**2. Eye care in the optometry setting using community based optical coherence tomography and virtual glaucoma clinics**

Current treatment for age related macular disease requires patients to be monitored closely ( usually on a monthly basis ) for recurrence of the disease. This disease affects elderly people, who may be unable to drive due to loss of visual acuity below driving standards. In rural areas, where there is a greater travel burden ( for example in rural Wales ) there is a major challenge for people to keep up with their appointments. Elderly people are increasingly reliant on relatives, neighbours and carers to transport them to clinics, and in many cases ambulance transfer is needed for routine clinic appointments. This causes additional stress and incon‐ venience for these patients. It increases the chance of further health problems as for example increased rate of falls. This costs either the health authorities and/ or the patients for organising and supplying this transport. More CO2 gases are released in the atmosphere from the increased pollution.

The solution for all these issues is to deliver healthcare closer to the home in the community. This can be achieved with community based OCT machines, together with (non- ) mydriatic fundus cameras. In areas with not very dense population or in countries, where the purchase of enough equipment is an issue, this equipment can be integrated into special mobile vans. Mobile vans can visit different areas with a pre- determined schedule, and are the topic of discussion of the next section in this chapter.

The information obtained with this equipment is sufficient for a trained ophthalmologist to assign appropriate treatment or follow up, using modern telemedicine equipment, even if he or she is thousands of miles away. This allows remote diagnosis and management of patients.

Glaucoma is a chronic disease, in which in the majority of cases lifetime follow up is required. This puts a large strain on the ophthalmology clinics. For most of the patients with stable glaucoma follow up in a virtual clinic is possible.

Trained opticians or nurses can check visual acuity, IOP ( Goldman application ), perform visual acuity test, nerve fibre layer scans (OCT, GDX, HRT ) and record fundus photos with a (non)- mydriatic camera. All these tests can be done in the community and after that the information can be digitally transferred to a regional ophthalmology centre, where it can be interpreted by ophthalmologists. In this way patients are not going to have travel long distances. The ophthalmologists will be able to increase the capacity of their clinics. They will have all the required information for changing treatment and assigning follow up appoint‐ ments. Prioritisation of patients who need to be seen for a face to face consultation can be made from the information.

#### **2.1. Optometry and teleophthalmology**

The main problem encountered in the change was the issue of confidentiality. The Caldicott Guardian deemed that the clinical need was greater in these instances, and once the decision

Smart Phone technology has been shown to be useful in the assessment and treatment of eye emergencies. All patients showed improvements in visual acuity ranging from 1 line to 7 lines,

A Consultant opinion was gained quickly in all 12 cases. The costs of patient and hospital transport were saved. There is a role for the use of smart tablets in digital image transfer to provide a larger image, and these could also be used for transfer of retinal optical coherence tomography images in a macular clinic. There is the potential for use of smart phone images

Eye Emergencies can be effectively treated in rural areas by Nurse Practitioners obtaining advice directly from a Consultant through high resolution images of the eye seen on a smart

It is possible to take slit lamp photos by placing the lens of a smart phone against the slit lamp lens; however, the use of an adapter will allows higher quality photographs. This may help to facilitate teleophthalmology for nurse practitioners and optometrists in the primary care

The Keeler Portable Slit Lamp iPhone 4 image adapter has been reported to be compatible with the Haag-Streit 900 BM (older series) and Topcon SL-3F slit lamps. The adapter is not com‐ patible with Topcon SL-D7, Mentor. When using the Keeler adapter, a moderate amount of force has to be applied to attach the adapter to most Haag-Streit slit lamp oculars (the diameter of my slit lamp's ocular is 30 mm and it requires a moderate amount of force to attach).

**2. Eye care in the optometry setting using community based optical**

Current treatment for age related macular disease requires patients to be monitored closely ( usually on a monthly basis ) for recurrence of the disease. This disease affects elderly people, who may be unable to drive due to loss of visual acuity below driving standards. In rural areas, where there is a greater travel burden ( for example in rural Wales ) there is a major challenge for people to keep up with their appointments. Elderly people are increasingly reliant on relatives, neighbours and carers to transport them to clinics, and in many cases ambulance transfer is needed for routine clinic appointments. This causes additional stress and incon‐ venience for these patients. It increases the chance of further health problems as for example

**coherence tomography and virtual glaucoma clinics**

was made, the images were to be deleted form both Smart phones

and complete resolution of symptoms due to prompt diagnosis and therapy.

*1.2.6. Lessons Learnt*

8 Telemedicine

phone.

setting.

in dermatological emergencies

**1.3. Smart phone adapters for slit lamps**

In the UK there are currently 2.3 ophthalmologists per 100 000 population, as described by Kulshrestha and Kelly (2011). This is the lowest pro rata than any other European Union country (www.uems.net). In the UK, optometrists play an important role in managing patients with eye complaints. Most of the patients seen in the Hospital Eye Service (HES) are referred by them either directly or through the patient's general practitioner (GP) (Bell and O'Brien 1997). For example more than 90 % of all suspected cases of primary open angle glaucoma are referred to the HES by optometrists according to Harrison and Wild et al (1988). The National Health Service (NHS) hospitals in the United Kingdom are a part of the public system. Optometry practices are private and have a dual role: they carry sight tests and dispense spectacles and contact lenses. The sight tests are reimbursed by the NHS.

The Hospital Eye Services (HES) in the UK are usually overloaded with patients and have waiting times of several months for new patients. There are also waiting times for follow up appointments. This means that for many patients allocated 6 months follow up appointments, the appointment may be delayed by a number of months. This is called slippage, and slippage has increased in recent years due to the introduction of new NICE guidance for glaucoma, which has increased referrals into HES from primary care. In addition, increased workload from the Vasoactive Endothelial Growth Factor antagonist treatment of wet age related macular disease has overloaded the service due to the demands of monthly OCT scanning and injections. This service is now affecting appointments in general ophthalmology clinics where glaucoma patients are seen.

Teleophthalmology provides us with the opportunity for these patients to be reviewed directly by the consultant and the HES staff who are already trained to do this by using virtual glaucoma clinics. At the Portsmouth-based glaucoma refinement scheme (Trickha et al 2012) designated refinement scheme optometrist examined the patients followed by a standard Humphrey 24-2 visual field (SITA fast) (Carl Zeiss Meditec,Dublin, CA, USA), applanation tonometry assessment of IOP (Goldmann model; Haag-Streit, Bern, Switzerland), and a digital disc photograph (Topcon, Tokyo, Japan). All the information is processed digitally to a named consultant, who takes the decision at a specially designated virtual glaucoma clinic, whether the patient needs an appointment at the HES or can be discharged and followed up in the community by a community optometrist. In this project only 11 % of the referrals to the virtual clinic needed an appointment in the HES and the other 89% did not need it. The positive predictive rate of the refinement scheme was 0.78 compared to 0.37 for the unrefined one.

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In addition to refining patient referrals, teleophthalmology can be used for glaucoma patients follow up in the community. In a study performed by Bunduchi et al. (2010) in Scotland, stable glaucoma patients were followed up in the community by a designated optometrist.They had visual acuities, visual fields test, intraocular pressure measurement and fundus photograph of the eye done at a local optometrist sometimes many miles away from the HES. All the information was transferred via secure electronic information exchange system to the hospital where the information was assessed by the consultant or trained hospital staff at a virtual glaucoma clinic. In the virtual glaucoma clinic more patients can be assessed compared to a standard glaucoma clinic. In this way more slots were available for the unstable glaucoma patients. This can reduce the waiting time for follow up appointments and reduce the necessity for the patients to travel long distances usually every 6 months with all the associated

Teleophthalmology provides the opportunity of setting up an efficient glaucoma referral refinement and follow up system under the care of consultant ophthalmologist. In this way patients can receive quality specialised hospital services in their local community without the need for travel. This can lead to savings for the NHS and the patient, as it can increase the

The optical coherence tomography (OCT) is the gold standard for diagnosis and follow up of many macular diseases. Many community optometry practices have OCT machines currently. In a study performed by Kelly at al. (2011) fundus photos and OCT scans were transferred by secure file transfer email (National Health Service or NHS mail) to the hospital ophthalmolo‐ gist. The images transferred via email are with superior quality compared to the standard method of communication (faxing) and are much faster than posting of hard copies or using a CD. In 96 % of cases in this study analysis of the referrals and a working diagnosis/care pathway was provided by the ophthalmologist to the optometrist within the next calendar day. In the cases where ophthalmic examination was required patients were referred through the GP. In some cases on the basis of information provided by the optometrist urgent oph‐

drawbacks.

capacity of the existing glaucoma services.

thalmology appointments were scheduled.

**2.3. Teleophthalmology and macular diseases**

With an aging population (baby-boomers are currently retiring) and financial strain on the NHS hospital services, new technological and organizational solutions are in need of imple‐ mentation to solve the capacity problems brought about by an increased demand on services. Involving optometrists as part of a team is one potential solution. To ensure that quality is guaranteed, this can be done under the direct supervision of the consultant ophthalmologist (or other trained HES trained staff) with the help of an IT teleophthalmology connection between them. In addition to assisting the Hospital Eye Service by using the human, techno‐ logical and the space capacity available at the optometry practices in urban areas, teleoph‐ thalmology provides invaluable benefits in rural areas. The availability of ophthalmology services at the community reduces the need of transport (cost and carbon emissions) and reduces the inconvenience (need of accompanying relative/ absence from work).

For example in the Hywel Dda Health Board, patients from Wales have to travel sometimes more than 1 hour in each direction for a HES appointment. Ophthalmology patients are usually elderly, some with impaired eyesight and not fit to drive. Even if they are fit to drive they usually need somebody accompanying them, because of the need for pupillary dilation. Very often the general health of these patients is impaired as well which makes the journeys even more unpleasant and add to the psychological burden on the patient. Many of the ophthal‐ mology conditions are chronic and need multiple follow up appointments (sometimes monthly visits) or on a lifelong basis (for example glaucoma). Waiting times for optometric appointments are usually a few days and these practices are situated in the community.

The teleophthalmology connection between HES and optometry practices can be significant‐ ly helpful in managing patients with 1) Glaucoma 2) Macular diseases 3) Emergency eye conditions.

#### **2.2. Teleophthalmology in glaucoma patients**

Management of patients with glaucoma and ocular hypertension is a significant part of the everyday workload in the glaucoma clinics. The North London Eye study and other population based surveys estimate that patients with ocular hypertension or primary open angle glaucoma (POAG) will increase by one third by 2021, as demonstrated by Morley and Murdoch (2006). According to Lockwood et al (2010) the positive predictive rate in the diagnosis of glaucoma and ocular hypertension was 0.37 before the National Institute of Clinical Excellence (NICE) guidelines published in April 2009 and has dropped to 0.2 after that. There are several glaucoma refinement schemes such as the Manchester, and Carmarthenshire Refinement Scheme, which rely on a specially trained optometrist to reduce the number of false positive glaucoma referrals and increase the positive predictive rate of HES referrals as described by Hensen et al (2003) and Devarajan et al (2011).In these schemes specially trained optometrists take the decision on which patients are to be referred to HES and which have to be discharged. Teleophthalmology provides us with the opportunity for these patients to be reviewed directly by the consultant and the HES staff who are already trained to do this by using virtual glaucoma clinics. At the Portsmouth-based glaucoma refinement scheme (Trickha et al 2012) designated refinement scheme optometrist examined the patients followed by a standard Humphrey 24-2 visual field (SITA fast) (Carl Zeiss Meditec,Dublin, CA, USA), applanation tonometry assessment of IOP (Goldmann model; Haag-Streit, Bern, Switzerland), and a digital disc photograph (Topcon, Tokyo, Japan). All the information is processed digitally to a named consultant, who takes the decision at a specially designated virtual glaucoma clinic, whether the patient needs an appointment at the HES or can be discharged and followed up in the community by a community optometrist. In this project only 11 % of the referrals to the virtual clinic needed an appointment in the HES and the other 89% did not need it. The positive predictive rate of the refinement scheme was 0.78 compared to 0.37 for the unrefined one.

In addition to refining patient referrals, teleophthalmology can be used for glaucoma patients follow up in the community. In a study performed by Bunduchi et al. (2010) in Scotland, stable glaucoma patients were followed up in the community by a designated optometrist.They had visual acuities, visual fields test, intraocular pressure measurement and fundus photograph of the eye done at a local optometrist sometimes many miles away from the HES. All the information was transferred via secure electronic information exchange system to the hospital where the information was assessed by the consultant or trained hospital staff at a virtual glaucoma clinic. In the virtual glaucoma clinic more patients can be assessed compared to a standard glaucoma clinic. In this way more slots were available for the unstable glaucoma patients. This can reduce the waiting time for follow up appointments and reduce the necessity for the patients to travel long distances usually every 6 months with all the associated drawbacks.

Teleophthalmology provides the opportunity of setting up an efficient glaucoma referral refinement and follow up system under the care of consultant ophthalmologist. In this way patients can receive quality specialised hospital services in their local community without the need for travel. This can lead to savings for the NHS and the patient, as it can increase the capacity of the existing glaucoma services.

#### **2.3. Teleophthalmology and macular diseases**

which has increased referrals into HES from primary care. In addition, increased workload from the Vasoactive Endothelial Growth Factor antagonist treatment of wet age related macular disease has overloaded the service due to the demands of monthly OCT scanning and injections. This service is now affecting appointments in general ophthalmology clinics where

With an aging population (baby-boomers are currently retiring) and financial strain on the NHS hospital services, new technological and organizational solutions are in need of imple‐ mentation to solve the capacity problems brought about by an increased demand on services. Involving optometrists as part of a team is one potential solution. To ensure that quality is guaranteed, this can be done under the direct supervision of the consultant ophthalmologist (or other trained HES trained staff) with the help of an IT teleophthalmology connection between them. In addition to assisting the Hospital Eye Service by using the human, techno‐ logical and the space capacity available at the optometry practices in urban areas, teleoph‐ thalmology provides invaluable benefits in rural areas. The availability of ophthalmology services at the community reduces the need of transport (cost and carbon emissions) and

For example in the Hywel Dda Health Board, patients from Wales have to travel sometimes more than 1 hour in each direction for a HES appointment. Ophthalmology patients are usually elderly, some with impaired eyesight and not fit to drive. Even if they are fit to drive they usually need somebody accompanying them, because of the need for pupillary dilation. Very often the general health of these patients is impaired as well which makes the journeys even more unpleasant and add to the psychological burden on the patient. Many of the ophthal‐ mology conditions are chronic and need multiple follow up appointments (sometimes monthly visits) or on a lifelong basis (for example glaucoma). Waiting times for optometric appointments are usually a few days and these practices are situated in the community.

The teleophthalmology connection between HES and optometry practices can be significant‐ ly helpful in managing patients with 1) Glaucoma 2) Macular diseases 3) Emergency eye

Management of patients with glaucoma and ocular hypertension is a significant part of the everyday workload in the glaucoma clinics. The North London Eye study and other population based surveys estimate that patients with ocular hypertension or primary open angle glaucoma (POAG) will increase by one third by 2021, as demonstrated by Morley and Murdoch (2006). According to Lockwood et al (2010) the positive predictive rate in the diagnosis of glaucoma and ocular hypertension was 0.37 before the National Institute of Clinical Excellence (NICE) guidelines published in April 2009 and has dropped to 0.2 after that. There are several glaucoma refinement schemes such as the Manchester, and Carmarthenshire Refinement Scheme, which rely on a specially trained optometrist to reduce the number of false positive glaucoma referrals and increase the positive predictive rate of HES referrals as described by Hensen et al (2003) and Devarajan et al (2011).In these schemes specially trained optometrists take the decision on which patients are to be referred to HES and which have to be discharged.

reduces the inconvenience (need of accompanying relative/ absence from work).

glaucoma patients are seen.

10 Telemedicine

conditions.

**2.2. Teleophthalmology in glaucoma patients**

The optical coherence tomography (OCT) is the gold standard for diagnosis and follow up of many macular diseases. Many community optometry practices have OCT machines currently. In a study performed by Kelly at al. (2011) fundus photos and OCT scans were transferred by secure file transfer email (National Health Service or NHS mail) to the hospital ophthalmolo‐ gist. The images transferred via email are with superior quality compared to the standard method of communication (faxing) and are much faster than posting of hard copies or using a CD. In 96 % of cases in this study analysis of the referrals and a working diagnosis/care pathway was provided by the ophthalmologist to the optometrist within the next calendar day. In the cases where ophthalmic examination was required patients were referred through the GP. In some cases on the basis of information provided by the optometrist urgent oph‐ thalmology appointments were scheduled.

In the last few years wet age related macular degeneration (AMD) and the intravitreal anti-VEGF injection treatment has put unprecedented strain on the ophthalmology services worldwide. Even when the patients do not need treatment they have to be followed up on monthly basis, because of the possibility of recurrence. Stable wet AMD patients can be followed up locally with their community optometrist. Optometrists can examine the patients; take OCT scans and fundus photos and all this information can be transferred digitally via secure connection to the eye clinic. Consultants or other trained staff at the HES virtual AMD clinic can assess the information and manage the patients appropriately. In this way the current capacity of the eye clinics can be increased.

transferred to a grading centre in Cardiff. In Exeter there is a mobile glaucoma service which has been developed to provide additional clinic capacity, run by Glaucoma Nurse Practition‐ ers. In York there is a Box Van where patients are seen to have OCT scanning and lucentis

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In Wales all diabetic patients undergo annual screening in local community hospitals or GP surgeries depending on the rural location. Digital fundus imaging is carried out with dilated pupils. The photographs are saved onto laptops with strict security access codes. Images are stored in data centres in North Wales, (Canaervon), Mid and South West Wales (Carmarthen) and Trefforest near Cardiff at Fairway Court which is the main centre to which all images are sent for data backup. These centres are linked through a DAWN2METRO VPN. Graders at

Any patients with sight threatening diabetic retinopathy are referred to their local eye clinic by a fax or letter referral depending on the urgency and the patients are seen appropriately in specialised diabetic eye clinics within the hospital eye service. Patients with background diabetic retinopathy or no retinopathy at all have annual follow up screening assessments. This has proved to be a world class, efficient and well coordinated screening service for all diabetics in Wales. Consultant Ophthalmologists throughout Wales have regular group meetings to discuss how the service is to be delivered and improved, and provide regular training for all the Graders at Trefforest. In addition, it has standardised ophthalmic care for diabetics throughout the whole country. Consultants may view images at the local Screening Centre. There are now developments in place to allow the images to be digitally transferred to individual clinics from the main centre, so Consultants can visualise them in the clinic setting

This service was set up to screening for new referrals and follow up care of stable patients according to NICE standards The Royal Devon & Exeter Hospital Wonford have a dedicated Mobile Eye Unit which goes out across the community which screens new referrals and provides follow up care of stable patients. It is Nurse led, the Specialist Glaucoma Nurses

injections in the van.

**3.1. Diabetic retinopathy screening service for Wales**

Trefforest carry out primary and secondary retinal screening.

**3.2. Exeter mobile glaucoma service**

**•** Visual field assessments,

**•** Goldman tonometry,

**•** Pupil assessment,

**•** Heidelberg Retinal Tomography,

**•** visual acuity,

**•** gonioscopy,

**•** Pachymetry,

carrying out investigations in the mobile unit including:

#### **2.4. Teleophthalmology and urgent ophthalmology referrals**

Many of the patients with eye complaints present initially at the optometrists practices. Sometimes the cases can be solved just with the advice of the ophthalmologist. The percentage of these cases can be increased significantly by using the opportunities of teleophthalmology. In this way unnecessary appointments at the HES and travel can be avoided. If emergency phone calls from the optometrists are accompanied by anterior segment photo or fundus photo the hospital ophthalmologist will receive much more information and can take immediate decision in most of the cases, whether to see the patient as an emergency or even to give appropriate management plan to the optometrist.

Most of the referral to the HES, even if they come from the GP are seen prior by their optom‐ etrists. If most of the referrals are accompanied by digital information received at the hospital the prioritisation consultant can more easily detect urgent cases, so they can receive sooner appointment.

Optometrists have the expertise to manage ophthalmology patients and with the help of teleophthalmology technology these skills can be expanded. The variety of patients managed in the community setting under the direct teleophthalmology supervision of a hospital consultant can be increased. In this way more resources at the hospitals can be spared for more challenging cases. On the other hand patients can receive high quality hospital service at their local community.
