Teleophthalmology for the elderly population: A review of the literature

Highlights

• Teleophthalmology has not been studied exclusively in the elderly population.

• Most of the benefits of teleophthalmology are applicable to the elderly population.

• Teleophthalmology for the elderly has some limitations that should be addressed.

• There is a need for more research of high quality in this field.

Abstract

Background

Ophthalmology is one of the most requested medical speciality services in the elderly population. Although numerous studies have shown the potentials of telemedicine for the provision of ophthalmology services, the extent of its usability in older adults and the aged population is not clear. The aim of this study was to investigate the characteristics and usability features of teleophthalmology for the elderly population.

Method

We searched PubMed, Embase, Scopus and CINAHL for relevant studies since 2008. Forty-five papers met the eligibility criteria and included in this review. We used a multifaceted model to extract the data and analyze findings by cross-tabulation.

Results

The majority of the reviewed papers included participants of 65 years of age or older. Most of the studies were conducted in the USA (38 %). Diabetic retinopathy, glaucoma, age-related macular degeneration and cataract were the most researched eye diseases, and among the imaging technologies, retinal photography had been used the most (72 %). The studies showed teleophthalmology can improve access to specialty care, reduce the number of unnecessary visits, alleviate overloads on treatment centers, and provide more comprehensive exams. It also made services cost-saving for stakeholders and cost-effective in rural areas. However, teleophthalmology was not cost-effective for patients above 80 and low-density population areas.

Conclusion

Evidence is lacking for the usability and effectiveness of teleophthalmology for the elderly population. The findings suggest that primary care providers in collaboration with ophthalmologists could provide more effective eye care to elderly population. Appropriate training is also necessary for primary care doctors to manage and refer older patients in a timely manner. Diagnostic value and cost-effective imaging modalities which are the core of the teleophthalmology, can be enhanced by image processing techniques and artificial intelligence.

Introduction

Age-related eye diseases are increasing yet greatly preventable global health concern [1]. According to World Health Organization, 285 million people are visually impaired globally and 39 million of them are blind. It is estimated that 65 % of the visually impaired and 82 % of the blind people are aged over 50 [2]. This burden is expected to increase with the demographic ageing of the population [3]. Vision impairment has been associated with a plethora of adverse ramifications, including increased morbidity and mortality, double the risk of falls, reduced quality of life, earlier nursing home placement, social decline, depression and decreased financial opportunities [1,4,5].

The most common eye diseases affecting the elderly include age-related macular degeneration (AMD), cataracts, glaucoma and diabetic retinopathy (DR) [4]. These diseases are frequently asymptomatic during their initial phases, particularly if the non-dominant eye is affected first [6]. This contributes to the significant number of undetected cases, and cases diagnosed after the ideal period of treatment has passed [7]. According to the US National Health and Nutrition Examination Survey, 73 % of participants with diabetic retinopathy and 84 % with AMD were undiagnosed [8]. International population-based studies show that approximately 50 % of diabetic individuals do not regularly undergo screening for DR [9]. For people with glaucoma, a major cause of vision loss is a delayed presentation [10]. AMD patients also may exhibit high rates of recurrence and visual deterioration after the conclusion of their treatment [11]. Regular screening and monitoring are therefore essential to prevent potentially severe vision impairment [7]. Furthermore, delays between diagnosis and treatment can lead to irreversible vision loss, indicating a need for efficient administrative procedures [12]. The cost and inconvenience of transport to eye clinics can be particularly onerous for elderly patients who frequently suffer from comorbidities and rely on pensions, especially if they are already on costly long-term treatments [13]. It has been shown that preventative screening for eye diseases not only reduces rates of vision impairment but also is immensely cost-effective [9]. The Centre for Eye Research Australia estimated that the total cost of vision disorders is $9.85 billion per year in Australia [14].

There is a growing demand for a paradigm shift in eye care, particularly for the elderly, which can overcome existing time, transport and economic barriers. Teleophthalmology is a means through which the assessment, diagnosis, treatment and monitoring of patients with eye-related diseases are provided at a distance. There are two main modes of teleophthalmology: store-and-forward (asynchronous) that entails the transmission of data to distantly-located healthcare professional for assessment and review, while real-time (synchronous) involves a live telemedical consultation in conjunction with simultaneous transmission and collection of data [15]. As ophthalmology is a highly image-driven speciality, the store-and-forward mode of teleophthalmology is an ideal means of information transmission and is more widely used than real-time videoconferencing [16].

Teleophthalmology has already been used to facilitate faster healthcare services for rural and remote areas [13]. It has been successful in particular for medically under-served populations such as American Indians and Alaska Natives [17]. Teleophthalmology programs for regular DR screening have been implemented in several communities across the US and Canada and have been shown to be dependable and cost-effective. It has the potential to greatly reduce travel and time inconveniences through the establishment of community-based programs [11,18]. This is particularly important for elderly residents. The aim of this study was to review the characteristics and usability of teleophthalmology programs that have been conducted for the elderly population and identify research gaps in this area.