The law of life
In his shortlisted essay for the 2021 John Henahan Prize, Dr Aaron Donnelly says there needs to be an urgent re-evaluation of the old way of doing things.
“Change is the law of life, and those who look only to the past and present are certain to miss the future” – John F Kennedy
The COVID-19 pandemic has posed colossal challenges to the sustainable delivery of eye care. The ophthalmic consultation, traditionally requiring a face to face examination, poses particular risks to the physician and patient alike. As such, in March 2020, the Royal College of Ophthalmologists announced that all routine outpatient activity should be postponed, and over a 3 month period at Moorfields alone, more than 100,000 outpatient appointments were cancelled.(1)
The resultant lockdown forced us to rapidly implement a number of off-the-shelf solutions. My own eye casualty in Dublin was converted into an efficient tele-ophthalmology service. A telephone triage team was assembled with whom patients could discuss their complaints and e-mail a clinical photograph if appropriate. Many patients were managed simply with advice, a prescription and a follow up call where necessary.
A drive-through glaucoma clinic was established in Dublin’s Citywest.(2) This innovative model invited known glaucoma patients to have an IOP measured from the safety of their own car with an iCare device. Patients with concerning IOP’s were flagged and followed up physically in a glaucoma clinic. Those with reassuring measurements continued to be followed up through a tele-ophthalmology consult.
Worldwide, and almost overnight, ophthalmology departments adopted tele-medicine and similar creative responses in an endeavour to continue the safe delivery of eye care. (3-6)
We are at a unique advantage in ophthalmology as being the speciality that best marries medicine and modern technology. Countless applications exist which allow physicians to remotely test a multitude of ocular vital signs like visual acuity, colour vision, Amsler grid distortion and even visual fields.(7-10) We are even close to an era where patients can capture their own fundus photographs with a commercially available iPhone attachment.(11) Going forward, validated versions of these applications could facilitate home-monitoring in a select patient population.
As an amateur photographer I am impressed also by the familiar names found in our photographic departments. Canon, Optos by Nikon, and Zeiss have revolutionised fundus photography and OCT respectively. Ours is a speciality where the diagnosis is often reached on history and observation alone, and these imaging systems allow us to appreciate much of the visual pathway at a resolution that matches that of the human eye.
The virtual clinic is one field which has arisen from this supposition. In this model, trained technicians measure visual acuity and IOP, and can perform fundus photography, OCT and visual field testing where indicated. The results can then be reviewed remotely by a specialist and decisions made on their care. A controversial opinion perhaps, but it might also be possible for the data to be analysed by artificial intelligence, removing entirely the need for physician input.
Stereo fundus photography has made virtual glaucoma clinics a reality,(12) and OCT has paved the way for virtual medical retina clinics.(13) I would argue that there are many other patient populations that could be followed similarly. I’m not advocating for our gradual obsolescence, but with 1,500 UK ophthalmologists managing 9 million outpatient appointments per year, we need to drastically re-imagine the way we “see” our patients. By pushing screening and monitoring away from the acute setting we can focus on treating patients who truly require our expertise.
As well as restructuring our outpatient services there will clearly be a need to manage the backlog of patients awaiting cataract surgery. Ophthalmology after all, is the speciality with the highest number of patients waiting on an outpatient procedure.(14)
Currently, many people with visually significant cataract are first diagnosed by their optometrist. Ideally, experienced optometrists working as part of an integrated cataract assessment pathway could refer suitable patients directly for surgery avoiding unnecessary delays.
Many patients undergoing cataract surgery for the first time will also have a second cataract warranting removal soon after. Consideration should be given to performing bilateral simultaneous cataract extraction in these individuals, a sentiment echoed by the Royal College of Ophthalmologists.(15)
Post operatively, patients who had uncomplicated surgery and have no ocular co-morbidities could be reviewed by their local optometrist or over the phone by a non-medical health care professional.
Don’t get me wrong, I look forward to the day when COVID is behind us. It has been an awful period both personally and professionally for many of us. I am excited however at the lessons to be learned from our response to the pandemic, and at how our long term clinical practice will change. If we are to manage the ever increasing demand on ophthalmic services then there needs to be an urgent re-evaluation of the old way of doing things. The COVID pandemic might just be the catalyst required to make such necessary changes.
* Aaron Donnelly is a resident at Cork University Hospital and the South Infirmary Victoria University Hospital in Cork, Ireland
1. Crossland MD, Dekker TM, Hancox J, Lisi M, Wemyss TA, Thomas PBM. Evaluation of a Home-Printable Vision Screening Test for Telemedicine. JAMA Ophthalmol 2021.
2. EuroTimes. Drive Through Facility for Irish Glaucoma Patients. Sep, 2020.
3. Portney DS, Zhu Z, Chen EM, Steppe E, Chilakamarri P, Woodward MA et al. COVID-19 and Utilization of Teleophthalmology: Trends and Diagnoses (CUT Group). Ophthalmology 2021: S0161-6420(0121)00118-00114.
4. Wong JKW, Shih KC, Chan JCH, Lai JSM. Tele-ophthalmology amid COVID-19 pandemic-Hong Kong experience. Graefes Arch Clin Exp Ophthalmol 2020: 1-1.
5. Lutz de Araujo A, Moreira TC, Varvaki Rados DR, Gross PB, Molina-Bastos CG, Katz N et al. The use of telemedicine to support Brazilian primary care physicians in managing eye conditions: The TeleOftalmo Project. PLoS One 2020; 15(4): e0231034.
6. Mastropasqua L, D’Aloisio R, Brescia L, Lanzini M, Bondì J, Libertini D et al. Teleophthalmology in COVID-19 era: an Italian ophthalmology department experience. Eye (London, England) 2020: 1-3.
7. Brady CJ, Eghrari AO, Labrique AB. Smartphone-Based Visual Acuity Measurement for Screening and Clinical Assessment. Jama 2015; 314(24): 2682-2683.
8. Campbell TG, Lehn A, Blum S, Airey C, Brown H. iPad colour vision apps for dyschromatopsia screening. J Clin Neurosci 2016; 29: 92-94.
9. Brucker J, Bhatia V, Sahel JA, Girmens JF, Mohand-Saïd S. Odysight: A Mobile Medical Application Designed for Remote Monitoring-A Prospective Study Comparison with Standard Clinical Eye Tests. Ophthalmol Ther 2019; 8(3): 461-476.
10. Jones PR, Campbell P, Callaghan T, Jones L, Asfaw DS, Edgar DF et al. Glaucoma Home Monitoring Using a Tablet-Based Visual Field Test (Eyecatcher): An Assessment of Accuracy and Adherence Over 6 Months. Am J Ophthalmol 2020; 223: 42-52.
11. Futurist TM. Handheld Retinal Camera as an Eye for Innovation – D-Eye Review. Jun, 2020.
12. Kotecha A, Brookes J, Foster PJ. A technician-delivered ‘virtual clinic’ for triaging low-risk glaucoma referrals. Eye 2017; 31(6): 899-905.
13. Kortuem K, Fasler K, Charnley A, Khambati H, Fasolo S, Katz M et al. Implementation of medical retina virtual clinics in a tertiary eye care referral centre. Br J Ophthalmol 2018; 102(10): 1391-1395.
14. HSE. National Clinical Programme for Ophthalmology, Model of Eye Care. 2017.
15. RCOphth. Restarting and Redesigning of Cataract Pathways in response to the COVID 19 pandemic. 2020.