New telemedicine approach may allow for remote treatment of DR
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A novel telemedicine approach combining the high speed of 5G wireless networks and navigated retinal laser photocoagulation could allow treatment of diabetic retinopathy at a distance.
In a prospective study, Youxin Chen, MD, PhD, a retina specialist at Peking Union Medical College Hospital in Beijing, treated nine eyes of six patients with proliferative or severe nonproliferative DR located 1,200 km away at the First People’s Hospital in Huzhou, China.
A Navilas laser system (OD-OS) for navigated retinal photocoagulation in Huzhou was set and operated remotely by Chen using the TeamViewer computer platform. 5G networks ensured high-speed data transmission. Before each intervention, medical records for each patient were reviewed and discussed on videoconferencing with the local ophthalmologist and the patient. Chen planned the treatment based on color fundus photographs on the telemedicine platform screen, which was visible at the other end of the laser machine display. Then, based on this treatment plan, the laser system performed photocoagulation automatically. Throughout the procedure, Chen remained constantly in contact with the ophthalmologist on the other end to adjust the laser parameters if needed and to intervene in case of complications.
5G networks are characterized by stable signal transmission, high speed and low latency. In the study, the mean data upload and download speeds were 88.45 MB per second and 853.63 MB per second, respectively, with no loss of signal quality and a mean latency time of 20 milliseconds. Such a short delay, according to the authors, is not perceivable and does not affect decision-making when management of complications and deviations from the original treatment plan are needed during the procedure.
Six of the study eyes underwent panretinal photocoagulation (PRP), one eye had focal/grid photocoagulation, and two eyes had a combination of the two. All treatments were carried out successfully with no intraoperative adverse events. In four patients, visual acuity was stable at 1 month, while two participants who did not present to follow-up visits until 6 months later due to the COVID-19 pandemic were found to have poor glucose control and loss of vision. One patient needed PRP re-treatment due to the presence of persistent neovascularization at 1 month.
“It is important to note that not all patients achieved satisfactory short-term outcomes in this study, potentially owing to the inherent limitations of navigated laser treatment,” the authors wrote.
They said that some of those patients lived in rural areas and were therefore unable to be regularly monitored and treated for their diabetes or to undergo regular treatment with intravitreal injections for DR.
“The underdeveloped regions where these individuals live are ideal targets for telemedicine development,” they wrote.
The COVID-19 pandemic has highlighted the potentials and usefulness of telemedicine. Several studies have evaluated remote screening and consultation approaches, but few have explored the feasibility of treatment.
“This is the first such application of 5G technology to retinal laser real-time telephotocoagulation that we are aware of,” the authors wrote.
This new approach could benefit many patients in rural areas where access to specialized, high-quality treatment is limited and could be “a potential health care solution for patients under adverse circumstances, as in the context of the COVID-19 pandemic,” according to the authors. The technologies used in this study could also be used to train local ophthalmologists on the retinal laser photocoagulation procedure.
Further studies comparing this approach with the standard of care are needed to determine whether safety and visual acuity differ, according to the authors. Also, barriers such as liability concerns and reimbursement policies need to be addressed. However, telemedicine development is an opportunity that cannot be missed to help reduce health disparities in countries with limited resources.
“As digital technologies continue to evolve, we believe that current barriers to health care access will be overcome such that more individuals will be able to obtain quality care,” they wrote.
Perspective
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In my opinion, the main message from this study is the promising future of ophthalmology and of medicine in general. As health care providers, we have an ethical obligation to contribute toward improving access to health care, help remove barriers and facilitate the best possible clinical practices through technological advancement.
The potential of this study to affect clinical practice is overwhelming. It symbolizes a beginning of change toward a more equal and accessible model of care. I believe that, with time, the high cost of these technologies will decrease, and with proper guidance and training, therapeutic telemedicine for diabetic retinopathy and other conditions will be feasible in the real world.
This study has, of course, the obvious limitation of its small sample size. Future research is required to evaluate the feasibility of such model in a larger study population and to compare it with other DR treatment strategies within the telemedicine framework. Also, there are some concerns due to the numerous technology requirements that have to be met. To complete such treatment, we need a laser system for navigation of retinal photocoagulation, a remote computer control platform, video conference software and 5G networks for high-speed data transmission. If one of these elements has a malfunction, a backup or some kind of alternative is required.
Another important limitation is the adoption barrier for such technologies because some physicians may be reluctant to use them due to technical, reimbursement or clinical reasons.
We should remember that this is only the beginning of a long process that aims at upgrading the quality and consistency of health care for all, but I am sure that with each step we are closer to its accomplishment.
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