Telemedicine was embedded into health care and optometry long before COVID-19, but the spring 2020 lockdown prompted even some virtual visit naysayers to rethink their position in order to ensure continuity of care.

One year later, most practices are now open for business as usual, prompting the question of whether telemedicine will retain a strong role in optometry going forward, especially concerning ocular diseases such as glaucoma that often require in-person attention.

Still, others have already been sold on the advantages of virtual formats and are launching long-term telemedicine initiatives.

Academia Test-drives Telemed Glaucoma Screenings

In an effort to better engage at-risk and vulnerable populations and those least likely to have access to eye care, the CDC recently provided funding to Columbia University, the University of Michigan and the University of Alabama at Birmingham for five-year pilot investigations, collectively known as the Screening and Interventions for Glaucoma and Eye Health Through Telemedicine (SIGHT) studies.

The investigators are assessing the usefulness of community health workers in conducting on-site vision screenings, “patient navigators and glaucoma coaches” and telehealth to ensure follow-up eye care for those diagnosed with glaucoma and other eye diseases.

MI-SIGHT, the University of Michigan’s phase of the study, seeks to identify whether telemed eye health screening programs in local community clinics that serve higher risk glaucoma populations can detect the condition at a higher rate than the 2% found in the general population, explains researcher Paula Anne Newman-Casey, MD, MS, education director at the Kellogg Eye Center for eHealth and assistant professor and interim associate chair for research in the Department of Ophthalmology and Visual Sciences at the University of Michigan.

Through MI-SIGHT, certified ophthalmic technicians will conduct vision screenings at two community clinics, the Hope Clinic, a free facility in Ypsilanti, and the Hamilton Community Health Network, a federally qualified health center in Flint. Each testing room is equipped with a vision chart, autorefractor, phoropter, trial lens set, Finhoff transilluminator, pachymeter, iCare tonometer and fundus/SD-OCT camera. Once the tech has completed the eye health history and taken all of the requisite measurements, the data is securely sent to a university-based ophthalmologist for review.

Ophthalmologists will then send their recommendations back to the tech, who will educate patients about their diagnoses and dispense and fit glasses as needed.

If a participant screens positive for glaucoma or suspected glaucoma, they will be randomized to either receive standard education or personalized glaucoma coaching to determine which approach helps more patients return for their recommended follow-up.

Fifty percent of people with glaucoma do not know they have the condition and are currently undiagnosed, Dr. Newman-Casey says. Adding to that sobering statistic, the need for glaucoma screening in underserved and at-risk populations, including those of African American descent and lower incomes, is great, she adds.

“The public health need to detect and treat glaucoma more effectively among people of African ancestry is critical in mitigating needless vision loss from glaucoma. In the MI-SIGHT program, we are testing whether using a telemedicine approach to embed glaucoma screening programs in trusted community clinics can help bridge this critical gap,” she says.

The MI-SIGHT study has great replication potential in other community clinics, Dr. Newman-Casey believes.

The purpose of using telemedicine is to provide eye health and glaucoma screening in trusted community clinics, since trust is one important barrier to engaging underserved populations in glaucoma screening, she says.

Private Practice Poses Glaucoma Screening Challenges

“I think telemedicine can play a part in glaucoma screening and management, which was particularly evident during the early days of the COVID-19 pandemic,” says optometrist Ian Gaddie. However, he predicts that post-pandemic, telemedicine for glaucoma management will decrease as in-person visits return to normal.

“There are limits today governing the feasibility of telemedicine in glaucoma,” he explains. “How do you take a threshold field and have comparative data? How do you administer an SD-OCT online? Equally important, how do you measure IOP by telemedicine?”

Telemed could be a viable approach for glaucoma screening if a trained technician performs the appropriate testing from a remote location and the images are then sent to an eye care practitioner for a diagnosis, says James Fanelli, OD.

Corneal Issues Top Telemed Visits During Shutdown

Still, ophthalmology practices were not as quick to jump on board with virtual visits.

A new study that polled ophthalmologists found just 17% of MDs turned to telehealth during the April COVID-19 shutdown last year, with corneal and external eye diseases accounting for 48% of virtual visits.

Still, the investigation noted ophthalmologists saw an estimated 81% drop in visits, which represented the greatest amount of any specialty during the initial pandemic restrictions. Additionally, researchers noted MDs may have difficulty with telehealth visits because much of the evaluation requires a slit lamp, tonometer, dilation and advanced imaging such as an OCT.

The study used Blue Cross Blue Shield of Michigan claims data to identify ophthalmology encounters, including all outpatient and professional fee claims from September 1, 2019, through September 1, 2020. Not surprising, the majority of the telehealth visits occurred after March 24, 2020.

A total of 84 ophthalmologists (30%) used telehealth from March 29 to April 4 last year. By September, 228 out of 610 ophthalmologists (37%) were using telehealth.

The most common telehealth visit findings included:

  • Chalazia, the most reported telehealth diagnosis, accounted for roughly 9% of claims.
  • DED (4.8%), conjunctival hemorrhage (2.1%), allergic conjunctivitis (1.9%), unspecified blepharitis (1.9%) and squamous blepharitis (1.3%) represented other top-10 telehealth diagnoses, which were categorized as corneal and external disease.
  • Moderate POAG (2.8%), wet AMD  (2.2%), pre-glaucoma (1.3%) and mild POAG (1.3%) also were common diagnoses.

On the other hand, corneal and external diseases accounted for about 13% of in-person visits.

Retinal and vitreous conditions and glaucoma represented 17% and 13% of telehealth visits, respectively, compared with 39% and 24% of in-person visits, respectively.

Cataract and other lens disorders represented 3% of telehealth and 17% of in-person claims. Strabismus and neuro-ophthalmology claims were about equal.

“Our study identified the rapid increase and subsequent decrease in the use of telehealth by ophthalmologists during the initial phases of the COVID-19 pandemic and low levels of teleophthalmology use overall,” the researchers wrote in their paper. “Ophthalmology has been reported as the discipline with the lowest number of users of telehealth.”

Expansion of technology such as home tonometry and OCT may allow for increased adoption of virtual visits for glaucoma and retinal care, especially for established patients, they added.

Portney DS, Zhu Z, Chen EM, et al. COVID-19 and use of teleophthalmology (CUT Group): trends and diagnoses. Ophthalmology. February 10, 2021. [Epub ahead of print].

“Glaucoma is amenable to telemedicine as far as screening is concerned, but it’s a bit different with management because there are instances where you need to see the eye in vivo,” he says.

On the other hand, out of the plethora of conditions seen in a primary care clinic, glaucoma is one of the more amenable diseases for telemedicine management, although not exclusively, Dr. Fanelli adds. “A patient can’t be solely managed by telemedicine. Glaucoma screening lends itself to telemedicine because of the imaging capabilities we have. That would be a very different answer, for example, if we were talking about corneal ulcers.”

A patient sitting at home can’t be managed long-term for glaucoma, nor is there any screening capability from a home use perspective, Dr. Fanelli adds.

Unless the practice gives the patient a home tonometer or the practice has access to an online visual field instrument, Dr. Gaddie doesn’t see much utility in telemedicine for glaucoma. The exception is to see how the patient is tolerating medications or if refills are needed, he notes.

As for screening high-risk populations and those without access to eye care, Dr. Gaddie believes telemedicine could have some impact in environments specially designed with glaucoma testing capabilities. “This would be great in theory, but we have significant gaps to close to make this a mainstream reality,” Dr. Gaddie says.

 Telemed Extends Beyond Glaucoma in Private Practice

Telemedicine can be supplemental to a practice, but it shouldn’t be used in isolation, says optometrist Kelsey Moody Mileski. In certain instances, telemedicine could be ideal for follow-up visits with established patients, and this approach may be more personal than a telephone call if a video chat format is used, she says. However, telemedicine isn’t practical if the evaluation requires equipment that isn’t available in a virtual format, she explains.

A traditional video-based telemedicine visit would be an option in the case of minor ocular emergencies, such as a hordeolum or a subconjunctival hemorrhage.

Personally, Dr. Moody Mileski has found telemedicine visits to be helpful for dry eye patients after they have started a new therapy. If a fundus camera is available, additional screenings can be performed during a telemedicine visit, she says. “This is a wonderful option for patients who are seen in the emergency department (ED) or in another provider’s office, like neurology or endocrinology practices, where an eye care provider is not available,” she adds.

In this setting, an ED provider could obtain information that would not otherwise be available on a traditional video-based exam, such as visual acuity, pupil assessment and IOP. In this scenario, patients could be quickly diagnosed with more concerning and life-threatening conditions such as papilledema, retinal artery occlusion and/or diabetic retinopathy, she explains.

Still, telemedicine poses challenges, including time restraints, since virtual visits need to be scheduled, just like in-person exams. She suggests scheduling virtual visits at the beginning or end of the day, and for the same amount of time as an in-office visit. However, if the clinic is running behind, a patient may only wait a few minutes before leaving the video call, in which case, the entire exam may be missed.

Another telemedicine challenge is technology. Although patients are becoming more familiar with Zoom and FaceTime during the pandemic, technology can still pose difficulties, particularly in older patients. Also, internet accessibility has to be considered for patients in underserved areas, she adds.

Dr. Moody Mileski offered telemedicine exams when her clinics were closed for routine care at the beginning of the pandemic. Still, she found few patients opted for a video-based exam, and instead preferred an initial phone consult.

Even though she currently isn’t using telemedicine, as she believes the exams are too limiting, Dr. Moody Mileski thinks virtual visits could play a secondary role in patient care.

A future directive for telemedicine in optometry could include eye care providers engaged in virtual consultations with other health care providers, such as those in the ED. In this modality, exam information and imaging such as fundus photography could be sent to the eye care provider for review.

De Moraes CG, Hark LA, Saaddine J. Screening and interventions for glaucoma and eye health through telemedicine (SIGHT) studies. J Glaucoma. January 27, 2021 [Epub ahead of print].