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Vision-screening program provides care in Central Valley
Thousands of low-income residents at risk for diabetic retinopathy benefit from long-distance evaluations

| 24 August 2006

Armed with new telemedicine software, Berkeley optometrists are working with doctors at community clinics throughout the Central Valley to provide eye exams for thousands of low-income diabetic patients.

Latinos - who make up 40 percent of the Valley's population - are expected to be the principal beneficiaries of this pilot project. With a rate of diabetes that is nearly three times as high as that of the general population of the United States, this group is at particularly high risk for diabetic retinopathy, a sight-threatening side effect of the disease, says Jorge Cuadros, the project's director.

Since September 2005, when the project was launched, 13 clinics have received retinal cameras and an open-source image-management program developed at the School of Optometry for storing and transmitting patient information and diagnostic images. The equipment allows doctors to take high-resolution photos of patients' retinas and send them electronically to optometrists at Berkeley for interpretation and diagnosis.

"We're finding sight-threatening retinopathy in about 10 percent of the patients," says Cuadros, a clinical professor of optometry at the school and the driving force behind the project. "Without this new system, most of these patients would have fallen through the cracks. They would have ended up at an eyecare provider's office once they lost vision in an eye, instead of being diagnosed early on, when preventive measures can still help."

Diabetic retinopathy is the main cause of permanent blindness in working-age adults, Cuadros says. Annual eye exams are a crucial component of care for diabetes patients, yet less than half the people who should get exams do, he says. Low-income Latinos in the Central Valley are even less likely to obtain the required care. "There are so many barriers," Cuadros says, "like economics, language, or the lack of transportation to a specialist's office that may be in another town miles away."

Most low-income residents of the Central Valley go to community clinics for their general healthcare, but few clinics have the equipment or expertise to screen for vision problems. In 2003, Cuadros decided to address this problem as the research arm of his work toward a Ph.D. in medical informatics.

"The idea was to be able to set up a program where sight-threatening retinopathy could be detected in the clinic at the same time that patients were going for their medical visit," he says. "I knew that we had the technology to address this via telemedicine, but the challenge was to do it in a way that was economically sustainable."

At the heart of Cuadros's solution are three components: EyePACS, a license-free, Web-based system he developed over the last five years to send, store, and display eye-related patient information, images, and diagnostic data; his colleagues at the School of Optometry, who volunteered to read the retinal images sent to them from the clinics; and new legislation that permits Medi-Cal reimbursement for doctors who review dermatology or ophthalmology records that have been sent and stored electronically. (Until the bill went into effect, Medi-Cal would reimburse only for dermatology and ophthalmology services rendered via telemedicine when doctors and patients "met" face-to-face through Web cameras.)

Cuadros has equipped the 13 rural clinics in the project with grant-funded EyePACS and retinal cameras and provided training in their use to doctors and other clinic staff. About 40 patients a week are being screened now at all the clinics, but Cuadros expects that once staff become comfortable with their new equipment and procedures, each clinic will screen about 1,000 patients per year.

The project has paid off from the outset. Hundreds of cases of diabetic retinopathy in every stage have been diagnosed, and other health problems have been discovered as well. One example is the case of 40-year-old Michael Cheng Thao, a Merced resident who had been seeing a doctor in town about his headaches. After running various tests, the doctor scheduled an appointment for Thao with a local ophthalmologist for two months later, the first available opening. In the meantime, at his cousin's suggestion, Thao visited Golden Valley Health Center in May for retinal screening. The image was sent to Cuadros in Berkeley, who reviewed it within the hour. When he noticed that both of Thao's optic nerves were swollen, Cuadros immediately called the clinic, as the swelling could be a sign of a life-threatening condition. Three days later, Thao underwent surgery for a non-malignant brain tumor.

The retinal cameras are also impacting health care in unexpected ways, Cuadros says. "When clinic doctors look at the blood vessels in the retinal images, they get really excited because they are looking directly at the microvascular system of the human body," he says. "This is something a family-practice doctor usually doesn't get to see." If the arteries in the retina are diseased, the rest of the vascular system probably is, too, he added.

The images are making doctors and their patients pay attention. When a 34-year-old woman was shown the lesions in her retinal vessels - the first signs of retinopathy - she finally started taking steps to control her diabetes, including taking the insulin she had earlier resisted, Cuadros says.

The EyePACS system that Cuadros developed is what is known as a "picture archiving and communication system," or PACS. Working with a staff research scientist in the UC San Francisco Department of Radiology, Cuadros based his system on simple components for transmitting secure information and tailored it for retinal imaging. To spare clinics from paying thousands of dollars in licensing fees, the team built EyePACS on an open-source platform, incorporating various components, such as FreeBSD and PostgreSQL, that Berkeley's computer science department had helped to develop over the years.

Cuadros is now working on a variety of projects that are expanding the scope of the telemedicine system. He's creating the software and training program that will allow it to be used to examine glaucoma and other diseases, and he's in the process of developing affordable retinal cameras, hoping to lower their price from $20,000 to $5,000.

He's also establishing mobile screening clinics, taking retinal cameras to community centers and other places where needy patients can be examined on the spot. Last month he spent an afternoon at Glide Health Services in San Francisco's Tenderloin District and screened 15 diabetes patients there, including Glide Memorial Church's long-time pastor, the Rev. Cecil Williams.

"So often new technology broadens the gap between rich and poor," Cuadros says. "So it's particularly satisfying in this case to be able to minimize health disparities using technology and at the same time to evolve new ways to deliver health care."