A Novel Ophthalmic Telemedicine Program for Follow-Up of Minor Ophthalmic Emergencies

Introduction

Ophthalmic complaints comprise a large proportion of emergency department (ED) visits in the United States, accounting for ∼2 million encounters annually.¹ Post-acute near-term follow-up examinations are often necessary to assess for clinical improvement after initial ED visits and determine the need for subsequent intervention. However, accommodating near-term appointments can be challenging for ophthalmologists, who typically operate fully booked ambulatory clinics, which are scheduled weeks to months ahead of time. Patients also face challenges such as travel, limited time off from work, and considerable wait times due to overbooked clinics.^2,3 Thus, novel practice models designed to improve access to ophthalmic follow-up care would benefit both patients and providers.

Ophthalmic telemedicine historically was composed of asynchronous screening programs using ophthalmic imaging. However, telemedicine utilization increased during the COVID-19 pandemic and now encompasses more innovative models of care, driven by changes in payers’ and regulators’ policies.^4–10 In the process, telemedicine has been shown to reliably and safely triage, diagnose, and manage eye disease in a variety of ophthalmic specialties and settings.^6,8,11 However, the systematized application of telemedicine in the post-acute care setting has not yet been described. We hypothesized that a telemedical program could safely and effectively manage near-term acute follow-up for patients previously diagnosed with minor ophthalmic conditions.

In this study, we describe results from a novel pilot virtual emergency department follow-up (VEDFU) clinic, recently established in a single tertiary referral academic institution with a standalone ophthalmic ED.

Methods

STUDY DESIGN

This retrospective cross-sectional study assessed all patient encounters in the Massachusetts Eye & Ear (MEE) VEDFU clinic with a prior ophthalmic ED encounter from December 6, 2021, to June 26, 2022. The MEE Institutional Review Board approved this study (protocol no. 2022P001408) and waived informed consent requirements due to its retrospective nature. Patients were offered virtual follow-up at the time of ED discharge if they required near-term clinical re-evaluation for a diagnosis deemed suitable for the virtual clinic (Table 1), lived within Massachusetts, and consented to virtual care. Diagnoses deemed appropriate for telemedical care were selected based on clinical consensus of attending ophthalmologists and VEDFU clinic leadership. These were primarily conditions where the prognosis is generally good, where clinical improvement can be evaluated via video-based virtual visits and/or patient symptomatology, and where follow-up is warranted to ensure resolution of symptoms or detect potential sight-threatening complications.

Video-based appointments were conducted via Zoom™ (Santa Clara, CA) or Doximity™ (San Francisco, CA). VEDFU clinic ophthalmologists were instructed to utilize video for all telemedicine visits, with the ability to conduct a telephone-based visit if video was not possible. If the patient was not logged on at the time of their visit, the provider called the patient to prompt the video visit. If no contact could be made, providers were instructed to leave a Health Insurance Portability and Accountability Act-compliant voicemail to request the patient reschedule.

OUTCOMES

Primary outcome measures assessed included patient characteristics, safety metrics, and feasibility indicators. These parameters include the mode of telemedicine encounter (video-based vs. audio-only), missed appointment rate, clinical diagnoses, documentation of clinical examination findings, time interval between ED encounter and virtual visit, and referrals to ambulatory care or the ED after initial telemedicine follow-up, which were stratified by urgency (defined as follow-up <7 days), subspecialty, and reason for additional recommended follow-up.

Results

Between December 6, 2021, and June 26, 2022, the MEE ED registered 9,716 discrete ophthalmic patient encounters, of which 566 patients were referred to the traditional in-person ED follow-up clinic and 145 patients were referred to the pilot VEDFU clinic. The mean patient age in the VEDFU clinic was 38.1 years (standard deviation [SD] ±14.2) and 78 (53.8%) were men (Table 2). Ninety-nine patients (68.3%) completed their telemedicine visit, yielding a no-show rate of 31.7%; the no-show rate for the in-person ED follow-up clinic was 23.9%. The mean time interval between ED evaluation and virtual follow-up was 8.3 days (SD 3.9; range 1–32). Of the 84 completed video visits, 79 (94%) had at least one aspect of the ophthalmic examination recorded in the electronic medical record. The most common virtual diagnoses involved the periorbita and anterior segment, including chalazion (18), viral or allergic conjunctivitis (13), corneal abrasion (12), subsequent encounter after removal of corneal foreign body (7), and conjunctival abrasion (5) (Table 3).

After virtual follow-up, 23 (23.2%) patients had subsequent referrals for further care, of which 16 (16.2%) patients were referred for follow-up related to their initial ED diagnosis. Referrals were placed for comprehensive ophthalmology (11), virtual follow-up (3), ambulatory in-person follow-up (3), oculoplastics (3), cornea (2), and retina (1). One patient was referred for urgent in-person ambulatory re-evaluation (within 7 days). This patient reported persistent blurred vision after viral conjunctivitis and was found to have subepithelial corneal infiltrates, which subsequently responded to topical steroids and antibiotics. No patient seen in the VEDFU clinic returned to the ophthalmic ED.

Of the patients who missed their initial telemedicine follow-up visit in the VEDFU clinic, the most common ED diagnoses were of the periorbita and anterior segment, including corneal abrasion (15), subsequent encounter after corneal foreign body removal (6), conjunctivitis (5), chalazion (4), and conjunctival abrasion (2).

Discussion

Telemedicine is considered a means of reducing logistical and financial barriers to obtaining health care, especially for patients who face challenges related to distance, limited transportation, or disruption of daily activities.^2,3 Physicians in ophthalmology and across all of medicine have found telemedicine to be a useful tool to maintain or expand their clinical practice, especially during the COVID-19 pandemic.^4,6,7,12,13 Our institution’s high-volume ophthalmic ED sees patients for a variety of complaints, with many patients requiring follow-up care in subspecialty clinics or in the ED if clinics are overscheduled. Owing to full subspecialty clinics and long wait times for new ambulatory visits, novel models of care to accommodate follow-up patients have been explored. One such model is the VEDFU clinic, which was developed to provide a timely and safe alternative for post-acute near-term follow-up. This study reports outcomes from the first 6 months of this program.

Safety is the first imperative of any medical practice innovation. For a novel telemedicine program such as the VEDFU clinic, a key consideration is whether patients are referred for appropriate clinical indications and whether virtual care is comparable to that which would have been provided in a traditional in-person encounter. We found no instances of unscheduled revisits to the MEE ED for any patient referred to the VEDFU. Due to the nature of the diagnoses deemed appropriate for the VEDFU clinic, patient symptomatology or external evaluation of the eye and periorbita is generally sufficient to evaluate improvement or resolution of the condition. Accordingly, the majority of VEDFU clinic patients had complete resolution of symptoms by the time of their telemedicine follow-up visit, demonstrating that the appropriate patients had been referred to this novel telemedical program. One patient was referred for urgent in-person re-evaluation of ongoing symptoms after their virtual visit and received treatment in a timely manner without long-term ocular morbidity.

This suggests that ophthalmologists conducting VEDFU clinic visits can appropriately triage patients who require urgent and timely in-person follow-up when necessary. VEDFU physicians also referred patients to subspecialty eye care, including retina, oculoplastics, and cornea services, often for nonurgent evaluation of chronic ophthalmic conditions. Given that wait times for ophthalmic subspecialty care can often be long, targeted referrals by ophthalmologists in the VEDFU allow for appropriate utilization of health care resources. Overall, these findings suggest that telemedicine follow-up programs can be safe and efficacious in ensuring resolution of lower acuity diagnoses, while allowing for escalation of care or subsequent referral when warranted.

It has been proposed that a disadvantage of ophthalmic telemedicine is the inability to perform a complete ophthalmic examination through virtual video-based platforms.⁴ However, we found that virtual evaluation allowed for meaningful ophthalmic physical examination, as documented in the electronic medical record. Providers recorded external and gross anterior segment examinations for most video visits and tested extraocular movements, visual acuity, and pupillary function when clinically relevant. Although not recorded for patients seen in the VEDFU clinic, other ophthalmic telemedicine programs have been able to evaluate ocular alignment for strabismus, color vision, and visual fields, mainly through validated mobile applications.^4,14,15

Therefore, based on these capabilities, the virtual ophthalmic examination appears sufficient to guide triage and management of follow-ups for a range of common ophthalmic complaints. A majority of patients seen in the VEDFU were diagnosed with anterior segment, ocular surface, and periorbital conditions, consistent with other teleophthalmology programs.^6,9 This is not unexpected based on the diagnoses deemed suitable for the virtual clinic. Moreover, periorbital and anterior segment pathologies are generally better visualized over video-based visits compared with posterior segment pathologies and do not require as many advanced testing modalities. However, certain aspects of anterior segment evaluation such as corneal fluorescein staining, detection of small corneal infiltrates, or anterior chamber cell and flare cannot be assessed in current video formats. Therefore, cases requiring minor diagnostic procedures or slit lamp magnification were not referred for telemedicine follow-up.

Another current limitation of the VEDFU clinic, and of ophthalmic telemedicine in general, is a lack of rigorously validated and easily accessible methods to remotely measure intraocular pressure and visualize the posterior segment of the eye. The inability to gather these metrics restricts the ability for ophthalmic telemedicine programs such as the VEDFU clinic to evaluate conditions of the posterior segment, which historically has led to lower usage of teleophthalmology in subspecialties such as glaucoma and retina.^6,9,13,14

A number of home-based measurement devices such as at-home tonometry and optical coherence tomography are in development, however, which may extend the future scope of the VEDFU clinic. Another potential solution is hybrid telemedicine. In this model of care, patients present for brief in-person imaging and testing performed by nonphysician staff followed by a subsequent virtual visit with an ophthalmologist for review.^10,12 This model is particularly promising given that many ophthalmic conditions, including chronic retinal and glaucoma pathologies, are monitored through serial imaging and testing and thus may be safely managed through telemedicine formats.

Through the first 6 months of our program, the VEDFU no-show rate was approximately one in three patients. Relatively high no-show rates are characteristic of traditional in-person ophthalmic ED follow-up clinics, both at our institution and elsewhere. Within the study interval, our in-person ED follow-up clinic had a no-show rate of nearly one in four, while limited literature reports at other institutions have reported ophthalmic post-ED no-show rates ranging from 25% to 57%.^2,16,17 While we hypothesized that the VEDFU no-show rate would be lower given the relative ease of accessing virtual appointments compared with in-person encounters, it is possible that resolution of minor diagnoses led many patients to forego their follow-up visits.

Indeed, the majority of patients who missed their scheduled virtual follow-up visits were diagnosed in the ED with lower acuity conditions of the periorbita and anterior segment, which have been shown to be predictive of higher no-show rates in the follow-up setting.^2,16,17 The current VEDFU model also has no built-in patient reminder systems, such as automated pre-visit text messaging or telephone calls, which if implemented may further reduce no-show rates.^2,3

There are several limitations to our study. Given the retrospective nature of data collection, there may be information bias due to coding errors within the electronic medical record. We were also unable to assess clinical outcomes of patients who missed their VEDFU visits, although many of these patients had low-acuity diagnoses that typically resolve, and none of these patients represented for urgent ophthalmic evaluation at our eye center. In addition, our study is subject to potential sampling and ascertainment bias, as patients were offered telemedicine visits based on the ED ophthalmologist’s discretion. Patients also opted in to participate in the VEDFU clinic, resulting in a sample of individuals affirmatively amenable to virtual evaluation. Given the pilot nature of the VEDFU, our sample size was relatively moderate and larger investigations are needed to further validate teleophthalmic follow-up programs.

Conclusions

A novel virtual follow-up program for ophthalmic ED patients enabled safe and timely telemedical re-examination for a range of minor indications without any patients necessitating return to the ED. To the best of our knowledge, this is the first program of its kind and may serve as a model for other medical and surgical subspecialties with high rates of ED referrals, limited clinic availability, and diagnoses that can be managed safely through virtual visits. Larger longitudinal studies are warranted to further validate ophthalmic telemedicine as an alternative avenue for post-acute near-term follow-up care.

Authors’ Contributions

A.A.P.: Data curation, formal analysis, investigation, methodology, writing—original draft, writing—reviewing and editing. D.L.L.: Conceptualization, data curation, investigation, methodology, project administration, resources, writing—original draft, writing—reviewing and editing. G.W.A.: Conceptualization, investigation, methodology, project administration, resources, supervision, writing—reviewing and editing.

Disclosure Statement

The following authors have no relevant financial disclosures: A.A.P., D.L.L., and G.W.A. D.L.L. is a consultant for InfiniteMD. G.W.A. is a consultant for and co-founder of Ocular Technologies, Inc., consultant for Kriya Therapeutics, consultant for McKinsey & Company, consultant for Chart Biopsy, consultant for Xenon Ophthalmics, consultant for Genentech, and consultant for Dynamed.

Funding Information

No funding was received for this article.