Helpful Information Never Gets Old

Valley View 3 July 2016.jpg

Shortly after we launched this blog in late 2015, two of our dedicated program coordinators, Anna Sorenson (San Jose) and Amanda Joslin (Seattle) authored a series of instructive posts for EyePACS photographers. Anna explained the three steps to becoming a successful EyePACS-certified photographer, and Amanda logged her “aha moments” as she, new to the job, learned to use the iCam. 

That series of articles, posted to our blog two years ago, remains a frequently-accessed source of information and confidence for our growing cadre of certified photographers in 350+ clinics in five countries. Because these articles are read by someone every week, it seemed wise to link all ten of them right here, right now, to make it easy for ALL certified and would-be-certified retinal photographers to learn the basics, troubleshoot their potential errors, and build their confidence in helping to detect diabetic retinopathy. 

Here is a list of the ten helpful articles, each with a link and a brief synopsis. As you click on each link, and the blog opens, you might have to scroll just a bit to find the specific article you’re looking for:

The Certified Retinal Screening Photographer, Step 1: Learning the Basics.Why certification is important and how the DR screening photographer contributes to saving sight. Introduces the two training modules: capturing images and testing.

The EyePACS Photographer, Step 2: Operating the Camera. Explains the on-site training EyePACS representatives provide, including set up for the session, entering data and uploading the images, and how to deal with unusable images.

Become an EyePACS Photographer, Step 3: Navigating the Certification and Clinical Web SitesHow the eight images you’ve captured are uploaded to the certification and clinical web sites using your account (which will be created when you are certified).

Join Me as I Learn to Use the iCam– our new program coordinator shares “aha” moments.

·     Lesson 1: Starting in Focus. Explains how to correctly align the focus bars, including identification of “ghost bars.”

·     Lesson 2: Avoiding Small-Pupil Artifacts. Finding the optic disc and the very important macula in patients with small pupils: What can you do short of dilation?

·     Lesson 3: Illumination. Tips for adjusting flash level to patient eye color.

·     Lesson 4: Unclear Media Caused by Misalignment. You’ll want to avoid the hazy ring around the image when the camera isn’t positioned correctly. The solution? aligning the white working distance dots. (And what if you can’t find the first dot?!)

·     Lesson 5: Taking External Images. How to capture important images of the entire external eye for use by the consulting image reader. Troubleshoots what might go wrong.

·     Lesson 6: Image Artifacts. Reviews the most common obscuring artifacts, from smudges to eyelashes to water droplets, with tips for proper lens cleaning.

·     Lesson 7: Correct Eye Position. To get that important panoramic view of the retina, familiarize yourself with the fixation targets you’re asking the patient to view, including use of the printed guide EyePACS provides. Also explains how to image retinas of a patient with a nonfunctional eye.

We invite you to peruse these articles as often as you find them helpful. Remember, though, that our program coordinators are standing by to assist you by phone (800-228-6144) and email: contact@eyepacs.org. On-site assistance can also be arranged. We firmly believe that the certified EyePACS photographer in the primary care clinic is the first key to identifying and successfully treating diabetic retinopathy while vision can still be saved.

After DR screening, what happens next?

Let’s say you image the retinas of a long-term diabetes patient, and your EyePACS reader advises that signs of Vision Threatening Diabetic Retinopathy (VTDR) are clearly present in the images, and recommends referral to an ophthalmologist in, say, one month. You contact the patient and set the wheels in motion to help this patient get the appointment. From there, the patient follows up and begins the sight-saving procedures that will prevent blindness, right? 

 A successful DR screening session is just the beginning.

A successful DR screening session is just the beginning.

Unfortunately, according to a study we conducted several years ago, only about 23%  of patients with VTDR actually saw a  specialist and received treatment or follow up. (We are currently working to update that study.) Why? Because many patients dealing with a multi-faceted disease like diabetes face a cascadeof issues: conditions and determinants that can create insurmountable barriers to taking the next step in their own care.

 

The dictionary defines “cascade” as a series of shallow or step-like waterfalls... seeming to flow or fall in abundance. A recent study by EyePACS, Google Research, and medical anthropologists from Southern Methodist University and the RAND Corporation concluded that “cascade” is exactly the image healthcare professionals should keep in mind when addressing patients who have signs of VTDR. “Diabetic Retinopathy and the Cascade into Vision Loss,” published in Medical Anthropology in late March 2018, begins with the assumption that vision loss is a catastrophic event and an unnecessary one, even for people with diabetes. This team of researchers, including both the CEO and Medical Director of EyePACS, interviewed VTDR patients in their homes and the clinic staff who interact with them. They concluded that the multitude of social and health problems, interacting with each other, often make follow-up specialty referral and DR treatment a very difficult task. 

What, exactly, does this “cascade” include besides diabetes itself? Multiple other conditions (such as kidney and heart disease) that need medical attention, depression, social isolation, and competing responsibilities, to name a few. Patients observed and interviewed often seemed to have difficulty obtaining their medications or taking them properly, finding the stamina required for scheduling or attending dialysis and other treatment appointments, and making good decisions about food and exercise due to dizziness, weakness, foot pain, or other disabilities. Add to that family obligations, work schedules, lack of support, language barriers, and reduced mobility, and the cascade takes over the patient’s life. It’s easy to see how this can make it very difficult for patients to follow the recommended referral to an eye care specialist and adhere to eye treatment, even though loss of sight is often what our patients with diabetes fear the most.

And, if vision actually becomes impaired, the cascade of issues can be even more overwhelming – not only to the patients and their families, but also to the healthcare providers themselves. In addition, when delay in treatment of DR leads to visual symptoms, the  treatment is less effective in preserving or improving vision. Thus, we must ask ourselves, how can we get our patients into timely treatment before vision is irreversibly lost?

 DR screening provides a great opportunity for education, motivational interviewing and problem-solving. 

DR screening provides a great opportunity for education, motivational interviewing and problem-solving. 

Our researchers observed telemedicine screenings in three high-performing safety-net clinics to better understand the screening and specialty referral processes. They found little accessible take-home informational materials, insufficient two-way communications with patients regarding diabetic retinopathy and its treatment, and little time devoted to overcoming barriers to follow-up appointments. Shortcomings in the scheduling system for eye care visits were often cited by patients and staff alike as barriers to further care. Some patients were advised to call about their screening results if they hadn’t heard anything within a few days – but were given no name or phone number to call. 

 

How is it in your clinic?  Do you have clear data about how your patients with sight-threatening disease adhere to specialty referral and treatment recommendations? If, despite all your efforts to prevent diabetes-related vision loss, this “cascade” is the reality, what can a primary care clinic do? At this point there is no simple solution. There are no templates for ensuring that patients referred for specialty follow-up actually get the care they need to prevent vision loss. According to Dr. Jorge Cuadros, OD, PhD, CEO of EyePACS, the best thing clinics can do at this point is to collect reliabledata on what happens after the screening process, what the patients referred for follow-up actually do, and what efforts are being made to improve the patients’ chances of getting sight-saving care. “Our research continues,” said Dr. Cuadros. “This data is difficult to obtain and track. The problem is exacerbated when clinics assumetheir referrals are being completed.” 

Dr. Cuadros continued, “The primary care clinic will ultimately be the place where diabetic retinopathy will be stopped in its tracks.  Lack of adherence with eye treatment, however, is a problem that is largely unrecognized and, for correction, requires support from eye care professionals, social services, public health, and the community in general.  We need to grow this conversation and continue to work together to reliably link early detection with sight-saving treatment. Otherwise, what is the point of screening for retinopathy?”

Do not hesitate to get in touch with us if you know or discover that your clinic has similar problems. Given what we are finding elsewhere, it is very likely that many clinics share a similar challenge. By working together, we can also share solutions that seem to be working. Send us your recommendations and tell us about your solutions: 800-228-6144 or contact@eyepacs.org.  Read the entire report here.

Good News for Retinal Photographers: ARIQA

What does Automated Retinal Image Quality Assessment (ARIQA) mean for EyePACS-certified photographers who are submitting images to the EyePACS system? It can mean a lot, so we’d like to take just a few minutes to explain.

Images that are manually added to a new encounter on our clinical site in a web browser will now be assessed and labeled – automatically – for image type and image quality before the encounter has been saved. If your images are suboptimal, they will be identified for you immediately. Now, there are a few caveats. These features do not apply if you’re using the EyePACS Auto Uploader, and you will still receive image quality feedback from a consultant after your encounter has been graded.

So, how does ARIQA work for you? First, each image will receive a color-coded score: Green for “excellent,” yellow for “adequate,” and red for “insufficient.” You’ll discover a colored box around each image, so you’ll immediately know the rating of each one. And your images will have been labeled for you! No more need to label each image (although you may change labels manually if necessary). You’ll also see a flashing message about quality artifacts such as a dirty lens to remind you to clean the lens following our protocol found in the EyePACS Photographer Manual.                                                        

ARIQA provides feedback on artifacts, exposure, focus and lens, demonstrating whether a particular image is sufficient for this or any interpretation, and exactly why. We believe this new feature will move many EyePACS-certified photographers to a higher level of performance and greater job satisfaction, saving the sight of more patients with diabetes.

View a short, informative slide show here.

            

EyePACS Returns to Guyana

   
  
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    Patients wait to see a public health eye care professional in Georgetown, Guyana.

Patients wait to see a public health eye care professional in Georgetown, Guyana.

Guyana, one of South America’s most diverse and unique republics, is turning the corner on several of its biggest healthcare concerns. According to the World Health Foundation, the country has made significant improvements in the nation’s life expectancy, maternal and child mortality and   immunization rates in the past eight years. 

Chronic disease is now a major public health focus in Guyana, particularly diabetes that is currently at a significantly higher rate than the global average. The World Diabetes Foundation, in partnership with the University of Toronto, Orbis International and Guyana’s Health Ministry, launched the five-year Guyana Diabetes and Foot Care Project to address this problem.  EyePACS has been part of this project for two years, supporting their diabetic retinopathy screening program.  (See our article of April 8, 2016.)

   
  
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    Guyana is the only South American country in which English is the official language.

Guyana is the only South American country in which English is the official language.

“As EyePACS expands to more diverse settings,” said Dr. Jorge Cuadros, OD, PhD, Director of EyePACS, “we continue to learn from our collaborators how to refine our system to accommodate global needs and conditions. Completing our third visit to Guyana has helped us to adapt  EyePACS to   locations with limited internet connectivity. Together with the Guyanese project team we have been able to customize the software to automate user functions and create a workable solution for clinics with low bandwidth.”

EyePACS works with its partners to keep patients on track in their DR screening by providing equipment, training, and maintenance for an effective diabetic retinopathy screening program. This year we worked with optometrists Lani Lord and Fionna Todd; Fionna established the program in 2016. 

Dr. Brian Ostrow, MD, FRCSC, on the faculty at the University of Toronto Department of Surgery, is the project leader and also directs related research. Another leading force has been Dr. Shailendra Sugrim, M.D., Consulting Ophthalmologist at Georgetown Public Hospital, and, of course, Dr. Michelle Ming O.D., also of Georgetown Public Hospital, has been one of the “guardian angels” of the project from its inception.

Our ongoing work with the Guyana team fosters EyePACS to explore new models of global telemedicine, because each international program has its own local cultural, regulatory, and geographic realities that must be addressed. In Guyana, unlike in most U.S. eye care scenarios, the screening and diagnosis are generally accomplished in the same visit to a public eye clinic. The EyePACS software and store-and-forward system then provides the foundation for categorizing and tracking patients. Guyanese optometrists are trained to evaluate the EyePACS images on site, and if they need further support, they can consult the EyePACS web site and network of eye care professionals to weigh in on questionable cases.

   
  
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    Guyanese eye care professionals attend a lecture by Dr. Jorge Cuadros, Director of EyePACS.

Guyanese eye care professionals attend a lecture by Dr. Jorge Cuadros, Director of EyePACS.

On this latest visit, we fine-tuned the workflow to successfully identify, screen and refer patients for treatment. Dr. Cuadros shared with Guyanese eye care professionals the importance of establishing a reliable system for early detection and triage. Local optometrists and nurses were taught how to provide digital retinal screening with the Canon CR-2 AF camera. Eye care specialists were trained in the grading of DR levels based on those digital retinal photos, and they were all securely connected to the EyePACS cloud-based archive system. 

 

   
  
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   X-NONE 
   
    
    
    
    
    
    
    
    
    
   
   
    
    
    
    
    
    
    
    
    
    
    
    
    
  
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  
   
 
 /* Style Definitions */
table.MsoNormalTable
	{mso-style-name:"Table Normal";
	mso-tstyle-rowband-size:0;
	mso-tstyle-colband-size:0;
	mso-style-noshow:yes;
	mso-style-priority:99;
	mso-style-parent:"";
	mso-padding-alt:0in 5.4pt 0in 5.4pt;
	mso-para-margin:0in;
	mso-para-margin-bottom:.0001pt;
	mso-pagination:widow-orphan;
	font-size:12.0pt;
	font-family:Calibri;
	color:black;}
 
    Fionna Todd, OD, helps a diabetes patient understand the dangers his disease poses for his vision and eye health.