Telemedicine as a ‘guardian angel’ even for those who cannot see well. During the pandemic, even in the ophthalmology field, technology came to our aid and telemedicine experienced a strong acceleration. The role that telemedicine can also play in ophthalmology was discussed during a round table organized in Rome on the occasion of World Sight Day.
Advances in Ophthalmology
The main objective of telemedicine is to optimize health care in all its phases, namely the prevention, diagnosis, treatment and rehabilitation of a disease, bringing the advantage of speed of intervention, equity in ” access to the various services and also allowing the overcoming of the chronic problem of the length of waiting lists. Ophthalmology has all the characteristics to fully meet the criteria of telemedicine. “Ophthalmology has experienced unparalleled technological development in recent decades,” he explains Filippo Cruciani, scientific referent of Iapb. “Just think of the cataract surgery that allowed the total restoration of vision with the implantation of an artificial lens to replace the opaque lens with a rapid intervention and with an even more rapid functional recovery, when before months and months were necessary of rehabilitation “. The same goes for the OCT exam that allows you to analyze in section – as if it were a CT scan – and at high magnification – as in a histological exam – the eyeball and above all the retina, the macula and the head of the optic nerve, without be a minimally invasive investigation. “It is precisely the ophthalmological instrumental technology – continues Cruciani – that allows the acquisition of high definition images that can be sent remotely for their analysis”.
Telemedicine for prevention in ophthalmology
Teleophthalmology can be used in the various phases of eye care, starting with prevention. A practical example concerns the ‘Sight in health‘ campaign. With a mobile unit, consisting of a truck with four examination points, all patients who present themselves with more than 50 years can undergo some tests, including the evaluation of the refractive state with an auto-refractometer, the measurement of ocular pressure, the ‘Oct of the macula and optic disc and the examination of the visual function in virtual reality through a digital viewer. The presence of an ophthalmologist guarantees an initial evaluation and advice. “All the data – explains Cruciani – are sent to a server, analyzed by another ophthalmologist for the purpose of epidemiological studies to know not only the prevalence of a specific disease in the silent or overt state, but also its disabling power and above all the identification of the population at risk and any favoring factors. In this way, fundamental data can be collected through the computer network for a better understanding of diseases ”. From the first data analyzed from three Italian regions it emerged that about 40% of the subjects visited were affected or strongly at risk of contracting eye diseases.
Diabetic Retinopathy: How Much Timeliness Matters
The most important use on a large scale (national or regional) of teleophthalmology is, however, that concerning diabetic retinopathy in its early identification and in its follow up. The Ministry of Health estimates that there are more than 3 million diabetics in Italy (5% of the population) and that about one million, despite being affected by the disease, are not aware of it. “Diabetic retinopathy – continues the Iapb scientific referent – is one of the most frequent and serious complications of diabetes. Its global prevalence among diabetics is 35%, which, twenty years after the diagnosis of the disease, rises to almost 90%. It represents the first cause of legal blindness in the working-age population and is one of the four priorities in the ophthalmology field that the WHO reports to the health services of the various nations ”. Fortunately it is a preventable and treatable pathology but a lot depends on the timeliness of the therapeutic intervention. “Unfortunately – points out Cruciani – the periodic examination of the fundus in diabetics is performed in Italy in less than 20% of cases, despite the Guidelines establish a very precise periodicity according to the severity of the disease”.
Teleophthalmology for diabetic retinopathy
The identification of the lesions of diabetic retinopathy historically rests on the outpatient examination of the ocular fundus, performed by ophthalmoscopy by an ophthalmologist, with pupil dilation and with an average execution time of 20 minutes. “But in recent years – explains the expert – international scientific evidence has shown a diagnostic overlap between clinical examination of the fundus and digital photography, which can be obtained using a color retinograph and can be reported remotely by an ophthalmologist. Various studies have demonstrated the cost-effectiveness of this method, which is spreading in many countries “. Digital photography, for example, has been implemented in recent years by the British National Health System, with a program aimed at the entire diabetic population (DESP, Diabetic Eye Screening Program) and is mentioned among the methods provided for the examination of the fund in the Guidelines for Diabetic Eye Care ”of the International Council of Ophthalmology.
How digital photography works
This method can be carried out in any equipped structure, even by non-medical personnel and allows to greatly reduce the number of diabetics who do not undergo an examination of the fund due to forgetfulness or logistical unavailability; to considerably limit the ophthalmological outpatient visits for “ocular fundus”; to have digital images, which can be an important step towards the construction of a multidisciplinary electronic medical record, to identify or suspect other morbidities or comorbidities (for example, age-related macular degeneration or glaucoma). Furthermore, in this way it is possible to create a database, essential for developing epidemiological and clinical investigations, with the possibility of comparison with other countries.
It does not replace the doctor
Be careful, however, not to think that teleophthalmology can replace an eye examination, which is always the essential moment for a diagnosis and therapy. “It does not want and must not in the least affect – explains Cruciani – what is the doctor-patient relationship on which the health intervention is based. Its role is only to support the visit by providing information, from time to time analyzed and interpreted in a comparison with other data, whether they are anamnestic, objective and instrumental, respecting the uniqueness of each individual “.
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