Clinical Services

Oral Presentation

(CS11-02) An International Pediatric Diabetes Ocular Telemedicine Program – Ten-Year Experience

Tuesday, April 25
1:05 PM - 1:24 PM
Location: W224 AB

The Joslin Vision Network (JVN) Pediatric Diabetes Eye Care Program is an ATA category 3 ocular telehealth program for evaluation and management of diabetic retinopathy (DR). It is offered at the endocrine department of an inner city pediatric hospital since November 2006 via a partnership with M.M.G. Foundation in Venezuela and the Beetham Eye Institute at Joslin Diabetes Center (JDC) in Boston, Massachusetts, USA. The program, conceived as an education initiative aiming at long-term prevention of vision loss from diabetic eye disease, involves capturing nonmydriatic, stereoscopic, digital retinal images, automated refraction to evaluate refractive error; and patient history to identify medical risk factors for retinopathy progression in a pediatric diabetes population. All pediatric diabetes patients receiving care at the center are offered JVN at no cost. The program uses "store and forward" technology and all images are evaluated at a centralized reading center at JDC. The presence and severity of DR, macular edema, and nondiabetes findings are documented and risk factors for DR are reviewed. A semi-automated treatment algorithm developed by JDC guides the development of a treatment plan and a bilingual (English/Spanish) patient report that includes detailed information about the level of DR, risk for progression (based on the individualized patient risk factors), follow-up interval, and evidence based treatment plan.
The program has faced significant challenges that include technical issues related to internet connectivity and speed, limited availability of nonmydriatic cameras, limited access to laboratory testing and supplies, limited availability of ophthalmologists specialized in diabetic eye disease and patient related barriers to care (cost of transportation, limited access to diabetes supplies). Despite the challenges, the program completed 2,129 studies in ten years of operation, providing care for 662 pediatric and 100 adult persons. At the initial visit, the mean age of the pediatric patient was 10.8 ±3.7 years, mean age of diabetes onset 8.5±3.8 years, and mean diabetes duration 2.4±3.2 years; 53.7% were female and 96.3% used insulin. This telemedicine visit was the first retinal evaluation for 45.4% of the pediatric patients with type 1 diabetes (data available through February 2015). The mean age of the adult patients was 39.4 ±15.2 years, mean age of diabetes onset 28.6±19.1 years, and mean diabetes duration 10.8±8.9 years; 63.% were female and 67.3% used insulin. At their initial evaluation, any DR was present in 4.5% of pediatric patients and 32% of adult patients, and vision threatening DR (defined as moderate or more advanced nonproliferative DR) was present in 0.6% and 13%, respectively. Prior research performed in different populations and settings has demonstrated that visual impairment among persons with diabetes is substantially lower in populations that have access to systematic ocular telemedicine programs. The goal is to expand the program to additional locations, offering more individuals access to high quality eye care through telemedicine in Venezuela.

Learning Objectives:

Andreina Millan-Ferro

Patient Education & Clinical Outcomes Coordinator
Joslin Diabetes Center

Andreina Millan-Ferro is a dietitian and serves as the patient education and clinical outcomes coordinator at the Latino Diabetes Initiative at Joslin.
Originally from Venezuela, Andreina received the Lorenzo Campins and Ballester award from the Faculty of Medicine as the top student in her program at the Central University of Venezuela. Her role assures that the Latino Initiative's education program is perfectly aligned with Joslin’s Care structure and mission. Andreina is implementing a rigorous evaluation strategy to assess the impact of all educational activities on patients in the program


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Jerry Cavallerano

Staff Optometrist and Clinical Investigator
Beetham Eye Institute, Joslin Diabetes Center

Jerry Cavallerano, OD, PhD, FAAO, is Associate Professor, Department of Ophthalmology, Harvard Medical School, Boston, MA and Staff Optometrist, Beetham Eye Institute, Joslin Diabetes Center, Boston, MA. Dr. Cavallerano received his Ph.D. from Fordham University, Bronx, NY and his O.D. from the New England College of Optometry.
Dr. Cavallerano served as a clinical co-investigator for the Diabetes Control and Complications Trial, the Early Treatment Diabetic Retinopathy Study, and other National Institutes of Health-sponsored clinical trials. He has assisted in the design and implementation of single-center trials on behalf of the National Eye Institute sponsored Diabetic Retinopathy Clinical Research Network ( and is a named author on the manuscripts from these studies. He serves both as a certified refractionist and visual acuity examiner for the as well as a certifying examiner for both of these activities.
Dr. Cavallerano served on the American Optometric Association’s (AOA) Clinical Care Guidelines Committee, co-authored the AOA’s Clinical Care Guideline on Optometric Care of the Patient with Diabetes, and previously was a co-author of the American Diabetes Association’s Clinical Practice Recommendations for Diabetic Retinopathy and the Technical Review to support the Clinical Practice Recommendations.
Dr. Cavallerano is former Chairman of the Ocular Telehealth Special Interest Group of the American Telemedicine Association and recognized leader in the field of ocular telemedicine, and a co-author of the ATA’s Telehealth Practice Recommendations for Diabetic Retinopathy. He serves as Chief, Beetham Eye Institute Center for Ocular Telehealth at the Joslin Diabetes Center.
Dr. Cavallerano serves on the Continuing Medical Education Committee, the Clinical Guidelines Committee, and the Committee on Human Studies Review Board at the Joslin Diabetes Center.
Dr. Cavallerano has authored or co-authored more than 85 articles, reviews, and book chapters, predominantly on diabetic retinopathy and ocular telemedicine, and he has lectured extensively on diabetic eye disease.
Dr. Cavallerano has served as editor of the New England Journal of Optometry and on the editorial boards of Diabetes Spectrum and Clinical Diabetes. He is presently on the scientific editorial review board of Review of Optometry and Telemedicine and e-Health and a reviewer for numerous journals.


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Morella Grossmann

M.M.G. Foundation

Morella received a Bachelors degree in Management Science from the Georgia Institute of Technology in Atlanta, GA. In 1994, Morella founded the MMG Foundation in Caracas to help people with diabetes, especially children and adolescents, with emphasis in education and prevention of complications related to diabetes.


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Paolo S. Silva

Staff Opthalmologist and Clinical Investigator
Beetham Eye Institute, Joslin Diabetes Center

Dr. Silva’s primary expertise lies in the fields of ocular telehealth for diabetic retinopathy, ultrawide field (UWF) retinal imaging and electronic medical record review. Dr. Silva has contributed 20 original articles (12 as either first or last author), 6 study group publications, 16 review articles and 7 book chapters. His work and efforts have been recognized with 8 national and international awards that include Young Clinician Award from the Center for Integration of Medicine and Innovative Technology and Eleanor and Miles Shore 50th Anniversary Fellowship Program for Scholars in Medicine, Harvard Medical School. He has been recognized by Philippine President Benigno S. Aquino III as one of The Outstanding Young Men Awardee for Medicine in 2013 and the Presidential Award for Filipinos Overseas in 2014. Dr. Silva directs telemedicine and retinal imaging research programs that has led to collaborative efforts in Philippines with Joslin and the Diabetic Retinopathy Research Network ( Presently, the Philippine reading center is prospectively evaluating UWF angiograms and retrospectively evaluating optical coherence tomography scans from clinical trials conducted by


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Kristen Hock

Staff Optometrist and Clinical Investigator
Joslin Diabetes Center

Kristen M. Hock, O.D. is a staff optometrist at the Beetham Eye Institute at the Joslin Diabetes Center and is the first Morella M. Grossmann Global Tele-Ophthalmology Scholar.
She is Assistant to the Chief, Joslin Vision Network (JVN) Global Tele-Ophthalmology Program and Associate Chief, Venezuela JVN Diabetes Eye Care Program. She is actively involved in clinical care, research and telemedicine and is committed to developing cost efficient, high quality eye care programs that provide access to care and education for all patients with diabetes across geographic, socioeconomic and cultural boundaries in order to prevent diabetes eye complications and preserve vision.


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(CS11-02) An International Pediatric Diabetes Ocular Telemedicine Program – Ten-Year Experience

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