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Telehealth: an eyecare access breakthrough or dangerous gamble?

13/04/2018By Richard Chiu • Staff Journalist
Telehealth has the potential to revolutionise eyecare, especially with its ability to increase access amongst previously neglected demographics. But is the technology sufficiently advanced for it to be safe? RICHARD CHIU reports.

There are few countries in the world that are better positioned to both benefit from, and further develop, teleophthalmology than Australia. With our wide expanses, far-flung communities, and technical excellence, millions of people both at home and abroad could benefit from its increased use and evolution.

However, it is also a relatively new phenomenon, one which comes in many different forms, and whose scope and practical use has been the subject of much debate.

In Australia, telehealth has been promoted as part of the solution to rectifying the problem of underserved regional and remote areas, where treatable yet blinding eye diseases such as glaucoma, cataracts, and diabetic retinopathy are prevalent.

Nowhere has this gap in eye health been more obvious than Western Australia, where studies have shown that ophthalmology coverage in some areas is 19x lower compared to major cities.

Perth serves as the only major centre providing tertiary level ophthalmology services in the state, yet it is more than 3,000 kilometres away from some towns and communities in its most remote corners.


"Telemedicine as a tool to help a doctor better care for a patient is absolutely acceptable to most doctors including myself,"
Dr April Jasper, President of the Florida Optometric Association

A 2016 study published in the Australian Journal of Rural Health found that teleophthalmology is underutilised in Australia, despite its potential for improving eye health services for regional and remote patients.

The findings called for advocacy geared towards funding regulatory, training, and infrastructure programs to support teleophthalmology.

Such an investment could potentially support 15% of urgent patient transfers and 24% of outreach consultations, equating to cost savings of around $1.1 million per year.

According to the study authors, the real-world savings could even be higher.

Aside from the economic advantages, the study also found significant benefits related to teleophthalmology in terms of enhancing service delivery for rural patients, reducing wait times and non-attendance for consultations, and also improving access, quality of care and outcomes.

Online eye tests

While telehealth has succeeded in providing improved access to better eyecare, businesses – mostly in the US – are using similar technology and applying it in situations outside of remote and rural settings. Such an approach has proved divisive, with proponents of these often smartphone based applications arguing it improves screening rates, while critics have charged it will lead to patients avoiding essential in-person eye examinations that can only be performed by optometrists.

One of those businesses leading the charge is Smart Vision Labs, a start-up that has developed technology that allows a person to complete an eye exam in minutes without the need for an eye specialist.

Hubble Contacts has already expanded into Canada and Europe

As alluded to earlier, the technology is packed into a smartphone- powered device a fraction of the size of traditional refractors, and all that’s needed by the patient is to answer some questions on personal health and history, then sit through a simple passive test by staring into the device’s camera. It then runs three different tests – visual acuity, papillary distance and refraction error management.

The information derived from the tests is transmitted to optometrists or ophthalmologists partnered with the company, who send the results back via email within 24 hours of the patient taking the exam.

The US Food and Drug Administration (FDA) have cleared the technology and the company claims a high level of accuracy, with a 1% remake rate compared with the 10% average for traditional optometry practices.

Multiple companies have already integrated the technology into bricks and mortar stores, including Warby Parker in New York. It also found its way into stores in San Francisco, Los Angeles and San Diego.

However, the developers concede that the system does not provide a complete work-up as, for example, it cannot dilate pupils and there are still question marks regarding its ability to comprehensively detect eye problems. If the system does detect something, the company advises the patient should consult an optometrist or ophthalmologist.

Another startup, Simple Contacts, has followed closely on the heels of Smart Vision with a similar technology that allows people to record themselves taking a eye test, by using their phone as a virtual eye chart while wearing their current prescription contact lenses. It is followed by an exam where the camera is positioned to check the eyes for visible signs of infection or damage.

Both videos are then sent to an ophthalmologist for analysis. If the vision quality remains the same and no signs of problems are detected, the prescription lenses are reissued. It is also substantially cheaper than the traditional option in the US – it costs just US$10 (AU$13), whereas a visit to the optometrist or ophthalmologist can be 10x that amount.

The company has stressed that the process is not a full eye examination and there are restrictions. Patients are limited only to the renewal of prescriptions, and even then they have to have had a full check up within four years prior to completing the virtual test.

Yet another startup, Hubble Contacts, has attempted to make the process even more convenient, by giving patients access to contact lenses via an innovative subscription method. The company’s daily lenses are available in America for US$30 (AU$39.20) for a month’s supply, while the company also recently branched out to Canada and the UK.

Hubble Contacts already has a strong subscriber market of around 25,000, and revenues could hit US$20 million (AU$26.1 m) this year.

More and more companies are offering online eye exams
More and more companies are offering online eye exams
Simple Contacts allows patients to take an eye test from home
Simple Contacts allows patients to take an eye test from home

Safety concerns

The technology is not without its skeptics, with some eyecare professionals expressing concerns about the autonomous nature of the technology.

“Telemedicine as a tool to help a doctor better care for a patient is absolutely acceptable to most doctors including myself,” Florida Optometric Association president Dr April Jasper said in an interview with Business Insider.

“When telemedicine is advertised and promoted as a substitute for a comprehensive eye health examination, most doctors are going to have serious concerns for our patient’s safety.”

Jasper pointed out while there’s still no telemedicine technology that could substitute for a comprehensive eye health exam, such technology could lead to patients becoming complacent, or worse misled, and therefore bypass a visit to the optometrist.

Regulatory challenges

Smart Vision Labs
Smart Vision Labs' technology in action

Online eye test companies have faced opposition from powerful lobbying groups such as the American Optometric Association (AOA), which has resulted in multiple legislative challenges. Three states have already banned ocular telemedicine companies, and as such most of the US$8 million (AU$10.45 m) that Smart Contacts was able to raise in its most recent round of funding will go toward governmental affairs in order to get ahead of regulatory battles.

Woolfson Eye Institute clinical director Dr Tom Spetalnick believes such challenges are vital to protecting the public.

“Eyecare patients tend to think that an eye exam is just a measurement for glasses, and that is a real important test because people want to see well out of their glasses. But it’s a fairly small part of an overall comprehensive eye examination and has no impact, or very little impact, on assessing the health of the eye,” Spetalnick told CNN.

“There is a standard of care when an eye doctor is expected to perform an eye exam, and the eye exam is expected to determine if the patient does or doesn’t have things like glaucoma, retina problems – even diabetes can be detected.”

Aside from safety, Spetalnick also worries about efficacy: “Even if you’re talking about nothing but assessing the proper eyeglass prescription for an individual, a single test isn’t the way a doctor ought to be determining what to prescribe for that patient. You need to collect multiple data points,” Spetalnick said.

But while many professionals are still not convinced about the real value of online eye tests, their comparatively lower costs make them more attractive to the lay population.

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Yet, despite its obvious price advantage, Spetalnick still believes the online eye tests are not value for money, explaining, “first of all, you’re not getting an eye exam, and you’re talking yourself out of getting proper eye healthcare.

“For $40, $20, $1, it’s a bad call if you’re getting an eye test instead of a comprehensive eye examination. If you want an inexpensive eye exam, they’re out there.”

However, notwithstanding the criticism over safety, there is also an another incentive for optometrists to speak out against online optometry tests – money.

Money talks

Smart Vision Labs
Smart Vision Labs' technology in action

Potentially disruptive telemedicine has become a threat to the current business model of bricks and mortar optometry practices, and as mentioned earlier, this has seen telemedicine opponents enlist lobbyists to discredit the practice and encourage lawmakers to restrict the new technology through legislation.

In 2017, New Mexico Governor Ms Susana Martinez vetoed anti-ocular telemedicine legislation that was being pushed through by state legislators backed by optometry lobbyists, citing the need to protect the potential benefits the technology had in terms of patient access. Similarly, former South Carolina Governor Ms Nikki Haley also vetoed a bill that would have restricted access to online eye tests, arguing that the technology would “stifle competition for the benefit of a single industry.”

The conjecture surrounding the contact lens industry and its relationship with telehealth prompted the FTC to explore “issues regarding competition”, which led to multiple stakeholders participating in a workshop in March addressing the future of the sector.

One of the loudest voices at the workshop was the AOA.

Smart Vision Labs
Smart Vision Labs' technology in action

“Through the delivery of personalised healthcare, doctors of optometry assure precise and healthy vision, identify and treat glaucoma and serious infections, and ensure early diagnosis of immediate threats to overall health, including hypertension, stroke and diabetes, which may have no obvious signs or symptoms,” a statement presented to the FTC read.

“Some have used it as a smokescreen to try to mislead the public and undermine very basic quality care standards. Patients can receive inaccurate or misleading information when relying on an app for an eyeglass or contact lens prescription.”

The National Eye Institute (NEI) and the Centers for Disease Control and Prevention (CDCP) also agree that existing technologies still cannot match a comprehensive eye examination to effectively determine healthy eyes and vision.

Australian perspective

Back home, Optometry Australia (OA) has welcomed telemedicine as a new approach to help bridge the gap for underserved communities. However, OA also maintains that safeguards need to be in place through legislation to ensure it is not abused.

“While emerging technologies are something that Optometry Australia continues to observe and welcome, we must employ caution to uphold the highest standards when it comes to patient health and care,” an OA spokesperson told Insight.

Smart Vision Labs
Smart Vision Labs' technology in action

“We believe legislation should be strengthened to ensure that online dispensers are required to site a valid prescription from an optometrist prior to supplying contact lenses and to ensure that virtual eye exams are not able to give patients a false sense of security.”

The concerns OA has with telehealth are similar to those voiced by its counterpart in the US, in particular with regard to its potential to ineffectively replace comprehensive eye exams.

“This is an emerging situation that OA has been watching closely. We have concerns regarding the accuracy of such tests and the impact this may have on a patient’s vision and eye health,” the spokesperson said

“Typically online tests assess vision but do not provide a comprehensive consultation that may identify underlying pathology that may be associated with a visual change or that may be present but not yet symptomatic. If patients aren’t aware of this and don’t also access a comprehensive consultation from an optometrist, early signs of eye disease may be missed.”

The lack of companies such as Hubble Contacts and Smart Vision Labs operating in Australia means related legislation has not yet been drafted or likely even considered by lawmakers. However, given the ubiquitousness of technology and the increasingly global nature of society, their arrival is surely a matter of when, not if, which means Australia and its ophthalmic sector need to be prepared.


Better access equals enhanced compliance

Telehealth is not just restricted to ophthalmology. A study of the Lions Outback Vision (LOV) telehealth service that included collaboration with optometrists in remote areas, showed similar improvements in patient outcomes once it became more prevalent.

It was able to demonstrate this by conducting three five-month audits – one in 2012 prior to an intervention that removed perceived barriers for its use, followed by a second in 2014 after logistical support, remuneration to optometrists, a more user-friendly referral pathway and awareness raising measures had been put in place.

The final audit, completed in 2016, clearly showed that real-time videoconferencing between optometrists, patients and ophthalmologists was having a positive impact.

The audits compared a range of key indicators identified at the start of the study and found that once optometrists began utilising the technology more efficiently, telehealth services increased by 350%. As a consequence, patients received better basic care, as evidenced by a greater percentage (32% vs 69%) of non-urgent referrals in the second audit, as well as fewer consultations that required follow up with an ophthalmologist.

Director of Lion’s Outback Vision, Associate Professor Angus Turner
Director of Lion’s Outback Vision, Associate Professor Angus Turner

Most recently, an analysis of patient satisfaction published in January in Clinical and Experimental Optometry, found the majority of the 109 participants who completed a survey on their experience were either ‘very satisfied’ (69.1%) or ‘satisfied’ (24.5%) with the service, while no one reported being ‘dissatisfied’.

The service was found to be especially beneficial for older patients, who felt they could easily explain their medical problems to the doctor in the video consultation, and believed that telemedicine enabled them to save time and money.

Meanwhile, halfway around the world, researchers from the University of Carolina have reported that screening rates in rural and underserved populations for diabetic retinopathy (DR) significantly improved from around 25% to 40% following the implementation of telehealth. The three-year study involved 1,661 patients and lead investigator Dr Seema Garg said the technology was becoming more valuable as barriers to care continue to increase.

“There are more economic pressures for patients and there are a greater number of diabetics – there’s an epidemic proportion of diabetes. We know that in the current paradigm, our healthcare system will not be able to meet the needs of these patients,” Garg told JAMA Ophthalmology earlier this year.

“I was seeing many patients coming in to my clinic blind from diabetes, and as retinal specialists we know this is a completely preventable disease ... we can prevent 90% of severe blinding disease from diabetic retinopathy.”

Garg’s study was unequivocal in its support of teleheath screening, especially as a tool for reducing vision loss from DR, which was described as a public health imperative.

“Telemedicine screening can increase rates of surveillance, reduce socioeconomic disparities, and increase access to care, ultimately preventing vision-threatening DR and improving visual outcomes and quality of life for patients with diabetes,” the study concluded.

According to Garg, one of the key turning points for telemedicine’s increased use was the development of nonmydriatic fundus cameras that can take high quality snapshots without the need for dilation.

“We can improve access to care for patients with diabetic retinopathy because we are not even screening half of the patients with diabetes in the current paradigm, where we send our patients from the primary care setting to an ophthalmologist for retinal evaluation,” Garg added.

 

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