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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 4
| Issue : 1 | Page : 43 |
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Teleophthalmology postoperative evaluation of patients following pterygium surgery in the Amazon
Nicole Bragantini Larivoir1, Luis Marcelo A Camargo2, Barbara N P Clemente1, Renata C Bertazzi1, Amanda M De Domenico1, Juliana S A A Camargo2, Heloisa Nascimento3, Eric P De Andrade3, Jose Alvaro Pereira Gomes4, Solange Rios Salomao4, Rubens Belfort Jr.3
1 Vision Institute, IPEPO, Sao Paulo, Brazil
2 Institute of Biomedical Sciences 5, University of Sao Paulo, Rondonia, Brazil
3 Vision Institute, IPEPO; Ophthalmology, Federal University of Sao Paulo, Sao Paulo, Brazil
4 Ophthalmology, Federal University of Sao Paulo, Sao Paulo, Brazil
| Date of Submission | 20-Jul-2022 |
| Date of Decision | 01-Aug-2022 |
| Date of Acceptance | 15-Aug-2022 |
| Date of Web Publication | 22-Sep-2022 |
Correspondence Address:
Nicole Bragantini Larivoir
MD, Rua Pedro Scapim 165/202, São Matheus, Juiz de Fora, Minas Gerais
Brazil
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/pajo.pajo_39_22
Introduction: Pterygium represents a significant cause of visual impairment and blindness in the Amazon and surgery is the only definitive treatment available. The cost of surgery and the need for prolonged postoperative follow-up have proved to be an obstacle to its management. The aim of this prospective study carried out in the southern region of the Amazon was to evaluate telemedicine in the pterygium surgery follow-up to help make pterygium surgery postoperative care feasible in places without ophthalmologic assistance.
Materials and Methods: Postoperative follow-up care was done through teleconsultation. It involved capturing photographs from the corneal and conjunctiva by trained technicians and sending them to a reading center for an ophthalmologist's assessment based on an asynchronous (store-and-forward) model. Patients and ophthalmologists were inquired about their satisfaction regarding the postoperative follow-up.
Results: All pictures were classified as adequate, allowing proper assessments of results and complications. It was possible to manage the postoperative and conclude there were no postoperative surgical complications during the 6-month follow-up. All patients reported satisfaction with the remote performed evaluation and considered that all their doubts and expectations were met.
Conclusion: Teleophthalmology allows remote access and can significantly improve eye care quality, access, and affordability. It may represent an alternative to providing pterygium surgery postoperative monitoring in areas without the availability of an ophthalmologist, making it possible to combat one of the leading causes of reversible blindness in the equatorial region.
Keywords: Blindness, primary eye care, pterygium, teleophthalmology, visual impairment
How to cite this article:
Larivoir NB, Camargo LM, Clemente BN, Bertazzi RC, De Domenico AM, Camargo JS, Nascimento H, De Andrade EP, Pereira Gomes JA, Salomao SR, Belfort Jr. R. Teleophthalmology postoperative evaluation of patients following pterygium surgery in the Amazon. Pan Am J Ophthalmol 2022;4:43 |
How to cite this URL:
Larivoir NB, Camargo LM, Clemente BN, Bertazzi RC, De Domenico AM, Camargo JS, Nascimento H, De Andrade EP, Pereira Gomes JA, Salomao SR, Belfort Jr. R. Teleophthalmology postoperative evaluation of patients following pterygium surgery in the Amazon. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 Sep 27];4:43. Available from: https://www.thepajo.org/text.asp?2022/4/1/43/356711 |
| Introduction | |  |
Pterygium is a degenerative ocular surface disorder with abnormal fibrovascular tissue proliferation on the cornea. Ultraviolet (UV) radiation is one of the most relevant factors related to its formation.[1] Surgery represents the only definitive treatment.[2] However, in regions of low-socioeconomic level, without access to proper medical assistance, the cost of the surgery and the need for prolonged postoperative follow-up has proved to be an obstacle to performing it, depriving patients of adequate visual care and quality of life.[3]
The aim of this pilot study carried out in the southern region of the Amazon was to evaluate the use of telemedicine in postoperative follow-up to increase its feasibility in places without ophthalmologic assistance.
| Materials and Methods | | |
A prospective cohort study was conducted in two cities in the Brazilian Amazon region, Ariquemes (09° 54' 48” S; 63° 02' 27” W) and Montenegro (10° 15' 6'' S; 63° 17' 14'' W), located in the state of Rondônia.
The institutional review board/ethics committees from invitare approved the study protocol (24419419.2.0000.8098). The study was carried out in accordance with the tenets of the Declaration of Helsinki. Written informed consent was obtained from all participants after explaining the nature and possible consequences of the study. The patients were also informed of the limitations inherent to teleconsultation due to the impossibility of carrying out a complete physical examination. In case of need or complication, the patient would be referred for a face-to-face consultation.
Seventeen eyes of 17 patients with primary nasal pterygium and an indication of excision due to impact on visual acuity (VA), chronic inflammation, or esthetic impairment were enrolled. Patients with other significant changes in the ocular surface, history of previous ophthalmic surgery, trauma, or glaucoma were excluded.
Preoperative
Data were collected regarding patient demographic characteristics and medical history. All patients underwent ophthalmic examination, performed in person by ophthalmologists from Sao Paulo, including VA with current correction, fundoscopy, intraocular pressure assessment, and slit-lamp biomicroscopy.
Surgical technique
All surgical procedures were performed in the local hospital by experienced surgeons. Under a combination of topical and subconjunctival anesthesia, the head of the pterygium was excised entirely from the cornea. Blunt and sharp dissections were performed to separate the pterygium from the underlying sclera and surrounding conjunctiva. The dimensions of the bare scleral bed were measured with a surgical caliper, and a free graft with an additional 1.0 mm of length and width was obtained from the supratemporal bulbar conjunctiva. The graft fixation was performed using fibrin glue or bipolar cautery. Antibiotic eye ointment was applied, and a simple pad and bandage were given for 24 h. Routine postoperative therapy consisted of 0.5% moxifloxacin eye drops every 6 h for 1 week; 1% prednisolone acetate eye drops every 4 h for 1 week to be tapered over a month, and lubricant eye drops every 4 h for 1 month.
Postoperative follow-up
Patients were followed up on day 1, week 1, month 1, month 3, and month 6. In addition to the physical medical record, an electronic medical record was created.
The evaluations on day 1 and week 1 were done in person by the same ophthalmologists who performed the preoperative evaluation. At each visit, a slit-lamp examination was performed to assess the graft adherence, its displacement, or retraction, and the presence of any other untoward effect such as symblepharon, infection, or corneal defect.
From the month 1 to 6, postoperative follow-up care was done through telemonitoring and involved capturing images from the corneal and conjunctival surface using anterior segment photographs with ICAM™ (Optovue, Inc., Fremont, CA, USA) by trained technicians under the remote supervision of ophthalmologists. Photographs were taken in primary gaze position, adduction, and abduction. The transmission was based on an asynchronous (store-and-forward) model. The same parameters evaluated in the face-to-face consultations described above were analyzed. All the doubts and concerns of the patients were transmitted to the ophthalmologists through the technician.
Patients were surveyed about their satisfaction with the remote assessment and assistance. Ophthalmologists were also surveyed about difficulties in the evaluation and level of satisfaction. Pictures were classified as adequate or not to evaluate for results and complications.
| Results | | |
Fifteen patients completed 6 months of postoperative follow-up. Two patients abandoned the postoperative follow-up, not attending the two first presidential appointments. Sociodemographic data and corrected distance VA are summarized in [Table 1]. There were no intraoperative complications in all cases.
Improvement in VA was significant in the most severe cases, showing the importance of surgical treatment for functional improvement.
All pictures from months 1, 3, and 6 were classified as adequate, allowing proper assessments of results and complications. The photographs made it possible to manage the postoperative and conclude there were no postoperative complications during the 6-month follow-up.
Concerning the remote monitoring of the postoperative period, all patients reported satisfaction with the performed evaluation and considered that all their doubts and expectations were met. Physicians also did not find any difficulties in postoperative management, which could be compared to that performed in person. No patient needed to be referred for face-to-face evaluation.
[Figure 1] shows the anterior segment photograph obtained by trained technicians after the 6th month of surgery, presenting the possibility of accurate analysis. | Figure 1: Intraoperative (a) photograph and 6-month postoperative report (b) of patient 11
Click here to view |
| Discussion | | |
Brazil has a vast territory in the intertropical region and high exposure to UV radiation. Pterygium is a prevalent condition, affecting about 9.4% of the general population.[4] Notably, in the Amazon region, the prevalence of pterygium is 58.7%. It represents a significant cause of visual impairment (best-corrected VA with correction <20/63) and blindness (best-corrected VA <20/200), with rates of 14.3% and 3.9%, respectively,[2] which highlights the impact that this pathology can have on visual health and quality of life.
Pterygium surgery postoperative monitoring through teleophthalmology was successfully obtained in this small group of patients from the Brazilian southern Amazon. These findings corroborate the usefulness of teleophthalmology that has been described in the follow-up of patients undergoing cataract,[5],[6],[7],[8] glaucoma,[6] refractive surgery;[7] corneal transplantation[9] and strabismus correction,[5] with good acceptance by both the attending physicians and patients. Furthermore, due to less time consumption and convenience of seeking consultation, it has improved compliance for follow-up.[10]
Teleconsultation for pterygium diagnosis has been successfully reported in India.[11] However, postoperative follow-up care to pterygium surgery through teleconsultation has not been reported. As it involves capturing images from the corneal and conjunctival surface, which is relatively trouble free due to its simple visual access, cameras provide excellent still images for store-and-forward consultation.[7]
The definitive pterygium treatment is surgical and, to ensure quality care, the follow-up to pterygium surgery requires programed visits over months. However, scant ophthalmic expertise is available in the Amazon region, as well as in several nonurban areas around the world. In Rondônia, where the study was conducted, there is one ophthalmologist per 31,422 inhabitants, and only 14% of the cities in the state had ophthalmologists in 2014, most of them attending private clinics and not available for most of the local population.[11]
The advent of teleophthalmology has made it possible to bring quality ophthalmic care to patients in hard-to-reach areas. Most studies indicate it is a valid, reliable, and cost-efficient method.[5],[12],[13] By this method, many patients' eye-related problems can be investigated, monitored, and treated, even though the physician and patient are located in different geographical areas.[14] Therefore, it may be helpful for patients who would otherwise not have access to an eye care professional, to be screened and treated earlier to prevent permanent visual complications.[10] Teleophthalmology also may avoid unnecessary travel and expense for patients, their families, and caregivers.[6],[10],[14],[15]
It is essential to highlight that this type of care has limitations, like the intraocular pressure measurement. However, this problem can be addressed with devices such as noncontact tonometers. Another limitation of our study was the small sample size. A possibility for future research for the late postoperative period of pterygium surgery in remote locations would be capturing images by the patient or companion through a smartphone and adequate training. This could further expand access to eye care, as smartphones with cameras are now widely available.
| Conclusion | | |
Teleophthalmology could represent an alternative to support the postoperative evaluation of pterygium surgery in areas without the availability of an ophthalmologist, making it possible to address better one of the leading causes of blindness in the Amazon.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Romano V, Cruciani M, Conti L, Fontana L. Fibrin glue versus sutures for conjunctival autografting in primary pterygium surgery. Cochrane Database Syst Rev 2016;12:CD011308. |
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| 10. | Sharma M, Jain N, Ranganathan S, Sharma N, Honavar SG, Sharma N, et al. Tele-ophthalmology: Need of the hour. Indian J Ophthalmol 2020;68:1328-38. [ PUBMED] [Full text] |
| 11. | Misra N, Khanna RC, Mettla AL, Marmamula S, Rathi VM, Das AV. Role of teleophthalmology to manage anterior segment conditions in vision centres of south India: EyeSmart study-I. Indian J Ophthalmol 2020;68:362-7. [ PUBMED] [Full text] |
| 12. | Bursell SE, Brazionis L, Jenkins A. Telemedicine and ocular health in diabetes mellitus. Clin Exp Optom 2012;95:311-27. |
| 13. | Labiris G, Panagiotopoulou EK, Kozobolis VP. A systematic review of teleophthalmological studies in Europe. Int J Ophthalmol 2018;11:314-25. |
| 14. | Kumar S, Yogesan K. Introduction to teleophthalmology. In: Yogesan K, Kumar S, Goldschmidt L, Cuadros J (eds). Teleophthalmology, 1 st ed. Berlin, Heidelberg: Springer-Verlag; 2006. |
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[Figure 1]
[Table 1]
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