Telemedicine uses telecommunication infrastructure to provide medical care to patients at distant sites. The concept has been in existence for a long time, as shown in an 1879 article published by Lancet when telephone consultations were used for patients who did not require visits to medical practices. Since that time, however, telemedicine has evolved significantly utilizing revolutionary technologies in imaging and communication. It was the COVID-19 pandemic in 2020, however, that significantly accelerated its usage when remote medical consultations became a necessity for everyone. During the pandemic, face-to-face consultation decreased by 88%–97% compared to the prepandemic period, jeopardizing the clinical care for a significant number of patients leading to delayed treatment and subsequent visual impairment.[2,3] As a measure to decrease this consequence, telemedicine was used to overcome the barriers of lockdowns and limitations of in-house medical care for emergency cases only. Telemedicine is an innovative solution which helps where there is a shortage of medical workforce. It also plays a great role in managing immobilized patients and rural populations as it facilitates convenient access to the necessary medical care. Ophthalmology is an area of specialty that has the potential to derive maximum benefit from telemedicine as the practice is mostly image-based. Many countries adopted different applications of teleophthalmology such as screening of patients, postoperative care, and teleconsultations.[4,5,6] In this article, we review the currently available literature to garner a concise overview of the applications of teleophthalmology in Saudi Arabia.
CURRENT SITUATION IN SAUDI ARABIA
Saudi Arabia has a population of 36 million people spread across an area of around 2 million square kilometers. As is the case in many countries, there is a maldistribution of the medical workforce between the rural (understaffed) and urban (overstaffed) areas, which limits access to medical care for the rural populations. A study of ophthalmologists to the population in Saudi Arabia in 2014 indicated a ratio of 1:43,000 which had increased to 1:15,000 by 2021. While this seems comparable to the United Kingdom (1:43,000), and the United States of America (1:18,000) the distribution across cities of the Kingdom is problematic as the ratio is far lower in peripheral areas and smaller cities such as Tabuk where the ratio is 1:63,000. This makes timely access to an ophthalmology consultation extremely challenging in these areas. This is an issue in which teleophthalmology can be of great help.
On reviewing causes of blindness in the Kingdom of Saudi Arabia, the most common cause is cataracts followed by diabetic retinopathy (DR) and glaucoma. In the pediatric age group, retinopathy of prematurity (ROP) and congenital glaucoma are the most dominant causes.
Saudi Arabia has a high prevalence of diabetes affecting around 3.85 million citizens over the age of 20 years. It also has the highest age-adjusted diabetes prevalence in the Middle East and North Africa region by 17.7%. This constitutes a major challenge for ophthalmologists in the Kingdom as the associated DR requires regular medical consultations. According to Alhargan et al., compliance of Saudi diabetic patients to routine screening remains at an unsatisfactory level. This unmet demand due to the maldistribution and shortage of workforce can be addressed by teleophthalmology applications. Glaucoma on the other hand is common and was shown to have a prevalence of 5.6% in one study, with only 23% of glaucoma patients being aware of their diagnosis. The need to diagnose, treat, and follow-up this high percentage of glaucoma patients requires adequate ophthalmology workforce. The limited unevenly distributed available workforce can utilize teleophthalmology applications to follow-up glaucoma patients.
TELEMEDICINE AND TELEOPHTHALMOLOGY IN SAUDI ARABIA
Guidelines from the Ministry of Health
The direction of the Saudi Arabian government toward telehealth was clear from the relentless efforts of the Ministry of Health (MOH) to establish and regulate the service. The first national project for telemedicine, Saudi Telehealth Network, was launched in 2013 by the MOH. The MOH later published telemedicine guidelines in 2020 where it suggested that telemedicine was an acceptable alternative to – but not a replacement for – in-person consultations. Furthermore, it mandated all health-care providers involved in telemedicine to have a valid registration in the Saudi Commission for Health Specialties.
The National Health Information Center (NHIC), an organization belonging to Saudi Health Council, issued the governing rules of telehealth (telemedicine) in Saudi Arabia in 2020. It emphasized the importance of the presence of information technology in health sectors. According to the regulations, all telehealth data must be governed by the NHIC which must supervise and be the link between health-care organizations. The regulations even stated that the Central Board for Accreditation of Health-care Institutions must be informed of the approved telehealth (telemedicine) practices to add to their standards. For reimbursement issues, the NHIC coordinated with the Council of Cooperative Health Insurance to study the insurance coverage for the practice of telehealth (telemedicine). The guidelines did not stipulate terms for teleophthalmology specifically, but they identified several forms of telemedicine in general: teleconsultation; remote patient monitoring; telesurgery; tele-expertise; telediagnosis; tele-assistance; and telemanagement. They also defined the tools involved: mobile phones; artificial intelligence (AI); robots; and the Internet of things. All of these regulations laid the foundation for expanding telemedicine and teleophthalmology services in the Kingdom.
Teleophthalmology applications in Saudi Arabia
There are a lot of teleophthalmology applications that have been developed worldwide over the years. Applications of teleophthalmology are either asynchronous (store and forward) or synchronous (real time). Teleophthalmology models include: general eye care; emergency/trauma; school screening; AI; and disease-specific models of care. The most common disease-specific models of care are: DR; ROP; and glaucoma. Age-related macular degeneration, anterior segment, oculoplastic, pediatric, and neuro-ophthalmology have teleophthalmology applications as well, but to a lesser extent.
The most utilized teleophthalmology application is that for DR screening. Models using AI algorithms have been developed and used with excellent results and even have the approval of the Food and Drug Administration. Another important application in glaucoma is monitoring patients using an intraocular pressure (IOP) home measuring device.[25,26]
Most of the literature about teleophthalmology in the Kingdom was about DR screening, teleconsultation, predictability about online and smartphone applications, and ROP screening.
During the COVID-19 lockdown, and due to the inability of patients to physically attend clinics, there had to be a way to do follow-up patient care. Many centers adopted the virtual clinic concept to triage the patients, directing the urgent cases to the available channels.[27,28] They utilized a real-time video call with the patients to conduct the clinical appointments. While this helped filter out patients who did not need to be present physically, the major challenge was the inability to do microscopic clinical examinations, the findings of which ophthalmologists usually depend on to make their clinical decisions.
Most of the articles from Saudi Arabia were about store-and-forward diabetic telescreening.[29,30,31,32] The model involves nurses or technicians taking color fundus photos for diabetic patients which are stored, then sent on later for review by eye-care specialists. Kozak et al. performed a novel telephotocoagulation therapy in which patients with diabetic macular edema had their color photos and fundus fluorescein angiogram sent from King Khaled Eye Specialist Hospital (KKESH) in Riyadh, Saudi Arabia, to Palmetto Retina Center in West Columbia, South Carolina, USA, for the development of a treatment plan which was then carried out later in KKESH. They used the navigated laser photocoagulator, known as the NAVILAS laser system (OD-OS GmbH, Teltow, Germany), that has been shown to provide better visual outcomes than the conventional laser therapy for diabetic macular edema. Another pilot study of 101 patients used the AI-based DR detection system (TeleMedC DR grader) on retina images to grade DR and compare them with grading by two retina specialists. They found the accuracy of the system to be 97.7%. The project will be adopted on a wider scale and called the National Project of AI in DR Screening. This will have a major positive impact on the detection and treatment of DR in the Kingdom.
Retinopathy of prematurity
The MOH launched the Saudi Arabian ROP national telemedicine program in April 2019. This program is a telescreening program for ROP implemented by the National Committee of ROP.[35,36] The aim of the program is to prevent blindness of 400 premature babies annually. The program utilized 20 digital cameras in level-3 Neonatal Intensive Care Units across the Kingdom. Photos were sent to KKESH consultants for their recommendations on follow-up care and/or treatment. By the end of the year 2021, more than 2000 patients had been observed, with 26% having ROP, 29.7% of whom had the necessary treatment. Adopting this program on a national level would significantly decrease blindness and late presentations of ROP in the Kingdom.
A couple of publications covered the predictability of online and smartphone applications in certain ophthalmic and optometry tests. Raffa et al. conducted a study in Jeddah to determine the accuracy of a smartphone application – Smart Optometry, version 3.4 for Android and version 4.2 for Apple, Idrija, Slovenia – to assess conventional visual acuity in children. They found that the application had a high degree of accuracy, especially in younger children. They concluded that the application is an acceptable home-based visual acuity testing tool. Another study tested 50 participants by Ocular Check vision application and Melbourne Rapid Fields (MRF) Macular Lite applications and compared them to actual clinical testing. Results showed that while there is modest agreement between online and clinical testing in visual acuity, there was significant difference in visual field parameters between the clinical and the online app. These studies showed that smartphone applications in ophthalmology are a promising way of testing but cannot replace the actual clinical examination.
Patient satisfaction is an important factor affecting the implementation of teleophthalmology as shown in a systematic review of European teleophthalmology.
Alhumud et al. investigated patient satisfaction toward a teleretinal screening program in King Abdulaziz University Hospital in Riyadh. They found an overall satisfaction rate of 80.4% for the 163 patients surveyed. Sixty percent of the participants indicated concern that they would have to wait a long time before being referred to an ophthalmologist as the main reason for dissatisfaction. Interestingly, only 9.8% of the participants had doubts about the ability of the doctors to evaluate their retinas by photo. This indicates the high trust of the patients in this type of technology.
Another study conducted in a diabetic center in Riyadh in 2018 evaluated patients' perceptions toward diabetic telescreening. They interviewed 200 patients and recorded a positive attitude in 79.5% of the participants. They found that younger diabetic patients had a significantly better perception of telescreening, reflecting younger individuals' familiarity with technology applications.
According to previous studies, Saudi patients are mostly satisfied with teleophthalmology applications, although wider-scale surveys are needed to generalize this to our population.
The satisfaction of physicians is one of the key factors in determining the success of telemedicine as shown in many studies.[39,40,41]
Al Owaifeer et al. conducted a study exploring physicians' perceptions toward teleconsultation in a tertiary care hospital during the COVID-19 pandemic. They found that 56.3% were satisfied. The main reasons for dissatisfaction were the lack of adequate equipment to evaluate the patients (53.5%), followed by technical issues (43.7%) and patients' lack of experience in using virtual consultation services (38%). Retina specialists demonstrated higher satisfaction than other specialties. This might be due to the convenience of tele-diabetic screening. The satisfaction was higher among physicians who had conducted five or more teleconsultations before the survey. In another study, Althbiti et al. conducted a survey of 114 medical providers in Jeddah to evaluate their perception toward using telehealth. They found that 84% of participants were interested in implementing and using telehealth technology.
To expand the use of teleophthalmology in the Kingdom, more studies will be needed to explore medical personnel's perceptions toward teleophthalmology, detail their main reasons for dissatisfaction, and subsequently address these.
Challenges and future perspectives
One of the challenges of implementing teleophthalmology is the amount of infrastructure work required at a national level to reach equitable access to teleophthalmology services. Additional influencing factors include circumstances outside health care such as internet access and the startup costs of technology. Moreover, technology literacy and resistance to change are significant reasons for slowing the development of teleophthalmology in Saudi Arabia and internationally. As cataract and glaucoma are prevalent causes of visual impairment in Saudi Arabia, it seems reasonable to think that there should be a national teleophthalmology plan addressing these two diseases. One of the possible plans for glaucoma could be supplying glaucoma patients with IOP home-measuring devices and monitoring them remotely, saving a lot of hospital visits and providing timely access to intervention. Another teleophthalmology application could handle cataract cases, especially in rural areas. As cataracts can be diagnosed and graded by colored digital images, digital cameras could be provided to rural and remote areas. AI software could help detect and grade the cataract and refer patients in a timely manner.
According to currently available literature, while teleophthalmology in Saudi Arabia made good progress in the field of telescreening for DR and ROP, this is still not widely adopted. Initiating a teleophthalmology program directed toward cataract and glaucoma is needed to decrease the impact of these diseases on the population. Although VISION 2030 and national transformation plans have laid the foundation for telehealth in the Kingdom, work is needed to develop this into a more convenient, technology-driven resource in the medical community. More studies on teleophthalmology in Saudi Arabia, especially relating to efficacy and cost-effectiveness of current applications, are needed. Moreover, a special focus on building a strong infrastructure is mandatory to properly advance teleophthalmology in the Kingdom.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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