The United States Army Ocular Teleconsultation program 2004 through 2009

Applying a Military Teleophthalmology Mobile App in a Noncombat Emergent Care Setting

INTRODUCTION

Teleophthalmology has a natural role in the military due to the inherent organization of its medical system, which provides care to patients in remote locations around the world. Improving access to ophthalmic care enhances force readiness because ocular trauma and disease can cause vision impairment or blindness and can occur anywhere service members are located. Recently, a secure, Health Insurance Portability and Accountability Act-compliant mobile phone application (app) for teleophthalmology called Forward Operating Base Expert Telemedicine Resource Utilizing Mobile Application for Trauma (FOXTROT) was beta tested in Afghanistan and demonstrated that this solution can improve and extend ophthalmic care in a deployed environment. There are few civilian or military teleophthalmology solutions for ocular trauma and disease in an urgent or emergent ophthalmic care setting. Civilian teleophthalmology solutions have largely been developed for disease-specific models of care. In this work, we address this gap by testing the FOXTROT app in a non-deployed, emergent care setting.

MATERIALS AND METHODS

We evaluated the use of the teleophthalmology mobile phone app (FOXTROT) in a non-deployed military setting at the Malcolm Grow Medical Clinics and Surgery Center at Joint Base Andrews in Maryland. Consults from the emergent care center were placed by providers using the app, and the on-call ophthalmologist responded with treatment and management recommendations. The primary outcomes were response within the requested time, visual acuity tested in both eyes, agreement between the teleophthalmology and the final diagnosis, and the number of communication or technical errors that prevented the completion of consults. The secondary outcomes were average response time and the number of consults uploaded to the medical record.

RESULTS

From October 2020 to January 2022, 109 consults were received. Ten consults had communication or technical errors that prevented the completion of consults within the app and were excluded from the analysis of completed consults. Of the 99 completed consults, responses were given within the requested time in 95 (96.0%), with the average response time in 11 minutes 48 seconds (95% confidence interval, 8 minutes 57 seconds to 14 minutes 41 seconds). Visual acuity was tested in both eyes in 56 (56.6%). There was agreement between the teleophthalmology diagnosis and the final diagnosisin 40 of 50 (80.0%) consults with both a teleophthalmology and final diagnosis. Ninety-eight (99.0%) consults were uploaded to the patient's medical record.

CONCLUSIONS

Beta testing of a teleophthalmology mobile phone app (FOXTROT) in a noncombat emergent care setting demonstrated that this solution can extend ophthalmic care in this environment at a military treatment facility. However, improvements in the reliability of the platform are needed in future developments to reduce communication and technical errors.

Teleophthalmology in the United States Army: A Review From 2004 Through 2018

INTRODUCTION

We describe results of the U.S. Army Ocular Teleconsultation program from 2004 through 2018 as well as the current condition, benefits, barriers, and future opportunities for teleophthalmology in the clinical settings and disease areas specific to the U.S. Military.

MATERIALS AND METHODS

This was a retrospective, noncomparative, consecutive case series. A total of 653 ocular teleconsultations were reviewed; 76 concerned general policy questions and underwent initial screening to determine the year each request was received, the average and median initial consultant response time, the number of participating consultants, the country from which the request originated, the military status and branch of each U.S. patient for which a request was submitted, and the nationality, age, and military status of foreign patients for whom consults were requested. The remaining 577 requests were further analyzed to determine the diagnostic category of the request, whether or not an evacuation recommendation was provided by a consultant, the relationship of the request to trauma, if and what type of nonocular specialty consultant(s) participated in the consultation request, and if and what type of ancillary imaging accompanied the request.

RESULTS

The number of requests was 13 in 2004, compared to 80 in 2011 and 11 in 2018. The average response time in 2018 was 2.27 hours compared to 9. 73 hours in 2004. The number of participating ocular specialists was 5 in 2004, compared to 39 in 2013 and 13 in 2018. Requests originating from Iraq and Afghanistan comprised 61.1% (399/653) of requests. The U.S. Army personnel comprised the largest percentage of consults at 38.6% (252/653). Nonmilitary patients from the USA accounted for 18.5% (121/653) of consults. Non-U.S. patients including coalition forces, contractors, detainees, and noncombatants accounted for 14.4% (94/653) of consults, of which 22% (21/94) were children. Anterior segment consults accounted for 45.1% (260/577) of consults, with corneal surface disease being the largest subset within this diagnostic category. Evacuation was recommended in 22.7% (131/577) of overall cases and 41.1% (39/95) of trauma cases. Requests were associated with either combat-related or accidental trauma in 16.5% (95/577) of cases. Dermatology and neurology were the most commonly co-consulted specialties, representing 40.0% (32/80) and 33.75% (27/80) of consults, respectively. Photographs of suspected ocular pathology accompanied 37.4% of consults, with the likelihood requesters included photographs being greatest in cases involving pediatric ophthalmology (7/9, 77.8%) and oculoplastics (86/120, 71.7%).

CONCLUSIONS

Army teleophthalmology has been an indispensable resource in supporting and advancing military medicine, helping to optimize the quality, efficiency, and accessibility of ophthalmic care for U.S. Military personnel, beneficiaries, allied forces, and local nationals worldwide. A dedicated ophthalmic care and coordination system which utilizes new advances in teleconsultation technology could further enhance our current capability to care for the ophthalmic needs of patients abroad, with opportunity for improving domestic care as well.

Teleophthalmology Using Remote Retinal Imaging During the COVID-19 Pandemic

Introduction: Lower insurance reimbursements have limited the financial sustainability of remote eye screening programs. Greater utilization and insurance coverage for teleophthalmology screening during the coronavirus disease 2019 (COVID-19) pandemic in 2020 may enhance awareness and expand remote retinal imaging services. This retrospective cross-sectional study evaluates utilization and insurance coverage for remote retinal imaging in the United States in 2020. Methods: We analyzed teleretinal imaging utilization and insurance payments from January 1 to December 31, 2020, using the Optum Labs Data Warehouse, a comprehensive national database of deidentified administrative claims for commercial and Medicare Advantage enrollees in the United States. We evaluated frequency of claims and insurance payment for services using the Current Procedural Terminology codes 92227 and 92228 for remote eye imaging by any provider, and 92250 for fundus photography by non-eye care providers. Results: The use of remote retinal imaging in the United States declined rapidly during the initial COVID-19 lockdown from 3,627 claims in February 2020 to 1,414 claims in April 2020, but returned to 3,133 claims by December 2020, similar to mean prepandemic levels in 2019 (2,841 ± 174.8 claims). The proportion of insurance payments for remote imaging increased temporarily from 47.4% in February to 56.7% in April, and then returned to 45.9% in December of 2020. Discussion: Utilization of remote retinal imaging declined steeply, while the insurance coverage increased during the initial COVID-19 lockdown in 2020, but returned to prepandemic levels by end of the year. Changes in utilization and relaxed restrictions on insurance reimbursements for teleophthalmology during the COVID-19 pandemic were not sustained.

Tele-ophthalmology as an aid tool for primary care physicians in the IDF, during the Covid-19 lockdown

PURPOSE

To describe tele-ophthalmology consultations for primary-physicians in the IDF during the Covid-19 lockdown.

METHODS

Retrospective cross-sectional study. Medical records of tele-ophthalmology consultations from March to June 2020 were reviewed.

RESULTS

The study included 245 cases in which an ophthalmologist was consulted. In 62.0% cell-phone camera photographs were used. The mean age was 21.5 ± 6.4 years. The most common diagnoses were acute-conjunctivitis (8.6%); conjunctival-hyperemia (non-specific diagnosis, 8.2%); scleritis/episcleritis (7.3%); chronic allergic-conjunctivitis (7.3%); chalazion (7.3%) hordeolum (6.5%); acute allergic-conjunctivitis (4.5%). 37.6% of patients received primary physician-based treatment, 24.9% of patients received specialist-based treatment. 13.1% were referred to the ER. The consult prevented ER referral for 39.2% and changed the physician's treatment plan in 70.6% of cases. Foreign-body sensation complaints were more likely treated by a primary-physician (p = 0.015). Cases with suspected foreign-body diagnosis were referred more to the ER (p < 0.001). For most cases of eyelid complaints and diagnoses, primary physician care was sufficient (p < 0.001). Conjunctival complaints and diagnoses received significantly more ophthalmologist-based treatment (p < 0.001). Corneal disorders were significantly referred more to the ER (p = 0.001).

CONCLUSION

Despite of possible ethical and legal problems and clinical limitations of this instrument, Tele-ophthalmology using objective aids such as smartphone photography can be an efficient tool in aiding the primary-physician, especially for patients with low access to ophthalmologists, with major impact on patient management.

Diagnostic Error in Neuro-ophthalmology: Avenues to Improve

Purpose of Review

To highlight potential avenues to reduce preventable diagnostic error of neuro-ophthalmic conditions and avoid patient harm.

Recent Findings

Recent prospective studies and studies of patient harm have advanced our understanding. Additionally, recent studies of fundus photography, telemedicine, and artificial intelligence highlight potential avenues for diagnostic improvement.

Summary

Diagnostic error of neuro-ophthalmic conditions can often be traced to failure to gather an adequate history, perform a complete physical exam, obtain adequate/appropriate neuroimaging, and generate a complete, appropriate differential diagnosis. Improving triage and identification of neuro-ophthalmic conditions by other providers and increasing access to subspecialty neuro-ophthalmology evaluation are essential avenues to reduce diagnostic error. Further research should evaluate the relationship between misdiagnosis and patient harm, and help identify the most impactful potential targets for improvement.

Digital Transformation in Ophthalmic Clinical Care During the COVID-19 Pandemic

ABSTRACT

COVID-19 has placed unprecedented pressure on health systems globally, whereas simultaneously stimulating unprecedented levels of transformation. Here, we review digital adoption that has taken place during the pandemic to drive improvements in ophthalmic clinical care, with a specific focus on out-of-hospital triage and services, clinical assessment, patient management, and use of electronic health records. We show that although there have been some successes, shortcomings in technology infrastructure prepandemic became only more apparent and consequential as COVID-19 progressed. Through our review, we emphasize the need for clinicians to better grasp and harness key technology trends such as telecommunications and artificial intelligence, so that they can effectively and safely shape clinical practice using these tools going forward.

A Sub-Analysis of U.S. Africa Command Area of Operations Transportations for Ophthalmic Concerns, 2008-2018

INTRODUCTION

American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018.

METHODS

We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions.

RESULTS

Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary.

CONCLUSION

Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.

An algorithm in ophthalmic emergencies to evaluate the necessity of physical consultation during COVID-19 lockdown in Paris: Experience of the first 100 patients

Purpose

This study aimed to evaluate the ability of a freely accessible internet algorithm to correctly identify the need for emergency ophthalmologic consultation for correct diagnosis and management.

Method

This retrospective observational cohort study was based on the first 100 patients who requested recommendations on the necessity of breaking the lockdown for emergency ophthalmology consultation during the period from March to May 2020.

Results

Ninety-one patients completed questionnaires. Forty-nine were directed to emergency consultation and 42 to differed scheduled visits or telemedicine visits. One patient sent for emergency consultation had an overestimated severity and could have been seen later, while two patients initially recommended for a scheduled visit were considered appropriate for emergency consultation. However, these patients’ management did not suffer as a consequence of the delay. The sensitivity of the algorithm, defined as the number of emergency consultations suggested by the algorithm divided by the total number of emergency consultations deemed appropriate by the practitioner's final evaluation, was 96.0%. The specificity of the algorithm, defined as the number of patients recommended for delayed consultation by the algorithm divided by the number of patients deemed clinically appropriate for this approach, was 97.5%. The positive predictive value, defined as the number of appropriate emergency consultations divided by the total number of emergency consultations suggested by the algorithm, was 97.9%. Finally, the negative predictive value, defined as the number of appropriately deferred patients divided by the number of deferred patients recommended by the algorithm, was 95.2%.

Conclusion

This study demonstrates the reliability of an algorithm based on patients’ past medical history and symptoms to classify patients and direct them to either emergency consultation or to a more appropriate deferred, scheduled appointment. This algorithm might allow reduction of walk-in visits by half and thus help control patient flow into ophthalmologic emergency departments.

Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic

BACKGROUND

We introduced a video consultation (VC) during the coronavirus (COVID-19) pandemic in an ophthalmology practice with eight doctors to ensure continuous ophthalmological care, infection prophylaxis and to compensate a decreased number of patient presentations.

OBJECTIVE

Evaluation of the most common reasons for patient presentations in the VC, the proportion of re-presentations in the practice despite VC, practical challenges associated with the introduction of VC and patient satisfaction.

MATERIAL AND METHODS

Patients with a recent acute visual deterioration and severe eye pain were excluded from the VC. The VC were carried out by a trained specialist in ophthalmology. A questionnaire with eight questions was completed after the VC appointment in order to evaluate the proportion of completed VC and patient satisfaction.

RESULTS

We included 29 (13 male, Ø 52.6 years, 16 female, Ø 64.7 years) patients in this analysis. The VC could be performed with 68.97% of the participants who rated their overall experience with an average grade of 1.6 (1 very good to 6 insufficient) and all of them indicated that they would recommend the VC. Of presentations in VC 70% were related to the symptoms of the anterior eye segment. In 70% of the cases no re-presentations took place in the unit.

CONCLUSION

Our study represents a significant practical application of VC for the management of non-urgent ocular conditions with maximum infection prophylaxis. The introduction of VC was severely limited by technological or user-related issues by the establishment of video connections. Patient satisfaction with VC was high to very high.

Accuracy of periocular lesion assessment using telemedicine

Objectives

To assess the agreement in diagnosis and management plans reached between clinicians reviewing eyelid lesions remotely and in face-to-face clinics.

Methods

In this single-centre observational case series, data were prospectively collected on 50 consecutive adults referred with eyelid lesions suitable to be seen by a nurse. A proforma was completed to gather salient information. A nurse specialist saw patients in face-to-face clinics and collected information using the proforma, devising a diagnosis and management plan. Photographs of the eyelid lesions were taken by a medical photographer. A subsequent remote review was completed by an oculoplastic consultant using the proforma information and photographs in the absence of the patient. The diagnosis and management plan constructed by the nurse specialist were compared with those reached by the consultant.

Results

Complete data were available for 44 consecutive cases. There was an overall 91% agreement (40 cases out of 44) between the diagnoses reached by the nurse specialist, and the remote reviewer; kappa coefficient 0.88 (95% CI 0.76 to 0.99). There was an overall 82% agreement (36 out of 44 cases) in the management plans devised by the nurse-led clinic and remote reviewer; kappa coefficient 0.74 (95% CI 0.58 to 0.90). The average time taken for a remote reviewer to reach a diagnosis and management plan was 1 min and 20 s.

Conclusions

This study evaluated the feasibility of assessing eyelid lesions using asynchronous telemedicine. There was overall a high rate of concordance in the diagnosis reached, and management devised between the clinic and remote review.

Military Teleophthalmology in Afghanistan Using Mobile Phone Application

Importance

The coronavirus disease 2019 pandemic has highlighted the need to expand telemedicine solutions.

Objective

To beta test a secure teleophthalmology mobile app at military treatment facilities in Afghanistan.

Design, Setting, and Participants

This prospective case series included 16 military treatment facilities at diverse roles of care including forward operating bases in Afghanistan and 1 location outside of Afghanistan. Thirty point-of-care medics and medical professionals were included from September to November 2019.

Interventions

Users placed teleophthalmology consults on their mobile phone using the mobile eye care app, and an expeditionary ophthalmologist stationed at a military hospital in Afghanistan responded. Users graded the mobile app using a rating scale from 1 to 5, with 1 being very dissatisfied and 5 being very satisfied.

Main Outcomes and Measures

Mean initial response time, agreement between the teleophthalmology diagnosis and final diagnosis, treatment and management following recommendations outlined in the Joint Trauma System clinical practice guidelines, prevention of the need for aeromedical evacuation, user satisfaction, and security and the Health Insurance Portability and Accountability Act compliance of consult.

Results

There were 28 consults placed over 6 weeks by 18 different users that were received by the expeditionary ophthalmologist. The mean (SD) patient age was 30.3 (9.8) years. Most patients were male (26 [93%]) and active duty US military (22 [78%]). The mean initial response time was 3 minutes 58 seconds (95% CI, 2 minutes 30 seconds to 5 minutes 26 seconds). There was agreement between the teleophthalmology diagnosis and final diagnosis in 24 consults (86%; 95% CI, 72%-100%). The treatment and management followed recommendations outlined in the Joint Trauma System Clinical Practice Guidelines for Eye Trauma: Initial Care in 28 consults (100%). Teleophthalmology consultation prevented the need for aeromedical evacuation in 4 consults (14%; 95% CI, 0.7%-28%). The patient returned to duty in 15 consults (54%; 95% CI, 34%-73%). Median overall satisfaction was 5 (minimum, 3; maximum, 5). All 28 consults (100%) were secure and compliant with the Health Insurance Portability and Accountability Act.

Conclusions and Relevance

While only a limited number of consults were evaluated, this study suggests that teleophthalmology mobile phone apps may improve and extend ophthalmic care in combat zones.

[Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic]

BACKGROUND

We introduced a video consultation (VC) during the coronavirus (COVID-19) pandemic in an ophthalmology practice with eight doctors to ensure continuous ophthalmological care, infection prophylaxis and to compensate a decreased number of patient presentations.

OBJECTIVE

Evaluation of the most common reasons for patient presentations in the VC, the proportion of re-presentations in the practice despite VC, practical challenges associated with the introduction of VC and patient satisfaction.

MATERIAL AND METHODS

Patients with a recent acute visual deterioration and severe eye pain were excluded from the VC. The VC were carried out by a trained specialist in ophthalmology. A questionnaire with eight questions was completed after the VC appointment in order to evaluate the proportion of completed VC and patient satisfaction.

RESULTS

We included 29 (13 male, Ø 52.6 years, 16 female, Ø 64.7 years) patients in this analysis. The VC could be performed with 68.97% of the participants who rated their overall experience with an average grade of 1.6 (1 very good to 6 insufficient) and all of them indicated that they would recommend the VC. Of presentations in VC 70% were related to the symptoms of the anterior eye segment. In 70% of the cases no re-presentations took place in the unit.

CONCLUSION

Our study represents a significant practical application of VC for the management of non-urgent ocular conditions with maximum infection prophylaxis. The introduction of VC was severely limited by technological or user-related issues by the establishment of video connections. Patient satisfaction with VC was high to very high.

Tele-consultations in the wake of COVID-19 - Suggested guidelines for clinical ophthalmology

While telemedicine has been around for a few decades, it has taken great importance and prominence in recent times. With the fear of the virus being transmitted, patients and physicians across specialties are using consultation via a telephone call or video from the safety of their homes. Though tele-ophthalmology has been popular for screening, there are no clear guidelines on how to comprehensively manage patients seeking advice and treatment for a particular eye condition. Some major barriers to diagnosis and management are compromised detailed examination, no measurement of the visual acuity or intraocular pressure and a retinal evaluation not being feasible. Despite these limitations, we do need to help those patients who need immediate care or attention. Hence, this article has put together some guidelines to follow during such consultations. They are important and timely due to the medicolegal and financial implications.

Teleconsultation in primary ophthalmic emergencies during the COVID-19 lockdown in Paris: Experience with 500 patients in March and April 2020

This prospective observational cohort study is based on the first 500 patients who requested emergency teleconsultation during the initial days of the COVID-19 lockdown in Paris, France between 20 March and 10 April 2020. It is the first study to assess the utility of emergency teleophthalmology with a simple smartphone application or web browser and a webcam to manage emergency eye care in a population with sudden restricted access to ophthalmologists. In this study, every patient who asked for an ophthalmic emergency consultation in a single specialized center in Paris (‘SOS Œil’) first had to undergo a teleconsultation appointment to evaluate the indication for a physical consultation to preserve lockdown. Under medical advice only, a physical appointment was given within a day (if necessary). The aim of the study was to describe the population and diagnoses and evaluate the main judgment criteria, defined as the ‘ability of teleconsultation to properly indicate a physical consultation for fair diagnosis and treatment in eye emergencies’. This organization has permitted physicians and patients to preserve social distancing while avoiding 3 or 4 physical consultations per person. Notably, 27% of teleconsultations were followed by a physical appointment. There was a mean 4.12-day delay between symptom apparition and consultation, and less than 1 day for traumas, superficial corneal foreign body and neuro-ophthalmological emergencies. There was a 96% sensitivity and 95% specificity to properly evaluate the indication of a physical consultation and only 1.0% misdiagnoses that lead to delayed care. Hence, teleconsultation maintained satisfactory healthcare access to patients with severe ophthalmological disorders while preserving social distancing and sanitary precautions. Therefore, teleconsultation may be seriously considered as a way to efficiently regulate ophthalmic emergencies, especially for patients with limited access to a specialist.

Deployed ophthalmic workload in support of US and NATO operations in Afghanistan

PURPOSE

The extent and types of ophthalmic disease and non-battle injury (DNBI) seen by expeditionary ophthalmologists at deployed military medical treatment facilities have not previously been reported. We aim to characterise the extent and type of ophthalmic pathology including DNBI at a US military medical treatment facility in Afghanistan.

METHODS

We conducted a retrospective non-interventional cohort study of all patients seen by ophthalmologists at Craig Joint Theater Hospital at Bagram Airfield (BAF), Afghanistan, between 1 October 2018 and 31 August 2019.

RESULTS

There were 281 patients seen in 540 separate encounters, of which 146 patients seen were active duty military stationed at BAF with DNBI, of a population at risk of 6000 personnel. Diagnoses managed included open and closed globe injury, bacterial and herpetic keratitis and retinal detachment, with the most common being dry eye, corneal abrasion/foreign body, blepharitis, chalazion and uveitis. Thirteen patients (5%) required aeromedical evacuation out of theatre and 39 patients were aeromedically transferred within theatre for assessment. Expert consensus estimated that 89 patients (36%) would be likely to require aeromedical evacuation out of theatre without ophthalmic input.

CONCLUSIONS

The rate of ophthalmic DNBI among deployed US, UK and coalition forces at BAF was 2.65% per year, of whom 97% were returned to duty (95% of all patients). We estimate that evacuation and loss to unit would increase from 5% to 36% without an ophthalmologist present. The low number of within-theatre aeromedical transfers suggests that the local presence of an ophthalmologist at a patient's deployed medical treatment facility affects access to deployed ophthalmic care.

Telerehabilitation for people with low vision

BACKGROUND

Low vision affects over 300 million people worldwide and can compromise both activities of daily living and quality of life. Rehabilitative training and vision assistive equipment (VAE) may help, but some visually impaired people have limited resources to attend in-person visits at rehabilitation clinics to receive training to learn to use VAE. These people may be able to overcome barriers to care through remote, Internet-based consultation (i.e. telerehabilitation).

OBJECTIVES

To compare the effects of telerehabilitation with face-to-face (e.g. in-office or inpatient) vision rehabilitation services for improving vision-related quality of life and near reading ability in people with visual function loss due to any ocular condition. Secondary objectives were to evaluate compliance with scheduled rehabilitation sessions, abandonment rates for VAE devices, and patient satisfaction ratings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2019, Issue 6); Ovid MEDLINE; Embase.com; PubMed; ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any language restriction or study design filter in the electronic searches; however, we restricted the searches from 1980 onwards because the Internet was not introduced to the public until 1982. We last searched the electronic databases on 24 June 2019.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) or controlled clinical trials (CCTs) in which participants diagnosed with low vision were undergoing low vision rehabilitation using an Internet, web-based technology compared with an approach involving in-person consultations.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and then full-text articles against the eligibility criteria. We planned to have two review authors independently abstract data from the included studies. Any discrepancies were resolved by discussion.

MAIN RESULTS

We identified two ongoing studies, but did not find any completed RCTs and CCTs that met the inclusion criteria for this review. We did not conduct a quantitative analysis. We discussed review articles on telemedicine for facilitating communication with elderly individuals or for providing remote ophthalmological care.

AUTHORS' CONCLUSIONS

We did not find any evidence from RCTs or CCTs on the efficacy of using telerehabilitation for remote delivery of rehabilitation services to individuals with low vision. Given the disease burden and the growing interest in telemedicine, the two ongoing studies, when completed, may provide evidence in understanding the potential for telerehabilitation as a platform for providing services to people with low vision.

Military Teleconsultation Services Facilitate Prompt Recognition and Treatment of a Case of Syphilitic Uveitis Aboard a United States Navy Aircraft Carrier at Sea During Combat Operations Without Evacuation Capability

Background: In the United States Armed Forces, telemedicine can bring specialist care into the field, augmenting the capabilities of health care providers in remote, austere environments to nearly the point of injury or illness. The early intervention enabled by telemedical consultation can not only guide crucial temporizing measures to safeguard life, limb, and eyesight, but can also facilitate care in resource limited environments, potentially avoiding need for patient evacuation. In circumstances when a higher level of care is needed, but unavailable or operationally not possible, telemedicine can guide management in the field until transport can be achieved. Methods: In the present case, a young male patient presented to medical company aboard a U.S. Navy aircraft carrier while deployed at sea for evaluation of an acute red eye. Despite initial therapeutic measures, his vision subsequently deteriorated. Uveitis was suspected, but transport off the ship to an eye care specialist was not possible during combat operations. Results: Telemedical consultation with shore-based ophthalmologists guided initial diagnostic and therapeutic efforts, resulting in the presumed diagnosis of syphilitic uveitis. With remote support of ophthalmology and infectious disease specialist care, the patient was treated at sea for this vision-threatening condition. As operational conditions allowed, the patient was later evacuated to definitive care. Conclusions: At follow up after treatment, the patient had an excellent visual outcome, and was promptly returned to duty.

Barriers between community screening for visual problems and treatments in a tertiary center

OBJECTIVE

To evaluate the effectiveness of mobile ophthalmic unit screenings and to investigate barriers between community care and resolution of the problem at a tertiary center.

METHODS

This prospective study evaluated a convenience sample from 10 municipalities in São Paulo State, Brazil. Patients were assessed in the municipality by a mobile ophthalmic unit and underwent a complete ophthalmic consultation. Patients were referred as warranted to a tertiary hospital.

RESULTS

The mobile ophthalmic unit screened 1,928 individuals and 714 (37%) were referred. The mean age of the referred patients was 57.12 (SD = 19.5) years with best corrected visual acuity of 0.37 (SD = 0.36) logMAR. Forty-seven (6.6%) patients were blind and 185 (26.5%) were visually impaired. Cataracts (44.7%) and pterygium (14.7%) accounted for most referrals. Of those referred, 67.1% presented to the tertiary center. The diagnosis by the mobile ophthalmic unit corresponded to the one by the tertiary center in 88.5% of the cases. There were a significantly higher number of blind and visually impaired persons among those who presented to the hospital. There was a significantly greater attendance among patients living in more distant municipalities from the reference center with a higher number of inhabitants and a greater number of ophthalmologists in the cities of origin (p < 0.05, all comparisons). Complete treatment was performed in 65.6% of patients, and loss to follow-up was the main cause of incomplete treatment in 50.7% of patients. A total of 313 cataract surgeries were performed, which reduced the number of blind patients from 20 to 2 and of visually impaired individuals from 87 to 2 (p < 0.001).

CONCLUSIONS

Only 37% of the patients assessed by a mobile ophthalmic unit required referral to a tertiary hospital. Among the referred patients, 67.1% presented to the hospital, and complete resolution after treatment was approximately 65.5%. There was a significant improvement in visual acuity and a reduction in the prevalence of blindness and visual impairment postoperatively.

The Current State of Teleophthalmology in the United States

Telemedicine services facilitate the evaluation, diagnosis, and management of the remote patient. Telemedicine has rapidly flourished in the United States and has improved access to care, outcomes, and patient satisfaction. However, the use of telemedicine in ophthalmology is currently in its infancy and has yet to gain wide acceptance. Current models of telemedicine in ophthalmology are largely performed via "store and forward" methods, but remote monitoring and interactive modalities exist. Although studies have examined the effects of telemedicine, few reports have characterized its current status. We perform a descriptive analysis of the current state of teleophthalmology in the United States. We describe the use of teleophthalmology in the hospital and outpatient settings. We also review the applications to retinopathy of prematurity, diabetic retinopathy, age-related macular degeneration, and glaucoma, as well as anticipated barriers and hurdles for the future adoption of teleophthalmology. With ongoing advances in teleophthalmology, these models may provide earlier detection and more reliable monitoring of vision-threatening diseases.

Models of care in tele-ophthalmology: A scoping review

The objective of this review was to identify and describe telehealth models of care for ophthalmic services. We conducted a scoping review of the literature to identify how ophthalmic care can be delivered by telehealth. We searched the PubMed database to identify relevant articles which were screened based on pre-defined inclusion criteria. For included articles, data were extracted, categorised and analysed. Synthesis of findings was performed narratively. The scoping review included 78 articles describing 62 discrete tele-ophthalmic models of care. Tele-ophthalmic models of care can be used for consultative service, screening, triage and remote supervision. The majority of services were for general eye care and triage ( n = 17; 26%) or emergency services ( n = 8; 12%). The most common conditions for disease-specific models of care were diabetic retinopathy ( n = 14; 21%), and glaucoma ( n = 8; 12%). Most models of care involved local clinicians capturing images and transmitting them to an ophthalmologist for assessment. This scoping review demonstrated tele-ophthalmology to be feasible for consultation, screening, triage and remote supervision applications across a broad range of ophthalmic conditions. A large number of models of care have been identified and described in this review. Considerable collaboration between patient-end clinicians and substantial infrastructure is typically required for tele-ophthalmology.

Teleophthalmic Approach for Detection of Corneal Diseases: Accuracy and Reliability

PURPOSE

Corneal and anterior segment diseases cause most of the urgent visits to eye care professionals. We evaluated the diagnostic accuracy of detecting corneal diseases using external photographs from 2 portable cameras for telemedicine purposes.

METHODS

This is a prospective study of adults with a clinical diagnosis of corneal pathology including corneal abrasions, ulcers, scars, and pterygia. A cornea specialist provided the gold standard diagnosis by slit-lamp examination. Images of both eyes were obtained using iTouch 5S and Nidek VersaCam cameras in multiple gazes and interpreted by 3 cornea specialists for the presence of pathology. Accuracy to detect disease was compared with gold standard diagnosis, stratified by the camera and grader. Reliability was evaluated with weighted kappa statistics. Graders assessed image quality on a Likert scale from 1 (poor) to 9 (optimal).

RESULTS

A total of 198 eyes (110 subjects) were photographed. By gold standard diagnosis, 59 eyes (30%) had corneal scars, 34 (17%) had ulcers, 13 (7%) had abrasions, 10 (5%) had pterygia, and 82 (41%) were normal. Sensitivity to detect AS pathology ranged from 54% to 71% for the iTouch and 66% to 75% for the Nidek, across graders; specificity ranged from 82% to 96% for the iTouch and 91% to 98% for the Nidek. The intergrader reliability was moderate to strong (kappa ranges: 0.54-0.71 for the iTouch; 0.75-0.76 for the Nidek). Quality ratings were variable between graders.

CONCLUSIONS

External photographs taken by standard, nonenhanced portable cameras and interpreted remotely by ophthalmologist graders yielded sensitivity values that are not yet suitable for telemedicine applications. Additional work is needed to improve the ability to detect AS pathology remotely.

Teleconsultation and Clinical Decision Making: a Systematic Review

BACKGROUND

The goal of teleconsultation is to omit geographical and functional distance between two or more geographically separated health care providers. The purpose of present study is to review and analyze physician-physician teleconsultations.

METHOD

The PubMed electronic database was searched. The primary search was done on January 2015 and was updated on December 2015. A fetch and tag plan was designed by the researchers using an online Zotero library.

RESULTS

174 full-text articles of 1702 records met inclusion criteria. Teleconsultation for pediatric patients accounts for 14.36 percent of accepted articles. Surgery and general medicine were the most prevalent medical fields in the adults and pediatrics, respectively. Most teleconsultations were inland experiences (no=135), and the USA, Italy and Australia were the three top countries in this group. Non-specialists health care providers/centers were the dominant group who requested teleconsultation (no=130). Real time, store and forward, and hybrid technologies were used in 50, 31, and 16.7 percent of articles, respectively. The teleconsultation were reported to result in change in treatment plan, referral or evacuation rate, change in diagnosis, educational effects, and rapid decision making. Use of structured or semi-structured template had been noticed only in a very few articles.

CONCLUSION

The present study focused on the recent ten years of published articles on physician-physician teleconsultations. Our findings showed that although there are positive impacts of teleconsultation as improving patient management, still have gaps that need to be repaired.

Telemedicine for ophthalmic consultation services: use of a portable device and layering information for graders

Introduction We compared remote, image-based patient consultations to in-person consultations at emergency department and inpatient hospital settings. Methods Patients evaluated by the ophthalmic consultation services (gold standard) were imaged over a two-week period. A trained study coordinator took anterior segment photographs (AS) and posterior segment photographs (PS) with a portable camera (PictorPlus, Volk Optical, Cleveland, OH). Ophthalmologists (graders) determined photograph quality, presence of pathology, and their confidence in disease detection. At a separate session, graders reassessed photographs accompanied by a one-sentence summary of demographics and chief complaint (CHx). We computed accuracy and reliability statistics. Results We took AS photographs of 24 eyes of 15 patients and PS photographs of 39 eyes of 20 patients. The majority of images were rated as acceptable or excellent in quality (AS: 89-96%; PS: 70-75%). Graders detected AS pathology with 62-81% sensitivity based on photographs, increasing to 87-88% sensitivity with photographs plus CHx. Graders detected PS pathology with 79-86% sensitivity based on a photograph only, increasing to 100% sensitivity with photographs plus CHx. Discussion In this pilot study, there is evidence that portable ophthalmic imaging technologies could enable ophthalmologists to remotely evaluate anterior and posterior segment eye diseases with good sensitivity. The ophthalmologist could detect ocular pathology on photographs more accurately if they were provided brief clinical information.

Wartime toxicology: evaluation of a military medical toxicology telemedicine consults service to assist physicians serving overseas and in combat (2005-2012)

Those medical providers deployed to remote countries and tasked with caring for military personnel must diagnose and treat diseases and nonbattle injuries that result from exposures rarely seen in developed countries. Military providers must also function with limited resources and a lack of access to physician specialists, to include medical toxicologists. There have been limited published approaches to addressing this clinical gap for medical toxicology. To address this void, the US Army Medical Department deployed an electronic mail telemedicine system to provide teleconsultations for remote health-care providers worldwide, including Iraq and Afghanistan. This study aimed to describe the types and the frequency of toxicology teleconsultation and consultant responses using electronic mail to assist physicians serving in resource-limited locations. This was a retrospective observational study in which an unblinded data extractor independently reviewed all medical toxicology email consultations. Using a previously developed data collection worksheet, the extractor recorded the type of question asked by the consultant (overdose case, envenomation, occupational exposure, etc.) and the duration of time from when the teleconsultation was placed until the consultant replied. The extractor also recorded if the patient was adult or pediatric and if the patient was US military, US contractor, or local national. The extractor also recorded how often the toxicologist provided the consulting physician with information, resources, or protocols to aid in the management of future cases. In addition, for clinical teleconsultations, the extractor documented the frequency that the consulted toxicologist (i) provided a differential diagnosis or specific diagnosis, (ii) provided specific management guidelines for a patient, and (iii) recommended to evacuate or not evacuate a patient. The results were analyzed using descriptive statistics. Of the 99 consultations evaluated, the most common consultation was for snake envenomation and antivenom recommendations (n = 23, 23 %) followed by accidental chemical exposures (n = 14, 14 %), drug testing (n = 13, 13 %), and substance abuse (n = 10, 10 %). In 41 % of consults, the toxicologist provided a differential diagnosis or specific diagnosis, and in 60 % of cases, the toxicologist provided specific management or evaluation guidelines. In 11 % of cases, the toxicologist recommended for or against evacuation of the patient. In 25 % of consults, the toxicologist provided the consulting physician with information, resources, or protocols to aid in the management of future cases. The most frequent consultations for the military telemedicine consultation service were for direct patient cases, specifically snake envenomation management and accidental chemical exposures. Our results may be used to educate physicians prior to military deployment or international humanitarian efforts and to create toxicology clinical guidelines for remote locations. Expansion of the current military teleconsultation program capabilities to include video teleconsultation may improve the effectiveness of military medical toxicology teleconsultation.

Telerehabilitation for people with low vision

BACKGROUND

Low vision affects over 300 million people worldwide and can compromise both activities of daily living and quality of life. Rehabilitative training and vision assistive equipment (VAE) may help, but some visually impaired people have limited resources to attend in-person visits at rehabilitation clinics. These people may be able to overcome barriers to care through remote, Internet-based consultation (i.e., telerehabilitation).

OBJECTIVES

To compare the effects of telerehabilitation with face-to-face (e.g., in-office or inpatient) vision rehabilitation services for improving vision-related quality of life and reading speed in people with visual function loss due to any ocular condition. Secondary objectives are to evaluate compliance with scheduled rehabilitation sessions, abandonment rates for visual assistive equipment devices, and patient satisfaction ratings.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015 Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1980 to June 2015), EMBASE (January 1980 to June 2015), PubMed (1980 to June 2015), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any language restriction or study design filter in the electronic searches; however, we restricted the searches from 1980 onwards because the Internet was not introduced to the public until 1982. We last searched the electronic databases on 15 June 2015.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) or controlled clinical trials (CCTs) in which participants were diagnosed with low vision and were undergoing low vision rehabilitation using an Internet, web-based technology compared with an approach based on in-person consultations.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts, and then full-text articles against the eligibility criteria. We planned to have two authors independently abstract data from included studies. We resolved discrepancies by discussion.

MAIN RESULTS

We did not find any study that met the inclusion criteria for this review and, hence, we did not conduct a quantitative analysis. As a part of the background, we discussed review articles on telemedicine for facilitating communication with elderly individuals or for providing remote ophthalmological care.

AUTHORS' CONCLUSIONS

We did not find any evidence on whether the use of telerehabilitation is feasible or a potentially viable means to remotely deliver rehabilitation services to individuals with low vision. Given the disease burden and the growing interest in telemedicine, there is a need for future pilot studies and subsequent clinical trials to explore the potential for telerehabilitation as a platform for providing services to people with low vision.

The U.S. Army Telemedicine and m-Health Program: making a difference at home and abroad

This article highlights the deployment of telemedicine by the U.S. Army through the various echelons of care and in overseas locations, including range and scope of health services provided by telemedicine in a challenging environment. This is followed by a discussion of technological developments advances in mobile communications likely to change the practice of telemedicine in the military from limited fixed-point access to a highly mobile individual with handheld communication devices.

Teleophthalmology with optical coherence tomography imaging in community optometry. Evaluation of a quality improvement for macular patients

Purpose

To describe a quality improvement for referral of National Health Service patients with macular disorders from a community optometry setting in an urban area.

Methods

Service evaluation of teleophthalmology consultation based on spectral domain optical coherence tomography images acquired by the community optometrist and transmitted to hospital eye services.

Results

Fifty patients with suspected macular conditions were managed via telemedicine consultation over 1 year. Responses were provided by hospital eye service-based ophthalmologists to the community optometrist or patient within the next day in 48 cases (96%) and in 34 (68%) patients on the same day. In the consensus opinion of the optometrist and ophthalmologist, 33 (66%) patients required further “face-to-face” medical examination and were triaged on clinical urgency. Seventeen cases (34%) were managed in the community and are a potential cost improvement. Specialty trainees were supervised in telemedicine consultations.

Conclusion

Innovation and quality improvement were demonstrated in both optometry to ophthalmology referrals and in primary optometric care by use of telemedicine with spectral domain optical coherence tomography images. E-referral of spectral domain optical coherence tomography images assists triage of macular patients and swifter care of urgent cases. Teleophthalmology is also, in the authors’ opinion, a tool to improve interdisciplinary professional working with community optometrists. Implications for progress are discussed.