**4. Eye care to the paediatric population**

#### **4.1. Medico legal issues**

There is also the potential for the review and monitoring of other patients that require OCT scanning and slit-lamp review as part of their regular monitoring eg diabetic macular oedema,

By moving a proportion of the wet AMD service and glaucoma service out of the main unit it is proposed that there will be more capacity to meet the current and immediate future demands for intravitreal therapies. It is proposed that after 3-4 months of 'dry' status patients could be

The lucentis service at Aberystwyth caters for the population of Ceredigion (90,000), South Gwynedd (50,000 of a total of 130,000 for Gwynedd county and Powys (120,000). Some patients

All patients undergo OCT scanning at North Road Eye Clinic, and lucentis injection at Bronglais Hospital at a separate booked appointment. Currently up to 20-25 patients are booked for lucentis injection from North Road onto one injection list at Bronglais Hospital as

Patients are seen at local community clinics of Tywyn (South Gywnedd), Machynlleth (North Powys), Llanidloes (North Powys), Newtown (Mid Powys), Aberaeron (South Ceredigion) and Cardigan (South Ceredigion). All patients from these community clinics therefore have to travel twice per month when undergoing review of lucentis therapy for OCT scanning at North Road and subsequent injection at Bronglais. Provision of local Optical Coherence Tomography

Patients from Aberaeron, Machynlleth are within 30 minutes of Aberystwyth and can therefore continue to have their injections in Bronglais. Patients from South Gwynedd and Mid Powys may have to travel in excess of 1 hour to access the theatre facilities in Aberystwyth. This travelling time can be up to 1.5 or 2 hours in snowy winter conditions, where the roads are full of traffic from holiday makers from the Midlands in the summer or in rare instances where

This group of patients can potentially have injections in theatre facilities within Tywyn for South Gwynedd patients and Llandrindod Wells Hospital for Mid Powys patients. Cardigan patients are over 1 hour from Aberystwyth, and they may have the travel burden reduced by having both the OCT scan and injection facilities to be made available in two separate vans. It would be possible therefore, for certain sited to have a one stop service (Tywyn, Llandrindod Wells, Cardigan) and some to remain as a two stop (Aberaeron, Machynlleth) depending on

There remains scope to reduce the travel burden on patients from Powys who currently are scanned in Shrewsbury or Hereford to have local OCT scanning and/or injections in the community at Welsh Community Hospitals in the future to reduce their travel burden. This may be incorporated into the project once the project has been established within Hywel Dda

In order to set this develop this project, an Ophthalmic Mobile Unit team was set up to discuss development of a business case with regular meetings monthly for a year. The Project is now

in Powys are managed by the medical retina teams of Shrewsbury and Hereford.

scanning in the van in the community will allow this travel burden to be halved.

retinal vein occlusion, pre and post-op cataract assessments.

seen in the review van for follow up.

there has been a road traffic accident

the facilities available on each site.

Health Board.

a two stop service.

20 Telemedicine

The diagnosis of non-accidental injuries in children and babies frequently requires the presence of retinal haemorrhages. Court conviction depends on the testimony of the ophthalmologist who has to rely only on clinical notes as evidence. Having retcam video and photographs carry huge weight age in such proceedings.

#### **4.2. Retinopathy of prematurity**

Babies born prematurely or underweight are at risk of developing a devastating proliferative retinopathy of prematurity (RoP) that can be blinding. It remains a major cause of visual loss worldwide and there is approximately 50 000 babies annual rate of global blindness from RoP. This is potentially a treatable condition and therefore requires thorough and extensive screening. Unfortunately screening is dependant on the presence of highly skilled paediatric ophthalmologists. Most babies with RoP are in developing countries where there is a lack of properly trained paediatric ophthalmologists. Having a device that can photograph the fundus appearance and then either email or share these pictures with a central resource where trained ophthalmologists can grade them will obviously save sights. The answer has been in the use of the retcam, which can photograph and even video the fundi of such babies. The retcam images are now increasingly replacing the indentation indirect approach of fundoscopy.

Another source of problems is intra and inter grader variability. To overcome this issue software are in the process of development for "Automated Quantification of Retinal Vessel Morphology". Human input is still required, but the aim of development is to make screening entirely computerized.

#### **4.3. Retcam images**

Retcam images are similarly used for screening of premature or low birth weight babies for Retinopathy of Prematurity (ROP) using ophthalmoscopy and image-based telemedicine examinations. The number of premature infants is increasing throughout the world, and a larger percentage of them are surviving. A Telemedicine examination from images obtained from a Retcam may be more reproducible than if you see an infant's retina only briefly during ophthalmoscopy. These are manufactured by Spectrum and Clarity Medical systems. There is a rationale that image-based examination may be better because findings are documented photographically, rather than an indirect ophthalmoscopic examination, which may also be more uncomfortable for the baby. In many other ophthalmic diseases, definitions are based on standard images, so this has implications for the way we might deliver the best care to patients in the future.

The Retcam does require contact with the cornea and will therefore require training. It uses pupillary illumination to take digital photos of the fundus and skilled screeners may grade these images in a central location that can be remote from the neonatal unit. Where a shortage of trained paediatric ophthalmologists is stretching the services of ROP screening, this mode of teleophthalmology is not only valuable, but is in fact the only solution to maintaining a credible service. Other paediatric ophthalmic pathology can also be excluded via the retcam. An example is the presence of retinoblastomas4 in an eye with a white reflex, allowing decisions to be made on urgency of referrals. Photographs of shaken babies for diagnostic and medico legal purposes can also be taken via a Retcam and the images subsequently transferred for opinion.

**•** Extend patient care and expertise to remote areas

, Usman Mahmood1

2 Betsi Cadwaldr University Health Board, UK

We would envisage that this will help to reduce slippage on patient appointments, distribute the workload to the community staff and help to increase capacity. This will help to reduce also the travel burden on patients traveling to the main centre every month for some patients. This becomes increasingly more difficult for elderly patients with time, and saves them many hours of a long trip, with reduced need for hospital transport, or patients own transport costs in many instances. There is also reduced pollution directly arising from reduced travel needs.

, Chris Williams2

[1] Bar-sela, S. M, & Glovinsky, Y. (2007). A feasibility study of an Internet-based teleme‐ dicine system for consultation in an ophthalmic emergency room J Telemed Tele‐

[2] Bell, R. D, & Brien, O. C. Accuracy of referral to a glaucoma clinic. Ophthal Physiol

[3] Bunduchi, R, Smart, A, Charles, K, & Mckee, L. and Azuara-Blanco A Boundary spanning process innovation: The role of institutional pressures in shaping process

[4] Blomdahl, S, Calissendorff, B, & Jacobsson, U. (2002). Patient-focused urban tele-oph‐

[5] Camara, J. G, Zabala, R. R, Henson, R. D, & Senft, S. H. (2000). Teleophthalmology: the use of real-time telementoring to re move an orbital tumor.*Ophthalmology.* Aug;,

[6] Devarajan, N, Williams, G. S, Hopes, M, Sullivan, O, & Jones, D. D.The Carmarthen‐ shire Glaucoma Referral Refinement Scheme,a safe and efficient screening service.

and Manoj Kulshrestha1

Teleophthalmology: Eye Care in the Community

http://dx.doi.org/10.5772/55788

23

**•** Improve patient care with mobility solutions

**Author details**

Daniel Dragnev1

**References**

1 Hywel Dda Health Board, UK

care. , 13(3), 119-24.

Opt (1997). , 17, 7-11.

107(8), 1468-71.

Eye (2011). , 25(1), 43-49.

innovation across public and private sectors

thalmology services. J Telemed Telecare. 8;Suppl , 2, 43-4.

Advantages of the Retcam include its portability and manoeuvrability in constrained areas such as on the Neonatal Intensive Unit and outpatients. It is easily transportable between hospitals and clinics, and allows transfer of images to any networked system. It allows timely remote evaluation of patient images and provides advanced image analysis and comparison capability of previous images with retcam review software.

In 2008 at Nayayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, India, a tele ROP service was initiated using a nonphysician screening model as described by Vinekar A (2008). This was entitled KIDROP (Karanataka Internet Assisted Diagnosis of ROP). The Retcam Shuttle (clarity MSI) and a portable laser indirect ophthalmoscope were transported by a clinical team to 23 Neonatal Intensive Care Units in 7 districts around Bangalore city.

The images are exported from a laptop using a portable wireless data card which allows internet access. The images are uploaded onto a secure server using an n indigenously designed software (i2i Telesolutions;Bangalore, India), which are backed up at 2 geographic sites. A remotely situated expert will login read and report the image live.

Since 2009, images have been visualised on a smart phone remotely using a specially designed application for the device. The reports created on the smart phone are in PDF, and on sub‐ mission to the expert, they enter the server through the GSM cellular network and are accessible to the technician in any remote rural area.
