Autonomous Telemedicine is Coming to Cataract Surgery

AI-enabled patient follow-up screening and at-home visual acuity tests show promise. Howard Larkin reports

At-home visual acuity and refraction measurements are possible with a web-based tool. About 15% to 20% of patients may need additional help in using them.

“Do you have any redness in your eye?”

“Just in the corner.”

“Is the rest of the eye completely white?”

“Yes, it is.”

“It’s normal for your eye to be a bit red after cataract surgery, and it should get less red with time.”

They are the same screening questions your teleconsultation staff would ask patients in the days after cataract surgery. Except they’re being asked and followed up by an artificial intelligence-enabled autonomous telemedicine programme called Dora.

Dora also asks about pain, vision, flashing lights, and floaters. The program assesses natural language responses and asks follow-up questions about symptoms according to an algorithm. It then flags responses suggesting a problem for immediate review by staff, who may call in patients for in-person visits.

Developed by the UK firm Ufonia, a Dutch language Dora prototype has already been tested, optimised, and its questionnaire validated among healthy individuals at Maastricht University Medical Centre+, said Rudy MMA Nuijts MD, PhD. It will soon undergo a pilot study comparing it with regular care among postoperative cataract patients. If successful, the medical centre will implement the programme.

“Do patients like it? These are older patients after all,” Prof Nuijts said. On average, patients scored Dora 8.6 on a 10-point scale, which is a pretty good outcome, he noted.

The programme is an outgrowth of a shift to telemedicine responding to the COVID-19 pandemic. Before, bilateral cataract surgery involved six in-person visits for two separate surgery dates—with a refraction required by national practice guidelines before implanting the second eye. For many cases, this became three in-person visits, including an immediate sequential bilateral cataract surgery, with the day one followup screening visit conducted by telephone. This is a much more efficient use of residents and staff that Dora could take a step further by relieving them of routine screening calls, Prof Nuijts added.

“I think that visual acuity eHealth tools can function as a reliable screening method.”

HOME VISUAL ACUITY TEST A second telemedicine study Prof Nuijts is conducting is evaluating an at-home tool for assessing patients’ visual acuity after cataract surgery. It is based on a CE-marked web-based tool that measures distance and near VA, sphere, cylinder, and axis—and can even issue a prescription for visual aids.

The tool has been validated against in-person ETDRS manifest refractions. One study found an insignificant mean difference in uncorrected distance visual acuity measurements and in refraction of only 0.02 D in healthy patients with -3.0 D or less myopia. This makes it suitable for screening, though refractive accuracy is still an issue, Prof Nuijts noted. “In terms of visual acuity, it is quite, quite accurate.”i

The tool pairs a computer and a smartphone as a remote control and monitors the environment and user behaviour with a webcam. An AI-powered assistant gives instructions and guides the user to three metres from the screen to conduct the tests.

In a pilot study that screened 46 post-surgery cataract patients, Prof Nuijts compared the web-based tool’s results against Snellen and ETDRS manifest refractions. The in-person tests had slightly more consistent test-retest results by about one-third of a Snellen line. However, about 85% of the webbased tool’s measurements for both corrected and uncorrected VA fell within 0.15 logMAR of the ETDRS results, which was the threshold of clinical significance. The tool tended to underestimate VA slightly, which may be related to the lower accuracy of refractive error measurement.

Patient experience was also positive. About 65% said they trusted the results and about 70% said they would recommend the web-based test to other patients. About 15% to 20% might need additional help using the smartphone during the test, Prof Nuijts said.

Now underway is a multicentre, randomised test of the webbased VA and refractive error tool for monitoring patients after cataract surgery. It involves 188 eyes of 94 patients in three countries. In addition to validity, it will assess the safety and cost-effectiveness of remote monitoring, Prof Nuijts said. “We hope to inform you on this topic in Milan in September” at the ESCRS Congress.

“I think that visual acuity eHealth tools can function as a reliable screening method. The patients’ attitudes are quite positive toward it. It will improve the efficiency of our care in the future,” Prof Nuijts said.

Autonomous telemedicine also will help free up clinical staff and could make care more accessible, he said. “If you can do this automatically and save, say, 90% of the consultations, that is quite an efficiency improvement.”

i Wisse R et al. Journal of Medical Internet Research, 2019; 21(11): e14808.

Prof Nuijts’ presentation was part of a symposium featuring an international panel of expert speakers representing each of the Cataract and Refractive Surgery Societies (ASCRS, APACRS, ESCRS, and LASCRS) at the 2022 ASCRS Annual Meeting in Washington, DC.

Rudy MMA Nuijts MD, PhD is past president of the ESCRS, professor of ophthalmology, vice-chairman, and director of the Cornea Clinic and the Centre for Refractive Surgery at the University Eye Clinic Maastricht, Maastricht Medical University, the Netherlands. rudy.nuijts@mumc.nl