Chris J. Rudnisky

Improving Access to Eye Care: Teleophthalmology in Alberta, Canada

Background: Diabetic retinopathy in Alberta and throughout Canada is common, with a prevalence up to 40% in people with diabetes. Unfortunately, due to travel distance, time, and expense, a third of patients with diabetes do not receive annual dilated eye examinations by ophthalmologists, despite universal health care access. In an effort to improve access, a teleophthalmology program was developed to overcome barriers to eye care. Prior to clinical implementation, teleophthalmology technology was clinically validated for the identification of treatable levels of diabetic retinopathy. Method: Patients undergoing a teleophthalmology assessment underwent stereoscopic digital retinal photographs following pupillary dilation. Digital images were then packaged into an encrypted password-protected compressed file for uploading onto a secure server. Images were digitally unpackaged for review as a stereoscopic digital slide show and graded with a modified Early Treatment Diabetic Retinopathy Study algorithm. Reports were then generated automatically as a PDF file and sent back to the referring physician. Results: Teleophthalmology programs in Alberta have assessed more than 5500 patients (9016 visits) to date. Nine hundred thirty patients have been referred for additional testing or treatment. Approximately 2% of teleophthalmology assessments have required referral for in-person examination due to ungradable image sets, most commonly due to cataract, corneal drying, or asteroid hyalosis. Conclusions: In Alberta and throughout Canada, many patients with diabetes do not receive an annual dilated eye examination. Teleophthalmology is beneficial because patients can be assessed within their own communities. This decreases the time to treatment, allows treated patients to be followed remotely, and prevents unnecessary referrals. Health care costs may be reduced by the introduction of comprehensive teleophthalmology examinations by enabling testing and treatment to be planned prior to the patients first visit.

Optometric Referrals to Retina Specialists: Evaluation and Triage via Teleophthalmology

A retrospective noncomparative consecutive case series was conducted to evaluate the clinical outcomes of a novel teleophthalmology program linking optometrists to retina specialists in Alberta, Canada. One hundred seventy-one patients, referred by optometrists via teleophthalmology to a group retina practice between June 2004 and May 2006 underwent stereoscopic, mydriatic digital photography. Images were transmitted to a secure Web server and analyzed by a retina specialist. Diagnosis and recommendations were sent back to the optometrist and, if necessary, patients were referred for additional testing and clinical evaluation. A chart review of all clinical encounters was performed and the data was tabulated. Demographic features, diagnosis, testing, treatment, distance and time traveled by patient, durations between telemedicine referral, teleophthalmology consultation, in-person consultation, testing, and treatment were recorded. One hundred seventy patients were assessed via teleophthalmology for a total of 190 consultations. Eighty-nine patients (52.0%) required conventional in-person consultation with a referral completion success of 92.1% (82 patients). Fifty of these patients underwent additional diagnostic testing including fluorescein angiography (41), optical coherence tomography (14), laboratory testing (5), visual fields (2), carotid Doppler ultrasound (2), and ocular ultrasound (2). Twenty-five patients required surgical or medical treatment including focal argon laser (10), photodynamic therapy (8), panretinal photocoagulation (2), vitrectomy (2), scleral buckle (1), and other procedures (8). Average wait time between telemedicine referral and teleophthalmology review of images by the retina specialist was 1.9 days (maximum = 20 days). For those patients requiring office evaluation, the average wait time between teleophthalmology referral and in-person evaluation was 25.1 days. Twenty-one of the 25 patients (84.0%) requiring treatment underwent examination, testing, and treatment in a single day. When compared to conventional consultation methods, teleophthalmology reduced average travel distance and time by 219.1 km and 2.7 hours, respectively. Teleophthalmology reduced office visits to the retina specialist by 48% while improving the efficiency of clinical examination, testing, and treatment. Patients benefited through reduced travel time and distance.

Tele-Ophthalmology via Stereoscopic Digital Imaging: A Pilot Project

Diabetic eye disease is present in remote communities across Canada. A pilot study was designed to assess the feasibility of stereoscopic digital imaging to identify levels of diabetic retinopathy via teleophthalmology. Diabetic patients were assessed for diabetic retinopathy by seven field stereoscopic digital imaging through a dilated pupil. Images were transferred by satellite to a tertiary eye center for review by a retinal specialist. Images were viewed stereoscopically on a video monitor, with grading of all images using a modified Early Treatment Diabetic Retinopathy Study (ETDRS) classification. Patients found to have treatable diabetic retinopathy were transferred to a tertiary eye center for assessment and treatment by a retinal specialist. One hundred patients (199 eyes) had stereoscopic digital imaging of the retina. Microaneurysms were identified in 70 eyes, hard exudates in 31 eyes. Two eyes were identified with neovascularization of the disc (NVD) and 15 eyes with clinically significant macular edema (CSME). All eyes identified by stereoscopic digital imaging with treatable disease were confirmed by clinical examination with contact lens biomicroscopy. Stereoscopic digital imaging of the retina enables the identification of diabetic retinopathy. Further research is needed to delineate the sensitivity and specificity of stereoscopic digital imaging when compared to slide film and clinical examination.

Comparison of stereoscopic digital imaging and slide film photography in the identification of macular degeneration

BACKGROUNDnThis study compared the sensitivity and specificity of stereoscopic digital photography of the retina through a dilated pupil with a 45 degrees nonmydriatic camera and Joint Photographic Experts Group (JPEG) compression of the images with the sensitivity and specificity of 35-mm slide film photography in the identification of age-related macular degeneration (AMD).nnnMETHODSnConsecutive patients with a diagnosis of AMD were enrolled. Stereoscopic retinal images of the disc, macula and temporal macula were captured with a digital 45 degrees nonmydriatic camera (then compressed into JPEG format) and with a standard fundus camera and slide film. A single retinal specialist graded both image formats in masked fashion, at least 1 month apart, using a modified Age-Related Eye Disease Study (AREDS) severity scale. The digital images were displayed on a monitor and viewed with the use of liquid crystal display shutter glasses and stereo imaging software. The film images were mounted on a light box and graded with the use of a stereoviewer. Primary outcome measures included the presence or absence of AMD pathological features. Positive and negative predictive values (PPVs and NPVs), sensitivity, specificity and weighted kappaw statistics were calculated.nnnRESULTSnWe photographed 203 eyes (of 103 patients) with both digital and slide film cameras. Correlation of the 2 image formats was substantial in identifying AREDS level 3a or greater (kappaw=0.64, standard error=0.08, PPV=0.95, NPV=0.66, sensitivity=0.93, specificity=0.74) and excellent in identifying level 4b or greater (kappaw=0.83, standard error=0.05, PPV=0.81, NPV=0.98, sensitivity=0.94, specificity=0.94).nnnINTERPRETATIONnHigh-resolution stereoscopic, mydriatic, 45 degrees digital images captured with a nonmydriatic camera and JPEG compressed correlate well with stereoscopic slide film photographs in the identification of moderate to advanced AMD (AREDS level 3a or greater).

Discussing resident participation in cataract surgery

OBJECTIVEnTo investigate the proportion of patients who would consent to resident participation in cataract surgery.nnnSTUDY DESIGNnProspective observational case series.nnnPARTICIPANTSnConsecutive series of patients presenting for consideration of cataract surgery.nnnMETHODSnA specifically worded discussion of resident participation in cataract surgery was developed on the basis of literature recommendations and was used when obtaining consent for cataract surgery from eligible patients. The main outcome measure was the proportion of patients who consented to resident participation in their cataract surgery.nnnRESULTSnOf the 106 patients eligible for enrollment in the study, 101 (95.3%) consented to resident participation in their cataract surgery.nnnCONCLUSIONSnDespite suggestions in the previous literature to the contrary, surgeons can be reassured that the vast majority of patients, when informed by means of the wording described in this study, will consent to resident participation in their cataract surgery.

Prevalence and impact of depressive symptoms in patients with age-related macular degeneration.

OBJECTIVEnThis study sought to identify the point prevalence of depressive symptoms, quality-of-life (QOL) impairment, and demographic parameters associated with depression in patients with age-related macular degeneration (AMD) attending a retina clinic in Edmonton, Alberta.nnnDESIGNnA cross-sectional design was used.nnnMETHODSnConsecutive patients with AMD were invited to participate in the study. Demographic data, as well as ophthalmic, medical, and psychiatric histories, were collected. Participants completed the Center for Epidemiological Studies Depression Scale (CES-D) and the Visual Function Questionnaire (VFQ-25) scales to quantify the burden of depressive symptoms and vision-related QOL impairment.nnnRESULTSnThe study enrolled 101 patients, of whom 7 (6.9%) had a previous history of depression. Twenty (21.3%) of the remaining patients endorsed severe symptoms of depression that had not yet been diagnosed. Significant differences in vision-related QOL between depressed and not depressed patients were identified. Depressed patients were also found to have worse visual acuity (p = 0.047) and were less likely to live with others (p = 0.020) than those who were not depressed.nnnCONCLUSIONSnAfter excluding patients with a history of diagnosed depression, 20 (21.3%) patients demonstrated severe symptoms of depression. Development of depression screening protocols for patients with AMD would improve identification and referral of patients at risk. The finding that patients who lived with others had a lower prevalence of depressive symptoms suggests that further research into the relationship between mood symptoms and environmental supports is merited.

Prevalence and Severity of Diabetic Retinopathy in Northwest Cameroon as Identified by Teleophthalmology

OBJECTIVEnDiabetic retinopathy is a common ocular complication of diabetes mellitus, which can lead to significant visual impairment. The present study is the first to characterize the prevalence and severity of diabetic retinopathy and other ocular pathologies in a population of patients with diabetes who live in Northwest Cameroon using teleophthalmology.nnnMATERIALS AND METHODSnA retrospective review of the electronic charts of patients at the Banso Baptist Hospital and in neighboring communities between July 1, 2007 and June 30, 2008 was completed. The eyes of 253 consecutive patients with diabetes mellitus who attended mobile teleophthalmology clinics in Northwest Cameroon were included in the study. Eyes were graded for diabetic retinopathy using stereoscopic seven-field digital retinal images obtained by a mobile team in Cameroon and graded by ophthalmologists in Canada utilizing Early Treatment Diabetic Retinopathy Study criteria.nnnRESULTSnDiabetic retinopathy was identified in 20.6% of eyes (18.2% nonproliferative, 2.4% proliferative) and in 24.3% of patients. About 8.0% of eyes demonstrated evidence of macular edema. Additional nondiabetes-related ocular pathologies were identified in 14.6% of eyes.nnnCONCLUSIONSnDiabetic retinopathy was found to be common in people with diabetes who attended teleophthalmology clinics in Northwest Cameroon. The prevalence of treatable disease including macular edema and retinal neovascularization suggests that improved patient access to laser photocoagulation and vitreoretinal surgery would be beneficial in reducing vision loss in this vulnerable population. As the prevalence of diabetes increases across sub-Saharan Africa, the challenge of diagnosing and managing the complications of diabetes will increase.

The 1-year incidence of rhegmatogenous retinal detachment post 23-gauge pars plana vitrectomy

OBJECTIVEnThe purpose of this study was to evaluate the 1-year incidence of retinal tear or retinal detachment following 23-gauge pars plana vitrectomy (PPV) for epiretinal membrane (ERM), macular hole (MH), or vitreomacular traction (VMT).nnnMETHODSnA retrospective chart review of all patients who underwent 23-gauge PPV for ERM, MH, or VMT between January 1, 2007, and December 31, 2007, was performed. Inclusion criteria included age greater than 50 years and absence of other significant ocular pathology. Exclusion criteria included confounding retinal pathology, laser treatment at the time of surgery, previous laser treatment of the retina, or previous PPV.nnnRESULTSnA total of 272 eyes of 268 patients were eligible for inclusion: 159 eyes (58%) had the diagnosis of ERM; 108 (40%) had MH; and 5 (2%) had VMT. The average patient age was 70 years. Of the patients, 15 required additional surgery related to persistent macular pathology within 1 year (5 with ERM, 10 with MH). The incidence of retinal detachment after surgery was 1.1% (3 eyes of 3 patients). The mean time duration prior to development of retinal detachment was 159 days (range, 19 to 333 days).nnnCONCLUSIONSnThe 1-year incidence of rhegmatogenous retinal detachment post 23-gauge vitrectomy for repair of macular pathology without prophylactic laser of sclerotomy sites is approximately 1%.

Identification of ocular and auditory manifestations of congenital rubella syndrome in Mbingo

Purpose. Congenital rubella syndrome (CRS) is a global cause of preventable hearing impairment, blindness, and intellectual impairment. The present study sought to identify ocular and auditory manifestations of CRS in school-aged children in Mbingo, Cameroon. Design. Cross sectional study. Subjects. Students at two schools, one for children with hearing impairment, were screened for cataract, congenital glaucoma, and pigmentary retinopathy. Methods. Students underwent seven-field digital fundus photography through a dilated pupil using a Topcon NW200 nonmydriatic camera. Images were assessed by retina specialists in Canada via teleophthalmology. Clinical evidence was integrated to form case definitions for CRS based on Center for Disease Control and Prevention guidelines. Serological evidence of rubella infection was obtained using standardized IgG antibody titers. Main Outcome Measure. Number of probable and suspicious cases of CRS. Results. Between September 2009 and May 2010, 320 students participated. There were 28 (10.2%) probable cases, 104 (37.8%) suspects, and 143 (52.0%) unaffected. Rubella IgG serology was positive in 79 (48.7%) of children with hearing impairment and 11 (7.4%) of children with normal hearing. Conclusions. The present study identified 28 probable cases of CRS. Furthermore, 92.6% of students with normal hearing did not possess rubella IgG antibodies making future cases of CRS likely without intervention.

Visual and refractive outcomes following management of anterior capsular tears with a capsulorrhexis relaxing incision

OBJECTIVEnTo evaluate the refractive outcomes after anterior capsular tear (ACT).nnnDESIGNnRetrospective case-control study.nnnPARTICIPANTSnAfter ethics approval, the surgical operative records of 4301 consecutive patients undergoing cataract surgery by a single surgeon were reviewed for cases of ACT.nnnMETHODSnAll ACTs were managed using a balancing incision of the capsulorrhexis margin 180 degrees away from the tear. If the patients other eye had undergone cataract surgery by the same surgeon, it was included as a control.nnnRESULTSnFifty-one eyes of 51 patients were complicated by ACT (incidence = 1.2%). The mean age of patients in the study was 64.2 ± 12.1 years. Of the 51 patients with ACT, 34 underwent contralateral surgery. These eyes were used as the control group. There was no significant difference in preoperative visual acuity (p = 0.683) or proportion of eyes that received in-the-bag intraocular lens placement (p = 0.347) between groups (ACT = 92.2%; control = 97.1%). In 3 ACT eyes, the tear extended into the posterior capsule (5.9%), and although this did not occur in control eyes, this difference was not statistically significant (p = 0.150). There was no difference in best-corrected final logMAR visual acuity between groups (p = 0.424) or postoperative spherical equivalent between ACT (-0.23 ± 1.2D) and control (-0.15 ± 0.62D) eyes (p = 0.985).nnnCONCLUSIONSnCataract extraction complicated by ACT can result in equivalent visual and refractive outcomes as in uncomplicated surgery. The technique used in this study prevented extension of ACT to the posterior capsule in 94.1% of cases.