Validation of Home Visual Acuity Tests for Telehealth in the COVID-19 Era

Abstract

uring the initial portion of the COVID-19 pandemic, eye care professionals needed to reduce the risk of exposure to patients while continuing to provide highquality health care. The Casey Eye Institute at Oregon Health and Science University saw a decrease in clinic visits to 25% of prepandemic levels in April 2020 and did not return to baseline until March 2021. 1 With the need to limit clinic visits and an increase in the Centers for Medicare & Medicaid reimbursement for telehealth services, 2 teleophthalmology has played a critical role in responding to the COVID-19 pandemic. 1,3,4 Although published data are limited regarding teleophthalmology during the pandemic, a study looking at ophthalmology visits insured by Blue Cross Blue Shield of Michigan found a 4-fold increase in virtual visits compared with baseline data from the first 3 months of the pandemic. 5 A study at Casey Eye Institute demonstrated positive clinician attitudes with telehealth implementation during the pandemic 1 ; however, access to an easy-to-use, validated at-home visual acuity (VA) test for adults limited telehealth care.With increased use of telehealth technology, it is crucial to ensure that quality of care remains optimal. A key factor in evaluating and treating patients during eye care visits is the VA measurement. During a clinical encounter, this measurement is taken at specific distances using standardized charts, including Snellen, Early Treatment Diabetic Retinopathy Study (ETDRS), HOTV, and Tumbling E charts. 6 Historically, VA test-IMPORTANCE Visual acuity (VA) is one of the most important clinical data points in ophthalmology. However, few options for validated at-home VA assessments are currently available.OBJECTIVE To validate 3 at-home visual acuity tests in comparison with in-office visual acuity.DESIGN, SETTING, AND PARTICIPANTS Between July 2020 and April 2021, eligible participants with VA of 20/200 or better were recruited from 4 university-based ophthalmology clinics (comprehensive, cornea, glaucoma, and retina clinics). Participants were prospectively randomized to self-administer 2 of 3 at-home VA tests (printed chart, mobile phone app, and website) within 3 days before their standard-of-care clinic visit. Participants completed a survey assessing usability of the at-home tests. At the clinic visit, best-corrected Snellen distance acuity was measured as the reference standard. MAIN OUTCOMES AND MEASURESThe at-home VA test results were compared with the in-office VA test results using paired and unpaired t tests, Pearson correlation coefficients, analysis of variance, χ 2 tests, and Cohen κ agreement. The sensitivity, specificity, positive predictive value, and negative predictive value of each at-home test were calculated to detect significant VA changes (Ն0.2 logMAR) from the in-office baseline. RESULTSA total of 121 participants with a mean (SD) age of 63.8 (13.0) years completed the study. The mean in-office VA was 0.11 logMAR (Snellen equivalent 20/25) with similar numbers of participants from the 4 clinics....

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