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Ophthalmol Ther
Ophthalmol Ther
Ophthalmology and Therapy
2193-8245
2193-6528
Springer Healthcare Cheshire

39181973
1020
10.1007/s40123-024-01020-y
Original Research
Digital Exclusion, Social Deprivation, and Clinical Outcomes of Patients Undergoing Hyperacuity Home Monitoring
Mendall Jessica 1
Islam Meriam 2
Wong Karen 3
Sansome Stafford 3
Sim Dawn A. 3
Bachmann Lucas M. 4
Huemer Josef 35
http://orcid.org/0000-0002-1303-9188
Kang Swan swan.kang1@nhs.net

13
1 https://ror.org/02jx3x895 grid.83440.3b 0000 0001 2190 1201 University College London, London, UK
2 https://ror.org/01n0k5m85 grid.429705.d 0000 0004 0489 4320 Kings College Hospital NHS Foundation Trust, London, UK
3 https://ror.org/03zaddr67 grid.436474.6 0000 0000 9168 0080 Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, UK
4 https://ror.org/023g71078 grid.483560.c Medignition, Zurich, Switzerland
5 grid.473675.4 Department of Ophthalmology and Optometry, Kepler University Hospital, Linz, Austria
24 8 2024
24 8 2024
10 2024
13 10 27592769
2 7 2024
9 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.
Introduction

Digital exclusion is a growing challenge when deploying digital patient care pathways and a potential barrier to widespread implementation, especially in the field of smartphone-based self-monitoring of vision. This retrospective case series seeks to examine the characteristics of individuals who adhere to a smartphone home monitoring programme using the Alleye app for retinal disease, with a focus on digital exclusion, social deprivation and clinical outcomes.

Methods

We conducted a retrospective analysis of 89 patients with retinal pathologies including diabetic retinopathy and retinal vein occlusions at Moorfields Eye Hospital participating in an Alleye home monitoring programme between April 2020 and November 2022. Postcodes were used to determine the Digital Exclusion Risk Index (DERI) and the Index of Multiple Deprivation (IMD) rebased for London. Clinical information from the electronic patient record and Alleye app usage data were extracted for each patient. Associations between the DERI/IMD, clinical parameters and app use were examined using multivariable regression models.

Results

Mean DERI was 2.56 (standard deviation [SD] = 0.36), IMD was 6.25 (SD = 2.79), visual acuity (VA) in the better eye at study entry was 83.28 Early Treatment Diabetic Retinopathy Study (ETDRS) letters (SD = 7.92), and mean follow-up was 344.46 days (SD = 260.13). During the observation period, 36% received an intravitreal injection (IVI) and VA fell by at least ten letters in approximately one in four patients. In 87.5% of patients requiring IVI, the use of the app increased. We found no association between clinical parameters and programme adherence for DERI or IMD.

Conclusions

We found no association between high digital exclusion risk and high social deprivation with monitoring adherence to smartphone-based self-monitoring of vision, contrary to the currently available evidence. This suggests that smartphone-based self-monitoring of vision is accessible to population groups of varying digital exclusion and social deprivation risk, and can be safely employed to monitor clinical progression.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-024-01020-y.

Keywords

Smartphone hyperacuity testing
Self-monitoring
Digital exclusion
Social deprivation
Telemedicine
Teleophthalmology
issue-copyright-statement© Springer Healthcare Ltd., part of Springer Nature 2024
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pmcKey Summary Points

Why carry out this study?	
Smartphone hyperacuity testing using the Alleye app is a practical tool for early diagnosis and monitoring of macular disease with a validated real-world performance.	
Digital exclusion is a growing challenge when deploying digital patient care pathways and a potential barrier to widespread implementation, especially in the field of smartphone-based self-monitoring of vision.	
What was learned from the study?	
In this retrospective case series, we found no association between high digital exclusion risk and high social deprivation with monitoring adherence to smartphone-based self-monitoring of vision.	
This suggests that smartphone-based self-monitoring of vision is accessible to population groups of varying social deprivation and digital exclusion risk, and can be safely employed to monitor clinical progression.	

Introduction

Telemedicine is transforming service provision in the field of ophthalmology and has been instrumental in assessing patients remotely during the COVID-19 pandemic [1]. As more healthcare services have established telemedicine pathways, there is growing concern that digitally excluded patients will lose out and healthcare inequalities will be exacerbated. Digital exclusion is a facet of social deprivation whereby there is no universal access to and capacity to use digital technology. Recent evidence has demonstrated that digital exclusion and social deprivation may contribute to non-attendance in virtual clinics [2]. Whether digital exclusion will pose a barrier in other areas of teleophthalmology is yet to be determined.

The start of the COVID-19 pandemic forced non-urgent appointments and surgeries to be cancelled in ophthalmology and most other specialties in the UK in an effort to reduce face-to-face contact. Hospitals were challenged to rapidly expand their telemedicine services to provide online consultations and remote care [3]. One emerging and innovative digital tool in ophthalmology used to remotely monitor macular function is smartphone hyperacuity testing. Smartphone apps can detect changes in metamorphopsia indicative of worsening pathology and the need for intravitreal therapy in macular disease [4], enabling patients to receive timely treatment when needed and thereby personalising patient care.

Cystoid macular oedema (CMO) is a pathological sequel of exudative age-related macular degeneration (AMD), as well as of diabetic retinopathy (DR) and retinal vein occlusion (RVO) [5], the two most common retinal vascular diseases [6]. CMO involves cystoid pockets of fluid developing in the macula, which mechanically distorts the retina and causes metamorphopsia, the development of which can be indicated by smartphone hyperacuity testing [7, 8]. Exudative AMD, DR, and RVO are common indications for anti-vascular endothelial growth factor (VEGF) intravitreal injection therapy, which aims to preserve vision by inhibiting new vessel formation and reducing macular oedema [9, 10].

There are currently two Food and Drug Administration (FDA)-approved medical software applications for detecting metamorphopsia in macular disease: Alleye™ (Oculocare Medical Inc., Zurich, Switzerland) and myVisionTrack™, mVT (Genentech, South San Francisco, CA, USA) [11–13]. Both are downloadable onto the user’s personal mobile or tablet, and clinicians can access the test results remotely in the clinic. The Alleye app asks users to perform a monocular hyperacuity alignment task in order to test the central 12 degrees of vision, to give an objective measure of visual function. By contrast, mVT tests the central 3 degrees of vision via a shape discrimination task [14]. Consistent poor performance on the Alleye test will trigger alarms that alert the clinical team to review the patient, as described by Islam et al. [4]. Alleye has low false-alarm rates and is highly specific for monitoring metamorphopsia in macular diseases such as exudative AMD and diabetic macular oedema (DMO) [15].

There is, however, a scarcity of real-life data regarding the applicability of a smartphone home monitoring programme amongst a population with varying digital literacy and digital skills. The recently published Monitoring for Neovascular Age-related Macular Degeneration Reactivation at Home (MONARCH) study provided well-needed evidence and investigated the recruitment, adherence to and ability to use smartphone home monitoring amongst participants with exudative AMD using the mVT and MultiBit apps in a multicentre-controlled research environment. The MONARCH study found no association between age and social deprivation with adherence to testing in the study group that consisted predominantly of an elderly and white cohort [16]. There is a real need for further data to delineate the demographic characteristics of patients with a range of retinal diseases willing to engage in such a programme, in a real-world environment.

Therefore, the primary aim of this study is to examine the characteristics of participants willing to adhere to a smartphone-based home monitoring programme using the Alleye app for retinal disease in a diverse South London cohort. Secondly, we aim to examine the associations between adherence to smartphone hyperacuity testing and clinical parameters, social deprivation (using the Index of Multiple Deprivation, IMD, rebased for London) and digital exclusion risk (using the Digital Exclusion Risk Index, the DERI). Thirdly, this study aims to investigate how these patients experience the Alleye app using a telephone questionnaire.

Methods

Participant Enrolment

This retrospective case series study examined patients from Moorfields Eye Centre at Croydon University Hospital recruited to use the Alleye app between April and November 2020, during the first national COVID-19 lockdown in the UK. The study protocol has been previously described by Islam et al. [4]. Following the commencement of the lockdown in March 2020, Moorfields adopted a ‘forward triage’ system [17] whereby patients were classified into ‘low’, ‘medium’ and ‘high’ risk groups. Patients in the ‘low’ and ‘medium’ risk categories from the retinal service at Croydon University Hospital had their appointments postponed and were therefore invited to participate in a home monitoring programme using the Alleye smartphone app. Participants were trained to correctly use the Alleye app remotely, via telephone or video consultation using the Attend Anywhere platform (Attend Anywhere, Victoria, Australia). Patients who did not own a mobile device were provided with a new iPod Touch (6th generation, Apple, Cupertino, CA, USA) installed with the Alleye app. Poor performance on the visual tests would trigger an ‘alarm’, alerting the clinical team to telephone the patient and provide an urgent appointment if required. All participants were asked to contact the clinical team if any concerns arose during the monitoring period.

Questionnaire

All patients participating in the Alleye home monitoring programme were asked to complete a telephone questionnaire in January 2021. This involved ranking seven statements from 1 (strongly disagree) to 5 (strongly agree) on a Likert scale. The statements ranked were: (1) “I feel confident using a smartphone”; (2) “I think it is important that my vision test helps the doctors decide when my next appointment is”; (3) “Using the app to test my vision helps doctors understand my eye condition better”; (4) “I can include testing my vision into my daily routine”; (5) “Using the Alleye app is easy”; (6) “Using Alleye to test my vision reassures me”; and (7) “Using Alleye to test my vision worries me”.

Measurement of Digital Exclusion and Social Deprivation

Digital exclusion and relative social deprivation were measured using the DERI and the IMD rebased for London. The DERI is a composite, continuous score ranging from 1 (low risk of digital exclusion) to 10 (high risk of digital exclusion), developed by the Greater Manchester Combined Authority and the Good Things Foundation [18]. It provides a measure of the digital exclusion risk in a specific location in England, Wales or Scotland. The DERI is made of 12 components, encompassing deprivation, demography and broadband access. The IMD rebased for London is a score combined from 39 indicators of deprivation across seven different domains [19]. Regions across London are classed into deciles, with a score of 1 representing the most deprived 10% of the population.

Data Collection

Diagnosis, receipt of intravitreal injections, visual acuity (VA) at baseline, deterioration in VA (defined as a drop in ten letters or more on the Early Treatment Diabetic Retinopathy Study (ETDRS) test) and a number of consultations with Moorfields during the monitoring period (< 5 or ≥ 5 per year), either in person, virtually or via telephone, were obtained from the electronic medical record (Medisoft and OpenEyes). Whether patients had received eye surgery or laser treatment (as other potential influences on VA) during the follow-up period was also recorded.

Demographics recorded were age, gender, ethnicity and postcode. The DERI score, using the online DERI tool [18], and the IMD rebased for London [20] were calculated using patients’ postcodes. The duration of follow-up and percentage of patients adhering to the recommended frequency of home monitoring (twice weekly testing for the duration of the follow-up) were calculated.

Statistical Analysis

For continuous data, mean and standard deviation were calculated. For binary data, percentages are provided. Associations between the DERI and IMD rebased for London with clinical parameters and app use were assessed using multivariable regression models and 95% confidence intervals and p values were calculated. A p value of less than 5% was considered statistically significant. Statistical analysis was performed using Stata 16.1. statistics software package (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX, USA StataCorp LLC.).

Ethics

The research described adhered to the principles of the Declaration of Helsinki. This study was registered under the Digital Clinical Laboratory and Audit department of Moorfields Eye Hospital NHS Foundation Trust (Audit Number: 1385). All patients included as part of routine care gave their informed consent by accepting the user agreement within the app during sign-up, which allowed the use of their anonymised data for this analysis. Data for this analysis were obtained from a review of the electronic medical records of these patients.

Results

Demographics and Clinical Characteristics

Between April and November 2020, 89 patients were recruited into the study. The mean age of enrolled participants was 62.30 years (SD = 13.42, range 24–87 years) and 40.45% (36/89) were female (Table 1). The mean length of follow-up (i.e. the length of time for which patients used the Alleye app) was 344.46 days (SD = 260.13, range 0–922 days). Overall, 50.56% (45/89) of patients adhered to the recommended frequency of home monitoring (twice a week). Table 1 Patient characteristics

Characteristic	Mean	SD	
Age (years)	62.30	13.42	
Female gender (%)	40.45		
Baseline VA (ETDRS letters) in the better eye	83.28	7.92	
Mean length of follow-up (days)	344.46	260.13	
Ethnicity	n (patients)		
 White British/Irish	38		
 Any other white background	3		
 Indian	10		
 Pakistani	6		
 Bangladeshi	2		
 Any other Asian background	4		
 African	3		
 Caribbean	2		
 Any other Black background	2		
 Any other mixed background	1		
 Any other ethnic group	6		
 Not stated	12		
VA visual acuity, ETDRS Early Treatment of Diabetic Retinopathy Study, SD standard deviation

93.26% (83/89) were diabetic. The most common diagnoses (shown in Supplementary Table 1) were: DR (62.92%, 56/89), of whom 24 also had DMO (26.97%, 24/89); RVO (23.60%, 21/89); and non-exudative AMD (12.36%, 11/89). Of the patients with DR, three also had RVO and two also had AMD. One patient had both AMD and RVO; 8.99% (8/89) had other diagnoses.

During the observation period, 5.96% of patients received an intravitreal injection (IVI). The mean VA in the better eye at study entry was 83.28 letters (SD = 7.92). During the observation period, VA in either eye fell by at least ten letters in 33.71% of patients (30/89). One patient underwent a trabeculectomy in their better eye during the follow-up period, but no other patients received eye surgery or laser treatment.

Questionnaire Results

Eighty-nine patients answered the questionnaire, rating seven statements on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), with the full results displayed in Supplementary Table 2. Overall, patients most strongly agreed that they were confident using a smartphone (mean 4.57, SD = 0.71), found the Alleye app easy to use (mean 4.45, SD = 0.77), felt it was important that Alleye testing helps the doctors decide when their next appointment is (mean 4.27, SD = 0.65) and found using the Alleye app to test their vision reassuring (mean 4.07, SD = 0.85). Overall, patients disagreed that using the Alleye app to test vision worries them (mean 2.24, SD = 1.12).

Associations with DERI

The mean DERI was 2.56 (SD = 0.36). No significant association was found between the DERI and mean VA at baseline [0.002 (95% CI − 0.004 to 0.009; p = 0.482)] in univariate analysis. There was no significant association between the DERI and duration of follow-up, frequency of consultations with Moorfields (≥ 5 reviews/year) or drop in VA of ≥ 10 letters. There was no significant association between the DERI and adherence to home monitoring [0.002 (95% CI − 0.16 to 0.16; p = 0.984)].

Associations with IMD

The mean IMD rebased for London was 6.25 (SD = 2.79). There was no significant association between the IMD and mean VA at baseline [− 0.05 (95% CI − 0.10 to 0.003; p = 0.069)] in univariate analysis. No significant association was found between IMD and duration of follow-up, frequency of consultations with Moorfields (≥ 5 reviews/year) or drop in VA of ≥ 10 letters. IMD scores were significantly lower (representing greater relative social deprivation) in patients adhering to the home monitoring [− 1.25 (95% CI − 2.45 to − 0.05; p = 0.042)].

Associations with Clinical Parameters

Patients experiencing a drop of VA ≥ 10 letters in either eye stayed for longer on the home monitoring programme [275.77 days (95% CI 174.13 to 377.42; p < 0.001)] and were more likely to have consultations with Moorfields ≥ 5 times/year [odds ratio (OR) 6.84 (95% CI 2.58 to 18.17; p < 0.001)].

In patients requiring IVIs, the likelihood of having ≥ 5 consultations with Moorfields per year was markedly higher than in those patients not requiring IVIs [OR 42.88 (95% CI 11.84 to 155.28; p < 0.001)]. Duration of follow-up was slightly, albeit not significantly, longer in patients requiring IVIs [33.90 days (95% CI − 82.39 to 150.18; p = 0.564)]. Adherence to monitoring was not associated with receiving IVIs [OR 0.53 (95% CI 0.22 to 1.28; p = 0.159)] or drop of VA ≥ 10 letters [OR 0.99 (95% CI 0.40 to 2.41; p = 0.974)].

Discussion

In our retrospective case series, we investigated digital exclusion in smartphone hyperacuity testing, analysing 89 patients from South London, the vast proportion of patients having a diagnosis of diabetic retinal disease and retinal vein occlusions, and a mean follow-up period of just under 1 year. Amongst this cohort, we found that digital exclusion was not associated with adherence to smartphone self-testing of vision, patients at higher risk of social deprivation better adhered to the smartphone home monitoring programme and patients with worsening VA self-monitored their vision for longer. Overall, a high degree of confidence in the use of smartphones was identified with an ease of use of the Alleye app present, and patients gaining reassurance from regularly testing their vision using the smartphone application.

Regarding the existing literature, a recent study investigating factors influencing non-attendance at virtual clinics reported that greater levels of deprivation and not self-reporting ethnicity were strongly associated with non-attendance at telemedicine outpatient appointments as well as face-to-face appointments [2]. Those not self-reporting their ethnicity had worse broadband access (derived from the DERI) and lived in more deprived areas. By contrast, we found no association between the DERI and adherence to smartphone hyperacuity testing, and in fact found that patients with higher relative social deprivation better adhered to self-testing. Another recent study, the MONARCH study, found no association between social deprivation and adherence to the mVT and MultiBit apps [16]. Although the MONARCH study was multicentre and the cohort relatively large, it involved a predominantly elderly (mean age 74.9 years) and white cohort (69% of participants) with only AMD, did not directly investigate digital exclusion risk, used only one FDA-approved app and was conducted in a controlled research environment. In the UK, pathways for AMD include urgent referrals, and there is general consensus that the development of acute fluid development should be treated with a greater sense of urgency than in diabetic retinopathy. Our study adds to the available literature by providing real-life data with a younger cohort of patients with diverse ethnicities and socioeconomic backgrounds, with predominantly DR and RVO using the FDA-approved Alleye app. Therefore, the study is able to better reflect real-life patient behaviour with technologies and reduces potential selection bias towards certain demographic groups that are more willing to be recruited in research studies [21].

Previous studies have also identified other factors that could influence compliance with smartphone home monitoring of vision. Patients of older age, receiving treatment and with poorer vision in the worse-seeing eye were more likely to adhere to Alleye monitoring [22]. Similarly, we identified a trend that patients receiving IVIs stayed for longer on the home monitoring programme, and that patients experiencing a drop in VA of ≥ 10 letters adhered better. There are however differences between this cohort and ours: our patients received one-to-one training via video or telephone consultation versus receiving written instructions, and the majority of our patients had diabetic maculopathy, with fewer having AMD, due to the recruitment of our cohort with the ‘forward triage’ system.

Our findings demonstrate that the Alleye app is an inclusive and accessible tool for the highly motivated patients in our cohort who engaged in this home monitoring programme, many of whom had high levels of social deprivation and high digital exclusion risk, and indeed may have been socially isolated during a COVID-19 lockdown. Prior to the pandemic in the UK, delayed health service-initiated follow-up resulted in permanent and significant sight loss (defined as ≥ 3 lines reduced vision on the Snellen chart in at least one eye) amongst patients [23], and during the COVID-19 lockdown, delays in clinic visits could cause significant psychological effects in patients with sight impairment [24]. The UK has one of the lowest numbers of ophthalmologists per capita in the developed world [25], and there is now an even greater backlog of appointments in the UK after the pandemic with demand seemingly only ever increasing [26]. The need to improve the efficiency of ophthalmic service delivery in the UK and reduce unnecessary clinic visits is therefore greater than ever.

Upscaling of smartphone hyperacuity monitoring is a potential solution to individualise treatment intervals and clinic visits, reduce in-person attendances, review patients who have worsening VA more quickly and improve the workflow efficiency of clinic visits overall. The asynchronous and regular capture of home monitoring data provides clinicians with a more accurate representation of the dynamic course of chronic eye disease, which is significantly more informative than a single snapshot VA measured when patients attend at one static time point in a clinic environment. Furthermore, empowering patients with the right tools could also improve their clinic attendance rates and commitment to treatment, and provide patients with chronic eye disease with the potential to directly improve their visual outcomes [27].

Strengths and Limitations

The strengths of this study include its highly relevant nature, investigating a widely available, FDA-approved digital tool to improve monitoring and outcomes in retinal disease, a major global cause of visual disability [28]. Our findings that digital exclusion was not associated with adherence to smartphone hyperacuity testing in our cohort, and patients at higher risk of social deprivation better adhered to the programme are of clinical significance. This indicates that the Alleye app can be accessible to patients from differing backgrounds with varying digital capabilities. Our patient cohort was diverse, with varying IMD and DERI scores that are representative of London. The duration of our study, with an average follow-up length of 344.46 days, is also clinically meaningful.

We must, however, consider the findings of this study in the context of its limitations. Firstly, our cohort of patients was recruited during the first national COVID lockdown in the UK. It is possible that patients were more motivated to self-test their VA during this time as their appointments had been postponed and many had extra time at home, thus adherence could be inflated. Regarding the questionnaire, patients may also have gained more reassurance from using the Alleye app during a national lockdown where there was uncertainty about when face-to-face appointments would resume as usual. On the other hand, one could argue that the national lockdown could contribute to reduced adherence, as patients with poor digital skills were less likely to receive face-to-face support from family or friends. Repeating our study in the non-COVID era would enable us to see if adherence to Alleye monitoring amongst digitally excluded patients is still sustained and would improve the study’s generalisability.

A second limitation is that our dataset is limited geographically. Although the DERI scores of our South London cohort are representative of London as a whole [29], London has a relatively young population [30] with good broadband availability [31] compared to other areas of the UK. Thus, the DERI scores of populations living in more rural areas in less developed countries, or older populations, are likely to be higher (i.e. the risk of digital exclusion is greater). Our findings may not apply to these populations with lower digital access. Given that 82.9% of the UK’s population lived in urban areas in 2019 [32], and that in 2022, 95% of the world’s population had broadband access [33] and 86% currently own a smartphone [34], implementation of smartphone hyperacuity testing is likely to be possible on a large scale. However, wide digital penetration does not always translate to affordability, when high versions of mobile devices and proprietary software and monitoring costs are taken into consideration. Cost-utility analyses would therefore be required before governments and insurance companies can fund such home monitoring programmes.

Thirdly, the most common diagnoses amongst our patients were DR (with or without DMO) and RVO, but we did not have many patients with AMD due to the way our cohort was recruited with the ‘forward triage’ system [17], which might not reflect the broader population. Patients with DR tend to be of working age [35], hence could be more proficient in the use of mobile technology than those with AMD [36]. Nevertheless, the mean age of our cohort is representative of patients with retinal vascular disease, and with appropriate training, age is becoming less of a barrier to smartphone hyperacuity testing. For example, whilst younger patients are more likely to agree to participate in a self-monitoring programme with Alleye, older patients once enrolled in the programme are more likely to comply with self-testing [22].

Furthermore, this study was carried out amongst patients who agreed to participate in a home monitoring programme, and therefore likely had a positive attitude towards this technology. There is therefore an element of selection bias, as these patients have demonstrated motivation to maintain regular follow-up and adherence to the Alleye programme for the monitoring period. Our conclusions can therefore only be extrapolated to subjects with high social deprivation and a high risk of digital exclusion who can be motivated to start using and engage with a digital home monitoring app, limiting the generalisability. It is also important to acknowledge the retrospective design of this study, and our relatively small sample size. Repeat studies with larger datasets, more geographically diverse populations and prospective study designs would be important in validating our findings.

Conclusions

Smartphone hyperacuity testing using the Alleye app is a practical tool for early diagnosis and monitoring of macular disease with a validated real-world performance. This home monitoring programme amongst patients with predominantly diabetic maculopathy in our South London cohort included people with a high digital exclusion risk and high social deprivation. Interestingly, we found no association between digital exclusion, clinical course and monitoring adherence. Further research is necessary to investigate if patients with high digital exclusion risk and significant social deprivation could potentially benefit from such a programme.

Supplementary Information

Below is the link to the electronic supplementary material.Supplementary file1 (PDF 173 KB)

Author Contributions

Jessica Mendall, Meriam Islam, Dawn A. Sim, Lucas M. Bachmann, Josef Huemer and Swan Kang provided substantial contributions to the conception and design of the work. Jessica Mendall, Meriam Islam, Karen Wong, Stafford Sansome and Dawn A. Sim conducted the acquisition of data. Jessica Mendall drafted the initial manuscript. All authors critically revised the manuscript.

Funding

The authors have not declared any funding for this research. The authors are paying the journal’s Rapid Service Fee with their own funds.

Data Availability

All data relevant to the study are included in the article.

Declarations

Conflict of Interest

Josef Huemer has received travel support from Roche, Bayer and AbbVie, and  has served on advisory boards for Roche. Lucas M. Bachmann is a founding member of Oculocare Medical. The other authors (Jessica Mendall, Meriam Islam, Karen Wong, Stafford Sansome, Dawn A. Sim and Swan Kang) declare no conflicts of interest.

Ethical Approval

The research described adhered to the principles of the Declaration of Helsinki. This study was registered under the Digital Clinical Laboratory and Audit department of Moorfields Eye Hospital NHS Foundation Trust (Audit Number: 1385). All patients included as part of routine care gave their informed consent by accepting the user agreement within the app during sign-up, which allowed the use of their anonymised data for this analysis. Data for this analysis were obtained from a review of the electronic medical records of these patients.

Prior Presentation: The preliminary findings of this study have been presented as an oral presentation at the European Society of Ophthalmology (SOE) 2023 Congress in Prague, 16 June 2023 (FP05-7) and as a poster at The Association for Research in Vision and Ophthalmology (ARVO) 2024 Annual Meeting in Seattle, WA, 5-9 May 2024 (#618-A0281).

Josef Huemer and Swan Kang have contributed equally to this work.
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