Investigating the feasibility of home monitoring using game-based technology in individuals at high risk of developing diabetic retinopathy.

Abstract

Diabetic retinopathy (DR) is a complication of diabetes that is becoming increasingly prevalent. Current research highlights the importance of early intervention to detect subtle retinal functional changes prior to the development of structural changes to reduce the risk of sight loss. Visual function tests are becoming a popular method to do this due to their convenience and ease of use. Currently there are a limited range of validated app-based visual function tests. Existing apps test visual acuity and contrast sensitivity, but other modalities like colour, low luminance and frequency doubling have yet to be developed or tested with people with diabetes. Given the potential for diabetes apps to be routinely used within a home setting for monitoring we conducted a systematic review of their adherence to accessibility and usability guidelines using gold standard clinical frameworks. We found that for developers with limited funding, their design and development processes are often also limited. Adherence rates to the frameworks varied substantially across the diabetes apps and we noted the percentage of adherence for each category. This project developed a suite of novel visual function tests in collaboration with the industry partner OKKO health, conducted comprehensive pilot testing, including wireframing, prototyping, alpha, and beta, testing. The aim was to create visual function tests that could be used from home that were accessible, useable, convenient and clinically valid. Throughout development, iterative feedback helped us understand what users wanted and valued from the games. Early clinical comparison provided validity for the optotype shapes that were created. To further investigate the clinical validity of the games that were developed, the novel OKKO FDT, OKKO colour and OKKO optotypes games were compared against their clinical equivalents (i.e. Clinical FDT, Mollon-Reffin and the SKILL card). The pre-existing OKKO acuity and OKKO contrast games were also compared with the ETDRS and Pelli-Robson respectively. Alongside this clinical validation, the intersession repeatability of the games in diabetes and control groups was examined. Overall, the clinical test measures were more consistent across both groups, but the digital Mollon Reffin and SKILL card showed promise. We developed a questionnaire that assessed acceptability and adherence to technology like the OKKO app. This could help measure whether participants with diabetes would continue to engage with the games longitudinally, and the overall feasibility of home monitoring. We explored the acceptability, feasibility and challenges of longitudinal home monitoring in high-risk participants with diabetes using the OKKO Circles and OKKO Contrast games. Over the course of 6 months, we measured how app engagement varied across the high-risk pregnancy, dialysis and continuous glucose monitoring groups. We gathered user feedback using the accessibility and adherence questionnaire at the start and end of the study. Acceptability and feasibility varied widely by group, and we noted that the perceived risk of developing DR influenced adherence. Each group faced barriers to monitoring such as lack of suitable devices, pregnancy related illness and fatigue.

Date of Award	Jul 2026
Original language	English
Awarding Institution	Queen's University Belfast
Sponsors	OKKO Health & Co-operative Awards in Science and Technology (CAST) studentship (Department for the Economy)
Supervisor	Michael Donnelly (Supervisor), Ruth Hogg (Supervisor) & Tunde Peto (Supervisor)