Practice survival in the COVID-19 era
Reviewed by Terri-Diann Pickering, MD
COVID-19 changed the world in many ways, notably in how physicians practice medicine.
The need to social distance to prevent spread of the coronavirus provided the perfect moment for telemedicine to flourish, according to Terri-Diann Pickering, MD, a clinical instructor at California Pacific Medical Center and a member of the board of directors of the Glaucoma Research Foundation.
Before the virus arrived, the use of telemedicine was relatively limited
to patients who lived in isolated areas far from medical centers.
The technology provided remote monitoring that was facilitated by portable
In ophthalmology, telemedicine has facilitated screening for diabetic retinopathy, corneal and external ocular diseases, and pediatric ophthalmology.
Telecommunication also has facilitated international collaborations among specialists and in develop-ing countries to cover rural patients.
However, activity was limited before COVID-19. This changed in early 2020.
Li Wenliang, MD, was the first ophthalmologist to die from the virus in February 2020 after examining an infected patient with glaucoma.
Roughly 5 weeks later the American Academy of Ophthalmology recommended postponing elective procedures and office visits.
A public health emergency was declared soon after and telemedicine privacy requirements were waived in the United States.
Related: Li Wenliang: Ophthalmologist hero
“An analysis1 showed that ophthalmology lost more patient volume as the result of the pandemic than any other specialty,” Pickering reported.
This was the point at which ophthalmology practices went virtual, both to provide nonemergent patient care and peace of mind to patients and staff with social distancing.
She pointed out that patient volume decreased by 97% for cataract care and 88% for glaucoma.2
Overall, 81% of the ophthalmology volume was lost during March and April 2020 compared with the same period the previous year.1
Pros and cons of teleophthalmology
The areas in ophthalmology for which telemedicine is especially beneficial are for treating diabetic retinopathy, retinopathy of prematurity, and corneal and external disease.
Pickering also said the technology is good for triaging because it can reduce the number of office visits and costs.
Unfortunately, telemedicine has been less helpful in glaucoma because of the difficulty in measuring IOP. “It is just not the same as an in-person examination,” she emphasized.
However, virtual examinations grew out of necessity, and the available technology was called into use.
When conducting a virtual eye examination, physicians can use online charts to measure visual acuity.
IOP can be measured using the iCare Home monitoring device, and the optic nerve head theoretically can be evaluated using mobile phones and adaptors;
a Triggerfish contact lens sensor (Sensimed) is another potentially useful device for measuring IOP, although setting up this technology might be difficult for patients at home, she noted.
A low-tech visual field examination can be performed by showing patients how to perform confrontational visual fields.
Phone and online apps, virtual reality headsets, and other devices such as the ForeseeHome (Notal Vision) and Eyecatcher (HP Inc) also are available.
However, these devices may not detect early visual field loss. A pocket-sized fundus camera or a phone app with an adaptor can be used to evaluate the optic nerve head, but this requires dilation and an assistant.
The GlobeChek Kiosk is a relatively new device that performs 11 tests in less than 10 minutes without need for dilation.
“This was devised to help address the lack of a comprehensive eye examination, especially for patients with diabetes,” she said.
One year later
When the pandemic started, slit-lamp examinations were considered high-risk procedures for disease transmission, but now that is not the case.
As Pickering explained, no severe ophthalmic-related outbreaks have occurred since masks and other protocols were put into place.
As a result, use of telemedicine has decreased significantly or stopped altogether.
A survey conducted by Glaucoma Research Foundation found that most patients prefer to wait 6 weeks for an in-office appointment instead of a virtual office appointment in 2 weeks.
By June 2020, most practices had reopened and were resuming appointments, and telemedicine appointments decreased markedly. By October, outpatient visits had returned to baseline.
Pickering remarked that in the future, physicians will need readily available hardware.
That list could include wireless or easy-to-use implantable IOP sensors; smart contact lenses; the ability to perform imaging of the angle; online or app-based visual field testing; a home visual field device; and a handheld, portable optical coherence tomography scanner for optic nerve evaluation.
According to Pickering, teleglaucoma is here to stay because of the concept of crisis readiness.
“Advances in technology will help to improve accuracy and diagnosis,” Pickering concluded. “The expansion
of medical and nonmedical use of online programs due to COVID-19 will increase patient and physician acceptance.”
Terri-Diann Pickering, MD
Pickering is a consultant to Aerie.
1. Analysis: ophthalmology lost more patient volume due to COVID-19 than any other specialty. Strata Decision Technology. May 11, 2020. Accessed
July 1, 2021. https://eyewire.news/articles/analysis-55-percent-fewer-americans-sought-hospital-care-in-march-april-due-to-covid-19/
2. Leonard C. Telemedicine in the time of COVID-19. Review of Ophthalmolmology. May 6, 2020. Accessed July 1, 2021. https://www.reviewofophthalmology.com/article/telemedicine-in-the-time-of-covid19