Evaluation of Tele-Education in Malawi for Detection of Macular Features Using Optical Coherence Tomography

The study aimed to assess the reliability of tele-education in training a Malawian ophthalmology resident to interpret optical coherence tomography (OCT) images of patients with macular conditions.

This was a retrospective analysis of 1000 macula-centered OCT image series from 1000 eyes of 1000 consecutive patients from Malawi, which involved initial interpretation by a German retina specialist (observer 1) (T₀). Observer 1 then trained a Malawian resident (observer 2) via email, and observer 2 independently interpreted images at T₁, followed by face-to-face training in Malawi and reinterpretation at T₂ and T₃ (3-month intervals). The observers had to recognize, on OCT imaging, the normal macular structure, vitreofoveal traction (VFT), absent fovea depression (FD), epiretinal membrane (ERM), lamellar macular hole (LMH), full-thickness macular hole (FTMH), foveoschisis, intraretinal pseudocyst (IPC), intraretinal hyperreflective foci (IHF), subretinal fluid (SRF), pigment epithelial detachment (PED), and drusen. Cohen's Kappa statistic measured inter-observer agreement.

At T₁ post-tele-education, almost perfect agreement (κ = 0.86; 99.6% agreement) was observed for FTMH. Agreement remained high at T₂ post-face-to-face training (κ = 0.9; 99.7%) and decreased substantially at T₃ (κ = 0.77; 99.4%). Following tele-education (T₁), substantial agreement (κ range: 0.77 - 0.86) was found for IPC, PED, IHF, and FD, while ERM showed fair agreement (κ = 0.33; 81%). Face-to-face training notably improved agreement for SRF (T₁ κ = 0.6, T₂ κ = 0.63), LMH (T₁ κ = 0.6, T₂ κ = 0.67), and normal macular structure (T₁ κ = 0.6, T₂ κ = 0.62).

There was good agreement in the detection of the majority of the OCT features seen in most of the macular pathologies following training through tele-education and the results did not change significantly following face-to-face teaching. Tele-education could reliably complement training in vitreoretinal diagnostic skills in resource-limited settings.