Lecture: Cybersight Consult and AI Services: Transforming Patient Care & Mentorship With Telehealth Technologies

DR. NEELY: Well, greetings to all our Cybersight friends. We’re very excited to bring this panelist discussion to you. What we intend to do today is to give you some practical tips for using Cybersight Consult. And to that order, I’ve invited a few friends to join me here. So, I will move on to share my screen and then I’ll give introductions to my guests here. All right. So, today the title of this webinar is Cybersight Consult and AI Services: Transforming Patient Care & Mentorship With Telehealth Technologies so with what do with mean by that? What does this involve? Orbis has always been famous for the Flying Eye Hospital, of course. But the history of Cybersight really goes back to about 1998, when my mentor, Dr. Jew gene Helveston was on a tripicamide to Kube. And had infrastructure problems with supplies like we expect, but there was a great need to have ongoing mentorship with the people that he was working with. And the three Cuban ophthalmologists that he was working with, the way they solved this problem was that Dr. Helveston, who was Orbis’ first pediatric ophthalmologist. He arranged to purchase a couple inexpensive digital cameras and some computer equipment and got that to the doctors in Cuba. And then started having a mentorship dialogue back and forth to talk about the patients they cared for and the patients over time. It was such a big hit that Dr. Helveston expanded that to other locations. And one of our first S&Lists, Dr. Luminita, who I will introduce, was one of the first ten users of Cybersight back then. So, it kind of started growing just organically from this small group. And then in 2003 Dr. Helveston gifted what he had created to Orbis and it became the official Orbis Cybersight telemedicine that we know today. And it’s evolved since then. Kind of puttered along from three to 2020. And we went have a few initial consults to about 3,000. And then COVID hit. And we all know how that changed our practice. And all of a sudden, Orbis couldn’t go places. We couldn’t go work with people. And so Cybersight became our lifeline, and it really became a proof of concept. And all of a sudden, not only did we expand the teaching material, including starting these kind of — or enhancing these kind of webinars, but also we saw that the consultation service really, really grew. And so, now today here we are, fast forward, now today Cybersight has over 120,000 registered users like you. And approach represents every country in the world other than two. And so, we’ve seen just this tremendous growth. And I like the term that Dr. Helveston came up with which was “Extended presence.” All right? So, let me move on to our portfolio. We started with Consult. That was the base feature of what Orbis telemedicine was. The Consult feature. And one of the things that we’ve found out over time is that while Consult has grown, a lot of people don’t even know that this is part what have Orbis does. And it’s such a valuable thing because Consult, it allows you access, no matter where you are, you could be in Somalia, Afghanistan, Myanmar, you know, you could be in all of these places that are really difficult to access, and yet you have instantaneous access to a world expert in a sub-specialty topic. And it’s a free service that’s available to everyone. And so, that’s definitely one of the goals here today is to create some awareness and then give you some tips for how to use this service. So, Consult has grown to over 30,000 consults. We use it for all the pre-screenings before we go visit places. If I’m going to work with Dr. Tembo in Zambia, he’s showing me all the patients we’re going to work on that week before we even get there. It really enhances our boots on the ground experience as well as just having mentorship and second opinions available for you. The rest of the Cybersight portfolio that’s grown over time is the Learn section, you know, which you find in the library. We’ll touch on that. But all the learning material, whether it’s courses on live surgical videos, recorded webinars, live or recorded like this, all of that is found in the Cybersight Library. And then, of course, we have the live teaching, which we’re doing right now. But we also offer live surgical teaching and we’ve done some live surgical mentorship back and forth in real-time. And then, of course, the flying Eye Hospital, Those broadcasts are projected out over Cybersight. And then the more recent thing, which is still in its infancy, but I think is going to be increasingly popular, of course, is the AI component. And right now we’ll demonstrate that. Right now it’s kind of limited to things that are easy to capture with a fundus camera. Right now AI is largely limited to diabetic retinopathy screening as well as glaucoma screening. Now, today, who do we have here today? Well, I’m here. I’ve been a pediatric ophthalmologist at Indiana University for 28 years. Dr. Helveston was my mentor. So, very early on he got me involved in Orbis and it’s been my pleasure to continue his stewardship of Cybersight. I mentioned Dr. Teodorescu from Romania early on. And she has been with Cybersight since the beginning. So, I think it will be very interesting to get her perspective, because it’s really given her mentorship and she’s been doing this a long time. And yet, just like me, I still ask questions was my senior men torse. So, for instance, whether it’s Dr. Helveston or Dr. Plager here at my university, it’s always nice to have someone that you can ask an opinion of and Luminita has been a great example of that from the beginning. Dr. Lalloo who is in South Africa. He and I worked together about 15 — 10 to 20 years ago on several occasions. And he’ll introduce himself later, but he’s a general ophthalmologist who needs to do pediatrics as well as other sub-specialties. So, he has a very nice perspective on how being a general ophthalmologist, he has been supported by Cybersight. And then Dr. Tembo, who is one of the newer members of the Cybersight Consult community. He’s just finished his fellowship in India a few — a couple years ago and I’ve had the count to work with him in Zambia in his home hospital a couple times. So, we’ve got kind of the range of career experience here and I think that will give you a nice overview of just how all this works. And this brings us to our first poll question. We kind of want to get a little bit of an idea of who is with us today. So, if you could, take a look at these options and try to pick the one that best applies to your situation. All right? So the first option here is that you’re a health professional, eye health professional. You’re from a low-to-middle income country and you have a registered Cybersight account. Second option is that, again, you are in a low-to-middle income country. You have an account, but you also have the Consult AI access. You’ve upgraded your account. That’s what we hope to see a lot of people do today, upgrade their accounts. You’re an eye health professional in a low-to-middle income country. W a registered Cybersight account. Hopefully you do otherwise you couldn’t have signed up for the webinar. The other are you’re a healthcare professional and don’t have a Cybersight account or maybe not in a low-to-middle income country. Your best answer here and then we’ll have those results shared. So, yeah. As expected, I think most of us are in that top two categories. And I think looks like most, more than half already have the full Consult and AI capabilities. And about 15% of us, we’re going convert you today and I’ll show you how to do that. We’ll close the poll and to our next screen here. All right. First let’s talk about Cybersight Consult. All right. So, this is our online telemedicine platform, all right? This is where you can get free mentorship, free second opinions. You can talk about cases and you can get tips. And keep in mind, even though you submit something in a consult, you’re never obligated to follow that advice. But it’s a way to just get more opinions on your patients. And then I think some of the presentations today will highlight they’re, you know, user receives advice and then they kind of mix that into their own personal situation and so forth. And may come up with their own plan. But it’s always nice to have that input. You can do this on mobile, you can do this on a desktop, a laptop, it doesn’t really matter. It has been designed to fit nicely on to mobile platforms. All the material in Cybersight has been. It should be seamless, regardless of your platform. Who is eligible for this service. Well, eye care professional. But that’s a wide range of people. That can be ophthalmologists, optometrists, nurses, bio technicians. Really we support the gamut of the eye health community. Now to get this access to the consultation and AI features, there are some location restrictions, all right? This is not — this is not built for someone in Canada or Great Britain. Or the United States. This feature is built to support people until low-to-middle income where we know that sub-specialty care is limited and mentor care is limited. There is a list that you have to be from one of these countries. If you use that QR code, you can bring up the list. But it’s going to be the places that you would most likely suspect. There is a geographic restriction because that’s a community that Orbis supports. All right. Now how does this work? Well, here’s a demonstration on the mobile platform. And as you can see, once you download the app in this, the mobile app, which is probably how most users access Cybersight, the majority of the time. The mobile app is available in the App Store for iOS. Also and it’s available for Android users in the Google Store. So, all of those work very well. Once you have it downloaded. Then as you submit a case, you’ll — there’s not just one pathway here. You submit a case you know need to declare what kind of case that is. And that helps us give people the best feedback. So, the three choices are going to be — it can be a patient case, which is largely what our panelists will be discussing. Patient cases where it’s about a specific patient and in the care of that patient. Or the medical opinion for that patient. So, that’s a patient case. Then there is the AI-only case. And that’s — this is currently limited to, again, diabetic screening and glaucoma screening. And that could be submitted by you or you could delegate someone with your credentials to submit those images for AI-only screening. And we’ll demonstrate one of those and show you how fast it is. And then general question. This one gets a little confusing. But say you just have a question that’s not specific to a patient or it’s a question about optics or anything within eye care and ophthalmology or optometry. If it’s not about a specific patient, then that goes into the general question category. And you’ll see that the formats are just a little bit different. That’s a very non-template format. Once you have selected, say you’re doing a patient case, number one here. Then in the middle of the screen, as you — once you submit that you’re — select that you’re doing a patient case, well now you have to pick a sub-specialty. And the reason that this is important, there are two factors here. One, while the templates for the different case submissions are very, very similar, there are some small differences. So, if you’re doing strabismus case, it needs to have some strabismus template to it. If you’re doing a cataract case, then there’s some specific things about the lens findings. And so, the templates vary slightly. But the big deal is that this is how we route the case to the appropriate mentor. You know? You don’t — I’m a pediatric ophthalmologist. You don’t want your question about refractive surgery or age-related macular degeneration coming to me. You want those to go to the appropriate specialists and so forth. So, this is how we route the case to the correct person. That’s very important to get the case selection correct. And then what will happen is that once you have uploaded your information, then if it’s an AI case, you’re getting a response within a minute or two. It’s that fast. If it’s a patient consult case, our goal is to have that back to you within 24 hours. And then if it’s — because it’s patient care-related, right? And you may be needed to go to surgery soon. If it’s a general question, just kind of something more academic, we have a little more leeway and you can expect to get that result back in two to three days and at any time if something’s not being answered quickly, what will happen is it gets routed to me and I kind of triage it and we try to facilitate it, maybe find a different mentor, whatever needs to be done. We do our best to get these turned around as quickly as possible. A new thing that we have added recently is a little more information about who is answering your case. Right? Sometimes it’s gonna be someone you have worked one-on-one with. Like people who have worked with me, their cases will come to me. Unless they don’t want them to. But a lot of times it’s someone you don’t know, right? We have this new feature. And again with this QR code, you can bring up our list of mentors. And we keep a relatively small selection of mentors. And that’s for a few reasons. One, we’re covering 17 specialties. And you can see the list there. But we don’t to want dilute it so much that mentors aren’t getting used on a regular basis. So, each sub-specialty will have anywhere from two to four mentors assigned to that. And so, if you just submit something to cornea, it’s going to go to the next available cornea person. Unless you choose otherwise. But that’s a nice feature I think you can look up and learn about people like retina blastoma, Jessie Barry down in the middle, you can see what an amazing amount of research and work she’s done. And then right next to her, Karl Golnick, the neuro-ophthalmologist. And you can see how impressive these people are. And these are the caliber of people that are answering your questions. So, it’s incredibly informative. All right, which brings us to our next polling question. There are a lot of choices here. But give us some idea of what sub-specialty areas do you think are going to be most usable to you? And while you do that, you know, the reason this is important to us, kind of helps us gauge what we need to do a good job and provide what mentors to be in. And decide what webinar speakers to get topics on or quizzes. Or, you know, test your knowledge exams. Or coursework. Having some idea of what everyone is idea in is important to us. All right. So, we’ll show the results of the poll here. And so, a little bit all over the place. But nice to see general ophthalmology. Neuro-ophthalmology. That’s always a big one. We do try to do that. Genetics is certainly growing. Optometry. We have some optometry, and I would certainly like to see us expand that. And then the others are pretty evenly divided. All right. Now one thing you see here, once you have submitted your case, right? You’re gonna get the response pretty quickly. As quickly as we can. But as soon as you submit it, one thing, you’re going to get immediate feedback from Cybersight. And if you look at the bottom right of this screen, the AI system built within Cybersight will immediately scan all of the Cybersight library and consult offerings and try to suggest a few items that you would have access to immediately that might apply to your particular question. So if you submitted a case on — in this case, it was a question on Duane’s syndrome. The AI system brought up not only topics on Duane’s syndrome on lectures and webinars. But on questions four and five, it brought up other Duane syndrome cases so you can go to those and look at any publicly-accessible case within the Cybersight system that would be on Duane’s syndrome. A few might get recommended to you there, but you can also search public cases within Cybersight Consult and find a list of 20 Duane syndrome cases. You can do that on your our in addition to what gets recommended here. And I’ll just make a little comment about public versus private cases. And we’ll touch on this again as we do a demonstration. But we’d like to have cases be public. But there can only happen if the person submitting the case is comfortable with that. So, as you submit a case, if you allow it to be public, then other users can look at that case after it’s closed. Not while it’s being actively managed. But after it’s closed, then it’s searchable and people can learn from it as well. However, if you’re either not comfortable with that or maybe there’s a privacy reason that you don’t that to be the case, then you just set it to private and no one else could see that except your and the mentor answering the question. We encourage cases to be public. But, you know, we I want everyone to be comfortable. And all of this is still secure within the Cybersight system, right? Not just anyone can log on and look at Cybersight cases. You have to be an approved user that as a username and password that has been vetted. There are some precautions to maintain privacy here. All right. So Cybersight AI. Let’s touch on this first. All right. So, the QR code, if you want to learn more about it here. Again, currently restricted to diabetic retinopathy and glaucoma. But you can expect our offerings in this area to expand. We have ongoing meetings about this. And we’re looking for the next AI action to add. And so far this has been really incredibly popular. Maybe we’ve had 35,000 patients screened with the AI. And that’s become, oh, I think — oh, where’s the number? Up to 62% of consult cases currently are AI-only. That could show you — that’s a good evidence of how that’s been embraced. And this has only been available since 2021. All right. So, let’s kind of see how that works. But first we have another polling question. Okay. So, let’s get some idea of what has anyone used AI so far? So three choices. You’ve used AI and you had a positive experience. Or you’ve used AI and you had a negative experience. And then neutral is either haven’t used AI or you don’t know what to think of it. And none of these answers will surprise me. You know? This — not only is all of this in its infancy, but as we go through this, we fine-tune our programming, expand our databases. And so, even if it turns out — go ahead and show the results. All right. So, fortunately we don’t have too many in the negative column. But I would say that if you have had negative experiences, look, this is only gonna get better. But so mostly positive and then we have a large group of people who just haven’t had the opportunity to use it yet. All right. Why even do AI? Why not just do a regular consult? Well, I think they kind of serve different needs. You’re in the gonna submit a strabismus case to AI. Not yet, anyway. That’s my goal. But what’s the nice thing about AI? Well, it’s fast. It’s almost instantaneous for what we can offer. It’s something you can delegate. So, if your location does a lot of glaucoma or diabetic retinopathy screening, this is a way to have technicians or nurses take photographs and do the screening rather than having people sit in your chair. Increased compliance. I think this is one of the more interesting things to me is that when people have been screened and then get an immediate result from the staff, literally within a minute or two, they were 30% more likely to follow through with their referral. So, if that means you have someone with referable diabetic retinopathy, giving them that instantaneous feedback greatly increases the chances that they’re gonna show up and get the care that they need. All right? So, I think that in itself is really an important factor here. All right. We got a little video here. And.
>> In this short video, I’ll explain how to use Cybersight AI to report automated fundus images. Cybersight AI is a free, open access tool that can detect diabetic retinopathy, and macular disease. It can be working with a Cybersight Consult. It can be used in ways. First were AI-only, with no human mentor involved. Alternatively, images can also be attached to patient cases submitted for a second opinion. In either option you can attach up to eight images per case and the AI results are returned in about a minute. You’ll receive an email notification when your report is ready. The PDF report can be easily downloaded or printed for your records. Expert view gives you a more granular view of your images, allowing you to zoom in on areas of concern and turn AI annotations on and off for better visualization. If you’d still like advice from a human expert, you can also optionally resubmit your AI-only case to a Cybersight mentor for many a more in depth discussion, and mentors typically respond within a few hours. Here are tips for getting high-quality results from Cybersight AI. Use a 45 or 60 degree Mac a large-scale image. Use images directly from the fundus camera. Ensure only one fundus appears in the image and nothing else. By contrast, avoid SLO or wide field, patient reports, visual fields or multiple fundus images in a single file. And don’t submit a photo of your monitor a piece of paper. To get started, sign into your Cybersight account by going to Cybersight.org or scan the QR code to learn more. If you have questions or feedback about Cybersight AI, we’d love to hear from you. Email us as support.cybersight.org.
DR. NEELY: All right. So, that’s a brief overview. And how do you get access to Consult or the AI Consult? Well, if you’re a new user, of course, gonna create account. So, use the QR code on the left. You already have an account, which I assume applies to most people on that webinar, then on the right-hand side if you have the app and you can scan this QR code, then there’s a link there where you can simply upgrade your account. All right? Now, if you have any issues with that, then we could work with you directly one on one. And [email protected] will get you to a person like Andy or Lawrence who can help you out. All right. That’s how you get access. And then for those of you who aren’t in locations where that’s an opportunity, so if you’re not in a low-to-middle income country, you have access to all the other Cybersight material. The library, the teaching materials, the lectures, the courses. You just don’t have access to the Consult feature, which is restricted, all right? All right. So, I want to get to our panelists, but before we do, I want to do a quick demo. I’ll just show you kind of how easy it is to do a — Amy just gonna show you how easy it is to do a quick AI upload and then walk us all through what a patient case submits and looks like. And then we’ll move on to our panelists. And I’m gonna share my screen. Again. All right. So, here is — this is my home page when I log into Cybersight. So, I don’t have anything waiting for me. I have lots of closed cases. But let’s say I want to submit an AI Consult. From your home screen, you can either do it down here, bottom left where it says “New request,” and you can see the options come up there. Or to the big red button, start a new case. And let’s to an AI-only case. So now that have video that you just watched, you can watch that again here. But it’s just this easy. Choose files. And I’ve gone to my downloading. I’m gonna use this left eye and this right eye. And these are two different patients. But I’m just gonna use them because they’re a little bit different from each other. So, those two images, while being uploaded, they’re also being graded. So, they’ve both passed. The AI system has identified that they are actually fundus images because it’s the only thing it can deal with. And the AI system has confirmed that they are in fact gradable. That’s pretty quick. Once you chosen the images, you submit them, all right? Boom. Those are gone. So, that’s how fast the AI is. Now, in terms of the result, it’s usually there within just a couple minutes, all right? You’ll get a message in your email. This is one that I actually sent just prior to our webinar so I could make sure we had it. But I’m opening up — I got an email saying, okay, your AI result’s ready. And then this is — you’ll get this report. And it gives you some information about your image, whether it’s gradable or not and whether it’s abnormal. But the images are down here. And it gives you — this is the kind of overview, right? So, it starts to go through cup to disc ratio. Tells you is there a be anomaly on the disc. Then it looks at the macula and starts to do grading of that. I kind of like the expert view. I just clicked on that. That allows you to bring up a large-scale image. Let me go to the bad one. Let me go to this almost-proliferative diabetic retinopathy. All right. So, right away, these little eye icons. Click on that. Shows you how it’s degrading, the cup to disc ratio. But right here, doing the diabetic retinopathy screening. Refer diabetic retinopathy, yeah, this person needs to be seeing a doctor. And then grading, normal, mild, moderate, severe, or is it proliferative? And the AI system has done — it’s been tested enough with both humans and multiple databases that we feel pretty good about this feature at this point. The glaucoma — I think does a really nice job of cup-to-disc ratio. But we know that glaucoma is a little bit more complicated than that. And so, it takes — that’s an area where I’m hoping that we can add things like being able to add OCTs back into that and so forth. And visual fields. And kind of make that even more than just looking at the optic nerve. All right. How do you submit a patient case, all right? Patient case. Let’s do that. Patient case. Sub-specialty, remember that’s important. That’s how it gets triaged to the correct mentor. I’ll send this to myself. I’ll show you some tricks there. It’s going to the next available person. Or if you’re paired up with someone, I’m paired up with myself. I hope I agree with myself. I’ve selected my name and stays in my loop and this patient that I have, let’s just say it’s a 6-year-old little girl. And so there’s some red asterisks here, right? You got to pick the sub-specialty. You got to input the age. We need to put in some history. We don’t just want you sending in pictures. There has to be some basic history. As basic or as detailed as you want. But the red asterisk areas, there’s four of them, those have to be completed or the case won’t submit. Everything else that’s not in red or doesn’t have an asterisk is optional, right? Esotropia for 3 years. I’m gonna keep that real basic. Visual acuity. All right. So, I’m in the United States. We use 20 feet, right? But I’ll just put some in real quick. But if you use meters, or decimal or LogMAR, you put it in whatever format you use. And then when it comes to me, it will be transcribed into whatever format I have set in my profile. So, that’s handled automatically. Use whatever you like. And the other stuff. There’s lots of stuff here. People get hung up on the other stuff. All this is required. It’s optional. But because this is strabismus case, motility is required. Let me bring up the patient image. This is the case that I’m thinking I want to upload, right? This is esotropia. They’ve got bilateral inferior over action, and more esotropia on upgaze and less on down gaze. An inverted esotropia. All right. Get back to my screen. All right. So, I’ll be inputting the motility. And if I say that the alignment is not normal, then I get a motility grid, and I can input all that have stuff. Now, so this is the strabismus case. Well, what if this wasn’t a strabismus case, how does it look different? So what if I had selected a template for cataract? Well, now what’s required? Now what’s required is some information about the lens. And now motility isn’t even on there, right? The forms do change just a little bit based on the sub-specialty. And then, oh. Let’s just go to glaucoma, right? Well, guess what’s gonna be required for glaucoma? Well, still vision. But now intraocular pressure, of course, right? So, there are some small variations. All right. So, all right. And then I’m not gonna actually go through all this and submit a case because I want to save time for the panelists. But diagnosis. This is just free text, right? It doesn’t matter what you put in. But we like to have what your diagnosis is. We like to have some idea of your treatment plan. So you’re gonna do — I’m just gonna abbreviate bilateral media rectus recession, BMR. But maybe I have a question about what to do about the V-pattern? And inferior oblique overaction. All right? So, this is — this is important. All right? We need to not only have the case information in a usable format, which is why the templates are here, but we need to know what the person’s thinking who is taking care of the patient. And what is their thinking about how they’re gonna treat it? And what questions do you have? It’s much more beneficial to everybody if you have some basic concept of what you might do. And this gives the mentor a little bit of frame of reference of what your level is. And then well, what question do you want? Not, don’t just send a question and say, oh, patient has retinopathy, what should I do? Well, let’s get a little more discussion going here, because this is all about discussion. All right. So, one last thing. A couple two more things I’ll point out. If you are choosing files, all right? So, I can — I can choose as many — what did I say? Up to eight. I can do OCTs, optic nerve, retina. Normal fundus. My collage. There’s a B scan. All right. So, these are obviously not all from the psalm patient. But I’m showing you can upload whatever supporting documents you want. And this 9 gauge is a nice collage. But if you just have five different pictures of the eyes in different directions, that works, too. But all of this is helpful. B scans, OCTs, fluorescein angiogram. You can upload any of that, and you can upload videos as well, all right? And sometimes that’s really helpful in some of these cases, especially for oculoplastics and ophthalmology and strabismus. And you can upload all of that. And if you do have a fundus image like to one, I can ask it to run the AI interpretation on that. Now, it’s not necessary. But that’s an option if you have a fundus image, you can run AI for diabetic retinopathy and glaucoma. This is what I was talking about earlier. All right. So, if I don’t do anything and just submit this case, it’s going to be public. And so it will be searchable once it’s closed. If you not want anyone else to be able to view this case, you just simply click that. And then once you’ve clicked keep case private, it just stays between you. And then I’m just gonna submit this AI, no. AI. And submit it. And I’ve not — it won’t let me because I — oh, I didn’t — oh, that’s right. It’s a glaucoma case. I never put in a pressure. So, it will stop you if you don’t have all those red fields clicked. All right. So, that’s the mechanics of submitting a case. I’m not going through and submitting it and open it back up. But the whole point with these cases is you can include as much material or as little as you want. But try to give enough that people can work with it to answer your question. And the whole point, which you’ll see how as we start talking to our panelists, the whole point is that we’re opening a discussion. This is not you send in a case and someone says, you have to do that. See you later, bye. The whole point is to discuss the case, have various options. See what’s available in your area for logistics and supplies and capabilities. And then, you know, between the two of you, you make the decision, especially on your own, you make the decision of what’s gonna work best for you with that input. And then it’s also nice that once you something, you can tell that person after you did the surgery or whatever, well, how did it turn out? You know, it was great, thank you. Or, hey, I still have this problem. What should I do next? And to me, those are the most valuable cases where there’s this ongoing back and forth and it’s not just do this, do that, see you later, bye. This is really about discussing the case and everybody on both sides learning from this. Because I can tell you that I think you’ll see one of Dr. Lalloo’s cases, you know, I learned something from it, too. And it changed how I practice just because of our discussion. All right. So, I’m gonna quit kind of hogging the show here. And we will move on to our next set here. And I think Dr. Lalloo, I will — I’m gonna stop my screen share and let him take over. And he’s gonna tell you a little bit about his background. And after Dr. Lalloo, then to Dr. Teodorescu and then to Dr. Tembo. All right, Sanjay. Turn it over to you.
DR. LALLOO: Okay. Thank you, everyone. It’s a huge privilege to be presenting here today. And thank you to Dan and Orbis for giving us this opportunity. So, I’m a general ophthalmologist in South Africa with a special interest in cataract surgery, pediatric ophthalmology, strabismus, and glaucoma. So, we are based in a small city in South Africa called Pietermaritzburg. And the background to this. I was fortunate enough to be exposed to Orbis via the Cybersight mentorship program in 2012. It ran for five years. And it had online Cybersight consults as well as this hospital-based training. And the host site was a different hospital in Pietermaritzburg. And focused on pediatric ophthalmology and strabismus. And I’ve used the Cybersight consult platform from the first exposure to today for multiple sub-specialties. And the issue if in South Africa, there’s a limited number of subspecialty trained ophthalmologists. And the care is usually provided by a general ophthalmology that has a special interest in that area, that has done a little bit more training. In our hospital, there are five ophthalmologists with different areas of interest. A common condition such as cataract surgery, glaucoma, medical retina are treated by all ophthalmologists, but specific sub-specialties are referred to the relevant doctor. Going through a few cases just to illustrate the benefit of the Cybersight platform. So, the first case is a 6th nerve palsy. A 64-year-old male that had binocular diplopia for one year. Hypertensive and had a neurological workup that showed an ischemic 6th nerve palsy. He was patching his left eye and essentially it was non-functional. As you see in the photo, the 35 diopter left esotropia and limited to the left. As he was not using the eye, he opted for surgical correction. So, as I it not done a 6th nerve palsy in some time, I did a little bit of a literature search and I came across this webinar by Dr. Simon who presented this as a Cybersight education webinar. Previously, you know, when Dan taught us to do a full tendon transfer. But this technique seemed quite interesting. So, I asked Professor Neely for his advise and thoughts on the procedure. This was the consult we loaded on and the measurements we put forward for the specific patient. And then we had a response back. Some of the issues were, we weren’t totally familiar with the procedure. The suture that was advised was not really available. So, remarkably, Dan responded in five hours. And then, you know, he made some suggestions in the suture type. So, the Nishida is basically using the superior and inferior rectus to pull towards the lateral rectus. So, that gives you a little bit of lateral movement. And I’m not gonna go into the details of the procedure. So the results, the left modified Nishida Procedure, which was the first case that I had done of this kind. Which was in the specific patient day one looked straight. Although we many a 16 prism diopter subjective esotropia. At two weeks, it was around 30. Although it looks straight to me, this was more with him using the paretic eye to fix. And the plan was to review in three months and consider middle rectus recession. Case 2 was also 6th nerve palsy, which coincidently occurred at a similar time. It was a 51-year-old female who also had binocular diplopia for three months. And her issue was post-motor vehicle accident or traumatic 6th nerve palsy. We tried Botox to the medial rectus at 3 months, this reduced the squint a little bit. But ultimately it returned. So, she also opted for surgery. Request her, as you can see, much more limited abduction to the left. Although we measured her squint at between 50 to 68 prism diopters. I think it’s got to do with which eye she was fixing with. This was the second modified Nishida that we did. Day one she looked quite straight, although claimed 20 prism diopter subjective esotropia. At two weeks, also had a similar amount. And the plan was to review in three months to decide on a medial dissection if needed.
what I learned, modified Nishida is useful for single muscle proptosis. It would be my choice going forward. It’s not always predictable in my series of with 2, but read around about that. And the mentors offered me guidance and treatment options for this patient. The third case was corneal hydrops. A 45-year-old male, uniocular. Had keratoconus. A two day history of pain and reduced vision. A marked swelling and a few corneal blood vessels. And opted for conservative treatment with hypertonic saline. And he did not improve and was not keen on immediate corneal graft. What did I do? I did a literature search again and found a few articles detailing the use of SF6 for acute corneal hydrops. Coincidentally, there was also a nice Cybersight YouTube video that ill I came across that showed an interesting technique. So, I logged a case just to get some advice. And, you know, just some pulse for the case. although the mentor discussed a different technique. After discussing with the patient, we opted for the SF6 18% full with the 50% full. And as you can see, the pictures on the left showed the pre-treatment. The pictures on the right show post-treatment. So, the patient had a good response initially. The gas did absorb after a few weeks and then the partner advised to just repeat the gas with the c3f8, which obviously helped quite remarkably. There was a central corneal scar and the patient underwent a corneal graft. What I learned from this case, non-expansile gas is a useful technique for corneal hydrops. And the mentor offered support even though not familiar with the technique and provided video links to assist with the procedure sequentially. The last case was that of a leaking trabeculectomy bleb. And a 64-year-old female, uniocular, had trabeculectomy in that eye 10 years prior. And presented with bleb leak and shallow AC on the right. And double padding did not help. So, obviously the need was there to close the leak. So I did subset consult to just get any pulse or advice on this technique. So, this was the consult to Dr. Jody Plitz-Seymour. And he wasn’t as quick as Dan, but eight hours, still remarkable. So, we had a discussion, you know, back and forth. And I come across some of the videos and, you know, asked her about what her experience was with that. And, you know, as we went through the case, she gave advice as we went along. So, these are some of the pictures after the repair that the conjunctiva is very friable and very, very difficult case. So the patient had a bleb leak post-repair. And as I mentioned, we asked for advice on how to approach this and the risk of failure. So, she gave advice on how to do certain needling techniques. So, the result, the patient settled on 2 agents with the pressure of 15 millimeters mercury. She had a significant cataract and opted for cataract surgery which was successful. And her pressure was well-controlled on two agents. At that stage needling was not needed. What did we learn from this case? The technique for bleb leak management was enhanced and suggested. The mentor offered support and advice through the course of the case. And the technique for needling was also informed. So, in conclusion, the Cybersight consult platform is an invaluable tool. The partners are highly skilled, committed, and respond timeously. Make not as quick as Dan, but really remarkably so. Orbis is committed to improve ophthalmic care worldwide. And how that is helped me? It’s helped me to better manage patients, improved patient outcomes. It’s improved my skill and knowledge. And although we don’t always follow exactly what is advised, it is useful to get experience because knowledge is lots of the times based on experience from the mentors. And critical to get a second opinion and work collegially. Sometimes we tend to work in isolation, but it’s such a huge benefit to get that and a big thank you to Orbis and Dan. Dan was a little bit younger here. And we are just so grateful for all the work and selfless work that Orbis and Cybersight does. Thank you, everyone.
DR. NEELY: Thank you. Yeah, I think we were all a little bit younger then. You know, I like his cases because I think it highlights a couple things. One, that there’s this discussion. It wasn’t just a question and an answer and that was the end. It was some good examples of discussing the case there. And I think that’s more than anything that’s probably where the value is, is just having that dialogue. Two, you know, there’s no obligation to do what someone recommends. You know. There was — even though the mentor that wasn’t their preferred technique, the mentors were like, yeah. We can make this work and then they supported each other and discussed it. And as supplemental materials were sent, which is something I like to do, too. If someone doesn’t know a technique, send a diagram or a link or a video. I think that’s a good example of that. And both parties learned. I learned about the Nishida when we talked about it. I had just started doing it at that point and learned from the same video that you learned from. Because I traditionally had done full tendon and maybe adding phosphagen. There’s benefits and pros and cons to both of those. And I think we both benefited from that. And again, the bottom line, anything we do in medicine, there’s no right or wrong way. You have to take everything into consideration and those are just excellent examples, Sanjay, thank you. Luminita, we’re gonna turn it over to you. Are you ready? And I want to say thanks to all the panelists today. You know, I’m just waking up. But three of them have just been through a long day of work and so they’re — we appreciate their commitment and willingness to do this. And Luminita, whether you’re ready, take yourself off mute, also.
DR. TEODORESCU: Can you see my slides?
DR. NEELY: Yeah. We have your slides and you are off mute. We’re good to go.
DR. TEODORESCU: Thank you so much. Let me first thank you for inviting me in this webinar. I would like to tell you some words about my professional story. I completed the three-year residency in Bucharest, Romania. In Romania, we don’t have a fellowship program in pediatric ophthalmology yet. And at that time, except 2 weeks in training in another town in Romania and some books, we had no other means of training and information at that time. My first contact with Orbis was in January 2002 when Professor Eugene Helveston visited us for the first time. Starting in 2000 under his supervision and with the support of Orbis, the telemedicine program was successfully launched in Romania. It was perfected in 2003 when Cybersight was created. And since then, I sent 314 cases to discuss with different mentors, especially with Professional Neely. In 2009, I opened a new pride pediatric ophthalmologist clinic in Bucharest, OFTALMIX. Three doctors from the clinic are involved in this program. Patients are generally coming directly to the clinic or they are referred by another ophthalmologist. They’re also children from disadvantaged social backgrounds who are brought to the clinic by a foundation and for whom we offer volunteer services. The case I’m about to present is one of these children. She is a 5 year old young girl. The patient’s mother noticed the exotropic eye position and lid changes since birth. And then after a while, she also noticed the left head turn. The vision was 20/20 in the right eye and 20/60 in the left eye. Exotropia 30 prism diopter and left hypertropia ya of 15. We can notice the large upshoot in adduction, limited adduction, mild limited adduction, and fissure narrowing in adduction. The first poll question is, what is the diagnose? Could the partial 3rd nerve paralysis be innervation? Exotropic Duane syndrome, or a left superior optic palsy? Let’s see what are your answers.
DR. NEELY: Right. While people are answering this, this is a discussion that — actually, keep the poll up there, or is it gone? And this is a discussion that Dr. Teodorescu and I were having. We went through this differential and just based on the information we had, kind of analyzed each of these diagnostic questions and said, well, it could be this, but it could be that. How would we sort out which one of these that it is? And so, we had that discussion. And I know she’s gonna show you that in a minute. Do we have a result for the poll at this point? All right.
DR. TEODORESCU: Almost half the nerve palsy or exotropic Duane syndrome. In the point, I had the case with the details they showed you and, of course, with the pictures to Professor Neely. And here is his answer. So, I summarize in this slide his answer. So, for the first — or not first place is the XT Duane, probably type 2 or type 3. Large upset shoot, upshoot. And the palsy with aberrantly, the media could be palsy, but causing the exotropia and — and the partial three is not like this because there’s no such depression in the adduction. How to look at the three possibilities is to do a traction test under anesthesia as suggested. At this test, the left lateral rectus was very tight, the left superior rectus was not tight, and the laxity of the left was almost the same as compared to the right. In conclusion, it is an exotropic Duane. The next question is: What is the surgical plan? Do only a left lateral rectus recession? Or option two, to add to this medial recession? And option three, to add a left rear recession at the far surgery.
DR. NEELY: While people are answering this, this highlights one of the things that we deal with all the time. There are time when is you’re going into surgery and you’re not 100% certain of the diagnosis. And a lot of times our passive adductions and traction testing will kind of lead us down the right path. And so we’ll go into it, discuss all the options and go into the surgery with a plan A, plan B, and plan C. And we had discussed each of the options depending on the what the findings were. And I think that’s a nice example of going into it prepared for just about anything. All right. Results for our poll, then.
DR. TEODORESCU: A lot of people are going for the second surgery. Lateral rectus recession with Y split and left medial recession. Probably in order to reduce core contraction. But we have to remember that the esotropia was 35, so large. So, I’m glad I didn’t do the second one. So Professor Neely’s answer was to choose this lateral rectal recession with Y split. I asked him about what does henge about inferior oblique myectomy in the left eye, but not usually found in the Duane syndrome. And I wanted to discuss a little bit more about the details of the surgical plan. How much the recess of the muscle half? And he suggested that if the lateral rectus is restricted, I can get a larger effect to do let’s say about 8 or 10 recession of only the lateral. And what about to do with the left hyper. This left hyper could be just from the tight lateral rectus, he answered. And if the lateral rectus is tight, recession may be enough. So, that’s why I considered to do only the left lateral rectus Y split 10 millimeters, sorry. And I reserved the seventy superior rectus recession for the next surgery, maybe, if it’s needed. These are the pictures of the surgery. The exotropia decreased from 30 to 15. And the left decreased a little from 15 to 12. It was a mechanical and innervational upshoot in this patient. So, the next question: What is the plan for the next surgery? What do you think? Is to do a left superior rectus recession? Ptosis surgery at the same time or not? The question is what to do for the next surgery. There’s children that are coming from this humanitarian association. Sometimes they are difficult for them to travel to Bucharest. But sometimes we need the second surgery. And we’re trying to do, yes. The majority also the left superior rectus recession. This is also — I’m still waiting for the patient to come.
DR. NEELY: All right. Thank you. These cases — well, one thing I can tell you, and you’ll see from our next presenter, too. That Duane syndrome is at least within the strabismus subspecialty, that is one of the most common questions. And that’s because these are difficult cases. And there’s a lot of times no right or wrong answer, but there are some basic principles and I think your case highlighted that nicely. So, I like that your case — we had a definitive technique and we had multiple diagnostic possibilities that became more clear over time. And we had contingency plans, right? So, if the exam under anesthesia showed one thing, we were gonna go one way, if it showed another, we were gonna go another. What looked like maybe a type 2 Duane’s splitting after the procedure, it was definitely a type 3. The adduction on that left eye was limited. I think they’re just kind of fascinating cases and they’re a spectrum. And you can talk to ten people and get ten different recommendations on that and so, I think that’s another just a good example of why discussing cases with different people is of interest. Thank you, Dr. Teodorescu.
DR. TEODORESCU: And I imagine I would like to add how much I learned from you and from Professor Helveston, of course, and it was very, very important for me. It was a huge progress for me since I started program. Thank you very much.
DR. NEELY: Well, you’re very welcome. And I tell people all the time that maybe the most rewarding aspect of my career has been working with people like you and Sanjay and Chimozi. And it’s just really rewarding to see people so dedicated and hungry for knowledge and dedicated to their patients and to their profession. You guys all do a great job. And Dr. Tembo is now batter up. Dr. Tembo is going to be a rising star. He’s in the infancy of his career. But I expect great things from him. And I have been very impressed. So, Chimozi, it’s all yours. Good morning.
DR. TEMBO: Thank you. Someone is still sharing.
DR. NEELY: Let’s see. I think it’s off now.
DR. TEMBO: I’m going try again.
DR. NEELY: Okay. All right. Yep. You are sharing now. It’s yours. We see your slides.
DR. TEMBO: Thank you. Thank you. And good day, everyone. Thank you for inviting me to be part of this webinar. So, my name Chimozi Tembo. I’m a pediatric ophthalmologist at the University Teaching Hospital-Eye Hospital in Lusaka, Zambia, as well as an honorary lecturer at the University of Zambia. It is my pleasure to share my experience with Cybersight Consult and how telehealth tools, particularly the case-based mentorship, can transform the quality of care we provide even in low resource settings. So, briefly about our hospital, the University Teaching Hospitals-Eye Hospital, is like located in Lusaka, Zambia. This is the eye care in Zambia. We look at complex pediatric and adult cases and also are the training center for ophthalmology residents. With all these things, you can imagine there is a great need. However, in resource-limited setting, we can only do so much. We have in Zambia currently just over 60 ophthalmologists and there are very few centers. I think only four centers that are able to handle pediatric ophthalmology and strabismus in the whole country. So the need is great. A bit about my story. I completed my residency training in 2020. After which I pursue at long-term fellowship in pediatric ophthalmology, strabismus, and neuro-ophthalmology at the Prasad Eye Institute in India. After I returned from India in 2023, I was privileged to head the Pediatric Ophthalmology and Strabismus unit. And when you are alone in a setting, it becomes quite challenging. And having Cybersight on hand to discuss different cases with different mentors has been a major part of my growth. Because we deal with quite complex cases. And leveraging Cybersight as a companion has really helped me navigate these complex cases. So I started using the Cybersight platform way back before I even finished my fellowship. I submitted my first case during my residency training. This was in 2018. So, the first case was created — back in November 2018. And this was the case of a syndrome. And we had few faculty within the hospital and we used the webinar on Cybersight. We would get a project, project these presentations and sit in together, the team, just to listen to these webinars. And they were very helpful during our residency training. I will present briefly two cases that — so, just to present the first case, this is patient case number 94625 on Cybersight. And the informant was the mother. This was a 11-year-old girl from within Lusaka District who presented to our pediatric clinic complaining of outward deviation of the right eye and abnormal head posture. The past medical history and other history was unremarkable. Of note was she had a significant head posture, abnormal head posture. She adopted the left face turn. She had no facial dysmorphic feature, but, however, we could mark on her hand that she had thenar hypoplasia in the left and then on the right. And the statement was essentially normal. Looking at her nine gaze, we could see in the primary cause, had an exotropia, 25 prism diopters. When attempted adduction of the right eye, had palpebral fissure familiar rogue and down shoot. And at this point, a diagnosis of Duane’s retraction syndrome type 3. Of course it be it was difficult to tell with the significant down shoot whether there was limitation in adduction. So, I posted the case on Cybersight. This was patient case number 94625. And posted the case on the 13th of February. And Dr. Neely promptly responded. his diagnosis was Duane’s syndrome type 3. And looking at the other features the patient presented, I was trying to ask whether pediatric cardiology to rule out any other systemic disorders. And also whether this patient needed surgery and in that case, what type of surgery would most be helpful for this patient? So, Dr. Neely promptly responded that the patient would be a perfect candidate for lateral rectus recession with Y-split. And looking at the deviation, recommended an 8.5 millimeter lateral rectus recession. So, we continued the discussion. And upon concluding with the diagnosis, we agreed that the patient needed to get a pediatrician’s review to rule out any systemic association. And at that point we advised that the patient undergoes surgery to improve the anomalous posture as well as to improve their ocular alignment. The patient did agree to have the surgery after the risks and benefits were explained. So, for surgery I proceeded to do the right eye lateral rectus recession with Y-split under general anesthesia. And the patient was happy with the results. Post operatively, she was autotropic. And as you can see from the image — orthotropic — and as you can see in the right eye in the adduction, there is the improvement. She no longer has that significant down sheet that she was experiencing. The next case presentation was a patient who was referred from the Chipata District. Now, Chipata District is approximately 600 kilometers from Lusaka, and quite a distance to get to Lusaka. The mother presented with the baby on the 4th of June 2024. Chief complaint was abnormal head posture. Family history, past medical history and birth history were non-significant. The anterior and posterior segments were normal. And on examination, ocular examination, the child did have right eye hypertropia and when we did the motility exam, was noted to have significant inferior oblique over action. So, at this point I submitted the case to Dr. Neely. My main questions being I was querying is this a superior congenital superior oblique palsy? And I wanted to find out whether MRI was indicated in the patient and what would be the best treatment option for this child at 18 months of age? So Dr. Neely responded that indeed it looked like a congenital superior oblique palsy with inferior oblique over action. And he also mentioned that begin that it was acquired, he would not do — sorry, that it was not acquired, he wouldn’t do any neuro imaging. At this point, he did offer and suggest that inferior oblique myectomy would give more action rather than a non-inferior oblique recession. So I proceeded to do an inferior oblique myectomy of the right eye under anesthesia. The patient did go back and has not come back. But when we discussed with the mother on the phone, she reported no significant head posture at this point. We are waiting for them to come back for review. She sent in some of the photos she was able to take. So, the lessons and takeaways from these cases are that as clinicians, we often get complex cases where multiple approaches are possible. And sometimes it’s always important to discuss such cases where you may have some doubts with the experienced mentors. And Cybersight gives that platform where you can discuss with the experienced mentors who are on stand by and are ready to assist come up with — with treatment plans as Dr. Neely had said, it’s up to the clinician whether they take the advice or not. But after talking with different clinicians and mentors, their suggestions really helped me manage some of these complex cases. So, I would like to thank the Orbis Cybersight team. Particularly Andy and Lawrence, Dr. Daniel Neely, from my fellowship in India, has been on stand by. Has come to any hospital on a couple of occasions and we’ve operated together. I would also like to thank my colleagues and the residents at UTH-Eye Hospital. Thank you.
DR. NEELY: Well, thank you, Dr. Tembo. That was excellent. And again, I think just highlighting the fact that most of this is about mentorship and discussion, and not telling people you have to do it this way or you have to do it that way. And, you know, it’s just — it’s just really valuable to have anybody’s feedback. And whether they have been in practice same amount of time as me or whether, like Dr. Tembo, he’s been doing strabismus for a couple of years now. Since his fellowship. And, you know, I’ve done it for 28 years. It’s nice to have someone else’s perspective. Because how you approach patients, it does evolve over time and so, just like some of these questions, about, well, do you do neuro imaging on a kid with oblique palsy or not? I think it’s important to have the input of someone who has more time under their belt and to guide you on that journey. So, you know, I think we’re at about an hour and a half here. I have been answering some of the chat questions offline just in the — in text. And so, that chat is available for people to review. But some of the things that I’ve seen come up have been about the AI and the, you know, is it going to replace physicians and this and that what is the use? Keep in mind that AI can only deal with what you input. And so, in ophthalmology, we’re kind of limited at which we can input. A fundus photograph. That’s one of the simplest inputs we can do, and yet even that’s complicated because of image quality and user ability and so forth. So, all of this is just a tool. Whether it’s the AI or the mentorship of consult, it’s just a tool. And at the end of the day, you’re the person who is making the decision. And this is just one more way to make the best decision that you can. Anyone who — I would assume that most people on this webinar are familiar with the Cybersight Library. I’m not going to take us there and walk through that, but keep in mind that the library has all of these webinars. Many of — all of them are transcribed as are the surgical videos. And I think that’s one of the key benefits of the Cybersight surgery videos is they’re all narrated, they’re all transcribed. A lot of this stuff is Translated. And one of the things that I didn’t talk about during Consult is that there’s a translate feature which has been incorporated into Cybersight Consult. So, as much as possible we’re trying to make this user-friendly. We’re trying to use local mentors and same language mentors and so, along with growing the AI, that is the future of Cybersight is mentorship that’s local. That’s in your language. That’s responsive. And we’re kind of all in this together. We’re just trying to make it work for everybody. So, with that, I will say a big thank you to all of our panelists. All three of you, thank you. I know that this is a big obligation and I appreciate you making time to do this. And I will bring our webinar to a close. Thank you.