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