Telemedicine Screening Research Articles

Evaluation of Telemedicine for Screening of Diabetic Retinopathy in the Veterans Health Administration

To explore the cost-effectiveness of telemedicine for the screening of diabetic retinopathy (DR) and identify changes within the demographics of a patient population after telemedicine implementation. A retrospective medical chart review (cohort study) was conducted. A total of 900 type 1 and type 2 diabetic patients enrolled in a medical system with a telemedicine screening program for DR. The cost-effectiveness of the DR telemedicine program was determined by using a finite-horizon, discrete time, discounted Markov decision process model populated by parameters and testing frequency obtained from patient records. The model estimated the progression of DR and determined average quality-adjusted life years (QALYs) saved and average additional cost incurred by the telemedicine screening program. Diabetic retinopathy, macular edema, blindness, and associated QALYs. The results indicate that telemedicine screening is cost-effective for DR under most conditions. On average, it is cost-effective for patient populations of >3500, patients aged <80 years, and all racial groups. Observable trends were identified in the screening population since the implementation of telemedicine screening: the number of known DR cases has increased, the overall age of patients receiving screenings has decreased, the percentage of nonwhites receiving screenings has increased, the average number of miles traveled by a patient to receive a screening has decreased, and the teleretinal screening participation is increasing. The current teleretinal screening program is effective in terms of being cost-effective and increasing population reach. Future screening policies should give consideration to the age of patients receiving screenings and the system's patient pool size because our results indicate it is not cost-effective to screen patients aged older than 80 years or in populations with <3500 patients.

Telemedicine for retinopathy of prematurity

To examine and review digital retinal imaging via telemedicine as an important screening and diagnostic tool in the management of retinopathy of prematurity (ROP). The use of wide-angle digital retinal photography to detect clinically significant ROP has been described in numerous reports since 2000. Comparisons with the gold standard of binocular indirect ophthalmoscopy have been favorable. Digital image capture can provide more objective information for disease detection, thereby facilitating internet consultation and retrospective analysis as part of the electronic medical record. As the presence of plus disease in ROP is now the most important criteria for determining the need for laser treatment, computer-based image analysis can potentially provide additional benefit to digital retinal imaging. Telemedicine screening also allows for the extension of diagnostic expertise to underserved areas in both the developed and third world. The role of telemedicine in ROP education will impact both screening efforts and traditional fellowship training in future years. As the worldwide incidence of ROP continues to rise, the use of telemedicine for screening, diagnostic and educational purposes will assume increasing importance in the delivery of healthcare for premature infants.

Telemedicine screening for diagnosis of retinopathy of prematurity in clinical practice

AbstractPurpose To compare the Retcam Shuttle used in telemedicine and performed by a non‐ophthalmologist with the “gold standard” of binocular indirect ophthalmoscopy performed by a referent ophthalmologist for the diagnostic of retinopathy of prematurity.Methods Retrospective analysis of the archival data gathered in 18 months between 1 May 2011 and 1 November 2012 in two centers: one practicing telemedicine and one using indirect ophthalmoscopy. The same ophthalmologist was reading the images obtained by Retcam in the first center and performing the fundus examination in the other center. A total of 255 infants were examined, 74 by Retcam and 181 by indirect ophthalmoscopy, resulting in 570 examinations (141 and 429 respectively).Results The mean birth weight of the infants was 1300 grammes (SD 340 grammes) in the center practicing telemedicine and 1130 grammes (SD 440 grammes) in the center using indirect ophthalmocopy. The mean gestational age were 28 weeks (SD 12 days) and 27 weeks (SD 19 days) respectively. A total of 1.8 examinations per infant were performed in the center practicing telemedicine, 2.4 in the other one. Retinopathy of prematurity was diagnosed in 13% of infants of the center using telemedicine and 20% of the other one.Conclusion Telemedicine can be useful to diagnose retinopathy of prematurity especially in remote areas but it seems to have a lack of sensibility. A very tiny collaboration between the center practicing telemedicine and the ophthalmologist should be sought to improve the results of screening.

Telemedicine Screening for Cytomegalovirus Retinitis Using Digital Fundus Photography

Screening for cytomegalovirus retinitis (CMVR) is important in patients with acquired immune deficiency syndrome and low CD4(+) counts. However, many human immunodeficiency virus (HIV) patients lack access to specialist ophthalmological care. Telemedicine screening is a cost-effective method for screening these patients. We aimed to report the use of composite nine-field digital fundus photography (DFP) images for CMVR screening. We report its sensitivity and specificity in detecting CMVR and the level of agreement with gold-standard binocular indirect ophthalmoscopy. An audit was performed on our national CMVR screening program that screened all HIV patients referred to the Ophthalmology Department at Tan Tock Seng Hospital, Singapore. All patients underwent retinal screening with DFP. Images were categorized as CMVR-positive, CMVR-negative, suspicious, or unreadable by blinded retinal specialists. Patients subsequently underwent dilated gold-standard indirect ophthalmoscopy by a different retinal specialist. Diagnoses were categorized as CMVR-positive, CMVR-negative, or unreadable. Sensitivity and specificity of retinal findings on DFP and kappa values for level of agreement between the two screening methods were calculated. Three hundred seventy screenings on 188 patients were performed. Twenty-three eyes diagnosed with CMVR on indirect ophthalmoscopy were also identified on DFP (100% sensitivity). A 99.9% specificity was achieved. The fundus photograph of one eye without CMVR was read as CMVR-positive because of an artifact, accounting for a false-positive. Kappa values ranged from 0.739 to 0.987. DFP is a sensitive and specific method of screening HIV patients for CMVR and has a high level of agreement with indirect ophthalmoscopy.

Fundus Autofluorescence and Colour Fundus Imaging Compared During Telemedicine Screening in Patients with Diabetes

We investigated the use of fundus autofluorescence (FAF) imaging in screening the eyes of patients with diabetes. Images were obtained from 50 patients with type 2 diabetes undergoing telemedicine screening with colour fundus imaging. The colour and FAF images were obtained with a 15.1 megapixel non-mydriatic retinal camera. Colour and FAF images were compared for pathology seen in nonproliferative and proliferative diabetic retinopathy (NPDR and PDR, respectively). A qualitative assessment was made of the ease of detecting early retinopathy changes and the extent of existing retinopathy. The mean age of the patients was 47 years, most were male (82%) and most were African American (68%). Their mean visual acuity was 20/45 and their mean intraocular pressure was 14.3 mm Hg. Thirty-eight eyes (76%) did not show any diabetic retinopathy changes on colour or FAF imaging. Seven patients (14%) met the criteria for NPDR and five (10%) for severe NPDR or PDR. The most common findings were microaneurysms, hard exudates and intra-retinal haemorrhages (IRH) (n = 6 for each). IRH, microaneurysms and chorioretinal scars were more easily visible on FAF images. Hard exudates, pre-retinal haemorrhage and fibrosis, macular oedema and Hollenhorst plaque were easier to identify on colour photographs. The value of FAF imaging as a complementary technique to colour fundus imaging in detecting diabetic retinopathy during ocular screening warrants further investigation.

The Cost-Effectiveness of Prenatal Detection for Congenital Heart Disease Using Telemedicine Screening

We estimated the longer-term cost-effectiveness of using telemedicine screening for prenatal detection of congenital heart disease (CHD). One hospital in south-east England with a telemedicine service was connected to a fetal cardiology unit in London. A UK health service perspective was adopted. Evidence on costs and outcomes for standard-risk pregnant women during the antenatal period was based on patient-level data. Extrapolation beyond the end of the study (just after delivery) was carried out for the lifetime of children born with and without CHD. Expert opinion and data from published sources was used to populate a decision model. Future costs and benefits were discounted. The main outcome was quality-adjusted life years (QALYs) and results were expressed as cost per QALY gained. Various one-way sensitivity analyses were conducted. The model showed that offering telemedicine screening by specialists to all standard-risk pregnant women was the dominant strategy (i.e. cheaper and more effective). The sensitivity analyses found that the model was robust, and that telemedicine remained the most cost-effective strategy. The study showed that it would be cost-effective to provide telemedicine examinations as part of an antenatal screening programme for all standard-risk women.

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): Four-years of Screening with Telemedicine

Purpose: To report the four-year experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative, which was developed to reduce the risk of blindness from retinopathy of prematurity (ROP).Materials and methods: A retrospective analysis of the SUNDROP archival data between 12/1/2005 and 11/30/2009. A total of 410 consecutively enrolled infants meeting ROP screening criteria had nurse-obtained fundoscopic images evaluated remotely by an ROP specialist. Every infant then received at least one dilated bedside binocular indirect ophthalmoscope (BIO) examination within one week of discharge. All infants were then followed with both telemedicine images and bedside evaluation in clinic according to recommended screening timelines. Primary outcomes were treatment-warranted ROP (TW-ROP), defined as Early Treatment of ROP Type 1, and adverse anatomical outcomes.Results: The SUNDROP telemedicine screening initiative has not missed any TW-ROP in its four-year evaluation period. A total of 410 infants (820 eyes) were imaged, resulting in 1486 examinations and 18,097 unique images. An average of 12.2 images were obtained per patient. Fourteen infants met TW-ROP criteria on telemedicine examination. After bedside evaluation, 13 infants required laser photocoagulation and one was followed until he spontaneously regressed. Infants with TW-ROP had a significantly lower gestational age (24.9 weeks), birth weight (658.7 grams), and were more likely to be male than the no TW-ROP cohort (all p values <0.00001). Telemedicine had a calculated sensitivity of 100%, specificity of 99.8%, positive predicative value of 92.9% and negative predictive value of 100% for the detection of TW-ROP. No patient progressed to retinal detachment or any adverse anatomical outcome.Conclusions: The SUNDROP initiative demonstrated a high degree of diagnostic reliability and was able to capture all infants with TW-ROP. Telemedicine offers a cost-effective, reliable and accurate screening methodology for identifying infants with TW-ROP without sacrificing quality of care.

Telemedicine detection of type 1 ROP in a distant neonatal intensive care unit

To demonstrate the feasibility of telemedicine screening for retinopathy of prematurity (ROP) by summarizing the results of our experience screening premature infants at a distant hospital in a rural location. Records of all premature infants remotely screened for ROP at a neonatal intensive care unit in Great Falls, Montana, from January 1, 2007 to June 30, 2011, were retrospectively reviewed. The RetCam II imaging system was used to capture retinal images, which were posted on a secure server for evaluation by one of two pediatric ophthalmologists. Infants suspected of having ROP approaching the criteria for laser treatment were transferred to a hospital, where a diagnostic examination was performed and treatment administered when indicated. All other infants received an outpatient diagnostic examination within 2 weeks of discharge. A total of 582 telemedicine examinations were performed on 137 infants during the study period. Of 13 infants transferred for referral-warranted ROP, 9 ultimately required laser treatment. Good outcomes were noted in all cases, with none progressing to stage 4 or 5 ROP. Telemedicine ROP screening detected patients at a remote site in need of laser treatment, allowing prompt transfer with no poor outcomes over a 4.5-year period. Our experience demonstrates the utility of remote screening for ROP.

Telemedicine screening for retinopathy of prematurity: Novel use of a live connection

Telemedicine screening for retinopathy of prematurity: Novel use of a live connection

The cost-effectiveness of three screening alternatives for people with diabetes with no or early diabetic retinopathy.

To determine whether biennial eye evaluation or telemedicine screening are cost-effective alternatives to current recommendations for the estimated 10 million people aged 30-84 with diabetes but no or minimal diabetic retinopathy. United Kingdom Prospective Diabetes Study, National Health and Nutrition Examination Survey, American Academy of Ophthalmology Preferred Practice Patterns, Medicare Payment Schedule. Cost-effectiveness Monte Carlo simulation. Literature review, analysis of existing surveys. Biennial eye evaluation was the most cost-effective treatment option when the ability to detect other eye conditions was included in the model. Telemedicine was most cost-effective when other eye conditions were not considered or when telemedicine was assumed to detect refractive error. The current annual eye evaluation recommendation was costly compared with either treatment alternative. Self-referral was most cost-effective up to a willingness to pay (WTP) of U.S.$37,600, with either biennial or annual evaluation most cost-effective at higher WTP levels. Annual eye evaluations are costly and add little benefit compared with either plausible alternative. More research on the ability of telemedicine to detect other eye conditions is needed to determine whether it is more cost-effective than biennial eye evaluation.

Telemedicine screening for ROP in Montana

Purpose: To demonstrate the feasibility of telemedicine screening for retinopathy of prematurity (ROP) by summarizing the results of our 3.5-year experience screening premature infants at a distant hospital in a rural western state.

Applying newer technology to your practice in pediatric ophthalmology and strabismus

Relevance: Imaging modalities like optical coherence tomography enable us to view and document details of ocular anatomy. These tools which are commonly used by our colleagues in cornea, glaucoma and retina, should be incorporated in the pediatric ophthalmology practice. Posterior segment OCT can be used to objectively monitor children with glaucoma, measure RNFL changes in papilledema or optic atrophy, study foveal morphology in diseases like retinoschisis. Anterior segment OCT can be used to assess anterior chamber depth, measure white-to-white distance, document the thickness of both the ciliary body and lens in children with anterior segment abnormalities. Newer technology now allow us to acquire high-quality ROP images, making telemedicine screening for ROP viable. Various computer programs have been developed to measure vascular dilation and/or tortuosity in premature infants. These measurements will be useful to study the evolution and mechanism of plus disease, correlate with prognosis and affect treatment decisions in ROP. RetCAM with fundal fluorescein angiography is useful in management of pediatric retina pathology. Extraocular muscle imaging by MRI is a valuable adjunct in evaluation of complex strabismus like myopic strabismus fixus, strabismus post endoscopic sinus surgery.

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): 36-Month Experience with Telemedicine Screening

to report the 36-month experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative. retrospective analysis of the SUNDROP archival data between December 1, 2005, and November 30, 2008, to evaluate this diagnostic technology for retinopathy of prematurity (ROP) screening. A total of 230 consecutively enrolled infants meeting ROP examination criteria were screened with the Ret-Cam II (Clarity Medical Systems, Pleasanton, CA) and evaluated by the SUNDROP reading center at Stanford University. Outcomes included referral-warranted ROP, treatment-warranted ROP, and anatomic outcomes. in the initial 36-month period, the SUNDROP telemedicine initiative did not miss any treatment-warranted ROP. A total of 230 infants (460 eyes) were imaged, resulting in 1,059 examinations and 10,921 unique images. Ten infants were identified with referral-warranted ROP: nine underwent laser photocoagulation and one regressed spontaneously. The sensitivity was 100% with a specificity of 99.5%. No patient progressed to retinal detachment or other adverse outcomes. the SUNDROP telemedicine screening initiative for ROP has demonstrated high reliability for identification of treatment-warranted disease. All cases of treatment-warranted disease were captured. There were no adverse outcomes.

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): 24‐month experience with telemedicine screening

To report the 24-month experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative. Retrospective analysis of the SUNDROP archival data gathered between 1 December 2005 and 30 November 2007 to evaluate this diagnostic technology for ROP screening. One hundred and sixty consecutively enrolled infants meeting ROP examination criteria were screened with the RetCam II and evaluated by the SUNDROP reading centre at Stanford University. Nurses obtained five or six images in each eye. All patients also received a dilated examination within 1 week of discharge. Outcomes included treatment-warranted retinopathy of prematurity (TW-ROP) and anatomical outcomes. In the initial 24-month period, the SUNDROP telemedicine initiative has not missed any TW-ROP. A total of 160 infants (320 eyes) were imaged, resulting in 669 exams and 7556 images. Seven infants were identified with TW-ROP; six underwent laser photocoagulation and one regressed spontaneously. The sensitivity was 100%, with specificity of 99.4%. No patient progressed to retinal detachment or other adverse outcomes. The SUNDROP telemedicine screening initiative for ROP has been proven to have a high degree of sensitivity and specificity for the identification of treatment-warranted disease. All cases of treatment-warranted disease were captured. There were no adverse outcomes.

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): 18-month experience with telemedicine screening

To report the 18-month experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative. Retrospective analysis of the SUNDROP archival data between 1 December 2005 and 30 May 2007, evaluating this new diagnostic technology for ROP screening. All 97 consecutively enrolled infants in the SUNDROP network. All patients were screened using the RetCam II, and evaluated by the SUNDROP reading center at Stanford University. Nurses were trained to obtain five images in each eye. All patients were screened by an ophthalmologist trained in diagnosing ROP within 1 week of discharge from the hospital. Outcomes included referral-warranted disease, need for treatment, and anatomic outcomes. Referral-warranted disease was defined as any Early Treatment Retinopathy of Prematurity Disease Type 2 or greater, threshold disease, any plus disease, and any stage 4 or higher disease. In the initial 18-month period, the SUNDROP telemedicine screening initiative has not missed any referral-warranted disease for ROP. A total of 97 infants (194 eyes) were enrolled, resulting in 443 unique examinations and 4,929 unique images. The mean birth weight of the infants was 1,186.9 grams, with a mean gestational age at birth of 28.9 weeks. Seven infants were identified with referral-warranted disease; six patients underwent laser photocoagulation and completely regressed. The one remaining patient regressed spontaneously, and did not require intervention. Calculated sensitivity and specificity was 100% and 98.9% respectively. No patient progressed to retinal detachment or other adverse outcome. Inadequate exposure, artifact, poor visualization of the periphery, and lack of a complete standardized image set in some patients were identified as areas requiring further assessment. The SUNDROP telemedicine screening initiative for ROP has proven to have a high degree of sensitivity and specificity for identification of referral-warranted disease. Training was easily implemented. All cases of referral-warranted disease were captured. There were no adverse outcomes.

Methods of screening

AbstractDiabetic retinopathy (DR) is one of the leading causes of adult blindness in working age population worldwide due to its late diagnosis and treatment. In effort to early detect DR, before visual loss, international guidelines for DR screening recommend an annual fundus examination for all diabetic patients. A variety of techniques can be used to detect and classify DR, including direct and indirect ophthalmoscopy, stereoscopic color film fundus photography, mydriatic and nonmydriatic (NM) digital color and monocromatic photography. Although ophthalmoscopy is the most commonly used technique to screen for DR, it has poor sensitivity when performed by nonophthalmologists in nonmydriatic conditions. The sensitivity of direct ophthalmoscopy in detecting proliferative DR is about 50% when performed by non‐ophtahlmologists in NM conditions. Seven‐field stereoscopic color fundus photographies have been considered as reference standard for diagnosing DR in randomized clinical trials. But this method is time consuming with uncertain practicity for widespread screening programs. Several studies have reported sensitivity and specificity in detecting DR and diabetic macular edema (DME) using limited number of fundus fields, proposing an alternative method for diabetic retinopathy evaluation to the ETDRS 7 fields. Recently introduced telemedicine screening programs based on digital images have the potential to allow for increased detection of DR, resulting in timely treatment and preservation of vision. Also important cost savings have been reported with DR screening, either by manual (human) or automatic (computer‐based) grading. Therefore, there is a critical need for a sensitive, specificic and cost‐effective screening method.

Detección de glaucoma mediante telemedicina con SisGlaTel: satisfacción y aceptación entre los participantes y problemas detectados

To evaluate the problems, and the degree of acceptability and satisfaction among participants in a telemedicine screening program. This study forms part of a global project for the design, implementation and evaluation of SisGlaTel funded by the Fondo de Investigaciones Sanitarias (Spain) and Pfizer Ophthalmics. A telemedicine system was built based on a specific program written in JAVA. The remote station was located at a Primary Care Center. Participants signed an informed consent, and completed a questionnaire and undertook different tests (frequency doubling perimetry-FDT, confocal scanning laser tomografy-HRT and tonometry). Test results and problems detected were analysed. Ninety-nine subjects completed a satisfaction questionnaire after voluntarily participating in the screening program among an at-risk population. The questionnaire included 7 questions, four of which required participants to categorise their responses, ranging from very bad (1) to excellent (5), to questions about the screening program, its usefulness, the care received and the installations. Six hundred and forty-one at-risk subjects were examined. After 2 exams per eye, 22.3% (143) presented abnormal FDT and 4.2% (27) had pathologic HRT. One hundred percent of respondents affirmed they would participate again in a similar program. The mean qualification (SD) was 4.5 (0.6), 4.5 (0.6), 4.8 (0.5), and 4.3 (0.7) for global opinion, usefulness, care and equipment. SisGlaTel allows integration of several diagnostic tests useful for glaucoma tele-screening. The global degree of satisfaction among participants was good.

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): 12-month experience with telemedicine screening

Background/aims:To report the 1-year experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative.Methods:Forty-two consecutively enrolled infants who met ROP examination criteria were screened between...

Telemedicine screening for retinopathy of prematurity in developing countries using digital retinal images: A feasibility project

To determine the feasibility in a middle-level human development country of onsite training, image collection, Internet transfer, and remote grading of digital retinal images from babies screened for retinopathy of prematurity (ROP). Two experienced nurses in a neonatal nursery in Lima, Peru, were trained to take posterior pole (30 degrees ) digital retinal images. Nurses obtained posterior pole retinal images from babies undergoing routine ROP screening and selected images for uploading via Internet for remote evaluation by five masked ROP experts. Results of gradings were compared with same-day clinical diagnostic examinations by an experienced ophthalmologist. Success rates for image acquisition and transfer for grading by expert readers were calculated. Serial image sets from 26 of the 28 babies enrolled in this study were obtained; two babies were too unstable for imaging. Fifty-six of 58 (96.6%) imaging sessions were successful in obtaining retinal images. Three hundred thirty of 336 (98.2%) images obtained were successfully uploaded to an interactive database. Remote graders judged 93.6% to 97.3% of image sets suitable for ROP grading. Preliminary results indicate sensitivities for detection of serious ROP from 45.5% to 95.2% among individual readers, with specificities of 61.7% to 96.2% when images were gradable. A telemedicine approach for ROP screening using digital retinal images obtained by nonophthalmologists is feasible in rapidly developing countries that lack ROP-trained ophthalmologists. If remote grading of digital images is validated as an effective method for identifying referral-warranted ROP (RW-ROP), images obtained by nonphysicians may provide a means of identifying babies who require a diagnostic examination by an ophthalmologist.

Advances in the management of retinopathy of prematurity

Retinopathy of prematurity is one of the leading causes of blindness in medically advanced countries and is becoming more prevalent in developing countries. It affects premature infants and may result in retinal detachment and significant visual impairment. Management of retinopathy of prematurity begins in the nursery with screening and follow-up examinations. When required, prompt treatment is carried out via laser diode photoablation of the avascular retina to prevent retinal detachment. Treatment prior to threshold is more effective in preventing retinal detachment and vitrectomy is effective for some cases of stage 4 disease. Telemedicine screening is evolving and may have particular application for underserved areas. Novel treatments are under investigation and show promising results in animal studies.