A new tele-ophthalmology screening program at the UC Davis Midtown Ambulatory Care Center offers convenience, the latest technology and new hope to save vision for patients with diabetic retinopathy, the leading cause of vision loss among working-age adults.
According to Glenn Yiu, associate professor and director of tele-ophthalmology at the UC Davis Eye Center who partnered with the Primary Care Network to launch the program, it is important to detect early signs of disease when it is most responsive to treatment.
“Fewer than 50 percent of the 29.1 million Americans diagnosed with diabetes undergo annual eye screening as recommended by the American Diabetes Association,” Yiu said. “In fact, many major health systems, including UC Davis, have annual screening rates between 30 to 50 percent.
“The new clinic service allows patients to get their eye images taken while waiting to see their primary care providers, and have those images read by an ophthalmologist without having to schedule a separate visit to an eye care specialist,” he said.
To implement to project, which was funded with grant support from the UC Davis Collaborative for Diagnostic Innovation and the CITRIS/Banatao Institute, Yiu teamed up with Christopher Lillis, medical director of the PRIME and Patient Centered Medical Home programs, Scott MacDonald, EHR medical director, and Eye Center Medical Director Michele Lim.
Retinal images captured without dilating eye drops
The team obtained a non-mydriatic fundus camera to capture a retinal image without dilating eye drops, trained a team of ophthalmic photographers to operate the camera, and more importantly, designed and integrated both physical and electronic workflows at the midtown clinic. The site’s central location near the UC Davis Medical Center and its high volume of diabetic patients made it a good fit to launch the new service, Yiu noted.
While tele-ophthalmology has been around for years, mainly in underserved communities or underdeveloped countries where access to eye care is limited, recent innovations in technology have made more widespread use possible. Some of these innovations include having EHR systems fully integrated into physician workflow, automated triggers to alert doctors that a diabetic patient may be overdue for an eye exam as well as high-quality, easy-to-use fundus cameras.
“The newest generation of fundus cameras can automatically locate, focus and photograph the retina with just one or two clicks of a button,” Yiu said.
Tele-ophthalomology Reading Center established, AI on the horizon
Advances in technology also require ophthalmologists and processes for interpreting the images to become faster and more efficient. A new Tele-ophthalmology Reading Center at UC Davis Health that Yiu established can provide retinal reading services for health systems in California.
“The work involved in personally grading and providing interpretations for every single fundus photo is a challenging task that will likely continue to expand,” Yui said. Yiu along with eye center glaucoma specialist Jamie Brandt are teaming up with research partners to employ artificial intelligence (AI) to assist in the tele-ophthalmology screening initiative.
In 2016, Google published the first report of a fully-automated “deep-learning” algorithm that could detect diabetic retinopathy from fundus photographs with the accuracy matching human graders. AI for remote diabetic retinopathy screening has the advantage of “providing instantaneous feedback and not getting tired or making a mistake,” Yiu said.
If AI-integration becomes fully-realized in tele-ophthalmology, diabetic patients could have their retinal photos taken and immediately find out if they will need an ophthalmology referral, even before they enter the exam room to see their primary care doctors.
Systemwide screening a goal
Yiu’s goal is to increase screening of diabetic patients at UC Davis until it reaches 100 percent. However, the midtown clinic tele-ophthalmology program is only a first step. Eventually, successful systemwide implementation will require more physician involvement, cameras and funding.
“Financial barriers limit the expansion of tele-ophthalmology programs because screening services are not adequately reimbursed by many insurance carriers,” Yiu said. “Early stages of diabetic retinopathy may not only be markers for sight-threatening disease, but also could be harbingers of other serious systemic complications of diabetes.”
Yiu believes insurance payers need to be educated about the potential benefits of early diabetic retinopathy detection.
“Most patients with early stages of diabetic retinopathy are asymptomatic, so routine screening is necessary to look for early disease," Yiu said. "Even a single diabetic patient who is prevented from progressing to kidney dialysis or leg amputation could translate to substantial cost savings, not to mention the incredible benefit to our patients."