Telemedicine Eases Rising Burden of Macular Degeneration

Damian McNamara

October 01, 2013

HAMBURG, Germany — Telemedicine is as effective as a face-to-face office consultation for the follow-up evaluation of patients with age-related macular degeneration. Retreatment decisions made during office consultations and those made by a remote ophthalmologist were in agreement 90% of the time, a new study has found.

A benefit of telemedicine is that patients can be assessed faster, which "should allow ophthalmologists to evaluate a greater number of cases and therefore improve the follow-up of patients with wet macular degeneration," said José Andonegui Navarro, MD, from the ophthalmology service at Hospital de Navarra, in Pamplona, Spain.

The effectiveness of vascular endothelial growth-factor inhibitors combined with an aging population and the chronic nature of treatment for neovascular age-related macular degeneration has led to an increasing number of patients requiring evaluation for recurrence and retreatment. Telemedicine offers an innovative technologic solution to this clinical conundrum, Dr. Andonegui Navarro explained.

He presented the study results here at the 13th EURETINA Congress.

Dr. Andonegui Navarro and his team evaluated 185 patients, 79 men and 106 women, with a mean age of 81 years (range, 64 to 96 years), who had received at least 3 injections of ranibizumab (Lucentis, Novartis, Genentech).

 
It is good for patients and doctors and an example of how we can save time.
 

Office assessment included visual acuity measurement, optical coherence tomography, fundus evaluation, and digital images. Remote evaluation weeks later included a review of the visual acuity findings and digital data related to each patient.

The office-based retinal specialists recommended retreatment for 76 patients (41%) and determined that the remaining 109 patients (59%) did not require reinjection.

Remote decisions differed in 19 cases (10%). With office evaluation as the gold standard, remote assessments yielded a false-negative rate of 1.6% (3 false-negative findings) and a false-positive rate of 8.6% (16 false-positive findings).

"We consider both these rates to be acceptable," Dr. Andonegui Navarro noted.

Table. Remote Assessments Compared With the Gold-Standard Office Evaluation

Performance Measure Percent
Sensitivity 96
Specificity 87
Positive-predictive value 82
Negative-predictive value 97

 

"The most surprising result has been the mean time spent in the remote assessment of the patients," he said. The mean of 1 minute and 21 seconds "compares favorably with the 10 minutes assigned for office evaluation of these patients." The difference was statistically significant (P < .00001).

"This is a good study that can help with the follow-up of patients. It is good for patients and doctors and an example of how we can save time," said Marcio Nehemy, MD, from the Department of Ophthalmology at Federal University of Minas Gerais School of Medicine Belo Horizonte in Brazil.

Although the telemedicine strategy has potential, "it will be necessary to check how it works in the real world," he told by Medscape Medical News.

Retinographies and optical coherence tomography images were converted to digital imaging and communication in medicine (DICOM) files and stored in a picture archiving and communication system (PACS) server. A DICOM visualizer allowed ophthalmologists to remotely access images on the server.

The technology offers a lot of flexibility, Dr. Andonegui Navarro said. "We can evaluate images at full screen, can travel through different sections of the tomography images, and can use magnification to further explore areas of the retina we are interested in."

To standardize recommendations in this study, retreatment criteria were prespecified. Optical coherence tomography had to detect persistent macular fluid, 1 line of vision loss associated with macular fluid, or new-onset macular hemorrhage.

This telemedicine model "can be a useful alternative for exudative macular degeneration follow-up," Dr. Andonegui Navarro said. In addition, because all diagnostic images are stored on the PACS server, they can be used for future epidemiologic or research studies.

This study was funded by grants from the Health Institute Carlos III of the Spanish Government and Novartis Spain. Dr. Andonegui Navarro has disclosed no relevant financial relationships. Dr. Nehemy is a consultant for Bayer, Novartis, and Alcon.

13th EURETINA Congress. Presented September 27, 2013.

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