Extending the reach and task-shifting ophthalmology diagnostics through remote visualisation

Driven by the global increase in the size and median age of the world population, sight loss is becoming a major public health challenge. Furthermore, the increased survival of premature neonates in low- and middle-income countries is causing an increase in developmental paediatric ophthalmic disease. Finally, there is an ongoing change in health-seeking behaviour worldwide, with consequent demand for increased access to healthcare, including ophthalmology. There is therefore the need to maximise the reach of resource-limited ophthalmology expertise in the context of increasing demand. Yet, ophthalmic diagnostics critically relies on visualisation, through optical imaging, of the front and of the back of the eye, and teleophthalmology, the remote visualisation of diagnostic images, shows promise to offer a viable solution.In this chapter, we first explore the strategies at the core of teleophthalmology and, in particular, real-time vs store-and-forward remote visualisation techniques, including considerations on suitability for different tasks and environments. We then introduce the key technologies suitable for teleophthalmology: anterior segment imaging, posterior segment imaging (retinal imaging) and, briefly, radiographic/tomographic techniques. We highlight enabling factors, such as high-resolution handheld imaging, high data rate mobile transmission, cloud storage and computing, 3D printing and other rapid fabrication technologies and patient and healthcare system acceptance of remote consultations. We then briefly discuss four canonical implementation settings, namely, national service provision integration, field and community screening, optometric decision support and virtual clinics, giving representative examples. We conclude with considerations on the outlook of the field, in particular, on artificial intelligence and on robotic actuation of the patient end point as a complement to televisualisation.