COVID-19 has pushed teleophthalmology to the fore

Pioneering telemedicine project

Scottish tele-ophthalmology project points to the future of eye care. Dermot McGrath reports

Telemedicine offers rich potential to serve dispersed populations in rural areas, reduce crowded clinics and avoid unnecessary hospital visits for patients, according to a presentation at the 25th Winter Meeting of the ESCRS.

In a wide-ranging talk, Iain Livingstone MD discussed his experience helping to set up a pioneering virtual emergency teleophthalmology programme covering a large part of Scotland in response to the COVID-19 emergency. The innovative network uses inexpensive equipment and a live video feed to securely connect doctors, opticians and patients and ensure that patients with serious eye problems can be immediately diagnosed and treated.

“We have been using digital mobile technologies and leveraging them for decision support since around 2017. However, the technology really came into its own when the COVID-19 pandemic struck and completely disrupted traditional eye care,” said Dr Livingstone.

The tele-ophthalmology system was developed in collaboration between the University of Strathclyde in Scotland and NHS Forth Valley, which is one of the “health boards” that make up the Scotland National Health Service (NHS), explained Dr Livingstone.

A network of optometrists in different regions of Scotland was enlisted to attend to urgent eye problems, meaning that only cases that need secondary care were directed to hospitals. The system works well with screenshare from any video slit lamp, but can also be achieved with four basic components: a slit-lamp microscope, a 3D-printed bracket mount for stability, an iPad or webcam to provide a live video feed between the patient, the on-site clinician and the remote ophthalmologist and a telemedicine platform, such as Attend Anywhere, a Chrome-based web platform in the case of NHS Scotland.

“The paradigm basically involved interposing a webcam or iPad into the slit lamp that enables video consultation whereby we could see through the optical equipment and give more nuanced advice

...the technology really came into its own when the COVID-19 pandemic struck and completely disrupted traditional eye care

Iain Livingstone MD

and often prevent an escalation to hospital. The system essentially means that an eye specialist is able to review patients at the moment advice is needed, offering decision support to the optometrist and ensuring any follow-up treatment is more streamlined,” he said.

Since first using the system to diagnose and grade a chemical injury of a patient in 2017, Dr Livingstone said that its utility really came to the fore during the COVID-19 pandemic when a lot of routine healthcare ground to a halt in Scotland.

“In March 2020, NHS Scotland changed the way that it handles acute eye care. The population was told to stay home, and in several NHS boards, including my own, optometric practices were only opened if there were going to be providing exclusively acute eye care. Using the teleophthalmology system, we activated one optometrist per 100,000 population. In my NHS board, we had three optometric practices for a population of around 320,000,” he said.

The goal was to massively increase the remit of what optometrists could typically do by giving them the digital tools to include experts directly in their consultations as needed, said Dr Livingstone.

“Whether it was viewing the OCT in a live way that we could see the volume scans and discuss with them and the patient at the same time, or whether it was through the video slit-lamp and looking at a cornea, the system meant that we could get much more nuanced plans. We would typically receive up to nine calls a day for consultations,” he said.

Using this approach, the experts were able to successfully manage between 50 and 70% of cases at a distance without the need for a second consultation for the patient.

“We use NHS Near Me, powered by Attend Anywhere, which is a Google Chrome-based video conferencing platform specifically designed to embody a virtual clinical workspace. We found that the level of escalations before lockdown was decreased significantly. In about 64% of all the video calls, we felt at least one appointment was saved and that increased to 86% during the first lockdown,” he said.

Dr Livingstone said that the system has also proven its worth in enabling emergency consultations directly from the patient’s home in certain instances.

He cited the example of one patient whose optometrist forwarded a photo of possible COVID-19 conjunctivitis to the experts for a second opinion.

“These optometrists were in harm’s way at the time as there was limited personal protective equipment available. So, we agreed to set up a video call with the patient and we were able to examine the eye and perform a visual acuity test. It became clear this was not conjunctivitis but a pupil-involving orbital problem, causing proptosis and limitation of eye movements. The patient went directly for a CT scan without seeing an optometrist or ophthalmologist face to face. It turned out he had a fistula and went straight to the neurosurgeon,” he said.

Going forward, Dr Livingstone said that ongoing advances in technology and increasing pressure on healthcare systems to make better use of resources will further spur demand for tele-ophthalmology.

“I honestly think that this kind of system is going to be the heart of a forwardlooking ophthalmic service in 2021 and beyond,” he concluded.