Covers telehealth and telemedicine in general. Tele-ophthalmology development in India. Practice and patterns as defined by concerned authorities. Guidelines as set up Govt of India. Current tele-ophthalmology projects in India

1. TELE-OPHTHALMOLOGY
Dr. Obaidur Rehman
Junior Resident
Government Medical College & Hospital
Chandigarh

2. “It is an amazing invention, but who would ever
want to use one”
- Rutherford Hayes, after using telephone for the first time
( Former US president)

3. CONTENTS
Introduction
and
definitions
Historical
perspective
Ways,
types and
modes
Telemedicine
practice
guidelines
Tele-
ophthalmology
in India
Tele-
ophthalmology
projects
Tele-
ophthalmology
guidelines
GMCH
data
Conclusion

4. Introduction and definitions
 Telehealth: Broad term, related to all health care service, includes
remote clinical as well as non-clinical services such as
training, administrative meetings and continued medical
education
 Telemedicine: use of medical information exchanged from one site to
another via electronic communications to improve
patients’ health status - American Telemedicine
Association (ATA)
 World Health Organization definition : “The delivery of health-care
services, where distance is a critical factor, by all health-care
professionals using information and communications technologies for
the exchange of valid information for diagnosis, treatment and
prevention of disease and injuries, research and evaluation, and the
continuing education of health-care workers, with the aim of
advancing the health of individuals and communities.”

5.  Remote monitoring: where patients use mobile medical devices to
perform a routine test and send results to a
health care professional in real-time
E.g – blood glucose, BP monitoring
 Teleophthalmology: telemedicine in the field of ophthalmology
 Ophthalmology is one field of medicine, in which imaging plays a
major role
Apt for application of IT in this branch
 Enables a doctor from one end to interact with a patient at a remote
end through video conferencing, share data online and diagnose the
patient

6. Telemedicine: Historical perspective
Chellaiyan VG, Nirupama AY, Taneja N. Telemedicine in India: Where do we stand?.
J Family Med Prim Care. 2019; 8:1872-76.
Role in disaster management
NASA first used telemedicine services during the 1985 Mexico City
earthquake, and in 1988, during the Soviet Armenia earthquake
First real-time (live) video consultation
In 1959 when the doctors at University of Nebraska used interactive
telemedicine to transmit neurological examinations
Earliest published record of telemedicine
first half of the 20th century when ECG was transmitted over telephone lines

7. • Commercial space center MITAC (Medical Informatics and
Technology Applications Consortium) at Yale University in 1997 by
NASA
- paved way for the current trend of private participation in public
health management using telemedicine.
• Organizations like the American Telemedicine Association,
Washington DC, have been set up – which are solely dedicated to
provision of telemedicine services
• NASA has integrated telemedicine into every human spaceflight
program, including the International Space Station

8. Telemedicine in India
 75% doctors in cities and towns while 68.84% of population belongs
to rural India
- unequitable distribution of healthcare
 ISRO, Department of Information Technology (DIT), Ministry of
Health and Family Welfare have been contributing to the
development of telemedicine services
 ISRO made a modest beginning in telemedicine in India
- Telemedicine Pilot Project in 2001
- linking Chennai's Apollo Hospital with the Apollo Rural Hospital at
Aragonda village in the Chittoor district of Andhra Pradesh

9.  Standardized telemedicine practice guidelines by the Department of
Information Technology and National Telemedicine Task Force set up
by the Health Ministry in 2005
 Successfully established telemedicine services in India
- mammography services at Sri Ganga Ram Hospital, Delhi
- oncology at Regional cancer center, Trivandrum
- surgical services at Sanjay Gandhi Postgraduate Institute of Medical
Sciences
 ISRO's telemedicine network expanded to connect 45 remote/rural
hospitals and 15 super specialty hospitals
- include the islands of Andaman and Nicobar and Lakshadweep
- the hilly regions of Jammu and Kashmir

10. C-DAC
 A pioneering project entitled, “Development of Telemedicine
Technology” founded at the Center for Development of Advanced
Computing (C-DAC) at Mohali in 1999
- to enhance the current healthcare delivery system
 “Sanjeevani” software: teleconsultations, primarily teleradiology,
telecardiology and telepathology
- clinical information consolidated as Electronic Patient Record
(EPR) and sent to specialist
- network between primary, secondary, and tertiary facilities using
the Sanjeevani software which is linked to the Central Support Site
at C-DAC Mohali

11.  MercuryTM Nimbus suite: cloud-enabled comprehensive Electronic
Medical Record and Telemedicine solution
 'eSanjeevani’: web-based comprehensive telemedicine solution,
modeled on ‘Sanjeevani’ software
- browser-based application facilitating both doctor-to-doctor and
patient-to-doctor tele-consultations

12.  Mobile Telemedicine: vehicle based, equipped with all necessary
diagnostic equipments
- developed by C-DAC, Thiruvananthapuram
- travel to remote areas with medical personnel onboard for
conducting medical camps
- Sanjeevani - Early Cancer Detection Unit
- AshaKirana - Early Cancer Detection Unit for Karnataka
- SeTHU - Early Detection of Disease for Tribal Care in Waynadu
- Sunayanam - Mobile Tele-Ophthalmology Unit, RIO
Thiruvananthapuram
- Naynapadham - Mobile Tele-Ophthalmology Unit, Palakkadu

13. Principles of telemedicine
 Telemedicine applications and sites should be selected pragmatically
 The technology should be as user-friendly as possible
 Telemedicine users must be well trained and supported, both
technically and professionally
 Information about the development of telemedicine must be shared

14. Types of
telemedicine
Real time/Synchronous
Live face to face visit
a) Virtual visit: Video visit
between patient and physician
b) Virtual consult: Between 2
or more physicians
Store & forward/Asynchronous
Audio, images and videos along with
patient data forwarded to a specialist.
Diagnosis and advise given from
remote site.
Suitable for non-emergency cases.
a) eVisit
b) eConsult

15.  In image-oriented specialties such as ophthalmology, radiology,
cardiology, and dermatology, diagnostic decisions are often based
on review of photographic/imaging studies and which are often
captured by technicians.
 Remote diagnosis using store-and-forward telemedicine may be a
promising strategy for improving the delivery and accessibility of
care in image-oriented fields.

16. Ways of communication
• Point to
point
• One
patient
with one
specialist
doctor
• Point to
multi-
point
• One
patient
connected
to many
specialist
doctors
• Multi-
point to
multi-
point
• Multiple
patients
connected
to multiple
specialists

20. Modes of communication
Mode Pros Cons
Video
•Telemedicine facility
•Chat platforms
- Whatsapp
- Facetime
• Close to in-person
interaction
• Real time consultation
• Visual cues can be
seen
• Inspection can be done
• High quality internet
connection needed at
both ends
• Maintaining privacy
is important as there is
risk of misuse
Audio
• Telephone
• Apps with
calling/recording
- Whatsapp
• Convenient and fast
• Privacy ensured
• Real time interaction
• No extra infrastructure
needed
• Non verbal cues
missed
• Inspection not possible
• Risk of malingering

21. Mode Pros Cons
Text based
• Text message
• Chat apps
• Messaging websites
• Quick and convenient
• Documentation done
• Suitable for follow
ups
• No additional
infrastructure
• Can be real time
• Verbal cues missed
• Difficult to establish
rapport
• Reassurance difficult
• Unsure of identity of
doctor/patient
Asynchronous
• Email
• Fax
• Recordings
• Convenient
• Documentation easy
• Reports can be shared
and second opinions
seeked
• Useful for follow ups
• No real time
interaction
• Difficult to establish
patient identity
• Delay in consultation

22.  Seven Elements to be considered before any telemedicine
consultation
1. Context
2. Identification of RMP and Patient
3. Mode of Communication
4. Consent
5. Type of Consultation
6. Patient Evaluation
7. Patient Management

23. 1. Context
- the RMP should judge if teleconsultation appropriate or not, with
regards to the mode of communication
- whether teleconsultation is sufficient for the condition or in-person
visit required
2. Identification
- teleconsulation should not be anonymous
- RMP should identify himself at the beginning
- confirm patients identity and details
- registration number of RMP should be displayed on prescription

24. 3. Mode of communication
- real time consultation preferred over
asynchronous in emergencies
- RMP should decide the suitable mode, based
on experience and expertise
4. Patient consent
- Necessary for any type of teleconsultation
- If patient initiates consultation, consent is
implied
- Explicit consent needed if health worker
initiates consultation. May be received as
text/mail or recorded as audio/video

25. 5. Type of consultation
- consulting for first time - consulting for same health
- consulted earlier but 6 problem within 6 months
months lapsed
- consulting for different
health condition
6. Patient evaluation
- RMP should ensure patient identity/details are correct and judge the
patient’s condition
- if physical examination is critical, should arrange in-person consult
First consult
Follow up consult

26. 7. Patient management
- health education: related to diet, exercise
- counselling: do’s/don’t’s, diet restrictions
- prescription: depends on physician’s discretion
Prescribing Medicines without an appropriate
diagnosis/provisional diagnosis will amount to a professional
misconduct

27. Duties of RMP
maintain medical
ethics
protect patient’s
privacy and
confidentiality
maintain the records
and documents
receipt/invoice for the
fee charged should be
provided
Should not indulge in misconduct
- insisting on Telemedicine, when
patient is willing to travel to a
facility and/or requests an in-
person consultation
- misusing patient images and
data, especially private and
sensitive in nature

28. Emergency situations
 Goal should be to provide in-person care at the soonest
 The RMP, based on his/ her professional discretion may
- Advise first aid
- Counselling
- Facilitate referral
 In all cases of emergency, the patient MUST be advised for an in-
person interaction with a Registered Medical Practitioner at the
earliest

29. Applications
1. Educational
- Tele-education: long distance training and updates on advances
- Tele-conferencing: workshops/seminars
2. Health care delivery
- School based health center: assistance to school nurses
- Correction facilities: cater to inmates without dangers of transport
and exposure of health personnel
- Mobile health clinics
- Industrial health: provide triage at site in emergencies

30. 3. Screening purposes
- Diabetic screening project by MDRF: The Chunampet Rural
Diabetes Prevention Project
- Ophthalmology screening by Aravind Hospitals
4. Disaster management
- portable telemedicine system with satellite connectivity in regions
where all other modes of connectivity are disrupted
E.g. NASA tele-medicine services provided during 1985 Mexico
City earthquake and 1988 Soviet Armenia earthquake

31. Uses in specialties
 The American Medical Association (AMA) telemedicine study in
December 2018
- data collected from 3,500 physicians
- Overall use: 15% of physicians work in practices using
telemedicine with patients while 11% use
telemedicine for interacting with other
healthcare professionals

32. 0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
Radiologists Psychiatrists Cardiologists Other
specialties
• 12.6% of physicians use videoconferencing - emergency medicine, psychiatrists, and
pathologists
• 9.4% of physicians use store-and-forward - radiologists, pathologists, and cardiologists
• 7.3% of physicians use remote patient monitoring - cardiologists, nephrologists, and
neurologists

33. Opinion poll on usage of telemedicine
in India (2018)
 Approximately 500 respondents, age group 16-64 years
https://www.statista.com/statistics/917308/india-attitude-towards-using-telemedicine/

34. Tele-ophthalmology in India
 Ophthalmology is a largely image based branch
 1 Ophthalmologist per 100,000 population in India
 70% Ophthalmologists practicing in urban areas
 India’s internet subscriber base of 560 million is second only to that
of China
 McKinsey Global Institute (MGI) has estimated that it could save
India $4 billion to $5 billion annually
 Potential to replace half of in-person outpatient consultations in the
country
Archives of Ophthalmology. 2000; 118: 1431-2

35. Scope of Tele-ophthalmology
Specialist opinion
Eye examination in rural
areas
Eye screening - school
screening, diabetic
retinopathy screening
Teaching and training
Awareness programs

37. Advantages of Tele-ophthalmology
For patients For hospitals
- patients from remote areas get
access to opinions of specialist
- reduces travel cost
- saves time
- saves visit to hospital for trivial
problems like refractive errors
- can serve remote areas without
investing on infrastructure
- primary diagnosis done through tele-
ophthalmology and only cases
needing advanced treatment
referred to tertiary care
- primary care doctors learn newer
techniques and treatments by
interacting with specialists
- instant consultations and second
opinions from consultants across
the world

38. Challenges in Tele-ophthalmology
 Connectivity: stable internet connection needed across both ends
 Lack of trained personnel
 Not everyone is confident about making diagnosis over
teleconsultation
 Detailed examination is compromised. No measurement of visual
acuity or intraocular pressure
 Is relatively new so maintaining sutainability in the long term has to
be looked into

39. Tools in Tele-Ophthalmology
 Mobile Tele-Ophthalmology units
 Equipped with Fundus Camera, Slit Lamp, Indirect Ophthalmoscope,
Refraction Unit, Tele-Ophthalmology software, video conferencing
unit, backup generator and water tanks

40. • Anterior segment digital camera
• Anterior segment cameras can be used in accident and emergency
settings by nurses and technicians
• The ophthalmologist in a central location is then able to make
decisions on the urgency of an ophthalmic opinion, suggest treatment
online

41. Digital Fundus camera and OCT
 High resolution fundus photographs and
OCT scans are taken and linked via servers
to trained primary retinal screeners
 Grade the image by retinopathy severity
status and arrange referral if needed

42. Retcam
 Digital retinal image capture is used for
screening of premature or low birth
weight babies for retinopathy of
prematurity (KIDROP; Karnataka)
 Images can be captured by
non-ophthalmic staff in the neonatal
ICU
 Retinoblastoma, can also be imaged via the Retcam.
 Fundus images of retinae of suspected non-accidental injury (shaken
babies) for diagnostic and medico legal purposes can also be taken

43. Video conference unit
 Allows for face to face interaction and inspection in cases of
emergencies
 Pre-recorded clips by technician/optometrist can also be played for
opinion

44. Tele-ophthalmology projects in India
1. MDRF/WDF Rural India Diabetes Prevention Project
 Madras Diabetic Research Foundation (MDRF), Chennai, in collaboration
with the World Diabetes Foundation(WDF)
 Rural community outreach programme serves a cluster of 42 villages (in and
round Chunampet village) in Kancheepuram District, Tamilnadu
 Screening is carried out in Chunampet district for diabetic eye diseases by
using a mobile telemedicine van with satellite connectivity
 Van is equipped with a digital retinal camera. Images are then transmitted via
very small aperture terminal (VSAT) satellite connectivity provided by the
Indian Space Research Organization (ISRO) to our base hospital in Chennai

45. 2. Teleophthalmology project by Sankara Nethralaya Medical
Research Foundation at Chennai
 Customized mobile van with an in-built ophthalmic examination
facility having a social worker and an optometrist
 Satellite connectivity provided by ISRO
 Photographs are taken using a digital camera
 After pupillary dilatation, a single 45◦ digital fundus photograph
 Real-time interaction by the ophthalmologist with the examining
optometrist, as well as the patient, is then established using the
videoconferencing system

46. 3. Aravind Teleophthalmology Network
 Mobile eye-screening van fitted with a satellite has been specially
designed to screen the diabetic patients in the camps
 Data up to July 2006 shows 74 screening camps had been conducted
and 20,080 patients screened in the van
 The Aravind Comprehensive Eye Survey Research Group Study
showed that the prevalence of diabetic retinopathy in rural South
Indian population was 10.5%
 Only 6.7% of individuals with diabetic retinopathy had previous eye
examinations

47. 4. eSanjeevani app
 CDAC Mohali’s flagship web based integrated telemedicine solution
 A platform independent, browser-based application facilitating both
doctor-to-doctor and patient-to-doctor tele-consultations
 User friendly interface, launched on 16th June 2009

48. Key features
 Management Informative System based application: The users can
choose the desired specialists and hospitals for tele-consultation as
per their requirements. Various logs are maintained to record user
activity
 Comprehensive Electronic Medical Record (EMR): demographic and
other patient data. Enables import and export of complete patient
record
 Tele-Consultation: both 'store and forward' and 'real-time' mode
 Appointment Scheduler: seek appointments with specialists
depending on their availability

49.  Medical Equipment Interface: interface with a wide range of
diagnostic/ medical equipment. Some of the medical diagnostic
equipment interfaced with eSanjeevani include ECG machine,
digital slit lamp, digital microscope

51. 5. Mobile Tele-ophthalmology units
 Two Mobile Tele-Ophthalmology Units were designed, built and
implemented at Regional Institute of Ophthalmology (RIO),
Thiruvananthapuram and District Hospital, Palakkad, Kerala
a) Sunayanam: commissioned in 2011 at RIO, Thiruvananthapuram.
Serves rural people of Palode, Neyyattinkara, Vizhinjam,
Chiranyankeezhu, Peroorkada
b) Nayanapadham: commissioned in 2012 at District Hospital,
Palakkad . Serves tribal areas and rural areas
 Data from 2013 shows that these mobile units have conducted 270
screening camps in rural areas and screened 8403 patients, detected
428 Glaucoma and 1014 Diabetic Retinopathy cases

52. Tele-ophthalmology during Covid-19 pandemic
 Teleconsultation has gained prominence during recent times due to
ongoing pandemic
 All India Ophthalmological Society (AIOS) has issued guidelines
regarding tele-ophthalmology as per the Telemedicine Practice
Guidelines issued by BOARD OF GOVERNORS on 25.3.2020
 Video consultation is preferable as we can see the patient directly,
look for general and eye signs

53. 1. Cataract
 Assessment of vision can be done by
asking the patient to occlude one eye and
assess for finger counting by a relative
 A tele-consultation helps determine
immediate/early visit to the hospital
Indian J Ophthalmol 2020; 68:1316-27

54. a) Phacolytic glaucoma – short duration of acute pain and congestion, a
cloudy cornea, turbid anterior chamber and in certain cases, a hypermature
cataract may be visible
b) Intumescent mature cataract - white reflex that is easily visible on
tele-examination
c) Subluxated natural crystalline or intraocular lens, with history of sudden
decrease in vision with or without associated history of trauma
d) Post-operative uveitis in patients complaining of pain and visible
circumciliary congestion
e) Traumatic cataracts

55. 2. Cornea
 Gross examination in various gazes
 For potentially visual threatening conditions
like a corneal ulcer or trauma, an in-person
consultation is mandatory
 Red Eye: if any pain, blurring of vision,
burning, itching or irritation, discharge
and trauma
 Allergic conjunctivitis: with increased use of sanitizers and aerosols
generated, more such complaints are coming

56.  Unless absolutely essential, it is better to avoid topical steroids due to
its potential side effects and unmonitored usage
 Those with altered vision, severe eye pain or worsening, despite
treatment, will require immediate referral to the clinic
 Blunt or penetrating trauma or chemical or thermal injury: Many of
these are medicolegal cases or require emergency surgical
intervention, documentation and management at a hospital is
mandatory
 Many patients need to be educated about Computer Vision Syndrome
and advised lubricating drops, if need be

57. 3. Glaucoma
 Inability to acquire information regarding IOP, optic disc or visual
field changes
- futility of this interface for the management of chronic glaucoma
 Acute rise in IOP: symptoms such as pain and redness of the eye,
blurring of vision, headache and vomiting
- Based on the history, determine if this is a primary acute angle
closure glaucoma or an acute secondary glaucoma such as
neovascular glaucoma. Require urgent referral to a hospital for
management

58.  Advice regarding eye drops remains the main utility of
tele-consultation in glaucoma
- patients can be reminded about the correct dosage, the technique of i
instillation, and identification of possible side effects
 Drug prescription should contain a disclaimer that the treatment was
advised based on the history alone and a clinical examination was not
performed
 Any change in the drug prescription requires a follow-up visit to
ensure resolution of symptoms and control of IOP

59. 4. Retina
 Telemedicine has been a successful screening tool for DR
 Diagnosis and treatment of retinal conditions is difficult unless
accompanied by non-mydriatic wide field fundus imaging
 Patients presenting with acute symptoms will need a careful history
 Past history and any known systemic conditions will help rule out
conditions such as retinal artery occlusion, vitreous hemorrhage and
retinal detachment

60.  Deterioration of vision: those with pre-existing retinal conditions like
DR, age-related macular degeneration and previous cataract surgery
can present with gradual drop in vision
 Need for laser or intravitreal injections or surgery: urgent referral
advised
 Post-operative patients: decreased vision, severe pain, discharge, lid
edema, headache, vomiting and nausea, the patient should be asked to
visit the hospital
 Red flag signs like premature infants requiring ROP screening,
retinoblastoma patients undergoing therapy, trauma with possible
retinal involvement and leukocoria require emergency retinal
evaluation by the specialist

61. 5. Uvea
 Uveitis patients mostly have a compromised immune system either due to
underlying infective etiologies or the systemic immunosuppressive therapy
they are on, posing a high risk for contracting COVID-19 disease
 Stable patients can be followed up with the known clinical background,
relevant history and external eye examination
 Patient should be advised not to stop or reduce immunosuppressive therapy
if there is no confirmed COVID-19 infection
 Avoid high dose of systemic steroids in severe cases of COVID-19
 Drugs like hydroxychloroquine, interferons, tocilizumab can be continued
because they are also used in the management of COVID-19 infections

63. 6. Neuro-ophthalmology
 Determine which patients require urgent neuroimaging and/or a
consult with a neurologist or neurosurgeon
 Three common scenarios – sudden loss of vision, headache, and
diplopia that can be managed on tele-consultation

65. 7. Oculoplasty and oncology
 Uniquely positioned in that a large proportion of patients can be
diagnosed, treated and reviewed via tele-ophthalmology
 Use clinical acumen to determine if the information available on
remote consultation is adequate to make management decision or in-
person visit needed
 Consultations that show a white/grey reflex on the camera will need
to be seen in the hospital without delay
 Follow-up of patients with ocular malignancies, who are on
maintenance therapy or in remission

66. GMCH data
May 1 to July 31 2020
Total cases
New cases
Old cases
181 58 123
Total cases
New cases
Old cases

67. Medico-legal considerations for tele-consultation
No clear medicolegal guidelines available
Valid for those
residing in India,
but not for
international
patients
Data storage,
confidentiality,
and data
privacy is
paramount
Most routine
drugs can be
prescribed by
electronic
prescriptions
Digital or
e-signatures on
prescriptions are
accepted for
dispensing
medication
Tele-consultation
for minor patients
should be done in
the presence of an
adult
A detailed
disclaimer about
the limitations of
tele-consultation
should be
mentioned on the
prescription

68. Conclusion and take home message
 Tele-consultation is here to stay beyond the pandemic
 Need to modify our practices as per recent or updated telemedicine
guidelines
 Repeatedly stress the limitations of tele-consultations and make sure
that patients are aware of the need to visit the hospital if required
 Technology awareness and limitations must be recognized
 Medicolegal considerations including legal and clinical disclaimers,
consents, right to refusal (for both the patient and the doctor),
monetization and its implications have to be refined

69. Thank You