Ophthalmology, Telemedicine, and the Implications Since COVID-19

The COVID-19 pandemic has drastically changed medicine and its reliance on technology to relay patient care. The purpose of this review is to assess the use of teleophthalmology given the sudden surge in telemedicine demand due to COVID-19.

Recommendations and policies from the government and social distancing rules have significantly affected ophthalmology surgical volumes and clinic visits. Some physicians reported a 75% decline in the number of patients in clinic and a 97% reduction in cataract surgical volume.⁹

Tele-ophthalmology during the pandemic

Ophthalmologist practices have moved towards tele-ophthalmology as an integrated way to deliver safe and effective care. Some leading telehealth platforms have reported virtual patient visits have increased between 250 to 700%. Tele-ophthalmology can be used to triage patients (especially in emergency departments), medication reconciliation, common diagnosis, and long-term treatment of chronic conditions.

With many patients requiring prolonged isolation until recovery with the COVID-19 pandemic, telehealth has become increasingly essential. In a study by Sommer and Blumental (2020), they found tele-ophthalmology to be effective in the screening and management of a range of adult and pediatric chronic ocular conditions including retinopathy of prematurity, diabetic retinopathy, age-related macular degeneration, and glaucoma.¹ It also helps to assist primary care physicians to better triage patients with acute ocular complaints and quickly refer emergent patients to ophthalmologists, which helps to widen the diagnostic and therapeutic options for ocular emergencies.

Doctors can also utilize real-time medicine to conduct many parts of an in-person exam. Technological advances allow for increased remote monitoring, screening, and management of common eye diseases. Telemedicine also allows for ophthalmologists to broaden their reach to around the country or even the world. Remote examinations can be set up to take place in traditionally underserved communities. With the COVID-19 pandemic, reimbursements for telehealth are also changing substantially. According to Bajowala et al. (2020), telemedicine reimbursements policies have been slowly adapting to the increase in demand and advances in technology.2 The COVID-19 pandemic has jumpstarted a major expansion of telemedicine and increases in reimbursements with insurance companies like Medicare and Aetna reimbursing telephone visits to approximate rates for in-person visits.

There are various formats of tele-ophthalmology, including telephone appointments, interprofessional collaborations, remote data interpretation and access, and video visits. They help to improve cost efficiency, convenience, decrease the need for long-distance travel for patients, and reduce person-to-person contact during this global pandemic.

Telephone appointments have been shown to be successful in lieu of non-urgent, face-to-face outpatient clinics. Patel et al (2021) studied the success of telephone appointments for new and follow-up patients in a large low vision clinic in London. The study found that the majority of patients could be assessed using the telephone low vision service. Around one-fourth of patients received a new low vision aid, which was found to be useful in over 80% of patients. In addition, 21% of patients were able to get internal referrals, and only 8.9% needed to be reassessed in an ophthalmologist-led service. There were, however, some limitations and common reasons for noncompliance to telephone visits were people not answering their phone calls, patients declining the assessment, and hearing loss.³

Video visits were found to be a successful alternative to telephone meetings. Host et al (2018) demonstrated that patient satisfaction with real-time video consultation for a variety of ocular conditions was high, with 69% reporting very satisfied and 25% reporting satisfied. Many patients reported that telemedicine enabled them to save both time and money while virtually being able to talk to their doctor in real-time over video.⁴

Beauregard et al (1999) studied the use of telemedicine as a medium for teaching opportunity collaborations between optometry and ophthalmology at the University of Houston. It was found to be successful not only in tele-education in multiple subspecialties of ophthalmology but also useful in enhancing clinical working with professionals.⁵ Telemedicine was also found to be helpful in collaboration of research opportunities as it allowed practitioners and students to remotely access and interpret data easily.

Telemedicine is especially helpful to rural populations of the United States where there are few specialties and appointments that require long traveling times. Tele-ophthalmology has also shown to lower barriers to screening, helping to screen known at-risk patients that may have been lost in the traditional health system. For instance, in a study by Das et al (2019), they described how a dedicated app could assist tele-ophthalmology video consultations in rural areas in India; with 47% receiving medical management and 16% of patients being prescribed glasses using this tele-ophthalmology platform.⁶ The rest were referred to higher centers for medical intervention. Overall, tele-ophthalmology has the potential to increase access to primary and specialty care in areas that are underserved and low/middle income.

Potential problems with tele-ophthalmology

Some of the possible barriers are decreased data quality, patient engagement, workflow integration, physician confidence in their virtual assessment, and reimbursements. There may be increased medical liability for physicians in telemedicine, as 59% of ophthalmologists reported ‘low confidence’ in their ability to make decisions based solely on images. This often leads physicians to advise patients to come in for a necessary in-office exam to confirm their diagnosis at a later date. However, telemedicine-based diagnosis may still allow for early treatment initiation and treatment modifications once in-office evaluation is possible. With improving digital imaging resolution and advancing remote disease management programs, tele-ophthalmology has a bright future ahead.

Especially in ophthalmology, there is great reliance on face-to-face encounters with patients and the appreciation of disease subtleties through careful history and physical exam. It is possible that telehealth cannot achieve that same level of assessment, although new innovations in patient workflows suggest that it might offer a valuable supplement.

New innovations in telehealth

Obtaining a high-quality ophthalmologic examination is critical to telehealth adaptation. Currently, there are mobile applications for some components of the exam to assess visual acuity (PEEK Acuity and Vision@home), color vision (EyeHandbook), and visual fields. Others can assess torsion and measure esotropia and heterophorias.

In a study by Bastawrous et al (2015), for instance, they studied the use of the smartphone-based Peek Acuity in diabetics in Kenya and found that the test was capable of accurate and repeatable acuity measurements consistent with published data.⁷ In a study by Ozgur et al (2018) they found that the smart phone-based testing modality for color vision (EyeHandbook) showed similar results to Ishihara color plates (ICP). Furthermore, 59% preferred EyeHandbook to ICP.⁸

Conclusions and relevance

Overall, telemedicine has transformed the way healthcare is delivered. It has increased cost-effective access to ophthalmologic care and helps to reinforce social distancing within medical practice. Especially with social distancing rules, online modes of communications are more important than ever. Telemedicine allows for improvements in detection and earlier treatment of eye diseases through screening and automatic diagnostics. Of the various forms of tele-ophthalmology, video visits have been seen as particularly effective. Online visits are useful for easier patient access, lowered costs, and collaboration between specialties.

Nevertheless, telemedicine presents new barriers when compared to in-person medicine when it comes to quality of care, liability for ophthalmologists, and cost for certain devices needed for a complete physical exam.

Fundoscopy remains a major barrier to a complete tele-ophthalmology examination. While there are developments of a portable fundus camera for patients, there remain issues of portability, cost, and technical training requirements to obtain high-quality images. Optical coherence tomography is another aspect of the ophthalmologic examination that is facing similar challenges.

References

Sommer, A. C., & Blumenthal, E. Z. (2020). Telemedicine in ophthalmology in view of the emerging COVID-19 outbreak. Graefes Archive for Clinical and Experimental Ophthalmology, 258(11), 2341-2352. doi:10.1007/s00417-020-04879-2
Bajowala, S. S., Milosch, J., & Bansal, C. (2020). Telemedicine Pays: Billing and Coding Update. Current Allergy and Asthma Reports, 20(10). doi:10.1007/s11882-020-00956-y
Patel A, Fothergill AS, Barnard KEC, Dunbar H, Crossland MD. Lockdown low vision assessment: an audit of 500 telephone-based modified low vision consultations. Ophthalmic Physiol Opt. 2021 Mar;41(2):295-300. doi: 10.1111/opo.12789. Epub 2021 Feb 2. PMID: 33529405; PMCID: PMC8014140.
Host, BK, Turner AW, & Muir J (2018). Real‐time teleophthalmology video consultation: an analysis of patient satisfaction in rural Western Australia, Clinical and Experimental Optometry, 101:1, 129-134, DOI: 10.1111/cxo.12535
Beauregard D, Schiffman JS, Tang R. Collaborative telemedicine between optometry and ophthalmology: an initiative from the University of Houston. Stud Health Technol Inform. 1999;64:173-8. PMID: 10747536.
Das AV, Mididoddi S, Kammari P et al (2019) App-based tele ophthalmology: a novel method of rural eye care delivery connecting tertiary eye care center and vision centers in India. Int J Telemed Appl:2019.
Bastawrous A, Rono HK, Livingstone IA, Weiss HA, Jordan S, Kuper H, Burton MJ. Development and Validation of a Smartphone-Based Visual Acuity Test (Peek Acuity) for Clinical Practice and Community-Based Fieldwork. JAMA Ophthalmol. 2015 Aug;133(8):930-7. doi: 10.1001/jamaophthalmol.2015.1468. Erratum in: JAMA Ophthalmol. 2015 Sep;133(9):1096. PMID: 26022921; PMCID: PMC5321502.
Ozgur OK, Emborgo TS, Vieyra MB, Huselid RF, Banik R. Validity and Acceptance of Color Vision Testing on Smartphones. J Neuroophthalmol. 2018 Mar;38(1):13-16. doi: 10.1097/WNO.0000000000000637. PMID: 29438263.
Assaf A, Mearza AA, Schoenberg ED, Tognetto D, Vinciguerra AL, Giglio R. The Impact of COVID-19 on Ophthalmic Surgery. CRSToday. Jan 2021.