The Promise of Tele-ophthalmology
A pilot study in Scotland recently showed that in as many as half of cases, tele-ophthalmology practices can reduce wait time for eyecare patients while also eliminating the need for follow-up appointments
By Todd Farley
A pilot study in Scotland recently showed that in as many as half of cases, tele-ophthalmology practices can reduce wait time for eyecare patients while also eliminating the need for follow-up appointments. Those results — wherein Scottish patients in need of eyecare were seen remotely by an ophthalmologist via video feed — are not only promising but may one day soon become standard operating procedure for the entire nation.
“There might be obstacles,” says Iain Livingstone, MBChB, project lead and National Health Service (NHS) Forth Valley Consultant Ophthalmologist, “but we’d be disappointed if this wasn’t the standard in ophthalmology within five years.”
Accessing Specialists Remotely — and Securely
The tele-ophthalmology system at the heart of the recent study was developed in collaboration between the University of Strathclyde and NHS Forth Valley, which is one of the Scottish “health boards” that make up NHS Scotland. It entails using a slit-lamp microscope (which allows the entire eye, front and back, to be examined), a 3D printed bracket mount built at Strathclyde to maintain stability, and an iPad to provide a live video feed between the patient, the on-site clinician, and the remote ophthalmologist. The three components of the tele-ophthalmology system allow ophthalmologists to provide remote feedback to other eyecare providers and patients who might otherwise not have easy access to specialists.
“This means anyone with a serious eye problem who goes into the emergency department or to a nonspecialist eyecare provider such as an emergency optometrist can be seen directly by a specialist through tele-communications — and be diagnosed immediately,” says Mario Giardini, PhD, senior lecturer of Biomedical Engineering at the University of Strathclyde, who developed the system in conjunction with Dr. Livingstone.
Vitally, that telecommunication connection is also secure to medical standards.
“You couldn’t risk a medical consultation on Skype, for instance,” says Dr. Giardini. “But the conversations on our system are adequately encrypted and satisfy all the government’s prerequisites to ensure confidentiality for a medical consultation.”
“This ‘Attend Anywhere’ software has gone through quite a governance system and is the national tele-medicine platform adopted by the National Health Service in Scotland,” Dr. Livingstone confirms.
Increased Efficiency
If such advances in tele-ophthalmology seem promising, they are also necessary in Scotland because most patients experiencing an eyecare emergency there end up going to clinics or emergency departments where the “staff are not eye specialists,” Dr. Giardini says. Frequently in those situations the patient will then be sent to an emergency ophthalmologist at another facility, thus resulting in more travel and more waiting before adequate care is provided.
“With our tele-ophthalmology system, we are trying to obviate the problem with the current standard of care for emergency ophthalmology today in Scotland and in the United Kingdom,” says Dr. Giardini. “At least half of those second appointments are avoidable. If you manage to avoid that second referral, you have happier patients, but you’re also off-loading some of the work of the system.”
In NHS Forth Valley, tele-ophthalmology helps Dr. Livingstone handle what would otherwise be an overwhelming task. As the on-call ophthalmologist in a region that has 320,000 patients, using these new technologies allows him to provide specialized eyecare for the many clinics under his supervision.
“I can see what is happening in a patient’s eye through the magnified optics of a slit-lamp microscope feed,” Dr. Livingstone says. “And along with the audio conversation between the patient, the on-site clinician, and me — the ophthalmologist — we end up with an agile three-way conversation and a high-fidelity feed of the eye.”
The system, which has minimal technological requirements, can function on most devices, whether a laptop or smartphone, and on either a 4G or a WiFi connection. Using this system, the ophthalmologist can instruct the patient to move his eyes left or right or tilt his head forward or back, or apply eyedrops, all while viewing the patient’s eye over the video feed. As a result, the patient — regardless of what isolated section of Scotland he may be in or what remote clinic he may have ended up at — is able to receive a quick consult from an experienced ophthalmologist without having to travel anywhere else. The remote ophthalmologist can also call in prescriptions to those patients in need, saving those people from a secondary consult or visit.
“What we’ve learned is that between 50% to 70% of cases can be managed completely at a distance, without the patient having to go in for a second consultation,” Dr. Livingstone explains. “We can diagnose minor conditions or just say to the on-site optometrist, ‘See the patient again in three days or so, and if it’s not getting better, call me again.’ That basically saves secondary care appointments from having to happen.”
“A Deluge of Referrals”
Dr. Livingstone and his team are receiving numerous calls for consults from private care opticians and “High Street” (the name given to the large Scottish chains which offer eye exams, sell glasses, and even do some minor eye surgeries). Many of these practices have advanced OCT technology which performs a laser-like scan of the retina and produces an image of the patient’s macula, but often those organizations lack the personnel needed to properly read those scans. That has led to Dr. Livingstone and his team being on the receiving end of “a deluge of referrals” from High Street. Because they can view those scans (as well as a patient’s previous scans) remotely, the NHS Forth Valley staff are able to look for changes and possibly make decisions from afar that eliminate the need for secondary-care appointments.
“I’ve even diagnosed macular degeneration remotely,” Dr. Livingstone explains,” and been able to counsel the patient directly about injection service, meaning they don’t see an ophthalmologist but are seeing a nurse injector instead.”
From Africa to Scotland
The tele-ophthalmology system was borne of various technological advances, including the aforementioned “Attend Anywhere” software, high data transmission speeds, improvements in mobile audio and cameras, and the University of Strathclyde’s eye-imaging technology. Its genesis occurred around 2012, when Drs. Giardini and Livingstone were tasked with developing some “devices and technologies” for a large project focused on tropical medicine in sub-Saharan Africa. After that project concluded, Drs. Giardini and Livingstone continued their work, ultimately leading to some of the technologies they have incorporated into their tele-ophthalmology system.
“What happened was that we finished the project in Africa, and Iain had this opportunity to begin a pilot trial to effectively start trying tele-ophthalmology here in Scotland,” Dr. Giardini says. “He pulled me in to deliver some of the technologies being built at Strathclyde at this time.”
The entire project was funded by the Scottish government, which awarded £37,200 (about $41,000 US) to NHS Forth Valley through its Technology Enabled Care (TEC) Programme.
“We went from proposal to funding inside a month and a half,” Dr. Livingstone laughs, “which is quite a unique type of scenario, getting operational that quickly.”
Not a Replacement for Office Visits
Their first tele-ophthalmology test was run in 2014, between the United States and Scotland, when via mobile phone Dr. Livingstone in Glasgow was able to examine the retinal images of a collaborator in San Francisco. By 2018 technological improvements (including the design and production of the devices Dr. Giardini created at Strathclyde) led to the launch of the pilot study. Based on nearly 200 surveys done at NHS Forth Valley eye clinics, the results of that study indicate that using tele-ophthalmology can save Scottish patients from an unnecessary second eye appointment in as many as 50% of cases.
Scaling the study up to a national level would greatly increase the number of participants, but neither Dr. Giardini nor Dr. Livingstone imagine the results would change.
“This is only a pilot test, but tele-ophthalmology has become business as usual in NHS Forth Valley,” Dr. Livingstone explains. “Our consultant body of ten doctors have all learned and use the system.”
None of which is to say that anyone is suggesting tele-ophthalmology will one day replace visiting a live ophthalmologist if possible, as both men are clear to state.
“Tele-ophthalmology is not about trying over a video conversation to give a diagnosis that cannot be delivered over a video conversation,” Dr. Giardini asserts. “In other words, there are some safe things to do here, but 50% of patients still need an in-person consultation.”
For Dr. Livingstone, what tele-ophthalmology can’t deliver is providing him the context clues for diagnosis that an office visit does. A tele-ophthalmologist consult may show him a high-tech feed of a patient’s eye, in other words, but it wouldn’t allow him to see other symptoms that might affect his consult, things like a rash or shingles around a patient’s eye, the smell of alcohol emanating off a person, or the non-verbal messages being communicated by a family member.
“We need to be clear that there’s a trade-off between the safety of decision-making with tele-ophthalmology and the efficiency of decision-making,” Dr. Livingstone says. “Compared to a phone call, with tele-ophthalmology you miss much less and can do much more, but if you pose the question ‘how does a tele-ophthalmology video call compare to seeing a patient in person,’ that’s different. Video calls or tele-ophthalmology are set in the space between a phone call and an in-person review, but it doesn’t replace [an office visit].”
The Wave of the Future
In spite of the limits of tele-ophthalmology, Dr. Giardini and Dr. Livingstone are optimistic it will soon be the wave of the future in Scottish eyecare. Along with NHS Forth Valley, the program is being tried at four other NHS health boards, and patient satisfaction has been nearly universally positive. Long-term, the doctors imagine tele-ophthalmology will grow from being a local or regional practice and eventually turn into a national one, with Dr. Livingstone saying he pictured a future where newly-appointed consulting ophthalmologists would turn into the on-call tele-ophthalmologists of the entire nation.
Will that happen within the 5 years Dr. Livingstone predicted at the top of this story? Dr. Giardini isn’t so sure.
“I’d say five years is quite conservative in the sense that we are hoping to be faster than that,” he posits. “Actually, I’d say five years is a realistic but conservative estimate.”
