Introducing e-health technology to routine cataract care:patient perspectives on web-based eye test for postoperative telemonitoring

Purpose:To explore cataract patients' experiences with an e-health tool for self-assessing visual function (ie, a web-based eye test), and to formulate recommendations for its successful adoption in routine cataract care.Setting:Clinics in the Netherlands, Germany, and Austria.Design:Mixed-methods study.Methods:22 participants were included in this study; in-depth interviews were conducted with 12. Questionnaires and in-depth semi-structured interviews were conducted alongside a multicenter randomized controlled trial evaluating the validity, safety and cost-effectiveness of remote care after cataract surgery (Cataract Online Refraction Evaluation, a Randomized Controlled Trial). Results were analyzed thematically.Results:Participants reported positively about performing the web-based eye test at home. 4 overarching themes were identified in the interviews. First, participants were inventive in overcoming practical barriers encountered while conducting the test. Second, participants desired a clear presentation of test results and their meaning. Third, the ability to self-monitor visual function was appreciated. Fourth, most participants preferred to keep the option to contact their eyecare professional (ECP) postoperatively, especially when experiencing symptoms. Most would be satisfied with a phone consultation or an e-consult. Participants reported positive experiences with the web-based eye test. Barriers for successful adoption were identified, including insecurity about correctly performing the test, incomplete information on how to interpret test results, and a feeling that in-hospital assessments were superior to remote assessments.Conclusions:It is recommended to focus on building trust in remote eyecare delivery and that access to the ECP be retained when medically indicated or deemed necessary by the patient.</p

Digital Tools for the Self-Assessment of Visual Acuity: A Systematic Review

Introduction: Numerous digital tools to self-assess visual acuity have been introduced. The recent COVID-19 pandemic underlined the need for high-quality remote care. This review gives a current overview of digital tools for remotely assessing visual function and reports on their accuracy. Methods: We searched the databases of Embase and Pubmed, and systematically reviewed the literature, conforming to PRISMA guidelines. Two preliminary papers were added from medRxiv.org. The main outcome was the agreement of the digital tools with conventional clinical charts, as expressed by mean differences and 95% limits of agreement (95% LoA). Results: Seventeen publications included studies reported on 13 different digital tools. Most of the tools focus on distance visual acuity. The mean differences of the digital tools ranged from − 0.08 to 0.10 logMAR, when compared to traditional clinical assessments. The 95% LoA differed considerably between studies: from ± 0.08 logMAR to ± 0.47 logMAR, though the variability was less pronounced for higher visual acuities. Conclusion: The low mean differences between digital visual acuity assessments and reference charts suggest clinical equivalence, though the wide 95% LoA identify a lower precision of digital self-assessments. This effect diminishes in individuals with better visual acuities, which is a common feature of visual acuity assessments. There is great potential for the digital tools to increase access to eye care and we expect the accuracy of the current tools to improve with every iteration in technology development

Nationwide epidemiological approach to identify associations between keratoconus and immune-mediated diseases

Background: The aetiology of keratoconus (KC) remains poorly understood. KC has typically been described as a non-inflammatory disorder of the cornea. Nonetheless, there is increasing presumptive evidence for the role of the immune system in the pathogenesis of KC. Aim: To evaluate the association between KC and immune-mediated diseases on a population level. We hypothesise that KC is immune-mediated rather than a predominantly degenerative disease. Methods: Data were obtained from the largest health insurance provider in the Netherlands. Dutch residents are obligatorily insured. The data contained all medical claims and sociodemographic characteristics from all KC patients plus all those data from a 1:6 age-matched and sex-matched control group. The primary outcome was the association between KC and immune-mediated diseases, as assessed by conditional logistic regression. Results: Based on our analysis of 2051 KC cases and 12 306 matched controls, we identified novel associations between KC and Hashimoto's thyroiditis (OR=2.89; 95% CI: 1.41 to 5.94) and inflammatory skin conditions (OR=2.20; 95% CI: 1.37 to 3.53). We confirmed known associations between KC and atopic conditions, including allergic rash (OR=3.00; 95% CI: 1.03 to 8.79), asthma and bronchial hyperresponsiveness (OR=2.51; 95% CI: 1.63 to 3.84), and allergic rhinitis (OR=2.20; 95% CI: 1.39 to 3.49). Conclusion: Keratoconus appears positively associated with multiple immune-mediated diseases, which provides a population-based argument that systemic inflammatory responses may influence its onset. The identification of these particular diseases might shed light on potential comparable pathways through which this proinflammatory state is achieved, paving the way for pharmacological treatment strategies

Evaluation of a visual acuity eHealth tool in patients with cataract

To validate the Easee web-based tool for the assessment of visual acuity in patients who underwent cataract surgery.Setting:University Eye Clinic Maastricht, Maastricht, the Netherlands.Design:Prospective method comparison study.Methods:Subjects aged between 18 and 69 years who underwent cataract surgery on 1 or both eyes at the Maastricht University Medical Center+ were eligible to participate in this study. The uncorrected (UDVA) and corrected distance visual acuity (CDVA) assessments were performed using the web-based tool (index test) and conventional ETDRS and Snellen charts (reference tests). The outcomes of the different tests were expressed in logMAR, and a difference of <0.15 logMAR was considered clinically acceptable.Results:46 subjects with 75 operated eyes were included in this study. The difference of the UDVA between the web-based tool and ETDRS or Snellen was -0.05 ± 0.10 logMAR (P <.001 [0.15; -0.26]) and -0.04 ± 0.15 logMAR (P =.018 [0.24; -0.33]), respectively. For the CDVA, these differences were -0.04 ± 0.08 logMAR (P <.001 [0.13; -0.21]) and -0.07 ± 0.10 logMAR (P <.001 [0.13; -0.27]), respectively. The Pearson correlation coefficients between the web-based tool and ETDRS were maximally 0.94 and compared with Snellen 0.92. In total, 73% to 88% of the visual acuity measurement differences were within 0.15 logMAR.Conclusions:The web-based tool was validated for the assessment of visual acuity in patients who underwent cataract surgery and showed clinically acceptable outcomes in up to 88% of patients. Most of the participants had a positive attitude toward the web-based tool, which requires basic digital skills

Web-based telemonitoring of visual function and self-reported postoperative outcomes in cataract care: international multicenter randomized controlled trial

Purpose: To compare web-based, self-administered follow-up after cataract surgery to conventional face-to-face follow-up. Setting: Eye clinics in the Netherlands, Austria, and Germany. Design: Randomized controlled trial with an embedded method comparison study (ClinicalTrials. gov: NCT04809402). Methods: Routine patients with cataract were randomized into 2 groups: The telemonitoring group undertook web-based vision self-assessments and questionnaires from home, while the usual care group received conventional care. All participants had a 4- to 6-week postoperative clinic visit for safety and validation purposes. Outcomes included, the web test's accuracy for assessing postoperative visual acuity (VA) and refractive error, adverse event rates, and patient-reported outcome measurements (PROMs). Results: 94 participants (188 eyes) were enrolled. Web-based uncorrected distance VA testing demonstrated a negligible mean difference (-0.03 ± 0.14 logMAR) when compared with conventional Early Treatment Diabetic Retinopathy Study chart testing, with 95% limits of agreement ranging from -0.30 to 0.24 logMAR. The web-based refraction assessment overestimated the postoperative refractive error (mean difference in spherical equivalent 0.15 ± 0.67 diopters), resulting in a poorer corrected distance VA compared with subjective refraction (mean 0.1 vs -0.1 logMAR). Rates of adverse events and unscheduled consultations were minimal across both groups. Preoperative and postoperative PROM questionnaires had a 100% response rate. Visual functioning (Catquest-9SF and National Eye Institute Visual Function Questionnaire-25) improved postoperatively (mean improvement -0.80 and 16.70, respectively) and did not significantly differ between the 2 groups. Conclusions: The patients with cataract in this study effectively provided postoperative outcome data using a web interface. Both conventional and web-based follow-ups yielded similar PROMs and adverse event rates. Future developments should reduce the variability in the web-based VA test and yield representative refraction outcomes

Correction to: Digital Tools for the Self-Assessment of Visual Acuity: A Systematic Review (Ophthalmology and Therapy, (2021), 10, 4, (715-730), 10.1007/s40123-021-00360-3)

In Fig. 4 of this article, the 95%LoA are not properly visualized for three studies (Muijzer 2021, VA B 0.5 logMAR; Rosser 13 2001 [ETDRS] and Lim 2010 [ETDRS]); the figure should have appeared as shown below. The original article has been corrected. (Figure presented.)

Nationwide epidemiological approach to identify associations between keratoconus and immune-mediated diseases

Background: The aetiology of keratoconus (KC) remains poorly understood. KC has typically been described as a non-inflammatory disorder of the cornea. Nonetheless, there is increasing presumptive evidence for the role of the immune system in the pathogenesis of KC. Aim: To evaluate the association between KC and immune-mediated diseases on a population level. We hypothesise that KC is immune-mediated rather than a predominantly degenerative disease. Methods: Data were obtained from the largest health insurance provider in the Netherlands. Dutch residents are obligatorily insured. The data contained all medical claims and sociodemographic characteristics from all KC patients plus all those data from a 1:6 age-matched and sex-matched control group. The primary outcome was the association between KC and immune-mediated diseases, as assessed by conditional logistic regression. Results: Based on our analysis of 2051 KC cases and 12 306 matched controls, we identified novel associations between KC and Hashimoto's thyroiditis (OR=2.89; 95% CI: 1.41 to 5.94) and inflammatory skin conditions (OR=2.20; 95% CI: 1.37 to 3.53). We confirmed known associations between KC and atopic conditions, including allergic rash (OR=3.00; 95% CI: 1.03 to 8.79), asthma and bronchial hyperresponsiveness (OR=2.51; 95% CI: 1.63 to 3.84), and allergic rhinitis (OR=2.20; 95% CI: 1.39 to 3.49). Conclusion: Keratoconus appears positively associated with multiple immune-mediated diseases, which provides a population-based argument that systemic inflammatory responses may influence its onset. The identification of these particular diseases might shed light on potential comparable pathways through which this proinflammatory state is achieved, paving the way for pharmacological treatment strategies