Delivering vital eye care out-of-hours through telecommunications technology

Background:

If you live in North Wales and have an urgent eye problem during the day, you will probably see your optometrist or GP first and then be referred to an eye clinic.

However, if your eye problem occurs after 5pm you will be assessed in your local Emergency department initially and then referred to an on-call ophthalmologist. Currently, this will be a local on-call ophthalmologist until 10pm and afterwards it is an on-call ophthalmologist based in Glan Clwyd Hospital.

This means that if you live closest to Bangor or Wrexham you may have to travel an hour’s journey to be seen, unless the on-call ophthalmologist feels the problem can be safely diagnosed by discussion and treatment carried out locally. Assessment of an eye problem prior to phoning for advice is difficult for the Emergency Doctor as most doctors spend just 1 week studying ophthalmology during Medical School.

If the on-call ophthalmologist could both receive the history and see the front of the eye and the retina they could make a more confident diagnosis. Sending external eye and retinal photographs from the spoke unit to the hub is the basis of this project, which aligns with prudent healthcare by reducing variation in the standard of care for patients.

Aims:

The project’s main aim is to provide better and fairer acute eye care for patients living in North Wales.

Challenges:

Initially the team wanted to use Paxos DigiSight, an adapted iPhone with a macro lens for the front of the eye and an attachable arm with a convex lens for the retina. However, on trialling the kit, they encountered two major problems:

• Firstly, it was difficult for a specialist ophthalmologist to obtain good quality retinal photos so therefore it was unrealistic to expect an Emergency doctor to do this.

• Secondly, although acceptable in the USA, the temporary storage of images on a web cloud was unacceptable in terms of security for our IT department.

The solution to both problems lay in an automated high-quality retinal camera and a macro adapted Canon camera. Both can use an interface to send images direct to the existing hospital Ibex image store, avoiding a cloud system.

Outcomes:

A teleophthalmology service should reduce the number of patients who have to travel at night to have their eye condition diagnosed. Treatment can be started promptly in the Emergency department and continued the next day in the local eye clinic. Photographs will educate emergency staff and provide comparison in follow up care.

Currently the number of patients who may benefit from this is small, but in future there will be fewer staff grade ophthalmologists available for out of hours cover and so greater use of a hub and spoke system of ophthalmic advice is planned.

Next steps:

The team has submitted a funding application for the equipment and hope to trial the system in two or three of the emergency departments within the Health Board.

A period of training will be required for the emergency staff involved, and in addition to the taking of photographs, they will be asked to complete a standard history and will be trained on the taking of eye pressures using a portable contact eye pressure measurer (Tonopen).

Over the next 12 months, the team hopes to be able to record the outcomes of acute out-of-hours eye care management with regard to diagnostic quality of images, number of patient transfers avoided, and the satisfaction of patients and staff with the system.