Detecting Glaucoma in Rural Kenya: Results From a Teleglaucoma Pilot Project in Nyamira, Kenya.

PRECIS: A teleglaucoma (TG) case-finding model was used in Kenya. Of the patients, 3.46% had definite glaucoma and 4.12% were glaucoma suspects. Most cases were of moderate to advanced stage and referred for further assessment. PURPOSE: The aim was to evaluate glaucoma prevalence in a high-risk population using a TG model. METHODS: Patients aged 35 or over were referred to the TG program from the outpatient diabetic and hypertensive clinics at Nyamira District Hospital (NDH) and from community awareness programs. Comprehensive ophthalmic examination included structured history, visual acuity, intraocular pressure, central corneal thickness, stereoptic nerve, and macular images. A glaucoma specialist provided diagnosis and management recommendation through virtual consultation. Glaucoma diagnosis and staging were based on at least 1 eye meeting the optic nerve criteria as specified by the Canadian glaucoma guidelines. RESULTS: In all, 1206 participants were seen and 19 of these could not complete the examination. Of 1187 patients, 56% were women and the mean age was 56.60±12.36 years. Of the patients, 11.8% had images that were ungradable in at least 1 eye. The prevalence of glaucoma and glaucoma suspects was 3.46% (n=42) and 4.12% (n=50), respectively. The proportion of patients with early, moderate, advanced, and absolute glaucoma was 2.4%, 33.3%, 52.4%, and 2.4%, respectively. Other diagnoses (pathology in at least 1 eye) included cataract in 13.2%, diabetic retinopathy in 1.48%, and optic atrophy in 1.98%. Of the patients, 28.2% were referred to the Innovation Eye Centre, Kisii, for further assessment. CONCLUSION: A structured TG program detected glaucoma in 3.46% of a rural Kenyan population. Timely patient referral was also initiated.

The Muranga Teleophthalmology Study: A Comparison of Virtual (Teleretina) Assessment with in-person Clinical Examination to Diagnose Diabetic Retinopathy and Age-related Macular Degeneration in Kenya.

PURPOSE: This study compares a web-based teleophthalmology assessment with a clinical slit lamp examination to screen for diabetic retinopathy (DR) and age-related macular degeneration (AMD) among diabetic patients in a rural East African district. METHODS: Six hundred and twelve eyes from 306 diabetic patients underwent both a clinical slit lamp examination and a teleretina (TR) assessment by an experienced ophthalmologist. Both assessments were compared for any DR and AMD using the early treatment diabetic retinopathy study and age-related eye disease study grading scales, respectively. RESULTS: Of the 612 TR assessment photos, 74 (12%) were deemed ungradable due to media opacities, poor patient cooperation, or unsatisfactory photographs. The ability to detect DR and AMD showed a fair agreement (kappa statistic 0.27 and 0.23, respectively) between the TR and clinical slit lamp examination. Relative to a clinical slit lamp evaluation, a positive TR diagnosis carried a 75.0% positive predictive value when diagnosing DR and a 27.3% positive predictive value when diagnosing AMD. A negative TR diagnosis carried a 97.2% negative predictive value for the diagnosis of DR and a 98.1% negative predictive value for the diagnosis of AMD. CONCLUSION: When comparing TR assessments to clinical slit lamp examinations to diagnose DR and AMD, there was a fair agreement. Although further validation is needed, the TR approach provides a promising method to diagnose DR and AMD, two major causes of ocular impairment worldwide.

The Muranga Teleophthalmology Study: Comparison of Virtual (Teleglaucoma) with in-Person Clinical Assessment to Diagnose Glaucoma.

PURPOSE: While the effectiveness of teleophthalmology is generally accepted, its ability to diagnose glaucomatous eye disease remains relatively unknown. This study aimed to compare a web-based teleophthalmology assessment with clinical slit lamp examination to screen for glaucoma among diabetics in a rural African district. MATERIALS AND METHODS: Three hundred and nine diabetic patients underwent both the clinical slit lamp examination by a comprehensive ophthalmologist and teleglaucoma (TG) assessment by a glaucoma subspecialist. Both assessments were compared for any focal glaucoma damage; for TG, the quality of photographs was assessed, and vertical cup-to-disk ratio (VCDR) was calculated in a semi-automated manner. In patients with VCDR > 0.7, the diagnostic precision of the Frequency Doubling Technology (FDT) C-20 screening program was assessed. RESULTS: Of 309 TG assessment photos, 74 (24%) were deemed unreadable due to media opacities, patient cooperation, and unsatisfactory photographic technique. While the identification of individual optic nerve factors showed either fair or moderate agreement, the ability to diagnose glaucoma based on the overall assessment showed moderate agreement (Kappa [κ] statistic 0.55% and 95% confidence interval [CI]: 0.48-0.62). The use of FDT to detect glaucoma in the presence of disc damage (VCDR > 0.7) showed substantial agreement (κ statistic of 0.84 and 95% CI 0.79-0.90). A positive TG diagnosis of glaucoma carried a 77.5% positive predictive value, and a negative TG diagnosis carried an 82.2% negative predicative value relative to the clinical slit lamp examination. CONCLUSION: There was moderate agreement between the ability to diagnose glaucoma using TG relative to clinical slit lamp examination. Poor quality photographs can severely limit the ability of TG assessment to diagnose optic nerve damage and glaucoma. Although further work and validation is needed, the TG approach provides a novel, and promising method to diagnose glaucoma, a major cause of ocular morbidity throughout the world.

Improving diabetic retinopathy screening in Africa: patient satisfaction with teleophthalmology versus ophthalmologist-based screening.

PURPOSE: To assess patient preference for diabetic retinopathy (DR) screening with teleophthalmology or face-to-face ophthalmologist evaluation in Nairobi, Kenya. MATERIALS AND METHODS: Fifty seven diabetic patients from a one-stop multidisciplinary diabetic clinic (consisting of a diabetologist, nurse educator, foot specialist, nutritionist, ophthalmologist, and neurologist) in Nairobi, Kenya were included if they had undergone both a teleophthalmology (stereoscopic digital retinal photographs graded by an ophthalmologist remotely) and a traditional clinical screening exam (face to face examination). A structured questionnaire with a 5-point Likert scale was developed in both English and Swahili. The questionnaire was administered over the telephone. Ten questions were used to compare patient experience and preferences between teleophthalmology and a traditional clinical examination for DR. A mean score >3.25 on the Likert scale was considered favourable. RESULTS: Successfully telephone contact was possible for 26 (58% male, 42% females) of the 57 patients. The mean ages of the male and female patients were 52.4 and 46.5 years respectively. Patients were satisfied with their teleophthalmology examination (mean 4.15 ± 0.97). Patients preferred the teleophthalmology option for future screenings (mean 3.42 ± 1.52). This preference was driven primarily by convenience, reduced examination time, and being able to visualize their own retina. CONCLUSION: In this study, diabetic patients preferred a teleophthalmology based screening over a traditional ophthalmologist-based screening. The use of teleophthalmology in Africa warrants further study and has the potential to become the screening model of choice. Cost effectiveness in comparison to an ophthalmologist-based screening also requires evaluation.

The Sandwich fellowship: a subspecialty training model for the developing world.

Health care systems in many developing countries are rapidly evolving to respond to urbanization and shifting epidemiological profiles, creating an environment favorable for subspecialty development. The struggle for developing nations to train and retain highly skilled clinicians within academic institutions has highlighted the need for creative approaches to subspecialty education in these regions. The "Sandwich fellowship" is an educational model in which a fellow completes rotations at an academic institution in the developed world as well as in his or her home environment. An important component of the model is the expansion of institutional capacity at the fellow's home institution to create an enabling environment to practice newly acquired skills. The fellowship provides experience in diverse geographic and cultural contexts under the guidance of a preceptor from an institution in the developed world who teaches in both settings. Preceptors are given opportunities to continue professional growth and gain from exposure to pathology not commonly seen at home. Successful pilots of a Sandwich fellowship took place in ophthalmology and orthopedic surgery at the University of Ottawa in 2007-2008 and required funding from multiple sources with bilateral institutional support. Emphasis was also placed on teaching, leadership, management, and research so the fellows could return home and lead the development of their subspecialty areas. Early contact between administrations enables the model to serve as a gateway to a long-term partnership between developed world academic establishments and developing world institutions. Such a relationship yields a mutually beneficial exchange of knowledge and skills. Beneficiaries include the hospitals, their staff, and patients at both institutions.