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Teleophthalmology for the elderly population: A review of the literature
Journal Pre-proof Teleophthalmology for the elderly population: a review of the literature Farhad Fatehi, Farzad Jahedi, Mei-Ling Tay-Kearney, Yogesan Kanagasingam
PII:
S1386-5056(19)30519-2
DOI:
https://doi.org/10.1016/j.ijmedinf.2020.104089
Reference:
IJB 104089
To appear in:
International Journal of Medical Informatics
Received Date:
11 May 2019
Revised Date:
13 December 2019
Accepted Date:
27 January 2020
Please cite this article as: Fatehi F, Jahedi F, Tay-Kearney M-Ling, Kanagasingam Y, Teleophthalmology for the elderly population: a review of the literature, International Journal of Medical Informatics (2020), doi: https://doi.org/10.1016/j.ijmedinf.2020.104089
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
Teleophthalmology for the elderly population: a review of the literature
Farhad Fatehi MD PhD,1,2 Farzad Jahedi, MD MSc,2 Mei-Ling Tay-Kearney3, and Yogesan Kanagasingam, PhD2 1
Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane,
Australia Australian e-Health Research Centre, CSIRO, Australia
3
Lions Eye institute, University of Western Australia, Perth, Australia
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2
*
Corresponding author:
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Dr Farhad Fatehi, Ground floor, Building 33, Princess Alexandra Hospital, Brisbane, QLD
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4102, Australia
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Telephone: +61 (07) 3176 5678, Fax: +61 (07) 3176 6945, Email: [email protected]
Highlights:
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Teleophthalmology has not been studied exclusively in the elderly population Most of the benefits of teleophthalmology are applicable to the elderly population Teleophthalmology for the elderly has some limitations that should be addressed There is a need for more research of high quality in this field
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ABSTRACT Background: Ophthalmology is one of the most requested medical speciality services in the elderly population. Although numerous studies have shown the potentials of telemedicine for the provision of ophthalmology services, the extent of its usability in older adults and the aged population is not clear. The aim of this study was to investigate the characteristics and usability features of teleophthalmology for the elderly population. Method: We searched PubMed, Embase, Scopus and CINAHL for relevant studies since 2008.
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Forty-five papers met the eligibility criteria and included in this review. We used a multifaceted model to extract the data and analyze findings by cross-tabulation.
Results: The majority of the reviewed papers included participants of 65 years of age or older. Most of the studies were conducted in the USA (38%). Diabetic retinopathy, glaucoma, age-
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related macular degeneration and cataract were the most researched eye diseases, and among the imaging technologies, retinal photography had been used the most (72%). The studies
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showed teleophthalmology can improve access to specialty care, reduce the number of unnecessary visits, alleviate overloads on treatment centers, and provide more comprehensive
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exams. It also made services cost-saving for stakeholders and cost-effective in rural areas. However, teleophthalmology was not cost-effective for patients above 80 and low-density population areas.
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Conclusion: Evidence is lacking for the usability and effectiveness of teleophthalmology for the elderly population. The findings suggest that primary care providers in collaboration with ophthalmologists could provide more effective eye care to elderly population. Appropriate
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training is also necessary for primary care doctors to manage and refer older patients in a timely manner. Diagnostic value and cost-effective imaging modalities which are the core of the
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teleophthalmology, can be enhanced by image processing techniques and artificial intelligence.
Keywords: Teleophthalmology, Ocular Telemedicine, Telehealth, Elderly, Aged
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1. INTRODUCTION Age-related eye diseases are increasing yet greatly preventable global health concern 1. According to World Health Organization, 285 million people are visually impaired globally and 39 million of them are blind. It is estimated that 65% of the visually impaired and 82% of the blind people are aged over 50 2. This burden is expected to increase with the demographic ageing of the population 3. Vision impairment has been associated with a plethora of adverse ramifications, including increased morbidity and mortality, double the risk of falls, reduced quality of life, earlier nursing home placement, social decline, depression and decreased financial opportunities 1,4,5.
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The most common eye diseases affecting the elderly include age-related macular degeneration (AMD), cataracts, glaucoma and diabetic retinopathy (DR) 4. These diseases are frequently asymptomatic during their initial phases, particularly if the non-dominant eye is affected first 6
. This contributes to the significant number of undetected cases, and cases diagnosed after the
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ideal period of treatment has passed 7. According to the US National Health and Nutrition Examination Survey, 73% of participants with diabetic retinopathy and 84% with AMD were
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undiagnosed 8. International population-based studies show that approximately 50% of diabetic individuals do not regularly undergo screening for DR 9. For people with glaucoma, a major
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cause of vision loss is a delayed presentation 10. AMD patients also may exhibit high rates of recurrence and visual deterioration after the conclusion of their treatment 11. Regular screening and monitoring are therefore essential to prevent potentially severe vision impairment 7.
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Furthermore, delays between diagnosis and treatment can lead to irreversible vision loss, indicating a need for efficient administrative procedures
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. The cost and inconvenience of
transport to eye clinics can be particularly onerous for elderly patients who frequently suffer
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from comorbidities and rely on pensions, especially if they are already on costly long-term treatments 13. It has been shown that preventative screening for eye diseases not only reduces
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rates of vision impairment but also is immensely cost-effective 9. The Centre for Eye Research Australia estimated that the total cost of vision disorders is $9.85 billion per year in Australia 14
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There is a growing demand for a paradigm shift in eye care, particularly for the elderly, which can overcome existing time, transport and economic barriers. Teleophthalmology is a means through which the assessment, diagnosis, treatment and monitoring of patients with eye-related diseases are provided at a distance. There are two main modes of teleophthalmology: store-
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and-forward (asynchronous) that entails the transmission of data to distantly-located healthcare professional for assessment and review, while real-time (synchronous)
involves a live
telemedical consultation in conjunction with simultaneous transmission and collection of data 15
. As ophthalmology is a highly image-driven speciality, the store-and-forward mode of
teleophthalmology is an ideal means of information transmission and is more widely used than real-time videoconferencing 16. Teleophthalmology has already been used to facilitate faster healthcare services for rural and remote areas
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. It has been successful in particular for medically under-served populations
such as American Indians and Alaska Natives 17. Teleophthalmology programs for regular DR
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screening have been implemented in several communities across the US and Canada and have been shown to be dependable and cost-effective. It has the potential to greatly reduce travel and time inconveniences through the establishment of community-based programs
11,18
. This
is particularly important for elderly residents. The aim of this study was to review the
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characteristics and usability of teleophthalmology programs that have been conducted for the elderly population and identify research gaps in this area.
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2. METHODS
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2.1 Electronic search
We searched PubMed, Embase, Scopus and CINAHL databases for studies on teleophthalmology for the elderly population which were published from 2008 to 2018. A
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combination of controlled vocabulary (e.g. MeSH terms) and free-text keywords was used for the electronic search. The free-text keyword search strategy comprised two clusters: A) a search query for various forms of teleophthalmology (e.g. ‘tele ophthalmology’ OR
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‘teleophthalmology’ OR ‘tele-ophthalmology’); B) a combination of ophthalmology search terms (e.g. ophthalmology OR “eye diseases” OR “eye care”) AND telemedicine-related search
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terms (e.g. telemedicine OR telehealth OR mhealth OR “mobile health” or ehealth). The search query was fine-tuned for each database according to their user’s guide. The search results were filtered by age (Aged, Very Elderly, 65+ years, 80 & over, older people) and date of publication (2008 – 2018) and language (English). We excluded non-peer-reviewed papers such as letters, comments, or opinion, as well as conference abstracts. Age was an important parameter for our research. Although there are controversies in the definition of “aged” and “old aged” in the elderly, the age above 65 years can be defined as elderly ages. Therefore, we restricted our electronic search results to the ages of above 65 years. 4
2.2 Screening and selection The results of the electronic search in all the databases (514 records) were exported to Mendeley reference management software and duplicates were removed. Then 278 unique records were screened at Title/Abstract level and 108 records were identified as potentially relevant and their full-text were obtained to check for eligibility. After inspecting the full-text of these papers, a final set of 45 papers were selected to be reviewed. The PRISMA flow
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diagram of this review is shown in Figure 1.
Figure 1. PRISMA flow diagram of the study
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2.3 Data extraction and synthesis We developed a framework for data extraction and synthesis in this review. This framework was inspired by the results of recent systematic reviews on teleophthalmology in the USA, Europe, and UK
19–22
. The four pillars of this framework are: Functionality, Diseases,
Technology (telecommunication and medical), and Staff. The functionality is about different aspects of eye care and comprises of screening, diagnosis, treatment and monitoring. The diseases are mainly focused on the most prevalent elderly ophthalmologic diseases (i.e. glaucoma, cataract, AMD and DR). However, an option for other diseases is appended. The technologies are categorized into two groups of telemedical technology as synchronous (real-
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time) and asynchronous (store & forward), and medical instruments (e.g. retinal photography or anterior segment imaging). In addition to real-time and store and forward solutions in telemedicine, digital ophthalmology was appended as a subcategory because of the importance of some studies on the efficacy of the digital medical instruments to be utilized in
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teleophthalmology solutions. The last pillar is the staff (human resource) which refers to the people who are involved in the teleophthalmology procedures (e.g. ophthalmologists,
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optometrists, nurses, and trained technicians).
Additionally, we tried to distinguish and categorize the location of the service. If the service
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was designed to provide teleophthalmology inside one health center like one hospital with a screening clinic at the front and an ophthalmology department at behind, it is considered as ‘central’ in this review. But in case of providing the screening service in another geographical
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location with the support of a remote specialist center, it is considered as peripheral. The study designs were categorized into feasibility studies, comparison with conventional methods, pilot studies, assessing the patient satisfaction and prevalence of diseases. In order to depict a better
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picture of the research designs, the research methodologies were analyzed too.
2.4 Analysis Approach
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The results were not only quantitatively described but also cross-tabulated in several matrices including a couple of above-mentioned items from different perspectives. For instance, functionalities versus the diseases, and medical instruments versus locations. Furthermore, the limitations and conclusions of the included studies were analyzed and consolidated. It was expected that this data would answer the following questions around elderly teleophthalmology:
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1. What technologies, tools and instruments have been used for the evaluation? 2. What telemedicine mode has been adopted? (Real-time or Store-and-forward) 3. What Functionalities have been considered and what disorders have been covered? 4. Who has conducted the research practice? (optometrist, nurse, specialist, etc.) 5. What objectives have been defined and to what extent they were achieved? 6. What types of studies have been conducted? (RCT, Case series, Case-control, Cohort, etc.) 7. What achievements have been presented and what suggestions have been made for future research?
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3. RESULTS
We reviewed 45 papers in this study. One of the crucial inclusion/exclusion criteria was the age of the participants. Even though we applied the age-group filters of the databases to limit the results to the elderly population, the results still exhibit a wide range of the age of
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participants from 7 to 99. Though, except for two articles with undefined participants’ age, almost all articles included participants aged 65 and older. None of the included studies was
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exclusively conducted on the elderly population.
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3.1 Characteristics of the included studies
We examined the aims and design of the studies. The results show that most of the included studies are feasibility trials of a new teleophthalmology intervention (26/45) followed by
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comparative studies, which compare teleophthalmology solutions with the conventional functionalities (12/45). In four studies teleophthalmology was used for assessing the prevalence of diseases. In terms of study design, only two studies were randomized controlled trials. The
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highest number of the studies were case series or case reports (20 papers) followed by noncontrolled clinical trials (14 papers).
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We also looked up the country of the studies and location of the service. Although several studies are the results of teamwork among researchers from different countries and thus it is not possible to attribute them to a single country, the locations of the research studies according to their corresponding address is listed in Table 1. Moreover, the location of teleophthalmology service in each country was explored in terms of remoteness and broadly classified as urban (U) or rural (R) areas (Table 1). The most significant number of studies were conducted in the USA with more concentration in urban areas.
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Moreover, the topology of the teleophthalmology services was classified into two main groups of central and peripheral. Central teleophthalmology is defined as services were launched in one center such as tertiary hospitals and their affiliated eye-care clinics. The peripheral teleophthalmology is the services were running in two different locations that might be the patients’ place or a satellite center in communication with a specialist center or hospital. The dominant topology was peripheral services in 27 studies (60%)
23–49
while central services
found in 18 studies (40%) 50–67. The main results of this study are presented according to the four pillars of the framework that was described in the Methods: Technology, Staff, Diseases
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and Functionalities.
3.2 Technology 3.2.1. Technologies and instruments
It is common to employ a combination of multiple technologies and instruments in a
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teleophthalmology service for the elderly. This often happens because a comprehensive evaluation of eye diseases comprises of various examinations and investigations, ranging from
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physical examination of pupillary reactions to taking images of the retina (retinal photography). Although there were various technologies reported in the papers, we categorized them into the
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following four main groups in the order of their utilization: Imaging investigations
Automated solutions
Real-time Communications
Usability
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As shown in Table 2, imaging investigations were utilized the most. Imaging investigations include taking photos and videos recording of various parts of the eye such as retinal
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photography. The two main types of imaging are retinal and anterior segment photography. Retinal photography, as the most common procedure in these teleophthalmology research studies, has been conducted with or without pupil dilation (mydriatic or non-mydriatic). The majority of these experiments utilized the non-mydriatic retinal photography regardless of the functionalities and the target disease. The least utilized methods in the imaging measures are OCT (Optical Coherence Tomography) and Confocal SLO (Scanning Laser Ophthalmoscopy).
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The second most utilized technologies were automated solutions which refer to the procedures in which digital technology has been employed to assist with the conduct of an examination such as detection of diabetic retinopathy using Artificial Intelligence or self-administered visual acuity tests suing smartphones. A number of solutions such as digital optotypes (figures or letters of standard size for testing the acuity of vision) can be used by both healthcare providers and patients for testing the eyes. The real-time technologies mainly involved teleconsultation (videoconferencing) in which two or more parties communicated in real-time. Teleconsultations happened between patient-
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doctor, doctor-doctor, or optometrist-ophthalmologist. The usability measures are those studies in which the satisfaction of the users or patients with the technology has been assessed, or the impact of the prior experience of working with computers (digital literacy) on the acceptance of technology-based solutions have been evaluated. These categories do not show the
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utilization of merely one of these measures. In a total number of 45 articles, about 70% have utilized only one technology while there are 30% using different combinations of technologies.
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The combination of two, three or five were identified. In 12 articles the researchers used at least a combination of two and in two projects a combination of three or five. Furthermore, in
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cross-tabulation of the technologies against the locations, it is revealed that confocal SLO has been utilized only in central locations and teleconsultation has been used mostly (75%) in peripheral locations. Non-mydriatic retinal photography has been the most common
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technology in both locations while its usage in peripheral locations has been more than twice. 3.2.2 Telemedicine modalities
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Telemedicine is traditionally classified into two main groups: Synchronous and Asynchronous. The most popular modality of telemedicine in the included studies were asynchronous (38 papers) followed by synchronous telemedicine. In this review, another category of
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Digital/Virtual Ophthalmology is appended based on the valuable findings on the evaluation of methods that may influence the quality of teleophthalmology services while they are not necessarily based on telecommunications. These modalities can be utilized by the patients or healthcare providers without the need of data exchange or communication with other healthcare providers. In a number of studies, only the quality of a digital ophthalmology solution has been studied for the purpose of evaluating the efficacy of the solution, so they are categorized under Digital Ophthalmology. Moreover, there were a few studies on the design of a virtual set of 9
cases to be compared with the real cases, so they were categorized under virtual ophthalmology.
3.3 Staff The staffs who conducted the procedures in the point of service are categorized in five types of healthcare professionals. In addition to these 5, in one article the operators were the patients themselves for self-evaluation assessment. Although in many research studies a combination of these staff team up to provide the services, the significant one is the trained healthcare staff (23 cases). The next high numbers relate to the optometrists (13 cases) and nurses (11 cases)
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while the general practitioners (7 cases) and ophthalmologists (6 cases) are the lowest.
Functionality
In our review, the functionality has a general definition to cover the basic types of care and comprises Screening, Diagnosis, Treatment and Monitoring (after or during treatment). The results showed that Treatment has not been adopted in the included studies. In addition,
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Monitoring with the purpose of the follow-up or rehabilitation had the lowest number (3 papers,
followed by Diagnosis (10 cases, 22%).
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3.5 Diseases
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7%) of the models. In contrast, the most common functionality was Screening (32 papers, 71%)
Examining the diseases in the articles, although our research model was based on four main elderly ophthalmic disorders (Glaucoma, Retinopathy, Cataract and AMD), there were several
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studies that covered other disorders. Regardless of the details of these diseases, they were categorized under “Others”. There are several instances of studying more than one disorder in a study, however, diabetes is undeniably examined the most (27 cases) specifically as diabetic
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retinopathy in the elderly. Irrespective of the “Others”, which is a combination of various disorders, the next high rate disorder is Glaucoma (19 cases) that is closely followed by AMD
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(18 cases) and Cataract (12 cases). In the cross-tabulation of the results of functionality against the diseases, the diseases that have been examined more have been consecutively retinopathy, Glaucoma and AMD while cataract has been evaluated only in combination with other diseases. In the other perspective, the most screened disease has been retinopathy while the most diagnostically assessed disease has been glaucoma, and the only monitored disease has been AMD (Table 3). Of the 45 papers which were studied, their conclusions were scrutinized based on their significant findings and abovementioned diseases categories, as follows. 10
3.5.1 AMD A pilot trial in Singapore has shown teleophthalmology can achieve 100% sensitivity and specificity for the diagnosis AMD as well as media opacity and keratopathy of any type
50
.
Moreover, teleophthalmology allows regional eye specialists to quantify the risk of disease progression and accelerate the referrals effortlessly 51. A rural area study in Australia revealed digital retinal cameras (capture) and smartphones (transmission) is useful in rural areas but as a supplemental ophthalmologic service rather than the main outreach service 42. 3.5.2 Glaucoma Using the combination of imaging technologies with clinical history increase the accuracy of
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diagnosis in Teleophthalmology. Adding elements such as history, vision and intra-ocular pressure (IOP) to the photography-only protocol may increase the detection rate of eye-diseases 61
3.5.3 Retinopathy
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Teleophthalmology in rural and urban regions increase successful screening and early detection and treatment of Diabetic retinopathy. Although fundus photography is not a substitute for the
necessary eye exam
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comprehensive eye examination, it is beneficial to the patients who do not regularly attend the . In addition to successful screening and referral in Teleophthalmology,
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the rate of loss to follow-up is low which improves triaging referrals 64. 3.5.4 Cataract
The studied mobile (tablet application) solution, improved the efficiency (timely detection) and
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effectiveness in the detection of cataract, in particular, and other eye disorders, and their referral as well as treatment of potentially blinding conditions 26.
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3.5.5 Other diseases
Teleophthalmology with mobile retinal imaging and remote ophthalmological analysis showed
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the significant prevalence of retinal issues in TIA patients 62
3.6 Cross-tabulation of Location against other aspects of teleophthalmology Cross-tabulation of the location against the technology, diseases, staffs, functionality and the study design comply with their dominant results. Hence, the most utilized technology is nonmydriatic retinography, the most employed staff is trained healthcare staff, the most evaluated disease is retinopathy, the most delivered care is screening, and the most common adopted 11
study design is feasibility study in both central and peripheral services. However, the other members of each group do not depict the same results (Table 4).
4. DISCUSSION Although ophthalmology is one of the most requested specialty services by the elderly population, and research shows ophthalmology services can be safely delivered at a distance using telemedicine solutions, the lack of exclusive studies on elderly population depicts the importance to focus more on this demanding area. Most of the studies were either feasibility
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assessment or non-randomized clinical trial, and we identify only two RCTs. This suggests that teleophthalmology solutions for the elderly population are still not an established domain for the researchers, which needs to be considered and studied from different aspects.
4.1 Technology and equipment
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Portability, costs and operability might be the main reasons that limit the use of devices for non-mydriatic retinal photography. It seems imaging (photography) is the demanding approach
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in both synchronous and asynchronous telemedicine solutions. Moreover, the elderly common eye diseases like AMD, Glaucoma and Diabetic Retinopathy are diseases of the posterior
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segment that can be easily evaluated via retinal examination. Therefore, retinal photography, unlike visual acuity tests and tonometry, can lead to the cause of disease as an effective diagnostic tool in the elderly teleophthalmology.
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In several research projects, a combination of instruments has been utilized, for instance utilizing two, three or five instruments in the study, to meet the requirements of a
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comprehensive optometry/ophthalmology assessment. In 12 pieces of research two instruments have been used where non-mydriatic retinography has been the most across all combinations, even in combinations of 3 and 5. Moreover, the instrument that has been used the most in both
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central and peripheral setups is non-mydriatic retinal photography. Although this dominance reveals the importance of this instrument in the teleophthalmology, it depicts the other instruments have not been experienced in such extent. The obvious findings are using Confocal SLO merely in the central teleophthalmology services while Teleconsultation is utilized more in the peripheral setups. These support the importance of portability of photographic devices and providing teleconsultation access to specialists for peripheral locations. Utilizing the photography capability of smartphones facilitates the 12
portability in teleophthalmology while the photographic quality for the smartphone images is still challenging.
4.2 Telemedicine modalities The most dominant modality of telemedicine for elderly teleophthalmology was store-andforward that has been scrutinised in more details than the real-time solutions. Although the telecommunication and hardware infrastructure for a standard synchronous (real-time) solution might be technically complex and financially exclusive, it is necessary to be assessed for its efficiency and cost-effectivity in the relevant models of healthcare services in elderly teleophthalmology. Moreover, the lower number of automated solutions like grading and
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decision support systems reveals the wide range of research opportunities on clinical decision support systems using artificial intelligence to maximize the accuracy of teleophthalmology cares in screening, diagnosis, treatment and monitoring.
Several studies show improved access to specialty eye care services, especially for the residents 44,58
, that can accelerate the treatment process. Although many
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of remote and rural areas
reviewed studies report positive findings on economic analysis of teleophthalmology services 27,41
, avoiding unnecessary visits
36
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compared with conventional functionalities, which are mainly contributed to reducing travel , and reducing specialist burden
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, there are reports that
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indicate the cost-effectiveness of teleophthalmology for patients older than 80 years old need more investigations. Despite the low number of satisfaction studies on teleophthalmology services, they show high satisfaction of the patients with provided services
29,43,59
. Although
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the suitability of some portable imaging devices for teleophthalmology is controversial: some researchers have shown that the diagnostic value of such devices is comparable to standard office-based equipment
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, others claim that currently available portable devices need more
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maturity for diagnosis of some eye diseases, though could be useful for monitoring purposes
4.3 Staff
The highest rate of employing the trained staffs, optometrists and nurses across the researches (%78, 47 out of 60) is a solid support to depict teleophthalmology service can be provided by non-specialists. The healthcare staff who would receive the required training have higher availability and lower costs in comparison to the specialists. One of the key factors in the success of teleophthalmology services is the involvement and collaboration of different stakeholders including ophthalmologists, optometrists, GPs and nurses 31,38,49,51. Nevertheless, 13
training of the staff and change management are essential for the successful implementation of teleophthalmology services.
4.4 Functionality The most examined ophthalmologic disease and functionality in the elderly are diabetic retinopathy and screening. Various measures have been applied to the screening and diagnosis models to increase the sensitivity and specificity of the teleophthalmology examinations. These protocols for photography, grading and diagnosis tried to improve the quality and accuracy of the referrals. This might be an indicator for future investigators to extend their focus on other diseases and functionalities. In particular, these protocols and service design should be
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specialized for the elder age group in order to improve the elderly teleophthalmology services to a practical level.
Although the most common model is screening, it seems the diagnosis has provided proportionally more in central rather than peripheral services. It is likely because of the
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availability of diagnostic instruments and specialists. This deduction is supported by the utilized instruments in the central teleophthalmology services that are not available in the
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peripheral areas. Teleophthalmology solutions that have been developed mainly for improving access to care for people in remote and rural areas, can also be helpful for residents of urban
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areas 34. However, the remaining challenges for the delivery of practical and viable solutions should be addressed to facilitate the uptake of teleophthalmology 68.
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4.5 Diseases
Although several research projects were designed to cover a specific eye disorder, a wide variety of other eye disorders have been found during the screening. Whilst Diabetic
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retinopathy has been the most popular target of the studies, Glaucoma and AMD followed by Cataract are investigated respectively. Cataract and anterior chamber problems have been
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considered in fewer studies that might be due to the technical limitations of photography instruments.
The results indicate that teleophthalmology is most utilized for screening of diabetic retinopathy, diagnosis of Glaucoma and monitoring of AMD. The list of the main eye disorders that have been approached by teleophthalmology in these studies is nicely matched with the prevalent eye diseases in the elderly. This is a promising sign for future studies in elderly teleophthalmology.
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4.6 Challenges and limitations Since none of the reviewed studies was exclusively conducted on elderly population or compared the usability and outcome of teleophthalmology between adults and elderly population, it is not possible to identify the specific challenges of elderly teleophthalmology from the current literature. However, considering various solutions that have been presented in the papers, there are a number of issues that may limit the feasibility of teleophthalmology for the elderly population. Firstly, the high prevalence of cataract in the elderly population, limits the functionality of teleophthalmology for diagnosis and treatment of eye diseases for this age group, especially the conditions pertaining to the posterior segment. Secondly, as most of
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teleophthalmology projects are designed to be utilized in places other than eye clinics, usability of the ophthalmic instruments for elderly population should be demonstrated. Our observation from a pilot trial (unpublished data) showed that frailty and comorbidities of a large proportion of the elderly population, limits the suitability of conventional portable ophthalmic instruments
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to be used for teleophthalmology. Although remarkable advances have been shown in manufacturing ultra-portable devices for ophthalmologic examinations, safety and accuracy of
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them are yet to be confirmed in scientific studies.
5. CONCLUSION
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Although there is a lack of evidence on usability and effectiveness of teleophthalmology services exclusively for the elderly population, reviewing the current literature indicates that aged people can benefit from teleophthalmology. Despite the fact that the elderly have their
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special requirements, teleophthalmology services in the reviewed papers exhibit many common features that can be used for aged persons. Although ophthalmologists are the core of teleophthalmology, the most engaged group was trained practitioners including optometrists
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and nurses. For teleophthalmology to be more usable for the elderly population, technical features of imaging modalities should be improved. The dominance of proof-of-concept and
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feasibility studies, and scarcity of effectiveness trials show this field of research is still emerging and there is a need for well-designed studies to inform the best practice models in teleophthalmology, especially for elderly.
SUMMARY POINTS What was already known on the topic:
Telemedicine has been used for the delivery of specialty eye care at a distance 15
While ophthalmology is one of the most requested services by the elderly population, it is not clear to what extent teleophthalmology has been used for this age group.
What this study added to our knowledge:
Teleophthalmology has not been studied exclusively in the elderly population Most of the benefits of general teleophthalmology are applicable to the elderly population, but there are some limitations that should be addressed There is a need for more research of high quality in this field to inform the development of innovative models of eye care for the elderly population
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FUNDING SOURCE
FF received financial support from the Queensland Government through an Advance Queensland Research Fellowship (2016-2019).
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AUTHORS’ CONTRIBUTIONS
FF and YK designed the study. FF and FJ conducted the electronic search and screened the
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records. FJ was responsible for data extraction, data analysis approach, synthesis of results and writing the first draft. FF contributed to the writing of Introduction, Discussion and Conclusion.
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MT was the clinical supervisor and contributed to information synthesis. YK was the scientific supervisor and contributed to the data analysis. All authors read, provided feedback, and approved the final draft.
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CONFLICT OF INTEREST
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No competing financial interests exist.
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11. Li B, Powell AM, Hooper PL, Sheidow TG. Prospective evaluation of teleophthalmology in screening and recurrence monitoring of neovascular age-related macular degeneration: a randomized clinical trial. JAMA Ophthalmol. 2015;133:276– 82. 12. Muether PS, Hermann MM, Koch K, Fauser S. Delay between medical indication to anti-VEGF treatment in age-related macular degeneration can result in a loss of visual acuity. Graefe’s archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie. 2011;249:633–7. 13. Azzolini C, Torreggiani A, Eandi C, Donati S, Oum MA, Vinciguerra R, et al. A teleconsultation network improves the efficacy of anti-VEGF therapy in retinal diseases. J Telemed Telecare. 2013;19:437–42.
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14. Taylor HR, Pezzullo ML, Keeffe JE. The economic impact and cost of visual impairment in Australia. Br J Ophthalmol. 2006;90:272–5. 15. Kumar S, Kanagasingam Y. Overview of Teleophthalmology. In: Yogesan K, Kumar S, Goldschmidt L, Cuadros J, editors. Teleophthalmology. 1st ed. Germany: SpringerVerlag Berlin Heidelberg; 2006. p. 3–6. 16. Kanagasingam Y, Bhuiyan A, Abramoff MD, Smith RT, Goldschmidt L, Wong TY. Progress on retinal image analysis for age related macular degeneration. Prog Retin Eye Res. 2014;38:20–42. 17. Carroll M, Horton MB. Telehealth and Indian healthcare: moving to scale and sustainability. Telemed J E Health. 2013;19:377–9.
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20. Sim D.A., Mitry D., Alexander P., Mapani A., Goverdhan S., Aslam T., et al. The Evolution of Teleophthalmology Programs in the United Kingdom: Beyond Diabetic Retinopathy Screening. J Diabetes Sci Technol. 2016;10:308–17.
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25. Xu L, Jonas JB, Cui TT, You QS, Wang YX, Yang H, et al. Beijing Eye Public Health Care Project. Ophthalmology. 2012;119:1167–74. 26. Imtiaz SA, Krishnaiah S, Yadav SK, Bharath B, Ramani RV. Benefits of an Android Based Tablet Application in Primary Screening for Eye Diseases in a Rural Population, India. Journal of Medical Systems. 2017;41:49. 27. Maa AY, Wojciechowski B, Hunt KJ, Dismuke C, Shyu J, Janjua R, et al. Early Experience with Technology-Based Eye Care Services (TECS): A Novel Ophthalmologic Telemedicine Initiative. Ophthalmology. 2017;124:539–46. 28. Chasan JE, Delaune B, Maa AY, Lynch MG. Effect of a Teleretinal Screening Program on Eye Care Use and Resources. JAMA Ophthalmology. 2014;132:1045–51. 18
29. Creuzot-Garcher C, Martin-Phipps T, Beynat J, Astruc K, Brassac K, Bron AM. Effectiveness of a Mobile Diabetic Retinopathy Screening Campaign to Encourage Diabetics to Undergo Regular Ophthalmic Follow-Up. Ophthalmic Research. 2014;52:206–11. 30. Kirkizlar E, Serban N, Sisson JA, Swann JL, Barnes CS, Williams MD. Evaluation of Telemedicine for Screening of Diabetic Retinopathy in the Veterans Health Administration. Ophthalmology. 2013;120:2604–10. 31. Park D, Mansberger SL. Eye Disease in Patients with Diabetes Screened with Telemedicine. Telemedicine and e-Health. 2016;23:113–8.
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32. Rodríguez Villa S, Alonso Álvarez C, de Dios del Valle R, Salazar Méndez R, Cuesta García M, Ruiz García MJ, et al. Five-year experience of tele-ophthalmology for diabetic retinopathy screening in a rural population. Archivos de la Sociedad Española de Oftalmología (English Edition). 2016;91:426–30.
33. Peng J, Zou H, Wang W, Fu J, Shen B, Bai X, et al. Implementation and first-year screening results of an ocular telehealth system for diabetic retinopathy in China. BMC Health Services Research. 2011;11:250.
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34. Chin EK, Ventura BV, See K-Y, Seibles J, Park SS. Nonmydriatic Fundus Photography for Teleophthalmology Diabetic Retinopathy Screening in Rural and Urban Clinics. Telemedicine and e-Health. 2013;20:102–8.
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35. Shahid K, Kolomeyer AM, Nayak NV, Salameh N, Pelaez G, Khouri AS, et al. Ocular Telehealth Screenings in an Urban Community. Telemedicine and e-Health. 2012;18:95–100. 36. Hanson C, Tennant MTS, Rudnisky CJ. Optometric Referrals to Retina Specialists: Evaluation and Triage via Teleophthalmology. Telemedicine and e-Health. 2008;14:441–5.
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37. O’Day R, Smith C, Muir J, Turner A. Optometric use of a teleophthalmology service in rural Western Australia: comparison of two prospective audits. Clinical and Experimental Optometry. 2016;99:163–7.
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38. Hark LA, Katz LJ, Myers JS, Waisbourd M, Johnson D, Pizzi LT, et al. Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Methods and Screening Results. American Journal of Ophthalmology. 2017;181:114–24. 39. Jivraj I, Ng M, Rudnisky CJ, Dimla B, Tambe E, Nathoo N, et al. Prevalence and Severity of Diabetic Retinopathy in Northwest Cameroon as Identified by Teleophthalmology. Telemedicine and e-Health. 2011;17:294–8. 40. Romero-Aroca P, Sagarra-Alamo R, Basora-Gallisa J, Basora-Gallisa T, BagetBernaldiz M, Bautista-Perez A. Prospective comparison of two methods of screening for diabetic retinopathy by nonmydriatic fundus camera. Clinical Ophthalmology (Auckland, NZ). 2010;4:1481–8. 41. Li B, Powell A-M, Hooper PL, Sheidow TG. Prospective Evaluation of Teleophthalmology in Screening and Recurrence Monitoring of Neovascular Age19
Related Macular Degeneration: A Randomized Clinical Trial. JAMA Ophthalmology. 2015;133:276–82. 42. Johnson KA, Meyer J, Yazar S, Turner AW. Real-time teleophthalmology in rural Western Australia. Australian Journal of Rural Health. 2015;23:142–9. 43. Host BK, Turner AW, Muir J. Real-time teleophthalmology video consultation: an analysis of patient satisfaction in rural Western Australia. Clinical and Experimental Optometry. 2018;101:129–34. 44. Ahmed R, Petrany S, Fry R, Krasnow M. Screening Diabetic and Hypertensive Patients for Ocular Pathology using Telemedicine Technology in Rural West Virginia: A Retrospective Chart Review. Internal Medicine [Internet]. 2013; Available from: https://mds.marshall.edu/int_med/24
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45. Beynat J, Charles A, Astruc K, Metral P, Chirpaz L, Bron A-M, et al. Screening for diabetic retinopathy in a rural French population with a mobile non-mydriatic camera. Diabetes & Metabolism. 2009;35:49–56.
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46. Al Alawi E, Ahmed AA. Screening for Diabetic Retinopathy: The First Telemedicine Approach in a Primary Care Setting in Bahrain. Middle East African Journal of Ophthalmology. 2012;19:295–8.
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47. Tsui I, Havunjian MA, Davis JA, Giaconi JA. Snapshot of Teleretinal Screening for Diabetic Retinopathy at the West Los Angeles Medical Center. Telemedicine and eHealth. 2016;22:843–6.
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48. Zapata MA, Arcos G, Fonollosa A, Abraldes M, Oleñik A, Gutierrez E, et al. Telemedicine for a General Screening of Retinal Disease Using Nonmydriatic Fundus Cameras in Optometry Centers: Three-Year Results. Telemedicine and e-Health. 2016;23:30–6.
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49. Thomas S, Hodge W, Malvankar-Mehta M. The Cost-Effectiveness Analysis of Teleglaucoma Screening Device. PLOS ONE. 2015;10:e0137913.
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50. Johnson Choon HT, Eugenie Wei TP, Sanjay S, Tock HT. A pilot trial of teleophthalmology for diagnosis of chronic blurred vision. Journal of Telemedicine and Telecare. 2013;19:65–9.
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51. Azzolini C, Torreggiani A, Eandi C, Donati S, Oum MA, Vinciguerra R, et al. A teleconsultation network improves the efficacy of anti-VEGF therapy in retinal diseases. Journal of Telemedicine and Telecare. 2013;19:437–42. 52. Bats FD, Nitenberg CV, Fantino B, Denis P, Kodjikian L. Age-Related Macular Degeneration Screening Using a Nonmydriatic Digital Color Fundus Camera and Telemedicine. Ophthalmologica. 2014;231:172–6. 53. Kumar S, Bulsara M, Yogesan K. Automated determination of distance visual acuity: towards teleophthalmology services. Clinical and Experimental Optometry. 2008;91:545–50.
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54. Chabouis A, Berdugo M, Meas T, Erginay A, Laloi-Michelin M, Jouis V, et al. Benefits of Ophdiat®, a telemedical network to screen for diabetic retinopathy: A retrospective study in five reference hospital centres. Diabetes & Metabolism. 2009;35:228–32. 55. Brody BL, Field LC, Roch-Levecq A-C, Depp C, Edland SD, Minasyan L, et al. Computer Use among Patients with Age-Related Macular Degeneration. Ophthalmic Epidemiology. 2012;19:190–5. 56. Eszes DJ, Szabó DJ, Russell G, Kirby P, Paulik E, Nagymajtényi L, et al. Diabetic Retinopathy Screening Using Telemedicine Tools: Pilot Study in Hungary [Internet]. 2016. Available from: https://www.hindawi.com/journals/jdr/2016/4529824/abs/
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57. Andonegui J, Aliseda D, Serrano L, Eguzkiza A, Arruti N, Arias L, et al. Evaluation of A Telemedicine Model to Follow Up Patients with Exudative Age-Related Macular Degeneration. RETINA. 2016;36:279. 58. Arora S, Rudnisky CJ, Damji KF. Improved Access and Cycle Time with an “In-House” Patient-Centered Teleglaucoma Program Versus Traditional In-Person Assessment. Telemedicine and e-Health. 2014;20:439–45.
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59. Kurji K, Kiage D, Rudnisky CJ, Damji KF. Improving Diabetic Retinopathy Screening in Africa: Patient Satisfaction with Teleophthalmology Versus Ophthalmologist-Based Screening. Middle East African Journal of Ophthalmology. 2013;20:56–60.
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60. Rathod D, Win T, Pickering S, Austin M. Incorporation of a virtual assessment into a care pathway for initial glaucoma management: feasibility study. Clinical & Experimental Ophthalmology. 2008;36:543–6.
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61. Maa AY, Patel S, Chasan JE, Delaune W, Lynch MG. Retrospective Evaluation of a Teleretinal Screening Program in Detecting Multiple Nondiabetic Eye Diseases. Telemedicine and e-Health. 2016;23:41–8.
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62. Wolz J, Audebert H, Laumeier I, Ahmadi M, Steinicke M, Ferse C, et al. Telemedical assessment of optic nerve head and retina in patients after recent minor stroke or TIA. International Ophthalmology. 2017;37:39–46.
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63. Kumar S, Yogesan K, Constable IJ. Telemedical diagnosis of anterior segment eye diseases: validation of digital slit-lamp still images. Eye. 2009;23:652–60.
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64. Hussain N, Edraki M, Tahhan R, Sanalkumar N, Kenz S, Akasha NK, et al. Telemedicine for diabetic retinopathy screening using an ultra-widefield fundus camera., Telemedicine for diabetic retinopathy screening using an ultra-widefield fundus camera. Clinical ophthalmology (Auckland, NZ) [Internet]. 2017;11, 11. Available from: https://www.ncbi.nlm.nih.govhttp://europepmc.org/articles/PMC5565372/ 65. Woodward MA, Musch DC, Hood CT, Greene JB, Niziol LM, Jeganathan VSE, et al. Teleophthalmic Approach for Detection of Corneal Diseases: Accuracy and Reliability. Cornea. 2017;36:1159. 66. Kiage D, Kherani IN, Gichuhi S, Damji KF, Nyenze M. The Muranga Teleophthalmology Study: Comparison of Virtual (Teleglaucoma) with in-Person 21
Clinical Assessment to Diagnose Glaucoma. Middle East African Journal of Ophthalmology. 2013;20:150–7. 67. Clarke J, Puertas R, Kotecha A, Foster PJ, Barton K. Virtual clinics in glaucoma care: face-to-face versus remote decision-making. British Journal of Ophthalmology [Internet]. 2016; Available from: https://bjo.bmj.com/content/early/2016/10/11/bjophthalmol-2016-308993
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68. Sim DA, Mitry D, Alexander P, Mapani A, Goverdhan S, Aslam T, et al. The Evolution of Teleophthalmology Programs in the United Kingdom: Beyond Diabetic Retinopathy Screening. J Diabetes Sci Technol. 2016;10:308–17.
22
Total
10 2 52,54 1 56 57,40,48 3 1 51 2 60,67 1 62 14
3 2 29,45 0 1 32 0 0 0 6
9 23,55,30,35,38,41,61,47,65 + 3* 28,31,34 2 36,58 3 2 25,33 0 1 50 2 1 64 1 46 2 2 59,66 0 2 2 53,63 30
5 27,28,31,34,44
13 4 1 4 1 2 1 20 14
1 49 2 0 24,26 2 0 0 0 0 1 0 1 39 3 3 37,42,43 15
3 5 2 2 1 2 1 1 3 2 1 5 5 45
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o Canada Asia o China o India o Singapore Middle East o UAE o Bahrain Africa o Kenya o Cameron Oceania o Australia TOTAL Count
Rural
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Europe o France o Hungary o Spain o Italy o UK o Germany North America o USA
Urban
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Continent / Country
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* Three studies have been conducted in both urban and rural areas Table 1 - Geographic location of teleophthalmology interventions
23
No of studies
Technology/Instrument
a.
2.
54
Imaging Investigations
39
Retinal Photography i. Mydriatic
7
ii. Non-mydriatic
24
iii. Undefined
8
b.
Anterior Segment Imaging
8
c.
Optical Coherence Tomography
5
d.
Confocal Scanning Laser Ophthalmoscopy
2 7
Automated Solutions (for patients or staffs) a.
Mobile devices
3
b.
Automatic Grading and Risk Assessment
2
c.
Digital Optotypes
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1.
2
d.
a. 4.
4
Real-Time Technologies
4
Teleconsultation
Usability a.
Satisfaction questionnaire
b.
Digital literacy
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3.
4 3 1
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Table 2 – The most utilized solutions for elderly teleophthalmology
24
Screening Diagnosis Monitoring Treatment
DR exclusive 13 1 0 0 14 27
mix 10 3 0 0 13
Glaucoma exclusive mix 1 11 4 3 0 0 0 0 5 14 19
Cataract exclusive mix 0 8 0 4 0 0 0 0 0 12 12
AMD exclusive mix 2 9 0 3 3 0 0 0 5 12 17
Others exclusive 3 0 0 0 3 18
mix 11 4 0 0 15
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Table 3 - The functionality of teleophthalmology vs diseases
25
Peripheral
Feasibility Study
9
17
SUM 26
Comparison with conventional methods
7
5
12
Patient Satisfaction
2
3
5
Pilot Study
2
3
5
Prevalence of Disease
1
3
4
Screening
8
24
32
Diagnosis Monitoring
7 3
3 0
10
Treatment
0
0
3 0
Retinography\Non-mydriatic Retinal Photography
7
17
24
Retinography\Undefined Retinal Photography
3
5
8
Anterior Segment Imaging
4
4
8
Retinography\Mydriatic Retinal Photography
3
4
7
Optical Coherence Tomography
2
3
5
Teleconsultation System
1
4
5
Mobile
1
2
3
Confocal scanning laser ophthalmoscopy
2
0
2
Digital Optotype
1
1
2
Automatic Grading or Risk Assessment
1
1
2
Questionnaire
1
1
2
Computer Usage
1
0
1
Trained evaluators
9
13
22
Optometrist
3
9
12
Nurse
7
3
10
Ophthalmologist
3
3
6
GP
0
5
5
Not Applicable
1
2
3
Patient
1
0
1
Retinopathy
5
23
28
Others
6
14
20
Glaucoma
6
13
19
AMD
6
11
17
Cataract
3
11
14
Not Applicable
1
1
2
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Diseases
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Staff
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Technology Utilized
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Functionality
Study
Central
Table 4 - Cross-tabulation of location against other aspects for elderly teleophthalmology services
26
PII:
S1386-5056(19)30519-2
DOI:
https://doi.org/10.1016/j.ijmedinf.2020.104089
Reference:
IJB 104089
To appear in:
International Journal of Medical Informatics
Received Date:
11 May 2019
Revised Date:
13 December 2019
Accepted Date:
27 January 2020
Please cite this article as: Fatehi F, Jahedi F, Tay-Kearney M-Ling, Kanagasingam Y, Teleophthalmology for the elderly population: a review of the literature, International Journal of Medical Informatics (2020), doi: https://doi.org/10.1016/j.ijmedinf.2020.104089
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
Teleophthalmology for the elderly population: a review of the literature
Farhad Fatehi MD PhD,1,2 Farzad Jahedi, MD MSc,2 Mei-Ling Tay-Kearney3, and Yogesan Kanagasingam, PhD2 1
Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane,
Australia Australian e-Health Research Centre, CSIRO, Australia
3
Lions Eye institute, University of Western Australia, Perth, Australia
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2
*
Corresponding author:
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Dr Farhad Fatehi, Ground floor, Building 33, Princess Alexandra Hospital, Brisbane, QLD
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4102, Australia
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Telephone: +61 (07) 3176 5678, Fax: +61 (07) 3176 6945, Email: [email protected]
Highlights:
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Teleophthalmology has not been studied exclusively in the elderly population Most of the benefits of teleophthalmology are applicable to the elderly population Teleophthalmology for the elderly has some limitations that should be addressed There is a need for more research of high quality in this field
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ABSTRACT Background: Ophthalmology is one of the most requested medical speciality services in the elderly population. Although numerous studies have shown the potentials of telemedicine for the provision of ophthalmology services, the extent of its usability in older adults and the aged population is not clear. The aim of this study was to investigate the characteristics and usability features of teleophthalmology for the elderly population. Method: We searched PubMed, Embase, Scopus and CINAHL for relevant studies since 2008.
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Forty-five papers met the eligibility criteria and included in this review. We used a multifaceted model to extract the data and analyze findings by cross-tabulation.
Results: The majority of the reviewed papers included participants of 65 years of age or older. Most of the studies were conducted in the USA (38%). Diabetic retinopathy, glaucoma, age-
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related macular degeneration and cataract were the most researched eye diseases, and among the imaging technologies, retinal photography had been used the most (72%). The studies
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showed teleophthalmology can improve access to specialty care, reduce the number of unnecessary visits, alleviate overloads on treatment centers, and provide more comprehensive
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exams. It also made services cost-saving for stakeholders and cost-effective in rural areas. However, teleophthalmology was not cost-effective for patients above 80 and low-density population areas.
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Conclusion: Evidence is lacking for the usability and effectiveness of teleophthalmology for the elderly population. The findings suggest that primary care providers in collaboration with ophthalmologists could provide more effective eye care to elderly population. Appropriate
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training is also necessary for primary care doctors to manage and refer older patients in a timely manner. Diagnostic value and cost-effective imaging modalities which are the core of the
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teleophthalmology, can be enhanced by image processing techniques and artificial intelligence.
Keywords: Teleophthalmology, Ocular Telemedicine, Telehealth, Elderly, Aged
2
1. INTRODUCTION Age-related eye diseases are increasing yet greatly preventable global health concern 1. According to World Health Organization, 285 million people are visually impaired globally and 39 million of them are blind. It is estimated that 65% of the visually impaired and 82% of the blind people are aged over 50 2. This burden is expected to increase with the demographic ageing of the population 3. Vision impairment has been associated with a plethora of adverse ramifications, including increased morbidity and mortality, double the risk of falls, reduced quality of life, earlier nursing home placement, social decline, depression and decreased financial opportunities 1,4,5.
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The most common eye diseases affecting the elderly include age-related macular degeneration (AMD), cataracts, glaucoma and diabetic retinopathy (DR) 4. These diseases are frequently asymptomatic during their initial phases, particularly if the non-dominant eye is affected first 6
. This contributes to the significant number of undetected cases, and cases diagnosed after the
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ideal period of treatment has passed 7. According to the US National Health and Nutrition Examination Survey, 73% of participants with diabetic retinopathy and 84% with AMD were
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undiagnosed 8. International population-based studies show that approximately 50% of diabetic individuals do not regularly undergo screening for DR 9. For people with glaucoma, a major
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cause of vision loss is a delayed presentation 10. AMD patients also may exhibit high rates of recurrence and visual deterioration after the conclusion of their treatment 11. Regular screening and monitoring are therefore essential to prevent potentially severe vision impairment 7.
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Furthermore, delays between diagnosis and treatment can lead to irreversible vision loss, indicating a need for efficient administrative procedures
12
. The cost and inconvenience of
transport to eye clinics can be particularly onerous for elderly patients who frequently suffer
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from comorbidities and rely on pensions, especially if they are already on costly long-term treatments 13. It has been shown that preventative screening for eye diseases not only reduces
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rates of vision impairment but also is immensely cost-effective 9. The Centre for Eye Research Australia estimated that the total cost of vision disorders is $9.85 billion per year in Australia 14
.
There is a growing demand for a paradigm shift in eye care, particularly for the elderly, which can overcome existing time, transport and economic barriers. Teleophthalmology is a means through which the assessment, diagnosis, treatment and monitoring of patients with eye-related diseases are provided at a distance. There are two main modes of teleophthalmology: store-
3
and-forward (asynchronous) that entails the transmission of data to distantly-located healthcare professional for assessment and review, while real-time (synchronous)
involves a live
telemedical consultation in conjunction with simultaneous transmission and collection of data 15
. As ophthalmology is a highly image-driven speciality, the store-and-forward mode of
teleophthalmology is an ideal means of information transmission and is more widely used than real-time videoconferencing 16. Teleophthalmology has already been used to facilitate faster healthcare services for rural and remote areas
13
. It has been successful in particular for medically under-served populations
such as American Indians and Alaska Natives 17. Teleophthalmology programs for regular DR
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screening have been implemented in several communities across the US and Canada and have been shown to be dependable and cost-effective. It has the potential to greatly reduce travel and time inconveniences through the establishment of community-based programs
11,18
. This
is particularly important for elderly residents. The aim of this study was to review the
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characteristics and usability of teleophthalmology programs that have been conducted for the elderly population and identify research gaps in this area.
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2. METHODS
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2.1 Electronic search
We searched PubMed, Embase, Scopus and CINAHL databases for studies on teleophthalmology for the elderly population which were published from 2008 to 2018. A
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combination of controlled vocabulary (e.g. MeSH terms) and free-text keywords was used for the electronic search. The free-text keyword search strategy comprised two clusters: A) a search query for various forms of teleophthalmology (e.g. ‘tele ophthalmology’ OR
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‘teleophthalmology’ OR ‘tele-ophthalmology’); B) a combination of ophthalmology search terms (e.g. ophthalmology OR “eye diseases” OR “eye care”) AND telemedicine-related search
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terms (e.g. telemedicine OR telehealth OR mhealth OR “mobile health” or ehealth). The search query was fine-tuned for each database according to their user’s guide. The search results were filtered by age (Aged, Very Elderly, 65+ years, 80 & over, older people) and date of publication (2008 – 2018) and language (English). We excluded non-peer-reviewed papers such as letters, comments, or opinion, as well as conference abstracts. Age was an important parameter for our research. Although there are controversies in the definition of “aged” and “old aged” in the elderly, the age above 65 years can be defined as elderly ages. Therefore, we restricted our electronic search results to the ages of above 65 years. 4
2.2 Screening and selection The results of the electronic search in all the databases (514 records) were exported to Mendeley reference management software and duplicates were removed. Then 278 unique records were screened at Title/Abstract level and 108 records were identified as potentially relevant and their full-text were obtained to check for eligibility. After inspecting the full-text of these papers, a final set of 45 papers were selected to be reviewed. The PRISMA flow
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diagram of this review is shown in Figure 1.
Figure 1. PRISMA flow diagram of the study
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2.3 Data extraction and synthesis We developed a framework for data extraction and synthesis in this review. This framework was inspired by the results of recent systematic reviews on teleophthalmology in the USA, Europe, and UK
19–22
. The four pillars of this framework are: Functionality, Diseases,
Technology (telecommunication and medical), and Staff. The functionality is about different aspects of eye care and comprises of screening, diagnosis, treatment and monitoring. The diseases are mainly focused on the most prevalent elderly ophthalmologic diseases (i.e. glaucoma, cataract, AMD and DR). However, an option for other diseases is appended. The technologies are categorized into two groups of telemedical technology as synchronous (real-
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time) and asynchronous (store & forward), and medical instruments (e.g. retinal photography or anterior segment imaging). In addition to real-time and store and forward solutions in telemedicine, digital ophthalmology was appended as a subcategory because of the importance of some studies on the efficacy of the digital medical instruments to be utilized in
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teleophthalmology solutions. The last pillar is the staff (human resource) which refers to the people who are involved in the teleophthalmology procedures (e.g. ophthalmologists,
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optometrists, nurses, and trained technicians).
Additionally, we tried to distinguish and categorize the location of the service. If the service
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was designed to provide teleophthalmology inside one health center like one hospital with a screening clinic at the front and an ophthalmology department at behind, it is considered as ‘central’ in this review. But in case of providing the screening service in another geographical
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location with the support of a remote specialist center, it is considered as peripheral. The study designs were categorized into feasibility studies, comparison with conventional methods, pilot studies, assessing the patient satisfaction and prevalence of diseases. In order to depict a better
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picture of the research designs, the research methodologies were analyzed too.
2.4 Analysis Approach
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The results were not only quantitatively described but also cross-tabulated in several matrices including a couple of above-mentioned items from different perspectives. For instance, functionalities versus the diseases, and medical instruments versus locations. Furthermore, the limitations and conclusions of the included studies were analyzed and consolidated. It was expected that this data would answer the following questions around elderly teleophthalmology:
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1. What technologies, tools and instruments have been used for the evaluation? 2. What telemedicine mode has been adopted? (Real-time or Store-and-forward) 3. What Functionalities have been considered and what disorders have been covered? 4. Who has conducted the research practice? (optometrist, nurse, specialist, etc.) 5. What objectives have been defined and to what extent they were achieved? 6. What types of studies have been conducted? (RCT, Case series, Case-control, Cohort, etc.) 7. What achievements have been presented and what suggestions have been made for future research?
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3. RESULTS
We reviewed 45 papers in this study. One of the crucial inclusion/exclusion criteria was the age of the participants. Even though we applied the age-group filters of the databases to limit the results to the elderly population, the results still exhibit a wide range of the age of
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participants from 7 to 99. Though, except for two articles with undefined participants’ age, almost all articles included participants aged 65 and older. None of the included studies was
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exclusively conducted on the elderly population.
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3.1 Characteristics of the included studies
We examined the aims and design of the studies. The results show that most of the included studies are feasibility trials of a new teleophthalmology intervention (26/45) followed by
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comparative studies, which compare teleophthalmology solutions with the conventional functionalities (12/45). In four studies teleophthalmology was used for assessing the prevalence of diseases. In terms of study design, only two studies were randomized controlled trials. The
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highest number of the studies were case series or case reports (20 papers) followed by noncontrolled clinical trials (14 papers).
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We also looked up the country of the studies and location of the service. Although several studies are the results of teamwork among researchers from different countries and thus it is not possible to attribute them to a single country, the locations of the research studies according to their corresponding address is listed in Table 1. Moreover, the location of teleophthalmology service in each country was explored in terms of remoteness and broadly classified as urban (U) or rural (R) areas (Table 1). The most significant number of studies were conducted in the USA with more concentration in urban areas.
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Moreover, the topology of the teleophthalmology services was classified into two main groups of central and peripheral. Central teleophthalmology is defined as services were launched in one center such as tertiary hospitals and their affiliated eye-care clinics. The peripheral teleophthalmology is the services were running in two different locations that might be the patients’ place or a satellite center in communication with a specialist center or hospital. The dominant topology was peripheral services in 27 studies (60%)
23–49
while central services
found in 18 studies (40%) 50–67. The main results of this study are presented according to the four pillars of the framework that was described in the Methods: Technology, Staff, Diseases
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and Functionalities.
3.2 Technology 3.2.1. Technologies and instruments
It is common to employ a combination of multiple technologies and instruments in a
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teleophthalmology service for the elderly. This often happens because a comprehensive evaluation of eye diseases comprises of various examinations and investigations, ranging from
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physical examination of pupillary reactions to taking images of the retina (retinal photography). Although there were various technologies reported in the papers, we categorized them into the
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following four main groups in the order of their utilization: Imaging investigations
Automated solutions
Real-time Communications
Usability
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As shown in Table 2, imaging investigations were utilized the most. Imaging investigations include taking photos and videos recording of various parts of the eye such as retinal
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photography. The two main types of imaging are retinal and anterior segment photography. Retinal photography, as the most common procedure in these teleophthalmology research studies, has been conducted with or without pupil dilation (mydriatic or non-mydriatic). The majority of these experiments utilized the non-mydriatic retinal photography regardless of the functionalities and the target disease. The least utilized methods in the imaging measures are OCT (Optical Coherence Tomography) and Confocal SLO (Scanning Laser Ophthalmoscopy).
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The second most utilized technologies were automated solutions which refer to the procedures in which digital technology has been employed to assist with the conduct of an examination such as detection of diabetic retinopathy using Artificial Intelligence or self-administered visual acuity tests suing smartphones. A number of solutions such as digital optotypes (figures or letters of standard size for testing the acuity of vision) can be used by both healthcare providers and patients for testing the eyes. The real-time technologies mainly involved teleconsultation (videoconferencing) in which two or more parties communicated in real-time. Teleconsultations happened between patient-
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doctor, doctor-doctor, or optometrist-ophthalmologist. The usability measures are those studies in which the satisfaction of the users or patients with the technology has been assessed, or the impact of the prior experience of working with computers (digital literacy) on the acceptance of technology-based solutions have been evaluated. These categories do not show the
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utilization of merely one of these measures. In a total number of 45 articles, about 70% have utilized only one technology while there are 30% using different combinations of technologies.
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The combination of two, three or five were identified. In 12 articles the researchers used at least a combination of two and in two projects a combination of three or five. Furthermore, in
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cross-tabulation of the technologies against the locations, it is revealed that confocal SLO has been utilized only in central locations and teleconsultation has been used mostly (75%) in peripheral locations. Non-mydriatic retinal photography has been the most common
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technology in both locations while its usage in peripheral locations has been more than twice. 3.2.2 Telemedicine modalities
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Telemedicine is traditionally classified into two main groups: Synchronous and Asynchronous. The most popular modality of telemedicine in the included studies were asynchronous (38 papers) followed by synchronous telemedicine. In this review, another category of
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Digital/Virtual Ophthalmology is appended based on the valuable findings on the evaluation of methods that may influence the quality of teleophthalmology services while they are not necessarily based on telecommunications. These modalities can be utilized by the patients or healthcare providers without the need of data exchange or communication with other healthcare providers. In a number of studies, only the quality of a digital ophthalmology solution has been studied for the purpose of evaluating the efficacy of the solution, so they are categorized under Digital Ophthalmology. Moreover, there were a few studies on the design of a virtual set of 9
cases to be compared with the real cases, so they were categorized under virtual ophthalmology.
3.3 Staff The staffs who conducted the procedures in the point of service are categorized in five types of healthcare professionals. In addition to these 5, in one article the operators were the patients themselves for self-evaluation assessment. Although in many research studies a combination of these staff team up to provide the services, the significant one is the trained healthcare staff (23 cases). The next high numbers relate to the optometrists (13 cases) and nurses (11 cases)
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while the general practitioners (7 cases) and ophthalmologists (6 cases) are the lowest.
Functionality
In our review, the functionality has a general definition to cover the basic types of care and comprises Screening, Diagnosis, Treatment and Monitoring (after or during treatment). The results showed that Treatment has not been adopted in the included studies. In addition,
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Monitoring with the purpose of the follow-up or rehabilitation had the lowest number (3 papers,
followed by Diagnosis (10 cases, 22%).
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3.5 Diseases
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7%) of the models. In contrast, the most common functionality was Screening (32 papers, 71%)
Examining the diseases in the articles, although our research model was based on four main elderly ophthalmic disorders (Glaucoma, Retinopathy, Cataract and AMD), there were several
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studies that covered other disorders. Regardless of the details of these diseases, they were categorized under “Others”. There are several instances of studying more than one disorder in a study, however, diabetes is undeniably examined the most (27 cases) specifically as diabetic
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retinopathy in the elderly. Irrespective of the “Others”, which is a combination of various disorders, the next high rate disorder is Glaucoma (19 cases) that is closely followed by AMD
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(18 cases) and Cataract (12 cases). In the cross-tabulation of the results of functionality against the diseases, the diseases that have been examined more have been consecutively retinopathy, Glaucoma and AMD while cataract has been evaluated only in combination with other diseases. In the other perspective, the most screened disease has been retinopathy while the most diagnostically assessed disease has been glaucoma, and the only monitored disease has been AMD (Table 3). Of the 45 papers which were studied, their conclusions were scrutinized based on their significant findings and abovementioned diseases categories, as follows. 10
3.5.1 AMD A pilot trial in Singapore has shown teleophthalmology can achieve 100% sensitivity and specificity for the diagnosis AMD as well as media opacity and keratopathy of any type
50
.
Moreover, teleophthalmology allows regional eye specialists to quantify the risk of disease progression and accelerate the referrals effortlessly 51. A rural area study in Australia revealed digital retinal cameras (capture) and smartphones (transmission) is useful in rural areas but as a supplemental ophthalmologic service rather than the main outreach service 42. 3.5.2 Glaucoma Using the combination of imaging technologies with clinical history increase the accuracy of
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diagnosis in Teleophthalmology. Adding elements such as history, vision and intra-ocular pressure (IOP) to the photography-only protocol may increase the detection rate of eye-diseases 61
3.5.3 Retinopathy
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Teleophthalmology in rural and urban regions increase successful screening and early detection and treatment of Diabetic retinopathy. Although fundus photography is not a substitute for the
necessary eye exam
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comprehensive eye examination, it is beneficial to the patients who do not regularly attend the . In addition to successful screening and referral in Teleophthalmology,
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the rate of loss to follow-up is low which improves triaging referrals 64. 3.5.4 Cataract
The studied mobile (tablet application) solution, improved the efficiency (timely detection) and
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effectiveness in the detection of cataract, in particular, and other eye disorders, and their referral as well as treatment of potentially blinding conditions 26.
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3.5.5 Other diseases
Teleophthalmology with mobile retinal imaging and remote ophthalmological analysis showed
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the significant prevalence of retinal issues in TIA patients 62
3.6 Cross-tabulation of Location against other aspects of teleophthalmology Cross-tabulation of the location against the technology, diseases, staffs, functionality and the study design comply with their dominant results. Hence, the most utilized technology is nonmydriatic retinography, the most employed staff is trained healthcare staff, the most evaluated disease is retinopathy, the most delivered care is screening, and the most common adopted 11
study design is feasibility study in both central and peripheral services. However, the other members of each group do not depict the same results (Table 4).
4. DISCUSSION Although ophthalmology is one of the most requested specialty services by the elderly population, and research shows ophthalmology services can be safely delivered at a distance using telemedicine solutions, the lack of exclusive studies on elderly population depicts the importance to focus more on this demanding area. Most of the studies were either feasibility
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assessment or non-randomized clinical trial, and we identify only two RCTs. This suggests that teleophthalmology solutions for the elderly population are still not an established domain for the researchers, which needs to be considered and studied from different aspects.
4.1 Technology and equipment
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Portability, costs and operability might be the main reasons that limit the use of devices for non-mydriatic retinal photography. It seems imaging (photography) is the demanding approach
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in both synchronous and asynchronous telemedicine solutions. Moreover, the elderly common eye diseases like AMD, Glaucoma and Diabetic Retinopathy are diseases of the posterior
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segment that can be easily evaluated via retinal examination. Therefore, retinal photography, unlike visual acuity tests and tonometry, can lead to the cause of disease as an effective diagnostic tool in the elderly teleophthalmology.
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In several research projects, a combination of instruments has been utilized, for instance utilizing two, three or five instruments in the study, to meet the requirements of a
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comprehensive optometry/ophthalmology assessment. In 12 pieces of research two instruments have been used where non-mydriatic retinography has been the most across all combinations, even in combinations of 3 and 5. Moreover, the instrument that has been used the most in both
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central and peripheral setups is non-mydriatic retinal photography. Although this dominance reveals the importance of this instrument in the teleophthalmology, it depicts the other instruments have not been experienced in such extent. The obvious findings are using Confocal SLO merely in the central teleophthalmology services while Teleconsultation is utilized more in the peripheral setups. These support the importance of portability of photographic devices and providing teleconsultation access to specialists for peripheral locations. Utilizing the photography capability of smartphones facilitates the 12
portability in teleophthalmology while the photographic quality for the smartphone images is still challenging.
4.2 Telemedicine modalities The most dominant modality of telemedicine for elderly teleophthalmology was store-andforward that has been scrutinised in more details than the real-time solutions. Although the telecommunication and hardware infrastructure for a standard synchronous (real-time) solution might be technically complex and financially exclusive, it is necessary to be assessed for its efficiency and cost-effectivity in the relevant models of healthcare services in elderly teleophthalmology. Moreover, the lower number of automated solutions like grading and
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decision support systems reveals the wide range of research opportunities on clinical decision support systems using artificial intelligence to maximize the accuracy of teleophthalmology cares in screening, diagnosis, treatment and monitoring.
Several studies show improved access to specialty eye care services, especially for the residents 44,58
, that can accelerate the treatment process. Although many
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of remote and rural areas
reviewed studies report positive findings on economic analysis of teleophthalmology services 27,41
, avoiding unnecessary visits
36
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compared with conventional functionalities, which are mainly contributed to reducing travel , and reducing specialist burden
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, there are reports that
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indicate the cost-effectiveness of teleophthalmology for patients older than 80 years old need more investigations. Despite the low number of satisfaction studies on teleophthalmology services, they show high satisfaction of the patients with provided services
29,43,59
. Although
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the suitability of some portable imaging devices for teleophthalmology is controversial: some researchers have shown that the diagnostic value of such devices is comparable to standard office-based equipment
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, others claim that currently available portable devices need more
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65
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maturity for diagnosis of some eye diseases, though could be useful for monitoring purposes
4.3 Staff
The highest rate of employing the trained staffs, optometrists and nurses across the researches (%78, 47 out of 60) is a solid support to depict teleophthalmology service can be provided by non-specialists. The healthcare staff who would receive the required training have higher availability and lower costs in comparison to the specialists. One of the key factors in the success of teleophthalmology services is the involvement and collaboration of different stakeholders including ophthalmologists, optometrists, GPs and nurses 31,38,49,51. Nevertheless, 13
training of the staff and change management are essential for the successful implementation of teleophthalmology services.
4.4 Functionality The most examined ophthalmologic disease and functionality in the elderly are diabetic retinopathy and screening. Various measures have been applied to the screening and diagnosis models to increase the sensitivity and specificity of the teleophthalmology examinations. These protocols for photography, grading and diagnosis tried to improve the quality and accuracy of the referrals. This might be an indicator for future investigators to extend their focus on other diseases and functionalities. In particular, these protocols and service design should be
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specialized for the elder age group in order to improve the elderly teleophthalmology services to a practical level.
Although the most common model is screening, it seems the diagnosis has provided proportionally more in central rather than peripheral services. It is likely because of the
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availability of diagnostic instruments and specialists. This deduction is supported by the utilized instruments in the central teleophthalmology services that are not available in the
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peripheral areas. Teleophthalmology solutions that have been developed mainly for improving access to care for people in remote and rural areas, can also be helpful for residents of urban
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areas 34. However, the remaining challenges for the delivery of practical and viable solutions should be addressed to facilitate the uptake of teleophthalmology 68.
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4.5 Diseases
Although several research projects were designed to cover a specific eye disorder, a wide variety of other eye disorders have been found during the screening. Whilst Diabetic
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retinopathy has been the most popular target of the studies, Glaucoma and AMD followed by Cataract are investigated respectively. Cataract and anterior chamber problems have been
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considered in fewer studies that might be due to the technical limitations of photography instruments.
The results indicate that teleophthalmology is most utilized for screening of diabetic retinopathy, diagnosis of Glaucoma and monitoring of AMD. The list of the main eye disorders that have been approached by teleophthalmology in these studies is nicely matched with the prevalent eye diseases in the elderly. This is a promising sign for future studies in elderly teleophthalmology.
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4.6 Challenges and limitations Since none of the reviewed studies was exclusively conducted on elderly population or compared the usability and outcome of teleophthalmology between adults and elderly population, it is not possible to identify the specific challenges of elderly teleophthalmology from the current literature. However, considering various solutions that have been presented in the papers, there are a number of issues that may limit the feasibility of teleophthalmology for the elderly population. Firstly, the high prevalence of cataract in the elderly population, limits the functionality of teleophthalmology for diagnosis and treatment of eye diseases for this age group, especially the conditions pertaining to the posterior segment. Secondly, as most of
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teleophthalmology projects are designed to be utilized in places other than eye clinics, usability of the ophthalmic instruments for elderly population should be demonstrated. Our observation from a pilot trial (unpublished data) showed that frailty and comorbidities of a large proportion of the elderly population, limits the suitability of conventional portable ophthalmic instruments
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to be used for teleophthalmology. Although remarkable advances have been shown in manufacturing ultra-portable devices for ophthalmologic examinations, safety and accuracy of
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them are yet to be confirmed in scientific studies.
5. CONCLUSION
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Although there is a lack of evidence on usability and effectiveness of teleophthalmology services exclusively for the elderly population, reviewing the current literature indicates that aged people can benefit from teleophthalmology. Despite the fact that the elderly have their
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special requirements, teleophthalmology services in the reviewed papers exhibit many common features that can be used for aged persons. Although ophthalmologists are the core of teleophthalmology, the most engaged group was trained practitioners including optometrists
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and nurses. For teleophthalmology to be more usable for the elderly population, technical features of imaging modalities should be improved. The dominance of proof-of-concept and
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feasibility studies, and scarcity of effectiveness trials show this field of research is still emerging and there is a need for well-designed studies to inform the best practice models in teleophthalmology, especially for elderly.
SUMMARY POINTS What was already known on the topic:
Telemedicine has been used for the delivery of specialty eye care at a distance 15
While ophthalmology is one of the most requested services by the elderly population, it is not clear to what extent teleophthalmology has been used for this age group.
What this study added to our knowledge:
Teleophthalmology has not been studied exclusively in the elderly population Most of the benefits of general teleophthalmology are applicable to the elderly population, but there are some limitations that should be addressed There is a need for more research of high quality in this field to inform the development of innovative models of eye care for the elderly population
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FUNDING SOURCE
FF received financial support from the Queensland Government through an Advance Queensland Research Fellowship (2016-2019).
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AUTHORS’ CONTRIBUTIONS
FF and YK designed the study. FF and FJ conducted the electronic search and screened the
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records. FJ was responsible for data extraction, data analysis approach, synthesis of results and writing the first draft. FF contributed to the writing of Introduction, Discussion and Conclusion.
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MT was the clinical supervisor and contributed to information synthesis. YK was the scientific supervisor and contributed to the data analysis. All authors read, provided feedback, and approved the final draft.
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CONFLICT OF INTEREST
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No competing financial interests exist.
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22
Total
10 2 52,54 1 56 57,40,48 3 1 51 2 60,67 1 62 14
3 2 29,45 0 1 32 0 0 0 6
9 23,55,30,35,38,41,61,47,65 + 3* 28,31,34 2 36,58 3 2 25,33 0 1 50 2 1 64 1 46 2 2 59,66 0 2 2 53,63 30
5 27,28,31,34,44
13 4 1 4 1 2 1 20 14
1 49 2 0 24,26 2 0 0 0 0 1 0 1 39 3 3 37,42,43 15
3 5 2 2 1 2 1 1 3 2 1 5 5 45
re
o Canada Asia o China o India o Singapore Middle East o UAE o Bahrain Africa o Kenya o Cameron Oceania o Australia TOTAL Count
Rural
ro of
Europe o France o Hungary o Spain o Italy o UK o Germany North America o USA
Urban
-p
Continent / Country
Jo
ur
na
lP
* Three studies have been conducted in both urban and rural areas Table 1 - Geographic location of teleophthalmology interventions
23
No of studies
Technology/Instrument
a.
2.
54
Imaging Investigations
39
Retinal Photography i. Mydriatic
7
ii. Non-mydriatic
24
iii. Undefined
8
b.
Anterior Segment Imaging
8
c.
Optical Coherence Tomography
5
d.
Confocal Scanning Laser Ophthalmoscopy
2 7
Automated Solutions (for patients or staffs) a.
Mobile devices
3
b.
Automatic Grading and Risk Assessment
2
c.
Digital Optotypes
ro of
1.
2
d.
a. 4.
4
Real-Time Technologies
4
Teleconsultation
Usability a.
Satisfaction questionnaire
b.
Digital literacy
-p
3.
4 3 1
Jo
ur
na
lP
re
Table 2 – The most utilized solutions for elderly teleophthalmology
24
Screening Diagnosis Monitoring Treatment
DR exclusive 13 1 0 0 14 27
mix 10 3 0 0 13
Glaucoma exclusive mix 1 11 4 3 0 0 0 0 5 14 19
Cataract exclusive mix 0 8 0 4 0 0 0 0 0 12 12
AMD exclusive mix 2 9 0 3 3 0 0 0 5 12 17
Others exclusive 3 0 0 0 3 18
mix 11 4 0 0 15
Jo
ur
na
lP
re
-p
ro of
Table 3 - The functionality of teleophthalmology vs diseases
25
Peripheral
Feasibility Study
9
17
SUM 26
Comparison with conventional methods
7
5
12
Patient Satisfaction
2
3
5
Pilot Study
2
3
5
Prevalence of Disease
1
3
4
Screening
8
24
32
Diagnosis Monitoring
7 3
3 0
10
Treatment
0
0
3 0
Retinography\Non-mydriatic Retinal Photography
7
17
24
Retinography\Undefined Retinal Photography
3
5
8
Anterior Segment Imaging
4
4
8
Retinography\Mydriatic Retinal Photography
3
4
7
Optical Coherence Tomography
2
3
5
Teleconsultation System
1
4
5
Mobile
1
2
3
Confocal scanning laser ophthalmoscopy
2
0
2
Digital Optotype
1
1
2
Automatic Grading or Risk Assessment
1
1
2
Questionnaire
1
1
2
Computer Usage
1
0
1
Trained evaluators
9
13
22
Optometrist
3
9
12
Nurse
7
3
10
Ophthalmologist
3
3
6
GP
0
5
5
Not Applicable
1
2
3
Patient
1
0
1
Retinopathy
5
23
28
Others
6
14
20
Glaucoma
6
13
19
AMD
6
11
17
Cataract
3
11
14
Not Applicable
1
1
2
ur
Jo
Diseases
na
Staff
lP
re
-p
Technology Utilized
ro of
Functionality
Study
Central
Table 4 - Cross-tabulation of location against other aspects for elderly teleophthalmology services
26