Partly, this is a problem of casting too wide a net—if one screens for all diabetic retinopathy, one is likely to find a lot of diabetic retinopathy that does not need intervention, ironically increasing the burden on the same physicians it is intended to be assisting. A notable exception has been for retinopathy of prematurity screening. This application has worked for three simple reasons: 1) the remote screening is highly effective at identifying a treatment intervention time point; 2) the disease is self-limited in that it will either spontaneously resolve or result in retinal detachment and blindness within a 15-week time frame; and, 3) all neonatal intensive care units (NICUs) are required to perform screening in order to maintain accreditation, removing most of the financial uncertainty. These three components give us great insight into greater application of telemedicine in ophthalmology. First, let us review the ROP scenario.
Universal Screening of Newborns
Pediatric vitreoretinal surgery physicians have been looking to expand upon the success of telemedicine screening for ROP. One potential opportunity is universal screening of newborn infants. In China, Brazil, Hungary and Spain, universal screening has been practiced in single-hospital settings for up to seven years.
|The telemedicine experience in pediatric retinal diseases has been successful because it has avoided the pitfalls of casting too wide a net.|
Other strategies that are being employed are assessment of axial length, refraction, optical coherence studies of the macula, and, potentially, intraocular pressure assessment in the near future. While the NEST program is currently being evaluated as a prospective study with longitudinal follow-up with pediatric ophthalmology/retina specialists, it is evident from early data that commercialization and widespread adoption will be offered in the future.
The telemedicine experience in pediatric retinal diseases has been successful because it has avoided the pitfalls of casting too wide a net. Instead, we have identified niche markets with well-defined intervention points that are easily identified using the technology. These markets, whether in ROP or congenital ocular pathology, have a limited timeframe in which therapy is beneficial, but can result in life-long benefit. Therefore, the societal and patient benefit is large from these screening programs. As ophthalmologists, we need to continue to define very narrow ranges of targeted telemedicine screening that will offer immediate relief and benefit, while still maintaining economic feasibility. REVIEW
Dr. Moshfeghi is an associate professor of ophthalmology at Stanford University School of Medicine where he is the director of the vitreoretinal surgery fellowship program and director of pediatric vitreoretinal surgery as well as director of telemedicine (ophthalmology). He may be reached at firstname.lastname@example.org.
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