Teleophthalmology-Enabled Direct Vitreoretinal Surgery Listing from Community Optometric Practice: Enhanced Efficiency During Coronavirus Disease 2019, and Beyond?

Introduction

The pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has created challenges for the practice of ophthalmology.¹ It has created a situation where clinicians are weighing the risk to sight with the risk to life. At all times, society recognizes the need to minimize the risks and protect patients and health care workers. On March 23, 2020, in an effort to contain the coronavirus disease 2019 (COVID-19) the UK government announced a lockdown and instructed all people to stay at home except for limited and specific circumstances, including the provision of emergency medical care.² To this end, the Royal College of Ophthalmologists recommended that all routine ophthalmic outpatient clinics and surgery should be postponed.³

Since then, the UK government announced a phased exit from lockdown.⁴ Underpinning the exit from lockdown and easing of restrictions is safety and virus containment throughout. In the current phase of lockdown, maintaining social distancing and avoiding unnecessary travel remain key priorities. Ophthalmology departments now face challenges running busy clinics while maintaining social distancing. Finding ways to reduce unnecessary patient contact and triage appropriately has become increasingly important.⁵ There is a need to continue to provide optimal care while maintaining social distancing, avoiding unnecessary patient contact, and reducing patient travel. Ophthalmology services can be connected and streamlined through live teleophthalmology to create a more efficient system where patients are appropriately directed to the correct ophthalmic center.^6,7

Typical of most systems, the ophthalmology care provided in Scotland and the United Kingdom is served by secondary care hospitals, with some subspecialist ophthalmic care provided at tertiary ophthalmology centers. Within the West of Scotland, vitreoretinal (VR) surgery provision is out of National Health Service (NHS) Greater Glasgow and Clyde’s Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow. This VR service provides care to remote Scottish islands and district general hospitals of surrounding towns. NHS Forth Valley serves a population of ∼320,000 within Central Scotland, with ophthalmology services provided from a community hospital. Before COVID-19, the typical patient journey would involve initial presentation to community optometrist or emergency department, who would refer on to the local district general on-call consultant ophthalmologist, who typically appoint urgently (on the same, or next working day within 24 h). Here a diagnosis would be made, and onward referral to tertiary center providing VR cover only if required.

After lockdown, NHS Forth Valley benefitted from service redesign and setup of peripheral Emergency Eye Care Treatment Centers (EETCs), 1 center/100,000 population.⁸ These centers were staffed by optometrists attending to patients with potential emergency presentations. If required, the primary care provider can connect/refer to an ophthalmologist, establishing an audiovisual link in real time, with teleophthalmologists on-call on a separate rota covering office hours, and the on-call consultant answering video calls out-of-hours.

Methods

Each EETC benefitted from a live teleophthalmology setup through a video slit lamp, or adapted slit lamp with mobile device optics interfacing with the slit lamp oculars.⁶ Attend Anywhere^® is a web-based software that enables patient consultation remotely and securely, accessible to patient/clinician through computer or mobile device. Within the NHS in Scotland, NHS Near Me is the remote consultation solution. NHS Near Me is powered by Attend Anywhere, which has been procured for this use. Attend Anywhere benefits from functionality that allows multiple clinicians to join a consultation from any location, when invited by the clinician leading the consultation. In addition to the patient, optometrist, and local teleophthalmologist in the video consult, the VR surgeon is invited through e-mail or SMS directly from the Attend Anywhere platform, joining the consult as a fourth party. This ability increases the application of videoconferencing by enabling multiple clinicians at different sites to contribute to the management and care of a patient inside a dedicated virtual clinical environment, at the point of presentation, when urgent intervention is felt indicated. Being able to communicate with colleagues/patient with high-fidelity visualization enables “face-to-face” communication, as well as multimodal imaging, informing surgical planning, enhancing teamwork and collaboration. After the consult, Webropol^® (Helsinki, Finland) survey was used to collect data from the receiving ophthalmologist, including questions related to quality of communication and management (Fig. 1).