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Crandall E Peeler, Kavita Dhakhwa, Shahzad I Mian, Taylor Blachley, Sushila Patel, David C Musch, Maria A Woodward; Telemedicine for Corneal Disease in Rural Nepal. Invest. Ophthalmol. Vis. Sci. 2014;55(13):4866.
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Poor utilization of eye health services in Nepal has been attributed to large distances between home and health facilities. We aim to test the reliability of remote diagnosis using anterior segment images compared to traditional exam techniques in rural Nepal.
Twenty-one patients with anterior segment disease presenting to the Lumbini Eye Institute (LEI) in Bhairahawa, Nepal agreed to undergo both standard ophthalmic examination and slit-lamp photography. The participants were examined by one of two cornea specialists at LEI. The examining physician provided a clinical diagnosis (the “gold standard”) and recommended follow-up interval. An ophthalmic technician then obtained anterior segment photographs of each participant using a Canon Powershot A540 digital camera with a slit-lamp adapter. Photographs and clinical histories were provided to three separate “readers” - the LEI ophthalmologist who had not performed the clinical examination and two cornea specialists at the Kellogg Eye Center in Ann Arbor, Michigan - who were similarly asked to provide a diagnosis and follow-up recommendations.
Clinical diagnoses included 14 patients (66.7%) with infectious or inflammatory keratitis, 3 patients (14.3%) with corneal/conjunctival neoplasm, 3 patients (14.3%) with trauma or surgical complications, and 1 patient (4.8%) with an inactive corneal scar. Recommended follow-up time based on clinical exam was 1 day for 14 patients (66.7%), 1 week for 5 patients (23.8%), and 1 month for two patients (9.5%). Compared to the examiner “gold-standard,” the individual diagnostic accuracy was 100% (21/21 cases) for the Nepal-based reader, 81% (17/21 cases) for US-based reader #1, and 90% (19/21 cases) for US-based reader #2. The kappa coefficient assessing diagnostic agreement between the examiner and all readers was 0.748 (p <0.0001). There was somewhat less agreement regarding the urgency of follow-up (kappa of 0.324, p < 0.0001).
Our results suggest that the transmission of slit-lamp photographs from satellite clinics and screening camps to LEI for review and triage is an effective means of identifying anterior segment pathology. Additionally, the good diagnostic accuracy of the foreign readers means that ophthalmologists abroad could volunteer to receive and interpret images from LEI (or eye hospitals in other locations), helping to alleviate disparities in access to eye care.
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