This was the actual cost involved per case taking into account the capital investment and management costs. The gross cost was estimated to be $79.5 (Rs. 3,600) for the base hospital and $37.3 (Rs. 1,680) for telescreening [29]. In a real-life situation, in our experience, the cost for telescreening for DR in Karnataka was $3.78.

13.12.4Telescreening for Diabetic Retinopathy: Our Experience

Tamil Nadu: We compared the prevalence of diabetic retinopathy in the ophthalmologist-based vs ophthalmologist-led models on different samples of self-reported people with diabetes in rural South India. From 2004 to 2005 in rural South India, 3,522 diabetics underwent the ophthalmol- ogist-based diabetic retinopathy screening, and 4,456 diabetics underwent the ophthalmologistled (telescreening) diabetic retinopathy screening. 519 (14.7%) were diagnosed with diabetic retinopathy in the ophthalmologist-based model and 853 (19.1%) in the ophthalmologist-led model (p < 0.0001). Similarly, the ophthalmolo- gist-led model had more sight-threatening retinopathies than the ophthalmologist-based model (6.3% vs 5%).

The ophthalmologist-led model overestimates diabetic retinopathy. However, as it obviates the need for travel by ophthalmologist, it is a good method for diabetic retinopathy screening in India.

Karnataka: Till now, nearly 60,000 diabetics have been screened for retinopathy, and approximately 5,000 sight-threatening diseases have been identified and treated.

13.13Future of Diabetic Retinopathy Screening

The advancements expected in telescreening in the future include:

•Miniaturization of diagnostic equipments

•Automation of diabetic retinopathy diagnosis

•Better and faster telecommunication Telescreening is advantageous for diabetic

retinopathy screening among the rural population

who do not have access to specialized eye care. The telescreening model can be considered as an efficient screening model for diabetic retinopathy as it satisfies all the criteria required for a good screening program.

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14.1Introduction

Nepal is among the poorest countries in the world. It is situated along the Himalayan mountain range, wedged in between India and China with a population of about 30 million. Given the ruggedness of the terrain and the lack of infrastructure, traveling across the country is extremely cumbersome.

There are approximately 90 ophthalmologists in Nepal, most of which are located in Kathmandu, the capital. There are several teaching hospitals with residency programs in Kathmandu, and all subspecialty services and modern technology are readily available.

In contrast, patients in rural Nepal are dependent on primary eye care centers which are usually staffed by general ophthalmologists who provide comprehensive medical care and in some cases cataract and oculoplastic surgery. However, access to subspecialists, especially vitreoretinal surgeons, is very limited and usually requires substantial traveling to Kathmandu.

The use of telemedicine with transmission of fundus images from rural clinics to a subspecialist in Kathmandu or internationally could substantially improve patient care and limit unnecessary and time-consuming referrals to the capital.

J.N. Ulrich, M.D.

Department of Ophthalmology,

University of North Carolina at Chapel Hill, 5151 Bioinformatics Building, CB7040, Chapel Hill, NC 27599, USA

e-mail: jnulrich@med.unc.edu

There are a few reports on the use of telemedicine in ophthalmology from India [1] and China [2], but to our knowledge, telemedicine in ophthalmology has never been utilized in Nepal.

This chapter describes our experiences with testing the feasibility of telemedicine in rural Nepal and the encountered difficulties.

14.2Methods

In March of 2008, two eye-screening camps were held in rural Nepal. This was organized by Tilganga Eye Center, one of the leading academic eye hospitals in Kathmandu. The team consisted of several Nepali and Thai ophthalmologists, multiple Nepali ophthalmic technicians, as well as an American retina specialists, ophthalmology resident, and ophthalmic photographer. Subjects from Hetauda, a town in the southern flatlands, and Phaplu, a remote village in the mountainous north, had been informed about the free eye exams through radio and posters.

In Hetauda and Phaplu, 259 and 195 subjects, respectively, were examined. All subjects underwent comprehensive ophthalmic exams including dilated fundus exams by a retina specialist. The results in regard to prevalence of diabetic retinopathy and age-related macular degeneration have been published previously [3].

Fundus photos of all patients with significant retinal pathology were taken using a Nidak-AFC 230® nonmydriatic fundus camera (Fig. 14.1) – a