International Partners

Saving Sight in the “Forest Zone” of Brazil

August 28, 2018

You might live in an important regional cultural center of a half-million people located among the great metropolises of your nation. Perhaps that city boasts a federal university and several private colleges, a bustling telecommunications industry, steel mills, and even a Mercedes-Benz factory.

Still, if you have diabetes, especially advanced diabetes, your chances of seeing an eye care specialist are slim, which means your chances of losing your sight to diabetic retinopathy (DR) are inordinately high. Because, even though your country provides free primary care through a National Health System, there is not an affordable ophthalmologist to be found in this mid-sized city if you are among the low-income population. Try to schedule an appointment – you’ll wait a year. After the wait, when you’ve seen the specialist, you’ll wait another year for the results and any directive about what to do next.

That’s the situation for many diabetes patients in Juiz de Fora, Brazil. Those patients are most grateful, therefore, for Serviço de Controle de Hipertensão Diabete E Obesidad (SCHDO), a primary care clinic for low-income, high-risk patients with diabetes and hypertension. So you can imagine how thrilled they were to see Rajika Jindani, Indian-born American medical student working toward a Masters of Public Health and an MD degree at University of Miami Miller School of Medicine, walk in with a Remidio “fundus-on-phone” portable retinal camera, ready to take swift action in detecting DR.

The camera was borrowed from EyePACS. The three-week project fell under the auspices of the University of Miami and was made possible by Universidade Federal de Juiz de Fora’s (UFJF) hypertension interest club and the Population Health Scholars Award. Rajika was conducting the field experience project required for her MPH degree.

“I had five clear objectives,” Rajika told us. “First, I wanted to teach medical students from UFJF how to use the fundus-on-phone camera EyePACS had provided to take retinal images. I hoped, simultaneously, to learn more about the demographics of this patient population and extend the diabetes education that SCHDO was already providing. And, of course, I wanted to conduct DR screening and get as many qualifying patients as possible to an ophthalmologist for specialty care.”

The Remidio fundus-on-phone camera is a one-key App design that is meant to be portable and easily used by non-specialists like Rajika. With no moving parts, it travels easily and requires minimal maintenance or service. The battery provides up to seven hours of back-up per charge, and the App allows printing of high quality images directly from the phone.

During her stay in Juiz de Fora, Rajika was able to screen 50 diabetes patients and send their retinal images – eight per patient – for evaluation and diagnosis. “We first uploaded the images to a website where they could be scored by ‘MIT read score’ software,” she explained. “This artificial intelligence algorithm ranked each picture on a scale from 0-4, from no indication of DR to mild nonproliferative DR, moderate nonproliferative DR, severe proliferative DR, and macular edema. In addition, I uploaded the images to the EyePACS site using airdrop. Then a trained eye specialist looked at the images through the online portal, diagnosed each patient and offered an appropriate plan for treatment.”

Committed to expanding patients’ understanding of their multi-faceted disease and the importance of taking action before symptoms of DR become apparent, Rajika created a brochure that was translated to Portuguese, and she gave one to each patient following the screening procedure. “The medical students working with me went through the brochure with each patient to ensure they understood the information.”

Image taken with the Remidio fundus-on-phone App

Of the 50 patients Rajika and her team screened, 44% showed signs of diabetic retinopathy ranging from mild nonproliferative to macular edema, and 26% were identified as urgent for referral to an ophthalmologist. That last step, of course, would provide the greatest obstacle, so Rajika and her team created an expedited process to significantly reduce the one-year wait patients would have endured, had they scheduled the appointments themselves.

Her project successfully completed, Rajika has returned to southern Florida where she is already deeply engaged in local eye health activities. “Through the University of Miami Department of Community Service,” she said, “I help with monthly health fairs throughout south Florida. I am involved in running the ophthalmology station, where we test for visual acuity, intraocular pressure, and corneal thickness. I think adding a diabetic retinopathy screening station would be beneficial.”

Raised in Thousand Oaks, California, Rajika majored in Public Health at UC Berkeley and then completed a Masters in Medical Sciences at Boston University before entering medical school. She discovered EyePACS while researching international diabetic retinopathy projects to design her MPH capstone project. Armed with knowledge that such a telemedicine solution could save sight, she was motivated to undertake her own international sight-saving mission. When she has earned both her MPH and MD degrees, Rajika hopes to return to California and complete a residency in ophthalmology.

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