Teleophthalmology Through Handheld Mobile Devices: A Pilot Study in Rural Nepal

Abstract

Background: To compare screening referral recommendations made by remotely located ophthalmic technicians with those of an ophthalmologist examining digital photos obtained by a portable ophthalmic camera system powered by an iOS handheld mobile device (iPod Touch). Methods: Dilated screening eye exams were performed by ophthalmic technicians in four remote districts of Nepal. Anterior and posterior segment photographs captured with a Paxos Scope ophthalmic camera system attached to an iPod Touch 6 th generation device were uploaded to a secure cloud database for review by an ophthalmologist in Kathmandu. The ophthalmic technicians' referral decisions based on slit-lamp exam were compared to the ophthalmologist's recommendation based on the transmitted images. Results: Using the transmitted images, the ophthalmologist recommended referral for an additional 20% of the 346 total subjects screened who would not have been referred by the ophthalmic technician. Of those subjects, 34% were referred to the retina clinic. Conversely, among the 101 patients referred by the technician, the ophthalmologist concurred with the appropriateness of referral in more than 97% of cases but thought eight (2.8%) of those patients had variants of normal eye pathology. Conclusion: An ophthalmologist who reviewed data and photos gathered with the mobile device teleophthalmology system identified a significant number of patients whose need for referral was not identified by the screening technician. Posterior segment pathology was most frequently found by the remote reader and not by the technician performing dilated slit lamp examinations. These results are promising for further clinical implementation of handheld mobile devices as tools for teleophthalmic screening in resource-limited settings.

Advances in Telemedicine in Ophthalmology

“…[6][7][8] A retinal screening study from Nepal using a Paxos Scope ophthalmic camera system (DigiSight Technologies, San Francisco, CA, USA) attached to a 6th generation iPod Touch showed that of 101 patients referred to an ophthalmologist based on screening results, the ophthalmologist concurred with the appropriateness of the referral in 97% of cases. 9 A 2019 study in JAMA Ophthalmology found that remote diagnostic imaging (fundus photography and OCT) using an FDA approved non-contact retinal imaging device (iFusion; Optovue) versus standard examination by a retinal specialist were equivalent in detecting referable macular degeneration. 8…”

Digital ophthalmoscopy: through a non-specialist lens

“…3,4,7 Easily accessible fundus imaging would provide enhanced documentation by saving time and by increasing accuracy through the minimisation of interpretation or communication errors. 3,4,14 The confidence of interpretation currently is dependent on the degree of training received, and subsequent frequency and self-rated competence of individual physicians. 3…”

“…3,7 Digital ophthalmoscopy, however, has been proven to build greater competence and confidence in students, optimising their learning within a smaller time-period. 3,4,14 Independence is essential for a lifelong career in healthcare and the current shortfall in training recruitment will likely continue to contribute to inefficiencies in service provision and patient care. 1,3,4,7 Given the risks associated with failing to visualise the fundus appropriately, training to promote competence and independence is essential to ensure high-quality patient care.…”

“…5 Also, developing skills in taking high-quality images which could be sent to a remotely based ophthalmologist will increase the scope to incorporate multidisciplinary input and would reduce the risks associated with inexperienced non-ophthalmologist interpretation of findings. 4,14…”

“…Telemedicine services are becoming increasingly common across a range of services. 8,14 Teleophthalmology has yet to become widely adopted, either in the sense of real-time remote consultations, or in the form of "store-and-forward" process of reviewing images and formally reporting these at a convenient time. 4,8,14 While there remain concerns over the sustainability of these initiatives, examples exist which demonstrate the cost effectiveness and relative ease of innovation in resource limited settings.…”