Expanding Access to Sight-Saving Care With Mobile Tech, AI | AAO 2024

Technology and artificial intelligence could greatly expand access to glaucoma care.

Image credit: Dmitrii Kotin - adobe.stock.com

Advances in mobile technology and artificial intelligence (AI) have opened the door to providing ophthalmologic care to ever-expanding patient populations, including those in underserved or vulnerable populations, according to a session at the 2024 annual meeting of the American Academy of Ophthalmology held in Chicago.

The focus of the session, which was cosponsored by Prevent Blindness, was placed on glaucoma, given its easily undetected nature and ability to cause blindness. Eve J. Higginbotham, M.D, from the University of Pennsylvania, noted there is an urgent need to address barriers in glaucoma care access both domestically and internationally. The discussion highlighted the projected rise in visual impairment, particularly in areas with limited resources.

“Even if you have access, even if you have insurance, inequities remain,” Higginbotham said. "Income inequality is really correlated to the degree of visual impairment that you see by state, as well as health literacy, the distance from an eye care provider, and whether or not there is an eye care provider within a facility that you can access."

The presentation underscored the importance of enhancing the medical workforce to meet rising demands, in a time a significant shortage of eye care professionals is projected. To this end, technology could play a critical role in overcoming this challenge to delivering care. Emerging technologies, such as telemedicine and improved patient triage systems, were spotlighted as vital tools for expanding access to glaucoma care.

"Technology as a resource to expand access ... patient triage can be enhanced, we can do more telemedicine, and both methods to access visual acuity, visual field and intraocular pressure," said Higginbotham. “Multiple factors are needed for the future in order to address the workforce shortages that we're predicting."

In her presentation, Lisa Hark, PhD, from Columbia University, highlighted findings from the Manhattan Vision Screening and Follow-up Study (NYC-SIGHT), funded by the CDC, as a way of revolutionizing glaucoma detection and management in underserved communities of New York City. Officially launched in 2021 due to a COVID-19 delay, the study focused on enhancing access to eye care by including telemedicine and community engagement directly into housing developments, significantly increasing participation among residents.

“We are bringing eye care to where people live, not in their apartments, but in the community rooms in the buildings,” Hark said. “We're improving access to eye care and utilization of eye care. The consensus was that poor follow-up after eye screenings was a major issue, and we wanted to address this need by bringing eye care into the community where people live.”

Findings from the study revealed that 78% of participants failed these initial screenings, underscoring the necessity of reaching this population. At a future date, after this initial screening was completed, an optometrist was deployed to the housing development for follow up, for which there was an 83% show rate for follow-up exams. When intervention was required, the rate of follow through with a navigator’s support for scheduling was 71.8% compared with 36.3% without the navigator.

A cost analysis indicated a relatively low cost per individual at $180.88 for each screen and $273.64 per case of eye disease that was detected, of which there were 468 cases. The costs associated with adherence to in-office exams was $24.25 in the intervention group for those with a navigator, which was $8.78 less than those without the navigator.

When it comes to broadening glaucoma screening even further, Barbara Marie Wirostko, M.D., from the University of Utah, said "Telemedicine is set up beautifully for this." Wirostko highlighted a potential shift in ophthalmology from a reactive to a proactive approach. With advancements in telehealth and teleophthalmology, care can now be delivered remotely, allowing for early detection and intervention.

As an example, Wirostko highlighted broad screening in the United Kingdom of over 1.7 million people with diabetes using fundus photography, which took place in 2011. This study showcased the effectiveness of digital innovations in expanding reach and improving patient outcomes, she noted.

Wirostko also pointed to the growing role of satellite clinics and home monitoring devices in glaucoma treatment, reducing the barriers posed by travel and economic constraints. These innovations not only enhance efficiency but are also cost-effective, she said, while referencing a study from 2012 that showed telemedicine assessments were cheaper than traditional office visits.

“Digital innovation and AI have definitely changed this. We also can have equipment for home use—so that equipment is being sent to the home. You can also have equipment in the satellite office," she said. "But the other thing too is it’s really helping patients with cost of travel, greenhouse gases, lost wages and caregivers that have to take off from work to drive patients hours just for a pressure check.”

With the affordability, access and ease of interpretation brought about by technology, the options for improving global access are ever-expanding. Nicolas Jaccard, BS, PhD, an employee of Orbis International, presented the steps his company has taken with its AI in Africa and Asia, primarily in diabetic retinopathy and now moving into glaucoma.

“We actually ran a study where we showed that non-medical graders who spent five hours on this course were matching local expert performance in the detection of glaucoma," said Jaccard. "Just five hours of this course was sufficient to train non-medical graders to detect glaucoma.”

By automating the interpretation of retinal photographs, the platform provides immediate referral recommendations, which has shown to significantly improve patient compliance, said Jaccard. Designed to work within existing retinopathy screening programs, the platform, which was labeled Cybersight AI, allows healthcare providers to apply broad screening for glaucoma, ensuring that more patients receive timely interventions.

“AI is the technology that we just need to ensure is used safely and efficiently,” Jaccard said. "Our goal is to make sure that AI agrees with experts as much as experts agree with each other, and that’s how we measure success in this space.”

As the program continues to evolve, ongoing data collection and monitoring will be essential for refining the technology and validating its impact across diverse populations; however, this approach underscores the potential for AI to not only enhance glaucoma management but also revolutionize patient care in resource-limited settings.

In addressing the pressing issue of glaucoma care in under-resourced countries, Anil K Mandal, M.D., from the LV Prasad Eye Institute in India, emphasized the critical need for a comprehensive and integrated approach to eye health. Glaucoma remains the third leading cause of blindness worldwide, with over 90% of primary open-angle glaucoma cases in countries like India going undiagnosed, he said.

The talk underscored the importance of establishing permanent infrastructure, training healthcare professionals at all levels, and employing innovative technologies for screening and referral processes. “The delivery system established and practiced in LV Prasad Eye Institute over a period of three decades can be replicated in different other low resource countries,” said Mandal.

The model proposed involves a pyramidal approach to eye care delivery, integrating training programs for volunteers and establishing vision centers equipped with modern diagnostic tools. This system has demonstrated success, catering to populations of up to 1.5 million and providing essential services from primary to tertiary care. By employing telemedicine and remote consultations, the initiative ensures timely diagnosis and treatment, ultimately improving patient outcomes in rural areas.