In early April, Dr. Jason Brinton, an ophthalmologist in St. Louis, was asked to assess a patient who was complaining of red and watery eyes. During a video visit, Brinton diagnosed the patient with conjunctivitis (aka pink eye) and prescribed eye drops. A few days later, Brinton learned that his patient had been hospitalized for COVID-19. “This was just around the time that we were learning that 1 to 3 percent of COVID-19 cases involved conjunctivitis,” he says.
Brinton was able to establish that the patient’s vision was fine, and that his eyes were comfortable. “In some cases, it would have been justified to bring the patient in, but in this case it was clearly better that we didn’t,” he says. “That would have potentially exposed a number of people along this patient’s journey to the office and back to COVID-19.”
The use of telemedicine has skyrocketed due to shelter-in-place orders across the country, even among medical specialties that might not seem to lend themselves to it, such as dentistry, gynecology and, arguably, ophthalmology. “I think the number of ophthalmologists that were offering telehealth visits before COVID was probably in the single digits,” says Dr. Sophia Saleem, senior director of tele-ophthalmology at New York Eye and Ear Infirmary of Mount Sinai. “Every week [since the COVID crisis started], the number of televisits we’re doing are climbing by around 15 or 20 percent.”
What an eye doctor can (and can’t) do remotely
“Ophthalmology is actually well-positioned for this [modality] because it is an image-heavy specialty and really based on how your eyes look,” Saleem says.
Optometrists — who differ primarily from ophthalmologists in that their training doesn’t qualify them to perform surgery or specialize in specific parts of the eye — also practice telemedicine. Here’s some of what either type of eye specialist can do remotely:
One of the most important uses of all types of telemedicine is to assess which patients need urgent or emergency care and which ones don’t. Brinton says there are “three legs of a stool” when it comes to eye health — decreased vision, eye pain and redness. If someone notices any one of these, they should contact an eye doctor, Brinton says. “Two of these symptoms at once would be cause for additional and more immediate concern.” Other symptoms that warrant medical attention include flashes of light and eye floaters.
Visual acuity tests
If your doctor wants to test how well you are able to focus, they can email you a pdf of an eye chart that you can print out or read right on your computer. Brinton says you can also stand about 20 feet away from objects in your home to give your doctor a rough idea of the extent of changes in vision.
Gross assessments based on a photo or video
Here’s how it works: You take a close-up eye selfie or video and share it with your doctor. They can then get an overall sense of your ocular motility (how well you can move your eyes around), your eyelids, lashes, clouding of the cornea, redness and any irregularity in shape of the pupil. Based on what they see, they can often prescribe an appropriate medication.
Chronic illness management
An eye doctor can’t make an initial diagnosis of a chronic condition such as retinal neuropathy or glaucoma, but new symptoms can be addressed in those who’ve already been diagnosed. For example, Saleem may ask a glaucoma patient to palpate their eye to give her a sense of the intraocular pressure, a key metric. “I ask them to describe how [hard] their eye feels compared to a piece of fruit! For instance, does it feel like a grape, a tomato or an apple? This is obviously not perfect, but it’s better than no data at all.”
… and here are some of the things that can only be done IRL:
Routine eye exams
A routine eye exam requires an examination with a slit lamp, a microscope with a bright light that allows for a close look at the different structures of the eye. It’s a key tool in determining the health of your eyes and detecting disease. Before a slit lamp exam, you’re given eye drops to dilate the pupil.
Detailed evaluations and diagnoses
While a doctor can get a general sense if something is off with your eyes via video, they can’t do things like assess visual field, evaluate the retina and optic nerve, get a detailed look at your lids, conjunctiva, cornea, iris and lens, or measure intraocular pressure — a critical test, especially in glaucoma management.
Refraction tests for glasses and contacts
In order to prescribe lenses for glasses or contacts, your doctor shines a light into each of your eyes and looks at the amount of light that is bouncing off your retina. Then you sit in front of a Phoropter, a piece of equipment with holes for you to look through. Your doctor switches out different lenses while you read an eye chart until you can see clearly.
How to prepare for a televisit
Here’s how to make your tele-ophthalmology visit as informative and efficient as possible for all concerned:
Fill out forms
If you’re a new patient (you may have been referred by your primary care doctor, for example), fill out the standard forms documenting your current symptoms, ocular and general medical history, allergies and medications prior to the actual visit.
Take a good picture of your eye
“Try to stand by a nice bright window that gets a lot of light,” advises Saleem.
Have your medications with you
One advantage of being at home for your visit is that you don’t have to try to remember the exact names and dosages of any medications you take — you can simply go to your medicine cabinet and bring them to the table. Brinton says he can distinguish types of artificial tears used for dry-eye syndrome just by looking at the container. “Multi-use bottles that contain artificial tears also have preservatives so that germs don’t colonize the bottle. It’s fine to use these bottles as long as you’re not taking the drop more than four to six times in a day,” he says. “For use that is more frequent than this, it’s important to use preservative-free artificial tears, which come in twist-top vials.”
Check with your insurance company
Medicare and Medicaid, as well as most private insurance companies, have relaxed their requirements for tele-visits during the coronavirus pandemic, even for specialized care. Still, it’s always a good idea to check with your insurance provider ahead of time to find out if there are any caveats and avoid surprises.
Saleem believes telehealth visits, ironically, actually enable one of the very things that is often missing from in-person appointments these days. Without access to in-depth exams and diagnostic testing, she points out, the doctor has to rely on the patient’s external appearance, medical history and how they describe their symptoms. “Listening to your patient is a skill that we all learn in medical school, Saleem says. “It is one of the most important parts of the patient encounter, but often not much time is spent on that part of the visit. With telehealth, it is one of the most critical parts of the visit. Dr. William Osler [a 19th century physician] said ‘Listen to your patient, they are telling you the diagnosis.’ And that doctrine is now more critical than ever. So, telehealth has brought us back to the basics of doctoring.”