1. Telemedicine Definition : The practice of medicine at a distance

2. A successful telemedicine program often starts with a face to face meeting

3. Then…ORBIS Telemedicine, Cyber-Sight Provides low cost extended presence connecting doctors on a continuous basis

4. Cyber-Sight How does it work?

5. The Server information original links  Located at Flight Safety, Flushing, NY

6. E-Consultation As described in the previous slide offers partners the opportunity to obtain consultation on difficult patients from an expert with the added opportunity to interact during the evaluation process and to share results of treatment in these patients

7. The consultation process goes like this: The partner is identified, trained, assigned a password and user name, and when needed given a camera and computer The partner is assigned to a mentor team A challenging patient is photographed by the partner and the history and pictures of the case are uploaded and sent The mentor is alerted, answers the consult, and a dialogue is established The partner closes the case when it is completed

8. Mentor Teams are made up of experts in the following sub-specialties Cornea Retina Glaucoma Oculo-plastics Pediatric ophthalmology/strabismus Uveitis ROP Genetics Retinoblastoma Cataract Neuro-ophthalmology Etc.

9. The patient’s clinical condition is documented with a digital camera* *The camera should be set at 640x480, PC or TV to obtain smallest picture

10. Partner logs on to web site Go to: www.orbis.orgwww.orbis.org Click on Cyber-Sight (left side of screen scroll down ¼ screen) Click on Cyber-Sight again on right side of screen Click on E-consultation Add user name and password – these are assigned by ORBIS This brings up the formatted page for patient information upload

11. Partner sees this screen and is greeted by name

12. Partner Selects sub- specialty from “drop down” menu

13. Sub- specialty selected

14. Strabismus format

15. Pictures have been uploaded

16. Should I cut the plus? If so should I cut the same percentage in each eye? Is it possible that wearing glasses will result in alignment? What should I do first? I know the child needs glasses, patching, and surgery. How would this be done best? Partner submits this information

17. The mentor sees the patient information, pictures, diagnosis, plan, and questions

18. The mentor Answers

19. A dialogue continues until The partner closes the case

20. Cyber-Sight Some examples of consultations

21. Partner diagnosis: Double elevator palsy Mentor diagnosis: Brown OS

22. Partner diagnosis: Duane Type III Mentor diagnosis:Duane Type II

23. Partner diagnosis: Left eye fibrous tissue Mentor suggestion: Simultaneous abduction: Duane IV

24. Partner diagnosis:Blow out fracture postop, recess RSR Mentor advises:Forced ductions, likely need to free RIR

25. Subconjunctival hemorrhage: Partner and mentor agree

26. Partner and mentor agree: Conjunctival laceration

27. Mentor: Unilateral hypoplasia of the optic nerve Partner: Amblyopia? Note double ring sign of optic nerve hypoplasia

28. Partner: Corneal dermoid Mentor: Agree – corneal dermoid

29. Partner: What is it? Mentor: Epithelial implantation cyst

30. Partner: What is it? Mentor: Granular dystrophy

31. Partner and Mentor agree: Traumatic cataract

32. Partner: Corneal foreign body Mentor: Agree – treat rust ring

33. Partner: Intraocular tumor – what is it? Mentor: Retinal angioma

34. Partner: Retinal angioma Mentor: Agree – retinal angioma

35. Partner: Foveal cyst Mentor:Idiopathic retinal epithelial detachment

36. Partner: Retinoschisis Mentor:Traction detachment

37. Three unusual and instructive cases…

38. Partner diagnosis:LSO palsy Mentor: I agree – LSO palsy; could the left SO tendon be missing?

39. Partner: What about the tendon? Mentor: The left superior oblique tendon complex is absent or severely atrophic Absent muscle Absent trochlea

40. Partner diagnosis: Congenital RSO palsy, 3 surgeries, what next? Mentor suggestion:CT for presence of RSO Muscle absent Trochlea present

41. I see two trochleas

42. Partner points out absence of RSO muscle belly

43. Partner diagnosis: Brown OD vs. LSO palsy Mentor comment:Most likely Brown OD; LSO palsy a long shot; depends on traction test

44. Partner demonstrates traction test – normal OD, lax OS Partner finds Absent LSO tendon at exploration

45. Two other parts of the Cyber-Sight Program:

46. E-Resource Ophthalmology Minute Featured Cases Question of the week Decision Making in Strabismus Eye Pathologist (link)

48. E- Learning BCSC questions Student course activity log in CME opportunities

49. BCSC and CME

50. Cyber-Sight is ORBIS Telemedicine Full program initiated spring 2003 140 mentors 296 partners 68 sites 32 countries 135 mentors 40 answering consults W2,075 consults – 6,000 communications 1,372 strabismus / ped. ophth. 200 E-Learning students

51. The flow of consults is as follows: The partner is congratulated for having the right diagnosis and correct treatment plan. Or an alternate diagnosis and treatment plan is suggested. Additional workup is recommended. Teaching points and suggested additional reading are made.

52. Thank you.