Telemedicine for Glaucoma: Guidelines and Recommendations

Vision impairment and blindness in individuals aged 60 years and older in Latin America and the Caribbean

Objective

To determine the prevalence and causes of vision loss and calculate the effective cataract surgery coverage (eCSC) in adults aged 60 years and older in Latin America and the Caribbean in 2020.

Methods

The International Agency for the Prevention of Blindness Vision Atlas and the Rapid Assessment of Avoidable Blindness databases were used as data source. The collected data were used to estimate the prevalence and causes of vision loss in people aged 60 years and older, and to determine the eCSC.

Results

The overall prevalence of moderate to severe vision impairment (MSVI) and blindness in Latin America and the Caribbean were 14.14% and 2.94%, respectively. Tropical Latin America was the subregion with the highest prevalence of blindness (3.89%) while Southern Latin America had the lowest (0.96%). For both MSVI and blindness, cataract was the main cause of vision loss. The eCSC rates showed great variation, ranging from 4.0% in Guatemala to 75.2% in Suriname.

Conclusions

The prevalence of vision loss in adults aged 60 years and older in Latin America and the Caribbean was higher than previous estimates on younger groups. Cataract was the main cause of blindness, and the eCSC indicates that the outcomes from cataract surgery should be improved. Specific actions associated with improving access, integrating eye assessment with primary care programs, expanding the use of telemedicine, and improving data quality should be taken by public health authorities aiming to address vision loss in this group.

Comparison of Glaucoma Diagnosis by Telemedicine, In-Person Ophthalmologist, and Optometrist

PRCIS

Diagnosis of glaucoma through telemedicine demonstrates moderate agreement with in-person ophthalmologist (MD) and in-person optometrist (OD) diagnosis, providing evidence that telemedicine is a timely, accurate screening method in settings where an in-person visit may not be feasible.

OBJECTIVE

To compare diagnostic agreement of glaucoma between in-person MD, in-person OD, and a simulated telemedicine program.

PATIENTS AND METHODS

A cross-sectional study of patients with normal optic nerve structural and functional imaging and new patients referred for glaucoma evaluation examined in-person by an MD for glaucoma with a dilated examination and structural and functional optic nerve testing (optical coherence tomography, photos, and visual field); examined in person by an OD with a dilated examination and optic nerve testing; and structural and functional optic nerve testing reviewed separately by 2 ophthalmologists [telemedicine ophthalmologist reviewer 1 (TMD1), telemedicine ophthalmologist reviewer 2 (TMD2)] with masking of prior MD and OD diagnoses. Interrater agreement between each diagnostic method (MD, OD, TMD1, and TMD2) of normal versus disease (open angle glaucoma, normal tension glaucoma, other types of glaucoma, other optic nerve disorders, ocular hypertension, and glaucoma suspect) for each eye was calculated (Cohen unweighted kappa).

RESULTS

A total of 100 patients with a median age of 66 years (interquartile range: 59-72), male (40%) and white (62%) were analyzed. There was moderate agreement between MD and telemedicine [TMD1 kappa 0.49 (95% CI: 0.37-0.61), TMD2 kappa 0.44 (95% CI: 0.32-0.56)] and between MD and OD diagnosis [0.41 (95% CI: 0.28-0.54)] and fair-moderate agreement between OD and telemedicine [TMD1: 0.46 (95% CI: 0.34-0.58), TMD2: 0.61 (95% CI: 0.50-0.72)].

CONCLUSIONS

The simulated telemedicine approach had comparable levels of agreement in glaucoma diagnosis with in-person fellowship-trained ophthalmologists, presenting a crucial complementary role in screening and increasing access to care, particularly in rural or underserved settings.

Novel Technologies in Artificial Intelligence and Telemedicine for Glaucoma Screening

PURPOSE

To provide an overview of novel technologies in telemedicine and artificial intelligence (AI) approaches for cost-effective glaucoma screening.

METHODS/RESULTS

A narrative review was performed by summarizing research results, recent developments in glaucoma detection and care, and considerations related to telemedicine and AI in glaucoma screening. Telemedicine and AI approaches provide the opportunity for novel glaucoma screening programs in primary care, optometry, portable, and home-based settings. These approaches offer several advantages for glaucoma screening, including increasing access to care, lowering costs, identifying patients in need of urgent treatment, and enabling timely diagnosis and early intervention. However, challenges remain in implementing these systems, including integration into existing clinical workflows, ensuring equity for patients, and meeting ethical and regulatory requirements. Leveraging recent work towards standardized data acquisition as well as tools and techniques developed for automated diabetic retinopathy screening programs may provide a model for a cost-effective approach to glaucoma screening.

CONCLUSION

Leveraging novel technologies and advances in telemedicine and AI-based approaches to glaucoma detection show promise for improving our ability to detect moderate and advanced glaucoma in primary care settings and target higher individuals at high risk for having the disease.

Telemedicine for Screening and Follow-Up of Glaucoma: A Descriptive Study

Introduction: Glaucoma is a leading cause of irreversible blindness. It is a prevalent disease worldwide, affecting ∼70 million people and expected to reach up to 112 million by 2040. Purpose: The aim of this study is to describe the implementation and initial experience of a telemedicine program to monitor glaucoma and glaucoma suspect patients in a large, integrated health care system during the COVID-19 pandemic. Methods: A retrospective chart review of established glaucoma or glaucoma suspect patients who participated in a telemedicine evaluation at the ophthalmic center of a large, Colombian health care system between June 2020 and April 2023 was conducted. Clinical and sociodemographic variables were analyzed. Generated clinical orders for additional testing, surgical procedures, follow-ups, and referrals, as well as changes in medical treatment, were evaluated. Results: A total of 11,034 telemedicine consults were included. The mean ± standard deviation age of this group was 63 ± 17.2 years and 67% were female. Of the patients who attended teleconsults, 49% were glaucoma suspects and 38.5% were followed with a diagnosis of open-angle glaucoma. After the consult, 25% of patients were referred to a glaucoma specialist, 40% had additional testing ordered, and 8% had a surgical procedure ordered, mainly laser iridotomy (409 cases). Almost a third of patients returned for subsequent telemedicine visits after the initial encounter. Despite some technical difficulties, 99.8% of patients attended and completed their scheduled telemedicine appointments. Conclusions: A telemedicine program aimed to monitor established glaucoma patients can be successfully implemented. Established patients within an integrated health care system have high adherence to the virtual model. Further research by health care institutions and government agencies will be key to expand coverage to additional populations. Clinical Trial Registration Number: CEIFUS 1026-24.

Satisfaction with Teleophthalmology Services: Insights from Remote Areas of Taiwan

During and after the COVID-19 pandemic, teleophthalmology provided access to eye care for rural populations. This study aimed to assess the efficacy of and satisfaction with an integrated real-time videoconferencing module. This project incorporated ophthalmic instruments and telecommunication devices and provided on-site consultations via videoconferencing. Both patients and healthcare providers completed satisfaction questionnaires. From May 2020 to May 2021, this project provided eye care services to 395 patients (aged 6-90 years). The most frequent eye condition was chronic conjunctivitis (n = 197), followed by senile cataract (n = 163), dry eye (n = 103), and refractive error (n = 95). Among them, 40 (10.1%) patients were referred to secondary or tertiary hospitals for further evaluation or treatment. In total, 181 recruited respondents provided good satisfaction scores in all dimensions, including quality of medical care (4.50 of 5.00), financial aspects of care (4.48), supportive attitude toward the project (4.47), quality of service (4.40), and quality of telecommunication (4.40). Women had a substantially more supportive attitude toward the project, and 25 healthcare providers provided low ratings in areas representing the quality of telecommunication (4.04) and user-friendliness of the instrument (4.00). This teleophthalmology system provided efficient and satisfactory eye care to participants in remote communities. However, better internet access and training in instrument use can reduce obstacles to the future implementation of the project.

Recent developments of telemedicine in glaucoma

PURPOSE OF REVIEW

Telemedicine has an increasingly significant role in the fields of ophthalmology and glaucoma. This review covers recent advancements in the development and optimization of teleglaucoma techniques and applications.

RECENT FINDINGS

Glaucoma monitoring and diagnosis via remote tonometry, perimetry, and fundus imaging have become a possibility based on recent developments. Many applications work in combination with smart devices, virtual reality, and artificial intelligence and have been tested in patient populations against conventional "reference-standard" measurement tools, demonstrating promising results. Of note, there is still much progress to be made in teleglaucoma and telemedicine at large, such as accessibility to internet, broadband, and smart devices, application affordability, and reimbursement for remote services. However, continued development and optimization of these applications suggest that the implementation of remote monitoring will be a mainstay for glaucoma patient care.

SUMMARY

Especially since the beginning of the COVID-19 pandemic, remote patient care has taken on an important role in medicine and ophthalmology. Remote versions of tonometry, perimetry, and fundus imaging may allow for a more patient-centered and accessible future for glaucoma care.

Social and Health Care Utilization Factors Associated With Ophthalmic Visit Nonadherence in Glaucoma: An All of Us Study

PRCIS

In a diverse nationwide cohort, lower education and income levels, cost saving on medications, fewer past-year medical/specialist visits, and concerns regarding dissimilarity with health care providers were risk factors for ophthalmic visit nonadherence among glaucoma patients.

PURPOSE

The purpose of this study was to characterize social and health care utilization factors associated with nonadherence with ophthalmic visits among patients with glaucoma.

MATERIALS AND METHODS

Glaucoma patients in the All of Us database who completed the Healthcare Access and Utilization Survey were included and categorized into "visit" and "nonvisit" groups based on visit adherence, defined by self-reported past-year encounters with eyecare providers (yes/no). Data regarding potential factors affecting ophthalmic visit adherence, including past-year medical visits, inabilities to afford health care, and self-reported reasons for delayed care, were extracted. χ 2 tests and logistic regression were used to compare the 2 groups. Odds ratios (ORs) of visit adherence were analyzed for potential risk factors.

RESULTS

Of 5739 glaucoma patients, 861 (15%) were in the nonvisit group. More participants in the visit group reported past-year general doctor/specialist visits (94%/65%; vs. nonvisit group: 89%/49.3%; P <0.05). The nonvisit group reported greater difficulty in affording medical care and learning about medical conditions, and higher rates of delayed/missed health care access for various concerns ( P <0.05). Older age (OR=1.02, 1.01-1.03), higher education (OR=1.25, 1.13-1.40), and income level (OR=1.06, 1.01-1.11), not employed for wages (OR=1.28, 1.08-1.53), and higher health care utilization in general medical/specialist visits (ORs range:1.08-1.90) were associated with visit adherence ( P <0.05). Visit nonadherence was associated with cost saving on medication (OR=0.62, 0.40-0.97) and delaying/avoiding seeing health care providers because of dissimilarity (OR=0.84, 0.71-0.99) ( P <0.05).

CONCLUSIONS

This study builds on prior literature by identifying potentially modifiable factors associated with visit nonadherence and underutilization of eyecare in glaucoma. These may inform strategies to improve real-world ophthalmic visit adherence and identify patients who might benefit from additional support.

Applications and Challenges of Telemedicine: Privacy-Preservation as a Case Study

Today, technology has an important impact on the development of medical services, especially during the outbreak of COVID-19. Telemedicine, known by terms such as telehealth and digital health, refers to the utilization of technology to provide health care services at a distance that leads to improved monitoring, detecting and treatment of disease, and provision of individual care. It has been considered in various fields such as radiology, cardiology, pulmonology, psychiatry, emergency care and surgery. The most important advantages of using telemedicine are saving time for the doctor and the patient, reducing the cost of multiple visits to the doctor, reducing the spread of contagious diseases and caring for patients who cannot see a doctor, such as the elderly. In this paper, we review the research in the field of applying telemedicine, as well as its advantages and disadvantages. Next, we discuss the challenges in the field of using telemedicine which are privacy preserving, data security, cost of infrastructures, lack of physical examination and responsibility for patients' compensation. One of the most important challenges is privacy preserving of patients' information during transmission and process. We categorize and compare the various methods that have been proposed to protect peoples' privacy.

The Role of Telemedicine in Glaucoma Care Triggered by the SARS-CoV-2 Pandemic: A Qualitative Study

Purpose

To explore and report on how glaucoma care was impacted by the SARS-CoV-2 pandemic (COVID-19) in New York City (NYC) with a specific emphasis on the role of telemedicine.

Patients and Methods

This was a qualitative, cross-sectional study that engaged glaucoma clinicians in semi-structured interviews to elicit perspectives on telemedicine and patient care experiences during the pandemic. Interview responses were coded and analyzed thematically.

Results

Twenty clinicians participated. Mean participant age was 48.8 ± 12.3 years, and the mean number of years in practice post-glaucoma fellowship was 17.5 ± 12.4 years. Four main themes pertinent to the role of telemedicine triggered by the COVID-19 pandemic were identified: (1) The Need to Ensure Patient and Staff Safety Drove Telemedicine Uptake; (2) Telemedicine Allowed Providers to Address Subjective Complaints; (3) Telemedicine was Discontinued Due To Concerns of Compromised Patient Safety and Measurement Inaccuracy; (4) Technological Advances are Needed for Continued Telemedicine Usage and Uptake in Glaucoma Care. The interviews suggested that telemedicine usage dropped markedly within just a few months during the pandemic, and for most physicians interviewed, telemedicine is no longer part of their clinical practice. Several clinicians reported optimism towards future implementation of telemedicine as the technology develops.

Conclusion

This study identified 4 themes outlining the uptake, application, discontinuation and overall perspectives on telemedicine by glaucoma clinicians. The role of telemedicine, as triggered by the COVID-19 pandemic, may have lasting implications for patient safety, continuity of care, and glaucoma care delivery beyond this public health crisis.

Three-year Outcomes of an Expanded Asynchronous Virtual Glaucoma Clinic in Singapore

PURPOSE

Virtual glaucoma clinics can help increase health care capacity, easing the disease burden of glaucoma. This study assesses the safety, rate of glaucoma progression, time efficiency, and cost-savings of our expanded Glaucoma Observation Clinic (GLOC) at the Singapore National Eye Centre over 3 years.

METHODS

All patients seen at GLOC between July 2018 and June 2021 were included. Visual acuity, intraocular pressure, and visual fields or optic nerve head imaging were recorded, followed by a virtual review of the data by an ophthalmologist. An objective review of the management of 100 patients was conducted by 2 senior consultants independently as a safety audit. Patient outcomes including the rate of instability (due to worsening of clinical parameters necessitating a conventional clinic visit), glaucoma progression, the consultation review time efficiency, and cost-savings of GLOC were measured.

RESULTS

Of 3458 patients, 16% had glaucoma, and the others had risk factors for glaucoma. The safety audit demonstrated a 95% interobserver agreement. The rate of instability was 14.6%, of which true progression was observed in 3.12%. The time taken for a glaucoma specialist to review a GLOC patient was 5.75±0.75 minutes compared with 13.7±2.3 minutes in a conventional clinic. The per capita manpower cost per GLOC patient per visit was $36.77 compared with $65.62 in the conventional clinic. This translates to a cost-saving of $280.65 over the lifetime of a hypothetical patient.

CONCLUSIONS

Our expanded virtual glaucoma clinic is a safe, time-efficient, and cost-effective model with low rates of glaucoma progression, which could allow for significant health care capacity expansion.

Teleglaucoma Using a New Smartphone-Based Tool for Visual Field Assessment

PRCIS

COVID-19 underlines the importance of telemedical diagnostics. The smartphone-based campimetry (Sb-C) is a newly developed digital application allowing visual field testing using a head-mounted device and a smartphone. It enables visual field screening remotely from a clinic.

BACKGROUND

Sb-C is a newly developed tool for functional ophthalmic diagnosis. This study aimed to examine the comparability of the Sb-C and Octopus 900 to ensure ophthalmological care in times of social distancing.

METHODS

Total 93 eyes were included in the study. After an ophthalmological examination, the visual field was tested by the Octopus program G1 and by the smartphone-based campimeter. The Sb-C was performed using VR glasses and an iPhone 6. The software Sb-C was downloaded and installed as SmartCampiTracker app and is examining the 30-degree visual field with 59 test positions corresponding to the G pattern of Octopus G1. Sensitivities were recorded and saved on the app. In addition, test-retest reliability was tested on 6 ophthalmologically healthy participants.

RESULTS

The group comprised 48 women and 45 men (mean age: 62.52±12.2 y) including 19 controls, 17 patients with ocular hypertension, 11 preperimetric glaucomas, and 46 perimetric glaucomas. The mean sensitivity (MS) of all points of G1 perimetry was 23.13 dB (95% CI, 22.08-24.18). The MS of the Sb-C was 21.23 dB (95% CI, 20.37-22.08). The correlation between the mean MS measured by G1 perimetry and the Sb-C was strong ( r =0.815, P <0.05). The test-retest reliability showed a correlation of r =0.591 ( P <0.05) .

CONCLUSIONS

With some technical adjustments, the Sb-C shows promise for screening glaucoma and monitoring disease progression remotely from an ophthalmologic clinic.

Indigenous Eye Health in the Americas: The Burden of Vision Impairment and Ocular Diseases

Review of the burden of vision impairment and blindness and ocular disease occurrence in Indigenous Peoples of the Americas. We systematically reviewed findings of the frequency of vision impairment and blindness and/or frequency of ocular findings in Indigenous groups. The database search yielded 2829 citations, of which 2747 were excluded. We screened the full texts of 82 records for relevance and excluded 16. The remaining 66 articles were examined thoroughly, and 25 presented sufficient data to be included. Another 7 articles derived from references were included, summing a total of 32 studies selected. When considering adults over 40 years old, the highest frequencies of vision impairment and blindness in Indigenous Peoples varied from 11.1% in high-income North America to 28.5% in tropical Latin America, whose rates are considerably higher than those in the general population. Most of the ocular diseases reported were preventable and/or treatable, so blindness prevention programs should focus on accessibility to eye examinations, cataract surgeries, control of infectious diseases, and spectacles distribution. Finally, we recommend actions in six areas of attention towards improving the eye health in Indigenous Peoples: access and integration of eye services with primary care; telemedicine; customized propaedeutics; education on eye health; and quality of data.

Surfing the COVID-19 Tsunami with Teleophthalmology: the Advent of New Models of Eye Care

Purpose of Review

In this article, we reviewed the impact resulting from the COVID-19 pandemic on the traditional model of care in ophthalmology.

Recent Findings

Though virtual eye care has been present for more than 20 years, the COVID-19 pandemic has established a precedent to seriously consider its role in the evolving paradigm of vision and eye care. New hybrid models of care have enhanced or replaced traditional synchronous and asynchronous visits. The increased use of smart phoneography and mobile applications enhanced the remote examination of patients. Use of e-learning became a mainstream tool to continue accessing education and training.

Summary

Teleophthalmology has demonstrated its value for screening, examining, diagnosing, monitoring treatment, and increasing access to education. However, much of the progress made following the COVID-19 pandemic is at risk of being lost as society pushes to reestablish normalcy. Further studies during the new norm are required to prove a more permanent role for virtual eye care.

The current use of glaucoma virtual clinics in Europe

Objectives

To assess and describe current utilisation, characteristics and perspectives on virtual glaucoma clinics (VGCs) amongst European glaucoma specialists.

Methods

Cross-sectional, anonymized, online questionnaire distributed to all European Glaucoma Society-registered specialists. Questions were stratified into five domains: Demographics, Questions about VGC use, Questions for non-VGC users, COVID-19 effects, and VGC advantages/disadvantages.

Results

30% of 169 participants currently use VGCs, with 53% based in the United Kingdom. Of those using VGCs, 85% reported higher patient acceptance compared to traditional care. The commonest virtual model was asynchronous remote monitoring (54%). Nurses (49%) and ophthalmic technicians (46%) were mostly responsible for data collection, with two-thirds using a mixture of professionals. Consultant ophthalmologists were the main decision-makers in 51% of VGCs. Preferred cohorts were: ocular hypertension (85%), glaucoma suspects (80%), early/moderate glaucoma in worse eye (68%), stable glaucoma irrespective of treatment (59%) and stable glaucoma on monotherapy (51%). Commonest investigations were: IOP (90%), BCVA (88%), visual field testing (85%) and OCT (78%), with 33 different combinations. Reasons for face-to-face referral included: visual field progression (80%), ‘above-target’ IOP (63%), and OCT progression (51%). Reasons for not using VGCs included: lack of experience (47%), adequate systems in place (42%), no appropriate staff (34%) and insufficient time/money (34%). 55% of non-VGC users are interested in their use with 38% currently considering future implementation. 83% stated VGC consultations have increased during the COVID-19 pandemic; 86% of all participants felt that the pandemic has highlighted the importance of VGCs.

Conclusions

A significant proportion of European glaucoma units are currently using VGCs, while others are considering implementation. Financial reimbursement and consensus guidelines are potentially crucial steps in VGC uptake.

How glaucoma care changed for the better after the pandemic

PURPOSE OF REVIEW

The current article reviews enhancements to the delivery of glaucoma care that developed in response to the coronavirus disease 19 (COVID-19) pandemic and are likely to persist beyond its resolution.

RECENT FINDINGS

Literature from the review period (2020-2021) includes reports highlighting contributions of the ophthalmology community to global health during the pandemic. Glaucoma practices worldwide have instituted more robust infection control measures to mitigate severe acute respiratory syndrome coronavirus 2 transmission in the outpatient setting, and many of these modifications will endure in the post-COVID era. Operational adjustments have led to the provision of more efficient glaucoma care. A hybrid care model involving technician-based diagnostic testing and subsequent virtual consultation with a glaucoma specialist has evolved as a useful adjunct to traditional face-to-face encounters with patients.

SUMMARY

Glaucoma specialists, patients, and staff have adapted to a 'new normal' of glaucoma care delivery during the COVID-19 pandemic. Although innovation has propelled several improvements to glaucoma care during this global health crisis, significant barriers to more widespread implementation of teleglaucoma still exist. Whether, and in what capacity, the pandemic has permanently altered glaucoma practice patterns remains to be seen.

Glaucoma Suspects: The Impact of Risk Factor-Driven Review Periods on Clinical Load, Diagnoses, and Healthcare Costs

Purpose

To model the healthcare impact (clinical attendance time and financial cost) and clinical outcomes (glaucoma diagnoses) of different risk factor–driven review frequencies for glaucoma suspect patients up until the point of discharge or diagnosis.

Methods

Medical records of 494 glaucoma suspects were examined to extract the clinical diagnosis. Two criteria for review periods were defined, based on contrasting stringency from established clinical guidelines: American Academy of Ophthalmology (AAO), more stringent/less frequent; and the Australian National Health and Medical Research Council (NHMRC), less stringent/more frequent. We used these data to model patient outcomes and healthcare costs using a Markov model.

Results

The less stringent/more frequent criterion resulted in more high-risk glaucoma suspects requiring more frequent review compared with the more stringent/less frequent criterion. Across the 15 Markov cycles (7.5 years), the less stringent/more frequent review criterion resulted in 6.6% more diagnoses and fewer overall clinical visits (14.7%) and reduced cost per diagnosis by 12% to 32% (P < 0.0001). The number of glaucoma diagnoses made using each criterion converged at 2.5 to 3 years.

Conclusions

The stringency of risk assessments for glaucoma suspects impacts review periods and therefore clinical load, healthcare costs, and diagnosis rates. Using current testing methods, more frequent review periods appear advantageous for diagnostic efficiency, with both lower clinic load and lower cost up until the point of discharge or glaucoma diagnosis.

Translational Relevance

A less stringent criterion for assessing the risk of developing glaucoma potentially offers a more cost-effective method for reviewing glaucoma suspects, especially within the first 2.5 years.

Exploring Ophthalmologists' Adoption of Telemedicine during the COVID-19 Pandemic: A Mixed Methods Study

INTRODUCTION

The COVID-19 pandemic promoted hitherto unseen uptake of telemedicine by ophthalmologists. We performed a mixed methods study to explore patters of utilization during the pandemic and perceived future utility.

METHODS

Ophthalmologists practicing in Canada between March and July 2020 were invited to complete an online questionnaire assessing demographics, clinical practice characteristics and telemedicine utilization prior to and during the pandemic. Descriptive and bivariate statistics were used to analyze the data. Agglomerative hierarchical cluster analysis was used to identify groups who varied on the types of visits offered using telemedicine. Ten one-on-one interviews were conducted and analyzed using thematic content analysis to explain trends observed in the survey data.

RESULTS

Seventy-three ophthalmologists completed the survey. Six percent reported using telemedicine prior to the pandemic compared to 80% during the pandemic. A significant majority (81%) primarily used the telephone for telemedicine visits. Overall, visit volumes during the pandemic declined to 40% of pre-pandemic levels, with a smaller decline for ophthalmologists who used telemedicine than those who did not. Those who used telemedicine for all visit types were more likely to use telemedicine software and to anticipate a modest-to-large role for telemedicine in their future practice.

DISCUSSION

For many ophthalmologists, integrating telemedicine into clinical practice may have partially offset the disruption to normal clinical activities during the pandemic. While the majority saw telemedicine as a temporary solution, a sizeable minority appear to have made considerable use of the technology and see an ongoing role for it once regular clinical activities resume.

Do Hospitals Need to Extend Telehealth Services? An Experimental Study of Different Telehealth Modalities during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has changed health care systems and clinical workflows in many countries, including the United States. This public health crisis has accelerated the transformation of health care delivery through the use of telehealth. Due to the coronavirus' severity and pathogenicity, telehealth services are considered the best platforms to meet suddenly increased patient care demands, reduce the transformation of the virus, and protect patients and health care workers. However, many hospitals, clinicians, and patients are not ready to switch to virtual care completely.

OBJECTIVES

We designed six experiments to examine how people (as an actual beneficiary of telehealth) evaluate five telehealth encounters versus face-to-face visits.

METHODS

We used an online survey to collect data from 751 individuals (patients) in the United States.

RESULTS

Findings demonstrate that significant factors for evaluating five types of telehealth encounters are perceived convenience expected from telehealth encounters, perceived psychological risks associated with telehealth programs, and perceived attentive care services delivered by telehealth platforms. However, significant elements for comparing telehealth services with traditional face-to-face clinic visits are perceived cost-saving, perceived time-saving, perceived hygienic services, perceived technical errors, perceived information completeness, perceived communication barriers, perceived trust in medical care platforms' competency, and perceived privacy concerns.

CONCLUSION

Although the in-person visit was reported as the most preferred care practice, there was no significant difference between people's willingness to use face-to-face visits versus virtual care. Nevertheless, before the widespread rollout of telehealth platforms, health care systems need to determine and address the challenges of implementing virtual care to improve patient engagement in telehealth services. This study also provides practical implications for health care providers to deploy telehealth effectively during the pandemic and postpandemic phases.

[Attitude of patients to possible telemedicine in ophthalmology : Survey by questionnaire in patients with glaucoma]

Hintergrund

Die COVID-19-Pandemie im Jahr 2020 und 2021 schränkt die Versorgung augenärztlicher Patienten vielfach ein. Teleophthalmologische Leistungen wie Videokonsultation oder medizinische Telefonberatungen könnten den Mangel an notwendigen Kontrollen bei chronischen Erkrankungen, zumindest teilweise, kompensieren. Teleophthalmologische Angebote sind jedoch in Deutschland aktuell noch deutlich unterrepräsentiert.

Ziel der Arbeit

Um die Bereitschaft auf Patientenseite zur Telemedizin und virtuellen Klinik zu ermitteln, führten wir bei Patienten der Hochschulmedizin mit bekanntem Glaukom als chronische Erkrankung eine Umfrage mittels Fragebogen während der ersten Welle der COVID-19-Pandemie zum Thema Teleophthalmologie durch.

Methoden

Es wurden 100 Patienten befragt. Der Fragenkatalog beinhaltete 22 Fragen mit Mehrfachwahl-Antwortmöglichkeiten. Als Einschlusskriterium galten das Vorhandensein eines Glaukoms als chronische Erkrankung, Alter über 18 Jahre sowie eine ausreichende sprachliche Verständigung zur Beantwortung der Fragen. Die Daten wurden anonymisiert erhoben, analysiert und ausgewertet.

Ergebnisse

In der Patientenumfrage konnte aufgezeigt werden, dass eine hohe Bereitschaft zur Teleophthalmologie bei den Befragten im Bereich des Glaukoms als chronische Erkrankung vorhanden ist und diese in Anspruch genommen werden würde; 74,0 % der Befragten würden Telemedizin und virtuelle Kliniken akzeptieren; 54,0 % der Befragten ophthalmologischen Patienten gab an, dass ihr Arzt‑/Klinikbesuch aufgrund von SARS-CoV‑2 nicht stattfinden konnte; 17,0 % der Patienten gaben an, dass sich durch die SARS-CoV-2-Pandemie ihre Meinung gegenüber der Telemedizin geändert hat.

Diskussion

Die Akzeptanz der Patienten für Telemedizin bei Patienten mit chronischem Offenwinkelglaukom scheint erstaunlich hoch. Diese ist durch die SARS-CoV-2-Pandemie noch weiter gesteigert worden. Diese Ergebnisse spiegeln eine generelle Bereitschaft bei Patienten mit chronischer Augenerkrankung wider, reflektieren jedoch nicht die Anwendbarkeit sowie die Akzeptanz aus ärztlicher Sicht. Diese Form der virtuellen Konsultation findet jedoch bei einem Großteil der Patienten mit Glaukom Akzeptanz und könnte überdacht werden.

Pediatric Ophthalmology Provider and Staff Attitudes and Patient Satisfaction in Telehealth Implementation During COVID-19

Purpose: Describe a comprehensive overview of a telehealth implementation process that highlights attitudes and satisfaction scores toward telehealth from patients, providers, and staff in an academic pediatric ophthalmology practice during the early months of the coronavirus disease 2019 (COVID-19) pandemic. Methods: The electronic medical record data for telehealth and in-person visits, as well as a patient experience survey in pediatric ophthalmology were retrospectively reviewed for March 1 to July 31, 2020 and March 1 to July 31, 2019. Patient experience survey results were retrospectively reviewed. All current providers and staff were invited to participate in an anonymous and voluntary survey focused on attitudes at the time of telehealth implementation. Results: During March 1 to July 31, 2020, there was significant increase in telehealth visits (n = 1,006) compared with the same period in 2019 (n = 22). Evaluation and management (E & M) codes (n = 527) were the most commonly used billing codes, and strabismus, nystagmus, and irregular eye movement (n = 496) were the most common telehealth primary diagnoses. The telehealth attitudes survey showed more positive responses from providers than staff. The patient experience survey showed more favorable scores for telehealth visits compared with clinic visits. However, only about 50% of the respondents were satisfied with the technology in terms of ease and quality of connection during their telehealth visits. Conclusions: Telehealth was a satisfactory alternative to clinic visits in our academic pediatric ophthalmology practice during the early phase of the COVID-19 pandemic. Providers and staff had largely positive attitudes toward telehealth; however, future efforts should include strategies to increase staff buy in. Patients had high satisfaction scores with telehealth visits despite connection challenges.

Teleophthalmology and Artificial Intelligence As Game Changers in Ophthalmic Care After the COVID-19 Pandemic

The current COVID-19 pandemic has boosted a sudden demand for telemedicine due to quarantine and travel restrictions. The exponential increase in the use of telemedicine is expected to affect ophthalmology drastically. The aim of this review is to discuss the utility, effectiveness and challenges of teleophthalmological new tools for eyecare delivery as well as its implementation and possible facilitation with artificial intelligence. We used the terms: “teleophthalmology,” “telemedicine and COVID-19,” “retinal diseases and telemedicine,” “virtual ophthalmology,” “cost effectiveness of teleophthalmology,” “pediatric teleophthalmology,” “Artificial intelligence and ophthalmology,” “Glaucoma and teleophthalmology” and “teleophthalmology limitations” in the database of PubMed and selected the articles being published in the course of 2015-2020. After the initial search, 321 articles returned as relevant. A meticulous screening followed and eventually 103 published manuscripts were included and used as our references. Emerging in the market, teleophthalmology is showing great potential for the future of ophthalmological care, benefiting both patients and ophthalmologists in times of pandemics. The spectrum of eye diseases that could benefit from teleophthalmology is wide, including mostly retinal diseases such as diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration but also glaucoma and anterior segment conditions. Simultaneously, artificial intelligence provides ways of implementing teleophthalmology easier and with better outcomes, contributing as significant changing factors for ophthalmology practice after the COVID-19 pandemic.

Implementation of Teleretinal Screening Using Optical Coherence Tomography in the Veterans Health Administration

Background: The Veterans Health Administration (VHA) has an existing teleretinal screening program that uses nonmydriatic fundus photography to screen for diabetic retinopathy in primary care clinics. Concurrently, optical coherence tomography (OCT) has become a routine screening modality in eye clinics for the diagnosis and management of retinal diseases. Introduction: This study aimed to evaluate the first year of a pilot tele-OCT program that used existing resources within the VHA. Without the tele-OCT program, all patients would have been referred to retina clinic for an in-person evaluation. Materials and Methods: This is a retrospective chart review study of patients evaluated by a retina specialist through asynchronous tele-OCT evaluation in 2019. Electronic medical records were used to assess patients' demographic and clinical characteristics, tele-OCT consult results, and patient adherence to tele-OCT follow-up plans. Results: There were 158 tele-OCT consults originating from optometry and nonretinal ophthalmology clinics in 2019. After tele-OCT evaluation, 113 (71.5%) patients were recommended to be monitored in their originating eye clinic, 27 (17.1%) were referred to intravitreal injection clinic, and 12 (7.6%) were referred to retina clinic for in-person evaluation. Patient adherence to tele-OCT follow-up plans was 76.4%. Patients with decreased central vision (p = 0.007) and patients referred to intravitreal injection clinic (p = 0.043) were most adherent to follow-up. Discussion: The tele-OCT program reduced unnecessary in-person clinic visits and enabled more retina clinic availability. Follow-up adherence was greatest among symptomatic patients and those requiring treatment. Conclusions: Tele-OCT can extend tertiary care resources and improve patient care in a large multidisciplinary eye care practice.

Impact of COVID-19 on follow-up and medication adherence in patients with glaucoma in a tertiary eye care centre in south India

Purpose:

COVID-19 pandemic has affected the healthcare system worldwide hindering the continuum of treatment of chronic disease patients. The objective of the study is to analyze the barriers encountered by the glaucoma patients for the follow-up visit and medication adherence during the pandemic.

Methods:

This cross-sectional study included glaucoma patients who did not attend the scheduled appointment from April 1, 2020 to July 31, 2020 in a tertiary eye care center (88.21%). Eligible patients of age >18 years and advised antiglaucoma medication in Madurai Zone were interviewed with validated questionnaire through telephonic call.

Results:

363 patients answered the questionnaire through telephonic interview. 57.3% of the patients were found to be non-adherent to medication. The main barriers for glaucoma follow-up visit during the pandemic were lockdown restriction, transport problem, and financial difficulties. The top barriers for medication adherence were non availability of medication (54.81%), financial difficulties (30.29%), did not feel much improvement with eye drops (20.19%). On multiple regression analysis, longer distance to hospital, low socioeconomic status, more than one antiglaucoma medication use, lack of awareness of glaucoma, non-complaint before COVID-19 and stress due to the pandemic were found to be significant factors for medication non adherence.

Conclusion:

COVID-19 pandemic has emphasized the need for reformation in health care system for accessibility of medical care to patients in rural areas. Decentralization of health system to primary care level and utilization of teleophthalmology should be considered by health care planners in future.

Digital technology, tele-medicine and artificial intelligence in ophthalmology: A global perspective

The simultaneous maturation of multiple digital and telecommunications technologies in 2020 has created an unprecedented opportunity for ophthalmology to adapt to new models of care using tele-health supported by digital innovations. These digital innovations include artificial intelligence (AI), 5th generation (5G) telecommunication networks and the Internet of Things (IoT), creating an inter-dependent ecosystem offering opportunities to develop new models of eye care addressing the challenges of COVID-19 and beyond. Ophthalmology has thrived in some of these areas partly due to its many image-based investigations. Tele-health and AI provide synchronous solutions to challenges facing ophthalmologists and healthcare providers worldwide. This article reviews how countries across the world have utilised these digital innovations to tackle diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration, glaucoma, refractive error correction, cataract and other anterior segment disorders. The review summarises the digital strategies that countries are developing and discusses technologies that may increasingly enter the clinical workflow and processes of ophthalmologists. Furthermore as countries around the world have initiated a series of escalating containment and mitigation measures during the COVID-19 pandemic, the delivery of eye care services globally has been significantly impacted. As ophthalmic services adapt and form a "new normal", the rapid adoption of some of telehealth and digital innovation during the pandemic is also discussed. Finally, challenges for validation and clinical implementation are considered, as well as recommendations on future directions.

Teleglaucoma Initiative at a Veterans Affairs Hospital: Pilot Safety Data and Early Experience

PURPOSE

To evaluate the safety, reliability, and efficacy of telemedicine in delivering tertiary subspecialty glaucoma care (herein referred to as teleglaucoma) to the veteran patient population.

DESIGN

Prospective case series.

PARTICIPANTS

Twenty patients being referred for glaucoma subspecialist opinion participated in the pilot safety study. One hundred eighteen patients participated in the secondary study of the acceptability and service efficacy of teleglaucoma.

METHODS

In the pilot study, safety was assessed by determining interobserver and intraobserver consistency (Krippendorff's α). This compared an in-person assessment by a glaucoma subspecialist with the remote assessment of 2 other glaucoma subspecialists (electronic health record alone reviewed). In the secondary study, teleglaucoma was implemented whereby testing and eye examination were carried out remotely by an optometrist or comprehensive ophthalmologist, and the clinical decision was made by the glaucoma subspecialist on review of the electronic health record alone.

MAIN OUTCOME MEASURES

In the pilot study, interobserver and intraobserver consistency in making a diagnosis and treatment plan (acceptable, ≥ 0.80 Krippendorff's α). In the secondary study, patient satisfaction measured by survey, wait time for teleglaucoma opinion versus wait time for in-person opinion, and time spent on teleglaucoma consultations.

RESULTS

Interobserver and intraobserver consistency showed an α of 0.86 and 0.92, respectively, for diagnosis, and 0.86 and 0.85, respectively, for treatment plan. In the secondary study, patient satisfaction was 4.55 of 5.00 (5 = maximum satisfaction; range, 3.28-4.93). Improved consultation lead time was demonstrated, with the median time for a doctor to respond to an electronic consultation being 3 days, versus 43 days for an in-person visit. Teleglaucoma also demonstrated positive benefits to the health care system by reducing the time doctors spent reviewing each patient's case (history, examination findings, imaging results, visual fields; 19 minutes for teleglaucoma consultation vs. 31 minutes for in-person evaluation).

CONCLUSIONS

Decisions regarding diagnoses and treatment plans between in-person consultation and the teleglaucoma program showed high reliability. Patient satisfaction was high. Additional benefits were observed in wait time for subspecialty glaucoma opinion, efficient allocation of the doctor's time, and fiscal benefit to the health care system.

Smartphone-based Ophthalmic Imaging Compared With Spectral-domain Optical Coherence Tomography Assessment of Vertical Cup-to-disc Ratio Among Adults in Southwestern Uganda

PRECIS

Using optical coherence tomography (OCT) measurements as a reference standard for vertical cup-to-disc ratio (vCDR), a smartphone-based ophthalmic camera has a sensitivity of 67.7% and specificity of 96.7% to detect a vCDR>0.5.

PURPOSE

The purpose of this study was to assess the performance of a smartphone-based ophthalmic camera system using an Apple iPhone 6S and an adapter, Paxos Scope, to obtain adequate dilated fundus photos to measure clinically useful vCDR cutoffs.

PATIENTS AND METHODS

Adult patients from a government tertiary level eye hospital in Southwestern Uganda were prospectively recruited from January to April 2019. All patients experienced a comprehensive eye examination, dilated posterior segment indirect ophthalmoscope imaging with the Paxos Scope, and spectral-domain OCT imaging with a Cirrus HD-OCT to measure vCDR. Patients' eyes excluded had media opacities or existing disease precluding a view of the fundus. Fundus images underwent a single masked review to assign vCDR at increments of 0.1. Descriptive statistics, parametric and χ2 tests for significance, repeated measures correlation, κ, receiver operating characteristics curve, and Bland-Altman were used to assess the data.

RESULTS

Among 467 (consecutive) individuals, fundus photographs acquired with the Paxos Scope demonstrated a 67.7% [95% confidence interval (CI), 63.0-72.0] sensitivity and 96.7% (95% CI, 94.2-98.3) specificity to detect a vCDR>0.5, using OCT as the reference standard. A total of 138 eyes were excluded due to poor imaging acquisition, such as dense cataract, rendering 796 eyes for analysis. The vCDR from graded Paxos Scope images and OCT correlated well with repeated measures correlation of 0.82 (95% CI, 0.77-0.86, P<0.001) and agreement, dichotomized as >0.5 or ≤0.5, was 80.9% (κ=0.63±0.034, P<0.001). Among glaucoma and glaucoma suspects (85 eyes), the sensitivity and specificity dichotomized using vCDR>0.5 were 97.5% (95% CI, 91.3-99.7) and 80.0% (95% CI, 28.4-99.5), respectively. The area under the receiver operating characteristics curve was 0.92 (95% CI, 0.89-0.94) for all eyes and 0.98 (95% CI, 0.78-1.0) for glaucoma and glaucoma suspects.

CONCLUSIONS

The Paxos Scope produced images that can be reliably used to estimate vCDR, which is closely aligned with the automated algorithm from the OCT optic disc cube scan. The low-cost, ready-to-integrate adapter, and minimal training requirements make it a viable option for population-based screening in low-resource settings.

Telemedicine for neuro-ophthalmology: challenges and opportunities

PURPOSE OF REVIEW

Telemedicine for neuro-ophthalmology (tele-neuro-ophthalmology) has the potential to increase access to neuro-ophthalmic care by improving efficiency and decreasing the need for long-distance travel for patients. Requirements for decreased person-to-person contacts during the COVID-19 pandemic accelerated adoption of tele-neuro-ophthalmology. This review highlights the challenges and opportunities with tele-neuro-ophthalmology.

RECENT FINDINGS

Tele-neuro-ophthalmology programs can be used for triage, diagnostic consultation, and long-term treatment monitoring. Formats include telephone appointments, interprofessional collaborations, remote data interpretation, online asynchronous patient communication, and video visits. Barriers to long-term implementation of tele-neuro-ophthalmology arise from data quality, patient engagement, workflow integration, state and federal regulations, and reimbursement. General neurologists may collaborate with local eye care providers for ophthalmic examination, imaging, and testing to facilitate efficient and effective tele-neuro-ophthalmology consultation.

SUMMARY

Tele-neuro-ophthalmology has tremendous potential to improve patient access to high-quality cost-effective neuro-ophthalmic care. However, many factors may impact its long-term sustainability.

Telemedicine in ophthalmology in view of the emerging COVID-19 outbreak

Purpose

Technological advances in recent years have resulted in the development and implementation of various modalities and techniques enabling medical professionals to remotely diagnose and treat numerous medical conditions in diverse medical fields, including ophthalmology. Patients who require prolonged isolation until recovery, such as those who suffer from COVID-19, present multiple therapeutic dilemmas to their caregivers. Therefore, utilizing remote care in the daily workflow would be a valuable tool for the diagnosis and treatment of acute and chronic ocular conditions in this challenging clinical setting. Our aim is to review the latest technological and methodical advances in teleophthalmology and highlight their implementation in screening and managing various ocular conditions. We present them as well as potential diagnostic and treatment applications in view of the recent SARS-CoV-2 virus outbreak.

Methods

A computerized search from January 2017 up to March 2020 of the online electronic database PubMed was performed, using the following search strings: “telemedicine,” “telehealth,” and “ophthalmology.” More generalized complementary contemporary research data regarding the COVID-19 pandemic was also obtained from the PubMed database.

Results

A total of 312 records, including COVID-19-focused studies, were initially identified. After exclusion of non-relevant, non-English, and duplicate studies, a total of 138 records were found eligible. Ninety records were included in the final qualitative analysis.

Conclusion

Teleophthalmology is an effective screening and management tool for a range of adult and pediatric acute and chronic ocular conditions. It is mostly utilized in screening of retinal conditions such as retinopathy of prematurity, diabetic retinopathy, and age-related macular degeneration; in diagnosing anterior segment condition; and in managing glaucoma. With improvements in image processing, and better integration of the patient’s medical record, teleophthalmology should become a more accepted modality, all the more so in circumstances where social distancing is inflicted upon us.

Virtual Ophthalmology: Telemedicine in a COVID-19 Era

Purpose

To discuss the effects of the severe acute respiratory syndrome coronavirus 2 betacoronavirus on ambulatory ophthalmology practices, the value proposition of telemedicine, teleophthalmology implementation methodologies, and the accelerated future of telemedicine.

Design

Review of the current telehealth landscape including usage, policies, and techniques for ambulatory practice integration.

Methods

We provide author-initiated review of recent trends in telehealth, governmental recommendations for health care delivery during the COVID-19 pandemic, and a PubMed Central query for telemedicine in ophthalmology or teleophthalmology. In addition, the authors' comprehensive experience in telemedicine design and implementation is provided.

Results

We provide a summary describing the present state of telehealth, teleophthalmology modeling, care delivery, and the proposed impact of telehealth surges on the future of ophthalmology practice.

Conclusion

Recent patient and provider interest in telemedicine, the relaxation of regulatory restrictions, increased remote care reimbursement, and ongoing social distancing practices compel many ophthalmologists to consider virtualizing services.

Current Glaucoma Practice: The Covid-19 Impact

How to cite this article: Bhartiya S. Current Glaucoma Practice: The Covid-19 Impact. J Curr Glaucoma Pract 2020;14(1):1–2.