We are now more than 6 months into the COVID-19 pandemic in the United States that has caused significant changes to everyday life and significant disruptions across all industries, particularly health care. The effect on retina practices has fluctuated at times depending on region, based on local mitigation guidelines and case numbers as well as practice patterns and disease burden. Unlike comprehensive cataract practices and many other subspecialties of ophthalmology, retina walks a fine line between elective care and urgent/required follow-ups, given the imminent or severe risk of vision loss in many retinal conditions. Since the onset of the pandemic, access to prevention and treatment services for retina patients has been severely disrupted globally. The previous standard of packed waiting rooms and long doctor visits quickly evaporated as social distancing and maintaining low patient densities became a critical public health need.

Our typical retina patient population is high risk, and therefore patients had significant concerns about our precautionary measures and maintaining near total isolation because of advancing age and comorbidities. As a result, practices started to incorporate telemedicine virtual visits into clinical workflows, using both telephone and video conferencing. Telemedicine has been around for decades, but the expansion by the US Centers for Medicare and Medicaid Services for coverage and reimbursement for these services to Medicare beneficiaries without previous restrictions helped to facilitate greater adoption and moving past longstanding roadblocks. Adoption of telemedicine services has been staggering, with a recent study at New York University showing a 4,345% increase in virtual visits for nonurgent care.¹ In addition, McKinsey recently published a report indicating that upwards of 20% of all health care could be provided virtually.²

Before COVID-19, telemedicine in ophthalmology primarily revolved around screening, notably for diabetic retinopathy, but also for glaucoma and macular degeneration. These programs have become widespread around the world, using “store-and-forward” models of screening for disease. Fundus cameras are strategically set up in various settings, such as the primary care physician’s office, an endocrinologist’s office, urgent care centers, laboratory settings, radiology imaging suites, dialysis centers, pharmacies, and even routine grocery stores. We expect that this model will likely continue to grow and gain even broader adoption as artificial intelligence is integrated in the years to come. Prior to the pandemic, telemedicine was gaining gradual acceptance, but with the arrival of coronavirus, along with the potential threat of its endemic persistence, telemedicine has rocketed to the forefront and is poised for rapid adoption and growth.

Early on in the pandemic, we prioritized patients who required emergency services and those who needed intravitreal injections to maintain their vision. As we began increasing the volume in our clinics, it was readily apparent that we should be considering alternative models for our patients to continue with routine care and monitoring. Our focus shifted toward dealing with this “new normal” and providing the best care possible for our patients. To optimize retina care delivery not only during COVID-19 but also beyond, we developed a hybrid tele-eyecare protocol. The primary goals for this model was to provide safe, efficient, and efficacious care for our patients, especially those with concerns about coming into the office and exposure to staff and other patients. From the outset, we wanted to offer patients a new type of visit where they could be in and out of the office in 15 minutes, and only interact with 1 person. We incorporated various telemedicine modalities: store-and-forward (ie, fundus photography and optical coherence tomography imaging [OCT]), real-time (ie, live video), and remote patient monitoring (ie, smartphone vision testing apps). This hybrid strategy combines in-office advanced imaging with real-time virtual communication to facilitate decision-making on complex retinal diseases.

With this workflow, patients are scheduled at a convenient time at an office closest to their home. The in-office component of the visit is to obtain work-up and imaging. Patient appointments are staggered every 15 minutes to 30 minutes to prevent having multiple patients in the office at the same time. The patient interacts with a single technician who tests the visual acuity, intraocular pressure, and obtains imaging (ultrawidefield fundus photos and spectral-domain OCT). From start to finish, visits last 15 minutes, sometimes fewer if the patient chooses to connect virtually from home at a later time. Virtual connection between the patient and physician can be performed while the patient is still in the office, or scheduled for a date and time within 24 hours to 72 hours. The physician reviews the collected data and imaging prior to virtual consultation, then obtains additional history, and performs education on the treatment plan during the virtual call.

Establishing protocols to enhance safety during COVID-19 has led to the use of parallel in-office clinics with hybrid/virtual clinics. Patients with emergencies and potential need for procedures (ie, intravitreal injections, lasers) continue to come in to the clinic, and we continue symptom and temperature checks prior to entering the office, as well as social distancing in clinic, extensive cleaning of high-touch-point surfaces between each patient, and requiring all staff and patients to wear masks. COVID-19 has required us to change the prepandemic reality of overbooked retina clinics, crowded waiting rooms, long wait times, and interaction with multiple staff members in the office as well as other patients in waiting rooms. Hybrid protocols facilitate visits that enhance safety and efficiency for patients while also indirectly facilitating safety and efficiency for in-office clinics by reducing the number of patients needing to be seen in person by 20% to 30%. This coincides with the recent McKinsey report that found that 20% to 25% of all outpatient clinical care could be performed virtually.2 By instituting hybrid protocols, we are not trying to replace in-office visits, but rather to supplement our offerings. After almost 6 months and several hundred patients seen with hybrid virtual visits, the majority of patients prefer this setup and praise the safety and efficiency.

As virtual telemedicine visit usage exploded after COVID-19, patients became more familiar and comfortable with the technology. Ideal patients to offer hybrid tele-eye-care visits include those coming in for diabetic eye screens, established diabetic retinopathy being monitored (ie, moderate nonproliferative diabetic retinopathy), dry macular degeneration, epiretinal membranes, choroidal nevi, and hydroxychloroquine screens, among others. We have witnessed that as adoption of these protocols in our clinics grow, we are seeing less busy waiting rooms, more adherence to social distancing guidelines in clinics, more on-time clinics with fewer delays, and an overall shift in the retina provider’s schedule toward dealing with mostly procedural visits in the clinic (ie, intravitreal injections, lasers, scleral depressed examinations, and surgery) with an increase in adjunct virtual visits for follow-up of routine care patients.

The long-term adoption of telemedicine by patients and providers in the aftermath of COVID-19 remains to be seen, but early indicators are that telemedicine is here not only to stay, but also to revolutionize long-standing care models. CMS has already discussed making most of the temporary emergency telemedicine changes permanent via legislative bills. However, changing patient management processes, reimbursement concerns, and disruption of traditional practice structures will present barriers that we must all work together to address. However, among the early adopters, our experience shows that many patients and physicians embrace this change and value the enhanced safety and efficiency. RP

REFERENCES

1. Mann DM, Chen J, Chunara R, Testa PA, Nov O. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020;27(7):1132-1135.
2. Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: a quarter-trillion-dollar post-COVID-19 reality? May 29, 2020. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality#