visulytix is going one step farther. Instead of sending test data to an ophthalmologist for review, the company is developing an artificial intelligence (AI) system to screen test results.
“The net result is above-human levels of diagnostic accuracy in a fraction of the time and at a fraction of the cost of a typical provider,” explained Sameer Trikha, MBA, FRCOphth, founder and chief medical officer. “We are developing a single algorithm, a single solution to screen for multiple eye diseases, including glaucoma, AMD, and diabetic retinopathy. It is quite conceivable that you can reach accuracies of between 85% and 99%, vastly superior to primary eye providers and equivalent to human experts.”
AI won’t replace clinicians, Dr. Trikha said. AI will handle the initial screening and reduce the incidence of false positives, streamlining workflow, and enabling ophthalmologists to focus on patients who need treatment.
Remote VF testing
The next step is remote visual field testing, which is already here.
The Visual Fields Easy App, designed for the iPad, is being used in Nepal and other remote locations for screening, said Ying Han, MD, PhD, associate professor of ophthalmology, University of California San Francisco.
The more complex Melbourne Rapid Fields (MRF), also iPad-based, has a nearly 1:1 correlation between MRF results and a conventional Humphrey Visual Field (HVF) Analyzer. A free web-based perimetry test, Peristat, at www.keepyourisght.org, can be used on any computer screen 17 inches or larger.
“Tablet and online field exams can be performed reliably and consistently,” Dr. Han said. “All have a strong correlation with HVF and can be good glaucoma screening tools.”
The Eye Institute of Alberta also is using tele-ophthalmology. One program links patients and non-specialist providers in remote communities with specialists in Edmonton, Canada. Images and screening data are provided by optometrists.
“We do the grading in Edmonton as a glaucoma specialist group,” said Karim Damji, MD, MBA, professor and chairman of ophthalmology, University of Alberta Faculty of Medicine & Dentistry. “(We) make recommendations about the diagnosis and management plan. About a quarter of patients needed to come in for further evaluation and many can be managed remotely.”
Teleglaucoma to speed assessment
Royal Alexandria Hospital, Edmonton, uses teleglaucoma to speed patient assessment. The wait time to see a glaucoma specialist is four to six months, Dr. Damji said. Using technicians for an initial interview, history, exam, visual field, and imaging, then sending the file to a glaucoma specialist for grading and treatment recommendations reduces access time from a mean of 88 days to 45 days and screening time from 115 minutes to 78 minutes.
“The whole field of mobile health is taking off with a number of different models,” Dr. Damji said. “Machine learning would be enormously helpful, but this is a very exciting time.”
The biggest barriers to the adoption of teleglaucoma are regulatory and financial.
“Telemedicine is still the practice of medicine, bounded in case law and medical practice acts,” said Mark Horton, OD, MD, director of the Indian Health Services/Joslin Vision Network Tele-ophthalmology Program, Phoenix, AZ. “Standards of care for telemedicine are still evolving.”
Some state practice acts speak to telemedicine or special exemptions, but over half require full and unrestricted licensure to provide care by telemedicine, Dr. Horton noted. The American Telemedicine Association (ATA) and the Center for Telehealth & eHealth Law offer current information on specific state requirements.
“Reimbursement depends of the payer, Medicare, Medicaid, or private insurance, and the services provided, screening, diagnosis, or management,” he said. “Assistance can be obtained from the ATA and the American Academy of Ophthalmology.”