TELE OPHTHALMOLOGY IN PRIMARY COMMUNITY EYE CARE

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Dr R V Ramani Sankara Eye Care Institutions- India
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Telemedicine

• Ability to provide interactive health care
  utilizing modern technology and
  telecommunications.
• Allows patients to visit with Physicians live
  over video
• or
• Captured and stored data are sent to the
  physician for diagnosis and treatment at a later
  time

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Why Tele-Ophthalmology ?

• Ophthalmology relies heavily on the images of the
  eye for diagnosis and treatment
• Multimedia Medical information as an alternative
  to physically transporting patients and eye care
  professionals
• A physician extender
• Great potential in rural areas to improve
  quality, access and affordability of eye care
• Effective supplement not alternative

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T.O. is........

• Eye Care freed of Geographic borders and
  personnel shortage leading to economical, wide
  spread screening, diagnosis and treatment.

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Looking back.....

• NASA -1987 Monitored Retinal vessels during space
  flights
• Distance diagnosis since the days of telegraph

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The Paraphernalia

• Large external peripherals to visualize a small
  enclosed part of human anatomy

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T-O Applications

• Both clinical and educational processes between
  the send and the receive sites which includes
• Screening of the disease
• Diagnosis and clinical management plan
• Secondary advice and support in clinical
  management
• Peer supervision and support
• Professional development through group
  discussions lectures and tutorials
• Research and administration activities

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Considerations for T-O

• Safety
• Practicality
• Appropriateness
• Acceptability
• Limitation
• Cost

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T-O Systems

• 1. Store and Forward Asynchronous relay of
  data.
• Medical Info acquired in one place, stored
  digitally in a computer, then transmitted at a
  later time to another location where it is stored
  and reviewed E.g.. Email
• 2. Real-time - Works Synchronously with speakers
  microphones and TV Cameras
• 3. Hybrid - combines 1 2- Ideal system

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T-O Image acquisition

• Three perspectives
• Anterior Chamber Slit lamp, the primary
  tool
• Posterior Chamber Fundus Camera, Direct
  Indirect ophthalmoscope
• External Digital Camera

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Community Eye Care

• Community eye care could be defined as providing
  high quality, cost effective, readily available
  eye care at the doorsteps of rural India.

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Blindness a challenge

• 45 million in India are visually impaired
• 12 million totally blind
• ¼th of the worlds population of blind are in
  India
• Majority of them are needlessly blind
• 80 live in rural areas

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• Solution lies in providing effective primary eye
  care at the village level.

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Primary Eye Care
Vision Centre
Primary Eye Care Centre
Involving an Ophthalmic Assistant
Involving a Vision Guardian
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Vision Centre

• One for 50,000 population in 10-15 villages
  manned by an ophthalmic Assistant.
• Trained for 18 months
• to take up Refraction, Referral, Review
  Rehabilitation

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Primary Eye Care Centre

• One Vision Guardian for 25,000 population
• In 5 to 7 Villages
• A plus 2 passed local girl
• 20 to 30 yrs of age
• Vision guardian moves around and establishes
  vision registry
• Refer patients
• Timely referral during emergencies
• Facilitates review
• Single contact point for Eye Care

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one T-O Centre

• For every 4 primary eye care centres
• Covering a population of 1 lakh
• Involving the co-ordination of 4 vision guardians

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Tele-Ophthalmology Infrastructure and Technology
Fixed Unit
Mobile Unit
Equipment
Building
Human Resource
Equipment
Van
Human Resource
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Infrastructure

• Fixed Facility 12 x 12' Room,
• Electrical backup/UPS
• Internet Connectivity
• Equipment
• Easy access to the presenter patient
  peripherals computers
• Lighting - Dim for computer Images
• higher illumination for video conferencing
• Acoustics closed door

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Mobile Unit

• A large van
• With dish antenna
• Examination room
• Electrical backup ups

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Van-disadvantages

• Huge size and dish antenna
• Navigating through narrow village road
• Acceptance level
• Logistics
• cost

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Protocols for T-O

• Well defined Protocols for supporting Tele
  Ophthalmology team members

Protocol
Clinical
Technical
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Clinical Protocol

• Collecting Clinical data
• Patient referral
• Consultants reporting
• Needs organized intensive
• training and orientation

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Technical Protocol

• Operation of the hardware and
• Software
• Data compilation
• Archiving
• Transmitting

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T-O presenter room layout

• 12' x 12' Room
• A - desktop computer with real time video
  conferencing store and forward software
• B Video camera on top of the monitor
• C Fundus camera
• D Slit lamp
• E Presenters revolving stool
• F Patient's stool

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Ideal System

• One digital camera with good resolution, zoom and
  macro for external images
• Attachment to slit lamp to capture intra ocular
  images
• Fundus camera

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Prerequisites

• T-O systems convert video signal to digital
  picture elements (pixels)

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Digital image quality

• Quality of the camera
• No. of pixels in the converted image
• No. of colors in each pixel
• Size of the screen
• Quality of the monitors phosphor display

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Benefits to the patients

• Less of traveling
• Decreased waiting time in the hospital OPDs
• Less of disruption of his normal routine
• Literally at their doorsteps

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Benefits to the specialists

• Minimizing consultants traveling cost
• More time to see the patients
• Increased efficiency in using consultants time
  and expertise
• Improvement in skill transfer and education

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T-O can cover.

• Cataract
• Cornea Especially long-term
• follow-up of the KP patient
• Glaucoma
• Retina
• Squint
• Childhood blindness

Cataract
Glaucoma
Squint
95 agreement with Tele Diagnosis
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Barriers

• T-O in experimental phase
• Steep learning curve for the remote presenter
• Cost of converting ophthalmic peripherals to
  digital
• Overall cost of equipments, systems , man power
  and recurring expenditure
• Inconvenience (Mindset)
• T-O is a new field Physicians unaccustomed to
  T-O perceive it as inconvenient barrier to pts.
  Will resolve with familiarity of the system
• Technical
• startup technical problems integrating hardware
  software with existing systems
• Logistics problems
• Coordination between the remote presenter and the
  consultant
• Lack of connectivity infrastructure like high
  speed telephonic lines cables, restrict
  connectivity.
• Acceptance in the community

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Can T.O be cost effective ?

• Yes

• For education
• Second opinion and
• Expert advice

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Cost effective approach

• T-O need not only be with a large van or a fixed
  facility
• Within limitations individuals can maximize IT
• Retnet India Yahoo group established by Dr
  Mahesh Shanmugam of Sankara Eye Hospital,
  Bangalore
• Open to all Retinal consultants
• Around 245 of them from different countries
  presently participate
• First response within 4 hours
• Totally free
• Cyber Sight by Orbis
• Dr. Helvesten replies within 48 hrs with a
  surgical plan once we post images of the patient
  with Squint.

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Primary Eye Care T-O

• Primary Eye Care - huge need
• Eye care professionals limited number in the
  country
• In-order to maximize output with existing
  expertise,
• Reaching out through T-O would be ideal
• Though T-O cannot replace traditional eye care
• Over the years
• with better connectivity
• advanced technology
• lowered cost
• Tele-Ophthalmology holds promises to
• Primary Eye Care in rural India