Eyeworld

EW GLAUCOMA 108 by Tony Realini, M.D. Telemedicine: Encouraging results for evaluating optic nerve disease T he potential benefits of an effective telemedicine sys- tem in ophthalmology are plentiful. Broad-based ap- plications of telemedicine could greatly enhance screening ef- forts for potentially blinding condi- tions such as diabetic retinopathy, macular degeneration, and glau- coma. Telemedicine could help bring subspecialty expertise to small or rural communities, or even to the developing world. A trio of new studies, presented at the annual meeting of the Associ- ation for Research in Vision and Ophthalmology in Ft. Lauderdale, Fla., in May 2010, demonstrated a global interest in adopting telemedi- cine for the evaluation of various optic nerve diseases, including glau- coma. Tele-glaucoma A research team in Canada pre- sented a 1-year snapshot of its expe- rience using telemedicine to provide glaucoma consultative services to Canadians outside the relatively few densely populated cities in Canada. "We are working with a group of approximately 10 optometrists in rural Canada," said team member Enitan Sogbesan, M.D., University of Alberta, Edmonton. "They exam- ine the patients and provide us with optic disc photographs and imaging, visual fields, clinical information such as intraocular pressure (IOP), central corneal thickness, and go- nioscopy, all via the Web." In addition, he said, all partici- pating optometrists send a provi- sional diagnosis to accompany each patient's data. Once the data—which often in- clude analyses obtained from the Heidelberg Retina Tomograph (HRT, Heidelberg Engineering, Vista, Calif.) or optical coherence tomography—is received in Edmonton, it is reviewed by a glaucoma specialist. After the first year of the pro- gram, 28 patients were evaluated via the telemedicine system. "There was agreement of the diagnosis between optometrists and the glaucoma spe- cialist in about 50% of the cases," said Dr. Sogbesan. More impressively, a large num- ber of potentially unnecessary con- sultations were avoided. "Only four of the 28 patients were referred to a glaucoma specialist after telemedi- cine review of their records," he said. Most of the remaining patients represented early-stage glaucoma or glaucoma suspects. "If this system had not been in place, all 28 would likely have been referred for consul- tation," he added. A research group in Spain de- scribed a similar approach relying on IOP, HRT results, and scanning laser polarimetry using the GDx Nerve Fiber Analyzer (Carl Zeiss Meditec, Dublin, Calif.). "We screened 414 subjects in this population-based, cross-sec- tional study, using structural measures rather than functional measures," said team member Monica Fallon, M.D., Barcelona Spain. "Of these, 51 met our criteria for referral for a glaucoma evalua- tion." Those criteria included the fol- lowing: IOP of 21 mm Hg or higher, HRT with global Moorfields regres- sion analysis of borderline or abnor- mal, or nerve fiber index of 30 or higher using the GDx. Subjects with only elevated IOP were deemed ocu- lar hypertensive, while those meet- ing two or more of the criteria were labeled glaucoma suspects. Of the 414 screened, 18 (4.3%) were found to be ocular hyperten- sive, and 31 (7.5%) were labeled glaucoma suspects. All of the sus- pects were referred for confirmatory testing, and 25 of the 31 completed the follow-up. "Of those, only five were found to be normal," Dr. Fallon said. The other 20 were classified as ocular hy- pertension, glaucoma suspect, or glaucoma. "Overall, our screening protocol had a 76% positive predictive value for identifying patients with glau- coma or who were at risk for glau- coma," she said. Other optic neuropathies Stateside, Beau Bruce, M.D., and colleagues, Emory University, At- lanta, presented a study evaluating the role of telemedicine to detect optic nerve abnormalities in a uni- versity hospital's emergency depart- ment. "We are conducting a prospec- tive study including consecutive pa- tients presenting to the ED with complaints of headache, acute focal neurological dysfunction, diastolic blood pressure greater than 120 mm Hg, or vision loss," said Dr. Bruce. All patients enrolled so far in this ongoing study underwent ex- amination by ED staff, including ex- amination of the optic nerves using direct ophthalmoscopy. "We then obtained non-mydriatic fundus pho- tography of both eyes," he said. The photos were taken by trained nurse practitioners. "Nurse practitioners can take quality photographs of the posterior pole that facilitate diagno- sis," he said. Once the photos were taken, they were reviewed within 24 hours by a pair of neuro-ophthal- mologists, who identified lesions that—if they had been detected in the ED—should have changed the patient's care in the ED. Out of 309 subjects in the study so far, 44 have had relevant poste- rior pole findings based on photog- raphy, including disc edema, intraocular hemorrhage, severe hy- pertensive retinopathy, retinal vas- cular occlusions, and disc pallor. "So far, the ED physicians have missed 27 of the 44 lesions identi- fied by the neuro-ophthalmolo- gists," Dr. Bruce said. Of the 17 lesions that were identified in the ED, 11 were described in the docu- mentation accompanying the pa- tient to the ED. "So the true undetection rate was 27 out of 33 findings, or 82%," he said. "Simply put, ED doctors are missing a lot of relevant findings." Future applications Telemedicine has many potential ap- plications in ophthalmology, from community screening to the provi- sion of expertise in areas where it is otherwise not available. These stud- ies demonstrate the viability of telemedicine approaches for a num- ber of different conditions in a vari- ety of settings. Because much of our diagnostic testing produces digital output, the potential for wider- spread application is tremendous. Perhaps someday soon there will be a virtual eye clinic on the internet, just a mouse click away. EW Editors' note: Drs. Bruce, Sogbesan, and Fallon have no financial interests related to their comments. Contact information Bruce: bbbruce@emory.edu Fallon: mfallon@monicafallon.com Sogbesan: sogbesane@ualberta.ca February 2011 March 2011 A research team uses analyses obtained from the HRT when practicing telemedicine Source: Theodore Krupin, M.D.

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