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Title: Use of ICT in Reduction of Blindness caused by Refractive Errors and Low vision: Focus on possibilit


1
Use of ICT in Reduction of Blindness caused by
Refractive Errors and Low vision Focus on
possibility of using Village kiosk in vision 2020
plan in Africa
  • AUTHORS
  • 1. DR. ENECHI GILBERT
  • (B.Sc. OD Optom, M.Sc Comp. Scn/Engr., CACLv
    (Low.Vis)
  • Principal Optometrist, College of Medicine,
    University of Nigeria, Clinical Optometrist,
    Dept of Ophthalmology, University of Nigeria
    Teaching Hospital (UNTH), Enugu Nigeria.
  • Emailelimehi_at_yahoo.com, Phone
    234-803-324-4064
  • 2. PROF INYIAMA H.C
  • Professor of Microprocessor-Based Electronic
    Control,
  • Dept of Computer Science, Ebonyi State
    University, (EBSU), Nigeria
  • 3. DR. OGUAMAH FELIX
  • B.Sc, OD Optom.
  • Chief Optometrist, ESUT Teaching Hospital.
  • Parklane, Enugu, Nigeria.

At the inaugural World Congress on Refractive
Errors and Service Development at ICC, Durban,
South Africa, March 2007
2
  • BACKGROUND
  • Over 60 of African population resides in rural
    areas where basic social and health
    infrastructure are lacking. Majority of those who
    are in need of Refractive error services and
    visual rehabilitation are poor and resident in
    these rural areas. Vision 2020 targets to salvage
    the needlessly blind through a four-level Eye
    care delivery approach with Community level at
    the root.
  • The eye care manpower currently available is a
    far out cry from what is needed. Hence there is
    need for adoption of other strategies (where
    enabling environment permits) which can work in
    synergy with existing plan.

3
  • Definitions
  • Teleoptometry is a procedure in Optometry where
    clinical data of a patient can be sent from a
    remote source via Information Communication
    Technology (ICT) network channels to another
    optometrist, authority or specialist irrespective
    of distance and time barriers with the aim of
    receiving direct feedback information in the
    diagnosis and treatment of the patient.
  • Teleoptometry is an aspect of Telemedicine.
  • Telehealth is a comprehensive delivery of health
    care services and other related health care
    activities in which the barriers of distance and
    time have been removed.
  • Teleoptometry is the practice of Telehealth
    within the scope of Optometry and therefore is
    the channel through which ICT can be used in
    Reduction of Preventable causes of Blindness in
    Africa.

4
  • ICT Village Kiosk
  • This is a small computer workstation or terminal
    in a community which is usually linked to other
    stations and is capable of carrying out basic
    information processing with further ability to
    permit small digital information shopping.

5
Patient
ICT Device
Local DR
Wireless
ICT Server
Wireless
Remote DR

Fig 1 TELEOPTOMETRY Demo

ICT network Server
Remote DR
Patient
ICT Device
Local Eye care Personnel/DR
Wireless ICT
Wireless ICT





Physical Connection
Wireless Connection
Logical Connection
Legends

Teleoptometry Model
Logical Connection
Physical Connection
Wireless Connection
6
  • Channels of Communication
  • Fixed Telephone Lines (Analogue)
  • Wireless Mobile Telephone GSM, WCDMA
  • Broadcast One-Way Transmission Radio,
    Television.
  • Fax
  • Internet, Extranet, intranet
  • Videoconference

7
  • Application of Teleoptometry
  • A Diagnosis of Ocular Pathology
  • Glaucoma, Retinal Diseases, Cataract, Corneal
    Diseases, Tropia, etc. are some of the conditions
    that can be diagnosed through Teleoptometry.
    Digitized images of the above ocular conditions
    can be sent to remote center for analysis and
    diagnosis (Ex Cannon Camera)

8
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9
Digital Slit Lamp
10
  • A SPECTACLE AND OTHERS
  • I Contact Lens fitting of contact Lens can be
    enhanced through Teleoptometry. With the use of
    Fluorescene dye and Cobalt blue light, it is
    possible to take the picture of the contact lens
    in situ (Canon Camera). Also a patient can try
    out various types and models of digitized contact
    lenses. The digitized images can be sent to
    specialist at remote center for analysis of best
    fit.
  • Ii Spectacle Fitting Digitized frames (by
    Maxseen) and physical frames of various sizes,
    shapes and models can be tried out by patient.
    The digitized image of the photograph can be
    sent to remote center for evaluation.
  • Iii Clinical Measurements The information on
    IPD, bifocal and varilux settings can be gotten
    in real time and sent to remote specialist for
    analysis and input.(Courtesy of Maxseen
    Technology)

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12
  • C Exchange of ideas between Optometrists
  • An Optometrist can share information about a case
    at hand online with another Optometrist as the
    patient is being examined.
  • D Education
  • An Optometrist can learn some clinical procedures
    online from another specialist in a remote
    center.
  • E Research
  • Sharing of patients data between optometrists
    brews a good background for research endeavors.
  • F Low Vision
  • By documenting and forwarding a video clip of a
    low vision patient at work/Task, it is possible
    for a low vision specialist to render useful
    suggestions on the environmental modifications
    for the activities of daily living.

13
  • REVIEW OF TELEOPTOMETRY IN AFRICA
  • The use of Teleoptometry in Africa is currently
    at low level and is limited in most countries to
    use of land telephone and GSM lines as the ICT
    channel. There is not yet a remarkable success in
    the use of internet channels, video conferencing,
    etc in Africa as is the case in Asia.
  • The telephone communication is used in the
    following directions
  • I Patient to Optometrist
  • Ii Optometrist to Optometrist
  • Iii Optometrist to other Professionals

14
  • I Patient to Optometrist
  • In this case a patient from a remote source
    (Villages, Towns, rural communities, etc)
    initiates a distress telephone call to an
    optometrist who usually resides in the city.
    Calls from the villages are mainly via GSM and
    fixed wireless while calls from the city may in
    addition include via non-wireless land line.
    Cases encountered in calls from villages are
    mostly trauma (Mechanical, chemical, penetrating
    injuries) and ocular emergencies resulting from
    application of harmful ocular concussions. Calls
    from the cities are mostly cases of broken or
    lost spectacles, contact lenses and low vision
    devices. The above data are the unpublished
    experience of some of the optometrists who are
    active in community based optometrycontd

15
  • In responding to such distress call, the African
    optometrist gives immediate ocular first aid
    directives and instructions to the patient or his
    care giver in Real time. In situations where the
    immediate remedy cannot be resolved after the
    first aid treatment, the patient is invited to
    the city for proper treatment.
  • Some eyes were saved from blindness by this
    approach as without such professional
    intervention from the optometrists, the patient
    in a remote city would have resorted to use of
    traditional harmful ocular medication on self
    help.

16
  • 2 Optometrist to Optometrist
  • In this situation, an optometrist makes a phone
    call to another optometrist (usually a senior
    colleague or specialist) to get clinical opinion
    on a case he is currently examining.
  • 3 Optometrist to other Professionals
  • In this situation, an optometrist makes a phone
    call to another professional/ authority (ie,
    Ophthalmologist, psychologist, Special Education
    teacher, Contact lens dealer, etc) to get his
    opinion on a case he is currently examining. In
    most cases this enables the optometrist to make
    an intelligent referral.

17
  • JUSTIFICATION FOR TELEOPTOMETRY IN AFRICA
  • I Situation in Africa
  • 60 of African population resides in rural
    communities where there is poverty, lack of
    social infrastructure, lack of appropriate health
    facilities, inaccessible roads and where doctors
    are very reluctant to go. Optometric services in
    these areas are very low. The rural dwellers in
    Africa need better information and eye care
    services which can be bridged by the concept of
    Teleoptometry..

18
  • Ii Recent Communication Explosion
  • Africa is a promising IT environment for the
    future. For the past five years Africa has
    outpaced other global IT markets in terms of new
    subscription with 58.2 growth. Nigeria has a
    large chunk of this share!
  • The network service providers in Africa are at
    severe competition to get the largest chunk of
    the IT market. The result is that many of them
    are now expanding their network services to
    penetrate the interior parts of the continent
    with a special target on rural communities. This
    has provided a fertile environment for
    Teleoptometry.

19
  • Iii Inaccessibility of rural communities
  • Most of the rural communities in Africa are not
    quite accessible by roads. Optometrists and other
    health care professionals find it extremely
    difficult to reach the rural dwellers in the
    above areas.

20
  • Iv Lack of social infrastructure
  • Lack of pipe-borne water, electricity,
    hospitals/health centers, recreational centers,
    etc, have made African villages unattractive to
    doctors and other health personals. Most
    optometrists therefore prefer to stay in the
    cities but those who are interested in community
    optometric practice visit the areas from time to
    time. These short trips are not enough to handle
    ocular emergencies. Hence Teleoptometry will help
    to deliver necessary services to the multitude of
    the underserved in a real time.

21
  • V Lack of information and practice of obsolete
    tradition
  • Majority of the rural dwellers still live in
    ignorance. They do not have reliable source of
    information on their ocular health. Some of them
    therefore resort to practice of obsolete
    traditions which are inimical to ocular health.
    Some harmful traditional concussions are still
    being used in some villages.
  • Such concussions include Urine, Breast milk,
    Alum, Pepper, Garlic, bitter-leaf juice, etc.
    Implementation of Teleoptometry through the
    establishment of Village Kiosks and ICT VISUAL
    centers will help to neutralize these negative
    behaviors and traits as the kiosk will double as
    information center.

22
  • Vi Climate
  • Some rural communities in Africa do not have
    favorable climate. The temperature in the North
    is high during the Dry seasons but in Rainy
    seasons, it becomes comparatively low. Some areas
    usually experience water logging and mud during
    the rainy seasons. The climatic conditions have
    made the areas unattractive to Optometrists and
    other NGOs who are desirous to bring refractive
    services to the rural dwellers. Teleoptometry
    will tend to neutralize this effect.

23
  • Vii Existence of TeleHealth working group in
    Africa
  • Optometry is a health profession and therefore
    works within the ambit of its legitimate scope in
    synergy with all other health professions. Hence,
    Teleoptometry will not exist in isolation but
    will operate within the ambit of teleHealth
    facilities and legislature in Africa.
  • Fortunately, a group of health professionals
    whose desires are to promote the practice of
    telehealth in Africa are already in existence.
    This group is already active lobbying the
    government and its agencies in their different
    countries towards legislature of Telehealth laws.
    It will be therefore easier to establish
    Teleoptometry in Africa as some interest groups
    are already doing some underground work in this
    direction.

24
  • RESOURCE REQUIREMENT
  • Teleoptometry involves use of ICT and other
    ophthalmic devices to transmit patients data to
    remote optometrist/authority.
  • The following resources are required

25
  • 1 ICT Devices Required
  • I Mobile station GSM mobile phones / Tabletop
    handsets
  • Features SMS, Multimedia, MPC(Multiple Party
    Calling), MDS (Mobile Data Service), VPN( Virtual
    Private Network), WAP (Wireless Application
    Protocol), GPRS, Edge, IR, Blue- Tooth, UMTS
    (Universal Mobile Telecommunication System), DTM
    (Data Transmission Speed) gt 2Mbps, etc
  • Ii Fixed, Wireless, fixed-wireless channels
  • Iii Laptop computers with appropriate software
  • iv Digital Video
  • v Digital Camera

26
  • Network Service Providers
  • i GSM servers Base station (BS),
  • Base Transceiver Station (BTS), Base Station
    Controller (BSC)
  • ii Internet Service Providers (ISP)

GSM Network
27
  • 2 Ophthalmic Devices
  • A Digital Ophthalmoscope
  • B Slit-lamp With Digital port
  • C Diagnostic Camera
  • D Diagnostic Video
  • e Virtual Optical Dispenser
  • ( Ex MaxSeen)
  • E Other Standard Ophthalmic/Optometric
    instruments

28
  • 3 Support Facilities
  • A Electric Power Supply National Grid system
    or Generating set
  • B Solar-powered Battery charger
  • C Office space

29
  • 4 Personnel
  • A CHEW, Nurse, Teacher, etc.
  • b Optometric Assistant
  • c Optometrist
  • d Experienced Programmer Optometrist
  • 5 The Patient

30
  • 6 Coordinating Authority
  • A The Government
  • I To provide enabling law for all the stake
    holders in the scheme.
  • Ii To subsidize the optometric services
    rendered
  • Iii Provide basic infra structure
  • Iv Establish a coordinating agent

31
  • B The Ministry of Health
  • I Regulate the practice of Telehealth in the
    country with aim of protecting both the patients
    confidence and the doctors
  • Ii Helps in recruitment of personnel in
    actualization of Telehealth.
  • Iii Provide all other health related logistics
    as may deem fit.

32
  • C The Ministry of Information and Communication
  • I Through the Communication Commission,
    regulates the activities of various service
    providers.
  • Ii Monitors network service production and
    quality.

33
  • D The Optometric Board
  • I To regulate the activities of its members in
    the application of Teleoptometry in the country.
  • Ii To Organize update courses for new and
    practicing optometrists in the art of
    Teleoptometry.
  • Iii To establish Teleoptometry Working Group
    which will be a research arm of the board on
    this procedure
  • Iv To Encourage optometry schools in the
    country to include Teleoptometry
  • in the academic curriculum.

34
  • IMPLEMENTATION
  • Teleoptometry can be implemented in Africa by
    adopting the primary health care delivery system
    already employed by vision 2020 working group.
    This involves the following levels
  • I Community/Primary level
  • Ii Secondary level
  • Iii Tertiary level

35
Fig 3 ICT VISUAL CENTER MODEL
36
  • I Community/Primary level VILLAGE KIOSK
  • This shall be the lowest level which operates
    within the rural community. The eye care
    personnel is either CHEW, TRADITIONAL HEALER,
    NURSE, COMMUNITY DWELLER, TEACHER, etc who shall
    be given basic training both in computer usage
    and in recognition and treatment of some minor
    ocular conditions and emergenciescontd

37
  • The patient visits the village kiosk to get
    services. The channel of communication at this
    level may be limited to wireless telephony. Here
    a patient through the assistance of a primary eye
    care personnel is able to explain his condition
    to the optometrist in the secondary level. The
    patient through the assistance of the personnel
    in charge may be given an instant direction by
    the optometrist on the treatment. The patient
    may also be invited to come over by the
    optometrist (in the secondary level) for further
    treatment/examination.

38
  • Ii Secondary level Local Govt ICT VISUAL
    center
  • An optometrist shall be in charge at this level
    as he oversees and is liable to all the
    Teleoptometric activities in the zone or
    district. Patients can come directly to him or
    are referred from the community/primary level.
    For cases beyond the facilities of the
    optometrist at this level, a connection via the
    GSM Phone or internet if present can be made to
    another optometrist or authority in his zone.
  • .

39
  • Iii Tertiary Level State ICT VISUAL Center
  • This shall be the highest level or authority in
    the scheme where services or clinical queries
    could be sought. The optometrist at this level
    can connect another optometrist or authority in
    another state or country to get instant guidance
    on the treatment of patient in question.
    Fortunately, interstate referrals can be possible
    in some countries as they do yet not have any
    legislation that forbids this.

40
  • MERRITS OF TELEOPTOMETRY IN AFRICA
  • A The Patient
  • I Gets Access to professional care easily
  • Ii Does not ALWAYS have to take a trip outside
    his domain to get optometric services.
  • Iii Improves patient satisfaction and better
    health economics
  • Iv Understands and gets more involved in his
    conditions as he views his Ocular images on
    large computer screens
  • V feels more comfortable
  • Vi less intimidated by the doctor
  • Vii Pays less overall medical bill in the
    treatment of his ocular conditions

41
  • B The Optometrist
  • I Learns from the process as he experiences
    from another specialists diagnosis of his
    patients.
  • Ii Can send patients information to schools of
    optometry for analysis and learns in the process
  • Iii Has Job satisfaction
  • Iv Monitors his patients in remote areas.

42
  • C Optometrist and Patient
  • I It enhances a mutual trust between the
    patient and optometrist
  • Ii It reduces language barriers between patient
    and optometrist
  • Iii REAL TIME It removes barrier of time and
    distance.

43
  • THE CHALLENGES
  • Full implementation of Teleoptometry in Africa
    will not go as smooth as may be expected. There
    are several logistic issues that will practically
    affect the tempo of the program. Such issues and
    their alternative solutions are mentioned below

44
  • A Power Supply
  • There is lack of Electricity power supply in most
    rural communities in Africa. The urban cities
    experience epileptic and low voltage power
    supply. Most of the ICT and ophthalmic devices
    used in Teleoptometry require stable and constant
    electricity supply. It may not be cost effective
    to run generating plants on 12hrs-6days-4weeks-12m
    onths basis. There is therefore need for a more
    reliable and constant power supplycontd.

45
  • Solution Fortunately Most towns in Africa have
    plenty of sunshine. Hence use of solar
    electricity shall be exploited to fullest. Some
    devices like PC laptop, digital camera, digital
    video, etc, run on rechargeable DC batteries.
    Solargised inverters and multi-purpose battery
    chargers can be used to power the ICT devices.
    Small low-cost less than 100.00 generating plant
    can also be used to power the battery chargers
    for less than 2hrs a day.

46
  • B High cost of providing internet /GSM
    services.
  • It is very expensive to operate internet /GSm
    services in Africa. The following may be some of
    the reasons
  • I High Registration cost To register and
    operate as service provider is very expensive.
    Some operators had to cough out several million
    of dollars in a bid to register its operation in
    Africa.
  • Ii Lack of Constant power supply The power
    supply in some African countries is not stable
    and since the operators must provide their
    services 24hrs-7days a week, they cannot rely on
    national grid Hence they invest a huge sum of
    money in purchase and maintenance of standby
    electric power generators in every of their base
    stations.

47
  • Iii Fuel scarcity
  • The incessant fuel scarcity in some African
    countries has been a nightmare to service
    providers as their numerous base station plants
    consume diesel on 24hrs-7days basis. During
    scarcity the fuel is sourced at exorbitant cost.
  • All the above adversities have made the overhead
    running cost of GSM/Internet services in Africa
    to be very high...contd

48
  • In self defense some of these providers tend to
    recover and sustain their investments by
    resorting to following practices
  • i Limited band width
  • ii Oversubscription of their channels to their
    clients
  • iii High service charges to clients
  • Solution Government shall look into the plight
    of GSM/internet service providers in the country.

49
  • c Congested Band width and lack of internet
    facilities
  • Internet facilities and network are completely
    lacking in most rural communities. Even in urban
    cities where the network exists, there is
    congestion of channel capacity in the available
    band width as GSM operators and service providers
    tend to oversubscribe their limited band width.
    This has led to slow data access speed. To
    download or upload a 10MB file may take several
    minutes to achieve. This low speed has already
    negated the philosophy of Teleoptometry which
    implies diagnosis in REAL time!, especially where
    the average data size of image/movie file runs
    in hundreds of megabytes.

50
  • Solution The Government through its regulatory
    body/agent shall forbid existing ISPs from
    oversubscription. New ISPs shall be encouraged to
    start business in the country. All the GSM
    operators in the country shall be stimulated to
    include internet services (WAP,GPRS, etc) as one
    of their primary service products. They shall
    also be encouraged to exploit the recent 3-D
    meshwork and fibre optics technology for mass
    internet connectivity. The Registration fees for
    ISPs in the country shall be drastically reduced
    or waived. However, competition in the IT
    market will naturally force the ISPs and GSM
    operators to improve their services in this
    regard.

51
  • d Job Threat
  • Introduction of ICT and computers into
    activities of man has been viewed by some
    categories of individuals (including some
    professionals) as a direct threat and competition
    to their means of livelihood. For instance one
    does not need to be a professional photographer
    before he can comfortably cover an event with
    his digital video. So also some optometrists may
    feel that with Teleoptometry, their job will be
    threatened. The traditional healers and those who
    make a living by providing ocular therapies may
    not feel at ease. If these pockets of resistances
    were neglected in the program, they might
    assiduously fight to the demolition of the
    program in timecontd

52
  • Solution Public awareness campaign and advocacy
    shall be done prior to introduction of
    Teleoptometry in any community.
  • The individuals who are already providing some
    ocular services in the area can be incorporated
    or integrated into the system if they so desire.

53
  • e Finance and Sustainability of the project
  • Establishment of Teleoptometry will require some
    funds. Some of the ICT and optometric devices
    used in Teleoptometry are relatively expensive.
  • The officer(s) who will man the program will
    require appropriate remuneration. If everything
    were left for government, the program may not
    survive as it cannot continue to inject funds
    into the system forever.

54
  • Solution
  • 1 Small amount of money shall be charged for any
    service rendered.
  • 2 There shall be community participation in the
    project where the residents are encouraged to
    make donations and regard it as their own.

55
  • f Legal Backing, Responsibility issue and
    Public Safety
  • There is no legislation in place in most African
    countries that stipulates the practice of
    Telehealth and Teleoptometry. However if
    Teleoptometry is regarded as a procedure and not
    a specialty in optometric profession, then it
    will be covered by ethics and code of conducts
    for optometrists. This is necessary as to avoid
    and discourage unwholesome practices and
    maneuvers which may be invented by practitioners
    in future. ..contd

56
  • The issue of responsibility is very important.
    For instance, in Teleoptometry, when a patient
    receives treatment from a second doctor through
    the help of the primary doctor, who will be
    responsible for the services? How will interstate
    and intercontinental consultations be resolved?
    Both the practitioner and the patient need legal
    protection as to avoid unnecessary litigation.

57
  • Solution The African governments through its
    legislative arms shall put in place spelt out
    Criteria and Scope for the practice of Telehealth
    and Teleoptometry in the country. This advocacy
    can be done by the TWG and respective Societies
    For Telemedicine and e-Health

58
  • CONCLUSION
  • There is both clinical and digital divide between
    the urban and rural communities in Africa. New
    graduating doctors keep on populating the cities
    while the rural communities keep experiencing
    acute shortage or total absence of optometrists.
    If ACTION is not taken fast, the target period
    for elimination of avoidable Blindness by vision
    2020 may experience serious setbacks. VILLAGE
    KIOSK or ICT visual centers can be used through
    Teleoptometry in rural communities in Africa to
    render refractive services yet undreamt of in the
    spirit of vision 2020. This will translate to
    reaching and treating more people who have
    refraction and low vision needs, thereby reducing
    the prevalence of Blindness due to refractive
    Errors in Africa.

59
  • THANK YOU
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