Telemedicine may play in the diagnosis of eye diseases

Two studies being presented at the American Academy of Ophthalmology's 2007 Annual Meeting suggest that telemedicine may have a significant role to play in the diagnosis of eye diseases, increased patient compliance and patient access to quality care.

In the first study, researchers examined the impact that telemedicine had on patients with diabetes being treated in multi-physician primary care practice. The study looked at the number of patients with diabetes over the course of a year who had the recommended retinal examination before the installation of a telemedicine remote imaging system in the practice versus the number of patients with diabetes who had a retinal examination in the two years following installation of the device.

"In the past, it has been shown that telemedicine is technically possible, but this study demonstrates the true impact of a telemedicine system on the number of patients with diabetes who end up having an evaluation for diabetic retinopathy," said Ingrid Zimmer-Galler, MD, assistant professor of ophthalmology at the Wilmer Eye Institute at the Johns Hopkins School of Medicine. "With this system, we've dramatically increased the rate of annual retinal evaluations."

In the first year, out of 1,257 diabetic patients in the study, only 15 percent had a retinal examination. Two years after implementation of the telemedicine system, 71 percent of the 1,395 diabetic patients in the practice had a retinal examination. Significantly, of the observed increase, 66 percent was due to an eye examination by a local ophthalmologist and only 33 percent was due to remote evaluation.

"It's very nice to see that increased rate of evaluations was not solely because these patients were undergoing remote imaging," said Dr. Zimmer- Galler. "It shows that by having this type of system in place, overall awareness of the problem increased and had a beneficial affect on all patients."

Increased awareness of the need for regular eye examinations by people with diabetics is important because of compliance issues among diabetics and the growing number of people with diabetes. Diabetic retinopathy affects an estimated 5.3 million people in the United States, as many as one-third of whom are unaware of their illness. People with diabetes are 25 times more likely to go blind than people who do not have the disease. Early detection and treatment of diabetic retinopathy significantly increases the chances of avoiding vision loss.

"There's been a tremendous push to raise diabetic retinopathy awareness and the need for regular eye examinations, but few other programs have demonstrated such a positive impact on overall rates of evaluation for diabetic retinopathy," said Dr. Zimmer-Galler.

Offering Quality Care to Premature Infants

In a second study presented at the annual meeting, researchers concluded that there was a high level of agreement between diagnoses of retinopathy of prematurity (ROP) made in low birth-weight babies using ophthalmoscopy and image-based telemedicine examinations.

"The number of premature infants is increasing throughout the world, and a larger percentage of them are surviving," said Michael Chiang, MD, assistant professor of ophthalmology and biomedical informatics at the Columbia University College of Physicians and Surgeons and presenting author of the paper. "The challenge is how do we make good care accessible to these babies. The purpose of this study was to see how well the results of telemedicine compared to those of an ophthalmoscopic examination."

Doctors at Columbia gathered data on 206 eyes from 67 prematurely born infants, performing up to two sets of examinations on each baby. In each instance, a pediatric ophthalmologist performed dilated indirect ophthalmoscopy on the infant to determine whether the baby had ROP. Diagnoses were classified in four categories: no ROP, mild ROP, type 2 prethreshold ROP, and treatment-requiring ROP.

Shortly after the physician's examination, a trained nurse captured retinal images of the same child using a wide-angle camera. A period of four to twelve months was allowed to elapse before images were shown to the same doctor who performed ophthalmoscopy, in order to minimize any chance that the examiner could remember details.

In 86 percent of the eyes, there was complete agreement between the diagnoses made by ophthalmoscopy and telemedicine. Among eyes where there was disagreement between the examination modalities, 12 cases involved clinically- significant discrepancies regarding presence of zone I disease or plus disease. Dr. Chiang suggests that telemedicine diagnosis may be more accurate in these cases, because images can be compared directly with standard photographic definitions of zone I or plus disease.

"Telemedicine exam may be more reproducible than if you see an infant's retina only briefly during ophthalmoscopy," he says. "There is a rationale that image-based examination may be better because findings are documented photographically. In many other ophthalmic diseases, definitions are based on standard images, so this has implications for the way we might deliver the best care to patients in the future."

About the American Academy of Ophthalmology

The American Academy of Ophthalmology is the world's largest association of eye physicians and surgeons-Eye M.D.s-with more than 27,000 members worldwide. Eye health care is provided by the three "O's" - opticians, optometrists and ophthalmologists. It is the ophthalmologist, or Eye M.D., who can treat it all: eye diseases and injuries, and perform eye surgery.

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