Among many, one major challenge COVID-19 has presented to eye care providers is how to effectively care for our patients while maintaining the safety of ourselves, our staffs and our patients. Multiple professional organizations, such as the American Academy of Ophthalmology (AAO) and American Optometric Association (AOA), have updated their recommendations when caring for COVID-19 and non-COVID-19 patients; as these recommendations evolve over time, we have a duty and responsibility to our patients to stay abreast of them.

Ocular visits present an interesting challenge in health care in that they often depend heavily on very close proximity between provider and patient. Additional obstacles include the age of patients, as the elderly are at high-risk for COVID-19. Other aspects of the clinical experience, such as educating students and trainees, have become difficult at a time when “social distancing” is part of the medical dogma.

While considering all these hurdles, telehealth is transforming the way we practice eye care; virtual health care allows us to address all these challenges in an effective way, ensuring all patients are adequately cared for. Hence, in our ophthalmology clinic, we have used telehealth and virtual interaction to optimize the care of our patients in three primary ways: triaging patients, communicating with other providers, specifically optometrists, and educating learners. We hope that these practices can be useful to other eye care providers as they consider how to best care for their patients.

TRIAGING PATIENTS

The most significant change to our daily practice is how we effectively examine and evaluate our patients virtually, so that we can triage accordingly. As a neuro-ophthalmologist, I see a vast array of vision-threatening and potentially life-threatening pathology, such as brain tumors, aneurysms, vasculitis and stroke, so it is imperative to evaluate all conditions appropriately. Several web- and electronic medical record (EMR)-based applications are present to facilitate the virtual evaluation of patients. While all platforms have strengths and weaknesses, they are not a replacement for an in-person visit.

Additionally, such applications allow us to perform many important ocular examination skills remotely. Depending on the quality of internet speed, we can perform a fairly effective external exam, including evaluation of pupils, nystagmus and extraocular movements. Multiple smartphone and tablet applications can provide virtual at-home elements of the neuro-ophthalmic exam (e.g., visual acuity, visual field, pupil and eye motility) that may be of interest, depending on the patient. While they are not perfect, they are highly useful tools to provide a basic idea of the patient’s condition.

Despite the developments in the virtual examination of the eye, certain parts, such as examining the fundus, simply are not possible remotely at this time. However, with a detailed history and a cursory virtual examination, if I am concerned about something that may be serious or may become serious, I encourage these patients to come to our clinic or even the ER to be fully evaluated. This method of triaging patients has been effective in minimizing the number of patients who have to endure potential COVID-19 exposure, but it also allows us to prioritize patients who have potentially serious pathology.

COMMUNICATING WITH OTHER PROVIDERS

Our relationship with optometric providers also has evolved during COVID-19, as patients who have already seen their optometrist may simply need the data (e.g. VF or OCT) and exam to be interpreted. In this setting, virtual visits have proven effective in adjudicating cases in which the exam has already been performed.

In our clinic, the technicians schedule and start the virtual visit with the patient and we communicate directly with the patient through the EMR. In this way, we are still able to access the chart and other elements of the EMR contemporaneous to the virtual visit.

EDUCATING LEARNERS

Another aspect of my clinical experience that has been aided by the use of telehealth modalities is in educating students and trainees. Typically, students, residents and fellows are live active participants who are physically present in my clinic and learn by interacting with patients and discussing cases during daily and morning rounds. In an effort to “socially distance,” we have shifted to an almost entirely virtual learning experience for our medical students. Residents and fellows participate in telehealth appointments alongside me. Medical students are encouraged to take part in the experience virtually; they log in via video conference from their own home, and we physically roll the wheeled, mobile stand-mounted tablets into the exam lane with us, so that the students are able to experience the setting virtually. It is an unorthodox system, but we have found it works quite effectively to keep students engaged with the clinical experience, while also maintaining a safe environment.

Additionally, morning rounds and grand rounds have shifted to an entirely virtual platform. This setting allows doctors from all backgrounds and locations to be “learners,” not just residents. Large eye care practices, such as Bascom Palmer Eye Institute (previous sessions available at bit.ly/BPEIGrandRounds ), and hospitals, such as Wills Eye Hospital (register at bit.ly/WillsEyeChiefsRounds ), also have opened up their grand rounds to greater virtual attendance. In my experience, multiple previous students, residents and colleagues from all over the country will often log on to these sessions to learn about interesting cases.

EXPANDING RELATIONSHIPS

In summary, the COVID-19 pandemic has created both challenges and opportunities for improving and expanding the virtual relationship between patients and providers and primary eye care providers with consulting specialists. The continued use of these tools constitute our current “now normal” and are evolving to become our “new normal.” Continued refinements and improvements will be necessary to determine the continued role of telehealth after the COVID-19 pandemic ends. OM

DR. LEE is chair of the Blanton Eye Institute, Department of Ophthalmology at Houston Methodist Hospital in Houston, Texas and is professor of ophthalmology, neurology and neurosurgery at Weill Cornell Medicine. He is adjunct professor of Ophthalmology at Baylor College of Medicine; Texas A&M College of Medicine; University of Iowa and the University of Buffalo; and clinical professor at the University of Texas Medical Branch in Galveston, Texas and the UT MD Anderson Cancer Center.

MR. GHOSH is a research fellow with the Ophthalmology Department at the University of North Carolina at Chapel Hill School of Medicine. He is a medical student at the Texas A&M University College of Medicine, Class of 2021, aspiring to pursue ophthalmology residency training program after graduation.