Tele–Neuro-Ophthalmology: Vision for 20/20 and Beyond

Abstract

Background: Telehealth provides health care to a patient from a provider at a distant location. Before the COVID-19 pandemic, adoption of telehealth modalities was increasing slowly but steadily. During the public health emergency, rapid widespread telehealth implementation has been encouraged to promote patient and provider safety and preserve access to health care. Evidence Acquisition: Evidence was acquired from English language Internet searches of the medical and business literature and following breaking news on the COVID-19 pandemic and responses from health care stakeholders, including policymakers, payers, physicians, health care organizations, and patients. We also had extensive discussions with colleagues who are developing telehealth techniques relevant to neuro-ophthalmology. Results: Regulatory, legal, reimbursement, and cultural barriers impeded the widespread adoption of telehealth before the COVID-19 pandemic. With the increased use of telehealth in response to the public health emergency, we are rapidly accumulating experience and an evidence base identifying opportunities and challenges related to the widespread adoption of tele-neuro-ophthalmology. One of the major challenges is the current inability to adequately perform funduscopy remotely. Conclusions: Telehealth is an increasingly recognized means of health care delivery. Tele-Neuro-Ophthalmology adoption is necessary for the sake of our patients, the survival of our subspecialty, and the education of our trainees and students. Telehealth does not supplant but supplements and complements in-person neuro-ophthalmologic care. Innovations in digital optical fundus photography, mobile vision testing applications, artificial intelligence, and principles of channel management will facilitate further adoption of tele-neuro-ophthalmology and bring the specialty to the leading edge of health care delivery.

Survey of Telehealth Adoption by Neuro-ophthalmologists During the COVID-19 Pandemic: Benefits, Barriers, and Utility

“…Telehealth modalities as a way to deliver neuro-ophthalmic care have been of interest in the profession for many years, as demonstrated by inclusion of symposia on this topic in the annual meetings of NANOS in 2013 and 2020 ( 4 , 5 ). During the COVID-19 pandemic, interest in and utilization in this area increased throughout the medical profession and in neuro-ophthalmology ( 3 , 6 ).…”

Neuro-Ophthalmologic Manifestations of Novel Coronavirus

“…However, the practice of neuro-ophthalmology poses an interesting challenge to this transition, given the benefit of physical exam findings and timely diagnostic testing on differentiation of benign from sinister underlying etiologies. 55 Certain aspects of the physical exam, such as visual acuity and a testing for an afferent pupillary defect, can be performed by the patient via videoconferencing with detailed instruction. 56 , 57 However, fundoscopy and quantification of strabismus currently requires in-person assessment and subtle findings such as nystagmus may be missed depending on the quality of the video connection.…”

“…Interestingly, remote visual field testing has shown similar reliability to Humphrey visual fields in pilot studies but is not yet readily available. 55 Artificial intelligence optic disc analysis and digital fundus photography are on the horizon, but currently cannot replace clinic visits. 58 …”

“…While consultations often are best served by an office visit, appropriate triaging and pre-screening of appointments (for example, to appropriately arrange laboratory testing or imaging by the referring physician) allows telemedicine to reduce the need for in-person visits. 55 , 58 Videoconferencing has gained popularity in medical education and research, with entire large-scale conferences being held via online platforms. As technology evolves and matches the demand for online visits, it certainly is possible that these innovations will propel us into an era where comprehensive virtual visits become commonplace, pandemic notwithstanding.…”

Severe Acute Respiratory Syndrome Coronavirus Disease 2019: More Safety at the Expense of More Medical Waste

“…Ophthalmology, like other specialties, will need to sort out how best to use telemedicine, 23 and COVID-19 has increased the motivation for doing so. The use of smartphone apps for vision testing and even refraction, 24 tablet and other portable perimeters, 25 , 26 home tonometry enabled by technological advances, 27 , 28 , 29 and virtual visits made feasible by improvements in electronic health records and telecommunications, 20 , 30 , 31 , 32 , 33 , 34 have all enabled patient evaluations that would otherwise have to be performed in person to be done remotely by the patient without technical expertise or onsite support. Perimetry on tablets could be done at home, and home tonometry would minimize the carbon footprint of diagnostic medications as well as tissues commonly used in routine glaucoma management.…”