Tele-ophthalmology for age-related macular degeneration during the COVID-19 pandemic and beyond

Abstract

Introduction COVID-19 has disrupted how ophthalmic practice is conducted worldwide. One patient population that may suffer from poor outcomes during the pandemic are those with age-related macular degeneration (AMD). Many practices are performing some form of teleophthalmology services for their patients, and guidance is needed on how to maintain continuity of care amongst patients with AMD using teleophthalmology. Methods A literature search was conducted, ending 1 August 2020, to identify AMD outcomes and telecare management strategies that could be used during the COVID-19 pandemic Results 237 total articles were retrieved, 56 of which were included for analysis. Four American Academy of Ophthalmology and Center for Disease Control web resources were also included. Discussion Risk-stratification models have been developed that let providers readily screen existing patients for their future risk of neovascular AMD (nAMD). When used with at-home monitoring devices to detect nAMD, providers may be able to determine who should be contacted via teleophthalmology for screening. Telemedicine triage can be used for new complaints of vision loss to determine who should be referred to a retinal specialist for management of suspected nAMD. To increase access and provider flexibility, smartphone fundus photography images sent to a centralized teleophthalmology service can aid in the detection of nAMD. Considerations should also be made for COVID-19 transmission, and teleophthalmology can be used to screen patients for the presence of COVID-19 prior to in-person office visits. Teleophthalmology has additional utility in connecting with nursing home, rural, and socioeconomically disadvantaged patients in the post-pandemic period.

The Impact of the First Peak of the COVID-19 Pandemic on a Paediatric Ophthalmology Service in the United Kingdom: Experience from Alder Hey Children’s Hospital

“…Capacity is more severely limited by social distancing as all patients will attend clinics accompanied by an adult. Although a gamut of teleophthalmology solutions, including remote vision testing, has been trialled and rolled out with moderate degrees of success in adult ophthalmology subspecialties (Bourdon et al 2020;Gillam et al 2020;Kang et al 2020;Kilduff et al 2020;Mintz et al 2020;Crossland et al 2021;Faes et al 2021), it may be more difficult to adapt these to the paediatric population. Our paper reveals a striking statistic: when triaging cancelled outpatient appointments during the first peak at AHCH, only 6.8% were deemed to be suitable for a telephone or video consultation.…”

Are intravitreal injections essential during the COVID-19 pandemic? Global preferred practice patterns and practical recommendations

“…There also should be a shift towards telemedicine, with models of care such as virtual clinics, where clinical decisions are based on imaging such as color fundus photography and OCT. Patients are then contacted remotely and their management plan conveyed through phone, messaging service, or video consultation [ 17 , 24 – 26 ]. In further efforts to reduce crowding in the tertiary centers, decentralization of services into the community, such as primary eye care centers, imaging centers, satellite clinics, and even home intravitreal services can be considered (Fig.…”

Digital health during COVID-19: lessons from operationalising new models of care in ophthalmology

“…• Multiple patient channels (eg, multiple primary care clinics) • Support from dedicated digital provider (eg, electronic personal protective equipment) 53,54 • Patient-led services • Mobile phone or internet of things applications (eg, Alleye) 59 • Provider or state-led surveillance (eg, travel and exposure) or disease monitoring using mobile phone or internet of things applications (eg, mVT, 41 ForeseeHome device by Notal) 42 • Stacked digital or physical clinical services, or both 55 Viewpoint non-essential appointments, such as opportunistic screening or elective surgical services, and was adopted for the Moorfield's Attend Anywhere virtual eye casualty during COVID-19. 51 These providers thereby help to augment front-line services by remotely reviewing patients with non-essential, non-urgent needs seeking to attend or queuing for in-person services to avoid overcrowding in health-care premises.…”

“…The pyramid model can be applied in ophthalmology by stacking digital technologies, beginning with the sorting conveyor model to triage patients into one of three possible care pathways: (1) self-management or observation; (2) remote video-consultation via hub-andspoke tele-ophthalmology with the use of approaches such as technology-based eye care services and hospital eye services, which can be augmented by shared care with community optometrists or general practitioners; or (3) referral for in-person secondary or tertiary care. 13,55 Technology combinations that have been similarly applied outside ophthalmology include the Babylon conversational AI-chat bots that triage patients and refer those requiring further assessment onwards for a video consultation. 56 Hybrid telehealth (the stacked combination of digital and physical clinical services) has also been illustrated in the SAVED trial of text-based asynchronous reviews with synchronous video consultations at emergency services in Singapore, 57 highlighting its potential to facilitate early discharge and reduce time in hospitals.…”

“…Issues from interactions with the existing models of care (either to overlay, augment, replace current models, etc) Ethics and medicolegal constraints Provider acceptance (eg, clinicians, nurses) 54 Pilot validation studies (with a focus on clinical outcomes or performance) 49,55 Guidelines for use, liability for negative outcomes, safety net mechanisms 61,66 Mesosystem (eg, hospital, hub-and-spoke model)…”