When ophthalmology visits became abruptly and severely limited by the COVID-19 crisis, Robert P L Wisse MD, PhD, and colleagues at the University Medical Center Utrecht, Utrecht, The Netherlands, implemented a web-based visual acuity test into their remote care delivery to help evaluate patient status and identify individuals in urgent need of direct care.
The digital test, which is offered by Easee BV, Amsterdam, The Netherlands, involves use of a smartphone and computer screen for measuring visual acuity along with spherical and cylindrical error. It is CE-marked and had already been validated as a valid and safe method for obtaining the functional and refractive data in a study involving healthy volunteers ages 18 to 40 years.
Wisse RPL, et al. J Med Internet Res. 2019 Nov;21(11):e 14808
Linkage with the electronic medical record (EMR) system at the University Medical Centre Utrecht had also been established, and in January, 2020, cataract surgery patients began to be enrolled in a randomised clinical trial designed to investigate the test’s use as a tool for remote postoperative follow-up.
Now, the clinical study is on hold, but the Web-based test is showing value in the dire, real-world situation.
Dr Wisse is Assistant Professor of Ophthalmology and Head of the Utrecht Cornea Research Group at the University Medical Centre Utrecht. He told EuroTimes: “Patients have almost no access to eyecare anymore. At our hospital centre, which has been essentially transformed into a coronavirus clinic, we are seeing approximately 30 ophthalmology patients a day who represent the most urgent cases and only about 10% of the pre-pandemic clinic volume.”
“Currently, we are reaching out to all of our patients with telephone and video consultations, and as part of the information we are collecting remotely, the Web-based test is helping us determine the next step for an individual’s care.”
Platform development and pandemic implementation
Dr Wisse, who disclosed that he is a consultant to Easee, said he was originally interested in the test as a solution to address the growing gap between supply and demand for eyecare services that is occurring with population aging. To that end, the cataract surgery clinical trial is comparing measurements obtained with the web-based tool versus in the clinic to determine the safety of its use for postoperative patient management.
Because cataract surgery patients were expected to be less digitally fluent than the younger adult population involved in the validation study, the developers came to Utrecht to observe how older users interacted with the system. Consequently, the product and its instructions went through several iterations to enable adoption by older patients.
“The test is now very intuitive and straightforward. Nevertheless, not all patients are able to do the Web-based testing because they either do not have access to the hardware that is required or are unable to follow the instructions,” said Dr Wisse.
“Yet we are confident from the development work that most older patients, particularly when assisted by a partner, can interpret the instructions and perform the testing successfully. Any patient who is familiar with using their digital ID for logging into government websites is probably capable of doing the online Web-based test.”
In the current real-world use situation, initial contact with patients for remote consultations is being made by telephone by the ophthalmic nurse or optometrist. These individuals take a detailed history and provide patients with instructions to prepare for the videoconsultation and complete online questionnaires and the visual acuity test.
All of the patient’s information is entered in the EMR, and the supervising ophthalmologist is aided in clinical decision-making after reviewing the data and clinical notes.
“Having access to validated data on a patient’s visual function is helpful in determining the urgency and necessity of an outpatient visit,” Dr Wisse explained.
“Having said that, I must stress that an online test is merely part of a much larger change in practice patterns towards remote monitoring of our patients. We reach out to our patients personally on the phone, or ideally via a video-consultation, and assess their needs on an individual level. The web-based test is a means, and not a goal per se.”
Dr Wisse observed that the effectiveness of using the information from the web-based test as part of the clinical decision-making process is not proven. However, the mass of data that are being collected through its integration into the remote visits will provide a rich resource for analysis in the future
“The current COVID-19 quarantine consequences evidently identify the need for out-of-the-box innovative thinking in order to provide access and continuity of care,” he said.
The remote visual acuity test has attracted a lot of interest from ophthalmologists around the world as centres scramble to adopt to the impact of the COVID-19 pandemic on patient care. The first implementation at an external clinic will be at Maastricht University Medical Centre, The Netherlands.
“ Six to seven applications for implementing the test are received every day, and work to manage those requests is being done around the clock,” Dr Wisse said.
“Easee, the company offering the test, began in 2016 as a solo startup venture, and now has just 13 employees rushing to meet the demand.”
Once the COVID-19 crisis is over, Dr Wisse said the cataract surgery clinical trial will be converted to a multicentre investigation. Although additional planning and preparation will be needed to implement a multi-centre trial, the timeline may be shortened because sites selected to participate will already have the online test in place.
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