Digital Eye Care and Teleophthalmology: A Practical Guide to Applications

Foreword
Preface
Contents
Current State of the Art
1 Teleophthalmology and COVID
Abstract
Introduction
Teleophthalmology Before COVID-19
Teleophthalmology and COVID-19
The Teleophthalmology Exam
Patient Acceptance of Teleophthalmology
Physician Acceptance of Teleophthalmology
Back to the Future
References
2 A Practical Guide to Telehealth in Ophthalmology
Abstract
A Reading Center
Introduction/Background
Benefits of Implementation
Institutional
Community
Reading Center Model
Introduction to MAILOR
Network Topology: Centralized Versus Hierarchical
Centralized Model
Hierarchical
Legal Considerations
Funding
Procedural and Technical Considerations
Hardware
Servers and Management
Imaging Modalities
Image Acquisition
Digitization
Communications
Software
Application Systems
DICOM
Artificial Intelligence
Operationalization and Clinical Experiences
MAILOR
Facility Considerations
Imaging Considerations
Disease-specific Considerations
International Programs
Reading Center Conclusions
Telemedicine
Key Concepts
Introduction
Teleophthalmology Around the World
Teleophthalmology in Mexico
Teleophthalmology in Queretaro
Virtual Reality and Simulation Based Training in Ophthalmological Surgery
Simulation and Its Use in Ophthalmology
Why a Virtual Reality Simulator for Manual Small-Incision Cataract Surgery (MSICS)?
Training a Cataract Surgeon
A Virtual Reality Simulator for MSICS at HelpMeSee®
The Current Outlook for Simulation
Disclosure
References
3 Smartphone Technology for Teleophthalmology
Abstract
Imaging Ophthalmic Anatomy
Smartphones Attached to Existing Ophthalmic Devices
Manual Smartphone Ophthalmoscopy
Handheld Indirect Smartphone Adaptors
Handheld Direct Smartphone Adaptors
Capturing Ophthalmic Function
Visual Acuity Applications
Visual Field Testing
Auto Refraction
Color Testing
Data Security
Conclusion
References
4 Ethical Recommendations for Online Medical Consultation and Teleophthalmology
Abstract
Introduction
Virtual Consultations
Teleconsultation in Ophthalmology
Discussion
Final Thoughts
References
5 The Use of Telehealth in Optometry: Present and Future Clinical Applications
Abstract
The Need for Responsible Innovation
Regulatory Overview of Telehealth in Optometry
Licensure Jurisdiction
Mode of Care Delivery
Quality of Care
Telemedicine in Integrated Healthcare System
Background and Program Overview
Disease Selection
Data Visualization Strategy
Separation of Enrollment, Testing, and Evaluation Sites
References
6 Low Vision TeleEye Rehabilitation
Abstract
Background
Importance of Low Vision TeleEye Rehabilitation Services
Steps for Implementing Low Vision TeleEye Rehabilitation Services [9–11]
Step 1: Build the Team
Step 2: Clinic Space
Step 3: Equipment
Step 4: Clinical Reports
Step 5: Low Vision TeleEye Rehabilitation Consultation
Step 6: Low Vision Therapist Clinical Video Telehealth Assessment
Conclusion
References
7 Best Practices: Telemedicine-Diabetic Retinopathy
Abstract
Background
Clinical Guidelines
Program Validation
Personnel
Technical Guidelines
Equipment
Data Management
Administrative Guidelines
Legal Requirements
Quality Control
Customer Support
Financial Factors
Summary
Acknowledgements
Appendix
References
8 Teleretinal Diabetic Retinopathy Screening in Primary Care Settings—Considerations for Safety Net Organizations
Abstract
Introduction
Barriers And Motivators to Providing Telemedicine for Retinal Screening in the Safety Net
Factors for Success: Incorporating Motivators and Facilitators Into DR Screening
Conclusion
References
Digital Imaging and Artifical Intelligence
9 Image Processing in Retinal Imaging
Abstract
Introduction
Image Processing Pipeline
Retinal Image Acquisition
Pre-processing
Fundus Image Pre-processing
Optical Coherence Tomography Image Pre-processing
Segmentation
Segmentation of Fundus Photograph
Segmenting Optic Disc
Segmenting Fovea
Segmenting Blood Vessels
Segmenting Retinal Lesions
Segmentation of OCT Images
Feature Extraction
Classification/Object Detection
Image Pre-processing for Deep Learning
Potential Clinical Applications
Applications of Using Image Processing for Retinal Images
Applications of Using Image Processing for OCT Images
Diabetic Retinopathy OCT Image Processing
Age-Related Macular Degeneration OCT Image Processing
Conclusion
References
10 OCT Imaging and Applications in the Retina
Abstract
Overview
Simple Review of the Retina and Retinal Imaging
The Retina and Beyond
Retinal Imaging
OCT Imaging
OCT Imaging and Interferometry
Time-Domain OCT
Spectral-Domain OCT
Swept-Source OCT
OCT Angiography
Other OCT Imaging Technologies
OCT Applications
Multiple Retinal Layer Segmentation in Healthy and Diseased Eyes in OCT
BMO/NCO (Bruch’s Membrane Opening/Neural Canal Opening) Detection Using Graph Search in Glaucoma Patients
Early Detection and Diagnosis of DR Using Artificial Neural Networks
Early Detection of AMD Features Using a Deep Learning Approach
Axial Signal Analysis in OCTA Images
Conclusion
References
11 Ultrawide Field Imaging in Retinal Diseases
Abstract
Introduction
Historical Perspectives
Evolution
Clinical Applications
Diabetic Retinopathy
UWF Imaging for Diabetic Retinopathy
Validation of UWF Imaging Use in DR Grading
Grading of DR
Predominantly Peripheral Lesions (PPL)
Diabetic Macular Edema (DME) and Peripheral Ischemia
Targeted Retinal Laser Photocoagulation (TRP):
Monitoring the Response to Treatment
Tele-Medicine and Ultra-Widefield Imaging
Future Trends in DR
Wide-Field Optical Coherence Tomography and Optical Coherence Tomography Angiography (OCTA) in DR
Retinal Vein Occlusion
Pediatric Retinal Imaging
Conclusion
References
12 Digital Glaucoma
Abstract
Background
Intent
Method
Results
Discussion
Summary
References
13 Digital Tools for Visual Acuity Self-Assessment
Abstract
Background
Digital Tools for Vision Self-Testing
Limitations
Conclusion
References
14 Transfer Learning for Artificial Intelligence in Ophthalmology
Abstract
Traditional Machine Learning and Transfer Learning
Machine Learning
Transfer Learning
Categories of Transfer Learning
Inductive Transfer Learning
Transductive Transfer Learning
Unsupervised Transfer Learning
Transfer Learning in Deep Learning
Deep Learning
Pre-trained Network
Generative Adversarial Network (GAN)
Neural Style Transfer
Application of Transfer Learning in Ophthalmology
Diabetic Retinopathy
Age-Related Macular Degeneration
Glaucoma
Transfer Learning on Color Fundus Photographs to Predict Systemic Disease
Summary
Acknowledgements
References
15 Beyond Predictions: Explainability and Learning from Machine Learning
Abstract
Introduction
Goals of Explainability
Types of Explainability Methods
Explainability Methods for Image-Based Models
Case Studies: Imaging Applications in Ophthalmology
Case Studies: Applications Outside Ophthalmology
Summary of Learnings from Case Studies
Perspective and Future Directions
Conclusion
Acknowledgements
References
16 Artificial Intelligence in Predicting Systemic Disease from Ocular Imaging
Abstract
Introduction
Building AI Systems with Ocular Images
Prediction of Demographic and Lifestyle Parameters
Prediction of Body Composition Factors
Prediction of Cardiovascular Disease and Its Risk Factors
Prediction of Hematological Parameters
Prediction of Neurological Diseases
Prediction of Metabolic and Endocrine Diseases and Biomarkers
Prediction of Renal Disease and Biomarkers
Prediction of Hepatobiliary Disease and Biomarkers
Current Challenges and Areas of Future Research
Conclusions
References
17 Natural Language Processing (NLP) in AI
Abstract
Introduction
Overview of Methods
NLP and Health Care
NLP Applications in Ophthalmology
References
Global Experiences
18 Smartphone Telemedicine Networks for Retinopathy of Prematurity (ROP) in Latin America
Abstract
Introduction
New International ROP Classification: ICROP 3
Conclusions of ICROP 3
Smartphone Hands-Free Indirect Funduscopy: ROP Images
Prematurity and Pediatric Ophthalmology Subnetworks (Comorbidities)
PAHO-WHO Standards for Telemedicine ROP Projects in Latin America
Artificial Intelligence and ROP Smartphone Images in Latin America
Conclusion
Acknowledgements
References
19 Cataract and Refractive Surgery: Teleophthalmology’s Challenge in Argentina, 20 Years Later
Abstract
Introduction
Our Evolution During These Past 20 Years
Sites
Telecommunication and Information Network
Teleconsultation Examining Rooms and Lanes Design
Methods
Project Team and Protocols
VEX: The Next Normal in Virtual Workflows
Pre-COVID Virtual Workflow
Covid Virtual Workflow
Results and Discussion
Population Assisted Remotely
Virtual Eye Exams (VEX) Dec 2012–April 2021
Patient Demographic Information
Gender
Origin
Specialty Eye Care
Image Quality and Transmission
Image Acquisition and Reception
Virtual Doctor-Patient Relationship
Sustainability
Our Legacy: Teleophthalmology Training Programs
Conclusions
Acknowledgements
Annexus
References
20 Teleophthalmology in Brazil
References
21 Veteran Affairs (VA) Ocular Telehealth Programs
Abstract
Introduction
Veterans Health Administration (VHA) Organizational Structure
VA Eye Care
VA Telehealth
VHA Office of Connected Care Eye Telehealth Structure
Introduction
TRI—History
TRI—Clinical Processes
TRI—Administrative Processes
Conclusion
Introduction and History
TeleEye—Administrative Processes
Conclusion
Introduction and History
Future Directions of Ocular Telehealth in the VA
Mobile Units
Tele-Follow-Ups
Other Developments—Anterior Segment, Remote Refraction, Remote Monitoring
Big Data and Research
Conclusion
References
22 Retinal Screening of Patients with Diabetes in Primary Care Clinics Why Has Uptake of This Promising Idea Been So Low?
Abstract
Promise of Teleretinal Screening for Diabetic Retinopathy
Few Primary Care Practices are Using Teleretinal Screening
How to Move Forward
Summary
References
23 Tele-Ophthalmology for Diabetic Retinopathy in the UK
Abstract
Introduction
Methodology in England
Methodological Differences in Scotland, Wales and Northern Ireland Screening Programmes
The Aim of the Programme is
Referrals from the English NHS DESP
Management of Patients with Ungradable Images
Management of Patients with Screen Positive Maculopathy and Background Diabetic Retinopathy (R1M1)
Improving the Specificity of Detection of Diabetic Macular Oedema Needing Treatment in Screen Positive Maculopathy patients
Extension of the Screening Intervals in Low-Risk Groups
The Use Artificial Intelligence for Grading in UK Diabetic Eye Screening Programmes
Newer Camera Technologies for Use in Screening—Hand Held, Small Devices and Scanning Confocal Ophthalmoscopes
Imaging Within Ophthalmology in the UK
References
24 Screening for Diabetic Retinopathy in Denmark
Abstract
Diabetic Retinopathy
Screening for DR
The Launch of a National Screening Program
Implementation of National Guidelines to Standardize and Support Screening
Classification of DR
Examination Techniques
Screening Intervals
Automated Screening
Hospital-Based Telemedicine Screening
Conclusion
References
25 Diabetic Eye Screening Using a Hand-Held Non-mydriatic Digital Retinal Camera: Experience from a Lower Middle-Income Country
Abstract
Introduction—Current Need of Screening for Diabetic Eye Disease
An Approach to the Development of a Diabetic Eye Screening Programme in a Resource Poor Setting
Process of Developing a Diabetic Eye Screening Model in a Non-Ophthalmic Setting: Sri Lanka as a Case Study
Scope of Hand-Held Retinal Cameras for Diabetic Eye Screening
Training, Assessment of Primary Graders, and Validation of the Screening Model
Implications for Research, Policy, and Practice
Conflict of Interest
References
26 More Than Retinopathy. Has the Time Come to Recognize Diabetic Retinopathy as Neuro-vasculopathy? Would This Change Your Practice?
Abstract
Introduction
History and Current Context
Obstacles to FPS
Strategic Approach to “Screen for Life”
References
27 Teleglaucoma: Tools for Enhancing Access to Glaucoma Care for At-Risk and Underserved Populations
Abstract
Introduction
Global Landscape of Glaucoma
Terminology in Teleglaucoma
Telehealth
Telemedicine
Asynchronous Telemedicine
Synchronous Telemedicine
Telehomecare
Teleophthalmology
Teleglaucoma
Biometric Data Acquisition, Storage, and Analysis in Teleglaucoma
Modular Extension Teleglaucoma Model
Collaborative Teleglaucoma Model
In-Office or Digitally Integrated Teleglaucoma Model
Successes and Challenges of Teleglaucoma
Alberta, Canada
Successes in Alberta, Canada
Challenges in Alberta, Canada
Addis Ababa, Ethiopia
Successes in Addis Ababa, Ethiopia
Challenges in Addis Ababa, Ethiopia
Nyamira, Kenya
Successes in Nyamira, Kenya
Challenges in Nyamira, Kenya
Carving a New Path Forward
Artificial Intelligence (AI) and Machine Learning (ML)
Mobile and Portable Technologies
Comprehensive Screening Tools
Guideline Development, Medico-Legal Coverage, and Physician Reimbursement
Quality Improvement (QI) and Validation
Global Health Equity
References
28 Teleophthalmology for Vision Centres
Abstract
Introduction
Scope of Telemedicine in Vision Centres
Technology at the Vision Centre
Data Documentation/Storage
Data Collection
Managing the Teleconsultation
Managing Patients with Chronic Conditions
Vision Centre Management
Considerations for Vision Centre Technology
Policies and Guidelines for Teleconsultation
References
29 Teleophthalmology—LVPEI Eye Health Pyramid Program Experience
Abstract
Introduction
LVPEI Pyramidal Eye Care Model
Evolution of Teleophthalmology at LVPEI Eye Helath Pyramid
Role of the Electronic Medical Record (eyeSMART EMR) in Teleophthalmology
Technical Features of eyeSMART EMR
Development of Mobile Teleconsultation App: LVPEI ConnectCare
Primary Eye Care Teleophthalmology
Technology Device Integration
Referral Tracking Mechanism
Numbers and Outreach
Secondary Level – Teleophthalmology
Tertiary Level Teleophthalmology
Unique Features
LVPEI’s Experience in Telerehabilitation
The Way Forward
Future of Teleophthalmology at LVPEI
Conflicts of Interest
References
30 Teleophthalmology in Timor-Leste: A Journey
Abstract
Introduction
Landlines and Mobile Phones (First Steps)
2012: Internet and Photo Slit-Lamps
2015: Smartphone-Based Telemedicine
2018: The Artificial Intelligence Era
Current Trends in Teleophthalmology
International Teleophthalmology Links
Remote Teaching in the Covid Era
Diabetic Retinopathy Screening
Improved, Affordable Internet Services Are Vital to Increase the Uptake of Teleophthalmology
Conclusion
References
31 Teleophthalmology in Nepal
Abstract
References
32 Developing a Comprehensive Diabetic Eye Service Model with Telemedicine—The CREST (Comprehensive Rural Eye Service and Training) Project in Rural China
Abstract
Introduction
The Guangdong CREST (Comprehensive Rural Eye Service Training) Project
The Telemedicine System of the CREST Project
Result
Discussion
References
Appendix_1
Appendix_2
Appendix_3
Session 1: Where Are We Now and Where Do We Want to Be?
Introduction and National Eye Institute Perspective
Radiology’s Experience
Imaging Standards: The Value of Interoperability
My 15-Year Saga of Integrating Clinical Imaging Using Standards
Why Do Ocular Imaging Standards Matter for Vision Science Research?
Imaging Data Standards in Clinical Research for Ophthalmology: Challenges to Enable Impact-Driven Data Mastery
Session 2: What Do We Need to Reach the “Vision for the Future”?
U.S. Food and Drug Administration Device Interoperability
Office of the National Coordinator for Health Information Technology Interoperability with Electronic Health Records
U.S. Core Data for Interoperability
Discussion with Session 1 and 2 Presenters
Potential for Deep Learning to Clone Proprietary Algorithms
Access to Raw Data
Needs Beyond the Scope of DICOM
Session 3: Panel Discussion—How to Address Barriers to Adoption of DICOM
Interoperability Needs for Clinical Practice and Research
Review Software and PACS Interoperability
Comparison of Quantitative Results
Data Access, Deidentification, and Standardization
EHR Integration
Usability of Standardized Processes
Challenges and Opportunities in Standardization for Manufacturers
Need for Consensus
Deployment Challenges
Improving Accessibility of Historical Device Data
Implementation Inertia
AI Integration for Biomarker Discovery
Approaches to Enhance Collaboration
Session 4: Panel Discussion—Evaluating Meaningful Adoption and What Else Is Needed (Beyond DICOM)
ONC Certification and Testing Overview
FDA Recognition and Use of Standards for Regulatory Decision-Making
Ocular Imaging in NEI-Supported Collaborative Clinical Research Studies
Discussion
Identifying and Evaluating Conformance
Creating and Expanding DICOM Standards for Ocular Imaging
Applications From Radiology
Advantages and Disadvantages of DICOM
Session 5: Panel Discussion—Approaches to Address the Challenges for Imaging Standardization to Improve the Ecosystem of Ocular Imaging
Academy Ideas for Approaches to Address Challenges for Imaging Standardization to Improve Eco-System of Ocular Imaging
Promoting the Adoption of Ocular Imaging Standards
ONC Perspectives
Addressing the Challenges of DICOM Adoption to Improve the Ocular Imaging Ecosystem
Observations of Conference Remarks
Discussion
Approaches to Incentivizing and Enforcing Ocular Imaging Standards
Advancing Ocular Imaging Standards through Research Funding
Role of Professional Societies
WG-09 and Next Steps
Closing Comments