Teleophthalmology in Retinal Diseases

Abstract

Recent advancements in teleophthalmology have transformed retinal disease management, benefiting healthcare providers and patients. By enabling remote monitoring, teleophthalmology significantly reduces the need for in-person consultations. Easy-to-use devices like at-home Optical Coherence Tomography (OCT) systems empower patients to generate high-quality images crucial for tailored treatment. Artificial intelligence (AI) aids in quick, affordable screenings by analysing fundus photographs and OCT images. These innovations underscore teleophthalmology’s pivotal role in streamlining patient care and optimising healthcare resources. Legal, ethical, and logistical considerations surrounding teleophthalmology, drawn from literature and experiences at Bristol Eye Hospital, are also discussed.

1. Introduction

Teleophthalmology leverages electronic communication technologies to exchange medical information across various locations, enhancing patient eye health. This field encompasses multiple methods of eye care, including real-time virtual consultations with eye specialists and the store-and-forward model, where digital ocular images are acquired and sent to remote specialists for analysis, remote monitoring and care planning.

Several key factors drive the rapid growth of teleophthalmology in retinal diseases. Firstly, there’s a significant increase in the worldwide incidence of conditions like age-related macular degeneration (AMD) and diabetic retinopathy (DR), with estimates suggesting AMD could impact nearly 300 million people by 2040 [1]. Secondly, a large portion of these individuals are elderly, often from low socioeconomic backgrounds and living in rural areas, highlighting the urgent need to make healthcare more accessible to these groups [2]. Thirdly, as the prevalence of these conditions rises, clinicians’ production needs to catch up with the demand for patient care. This gap necessitates alternative methods to deliver care efficiently.

The diagnosis and monitoring of retinal disorders heavily depend on imaging technologies. Fundus photography and optical coherence tomography (OCT) now enable capturing high-quality retinal images. Teleophthalmology allows for analysing these images outside traditional clinic settings, providing a solution for people who face barriers to accessing care, such as financial limitations, travel restrictions, or logistical issues. This method ensures broader access to specialised retina care, eliminating the need for extensive travel. However, several other critical factors need to be considered.

2. Technological foundations of teleophthalmology

2.1 Key technologies enabling teleophthalmology

The evolution of imaging devices and data transmission has significantly enhanced the efficiency and outreach of teleophthalmology. From its early days in the 1970s, utilising telephones and televisions, initially perceived as “cumbersome” with technical challenges, teleophthalmology has significantly progressed [3].

2.1.1 Digital communication tools

Teleophthalmology communication involves data acquisition, transfer, and reception by retina professionals (Figure 1). Advances in these three fundamental areas enable the success of teleophthalmology services.

Figure 1.

Flow diagram showing the various stages of teleophthalmology.

Effective and efficient communication is vital to the success of teleophthalmology programs, especially in clinics that manage a large volume of patients and need to transmit high-quality images quickly. The introduction of 5th generation (5G) wireless communication technologies has led to significant advancements in this area. 5G offers low latency, increased capacity, and quicker data transmission compared to the older 4G technology, making it ideal for supporting the demands of modern telemedicine. However, while 5G performs exceptionally well in urban settings where base stations can be placed approximately 250 meters apart, its effectiveness diminishes in rural areas, where different data transmission methods may be necessary. In addition to quickly transferring high-resolution images, 5G technology facilitates multimedia streaming. This capability enhances teleophthalmology by supporting remote consultations and allowing for real-time examinations using a slit lamp.

2.1.2 Retinal imaging and diagnostics advances

The first recorded photograph of the human retina was taken in 1886. The landscape changed dramatically with the introduction of scanning laser ophthalmoscopy (SLO) in 1981 and OCT in 1991 [4]. These innovations heralded a new era in eye care, characterised by rapid advancements and a shift from gradual improvements to a fast-paced evolution in diagnostic capabilities.

This shift was not just about the technology itself but also how it transformed our understanding and treatment of eye conditions. With these new tools, doctors gained a more nuanced view of the retina, enabling them to diagnose and treat eye diseases with unprecedented precision.

2.1.3 Fundus photography

Traditionally, mydriatic drops were indispensable for accurate retinal fundus imaging, but the advent of non-mydriatic cameras eliminated the need for such drops, sparing patients from temporary vision impairment. Utilising non-mydriatic cameras in fundus visualisation, particularly in diabetic eye screening programmes, has demonstrated notable benefits [5]. The application of this imaging modality is also associated with the advantages of remote monitoring, a crucial element in facilitating teleophthalmology [6].

2.1.4 Scanning laser ophthalmoscopy

SLO generates images through low-powered laser light penetrating the retina in a confocal raster technique. The resulting images of the retina and optic nerve head surpass the quality of standard fundus photography, with notable benefits observed, especially in patients with cataracts [7].

Based on SLO, the Optos or optomap® ultra-widefield (UWF™) (Optos Plc) imaging system captures ultrawide retinal images covering up to 82% of the retina [8]. This system incorporates non-invasive fundus autofluorescence (FAF) retinal images and invasive retinal images like fundus fluorescein angiography and indocyanine green (ICG) angiography.

2.1.5 Optical coherence tomography

OCT is a non-invasive imaging method providing high-resolution cross-sectional retinal images that unveil the retinal internal microstructure. It offers a detailed view of the retina’s intricate structure, aiding in anatomical assessment, identifying disease-related abnormalities, and monitoring disease progression. OCT, combined with clinical findings and other imaging modalities, exhibits high sensitivities and specificities in diagnosing retinal pathologies [9].

OCT angiography has also emerged as a non-invasive technique for imaging the retina and choroid microvasculature. The first clinical studies using this innovative technology were published in 2014 [10]. Barriers to accessibility, such as physical accessibility, limited funding, and scarce resources, have sparked interest in remote monitoring OCT devices, showing promising potential.

3. Integration of artificial intelligence and robotics for teleophthalmology in retinal diseases

3.1 Artificial intelligence (AI)

In the evolving landscape of ophthalmology, integrating AI and deep learning (DL) technologies has opened new frontiers in diagnosing and treating retinal diseases. Initially, the medical community was sceptical about AI’s diagnostic capabilities compared to the seasoned eye of trained clinicians. Yet, through rigorous trials and research, AI has demonstrated significant promise in enhancing retinal diagnosis accuracy and efficiency. A notable milestone was the Iowa Detection Program in 2013, which marked a breakthrough in diagnosing DR through retinal imaging [11].

Subsequent studies, such as the work by Abramoff et al. in 2016, further cemented AI’s role by showcasing DL’s high sensitivity and specificity in detecting DR through colour fundus photography [12]. This advancement underscored the potential of AI in ophthalmology and highlighted its capability to prevent blindness through early and accurate detection.

DL has since become the method of choice for developing algorithms that significantly improve the analysis of retinal images. However, despite these advancements, challenges still need to be addressed, including research gaps and the need for improved diagnostic accuracy by integrating AI with traditional imaging methods [13]. Moreover, deploying AI in retinal diagnosis faces practical challenges in rural settings, where poor image quality can hamper diagnostic performance.

3.2 Robotics

Parallel to the advancements in AI, robotic devices have been making remarkable progress in ophthalmology [14]. The primary focus of robotics in ophthalmology has been on complex and intricate procedures such as retinal interventions and cataract procedures [15]. Robotic systems, equipped with advanced imaging technologies and microsurgical instruments, enable surgeons to perform highly precise manoeuvres with enhanced dexterity and control. This level of precision is particularly crucial in procedures involving delicate eye structures. Cybersurgery, the concept of remote surgical intervention, has yet to be established in ophthalmology, as the issue of transmitting tactile information across low latency networks (ideally <200 ms) using haptic feedback systems must be solved [16]. Robot-assisted technology is being studied in intravitreal injections for patients with retinal pathologies with greater efficiency [17]. Despite the technological strides, patient receptiveness to robotic interventions, particularly in procedures like intravitreal injections, varies, with several factors influencing their willingness to embrace such innovations [18].

4. Teleophthalmology in retinal diseases: case studies

4.1 The case of diabetic retinopathy

Teleophthalmology is the backbone of multiple nationally and regionally implemented retinal screening initiatives, such as screening for DR in the United Kingdom (UK), Singapore, and India. DR screening initiatives are designed to achieve early identification and treatment of patients with potentially vision-threatening diseases, thereby mitigating the risk of sight loss.

4.1.1 United Kingdom

In the UK, the overarching body responsible for coordinating DR screening programs is the National Screening Committee. England, Wales, Scotland and Northern Ireland each have their local committee overseeing the screening efforts. Each program may have minor variations in its approach, but they share a standard core structure.

The process begins with mydriatic colour fundus photographs, which are then analysed by specialist graders, ranging from non-clinical technicians and optometrists to nurses, all trained in DR screening and supported by a supervising medical retina specialist. Outcomes are communicated to relevant services, leading to referrals for further investigations if necessary. Individuals with no identifiable retinopathy are informed via their general practitioners (GPs). Following the screening, patients may undergo additional diagnostic workup, accelerated surveillance, or continue on the current surveillance program [19]. Each local service is responsible for monitoring and enhancing its screening programme, and quality control regulations ensure high-quality care nationwide. Annual reports compile data on factors such as the number of patients invited to screening, the uptake of screening invites, referrals made, and outcomes [20].

The patient uptake of the DR screening programme is slowly increasing, with 78.3% national uptake in 2021/22. This shows increasing confidence in this new form of healthcare delivery; however, the rates are still lower than expected [21]. Multiple studies have identified patient and non-patient-related barriers, including competing priorities, screening anxiety, poor glycaemic control, misinformation, incorrect address, unavailability of clinical notes and forgetting appointments [22].

To bridge this gap, there are ongoing projects to improve patient education, address barriers, and enhance service outreach. Initiatives include optimising care for low-risk people, such as changing screening intervals from 1 to 2 years, depending on the outcome of consecutive screen results [23]. The national health service (NHS) diabetic eye screening program has carried out work to assess the use of AI systems in grading DR photographs, which has identified programs such as Retmarker and EyeArt as having acceptable sensitivity for referable retinopathy, false-positive rates, compared to human graders, and was cost-effective [24].

Telescreening for DR in the remote setting allows for retinal image grading, treatment decisions, and surveillance, with or without the assistance of AI, overcoming limitations associated with the availability of retinal graders on a global scale [25]. Other countries that have employed telehealth in DR screening include a few noteworthy instances, which are detailed below.

4.1.2 Singapore

In Singapore, 17% of individuals with DR exhibit sight-threatening DR (STDR) [26]. The Singapore Integrated DR Program, the national telemedicine DR screening initiative launched in 2010, screens nearly 200,000 diabetic patients annually using colour fundus photographs. These images are captured at 18 sites, transmitted through networks, and analysed by trained graders. Outcomes are communicated to clinics, with 90% receiving results within an hour of grading and 100% on the same day. The potential cost savings of this telemedicine program in Singapore are estimated to be 21.6 million dollars annually. Ongoing efforts are underway to integrate AI and DL into their DR systems [27].

4.1.3 India

In India, 3.6% of individuals with DR have STDR [28]. Due to the absence of recent studies on DR prevalence in India, obtaining up-to-date statistics for guiding screening and treatment programs takes a lot of work. Rural populations in India face limitations in accessing screening centres, prompting a shift towards the preferred remote monitoring and screening method. Despite challenges, many individuals in these areas have network connections and mobile phones. Smartphone-based imaging devices, such as the Remidio Fundus on Phone (FOP) camera, have demonstrated comparable capabilities to produce colour fundus photographs accurately compared to standard mydriatic fundus cameras [29]. In 2017, 16,226 individuals with diabetes underwent screening using the Remidio FOP camera, with 7% referred for further diagnostic workup and offered treatment [29].

4.1.4 China

China is actively working to develop effective strategies for detecting and managing DR. A study conducted by Nanchang First Hospital used the remote medical platform “Eye Grader” to store and transfer photos taken and uploaded by trained technicians and analysed in a grading centre. In 2022, when compared to ophthalmologist grading, GPs demonstrated a sensitivity of 93.99%, a specificity of 88.97%, and an overall accuracy of 92.86%. Suspected cases identified by GPs were subsequently referred for further diagnostic workup [30]. The high accuracy of this program shows the immense potential of teleophthalmology. However, it relies on the advanced telecommunication capabilities present in China.

4.1.5 Kenya

A prospective regional telemedicine screening program was conducted by nursing staff in Nairobi, Kenya, with local ophthalmologists reviewing the images. Implementation challenges included insufficient numbers and uneven distribution of ophthalmologists, low literacy levels among the population, limited medical insurance coverage, transportation and communication difficulties, and medication shortages. Despite these obstacles, patients expressed satisfaction with the program, particularly appreciating the information provided and the convenience of clinic attendance. However, accessibility emerged as the primary limiting factor, raising concerns about feasibility. Without sustainable and accessible means of attendance, specific populations may not receive adequate care [31].

4.1.6 Iran

A study analysed the implementation of the Iranian Retinopathy Teleophthalmology Screening (IRTOS) program. This secure web-based program used the local language and was adopted for patient use. Trained GPs interpreted colour fundus photographs, with subsequent referral and review by the specialist. DR recognition by GPs had a sensitivity and a specificity of 82.8% and 86.2% , respectively. Follow-up was an essential aspect of this program, which found that a text message-based communication update improved adherence to management plans, including urgent follow-up [32].

4.2 The case of retinopathy of prematurity

Retinopathy of Prematurity (ROP) is preventable and may lead to visual impairment or blindness if not promptly identified and treated. Preterm infants, especially those with low gestational age and birth weight, are at the highest risk. Approximately 60% of infants weighing less than 1500 g develop ROP. While most cases of ROP do not progress beyond mild stages that do not require treatment, 4% of screened infants require treatment [33]. Screening methods include binocular indirect ophthalmoscopy (BIO) and wide-field digital retinal imaging (WFDRI) [34].

BIO, the gold standard for ROP screening, requires an in-person examination by an experienced ophthalmologist. Telescreening programmes for ROP rely on WFDRI, which a trained individual can take. Images obtained through telescreening can be remotely analysed by human graders or AI, with studies in China providing evidence of its benefits [35]. Remote analysis of images addresses the decreasing availability of BIO screeners due to liability claims and poor reimbursement [36]. During the COVID-19 pandemic, telescreening for ROP proved effective, safe, and feasible compared to in-clinic screening and analysis [37]. Children identified through telescreening were then brought in for further evaluation using BIO.

Teleophthalmology in ROP has demonstrated long-term time and cost-effectiveness [38]. Its objective documentation ensures transferability, facilitates second opinions, supports education, and contributes to research work [39]. An example of a successful screening programme is seen in the San Francisco Bay Area. Dr. Moshfeghi developed the ROP screening programme, the Stanford University Network for Diagnosis of Retinopathy of Prematurity. Established in 2005 to address a shortage of graders and ROP specialists, the program served two local Neonatal Intensive Care Units (NICUs) and expanded to six NICUs. Utilising telescreening, trained nurses captured wide-angle retinal photographs, which were securely transferred via email or courier for remote interpretation by an ROP specialist at the Stanford University Byers Eye Institute reading centre. Outcomes were confirmed, and families were promptly informed of the results, with outpatient ophthalmology follow-up or BIO offered within 24 hours. Results were also compared to the gold standard of BIO assessment by a paediatric ophthalmologist within 1 week of discharge from the hospital. The telemedicine approach for detecting ROP requiring treatment demonstrated a sensitivity of 100%, specificity of 99.8%, a positive predictive value of 93.8%, and a negative predictive value of 100%, establishing it as a valuable tool in ROP screening [40].

4.3 The case of choroidal naevi

Integrating teleophthalmology into the management of choroidal naevi presents a promising advancement in patient care. Research by Lamis Al Harby et al. on a virtual clinic pathway for choroidal naevi management, the NAEVUS study, demonstrated an 83.1% agreement in management decisions between virtual and traditional face-to-face consultations, highlighting the safety and efficiency of telehealth services [41]. However, the study noted an increased rate of over-referrals in virtual pathways, suggesting the need for optimisations in cost-effectiveness. Similarly, Kelsey Roelofs and Ezekiel Weis found that teleophthalmology offers a highly reliable method for detecting naevus growth, with a remarkable sensitivity and specificity of 100 and 99%, respectively, compared to in-person evaluations [42]. Together, these findings underscore the potential of teleophthalmology and teleoncology in enhancing access to care, reducing the need for physical visits, and efficiently managing choroidal naevi with high accuracy and safety.

5. Teleophthalmology at University Hospitals of Bristol and Weston’s (UHBW): our experience

In 2017, Bristol Eye Hospital, part of the University Hospitals of Bristol and Weston, introduced teleophthalmology. The advent of the COVID-19 pandemic significantly increased its usage due to heightened demand. To manage this surge and ensure social distancing, BEH expanded its services to a separate site in February 2021, establishing virtual clinics outside its primary location. Initially, these clinics operated from the Nightingale Hospital, a facility adapted for the COVID-19 response, serving patients with retina and glaucoma issues through virtual healthcare.

The diagnostic hub for these services has since relocated twice, now finding its current home in The Galleries shopping centre, located in the heart of Bristol city centre. The diagnostic hub is equipped with appropriate equipment for measuring and capturing patients’ ocular findings, including Early Treatment Diabetic Retinopathy Screening (ETDRS) visual acuity (VA) charts, intraocular pressure check with iCare rebound tonometer, Humphrey visual fields machines for glaucoma patients and retinal imaging using spectral domain OCT (Triton, Topcon Corp) and Optos or optomap® ultra-widefield (UWF™) (Optos Plc).

The diagnostic hub operates with the support of nurses, technicians, and imaging staff responsible for recording patient data and capturing medical images. All collected information is digitally uploaded to an electronic patient record and imaging system for future analysis. These teleophthalmology services are asynchronous, meaning data and images are not assessed in real-time. Initially, a trained optometrist specialising in medical retina examines the data and images. If issues are detected, the case is escalated, and the patient is scheduled for a teleconsultation with a consultant ophthalmologist. During this consultation, conducted over the phone, the ophthalmologist discusses the results of the virtual examination and explores treatment options with the patient. Based on this discussion, patients may be directly scheduled for additional diagnostic tests, further review, or treatment, either in-person or virtual.

This healthcare model has significantly increased the unit’s capacity to see patients promptly. Despite relocating twice in the last 3 years, the diagnostic hub has scheduled appointments for over 20,000 patients within the medical retina service [43]. In its initial year, 2021, the hub managed 4611 patient appointments, which grew to 6958 in 2022 and 8569 in 2023. An internal review of the data revealed that 70% of the patients treated at the virtual hub were dealing with diabetic eye conditions, such as non-proliferative DR and diabetic macular oedema, which had progressed beyond the criteria for the diabetic retina screening program. This includes moderate nonproliferative DR, characterised by signs like blot haemorrhages and intraretinal microvascular abnormalities; proliferative DR, marked by the growth of new blood vessels; and diabetic maculopathy. Other conditions treated included AMD, central serous chorioretinopathy, retinal vein occlusion, choroidal naevus, and retinal dystrophies. Of those assessed at the diagnostic hub, only 15% required a follow-up teleconsultation with a consultant ophthalmologist, and fewer than 1% needed an in-person appointment. The hub’s innovative approach earned it the “Innovation and Improvement” award at the Recognising Success 2023 event. Looking ahead, the plan is to leverage this virtual diagnostic hub and telemedicine further to maintain a patient-centred approach, ensuring that patients receive care from the appropriate provider at the right time and in the most suitable location.

Additionally, with the upcoming integration of shared care imaging systems between primary care opticians and tertiary centres, the role of telehealth at BEH, especially for retinal diseases, is set to expand even more.

6. Teleophthalmology and remote monitoring

The COVID-19 pandemic has highlighted the importance and potential of using digital technologies, such as smartphones and tablets, for remote monitoring [44]. While home monitoring for VA is well-developed, with many applications available, using OCT for home monitoring is rare [45]. An example of innovation in this area is the Notal Vision Home OCT device, which can capture high-quality OCT images. This device is crucial in identifying fluid accumulation in the retina, a critical indicator for retinal diseases that significantly influence treatment decisions [46]. The AI analysis of these home-based OCT scans has been shown to match the accuracy of human graders in 96% of cases, particularly in monitoring neovascular AMD, showcasing the potential of at-home monitoring systems [47].

However, the cost of these self-monitoring devices remains a significant barrier to their widespread adoption [48]. Despite this, they offer a valuable solution for improving access to care, especially for older individuals who may face difficulties with mobility and travel. Sight-threatening conditions like AMD and diabetic macular oedema depend heavily on regular OCT imaging for early detection, initiation of treatment, and ongoing monitoring. This requirement can place a substantial burden on patients, caregivers, and healthcare resources [49]. Implementing remote monitoring for these patients appears promising in reducing the frequency of visits not requiring treatment and facilitating personalised treatment plans [50]. Efforts are ongoing among researchers and companies to enhance the technology’s affordability for broader use. For instance, Siloton Ltd. has developed a photonic chip named Akepa for OCT devices, which is small, durable, cost-effective, and suitable for mass production, aiming to make portable OCT machines more affordable [51].

Mobile applications (apps) have seen practical success in AMD patient monitoring [52]. Apps like Alleye and Okkohealth provide clinicians with timely alerts [53]. A particular study highlighted the effectiveness of the Alleye app, which uses threshold-based alerts for VA to signal worsening conditions reliably. These alerts can hasten the consideration for anti-vascular endothelial growth factor (anti-VEGF) treatments, underlining the critical role of thorough monitoring in preventing disease progression [50].

7. Teleophthalmology in patients’ consultation and education

7.1 Virtual consultations: methods and best practices

As technology advances, there is a growing push for healthcare services that are both accessible and efficient. Healthcare professionals are advised to consider the appropriateness of virtual consultations for each patient individually. This decision should consider the patient’s preferences, the specific health issue, and whether the necessary resources for a virtual consultation are available.

Video consultations have proven to be particularly timesaving for routine monitoring and check-ups, especially in the field of medical retina. This efficiency, however, hinges on several factors, including the patient’s ability to use digital tools, their technical expertise, and their capacity to solve technical problems. Setting up a digital environment for a consultation, navigating the internet, and effectively using technology requires skills that not everyone possesses. As a result, older adults and those not tech-savvy may need help accessing the healthcare services they need in the UK [54].

In the UK, the General Medical Council (GMC), which oversees doctors, has recognised the increasing importance of telemedicine by updating its professional standards [55]. It offers detailed guidance for clinicians on when and how to conduct remote consultations, emphasising the importance of patient consent and ensuring continuity of care, particularly in primary healthcare settings. The GMC’s guidelines on good medical practice and the Royal College of General Practitioners’ recommendations published at the onset of the COVID-19 pandemic address these critical issues [56]. They also stress the significance of both verbal and nonverbal communication during video consultations. Once patients have agreed, a guide helps both clinicians and patients prepare for video consultation appointments or follow-ups [57].

In 2021–2022, ophthalmology had the highest clinic attendance rate across all specialties in the UK, leading to the adoption of telemedicine to improve referral processes. Moorfield’s Eye Hospital’s implementation of a virtual clinic for medical retina, as outlined by the Royal College of Ophthalmologists, UK, was analysed and found to be effective and safe, meeting high clinical standards [58].

With telemedicine becoming more common in ophthalmology, training in telemedicine is increasingly recognised as essential for expanding service delivery to various patient groups. However, while the UK has yet to formally incorporate telemedicine training for its trainees, ophthalmology residency programs in the United States (US) have successfully integrated such initiatives. This training covers remote patient history collection, ophthalmic examinations, logistical setup, and documentation practices. Notably, it has boosted clinicians’ confidence in performing telemedicine consultations [59].

7.2 Effective virtual consultations

Effective verbal and non-verbal communication plays a crucial role in the success of remote healthcare delivery. This is especially true for patients with visual impairments, such as those treated in the medical retina speciality, where clear verbal communication and resolving connectivity issues are vital for effective telemedicine [60].

The successful incorporation of telemedicine into daily clinical operations requires the cooperative efforts of doctors, technicians, and allied health staff [61]. Teleophthalmology encounters several obstacles to effective communication, including vague goals for consultations, poor internet connectivity, and challenges in verbal and non-verbal interactions during video consultations. Tackling these issues calls for government and healthcare organisations to invest in better internet infrastructure. Setting up dedicated communication hubs with reliable internet could serve as a viable remedy, echoing the setup of internet cafes.

Enhancing video consultation communication involves positioning the positioning the patient close to the webcam to improve visual interaction and stressing the importance of verbalising emotions to compensate for the absence of in-person cues. Issues like technical difficulties and unfamiliarity with the telemedicine platform can cause confusion and delays. Providing easy-to-follow troubleshooting guides and ensuring access to technical support through expert tech support teams or training administrative personnel can alleviate these concerns [61].

For conditions like retinal diseases, which often result in varying degrees of visual impairment, the significance of verbal communication is even more pronounced. Hosting seminars and workshops to improve communication with visually impaired patients can bolster healthcare professionals’ effectiveness in remote consultations. By systematically addressing communication hurdles, telemedicine can become a more reliable and efficient means of providing healthcare remotely.

7.3 Patient education through telemedicine platforms

Patient education through telemedicine platforms has emerged as a crucial element in modern healthcare delivery, facilitating effective communication and information dissemination between healthcare providers and patients. This approach provides patients access to valuable information, fostering a collaborative approach to managing retinal disorders and promoting better outcomes through shared knowledge and understanding.

Lifestyle adaptations are crucial in managing ophthalmology pathologies, including diseases like DR and AMD [62]. A study in the American Journal of Lifestyle Medicine explored the use of telemedicine and various multimedia formats to improve patient engagement, which is vital in enhancing health outcomes [63]. Despite limited research on health outcomes and patient education using telemedicine, a growing body of evidence highlights the benefits of digital health technologies in improving lifestyle medicine. Tools such as wearable monitoring devices and smartphone applications could be utilised in conjunction with video consultations to educate patients about the reality of their condition and how lifestyle changes can improve their overall well-being.

8. Clinical outcomes, patients’ satisfaction and cost-effectiveness of telemedicine in retinal diseases

8.1 Clinical outcomes between traditional and telemedicine approaches

Studies on telemedicine are essential for understanding its effectiveness in remote healthcare delivery, focusing on important metrics such as treatment eligibility, missed diagnosis rates, and clinic attendance. Significant research in this field includes work on DR and ROP [64].

The Tribal Vision Project in the US revealed that telemedicine screenings increased the likelihood of patients getting screened for DR without any noticeable difference in DR progression compared to traditional screenings [65]. In the UK, telemedicine has significantly lowered DR rates, changing the leading cause of blindness in the working-age population as of 2021 [66]. Lorenz et al. found that telemedicine using WFDRI over 6 years effectively reduced vision loss secondary to ROP [67].

Further, telemedicine has been shown to decrease unnecessary specialist referrals, saving substantial resources [68]. A study at Moorfields Eye Hospital demonstrated that telemedicine could reduce wait times for routine clinic referrals without compromising patient safety, highlighting the efficiency of virtual clinics over traditional face-to-face ones [69].

However, the success of telemedicine heavily relies on the availability of trained diagnosticians, pointing to a workforce shortage [70]. These findings suggest that healthcare providers and policymakers could benefit from integrating traditional and telemedicine practices more effectively, although more research is needed for direct clinical outcome comparisons [71]. Mobile health apps for monitoring chronic conditions like AMD and DR have also emerged as supportive tools, enabling patient engagement and providing a cost-effective monitoring solution. Despite the potential benefits, the clinical effectiveness of these apps varies, with limitations in follow-up duration and the need for real-world studies restricting their adjunctive use in telemedicine-based care.

8.2 Clinician satisfaction

During the COVID-19 pandemic, the adoption of teleophthalmology saw mixed satisfaction levels among clinicians, influenced by their subspecialty and the volume of video consultations. Retina specialists reported the highest satisfaction, although challenges such as inadequate equipment and technical issues were common concerns [72].

8.3 Patient satisfaction and adherence in telemedicine

Evaluating patient satisfaction and treatment adherence has become vital in determining the effectiveness and viability of telemedicine in ophthalmology, especially following the COVID-19 pandemic. There’s been a noticeable trend toward patients preferring telephone consultations over traditional in-person visits [73]. By incorporating various tools such as multimodal imaging, video consultations, and home monitoring devices, healthcare providers can strengthen their clinical decision-making processes, thereby earning patient trust and boosting satisfaction levels.

Telemedicine has proven effective in breaking down geographical barriers and reducing travel inconvenience for patients, leading to higher satisfaction levels. Surveys have indicated that patient satisfaction with telemedicine services in eye care falls between 80 and 99% [74]. A specific study from Saudi Arabia highlighted that the primary cause of patient dissatisfaction was concerns about the timeliness of being assessed by an ophthalmologist following a screening test that suggested a need for referral [75]. Addressing this concern requires a well-structured referral system supported by efficient IT infrastructure to maintain high-quality patient care. Furthermore, introducing AI tools like chatbots can significantly enhance the patient experience. Chatbots can provide essential information on eye health, explain common eye procedures and treatments, and guide patients through pre-and post-operative care. This innovative approach in telemedicine encourages patients to play an active role in managing their eye health, thereby improving their adherence to treatment plans [76].

8.4 Cost-effectiveness and resource utilisation

The optimisation of cost-effectiveness and resource utilisation in teleophthalmology has become a focal point in healthcare systems striving to deliver efficient and high-quality care. In rural settings, establishing teleophthalmology centres emerges as a cost-effective solution, as the early diagnosis of undiagnosed pathologies can alleviate the substantial burden on patient care. This approach prevents additional travel, treatment, and post-operative monitoring costs [77]. Conversely, in densely populated areas with extensive DR programs, handheld portable non-mydriatic fundus cameras are viable and cost-effective alternatives [6]. However, it is essential to note that such technology may not be readily available in regions with lower economic status.

In the US, costs of assessment in the retinal diagnosis of DR were cheaper using telemedicine-based digital retinal imaging compared to conventional fundus examination [78]. The research found that telemedicine interventions led to notable cost savings by reducing the number of in-person visits and associated travel expenses for patients. Moreover, the study highlighted the efficient utilisation of healthcare resources, demonstrating that telemedicine allowed for a more streamlined allocation of specialist time and expertise [79].

An article examined resource utilisation in teleophthalmology clinics for medical retina conditions. The findings indicated that the virtual model allowed for more efficient scheduling and reduced waiting times, optimising the utilisation of clinical and administrative resources. This study underscores the cost-effectiveness and resource-efficient nature of telemedicine in medical retina within the UK, providing valuable insights for healthcare policymakers and practitioners seeking to implement and enhance teleophthalmology services [80].

To harness the full potential of telemedicine on a larger scale, increased government funding for screening programmes is essential. These programs aim to identify patients with early-stage DR and AMD [78]. Telemedicine is pivotal in facilitating early detection and timely intervention, ultimately preventing complications and reducing the overall economic burden associated with advanced sight-threatening eye disease and sight loss.

9. Legal, ethical, and regulatory considerations around telemedicine in medical retina

As with any transformative technology, teleophthalmology operates within a web of legal frameworks, ethical norms, and regulatory considerations that must be navigated with diligence. Considering the scope of this chapter, this section will discuss some of the critical considerations in this regard.

9.1 Legal considerations

9.1.1 Information security and data privacy considerations

At the forefront of legal considerations is the adherence to information security and data privacy standards to ensure that telemedicine infrastructures provide an environment for safe and effective care delivery. Telemedicine services encompass transferring patient health information via text, sound, images, and other data formats to aid in disease prevention, diagnosis and management. Where teleophthalmology is integrated in medical retina, this information generally includes detailed retinal images, patient-specific VA data, intraocular pressure readings, OCT scans, and patient-reported outcomes. Additionally, it may involve the transmission of electronic health records, medication history and laboratory test results pertinent to the patient’s ocular health. From a data privacy perspective, such information is highly sensitive, revealing detailed personal health details, potential genetic predispositions, specific medical conditions, and personal identifiers. Introducing AI, big data, and advanced analytics tools into healthcare has further heightened this sensitivity. These technologies can aggregate and analyse vast amounts of data from diverse sources, uncovering previously inaccessible insights [81, 82]. This capacity amplifies the potential for personalised medicine and raises significant privacy concerns as it could inadvertently reveal even more intimate and detailed aspects of an individual’s health status and predispositions [83, 84, 85, 86]. As a consequence, the processing of such information requires robust technical and organisational governance measures to ensure that its use is restricted to authorised personnel only and for the intended medical purposes. Such measures should align with legal standards, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, the General Data Protection Regulation (GDPR) in the European Union, and other relevant regional and international frameworks.

The GDPR constitutes the poster child of data privacy law, influencing data privacy regulation across the globe [87, 88]. It lays down rules for data subjects’ protection and the free movement of data within the EU. The GDPR is a principles-based regulation that sets out six fundamental principles for processing personal data: lawfulness, fairness and transparency, purpose limitation, data minimisation, accuracy, storage limitation, and integrity and confidentiality. In line with its lawfulness requirement, the GDPR furthermore outlines several grounds for lawful processing ¹, including consent and tasks carried out in the public interest, and it lays down the rights data subjects can rely on while balancing these against the obligation posed on organisations processing personal data.

As a first note, in the context of telemedicine delivery, healthcare providers should implement high standards of transparency, ensuring that patients are aware of the processing of their data where they are subjected to medical procedures involving telemedicine devices and applications. In practice, this involves clear communication about the types of data collected, the purposes for which it is used, the entities with whom it is shared, and the measures taken to protect patient privacy and data security. There are various ways in which this transparency can be achieved, including privacy notices and patient education initiatives. Patients should be informed about their rights regarding their data, including access, correction, and deletion rights, as well as how to exercise these rights. Additionally, healthcare providers must ensure that patients understand how their data contributes to their care, the benefits and risks of telemedicine, and any options to opt out or restrict certain uses of their data. With the advent of new regulations around AI, these obligations will be strengthened significantly, requiring healthcare providers to be transparent about their use of AI and, where the use of AI is not prohibited, to put measures in place to mitigate potential risks of such use.

Furthermore, the digital nature of telemedicine raises significant information security concerns. Protection against these threats to secure telemedicine platforms is complex and requires a multi-disciplinary, multi-stakeholder approach [89]. To protect sensitive patient information from unauthorised access and security threats, healthcare providers must implement robust technical and organisational information security measures. These include conducting regular risk assessments, enforcing robust data encryption methods, performing continuous security audits, and keeping software and protocols up to date. Regarding these requirements, the GDPR also emphasises accountability, ensuring that entities processing personal data are responsible for and able to demonstrate compliance with these principles.

Beyond the above-described foundational framework for data privacy protection, the GDPR contains several further provisions specifically about healthcare and health data, which—according to the GDPR—should be defined as “personal data related to the physical or mental health of a natural person, including the provision of health care services, which reveal information about his or her health status” ². In other words, health data encompasses information about an individual’s past, current, or future physical or mental health status. This includes data collected during registration for, or the provision of, health care services, unique identifiers for health purposes, test results from body parts or biological samples, and information about diseases, disabilities, disease risk, medical history, treatments, or physiological or biomedical state of the data subject obtained from healthcare professionals, hospitals, medical devices, or a medical device or an in vitro diagnostic test.

As a point of departure, the GDPR prohibits processing specific types of sensitive personal data, including health and genetic data. As such, health data enjoys enhanced protection as a ‘special category of personal data’ under the GDPR. However, this prohibition has several exceptions, some of which relate specifically to health data processing. Though conditioned by very high substantive and procedural requirements and subject to a certain level of discretion by Member States, where the data subject has given her ‘explicit consent’, the processing is, in principle, allowed ³. In addition, the processing of health data is permitted when necessary to protect the vital interests of the data subject or another person who is unable or legally incapable of giving consent ⁴. Under strict conditions, the GDPR also allows for the processing of health data where this is considered to be necessary for reasons of substantial public interest or other specific purposes, including preventive or occupational medicine, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services”.

Moreover, where sufficient safeguards are put in place, the GDPR permits the processing of health data for public health reasons, such as protecting against serious cross-border threats to health, without requiring the data subject’s consent ⁵. The relevance of these grounds for processing health data became particularly clear in recent years during the fight against the COVID-19 pandemic. Depending on the case and context, the processing of health data in light of telemedicine may be based on a variety of grounds for lawfulness.

Finally, the GDPR mandates a Data Protection Impact Assessment (DPIA) for high-risk processing activities, mapping potential risks and devising a strategy for mitigation ⁶. For instance, a DPIA is required when processing special categories of personal data on a large scale, among which health-related data. Consequently, the performance of a DPIA is typically necessary for handling health data, except when the data processing involves patients’ personal information managed directly by an individual doctor or another healthcare professional. Additionally, the GDPR mandates a DPIA in the case of automated decision-making or the systematic and extensive evaluation of personal aspects relating to a data subject based on automated processing, including profiling—which may include health data—, and based on which decisions are made that may affect them. Though the latter may be less relevant considering the current state-of-the-art telemedicine applications, its relevance may increase as we encounter advanced levels of autonomy.

9.1.2 Other considerations

Beyond data privacy considerations, a legal analysis of telemedicine integration in retinal disorders also requires considerations of various other aspects, including safety and liability. Traditionally, the concept of safety has been narrowly construed to refer primarily to hazards with direct physical effects on individuals, such as mechanical or chemical dangers. With the incorporation of advanced technologies into our direct surroundings, however, this perspective has shifted. Integrating digital technologies—both hardware and software—into the workflows across many different domains, including healthcare delivery, has led to heightened interconnectivity and an evolving landscape of human-robot interactions. This expansion challenges the traditional, limited view of safety, suggesting a need to broaden its definition to encompass a wider range of risks and implications in the era of advanced technology [90]. Beyond the physical dimension of safety, this also includes temporal, societal, cyber and social interaction dimensions [90]. This shift in perspective on the scope and meaning of safety is particularly relevant in the field of medical retina, where telemedicine introduces new dynamics in patient care. For instance, there are concerns about the accuracy and reliability of diagnostic algorithms, the security of patient data in transit, and the potential for delayed treatment due to technological failures or miscommunications. In this context, legal considerations must include the reliability and accuracy of telemedicine technologies, the responsibility for decisions made based on telemedicine consultations, and the protocols for data security and patient confidentiality.

Introducing advanced technologies into healthcare delivery, while beneficial, is not a straightforward process and presents new risks that are not associated with traditional medical procedures and instruments. Although there are numerous obvious advantages to continuously innovating in healthcare delivery, such as integrating telemedicine, its practical implementation reveals several shortcomings that could lead to harm in ways that might not be easily rectifiable or monitored by humans [91]. Liability issues arise when errors occur, whether due to technological malfunctions, misinterpretations of data by healthcare providers, or system security breaches. The virtual nature of patient interaction in telemedicine brings unique challenges in the attribution of liability and malpractice. In the complex healthcare technology ecosystem, where there is a significant interplay between humans and machines and a diverse array of stakeholders, pinpointing liability for specific harms becomes exceedingly difficult. This is especially true for risks that emerge from the combination of, and interactions among, components controlled by various entities, as opposed to issues arising from a single entity’s incompetence [92]. These factors pose a challenge to the innovation management, especially as the division of autonomy in technology-enabled healthcare delivery is shifting rapidly. Early examples of this can be found in robot-assisted surgery (RAS), where increasing levels of autonomy complicate the scene [93]. The same can be said for healthcare delivery through telehealth devices and applications, where liability attribution for the risks arising from the interplay between stakeholders remains unclear, and legal frameworks to address this issue comprehensively are currently lacking.

9.2 Ethical considerations

Teleophthalmology must align with the medical ethics requirements of maintaining high standards of patient care, ensuring patients’ overall well-being, and respecting their fundamental human rights [94]. Beyond complying with the four key pillars of medical ethics—autonomy, justice, beneficence, and non-maleficence—, this also includes considering privacy and confidentiality, accessibility to care, disclosure of medical errors, and expectations around informed consent.

Regarding the latter, informed consent has gained renewed significance in the digital age, where patients are increasingly pushed toward ‘participation’, requiring them to ‘consume’ information and produce data–also referred to as ‘prosumption’ [95]. In traditional healthcare settings, obtaining informed consent involves detailed discussions between patients and healthcare providers [96]. However, the digital landscape introduces unique challenges. In this context, transparent communication becomes paramount as patients interact with healthcare professionals virtually, necessitating a clear understanding of telemedicine’s implications, risks, and benefits in care delivery [97]. In the subspecialty of medical retinal care, informed consent in the digital age is crucial. Teleophthalmology requires explicit consent from patients to ensure they comprehend the virtual nature of consultations and the potential eye health implications of telehealth devices and applications. With advancements in imaging and remote monitoring devices, patients must be informed about the data collection methods deployed and the impact of their use on the care they receive. This also safeguards patient autonomy, establishing a stronger trust foundation between patient and provider.

Furthermore, the principle of justice in the context of telemedicine underscores the importance of equitable access to healthcare services. Telemedicine has the potential to bridge gaps in healthcare delivery, especially for patients in remote or underserved areas. Ethically, it is vital to address disparities in access to telemedicine services, ensuring that all patients, regardless of their geographical location or socioeconomic status, have equal opportunities to benefit from advancements in medical retina care. Closely tied to this is the ethical obligation to ensure the well-being of patients and avoid harm. In telemedicine, this translates to maintaining high standards of care, ensuring that the services provided are in the patient’s best interest and do not expose them to unnecessary risks. This includes the competent use of technology, adherence to clinical guidelines, and continuous monitoring of patient outcomes. Finally, in line with the ethical principle of transparency, any medical error or adverse events that occur in telemedicine must be disclosed to the patient promptly and honestly. This includes clearly explaining the error, its implications, and the steps taken to rectify the situation or prevent future occurrences.

9.3 Regulatory considerations

Finally, regulatory considerations are equally crucial, as integrating telemedicine into the practice of medical retina is not only a technological evolution but also a regulatory challenge. Beyond the complexity of compliance with evolving regulatory frameworks, telemedicine, like all healthcare services, falls under the purview of various regulatory bodies, further complicating the scene. Navigating the regulatory landscape and understanding how to translate regulatory obligations into actionable measures is essential for the responsible and sustainable implementation of telemedicine in this specialised field. To achieve this, healthcare providers must adopt a proactive approach to staying abreast of evolving regulations, ensuring compliance with existing standards, and communicating lacunas to the relevant regulatory authorities in line with their chosen innovation strategy [98]. Moreover, in shaping these efforts, the role of trust and confidence in influencing consumer acceptance of innovation cannot be undermined [99]. Where consumers do not merely benefit from innovation but also become strongly intertwined in the innovation process itself, acceptance does not solely depend on whether their needs and value expectations are met in an economic sense but also on trust and alignment with core values and rights. This also applies to digital healthcare innovation, where the successful rollout of new technologies and technology-driven processes relies on usability and desirability, as well as trust and concerns related to handling personal data [100, 101, 102]. Healthcare providers must acknowledge that telemedicine’s successful rollout in medical retina relies heavily on patient trust and confidence. Consequently, they should be transparent about their regulatory compliance efforts, as this transparency directly impacts patient trust and acceptance of telemedicine services.

10. Challenges and limitations of teleophthalmology

10.1 Digital limitations and challenges

The rapid growth of teleophthalmology is met with numerous technical challenges and limitations. Research indicates that bandwidth limitations are a notable obstacle, especially in remote or underprivileged areas lacking robust internet infrastructure [103]. Even with the rollout of 5G technology, significant areas within teleophthalmology still need enhancement, such as the widespread availability of advanced ophthalmic imaging technologies necessary for remote diagnosis and monitoring. This highlights the importance of developing solutions specifically designed to address the limitations of resources [27].

Data security and privacy concerns emerge due to the dependence on digital devices and platforms. Additionally, the varying levels of technological literacy among patients and healthcare providers can make integrating teleophthalmology into existing healthcare frameworks challenging.

These technical issues become particularly critical in diagnosing and managing retinal diseases, where high-resolution imaging is crucial for accurate assessment and ongoing monitoring. Continuous improvements in imaging technology, data transmission efficiency, and the user-friendliness of interfaces are required to overcome these technical barriers. Such enhancements must ensure that teleophthalmology meets the strict clinical precision and reliability standards. Government investment and clinical governance oversight are indispensable to support the development of these technologies.

10.2 Accessibility and disparity issues and strategies for overcoming them

Teleophthalmology highlights the existing health inequalities, with stark differences in healthcare access between developed and developing countries. These barriers are evident at the individual, health system, and societal levels.

At the health system level, disparities are seen in online health portals for telemedicine consultations. These platforms are less frequently used by older adults, racial and ethnic minorities, those with low health literacy, and individuals from lower socioeconomic backgrounds [104]. The effectiveness of telemedicine also depends on clinicians’ familiarity with and education on virtual clinic operations, presenting a significant barrier to its adoption. In response, American organisations are prioritising the training of medical students in telemedicine to equip them with the skills needed to conduct virtual clinics [105].

On an individual level, telemedicine services are primarily designed for non-disabled users, neglecting those with sensory impairments, low technological proficiency, or cognitive challenges [106]. This results in difficulties for patients with poor digital literacy in online services, thereby affecting the quality of care they receive [107].

Initiatives to improve access to telemedicine are in progress, focusing on technical training and support programs that have been shown to increase the use of health portals among vulnerable groups. Other potential solutions include offering free or low-cost internet services, providing more straightforward technology options like 2G or 3G for data transmission, and ensuring that software complies with legal and accessibility standards [108].

The COVID-19 pandemic further exposed the disparities in teleophthalmic care, with ethnic and racial minorities, older adults, and non-English speakers being less likely to utilise teleophthalmic services. Addressing these disparities requires more effort [109]. Successfully overcoming these barriers could significantly enhance telemedicine’s role in reducing disease burdens, especially in paediatric populations [110].

11. Future directions and innovations

11.1 5G technology

5G networks play a pivotal role in teleophthalmology by facilitating the rapid transmission of high-quality retinal images and relevant data essential for accurate diagnoses. Future applications of 5G could revolutionise remote treatments, such as telephotocoagulation, allowing for the collection, planning, and implementation of treatment across vast distances, potentially on an intercontinental scale [111]. However, the high costs associated with 5G technology pose challenges. Alternative solutions like Wi-Fi hotspots have proven effective in certain communities to bypass internet access issues [112]. As the development of 6G begins, it is anticipated to enhance connectivity and accessibility further, benefiting both rural and urban areas [27].

11.2 Big data, internet of things (IoT), and AI

Big data analytics are crucial in understanding extensive datasets to reveal patterns and insights not visible with traditional analysis methods [113]. The Fight Retinal Blindness database exemplifies this, tracking retinal disease outcomes and influencing clinical practices globally. DL systems, using big data, such as Singapore’s SELENA+ program, have made significant strides in disease pattern recognition using extensive image datasets [114].

IoT refers to the network of interconnected devices that exchange data autonomously. When combined with AI, IoT devices can monitor health outcomes efficiently, requiring clinicians only for final decision-making. This synergy has proven effective in retinal disease screening and diagnosis, offering accuracy that often surpasses human experts [115].

AI and machine learning (ML) are set to transform retinal disease diagnosis and screening, streamlining the process while ensuring the invaluable oversight of ophthalmologists [116]. The World Health Organisation stresses the importance of evaluating AI and ML tools based on several factors, including equity and resource utilisation [117]. Computer-aided diagnosis (CADx) systems, empowered by AI and ML, are facilitating the rise of teleophthalmology, especially in remote clinic setups, broadening access to care [118].

Convolutional Neural Networks (CNNs), a subset of DL, are revolutionising image recognition capabilities, including in retinal pathology diagnosis [119]. Recent advancements also highlight the application of AI in analysing OCT images, offering the potential for precise disease stage identification and treatment customisation [120]. Such technology promises real-time disease detection capabilities comparable to retina specialists in community settings [112].

Despite the potential of AI in ophthalmology, ethical considerations and the need to account for social, economic, and lifestyle factors in diagnosis and treatment planning remain crucial. AI systems might not fully grasp these aspects, potentially harming patients [121].

11.3 Collaborative efforts and global initiatives in teleophthalmology care

Global initiatives are crucial in enhancing tele-retinal healthcare, with the World Health Organization (WHO) World Report on Vision highlighting the need to incorporate eye health into universal health coverage [122]. The Lancet Global Health recognises the effectiveness of AI in screening programs for DR and ROP in both high-income and low- to middle-income countries.

International collaborations, such as those with the UK, are vital for enhancing teleophthalmology programs in developing countries. The UK’s diabetic eye screening programme is a model for such initiatives and is being piloted in the Philippines. Despite ideal conditions for screening in the Philippines, challenges such as a lack of trained staff and appropriate equipment highlight the need for global support [123].

A recent publication calls on retinal specialists in affluent countries to help improve outcomes for those at risk of retinal diseases. Key objectives include improving detection and diagnostic processes for early treatment, reducing treatment burden on patients and healthcare systems, enhancing monitoring and management of retinal conditions, and improving care coordination throughout the patient’s healthcare journey [124].

12. Conclusion

The landscape of teleophthalmology in retinal diseases represents a transformative advancement in healthcare delivery, primarily propelled by significant technological advancements. This cutting-edge methodology has proven invaluable, offering the ability to remotely perform diagnoses, monitor progress, and administer treatments for various retinal conditions. Specifically, establishing the virtual diagnostic hub at the BEH exemplified substantial enhancements in patient care efficiency well before the global emergence of COVID-19, which catalysed the broader international integration of virtual healthcare services.

Looking forward, it is imperative for future teleophthalmology initiatives to be meticulously designed to cater to the nuanced needs of diverse patient demographics. This includes focusing on ethnic minorities, individuals challenged by limited health and digital literacy, and those from lower socioeconomic backgrounds. These efforts are essential to ensure equitable access to and benefits from telehealth technologies across all population segments.

Despite its considerable potential to revolutionise care provision for patients with retinal diseases, teleophthalmology faces challenges. The integration of high-speed internet networks, AI, and big data analytics has significantly enhanced the efficiency and accuracy of remote care delivery. Nonetheless, the escalating incidence of DR, juxtaposed with relatively stagnant growth in the number of healthcare practitioners, underscores the indispensable role of AI and ML technologies in facilitating prompt detection, efficient communication, and effective management of populations at risk.

The evolution and expansion of teleophthalmology, particularly in the screening and management of retinal pathologies, depend heavily on sustained financial investment, formal recognition, and implementation by governments, as well as active collaboration on a global scale. Overcoming the hurdles of resource constraints, fostering international cooperation, and adapting to rapidly advancing technological landscapes are imperative actions to propel teleophthalmology forward. Nonetheless, these advancements hinge on the awareness, initiative, and concerted efforts of a broad spectrum of stakeholders, including clinicians, researchers, allied healthcare professionals, and, critically, policymakers. The latter group holds significant sway in enacting impactful changes and ensuring the sustainable growth of teleophthalmology. The collective engagement and forward-thinking policies are not merely advantageous but essential for realising the full potential of teleophthalmology in improving patient outcomes and expanding access to specialised retinal care.