Patients not triaged to in-person encounters or rescheduling were offered
video visits (Figs. 1, 2). Store-and-forward fundus photography has been used for diabetic
retinopathy screening , and real-time
interactions via phone and video have been described between eye care providers in rural
areas and remote consultant ophthalmologists .
Video visits have been reported in other surgical subspecialties
real-time video interactions for ophthalmic visits have not previously been described,
and video visits had not previously been offered by our department.
Perhaps more than in other specialties, decision-making in ophthalmology
requires examination techniques—refraction, slit-lamp examination, ophthalmoscopy,
visual field assessment, and imaging—that cannot feasibly be accomplished remotely. The
pandemic allowed our physicians to consider ways that video visits could be used for our
patients’ benefit, such as checking on symptoms, refining triage, ensuring adherence to
therapy, answering questions, and providing reassurance. We are also exploring tools to
maximize the potential of an eye exam by video encounter.
Platforms for measuring visual acuity have been developed for
computers and tablets, with modest evidence for their accuracy. Hundreds of
applications (“apps”) have become commercially available for eye-related
self-assessment , but agreement
between app-based measurements and office-measured Snellen visual acuity has been
modest [23,24,25,26]. Notably,
app-based platforms face limitations in usability, availability only on certain
devices, cost, and initial setup requirements.
Due to usability limitations of commercial visual acuity assessment
platforms, we designed and deployed an online eye chart available from a simple,
static webpage. The finished product is available at
includes a Rosenbaum-style near card, an Amsler grid, and a red dot for color
desaturation assessment (Fig. 4). Setup is
limited to adjustment of browser magnification settings such that a reference line
is matched to the height of a credit card.
While the accuracy of the chart requires validation, its ease of
accessibility has allowed its use for video visit intake. Prior to a video visit
with a provider, the patient is contacted by a department member who works with
them to ensure that they are able to use the video platform (Epic, Verona, WI,
USA). During that phone call, the patient is directed to
https://farsight.care for visual
acuity measurement. Amsler grid assessment and desaturation testing are done on a
case-by-case basis. At the time of the video visit, the provider has a summary of
the chief complaint and the near visual acuity. In several cases in our practice,
an afferent pupillary defect was predicted from the desaturation test. Over a
2-week period, approximately 61.4% (108/176) of teleophthalmology patients were
able to complete a visual acuity assessment with the Farsight platform. Barriers
to completion included patient unavailability for phone call, lack of access to
the webpage during prescreen calls, and inadequate time interval between
appointment scheduling and execution.
At our Children’s Hospital, parents are provided with instructional
video on measuring age-appropriate visual acuity using existing apps
Future directions in remote assessment of visual function could include
incorporation of validated programs, such as Odysight medical modules, for remote
monitoring of visual acuity or metamorphopsia .
Anterior Segment and Ocular Adnexa
Video visits allow for at least gross examination of the ocular
adnexa and anterior segment. Video visit encounters have been reported for initial
patient consultation for cosmetic facial or eyelid surgery , and remote assessment of ptosis by
photographs has good agreement with subsequent office evaluation .
The absence of a slit beam and magnification limit a detailed
anterior segment examination, but remote assessment may still provide valuable
diagnostic information. For example, video visits can be useful in triaging of
anterior segment trauma. Remote assessment of ocular injury in animal models can
accurately identify referable conditions, such as eyelid laceration and globe
rupture . Additionally, when
provided with patient history, corneal photography in telemedicine has
demonstrated modest diagnostic specificity compared with in-person slit-lamp
examination [31, 32], suggesting some diagnostic utility in
In our practices, video visits for patients with subconjunctival
hemorrhages and conjunctivitis resulted in an encounter that did not require
follow-up. In other cases, video visits were used to establish a clear need for an
in-person visit for patients with pain, redness, or orbital signs. Hundreds of our
previously scheduled patients have been identified for video visit encounters, and
these visits are ongoing.
Patients interviewed about video visits from a general medicine
practice have reported favorable access to providers and decreased travel and wait
times . Patients also note
limitations, however, and have expressed concerns about the diagnostic accuracy and
loss of patient–provider contact. Tools to mitigate some of these concerns have been
promoted as a “webside manner:” Providers should engage the patient in a video
encounter as they would in an in-person visit, maintaining eye contact, proper
posture, and patient-centered communication .
Video visits are new and clearly have limitations. Providers have
expressed concern for the medical and medicolegal ramifications of diagnostic error
in the absence of a traditional exam. One can imagine that a first episode of iritis
presenting as a red, painful eye could be misinterpreted as a corneal abrasion or
viral conjunctivitis, and remote eye exams are currently unvalidated. Research in
this realm is ongoing at UPMC regarding patient satisfaction, diagnostic error rates,
and clinical outcomes.
Although trainees can join or initiate video visits within Epic to
participate in patient care, the volume, quality, and overall impact of video visits
on their training and education remains uncertain. In the meantime, we have found
that the video visits provide benefit to our patients as a triage tool and as a means
to continue management of low-risk cases, and we expect to continue offering video
visit encounters post-pandemic.
Patient confidentiality and security must be ensured. We will continue
using an encrypted platform and giving providers private spaces for videos with the
same privacy levels of in-person visits. Lessons learned from the growing
implementation of video visits will inform future best practices.
Considerations for Practices Outside of Academic Medicine
New federal regulations allow for physician discretion while caring for
patients during the pandemic [34,
35]. Providers are permitted to
conduct telehealth in private settings with reasonable safeguards to limit disclosure
of protected health information. With new guidelines, practices without video visit
infrastructure in their electronic medical record system may practice
teleophthalmology visits using “non-public-facing” remote communication products such
as Zoom, Apple, or Google platforms. When patient access to these devices is limited,
telephone encounters can be implemented and billed based on time for 10-, 20-, and
30-min intervals [17, 36, 37].