**4. Telemedicine in management of retinoblastoma**

## **4.1. Telemedicine**

heating the tumor using a diode infrared laser system, and is usually performed in

This is a form of brachytherapy in which a radioactive implant is placed on the sclera over the base of a retinoblastoma. An average of 2 to 4 days of treatment time is required to deliver the total radiation dose to the tumor. It is useful for tumors less than 8mm thick and 16mm in base. Plaque radiotherapy can be used as a primary or secondary treatment. In the majority of cases it is used as a secondary treatment to salvage a glove after prior failed treatment. The visual outcome varies with tumor size and location as well as side effects such as radiation retinop‐ athy and papillopathy. Overall following 1 application of plaque radiotherapy there is an

Retinoblastoma is generally a radiosensitive tumor. External bean radiotherapy is a method of delivering whole eye irradiation to treat advanced retinoblastoma, particularly when there is advanced vitreous seeding. Recurrence of retinoblastoma after external beam radiation is a problem that can develop in the first 1 -4 years after treatment. Radiation damage to the retina,

External beam radiation was once employed in a large percentage of patients but has fallen out of favor, largely because external beam radiation has the potential to increase the risk of the development of additional nonocular cancers in survivors of germline retinoblastoma. It is estimated that the risk approximates 1% per year of life.[13] Patients who develop a second cancer and then survive that cancer have an increased risk for the development of nonocular tumors of approximately 2% per year from the time of the second tumor diagnosis. The average latency period between subsequent tumor diagnoses becomes progressively less with each additional cancer that develops. Children radiated during the first year of life are between 2-8

Nonetheless external beam radiation remains an excellent method of preserving vision in a child with retinoblastoma, and certain clinical situation demand its use. Unlike focal therapies, external beam radiation can provide an excellent opportunity for useful vision in a macula that is not affected by tumor. It may be considered as a primary option in children with small tumors located within the macula, or for multifocal tumors where focal therapies are ineffective. External beam radiation also continues to be the salvage treatment of choice after focal treatments have failed. For children with advanced extraoculaar or metastatic disease,

Enucleation continues to be a frequently used and important method for managing retino‐ blastoma If there is advanced disease with no hope for useful vision in the affected eye, or there is concern regarding tumor invasion into the optic nerve, choroid or orbit, then enuclea‐

times as likely to develop second cancers as those radiated after the age of 1 year.

radiation can also play a role in palliation along with chemotherapy.

conjunction with chemoreduction.

**3.6. External beam radiotherapy**

**3.7. Enucleation**

approximately 80% tumor control rate at 4 years.[13]

optic nerve, and lens can be challenging to manage.

*3.5.4. Plaque radiotherapy*

34 Telemedicine

Telemedicine can be defined as the delivery of healthcare and sharing of medical knowledge over distance using telecommunication means. It is used to support health care between participants who are separated from each other.[14] It has the potential to improve the accessibility, quality, and cost of healthcare, and may also contribute to medical education and research. The concept of telemedicine was introduced about 30 years ago through the use of telephones and facsimile machines. However today, telemedicine has advanced, integrating medical and network technology, comprising remote diagnosis, expert consultation, informa‐ tion service, online checkups, and remote communication.

Telemedicine can be broadly divided into two categories: synchronous telemedicine uses telecommunications for real-time interactions between participants (i.e. Videoconferencing), as compared to store-and-forward telemedicine which captures patient data for subsequent interaction with a remote expert (i.e. Digital radiology)

#### **4.2. Applications in ophthalmology**

The potential benefits of an effective telemedicine system in ophthalmology are many. Telemedicine has a variety of possible applications in ophthalmology, from community screening to the provision of expertise in areas where it is otherwise not available. Broad-based applications of telemedicine could greatly enhance screening efforts for potentially blinding conditions such as diabetic retinopathy, macular degeneration, glaucoma, retinopathy of prematurity and retinoblastoma to name but a few. Telemedicine can bring subspecialty expertise to small or rural communities, as well as to the developing world.

Tele-medicine applications in ophthalmology comprise both clinical and educational process‐ es between the send and receive sites. These can include:


**•** research and administration activities.

Typical telemedicine application in retinoblastoma includes the transfer of basic patient information, transfer of high resolution images such as fundal photographs, pathology images, magnetic resonance imaging pictures.

The use of telemedicine in retinoblastoma is not only useful to the specialist managing the condition, but is also of a source of confidence and comfort to parent and families of children with retinoblastoma to know that multiple experts are involved in the care of their child, and their child is receiving the best possible treatment.

#### **4.3. Importance of imaging in management of retinoblastoma**

The RetCam® wide-angle camera provides wide-field imaging of the retina and anterior segment, including the anterior chamber angle. Some small retinoblastomas, and vitreous seeds, may be better seen on RetCam® images than with indirect ophthalmoscopy. Sequential images are useful to determine if the tumors are growing or regressing. The anterior segment and anterior chamber angle can also be well visualized with the RetCam®. Fluorescein angiography using the RetCam® can assess vascularity, residual tumor activity, and recur‐ rences within laser scars.

#### **4.4. Images used in telemedicine for the management of retinoblastoma**

**Figure 4.** B scan ultrasonography of right and left eye of same patient at time of presentation in December 2011 showing multifocal tumors in the right eye, and the left globe filled with large tumor

*4.4.1. Diagnosis*

tocoagulation

implemented and the better the prognosis.

**Figure 5.** Right Fundus following chemoreduction February 2012

Telemedicine is invaluable when the diagnosis of retinoblastoma is in doubt. Diagnosis is generally established by the classic appearance of the retinal tumors by an experienced examiner. The sooner the diagnosis is established the sooner the appropriate treatment can be

**Figure 6.** May 2012: Images of the right eye during treatment with chemoreduction and focal therapy with laser pho‐

Telemedicine in Management of Retinoblastoma

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37

**Figure 5.** Right Fundus following chemoreduction February 2012

**Figure 6.** May 2012: Images of the right eye during treatment with chemoreduction and focal therapy with laser pho‐ tocoagulation

#### *4.4.1. Diagnosis*

**•** research and administration activities.

36 Telemedicine

magnetic resonance imaging pictures.

rences within laser scars.

their child is receiving the best possible treatment.

**4.3. Importance of imaging in management of retinoblastoma**

**4.4. Images used in telemedicine for the management of retinoblastoma**

Typical telemedicine application in retinoblastoma includes the transfer of basic patient information, transfer of high resolution images such as fundal photographs, pathology images,

The use of telemedicine in retinoblastoma is not only useful to the specialist managing the condition, but is also of a source of confidence and comfort to parent and families of children with retinoblastoma to know that multiple experts are involved in the care of their child, and

The RetCam® wide-angle camera provides wide-field imaging of the retina and anterior segment, including the anterior chamber angle. Some small retinoblastomas, and vitreous seeds, may be better seen on RetCam® images than with indirect ophthalmoscopy. Sequential images are useful to determine if the tumors are growing or regressing. The anterior segment and anterior chamber angle can also be well visualized with the RetCam®. Fluorescein angiography using the RetCam® can assess vascularity, residual tumor activity, and recur‐

**Figure 4.** B scan ultrasonography of right and left eye of same patient at time of presentation in December 2011

showing multifocal tumors in the right eye, and the left globe filled with large tumor

Telemedicine is invaluable when the diagnosis of retinoblastoma is in doubt. Diagnosis is generally established by the classic appearance of the retinal tumors by an experienced examiner. The sooner the diagnosis is established the sooner the appropriate treatment can be implemented and the better the prognosis.

**Figure 7.** June 2012: Image from examination under anesthesia following chemoreduction and focal laser consolida‐ tion

quality, and the most up-to-date treatments are employed. Selected cases may be further

**Figure 9.** September 2012.Fundal image from right eye taken during examination under anesthesia showing multiple

Telemedicine in Management of Retinoblastoma

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39

As discussed earlier there are multiple treatment modalities available to treat retinoblastoma. Treatment plans tailored to specific cases can be formulated between experts in different countries by sharing medical knowledge and experiences. Remote experts can closely monitor the progress of patients by sharing fundus images and other clinical information. In difficult cases, or cases requiring enucleation it is especially useful to have the second opinion of an

The relatively small numbers of retinoblastoma patients worldwide means that ophthalmol‐ ogists and oncologists in developing countries are unlikely to have the experience to treat without expert advice. As this is a curable disease, efforts toward early diagnosis and treatment are not only worthwhile, but cost effective. In countries with limited resources especially, telemedicine provides invaluable support and advice. For example, a telemedicine programme for retinoblastoma has been implemented in Jordan and has improved treatment and survival

There are strong arguments for tackling long term conditions to improve quality of life, while being mindful of the need to contain costs. In particular, there is considerable interest in the potential of telemedicine to generate cost effectiveness gains and even to yield cost savings,

for children in that country. The RetCam allows for real-time teleconferencing.

discussed via videoconferencing and electronic mail.

objective expert to ensure the best possible care is delivered.

**4.5. Treatment planning**

treated areas and inactive tumor

**4.6. Cost effectiveness**

**Figure 8.** August 2012. Fundal image from right eye following chemoreduction and focal laser photocoagulation

In our experience in the Children's University Hospital in Dublin, all new cases of retinoblas‐ toma are discussed using an internet consultation service where fundus images, clinical history, and proposed treatment are reviewed with a leading expert in retinoblastoma in the Hospital for Sick Kids in Toronto, Canada. The diagnosis is confirmed, and a treatment plan is agreed upon. This ensures standards of retinoblastoma management are of the highest

**Figure 9.** September 2012.Fundal image from right eye taken during examination under anesthesia showing multiple treated areas and inactive tumor

quality, and the most up-to-date treatments are employed. Selected cases may be further discussed via videoconferencing and electronic mail.

#### **4.5. Treatment planning**

As discussed earlier there are multiple treatment modalities available to treat retinoblastoma. Treatment plans tailored to specific cases can be formulated between experts in different countries by sharing medical knowledge and experiences. Remote experts can closely monitor the progress of patients by sharing fundus images and other clinical information. In difficult cases, or cases requiring enucleation it is especially useful to have the second opinion of an objective expert to ensure the best possible care is delivered.

#### **4.6. Cost effectiveness**

In our experience in the Children's University Hospital in Dublin, all new cases of retinoblas‐ toma are discussed using an internet consultation service where fundus images, clinical history, and proposed treatment are reviewed with a leading expert in retinoblastoma in the Hospital for Sick Kids in Toronto, Canada. The diagnosis is confirmed, and a treatment plan is agreed upon. This ensures standards of retinoblastoma management are of the highest

**Figure 8.** August 2012. Fundal image from right eye following chemoreduction and focal laser photocoagulation

**Figure 7.** June 2012: Image from examination under anesthesia following chemoreduction and focal laser consolida‐

tion

38 Telemedicine

The relatively small numbers of retinoblastoma patients worldwide means that ophthalmol‐ ogists and oncologists in developing countries are unlikely to have the experience to treat without expert advice. As this is a curable disease, efforts toward early diagnosis and treatment are not only worthwhile, but cost effective. In countries with limited resources especially, telemedicine provides invaluable support and advice. For example, a telemedicine programme for retinoblastoma has been implemented in Jordan and has improved treatment and survival for children in that country. The RetCam allows for real-time teleconferencing.

There are strong arguments for tackling long term conditions to improve quality of life, while being mindful of the need to contain costs. In particular, there is considerable interest in the potential of telemedicine to generate cost effectiveness gains and even to yield cost savings, while maintaining or improving patient outcomes. Evidence on the cost-effectiveness of telehealth is accumulating; systematic reviewers have judged it as promising for managing respiratory and cardiac disease and diabetes. Although evidence of the effect of telemedicine on retinoblastoma cost effectiveness remains scarce, it is promising.

**References**

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seeds. Arch Ophthalmol 2011;129:!399-406

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mic Surg 1980;11(8):596-8

Vb retinoblastoma. Retina 2010;30:S63-5

[1] Shields JA, Shields CL. Management and prognosis of Retinoblastoma. In: Intraocu‐

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[3] Shields CL, Shields JA. Genetics of Retinoblastoma. In :Tasman WS, Jaeger E,eds. Duane's foundations of Clinical Ophthalmology. 3rd ed. Philadelphia, Pa: Lippincott

[4] Shields JA, Parsons HM, Shields CL, et al. Lesions simulating retinoblastoma. J Pe‐

[5] Aziz HA, Boutrid G, Murray TG, et al. Supraselective injection of intra-arterial mel‐ phalan as the primary treatment for late presentation of unilateral multifocal stage

[6] Abramson DH, Dunkel IJ, Brodie SE, et al. A phase I/II study of direct intraarterial ophthalmic artery) chemotherapy with melphalan fro intraocular retinoblastoma ini‐

[7] Shields CL, Ramasubramanian A, Rosenwasser R, et al. Supraselective catheteriza‐ tion of the ophthalmic artery for intrarterial chemotherapy for retinoblastoma. Retina

[8] Ericson LA, Rosengren BH. Present therapeutic resources in retinoblastoma. Acta

[9] Smith SJ, Pulido JS, Salomao DR et al. Combined intravitreal and subconjunctival carboplatin for retinoblastoma with vitreous seeds. Br J Ophthalmol

[10] Shields CL, Bianciotto CG, Jabbour P, et al. Intra-arterial chemotherapy fro retino‐ blastoma: Report No.q, Control of retinal tumors, subretinal seeds, and vitreous

[11] Munier FL, Beck-Popovic M, Balmer A, et al. Occurrence of sectoral choroidal occlu‐ sive vasculopathy and retinal arteriolar embolization following supraselective oph‐ thalmic artery chemotherapy for advanced intraocular retinoblastoma. Retina

[12] Shields CL, Shields JA, Cater J et al. Plaque radiotherapy in the management of reti‐ noblastoma:long-term tumor control and treatment complication in 208 tumors.

[13] Abramson DG, Ellsworth RM. The surgical management of retinoblastoma. Ophthal‐

[2] Devesa SS. The incidence of retinoblastoma. Am J Ophthalmol. 1975;80:263-265.

lar Tumors: A text and Atlas. Philadelphia, Pa: WB Saunders; 1992.

#### **4.7. Medico-legal aspects**

#### *4.7.1. Protocols for telemedicine*

To avoid medico-legal pitfalls, comprehensive policies should be in place to ensure that patients receive the maximum benefit.

The limits of a telemedicine should be clarified. It is important to identify and outline the responsibilities of everyone in who is involved in telemedicine interactions to ensure seamless patient management. The credentials and insurance coverage of all licensed practitioners involved in telemedicine applications should be clear. Failure to verify the credentials of a consulting specialist could lead to claims of negligent referral if there is an adverse outcome.

The accepted "standard of care" for telemedicine in the relevant area should be identified. The process for assuring confidentiality of patient information should be outlined including: security and retention protections for electronic communication; protocols for identifying people at distant locations; confidentiality agreements for third-parties; compliance with confidentiality, and patient informed consent.

It is necessary also to outline standards for image acquisition, resolution bandwidth, trans‐ mission, storage resolution, method and time, retrieval, and manipulation, and to have backup procedures in place in case of equipment failure, weather interference, or other emergency.

## **5. Summary**

Retinoblastoma is the most common intraocular cancer of childhood; it continues to be a challenge both diagnostically and therapeutically. Telemedicine has a large role to play in the diagnosis and management of this retinoblastoma. In our experience, telemedicine enables invaluable expert collaboration to ensure the best outcomes for patients with retinoblastoma. Telemedicine has many potential applications in retinoblastoma management, both in the developing and developed world.

## **Author details**

Sarah MoranMichael O' Keefe

Mater Private Hospital, Dublin, Ireland

## **References**

while maintaining or improving patient outcomes. Evidence on the cost-effectiveness of telehealth is accumulating; systematic reviewers have judged it as promising for managing respiratory and cardiac disease and diabetes. Although evidence of the effect of telemedicine

To avoid medico-legal pitfalls, comprehensive policies should be in place to ensure that

The limits of a telemedicine should be clarified. It is important to identify and outline the responsibilities of everyone in who is involved in telemedicine interactions to ensure seamless patient management. The credentials and insurance coverage of all licensed practitioners involved in telemedicine applications should be clear. Failure to verify the credentials of a consulting specialist could lead to claims of negligent referral if there is an adverse outcome.

The accepted "standard of care" for telemedicine in the relevant area should be identified. The process for assuring confidentiality of patient information should be outlined including: security and retention protections for electronic communication; protocols for identifying people at distant locations; confidentiality agreements for third-parties; compliance with

It is necessary also to outline standards for image acquisition, resolution bandwidth, trans‐ mission, storage resolution, method and time, retrieval, and manipulation, and to have backup procedures in place in case of equipment failure, weather interference, or other emergency.

Retinoblastoma is the most common intraocular cancer of childhood; it continues to be a challenge both diagnostically and therapeutically. Telemedicine has a large role to play in the diagnosis and management of this retinoblastoma. In our experience, telemedicine enables invaluable expert collaboration to ensure the best outcomes for patients with retinoblastoma. Telemedicine has many potential applications in retinoblastoma management, both in the

on retinoblastoma cost effectiveness remains scarce, it is promising.

**4.7. Medico-legal aspects**

40 Telemedicine

**5. Summary**

**Author details**

developing and developed world.

Sarah MoranMichael O' Keefe

Mater Private Hospital, Dublin, Ireland

*4.7.1. Protocols for telemedicine*

patients receive the maximum benefit.

confidentiality, and patient informed consent.


[14] Field MJ. Telemedicine: a guide to assessing telecommunication in healthcare. J Digit Imaging. 1997;10 (3 Supp;1):28

**Chapter 3**

**Quality of Life in Telemedicine-Based Interventions for**

Worldwide, diabetes has become an overwhelming problem due to the increase of over‐ weightness and obesity. As estimated by WHO in 2011 [1], 346 million people globally suffer from diabetes and there is an approximate 3,4 million mortality rate from the consequences of DMT. WHO predicts that diabetes related deaths will double by 2030. Throughout the course of time, diabetes damages the heart, blood vessels, eyes, kidneys, and nerves. Indeed, 50% of people with diabetes die due to cardiovascular disease (primarily heart disease and stroke). Reduced blood flow and neuropathic pain can increases the chances of complications such as ulcers and even limb amputations. Diabetic retinopathy represents a significant cause of blindness, as a consequence of damage to blood vessels in the retina. 2% of diabetics become blind after 15 years. Diabetes can result in neuropathy, whose common symptoms are tingling, pain, numbness, or weakness both in feet and hands. Diabetes is the seventh leading cause of death in the US [2]. These complications are very important determinants of quality of life. Low QoL may, in turn, affect metabolic control by reducing regimen adherence. Treatment of diabetes involves lowering blood glucose and the levels of other known risk factors that could damage blood vessels. Lifestyle measures, such as the control of body weight, physical activity, a healthy diet and avoidance of tobacco use, have been shown to be effective in preventing the

In addition, estimated global healthcare expenditures to treat and prevent diabetes and its complications total at least \$376 billion in 2010. By 2030, this number is projected to exceed some USD490 billion. Expressed in International Dollars (ID), which correct for differences in purchasing power, estimated global expenditures on diabetes was ID418 billion in 2010, and it will be at least ID561 billion in 2030. An estimated average of USD703 (ID878) per person

> © 2013 Corti et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 Corti et al.; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

distribution, and reproduction in any medium, provided the original work is properly cited.

**Type-2 Diabetes Patients: The TECNOB Project**

Stefania Corti, Gian Mauro Manzoni,

http://dx.doi.org/10.5772/56009

**1. Introduction**

onset of type 2 diabetes.

Giada Pietrabissa and Gianluca Castelnuovo

Additional information is available at the end of the chapter
