Over the past few years in ophthalmology, and specifically retina, there have been exponential improvements in technology that can help physicians efficiently manage and care for patients. As practices and policies within the health care system continue to evolve, the field is always in search of innovative solutions to provide the best health care delivery. There have been many recent developments and meaningful innovations in the field of retina. This article will discuss some new technologies and ideas that are likely to gain greater acceptance in retina clinics and clinical practices in the coming years.

HYBRID TELEMEDICINE MODELS

The COVID-19 pandemic accelerated implementation of telemedicine practices. Traditionally, it was thought that telemedicine would be difficult to implement in ophthalmology, because proper care depends on a good physical exam with a slit lamp and indirect ophthalmoscope. However, the need to provide clinical care while limiting physical contact to prevent spread of COVID-19 catalyzed the implementation of telemedicine within ophthalmology.

The hybrid model platform, which combines aspects of telemedicine with traditional face-to-face clinic visits, has gained popularity, especially in retina.¹ This typically entails an in-person patient appointment where data is gathered, such as visual acuity, intraocular pressure, and necessary testing and imaging such as optical coherence tomography (OCT) and ultrawidefield fundus photos. Patients would then have a telemedicine encounter, either via telephone or video, to discuss results and next steps.

A study by Sanayei et al demonstrated a successful implementation of a hybrid ophthalmology telemedicine model, especially for patients affected by glaucoma or retinal diseases, noting that this model is most ideal for patients who need routine clinical care that is nonurgent and nonprocedural.² This model is less suited for patients who may need a procedure (ie, laser or an injection). In retina, this application likely works best for patients who have macular or relatively posterior disease process such as age-related macular degeneration (AMD), rather than peripheral pathology such as lattice or concern for a retinal break or hole, because it can be difficult for imaging to capture these peripheral pathologies.

Numerous factors are required for successful integration of the hybrid telemedicine model. These include a reliable and secure communication platform, access to retinal imaging, and appropriate patient selection. For the communication platform, there are options, such as Zoom for Healthcare or Eyecarelive, that offer improved privacy and data security. Some of these applications must be installed and downloaded, which may be difficult for older patients, while others are accessed through a web browser interface.

Paradoxically, some patients may feel that they have more face-to-face communication with their physician during a telemedicine visit, because physicians may be able to spend a greater amount of time in direct communication with the patient compared to an in-person visit. Patients may also appreciate shorter, more efficient, and less crowded office visits. Further, the applications of telemedicine may increase access to care, especially in underserved or rural communities.

HOME MONITORING WITH SMARTPHONES

Smartphone and tablet applications are also being developed to better monitor patients’ symptoms while they are not physically in the office. Home health monitoring has been utilized for many different chronic diseases, such as hypertension, diabetes, pulmonary disease, and dementia. More advances have been developed within the realm of ophthalmology to help better monitor chronic ocular diseases.

For example, the Alleye app (Oculocare Medical) is available for smart phone and tablets to help detect visual distortion from home in patients with AMD. This self-monitoring application, which is FDA cleared and CE marked, can be used by patients to screen for metamorphopsia and distortion, using a dot-alignment task involving 12° of the central visual field.³ Schmid et al found that Alleye could detect wet AMD with high accuracy, and could reasonably classify AMD as dry or wet in a small subset of patients.⁴

Another smartphone-based application is the Myvisiontrack (mVT) home vision monitor from Vital Art and Science LLC. This application enables patients to self-test their vision using a shape discrimination task.⁵ A recent study by Korot et al surveyed patients to capture their experience using the mVT smartphone app, and found that patients who best engaged with this application tended to have better comfort with technology and better visual acuity at baseline.⁶

A major benefit of home-based monitoring is that it can help improve patient engagement and health empowerment, which may lead to better compliance and potentially improved clinical outcomes. However, larger studies with randomization are needed to determine the best role for various home monitoring apps.

PORTABLE HOME OCTS

Patient-operated portable OCT machines are becoming more of a reality; there are several home OCT devices on the market. This can be a great management option for patients who have chronic ophthalmic conditions, and it enables ophthalmologists to receive vital diagnostic information through imaging of patients’ retinal structures without requiring them to travel to the clinic.⁷

One remote monitoring solution is the Notal Home OCT (Notal Vision), a patient-operated spectral domain OCT system that is lightweight and portable. Patients can use the device to generate analyzable images daily, or as often as is required. The large amount of data generated is reviewed by an artificial intelligence platform called the Notal OCT Analyzer, which examines the images for evidence of fluid in exudative retinal disease, such as wet AMD, macular edema, and retinal vein occlusion. Physicians can set specific alert thresholds for when they would like to be informed. For example, when there is an increase in retinal fluid, a report can be sent to the treating physician and the patient can be alerted to schedule an appointment. Keenan et al found that the artificial intelligence analysis by the Notal OCT Analyzer had high agreement with human grading and was able to properly monitor disease.⁸

One advantage of a portable, home-based OCT system is that it will help minimize certain barriers to patient visits, such as lack of access to transportation or distance of travel to the clinic. Use of this system also may reduce overall clinic visits for patients, which in turn will provide more time for ophthalmologists to work with other patients who have complex conditions. Overall, the use of these home-based OCTs should improve access to retinal imaging and make it easier for physicians to monitor certain chronic eye diseases and personalize care.

APPLICATION OF VIRTUAL REALITY HEADSETS

The technology underlying virtual reality (VR) headsets has continued to improve as well. This equipment employs high-accuracy head tracking and powerful graphic processors that enable detailed high-resolution displays. There is potential for implementation of these VR headsets for ophthalmologic use.

For example, the VisuALL VR device (Olleyes) acts as a vision care testing platform. The VR headset can measure visual acuity (near and far), color vision, and contrast sensitivity. It can also perform a variety of visual field tests to help characterize and monitor ocular conditions.⁹ Devices like this allow for improved office efficiency and productivity for patient work-up, as the screening and visual field tests can be done in less than 5 minutes. Although the VisuALL device is used in an office setting at this time, this technology does have the potential to help physicians monitor eye diseases remotely in the future.

Another potential use for VR headsets may be to enable better visualization of pathology by the retina specialist. A case report described a useful application of a Samsung Gear VR headset that was used to display high-resolution Optos widefield retinal photographs to a retinal specialist. The authors found that a VR display of a widefield fundus photograph may improve diagnosis of retinal pathology, given the increased display size and more realistic presentation in the VR display relative to the traditional two-dimensional screen display. Further, the authors described less distortion of the image relative to viewing on a 2-dimensional screen display, as the concave retina would not need to be flattened for display. The authors speculate that in cases of subtle retinal findings, this enlarged viewing system via a virtual reality display may be helpful in diagnosis.¹⁰

CONCLUSION

There are numerous questions to consider with these new technologies on the horizon. How do ophthalmologists ensure these technologies are sufficiently evaluated by regulatory commissions to ensure safety and efficacy for patients? How can these technologies be easily integrated into practice and the electronic health record to prevent additional workload burden on providers? Finally, how do ophthalmologists ensure that they are adequately reimbursed by payers when utilizing these new technologies? Regardless of the answers to these questions, the prospect of new innovations is exciting in ophthalmology, especially in the field of retina. Ophthalmology will continue to evolve as technologies become further refined and sophisticated, and it is important for the physician to stay up to date on all options to best treat patients. RP

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