Improving Access to Outback Eye Care with Cutting-Edge Technology

Associate Professor Angus Turner first met Teddy Biljabu in Jigalong seven years ago and has since seen him 40 times in five different locations to treat his diabetic retinopathy. Mr Biljabu has had extensive treatments including injections, laser, and surgeries. And yet, unfortunately, he’s now nearly blind, which for Mr Biljabu has meant losing his job and relying on his wife to drive him around. Mr Biljabu’s condition is entirely preventable, so imagine how different his life might have been if he had better access to regular eye checks from when he was first diagnosed with diabetes. A vision for the life Mr Biljabu could have had is the inspiration driving Assoc Prof Turner’s mission to provide better access to screening and treatment on country in remote Western Australia.

THE PILBARA

The Pilbara region has a population of approximately 60,000 people with about 14% identifying as Aboriginal and Torres Strait Islander.^1,2 The population is spread over half a million square kilometres, with an average of 1,600 km from Pilbara towns to Perth, and poor access to health services. In the Pilbara, diabetes and its complications are the second leading chronic cause of potentially preventable hospitalisations.³ Preventable vision loss due to diabetic retinopathy affects many aspects of life, including employment, social integration, self-care, and mental health and wellbeing.

Diabetes has recently been demonstrated to cause more retinopathy for Aboriginal and Torres Strait Islanders than nonindigenous people and yet only an estimated 34% had diabetic retinopathy screening in 2019–2020.^4,5 As there are no symptoms of diabetic retinopathy prior to it affecting vision in the advanced disease stages, people with diabetes are recommended to undergo regular screening. Annual screening is recommended for Aboriginal and Torres Strait Islander peoples, who are at higher risk. Early detection from a retinal image enables timely treatment, which can prevent vision loss in almost all cases.

The Pilbara region has 19 times less ophthalmology workforce than the Australian average.⁵ A surgical team flies down from the newly established Kimberley Eye Hub in Broome for two days each month and can keep up with surgery and intravitreal injections (for diabetic macular oedema, for example) due to highly efficient collaborative care via telehealth with local optometrists and short visits by the Lions Outback Vision Van. However, the current model of care for retinal screening does not result in adequate coverage for the diabetic population in the Pilbara in remote communities, despite many years supporting primary care services with retinal cameras.

THE PILBARA CHALLENGE

Assoc Prof Turner’s mission has recently aligned with the Western Australia Department of Health’s Pilbara Challenge, which seeks solutions that use technology to improve health outcomes for people living in the region. Participants in The Pilbara Challenge are competing for an AU$5 million prize, supported by the Future Health Research and Innovation Fund, Rio Tinto, and BHP. The Pilbara Challenge is now in its last stage as the top 10 finalists deliver their solution on the ground over a 12-month proof-of-concept phase.

Lions Outback Vision’s solution to The Pilbara Challenge is an innovative model of care that enables on country chronic disease care. A Sprinter panel van will travel throughout the Pilbara delivering screening for diabetic retinopathy with artificial intelligence (AI) diagnostics, integrated with existing primary health care and connecting to multi-specialist management.

Assoc Prof Turner said deployment of the innovative digital solution would increase access to diabetic retinopathy screening in regional and remote places and reduce vision loss from diabetes-related eye disease.

“Providing treatment in the region means we see the disease that results from a lack of regular screening, and we see the gaps in service delivery in the more remote locations.

“The Sprinter van and this new technology gives us the opportunity to visit remote locations that we’ve normally only visited for a very short time. It gives us the chance to build the trust that you need with the community, and to spend more time with people to make sure they really understand the risk of losing their eyesight if they don’t keep up with regular eye checks. This is an essential service for people with diabetes,” he said.

WARLU AI SPRINTER VAN

In August 2023, Lions Outback Vision officially launched the project, marking the beginning of a transformative journey to bring multidisciplinary health screening using AI diagnostic support to remote communities in the Pilbara. The service is now officially known as Warlu AI. The name has received Elder endorsement and relates to the Dreaming story of the Warlu sea serpent as it emerged from the sea and travelled through the red heart of the outback, Western Australia’s Pilbara region.

An automated retinal camera, with optical coherence tomography and an integrated deep learning system, is being evaluated in its real-world performance of diabetic retinopathy screening in remote locations. Minimal training is required to operate the device, meaning a technician with no qualification requirements can staff the service. A resident medical officer provides real-time reporting in the local healthcare electronic medical record to augment service delivery, while concurrently enabling systemic risk factor assessment.

High-speed internet connectivity using low earth orbit satellites enables connection to Lions Outback Vision’s on-call consultant ophthalmologist video telehealth service to discuss any results on the spot for any patient with disease detected, as well as remote viewing of all ocular imaging.

This more holistic approach to retinal screening has led to a trial exploring integration of other specialities via the primary care GP. There is potential to involve endocrinology, cardiology, and renal specialists for patients with advanced disease, with these specialists comprising part of the Warlu AI Challenge team.

Test results are explained and health education on diabetic retinopathy is provided using an award-winning health promotion video. Bad Sugars, Bad Eyes⁶ was developed by the Lions Outback Vision team in collaboration with Aboriginal health workers and has been evaluated and found to be very culturally appropriate.⁷ The videos have been translated into Martu Wangka, the most prevalent Aboriginal language in the Pilbara.⁸ Free reading glasses and sunglasses are provided to participants since consumer feedback suggests that this will increase engagement with the project.

SERVICE INTEGRATION AND COLLABORATION

Lions Outback Vision’s history of close working relationships with key stakeholders in regional Western Australia has enabled integration of the service with existing diabetes management services including shared electronic health records. Key partners in the West Pilbara include Karratha Central Healthcare and Panaceum Pilbara, as well as more local organisations such as Nintirri Centre and IBN Group. These organisations collaborate to provide the Strengthening Aboriginal Health program and Integrated Chronic Disease Care program in Tom Price, Paraburdoo, and Onslow. These programs provide regular access to allied health professionals including dietitians, podiatrists, exercise physiotherapists, and diabetes educators. With our collaboration bringing eye health to the table, people with diabetes can now get all the necessary regular diabetes checks at the same time, reducing their risk of complications.

In the East Pilbara, Lions Outback Vision has partnered with Puntukurnu Aboriginal Medical Service (PAMS), which provides primary healthcare services across the Great Sandy, Little Sandy, and Gibson Deserts. Through this collaboration, local Aboriginal health workers will be upskilled in operating the van and equipment, increasing the sustainability of the project. Furthermore, the Warlu AI project has partnerships with Diabetes WA to link to its diabetic education telehealth service, as well as with the Aboriginal Health Council of Western Australia and the Royal Flying Doctor Service Western Operations for further on the ground and strategic input.

AI INTEGRATION AND RESEARCH

For the past four years, Lions Outback Vision has undertaken pioneering work in collaboration with Google and University College London (UCL) to ensure that diagnostic tools using AI are fit for purpose when deployed in the Australian context, and specifically to ensure they work well for Aboriginal and Torres Strait Islander people. Lions Outback Vision researchers recently collaborated with Google Health, publishing results of a deep learning system in a retrospective study involving 864 Aboriginal patients in Western Australia demonstrating the diagnostic capability as superior to three retinal specialists.⁹ This included sensitivity for ‘more than mild disease’ at 98% compared with human specialist grading at 87% (p <0.0001) and for ‘sight-threatening disease’ at 93.7% compared with 84.4% (p <0.0001). Specificity remained high at 95.8%. The proposed model is an Australian[1]first; deployment of a camera developed with integrated AI diagnostic capability. In addition, an AI diagnostic tool developed in the Netherlands (Thirona RetCAD) is also being used in comparative studies for real world evaluation in Lions Outback Vision retinal screening.

LION LASER

An Australian first as part of Warlu AI has been to deploy a novel laser that is a fraction of the weight of other comparable treatment devices: the Norlase Lion (laser indirect ophthalmoscope). This enables follow-up on screening with treatment on country, where the specialist flies in to provide laser treatment for diabetic retinopathy with the head-mounted ultra lightweight laser.

Lions Outback Vision’s award-winning patient education videos are used to help with patient awareness and culturally safe consent for laser treatment.¹⁰ For many patients in remote locations, travel to regional centres is required for treatment. This barrier leads to treatment being delayed and poorer outcomes. Bringing treatment to patients on country using the Norlase Lion laser will increase the number of patients receiving timely treatment.

OCULOMICS

Looking into an eye is said to be the ‘window to the soul’, and since the vessels and nerves are visible in a retinal photograph, extraordinary AI breakthroughs are demonstrating systemic risk prediction and revealing biomarkers of many systemic conditions. The Warlu AI team members are world leaders in this realm of research. A recent paper in Nature demonstrated a foundational model that overcomes the challenge of using traditional self-supervised learning techniques when applied to distinct ethnic populations that have not been included in the initial training data.¹¹

This is a great stride forward in addressing concerns about healthcare inequity that have arisen with advances in medical AI. It is possible that, in future, a photo of the eye could be used to assess the risk of other conditions and will become a useful non-invasive tool in the hands of primary care service providers who have access to retinal cameras already.

Lions Outback Vision ophthalmologist Dr Vaibav Shah travels to the Pilbara from Broome.

Emma Douglas, Research Coordinator at Lions Outback Vision, plays a key role in coordination of the Warlu AI project. Ms Douglas has a broad interest and varied experience in public health research and, after living in the Pilbara region for several years, has a passion for regional and remote health.

Jocelyn Drinkwater, Research Fellow at Lions Outback Vision, is a registered nurse with a Master of Public Health and a PhD on ophthalmic complications of type 2 diabetes. Ms Drinkwater’s role is to increase the research capacity of Lions Outback Vision, with the aim of improving health outcomes for those living in remote WA.

References

1. Australian Bureau of Statistics, 2021 West Pilbara, Census All persons QuickStats, 2021. Available at: abs. gov.au/census/find-census-data/quickstats/2021/51003 [accessed Feb 2024].
2. Australian Bureau of Statistics, 2021 East Pilbara, Census All persons QuickStats, 2021. Available at: abs. gov.au/census/find-census-data/quickstats/2021/51002 [accessed Dec 2020].
3. WA Country Health Service, Pilbara Health Profile 2022. Available at: wacountry.health.wa.gov.au/About-us/ Publications/Health-profiles-and-service-plans. [accessed March 2024].
4. Holman, R.R., Paul, S.K., Bethel, M.A., et al., 10-year follow[1]up of intensive glucose control in type 2 diabetes, N Engl J Med 2008; 359:1577–1589. DOI: 10.1056/NEJMoa0806470.
5. Titmuss, A., Davis, E.A., O’Donnell, V., et al., Youth-onset type 2 diabetes among First Nations young people in northern Australia: a retrospective, cross sectional study, Lancet Diabetes Endocrinology, 2022, 10(1):11–3. DOI: 10.1016/S2213-8587(21)00286-2.
6. Lions Outback Vision, Bad Sugars, Bad Eyes (video) available at: outbackvision.com.au/videos.
7. Meyer, J., Johnson, K., Turner, A., Evaluating a health video on diabetic retinopathy, Health Promotion Journal of Australia, 2016, 27, 84–87. DOI: 10.1071/HE15056.
8. Australia Bureau of Statistics, 2021 Pilbara (Mining and Pastoral), Census All persons QuickStats, 2021. Available at: abs.gov.au/census/find-census-data/quickstats/2021/ SED54403 [accessed Feb 2024].

9. Chia, M.A., Hersch, F., Turner, A., et al., Validation of a deep learning system for the detection of diabetic retinopathy in Indigenous Australians, British Journal of Ophthalmology, 2024, 108:268–273. DOI: 10.1136/bjo-2022-322237.
10. Available at: outbackvision.com.au/videos.
11. Zhou, Y., Chia, M.A., Wagner, S.K. et al. A foundation model for generalizable disease detection from retinal images. Nature 622, 156–163 (2023). DOI: 10.1038 (ETC)/10.1038/s41586-023-06555-x.