Introduction
As technological advances allow greater virtual connectivity for many aspects of business and social life, the medical field is also developing innovative ways to extend our care. Certain specialties lend themselves more easily to this form of care. Neuro-ophthalmology relies heavily on in-person physical exam with specialized equipment and diagnostic testing that cannot be fully replicated in the home setting. Yet, some providers use a combination of telehealth applications and remote review of locally performed exams and imaging to provide care to patients in rural or underserved areas. The recent pandemic spurred further development and widespread utilization of new methods to evaluate and treat patients while minimizing face-to-face contact. According to a May 2020 survey of neuro-ophthalmologists’ telehealth use, video visit use increased from about 4% to 68% as a way to maintain patient care during the pandemic. Maintaining an appropriate standard of care must be balanced against our Hippocratic oath, particularly “first, do no harm.” Many neuro-ophthalmology patients have comorbid conditions that place them at high risk of morbidity or mortality with COVID-19 infection. In addition, a delay in care may lead to permanent vision loss and disability. As community home quarantine orders and patient fears of contracting COVID-19 impact patient presentation to clinic for initial and follow-up evaluations, use of telehealth technology can help maintain a relationship with these patients that is essential to their long-term well-being.
Preparing for a telehealth visit
Prior to initiating a teleneuro-ophthalmology evaluation, it is important to screen patients for appropriateness. The first step is a practical evaluation to ensure a patient can participate in a telehealth exam. Patients must provide consent to participate in a telehealth visit, and basic internet and/or telephone service is necessary to provide a synchronous connection between the patient and physician. While smartphones, laptops, and tablets are relatively common household items, not all patients have such a device available to them. Furthermore, some patients may not be comfortable using the necessary technology including the virtual visit platform and exam applications. It may be helpful to have a family member or friend present as a support person to help patients set up for a visit and to assist with certain portions of the exam during the visit.
Reviewing prior records and imaging allows the provider to triage patients for urgency as well as appropriate visit type. Efferent disorders typically have external signs in the pupil, eye, and lid movements that can be evaluated via video. Many afferent visual and sensory complaints can also be evaluated by a telehealth visit with supplemental exam and imaging information from a recent evaluation. In a survey of telehealth adoption by neuro-ophthalmologists, many providers reported that video visits can be helpful in the evaluation of cranial nerve palsies, migraine with aura, positive visual phenomenon, anisocoria, binocular diplopia, ocular myasthenia gravis, ptosis, and transient visual loss. With supporting imaging such as fundus photos, ocular coherence tomography, magnetic resonance imaging, and visual fields, one may also be able to evaluate optic neuritis, pituitary tumors, idiopathic intracranial hypertension, and certain eye pain complaints. Due to the variable nature of disorders such as myasthenia gravis, one often has to rely entirely on the history, as in-person exam may be completely unrevealing. Optic neuritis and temporal arteritis both have pain as a feature. The provider can evaluate this pain further during a remote exam by having the patient perform eye movements and/or palpate their own temples. The survey found that most respondents did not find video visits helpful for evaluation of nonarteritic anterior ischemic optic neuropathy, possible arteritic ischemic optic neuropathy, and optic atrophy. These conditions often require frequent fundus exams for monitoring. Recent records and use of the tools described later in the chapter can support a partial evaluation via telehealth until the patient can present to clinic for any neuro-ophthalmology concern. An initial telehealth visit may help one further triage the urgency of this in-person exam.
There are multiple types of telehealth visits that a provider can utilize for patient care. A real-time synchronous video visit is the closest to an in-person visit, as it allows for a history as well as a limited exam. While the standard face-to-face visit allows more natural interaction with the patient using subtle facial and body language cues, the current need for mask use by both patients and providers hampers this to a degree. In this way, use of video can be a superior method for safely interacting without masks until social distancing measures end. Telephone visits consist of synchronous verbal communication only. They are well suited for counseling established patients on test results and disease management. In instances where an in-person physical exam is necessary, the provider can perform a history via video or telephone to minimize time spent in direct contact.
Asynchronous telehealth consists of patients submitting symptom updates, videos, and/or images via a patient portal or other secure communication to the provider for review at another time. While asynchronous telehealth is most commonly used for established patients, some facilities offer second opinion evaluations for patients, which consist of an expert reviewing a set of records and providing a written report of their assessment, as well as answers to a set of questions submitted by the patient. If a patient consents, a referring provider can initiate an interprofessional consultation. The consulting provider reviews the records and provides a verbal and/or written report to the referring provider without ever interacting with the patient.
The virtual visit
History
The neuro-ophthalmology history is key to building a differential diagnosis. The history helps establish whether the visual disturbance is acute or chronic, stable or progressive, monocular or binocular, and painful or painless. One can also elucidate any other associated neurological or systemic symptoms. The patient can relate symptom onset and progression, subjective symptoms such as pain that we cannot objectively observe, and variable symptoms that may not be present at the time of evaluation. A history can always be documented for any visit type, but the level of detail and patient input varies. Even for asynchronous visits, patients can complete a history questionnaire and/or free text summary of their complaint for the physician.
Indirect history can come from the consulting provider, family, and review of records, which are often just as valuable as the patient’s account. Prior eye exam records help to establish baseline vision, when the ophthalmic changes started, and how they have progressed over time. This is particularly helpful in asymptomatic patients found to have significant pathology identified on routine exam. The complexity of the visual and neurological systems makes it difficult for some patients to describe their experience accurately. For instance, a person may not recognize vision loss until it reaches a certain threshold, or until they attempt to view monocularly with a nondominant eye. This “sudden realization” can seem like “sudden onset” to a patient. Patients may also confuse vision loss in one eye with loss of part of the visual field in both eyes. The term “double vision” may be used by patients experiencing blurry vision or another visual disturbance. Obtaining ancillary information from family may also help, particularly if the vision change impacts self-care, driving, or other routine tasks.
Physical exam
The greatest challenge to virtual neuro-ophthalmology visits is the exam. A virtual neuro-ophthalmology visit is not possible with current technology, but many exam components can be adapted to video evaluation and/or approximated with validated applications for the computer, tablet, or smartphone. If the referring optometry or ophthalmology provider evaluated the patient in person, they may be able to provide further support in the way of examination findings and diagnostic imaging. We will review remote evaluation options for each exam component. The physician can complete as much of the exam as possible virtually, and then have the patient complete any remaining components in-person on the same day or at a later date.
Visual acuity is the sharpness of vision, typically assessed by reading a chart of numbers or letters at a set distance. Loss of acuity can occur with pathology in various parts of the eye, including damage to the optic nerve. In the clinic setting, this is performed by a technician or the physician and may include use of lenses and instruments to correct refractive errors. A variety of tools exist for home assessment of visual acuity. Patients can print a vision card, or use a validated visual acuity application. Validated applications include PEEK Acuity, Visual Acuity XL, Vision@home, and Eye Cart Pro. A near-vision test card can be accessed at https://farsight.care ( Table 6.1 ).
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