Abstract
To evaluate the outcome of a web-based digital assessment of visual acuity and refractive error, compared to a conventional supervised assessment, in keratoconus patients with complex refractive errors. Keratoconus patients, aged 18 to 40, with a refractive error between -6 and +4 diopters were considered eligible. An uncorrected visual acuity and an assessment of refractive error was taken web-based (index test) and by manifest refraction (reference test) by an optometrist. Corrected visual acuity was assessed with the prescription derived from both the web-based tool and the manifest refraction. Non-inferiority was defined as the 95% limits-of-agreement (95%LoA) of the differences in spherical equivalent between the index and reference test not exceeding +/- 0.5 diopters. Agreement was assessed by a Bland-Altman analyses. A total of 100 eyes of 50 patients were examined. The overall mean difference of the uncorrected visual acuity measured -0.01 LogMAR (95%LoA:-0.63-0.60). The variability of the differences decreased in the better uncorrected visual acuity subgroup (95%LoA:-0.25-0.55). The overall mean difference in spherical equivalent between the index and reference test exceeded the non-inferiority margin: -0.58D (95%LoA:-4.49-3.33, P = 0.008). The mean differences for myopic and hyperopic subjects were 0.09 diopters (P = 0.675) and -2.06 diopters (P<0.001), respectively. The corrected visual acuities attained with the web-based derived prescription underachieved significantly (0.22±0.32 logMAR vs. -0.01±0.13 LogMAR, P <0.001). Regarding visual acuity, the web-based tool shows promising results for remotely assessing visual acuity in keratoconus patients, particularly for subjects within a better visual acuity range. This could provide physicians with a quantifiable outcome to enhance teleconsultations, especially relevant when access to health care is limited. Regarding the assessment of the refractive error, the web-based tool was found to be inferior to the manifest refraction in keratoconus patients. This study underlines the importance of validating digital tools and could serve to increase overall safety of the web-based assessments by better identification of outlier cases.
Highlights
An estimated 1 billion people have a visual impairment that can be prevented or is undetected and this number is expected to rise [1, 2]
The overall mean difference in spherical equivalent between the index and reference test exceeded the non-inferiority margin: -0.58D (95%limits of agreement (LoA):-4.49–3.33, P = 0.008)
Regarding the assessment of the refractive error, the web-based tool was found to be inferior to the manifest refraction in keratoconus patients
Summary
An estimated 1 billion people have a visual impairment that can be prevented or is undetected and this number is expected to rise [1, 2]. Main causes of visual impairment are refractive errors, cataract or chronic ophthalmic conditions (e.g. macular degeneration). To become less reliant on hospital facilities and trained professionals for monitoring eye conditions, there is a growing interest in telemedicine and digital tools. Promising advances have been made for automatic assessment of retinal images [5]. The refractive error and visual acuity are considered important clinical parameters for diagnosing and monitoring eye conditions and as such various tools to remotely assess refractive errors and visual acuity are developed and clinically validated [6, 7]
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