Tele-Robotic Ophthalmic Consultation

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Article initiated by:

Rita Vought, BA, Victoria Vought, BA, Priya Tailor, Bernard Szirth, PhD, Albert S Khouri, MD

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Albert S Khouri, MD

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Introduction

Tele-robotic consultation systems utilize robots to connect patients with their healthcare providers. In the field of ophthalmology, robots allow patients to speak directly with an off-site ophthalmologist for the purpose of diagnosis or consultation. Robots can be deployed in a wide variety of settings, including hospital clinics and community screenings. As remote consultations eliminate location as a limiting factor for access to care, telerobotic technology has the capacity to revolutionize the way medical services and consultations are provided to patients. During challenging times, such as the COVID-19 pandemic, direct access to medical care can be limited. Tele-robotic ophthalmic consultations may be critical link to providing continued eye care to patients while keeping both patients and health care providers safe.

Tele-robotic consultation can be an especially useful tool in community screenings for vision threatening diseases (VTDs). According to the Centers for Disease Control (CDC), the most prevalent VTDs are age-related macular degeneration (AMD), cataracts, diabetic retinopathy (DR), and glaucoma. Patients may have one or more VTDS, which can affect one or both eyes. Our experience shows that 30% of our African American population that are affected by Type 2 Diabetes are also affected by glaucoma as well as cataracts. Despite the prevalence of VTDS, the majority of patients are unaware of their affliction until their vision has been severely compromised or there is irreversible vision loss. In 2020, global estimates stated that approximately 8 million people over the age of 50 experienced moderate to complete vision loss due to AMD. Similar studies estimated almost 100 million individuals over the age of 50 with moderate to complete vision loss from cataracts. Estimates for individuals affected by diabetic retinopathy and glaucoma were 103 and 80 million people, respectively. The economic cost for treatment of VTDs is immense. In 2017, the total burden of vision loss and blindness in the US alone was $134.2 billion USD. Direct medical costs and lost productivity costs each affected individual almost $17,000 USD. These costs, alongside the significant decrease of quality of life for patients affected by VTDs, make the diagnosis and treatment of VTDs a public health priority.

VTDs disproportionately affect certain underserved populations. For instance, low socioeconomic status is associated with the underutilization of ophthalmic services. Such patients comprise many of the individuals seen at community screening centers. During the COVID-19 pandemic, patients from underserved communities experience greater disparities in access to medical services compared to their peers. With only 5.68 ophthalmologists per 100,000 patients, as measured in 2017, many individuals may not have access to an ophthalmologist. At the same time, the prevalence of VTDs is expected to more than double by 2050. The increasing demand for ophthalmologists requires novel solutions to increase the number of patients that can receive eye care. While community screenings are beneficial to provide free services to those in need, they require on-site technicians and image graders to interpret results and speak to patients. Because telerobotic consultation eliminates the need for on-site graders, it has the potential to play an important role in addressing gaps in medical access.

Tele-robotic deployment: practical considerations

Several corporations design robots for mixed use, including for healthcare telepresence. These robots are generally composed of similar components. At the base is a motorized gimbal wheel that allows for mobility of the robot. The top of the robot has a screen often a modified iPadTM which allows for interface between the physician and the patient (Figure 1). Some contain sensors to aid user driving, and they are usually lithium batteries powered to avoid the safety hazards and mobility limitations of a cord. The logistics of transporting telepresence robots are also relatively simple. These robots can sometimes be dismantled and stored in rolling storage containers. For the operation of the robot, a secure cloud-based software is necessary, as well as a HIPAA safe internet connection.

Figure 1. The Double Robotics Double 2 Telepresence robot in use in a clinical setting. An iPad Air2 serves as the display with a 150-degree wide-angle camera kit.  

A few robots which have been developed in the USA and used in clinical settings include Double (Burlingame, California), VGo Communications (Nashua, New Hampshire), and OhmniLabs (Santa Clara, California). The main benefit of utilizing telerobots is the ability to connect patients to a remote physician that is still autonomous in the clinic or screening space. The largest medical applications for this type of technologies especially since the pandemic has been in tele-psychiatry/psychology. Double Robotics currently markets their newest robot, the Double 3, at $4,499 USD. A $699 travel case can be purchased alongside it. Useful aspects of this model include the self-balancing features, sitting and standing heights, and sensors to aid in driving (Figure 1). However, it can only link two individuals in two locations, and would therefore still require an in-person translator or patient aid during screenings. This may be problematic in screening events that have non-English-speaking patients. The Double also lacks a direct interface for sharing and reviewing images.

In contrast, VGo Communications offers the VGo for $4,875 USD and a required $59/month subscription. A travel case can also be purchased for approximately $700 USD. The VGo has features meant for healthcare use, such as the ability to connect to and display medical scans or records. It also offers VGo translator services and the ability to connect an extra individual from another remote location (totaling 3 individuals that can be linked from different location). The VGo also includes sensors that warn the user of obstructing objects or staircases. However, restrictions in the mobility of the robot still remain. A busy clinic may lead to difficulty maneuvering for the controller. This could disrupt the flow of a busy screening event.

Another model of telepresence robot, the Ohmni Telepresence, produced by OhmniLabs, also provides tools useful in a healthcare setting. The Ohmni costs $2,699 USD. One benefit for community screenings is its dimensions: it weighs only 20 pounds and is easily foldable for transportation. It also has a zoom feature to allow the physician to better examine the patient and environment and a navigation camera directed towards the floor for easier use by the handler.

Generally, the main limitations of these telepresence technologies are centered around medical video communication issues. Determining an optimal balance between medical video quality for accurate diagnosis and the teleoperation process for smooth communication is important for continual use of robots. New video coding standards and wireless networks (5G networks) may play an integral role in this optimization.

Published data in ophthalmology or medicine on robotic use in health screenings

Tele-robotics have been utilized and evaluated in medical settings. It is worth noting that telerobotic systems were traditionally developed to allow for telesurgeries. Such robots were made with specific procedures in mind and have properties necessary for performing procedures, such as steady hand, motion scaling, etc. Telepresence robots have also been deployed in ophthalmic teaching settings, such as the Moorfields Eye Hospital in London. More recent technologies have expanded tele-robotics into diagnosis and consultation roles, although examination of its role and effectiveness has been somewhat limited. For instance, a telepresence robot, Beam Pro (Suitable Technologies, USA) piloted in a urology clinic found that 71% of patients were willing to be attended by a telepresence robot again in the future.

Cost-benefit analysis of robot-based telemedicine between a hospital in Korea and Vietnam was also conducted. The threshold, or point at which providing telemedicine consultation, equaled the cost of the same service in person, was 4.01 visits per year. This suggests high economic value for using robot-based systems for diagnosis and consultation and may provide a solution to addressing disparities in care for underserved populations. Another study in New Zealand found that using a Cafero telepresence robot in a rural family medicine clinic decreased consultation length by an average of 18%, improving efficiency for the clinic.

Integration at Rutgers New Jersey Medical School Department of Ophthalmology and Visual Science

Figure 2. The Double 2 Telepresence Robot can be controlled from a laptop in a remote setting. This allows for reduced patient contact in a community screening event, while still allowing patients to meet face-to-face with healthcare providers.    

At the University Hospital Department of Ophthalmology and Visual Sciences (Newark, NJ), there have been multiple pilot studies evaluating the use of telerobotic consultations at the University Hospital Department of Ophthalmology in the clinic (Figure 2). The onset of COVID-19 has placed further emphasis on the need for telemedicine in providing eye care to the Newark community. Approximately one quarter of Newark’s population falls below the federal poverty line. Newark’s population has experienced persistent socioeconomic obstacles that contribute to poor public health outcomes for the community, and these obstacles have been compounded by the pandemic. Therefore, in collaboration with the Department of Ophthalmology, medical students in the Student Sight Savers Program have partnered with local organizations to provide free screening events for the community. These screenings typically start with gathering sociodemographic data, patient history, and blood pressure. Then, eye health is assessed using SNELLEN charts, a puff tonometer, non-mydriatic retinal fundus camera, and optical coherence tomography (OCT). During these screenings, telerobotic consultation, using a Telepresence Double-2 robot (California, USA) has been piloted and its usefulness assessed. So far, telerobotic consultation has been efficacious at addressing the disparity in eye care in the Newark area, as demonstrated by two pilot studies. The main difficulty in community base ocular screenings is actual follow-up of patients with serious underlining problems such as retinopathies, glaucoma as well as AMD. Compliance in clinical referrals are virtually inexistent. Having on on-site real time referral answers this need and compliance becomes nearly 100%.

For instance, one pilot study evaluated patient preference for consultation type in a community screening in Newark, NJ. During remote consultations, the physician has access to the patient’s blood pressure, visual acuity, intraocular pressure, 45° retinal images, and ocular coherence tomography B-scans via TeamViewerTM, a cloud-based software. Of the 58 patients surveyed, 5% preferred robotic telepresence consultations, 55% preferred in person consultations, and 40% had no preference. In addition, there were no significant differences in number of questions asked, wait times, or encounter length between IP and TR consultations. Although patients typically preferred speaking in-person for their consultations, the robotic telepresence did not have any negative impacts on the efficiency of on-site consultations. The ability for patients to speak with a specialist, especially when other factors may typically deter patients from returning to a clinic for follow up, in fact increases the efficiency of the identification and treatment process for VTDs.

Another pilot study tested patient comfort levels with telerobotic consultation in a community screening setting. In this study, tele-robotic consultation was also successfully deployed alongside Artificial intelligence (AI) software to increase efficiency in grading fundus images and determining whether consultation with a specialist was necessary. Fourteen patients interfaced with a remote professional and completed a survey based on their experiences. No differences in preferences were found between interactions with a robot or in-person grader. In addition, interactions with a telepresence robot increased the likelihood of wanted robots involved in one’s healthcare. However, survey results highlighted the importance of addressing issues that may be of concern to patients. This includes questions of patient privacy and the credentials of the remote ophthalmologist.

Future Direction for Tele-Robotic Consultation in Eye Care

Tele-robotic consultation is a valuable tool that should be utilized in community screening settings. Individuals present at community screenings often have less access to routine eye care. If affected by one or more VTDs, individuals risk the progression of their disease before they receive care. Robotic telepresence allows for one or more specialists to be available to consult with patients immediately and determine severity and order of importance for a clinical follow-up visit. The ability to screen and consult in one visit reduces the impact of barriers that may normally decrease the follow up rate for individuals from underserved communities, such as cost, transportation, or family and work obligations. Therefore, the addition of an on-site consultation after screening also plays a role in reducing socioeconomic barriers that may reduce follow up participation in the individuals screened.

Onsite tele-robotic consultation offers many additional benefits during the COVID-19 pandemic. Remote consultation reduces contact between healthcare providers and patients. It also provides a more streamlined approach to directing individuals to specialists. The onsite results also improve the efficiency of screening and diagnosis in community screenings during critical periods of time where care may be limited. Robotic telepresence of providers therefore increases patient education and interaction in times where care may be inaccessible. Future examinations of telerobotic consultations should include expanding deployment to other clinics and settings to evaluate referrals. Efforts to increase patient comfort and understanding of physician telepresence may also reflect positively in patient understanding and follow ups. These factors are key to improving care for those with limited access and maintain access for the whole population in times of extenuating need.