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Eye Witness | U.C. Berkeley optometristís long-distance diagnosis technology saves sight. | By Cynthia Dizikes

Michael Cheng-Thao’s vision blurred, his hearing dimmed and he often felt dizzy and faint as he stacked magazines and phone books at his minimum-wage job in the San Joaquin Valley. Though doctors told the 40-year-old father of eight that he should see an eye specialist immediately, the only appointment he could find in his hometown of Merced was two months away.

Cheng-Thao, a Hmong immigrant from Laos who speaks little English, became afraid. As his condition worsened, he started to worry that he would lose his job—his family’s main source of income. So he called his cousin who works as a photographer at a nearby clinic in Merced that had just started using a digital camera to take pictures of patients’ retinas.

The cousin took pictures of Cheng-Thao’s eyes, posted the images to the clinic’s Web site, and five minutes later received a response from an optometrist 400 miles away in San Diego. He recommended that Cheng-Thao go to the emergency room immediately. About two weeks later surgeons operated on a non-malignant tumor in Cheng-Thao’s brain, which could have caused permanent damage had it been left to grow.

Though Cheng-Thao’s diagnosis a year ago may have been extraordinarily rare, his difficulties with the health-care system were not. The San Joaquin Valley includes some of the poorest areas in the state and has the fewest number of primary-care physicians and specialists per capita.

That’s why a socially conscious optometrist named Jorge Cuadros has created and started to install technology that has been nothing short of revolutionary for low-income people throughout California. The relatively cost-effective, digital medical technology, which helped to save Cheng-Thao’s life, is now helping thousands of people without insurance, or money to access eye-care specialists, and will likely do more in the coming years.

“The real innovation was applying license-free technology to this problem, therefore making it more available to indigent populations that have limited monetary resources,” says Cuadros.

Cuadros, a U.C. Berkeley optometry professor, at Highland Hospital, recognized the critical need to provide better eye-care access to the hundreds of thousands of uninsured farm workers in California. He saw how computer technology and optometry could converge to help patients who were struggling with the traditional health-care system. He targeted the Central Valley because Latinos, along with Asians and African Americans, are predisposed to retinopathy—a sight-threatening disease related to diabetes—and glaucoma.

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Cuadros has now installed his digital eye-care systems in 13 community clinics throughout the San Joaquin, Salinas and Sacramento valleys to help people like Cheng-Thao who are often limited by money, transportation and language. So far, some 4,800 patients have been served in California and 2,300 in Mexico.

Cuadros’s innovations are part of a larger movement in modern health care, in which “telemedicine” techniques are increasingly used by specialists in the long-distance treatment of disease and medical emergencies, from diagnosing skin cancer to identifying broken bones, and even to performing certain surgeries.

Cuadros, who lives in San Leandro, is the son of Bolivian immigrants and the father of three children ages 13, 15 and 21. He says being Latino in a system that has so few Latino health-care providers has largely driven his consciousness.

Early on in his practice, Cuadros noticed that many of his poorer Spanish-speaking patients kept falling through the cracks in the health-care system. He would see a patient with some type of sight-threatening condition, refer him to a specialist and later find that the patient had not gone.

Like most other optometrists at the time, Cuadros had performed only eye exams that required doctor and patient to be in the same room. After a chance conversation with a Harvard internist in 1994, Cuadros learned how to examine the eye through digital images with a camera mounted on a bio-microscope.

He adapted the technology to create his Web-based system called EyePACS, which stands for Eye Picture Archiving and Communication Systems. In 2005, he received a $630,000 grant from the California Telemedicine and eHealth Center and the California Health Care Foundation to install his system in the community clinics.

Last year, Merced’s Golden Valley Health Center—the same clinic that later helped Cheng-Thao—became the first Valley clinic to begin using Cuadros’s program. The Center, a cluster of flat one-story beige buildings, rests among crop fields and farm equipment distributors along Highway 99, a two-lane road that traverses some of the world’s most agriculturally productive land.

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On a fall afternoon in Merced, Cheng-Thao’s cousin Moua Thao aligned the clinic’s digital camera with a diabetic patient’s eye.

Amado Ramirez, a 45-year-old farm worker without insurance, sat awkwardly in front of the apparatus, which looks something like a film projector, with his chin cupped in a headrest, his forehead pressed against its padded metal band, and his eye opened and staring into the black circular camera lens.

“Can you open your eye more?” Thao asked.

“Abre los ojos,” Ramirez’s wife Dolores repeated from the corner of the dark room where she sat.

Ramirez widened his eye as Thao zoomed in on the image in the camera’s viewfinder and snapped the picture. The flash momentarily splashed a swath of light on the face of Ramirez, who sat blinking as the image of his retinal orb appeared on the computer screen next to the camera.

Thao took multiple pictures of both eyes before he turned the lights on and uploaded the pictures to the clinic’s central server. Cuadros would later look at these pictures from his office in Berkeley, San Jose or at home and would then post a recommendation for Thao to send to Ramirez’s primary-care physician.

After his appointment, Ramirez explained that doctors had diagnosed him with diabetes about three years ago but that this was the first time he had been instructed to have his eyes checked. As a diabetic who must see a variety of specialists including eye and foot doctors and dieticians, Ramirez said he appreciated the convenience of the camera.

“It was more helpful to not be running around to different places,” he said.

Currently, the clinics equipped with Cuadros’s technology mainly use it to screen diabetic patients for retinopathy, a slow but permanent condition that results when high blood sugar damages the eye’s capillaries, eventually weakening the tiny vessels and leading to ruptures across the retina. As the capillaries cease to be functional, less oxygen reaches the eye and eventually the tissue dies, causing blindness. Retinopathy can be stalled with laser treatment or prevented by strictly monitoring blood glucose levels through diet and medicine.

Diabetes that leads to retinopathy is the leading cause of blindness in working adults. According to the National Eye Institute, one in 12 diabetics over the age of 40 has vision-threatening retinopathy. Latinos, who make up at least 40 percent of the San Joaquin Valley’s population, are 1.5 times more likely to develop diabetes, according to the Centers for Disease Control and Prevention. At the Merced clinic, a majority of the patients have diabetes, which is often caused by a combination of poor nutrition and little exercise.

Many patients do not understand that their poor eyesight and diabetes are linked. Cuadros recalls how one of his female patients, who was going blind, thought that insulin had caused her diabetic sister to lose her sight and therefore had decided not to take her own medication. Cuadros showed the woman a picture of her own eye to explain that it was the diabetes and not the insulin causing damage.

“There are all kinds of problems that happen with this population,” says Cuadros. “A lot of it has to do with the plain fact that a lot of patients don’t understand what somebody is telling them. But there are a lot of social and economic barriers, too, like saying, ‘Oh, I was called into work so I didn’t take care of my retinal detachment, because I had to go to work.’ That makes no sense, but it happens all the time.”

Inside Merced’s exam room, Thao scrolls through picture archives on the computer. He points to a small dark smudge on the edge of a glowing circular retina; as he zooms in on the dark speck it blossoms into a red flower-like spot. This, he explains, is a minute hemorrhage, which is indicative of retinopathy.

Diabetics should have their eyes checked by an optometrist or ophthalmologist at least once a year. But, Cuadros says, fewer than half of diabetics get timely eye exams and that problem is more pronounced in the Valley because of limited access to specialists and spotty knowledge about the disease.

“Patients don’t really understand what diabetes does to their bodies over long periods of time,” says Phyllis Preciado, a physician who worked with Cuadros to incorporate his digital system into her diabetes programs in the Valley. “If you look at the progress of the disease, it is sort of silent. It just sits there until 10 or 15 years out and then you start going blind and getting other complications.”

Now the clinics using Cuadros’s technology screen every diabetic patient.

For mild cases of retinopathy, the pictures serve as a warning to patients and often prompt them to take control of their diabetes to stop the progression of the disease, says Chan Saeng-Inh, Merced’s diabetes team coordinator. For cases of severe retinopathy, however, the pictures alone do not always help. More advanced retinopathy sometimes requires a visit to the ophthalmologist and laser treatment. Although Cuadros’s technology may expose some conditions, very poor patients still may not have enough money to proceed with care.

“It is one of the downfalls [of EyePACS] that sometimes we know what is going on with the patient but we can’t do anything about it,” says Saeng-Inh.

Over the last decade the field of telemedicine has grown considerably. Medical specialists now conduct real-time videoconference exams and even perform surgeries with robots from hundreds of miles away. In the fields of radiology, dermatology and optometry, doctors are increasingly using digital technology to send images to specialists in other locations.

The technology, however, has come with a hefty price tag. Kaiser Permanente and the Department of Veterans Affairs have both spent millions on developing digital eye-care systems for retinopathy screening. Kaiser’s $1.35 million contract with the company Ophthalmic Imaging Systems pays for their hardware, software, implementation and training. In coordination with the digital eye system, Kaiser has also started a multi-billion dollar electronic health record where patient files, complete with retinal pictures, will be stored.

Cuadros wanted to make sure that community clinics could afford his eye-care program so he used the grant money to purchase the digital cameras and develop license-free software. Although the system is less comprehensive than ones used by large hospitals, it is affordable and within current security standards, Cuadros says. The camera and other equipment cost about $20,000 but he expects that amount to decrease in the coming years.

“My system may not be optimal for a mainstream clinic, but it is optimal for a community clinic that is short on resources,” Cuadros says.

Those community clinics are not limited to the Valley. Twenty more clinics from Humboldt to San Diego plus eight in Guanajuato, Mexico, now use his digital system. Every day these clinics post pictures to a central server and Cuadros, along with his colleagues at U.C. Berkeley’s School of Optometry, make recommendations.

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On a Wednesday afternoon in October, about 100 miles from Merced in Oakland’s Highland Hospital, Cuadros reviewed Thao’s photos with Timothy Miller, a third-year optometry intern. Between instructing Miller and seeing patients, Cuadros walked the hospital’s hallways, speaking in English and Spanish to the other doctors and volunteers about potentially expanding his program to include the Big Three: retinopathy, glaucoma and macular degeneration—a chronic disease that usually involves the deterioration of the retina and eventual blindness.

Since the California Assembly passed its telemedicine bill in July, which allows Medi-Cal to reimburse doctors who review ophthalmology records that have been sent and stored electronically, Cuadros’s program will likely be viable even after his grant money runs out.

Barb Johnston, former executive director of the California Telemedicine and eHealth Center, a Sacramento-based nonprofit organization that provides innovative technology to underserved communities, says that Cuadros’s program has exceeded all expectations. In fact, the eHealth Center recently gave Cuadros a $13,000 grant to expand his software to include dermatology and psychiatry.

“He is dramatically improving eyecare for diabetics and it is setting a standard,” Johnston says.

But Cuadros worries that as his program grows, it might meet resistance from optometrists and ophthalmologists, who perceive it as competition. Those fears would be unfounded, though, says Cuadros, because retinal pictures do not replace a traditional eye exam. At his own practice Cuadros uses digital photos, which only capture a portion of the retina, as a supplement to his exams.

“If people would come in for regular eye-care visits then this system wouldn’t need to exist,” Cuadros says. “It is because they don’t come in that you actually want to make [a version of the] service more accessible.”

Golden Valley Health Center, which includes 18 clinics throughout the Valley, has already planned to spread Cuadros’s system to other locations beyond Merced.

“A lot of people don’t actually sit down and think, ‘What would I do if I went blind?’” says Cuadros. “Until you are presented with that situation, you don’t start thinking about how valuable your vision is.”

Cheng-Thao, who unexpectedly faced blindness after a lifetime of clear eyesight, realized that the loss of his vision would mean the loss of his job and his family’s financial security. Cheng-Thao was lucky to reach a specialist in time to save his sight. Although he has lost hearing in one ear from the surgery and suffers from blurred vision and moments of forgetfulness, his eyesight is pretty much restored and he now receives disability payments from work to help care for his family.

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Cynthia Dizikes is currently a freelance reporter and student at U.C. Berkeley’s Graduate School of Journalism.

 


Image makers: Technicians take photos of a patientís eyes, then post them on Cuadrosís Web site where he can diagnose many diabetes-related eye problems. Photo courtesy Jorge Cuadros.

 

 

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A closer look: A “consultation zoom” allows the optometrist to view retinal images from afar. Photo courtesy Jorge Cuadros.