Lindstrom's Perspective

Teleophthalmology to play a larger role in patient care

Wikipedia defines telemedicine as the use of telecommunications to provide clinical health care from a distance. And yes, there is under the heading of telemedicine a section devoted to teleophthalmology.

As I was thinking about this again, I decided to go through the typical eye examination and see how much of what we ophthalmologists do might be duplicated from a distance either online, by telephone, or with the usually available devices such as a portable phone or laptop computer. The chief complaint, history of present illness, medical history, ocular history, social and occupational history, and any other needed information can definitely be obtained online or by telephone. Visual acuity, contrast sensitivity, color vision and Amsler grid testing are already available in multiple sites including the Zeiss online vision screener. A refraction is available online from Opternative. Pupils and motility can be tested and recorded with a portable phone camera. An external examination is easily photographed, and if we want to see other parts of the body such as the hands or face in general, a photo from a portable camera can again suffice. A slit lamp photo is not readily available, but portable slit lamps are being developed. Home IOP monitoring devices are now approved. Fundus photography is possible with a portable phone camera, but dilation is not readily available at home. I can imagine the time when dilation drops might be available over the counter or as a single dose delivered on prescription by Amazon the day ordered by a licensed provider.

In regards to ancillary testing, visual fields are readily available online. Preferential hyperacuity perimetry is available at home from ForeseeHome (Notal Vision), allowing early detection of macular disease progression. Corneal topography in a basic fashion can be done with a portable camera. Home OCT is being worked on by many including Zeiss, Heidelberg and Notal Vision. Today, astronauts are able to photograph their own optic nerves, macula and central retina with a portable OCT designed by Heidelberg as they investigate space-induced visual impairment and intracranial pressure syndrome. Many specimens can be obtained at home, including blood, urine and some cultures such as lid margin or conjunctiva. So, an excellent history and useful, somewhat incomplete but perhaps adequate examination for screening purposes can be done today with the readily available, at least in the first world, telephone, home lab gathering services, portable phone and laptop computer augmented as needed with some available home testing devices.

More sophisticated testing is becoming available when needed for the monitoring of retinal disease including dry and wet age-related macular degeneration, diabetic retinopathy and diabetic maculopathy. Armed with such a telemedicine-obtained history and examination, a distant eye care provider could then treat with telepharmacy and teleoptics. We can all e-prescribe or call in a prescription that can be delivered same day to the patient’s door step. Glasses can be selected and obtained online from many, including Warby Parker, and contact lenses from 1800contacts.com. So, a lot of treatment can occur without the patient ever visiting the eye doctor.

Surgery seems robust to telemedicine, but robotics may someday allow long-distance procedures to be performed. Success has already been achieved suturing lacerations robotically with the surgeon in a distant location. Of course, an experienced clinician still needs to interpret the history, ocular examination and ancillary testing, make a diagnosis, and recommend and implement appropriate treatment. However, artificial intelligence, beginning with diabetic retinopathy screening, is poised to invade this once secure turf as well.

As is often the case, technology is advancing faster than society can adapt. The physician who dedicates his or her practice to telemedicine faces many challenges, including the requirement for a license to practice medicine and prescribe therapy in every state where they might interact with a patient. Malpractice issues related to failure to diagnose with a less than complete examination and “no laying on of hands” are a concern. And, most important of all, there are challenges with third-party reimbursement. However, many patients are willing to pay cash for telemedicine services to avoid the cost and time required for a visit to the doctor, especially for a refraction and prescription of glasses and contact lenses.

Despite these challenges, telemedicine and teleophthalmology are growing with significant investment from both for-profit and nonprofit entities. Some of the interested parties investing in this field have access to nearly unlimited human and financial capital. The collaboration between Amazon, Berkshire Hathaway and JP Morgan Chase is a natural to leverage telemedicine, and I expect teleophthalmology to be an attractive target. These big three recently hired a CEO, Atul Gawande, MD, from Harvard. He stated in one of his first interviews: “The system is broken, and better is possible.”

I expect telemedicine and teleophthalmology to play an ever larger role in patient care. We physicians and the societies that represent us will need to actively participate as teleophthalmology evolves to ensure it truly is better for our patients.

Disclosure: Lindstrom reports he consults for Notal Vision and Zeiss.

Wikipedia defines telemedicine as the use of telecommunications to provide clinical health care from a distance. And yes, there is under the heading of telemedicine a section devoted to teleophthalmology.

As I was thinking about this again, I decided to go through the typical eye examination and see how much of what we ophthalmologists do might be duplicated from a distance either online, by telephone, or with the usually available devices such as a portable phone or laptop computer. The chief complaint, history of present illness, medical history, ocular history, social and occupational history, and any other needed information can definitely be obtained online or by telephone. Visual acuity, contrast sensitivity, color vision and Amsler grid testing are already available in multiple sites including the Zeiss online vision screener. A refraction is available online from Opternative. Pupils and motility can be tested and recorded with a portable phone camera. An external examination is easily photographed, and if we want to see other parts of the body such as the hands or face in general, a photo from a portable camera can again suffice. A slit lamp photo is not readily available, but portable slit lamps are being developed. Home IOP monitoring devices are now approved. Fundus photography is possible with a portable phone camera, but dilation is not readily available at home. I can imagine the time when dilation drops might be available over the counter or as a single dose delivered on prescription by Amazon the day ordered by a licensed provider.

In regards to ancillary testing, visual fields are readily available online. Preferential hyperacuity perimetry is available at home from ForeseeHome (Notal Vision), allowing early detection of macular disease progression. Corneal topography in a basic fashion can be done with a portable camera. Home OCT is being worked on by many including Zeiss, Heidelberg and Notal Vision. Today, astronauts are able to photograph their own optic nerves, macula and central retina with a portable OCT designed by Heidelberg as they investigate space-induced visual impairment and intracranial pressure syndrome. Many specimens can be obtained at home, including blood, urine and some cultures such as lid margin or conjunctiva. So, an excellent history and useful, somewhat incomplete but perhaps adequate examination for screening purposes can be done today with the readily available, at least in the first world, telephone, home lab gathering services, portable phone and laptop computer augmented as needed with some available home testing devices.

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More sophisticated testing is becoming available when needed for the monitoring of retinal disease including dry and wet age-related macular degeneration, diabetic retinopathy and diabetic maculopathy. Armed with such a telemedicine-obtained history and examination, a distant eye care provider could then treat with telepharmacy and teleoptics. We can all e-prescribe or call in a prescription that can be delivered same day to the patient’s door step. Glasses can be selected and obtained online from many, including Warby Parker, and contact lenses from 1800contacts.com. So, a lot of treatment can occur without the patient ever visiting the eye doctor.

Surgery seems robust to telemedicine, but robotics may someday allow long-distance procedures to be performed. Success has already been achieved suturing lacerations robotically with the surgeon in a distant location. Of course, an experienced clinician still needs to interpret the history, ocular examination and ancillary testing, make a diagnosis, and recommend and implement appropriate treatment. However, artificial intelligence, beginning with diabetic retinopathy screening, is poised to invade this once secure turf as well.

As is often the case, technology is advancing faster than society can adapt. The physician who dedicates his or her practice to telemedicine faces many challenges, including the requirement for a license to practice medicine and prescribe therapy in every state where they might interact with a patient. Malpractice issues related to failure to diagnose with a less than complete examination and “no laying on of hands” are a concern. And, most important of all, there are challenges with third-party reimbursement. However, many patients are willing to pay cash for telemedicine services to avoid the cost and time required for a visit to the doctor, especially for a refraction and prescription of glasses and contact lenses.

Despite these challenges, telemedicine and teleophthalmology are growing with significant investment from both for-profit and nonprofit entities. Some of the interested parties investing in this field have access to nearly unlimited human and financial capital. The collaboration between Amazon, Berkshire Hathaway and JP Morgan Chase is a natural to leverage telemedicine, and I expect teleophthalmology to be an attractive target. These big three recently hired a CEO, Atul Gawande, MD, from Harvard. He stated in one of his first interviews: “The system is broken, and better is possible.”

I expect telemedicine and teleophthalmology to play an ever larger role in patient care. We physicians and the societies that represent us will need to actively participate as teleophthalmology evolves to ensure it truly is better for our patients.

Disclosure: Lindstrom reports he consults for Notal Vision and Zeiss.