Teleophthalmology Tested for Managing Macular Degeneration

Larry Hand

December 12, 2014

Use of teleophthalmology could allow optometrists and community ophthalmologists to expand basic retinal services and let retina specialists focus on the more severe cases of age-related macular degeneration (AMD), according to an article published online December 4 in JAMA Ophthalmology.

Bo Li, MD, from the Ivey Eye Institute, Western University, London, Ontario, Canada, and colleagues conducted a prospective randomized trial involving 106 patients (106 eyes) referred for suspected neovascular AMD and 63 patients (63 eyes) with previously treated neovascular AMD. They randomly assigned patients into either routine care or teleophthalmologic care.

Both groups went to regular appointments at their respective locations for evaluation every 2 weeks for a year.

"To our knowledge, this is the first study that evaluated the use of teleophthalmology in the screening and monitoring of neovascular AMD," the researchers write.

The teleophthalmology patients experienced nonsignificant delays in days between diagnostic imaging and treatment, but the delays did not lead to any significant visual decline. On average, for the referral group, it took 22.5 days from referral to diagnostic imaging and 16.4 days from diagnostic imaging to treatment in the teleophthalmology group compared with 18.0 days from referral to diagnostic imaging and 11.6 days from diagnostic imaging to treatment in the routine care group.

Doing the diagnostic imaging in a community setting, rather than a specialist center, identified an overall 44% of false-positives in suspected AMD cases — patients who did not require specialist care at all.

In terms of accuracy, only 42.3% (44 of 106 patients) of suspected neovascular AMD cases turned out to be actual neovascular cases. Most other cases turned out to be dry AMD (34.6%, 36 patients), and other patients had other diagnoses.

Suspected Cases

Of the 106 suspected AMD cases, the researchers randomly assigned 54 to routine care at the Ivey center and 52 to teleophthalmology care at the Ocular Health Center in London, Ontario, a community-based stand-alone clinic run by community and general ophthalmologists. The study period lasted from November 1, 2011, to November 2, 2012.

The Ivey center patients received intravenous fluorescein angiography and optical coherence tomography (OCT) imaging of the macula. A retinal specialist also assessed patients individually for best corrected visual acuity and intraocular pressure, as well as by biomicroscopy and dilated indirect ophthalmoscopy.

The retinal specialists then made diagnoses in one of four categories: neovascular AMD, non-neovascular AMD, non-AMD-related, and untreatable disciform scarring.

The teleophthalmology patients received full evaluations, including for best corrected visual acuity and intraocular pressure and by color fundus photography and OCT of the macula. The clinic stored the images and patient data in a database, and retinal specialists could assess them and make diagnoses in the same four categories.

If patients had neovascular AMD diagnosis, there were insufficient data to make a diagnosis, or patients had a non-AMD diagnosis requiring treatment, they went to the Ivey center to see specialists.

Treated Cases

In the second group of the trial, involving 63 patients previously treated for neovascular AMD, the researchers randomly assigned 36 patients to routine monitoring for recurrence at the Ivey center and 27 patients to teleophthalmologic monitoring at the Ocular Health Center between January 1, 2012, and November 1, 2012. Four of the teleophthalmology patients had to be placed in the routine group later as a result of the closing of the community clinic.

On average, for the recurrence monitoring group, it took 13.6 days from recurrence detection to treatment for the teleophthalmology group compared with less than a day (0.04) for the routine care group. At the end of the study, however, clinicians found no statistical difference in best corrected visual acuity between the groups.

Overall, recurrence occurred in 71.2% of patients, and researchers found no difference between groups. Average time to recurrence also was similar between groups (103.9 days for teleophthalmology vs 108.1 days for routine care).

Real World

"I do believe that teleophthalmology in the real world will be able to offer significant cost savings if we factor in both the financial cost to healthcare systems and the human and time costs to patients and their families," Dr Li told Medscape Medical News. "I would say the most important finding in our study is that teleophthalmology can be used as a timely and feasible tool for neovascular AMD screening and recurrence monitoring.

"Our study clearly shows that 44% of new referrals for suspected neovascular AMD to retinal specialists did not require in-person consultation, follow-up, and/or treatment by a retinal specialist," he continued. "Teleophthalmology is in a unique position to allow retinal specialists to guide the referring physician or optometrist to manage those cases remotely, without the unnecessary retinal clinic visits. In turn, the reduced patient load at the retinal clinic should result in improved access, faster follow-up, and reduced wait time for patients who do have conditions that require management by retinal specialists."

With Limitations

The study does "show that there's potential for being able to screen patients for neovascular AMD with telemedicine technology," Ingrid Zimmer-Galler, MD, medical director of the Wilmer Eye Institute's Frederick, Maryland, clinic and associate professor of ophthalmology at Johns Hopkins University School of Medicine in Baltimore, told Medscape Medical News. "It's another example of how teleophthalmology is gaining ground, and I think it's going to [be] much more common in the coming years.

"A concern is while we know the number of false-positives, what we don't have information on is whether there were any false-negatives, and obviously you don't want to miss any disease that is either recurrent or new neovascular activity," she said. "In this study, they didn't have a way to monitor for that."

In practical terms, it might not be that expensive to go forward with this, she said. A retina specialist, Dr Zimmer-Galler is coauthor of a recent study on the cost of a community-based diabetic retinopathy screening program.

"Presumably, in either a general ophthalmology or optometry setting, very many of those already have fundus cameras and OCT in place, [which would require] relatively little additional cost," she explained.

"Something to explore for the future would be where this potentially has the greatest utility," she added. It "may end up being in screening the older patient population to look for macular degeneration in conjunction with a diabetic retinopathy screening program. Usually those programs are in the primary care setting, and they probably would not have OCT [capability]."

This research was funded by the Academic Health Science Center Alternate Funding Plan from the Academic Medical Organization of Southwestern Ontario. The authors and Dr Zimmer-Galler have disclosed no relevant financial relationships.

JAMA Ophthalmol. Published online December 4, 2014. Abstract

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