Tackling Diabetic Retinopathy Through Telemedicine

Can eye screening through PCPs change the paradigm for blindness prevention?

Diabetic retinopathy (DR) is the leading cause of blindness among U.S. adults aged 20 to 74 years. An estimated 4.1 million Americans are affected by retinopathy, and 899,000 have vision-threatening retinopathy, according to CDC data. The screening rate for DR remains steady at less than 50 percent among diabetics, in part due to cost, lack of access to eyecare providers, and poor compliance.

“The current medical paradigm for referring patients into ‘eye care provider networks’ is inadequate for population-based management of diabetic eye disease,” said Edward Chaum, M.D., Margy Ann and J. Donald M. Gass Professor of Ophthalmology at the Vanderbilt Eye Institute. “We continue to have poor visual outcomes because half the people with diabetes don’t get their recommended annual eye examinations.”

Screening Diabetics through PCPs

Chaum is the co-developer of a computer-based telemedicine network, TRIAD (Telemedical Retinal Image Analysis and Diagnosis), which permits effective DR screening of large patient populations through remote access to an expert. TRIAD, initially established to provide specialist eye care to health disparity communities in the rural Mid-South, was acquired by Welch Allyn in 2015 and now provides DR screening in all 50 states and rural Australia as the RetinaVue Care Delivery Model.

Instead of requiring the patient to visit a retina specialist, low-cost cameras are distributed to primary care physicians (PCPs) and DR screening is done in the primary care setting. Retinal images are sent to a national network of retina specialists via a HIPAA-compliant connection, and the diagnosis is returned to the PCP provider with a management plan for that patient based on the presence and severity of eye disease.

“This system has applications for rural areas and health disparity communities everywhere,” said Chaum. “There are large counties in the U.S. that have very few physicians and almost no specialists. This provides for real-time, expert management of diabetic retinopathy in the local community — wherever the community is located.”

Measuring DR Outcomes

Once patients in the Vanderbilt service area (Middle Tennessee and portions of surrounding states) are identified through telemedicine screening as having DR, they can be seamlessly referred and followed by retina specialists at the Vanderbilt Eye Institute.

“This is the future of the standard of care for diabetic retinopathy management.”

Currently, data are limited regarding the clinical outcomes of telemedical networks because many patients referred for specialty care are seen by specialists out of network. “What we want to do is identify patients, establish a treatment plan, refer them when needed, then manage them through the active phase of their eye disease to demonstrate improved visual outcomes,” Chaum said. “This is the future of the standard of care for diabetic retinopathy management.”

Chaum plans to use the Vanderbilt Health Affiliated Network to better track outcomes. “We think it will have an immediate impact,” he said, “with improved time, effort, and healthcare savings for the patient in their own community.”

Expanding FDA Approval

One limitation of expanding telemedicine for DR care has been lack of FDA approval of computer-assisted diagnostics. Telemedicine can be used to find and assess eye disease, but computer-based algorithms and artificial intelligence methods like deep learning have not been employed to diagnose or manage disease.

“Recently, the FDA approved the use of computer-assisted diagnosis for diabetic retinopathy in the primary care setting – which is very promising,” Chaum said. “With the addition of AI, telemedical screening and management of diabetic retinopathy can be leveraged to provide meaningful health care delivery and improved outcomes in a scalable, low cost, patient-centered manner.”

Advancing Ophthalmology through Engineering

In addition to his clinical work, Chaum has several research grants exploring the interface between technology and medical care including biosensors for safer anesthesia, new drugs to reduce scarring from eye injuries, and a “retina on a chip” that will allow scientists to study cellular responses to environmental stresses in high resolution.

“There are many medical problems for which we don’t currently have good solutions,” Chaum said. “And there are many engineering technologies that may have clinical applications. Our research translates bioengineering concepts into clinical medicine to advance ophthalmology in new, innovative ways.”