Dr. SANJAY SRINIVASAN, V. MURALI and Dr. RAJIV RAMAN write about the benefits of applying telemedicine to ophthalmology.

INDIA lives in its villages. According to the data available, there is a big void in eye care facilities for those who really need them. The World Health Organisation (WHO) estimates that the number of blind and visually impaired will double from 180 million to 360 million by 2020 unless concerted action is taken.

Ninety percent of the world's blind people live in developing countries,

"One of the basic Human Rights is to see and, therefore, it is to be ensured that no citizen goes blind needlessly; or being blind does not remain so, if, by reasonable deployment of skill and resources, his eye sight could be prevented from deteriorating and if already lost could be restored." (Resolution of the Central Council of Health and Family Welfare, 1975 meeting.)

Tele-ophthalmology

This is a combination of expertise and technology that delivers medical services and information over a distance. Tele-technology supplements and reinvents traditional healthcare delivery systems. Tele-ophthalmology plays a vital role in bridging the gap between those who can afford quality health care and those who cannot. Tele- technology delivers this information as voice, data, or video imagery from a remote village to the central hub where the doctor makes a diagnosis and also suggests treatment.

One of the first applications of telemedicine to ophthalmology was a 1987 project to monitor retinal vessels during space flights. A system was developed at the Johnson Space Center in Houston for real time transmission of retinal images acquired by a portable video funduscope. It was tested on the space shuttle "Columbia" during mission STS-50.

Ophthalmologists are trained to interpret images. Ophthalmologists are accustomed to diagnosing disease asynchronously from two-dimensional black-and-white imagery or angiograms. There are two systems in Tele-ophthalmology the store forward and real time and a combination of both. Store-and-forward systems relay data asynchronously. Medical information is acquired at one site, stored digitally on a computer, and then transmitted at a later time to another location where it may be stored again before review. E-mail is a form of store-and-forward system. Real time systems work synchronously. Speakers, microphones, and television cameras allow live audio conferences, videoconferences, and group whiteboards to pass information at near simultaneous speeds. Hybrid systems combine capabilities of real time and store-and-forward telemedicine

Store-and forward Tele-ophthalmology systems are well suited to sending photographs to specialists for review. Ophthalmologists, however, use relatively large external peripherals to gather information on the interior of small and enclosed parts of human anatomy. Direct ophthalmoscopes, indirect ophthalmoscopes, and slit lamps equipped with a variety of lenses are used to evaluate an organ only 1inch in diameter. Non-mydriatic cameras, though less costly than mydriatic cameras, are still relatively expensive medical peripherals. However, the convenience of non-mydriatic photography for remote operators and patients makes them compelling tools for Tele-ophthalmology.

New compression technologies allow multimedia sound, text, and graphics to be transmitted at high speeds and reasonable cost. Information can flow from one computer to another, be broadcast from one to many, or be linked many-to-many through a spider web structure of private networks and the public Internet.

Consider a remote emergency room with no ophthalmologist in a community in need of ophthalmology consultation and support. Because a variety of ophthalmic anterior and posterior segment conditions are encountered in emergency rooms, a slit lamp with a video camera attachment may be the telemedicine acquisition peripheral of choice.

A slit lamp with video camera attachment permits real-time video anterior segment views and some view of the posterior segment. Eye conditions presented may be acute and require immediate attention. Videoconferencing allows interaction between emergency room personnel and a consultant ophthalmologist. It also provides a virtual "hands-on" examination by the consultant ophthalmologist as she/he directs the remote emergency room physician's use of the slit lamp and camera. Additional history and image data may be collected during live interaction to increase the effectiveness of the consultation.

Tele-ophthalmology project requires identification of a geographical area, which is devoid of proper healthcare facility. Increased access to education for both patients and providers may prove even more effective in addressing the disparity of ophthalmology care in different parts of the world than telemedicine itself.

Tele-ophthalmology offers patients and healthcare providers access to sub specialists anywhere at any time. Medicine freed of geographic borders, time zones and personnel shortages opens the door to economical, widespread screening of disease and more accessible medical delivery systems. It suggests that no region of the world is too remote or too poor to receive high-quality medical care.