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Diabetes is no longer just a disease affecting industrialized countries. According to the WHO’s 2016 World Health Report, developing countries have meanwhile been affected the most. Among others, India; about every tenth person is diabetic there. Type 2 diabetes, which is considered to be a disease of the affluent, is preventable. Those who live a healthy life, exercise a lot and eat a balanced diet, maintain a normal body weight and avoid cigarettes are more likely not to suffer from this metabolic disease. And, if they are diagnosed early enough, they may hope to get by with just a few medications. Furthermore, their insulin resistance could even be reversed. Consequently, patients may not have to deal with secondary diseases such as heart attack, stroke, kidney failure, nerve damage, diabetic feet or blindness.

About one in three diabetics in India suffers from diabetic retinopathy (DR). This is a disease of the retina which is caused by diabetes. Untreated, DR often leads to visual impairment and even blindness. This is a problem which is particularly prevalent in rural areas where there is insufficient medical care.

Pilot project in Bangalore

And this is precisely the starting point for the pilot project that Dr. Maximilian Wintergerst, doctor at the Eye Clinic of the University Hospital Bonn, and his colleague Prof. Robert Finger, have launched in cooperation with Dr. Kaushik Murali and Dr. Mahesh Shanmugam from the Sankara Eye Foundation, Bangalore.

Dr. Divyansh Mishra, Dr. Mahesh Shanmugam, Dr. Maximilian Wintergerst, Dr. Kaushik Murali, Dr. Payal Shah (f.l.t.r.) © Eye Clinic / UK Bonn

The physicians want to collaborate on testing a portable, effective and economically viable solution for the early detection of DR on site. It is a standard smartphone that works in conjunction with a corresponding adapter. This allows medically trained assistants to perform the requisite eye examination, also known as a funduscopy or an ophthalmoscopy.

Dr. Wintergerst adds:

  “Smartphones are ubiquitous nowadays, and cameras on many devices are so good that in principle, they are suitable for medical imagery.”

A smartphone ophthalmoscope together with the accompanying adapter costs only a few hundred euros. It is also quick and easy to assemble. Doctors use the smartphone’s camera to look into the eye for the screening procedure. The adapter focuses the camera’s beam path and light source so that the mobile phone works like an ophthalmoscope.

Examination via telemedicine

This allows the assistants to take pictures of the patient’s retina far away from a medical center. The images are then sent from the smartphone via the internet to the ophthalmologist in the hospital. And they immediately recognize if a patient has DR or not.

“Ophthalmoscopy can be used to detect eye diseases at the rear part of the eye, such as diabetic retinopathy,” Dr. Wintergerst explains, adding that ” which shows up in damage to the fine blood vessels, known as microangiopathy”.

Using the information provided by telemedicine, the physician is able to immediately assess whether treatment is necessary. This could be a laser treatment, for example. A retina may become atrophied if it is insufficiently nourished. Of course, this all requires the thorough training for the doctors. Still, at least hospitals in India offer poorer people inexpensive to free treatment, and their expenses are compensated in other ways.

Preliminary study successful

Before the German and Indian physicians set up the current pilot project, they tested various applications on site in a preliminary study. Because, according to Dr. Wintergerst:

“There is a difference, of course, between testing the equipment in places where there is a maximum of care also carried out by experienced ophthalmologists, or in places where the infrastructure is not optimal and the examinations are carried out by ophthalmic support staff.“

For their first study, the researchers took pictures of the rear of the eyes of 200 diabetes patients in Bangalore with the specially upgraded smartphones. Their conclusion: In principle, a rear eye examination was possible using all of the smartphone-based methods. However, ultimately they chose the adapter that was best suited for their specific DR diagnostic application. There are other ways of using the smartphone in ophthalmology. Dr. Wintergerst adds:

“As an imaging device, a smartphone is able to detect damage to the optic nerve, for instance, which in turn can be a sign of glaucoma.”

Establishing DR Screening

The adapter selected by the German-Indian medical team which is to be used in Bangalore, will now be used for the duration of the pilot project. The goal for the next two years is to establish a telemedical DR screening service in the poorer districts of Bangalore and its rural surroundings.

Meanwhile, all the necessary preparations have been made so that the project can start. Training 20 optometrists in smartphone-based funduscopy has recently begun. Dr. Wintergerst also plans to personally supervise these screening camps from time to time.

Six ophthalmologists and employees of the Sankara Eye Hospital Bangalore will soon also be coming to the eye clinic in Bonn. The GRADE Reading Center there specializes in systematically standardized image analysis. Accordingly, the local experts will introduce them to the specific requirements involved in the evaluation of the smartphone images taken of the rear of the eye.

“It is important to us that there is an enduring transfer of knowledge so that telemedical screening can continue long after the end of the project,” Wintergerst emphasizes.

In the hope that everything will work out well, he and his collaborating partners from India share a grand vision:

“An extension of the telemedical DR screening program to other hospitals within the Sankara Eye Foundation, whereby the telemedical Reading Center which was established in Bangalore will serve as the coordinating center. This could significantly improve ophthalmic care for many people with diabetes, especially in rural areas where there is poor medical infrastructure”.

He also sees the potential that this telemedical screening concept, if successful, could spread to other emerging and developing countries.

Incidentally, the project is funded by the Federal Ministry for Economic Cooperation and Development and the Else Kröner-Fresenius Foundation as part of a clinic partnership worth around 50,000 euros over a period of two years.

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