Telemedicine in Neuro-Ophthalmology Is Ready for Prime Time

Introduction—Drs. Lee and Van Stavern Telemedicine—defined primarily as the use of telecommunications technology to provide, enhance, or expedite health care services—has an increased role in Medicare over the past decade. The use of telemedicine accelerated dramatically during the COVID-19 pandemic. However, the integration of telemedicine into routine health care has met challenges, dependent on the specialty, individual provider and patient preferences, and the existing infrastructure. There is still debate about how large a role telemedicine should play in delivering neuro-ophthalmic care. Two experts debate this topic. Pro—Telemedicine in Neuro-Ophthalmology Is Ready for Prime Time Kevin E. Lai, MD Yes, it is ready for routine use. Whether by fate, providence, or prescience, the organizers of the 2020 North American Neuro-Ophthalmology Society (NANOS) Annual Meeting felt it relevant and essential to present a symposium updating the NANOS membership about the use of telehealth in neuro-ophthalmology.1 Neuro-ophthalmologists such as Rosa Tang, MD, described and envisioned telehealth applications as early as 1999.2–4 A 2002 pilot study by Bremner et al5 found that conditions more reliant on clinical history, external examination, and slit-lamp examination findings were amenable to synchronous video telemedicine, but the technology at that time did not allow for adequate visualization of posterior segment details. It had been over 9 years since Bruce et al6 began reporting results from the FOTO-ED study. It had been 7 years since NANOS had highlighted this topic.7 Although the benefits and applications of telehealth were already established within neurology8 and ophthalmology9,10 for common case uses, telehealth within neuro-ophthalmology (“tele-neuro-ophthalmology” or “tele-N-O”) was still generally considered a futuristic curiosity rather than a clinical reality. Relatively few individuals had incorporated telehealth into their neuro-ophthalmology practice, and there were many concerns surrounding the infrastructure, reimbursement, medicolegal regulations, and practicality.11 Very little had been written or discussed about how neuro-ophthalmologists could adopt telehealth services, and, within the United States, synchronous telemedicine services were still limited to primary care or psychiatric patients living in health care provider shortage areas (HPSAs), with virtually no guidance for subspecialty care.12 Few asynchronous telehealth services had just gained approval for reimbursement in the United States, with narrowly defined applications.12,13 Little did we know that within a few months of planning this symposium, a novel coronavirus would emerge and impel this academic thought-experiment into the examination room. It is impossible to discuss tele-neuro-ophthalmology adoption without appreciating the contextual imprint of the SARS-CoV-2 virus and the coronavirus 2019 (COVID-19) pandemic. After all, the 2020 NANOS Annual Meeting in Amelia Island, Florida took place just days before the United States declared a national public health emergency (PHE), suspended air travel, and ordered a national lockdown of nonessential business.14 Many of us can recall that tumultuous time because heterogenous travel bans prevented some from attending the meeting at the last minute, whereas those attending practiced the “elbow bump” greetings, mask-wearing, and social distancing that became ubiquitous during that period. With the immediate expectation that in-person clinical care would be severely reduced, the tele-neuro-ophthalmology symposium pivoted its message from “is tele-neuro-ophthalmology feasible?” to “how do we implement tele-neuro-ophthalmology right now?” In the weeks that followed the 2020 NANOS Annual Meeting, the global neuro-ophthalmology community, aided by governmental expansion of telehealth support within health care systems,15 collaborated to rapidly develop and adopt telehealth services so that we could continue to provide timely care to our patients.16,17 In a survey of NANOS members by Moss et al18 conducted in June 2020 (3 months after the US PHE declaration), video telemedicine utilization by survey respondents grew from 3.9% pre-COVID to 68.2% (a 17-fold increase) within the first 3 months of the PHE declaration. Many of our colleagues published articles19–21 and videos22–24 describing and demonstrating techniques for evaluating neuro-ophthalmic conditions by synchronous telemedicine. A multicentered retrospective analysis by Moss et al comparing clinical volumes and adoption of tele-neuro-ophthalmology services during the first 3 months after the PHE declaration found a 30% reduction in unique patient visits compared with the previous year (670 in 2019, 477 in 2020), and a dramatic increase from 0% patient seen by telemedicine in 2019 to 36% in 2020.25 In a 1-year follow-up survey of NANOS conducted in June 2021, Moss et al found that 76% of respondents who were using synchronous telemedicine during the first 3 months of the PHE continued this practice 1 year later (67% during early COVID vs 51% 1 year later).26 And, despite the expiration of the PHE in 2023,27 there is still ongoing advocacy by NANOS, the American Academy of Neurology, and many other organizations to permanently encode expansive telehealth service support within the Centers for Medicare and Medicaid Services (CMS) guidelines.28 Tele-neuro-ophthalmology remains a hot topic, with updates featured at the 2021 and 2023 NANOS Annual Meetings.29,30 I remind us of these times because, broadly speaking, the question “is tele-neuro-ophthalmology ready for regular use?” has already been answered. We had to make tele-neuro-ophthalmology work for our practices during the early COVID pandemic, and even as most of us returned to the clinics, many of us continued to offer telehealth services.26 In the months and years that have followed since COVID first infested the world, studies from multiple institutions have provided us with aggregated subjective responses and objective data analysis regarding tele-neuro-ophthalmology (Table 1). These studies found that more established patients and efferent cases shifted to telemedicine evaluation during the lockdown phase of the COVID-19 PHE,25 that a store-and-forward virtual clinic model is safe and effective for the screening of papilledema,36 remote interpretation of visual field diagnostic testing was able to fully answer minimally complex clinical questions in most cases,38 and eConsults provided timely diagnostic and treatment direction for neuro-ophthalmic questions.39 TABLE 1. - Recent analyses of tele-neuro-ophthalmology Author, Publication Year Study Type Size Description Important Findings Utilization reporting and patient/provider sentiment Moss et al,18 2020 Survey 208 Reported rates of tele-neuro-ophthalmology adoption and neuro-ophthalmologists’ opinions of benefits and barriers to the use of telemedicine during the first 3 months of the COVID PHE (June 2020) 17-fold increase in video telemedicine adoption during the first 3 months of the COVID PHEPerceived benefits of telehealth: access, continuity, and patient efficiency of carePerceived barrier to telehealth: data qualityTelehealth most useful for conditions reliant on patient history, external examination, and previous recordsTelehealth not helpful for conditions requiring funduscopic examination Conway et al,31 2021 Prospective cross-sectional survey 159 patients, 157 neuro-ophthalmology visits Reported patient sentiments on synchronous video telemedicine visit preparation, satisfaction, challenges, and comfort; reported neuro-ophthalmologists’ impressions of individual elements of the evaluation 104 of 159 patients (65.4%) reported satisfaction with telemedicine visit137 of 157 visits (87%) were noted by neuro-ophthalmologists to gather sufficient information for medical decision-makingRange of eye movements (80.3%), visual acuity (74.5%), Amsler grids (58.0%), Ishihara color plates (50.3%), and pupil examination (45.9%) were among the examination elements found “surprisingly easy” to conduct by telemedicineOKN (0.0%), VOR suppression (0.6%), VOR (1.9%), smooth pursuit (21.7%), ocular alignment (21.7%), ocular oscillations (21.7%), convergence (22.3%), visual fields (29.9%), red desaturation (35.7%), and saccades (36.9%) were identified as more difficult to perform by telemedicineCited limitations to telemedicine visits included patient preparation before visits, inability to perform funduscopic examinations, pupil examination challenges, and technology/connectivity barriers Chen et al,32 2022 Retrospective cross-sectional study and survey 2,330 visits, 1,756 patients, 252 survey respondents Reported patient satisfaction of using synchronous video telemedicine for all ophthalmology specialties from March 1, 2020 to March 31, 2021; analyzed utilization of video visits over time, differences in patient satisfaction between subspecialties, identified predictors of repeat video visits, and characterized common diagnoses/problems Oculoplastic surgery (42.9%), neuro-ophthalmology (17.0%), and cornea (14.2%) had most video visit volumesNeuro-ophthalmologists had utilization of 199 visits per practitionerTele-neuro-ophthalmology utilization decreased from 197 visits (98.5 visits/practitioner) during early COVID (March 1, 2020 to June 30, 2020) to 48 visits (24 visits/practitioner) during the final 3 months of study (January 1, 2021 to March 31, 2021)19 of 57 (33.3%) neuro-ophthalmology survey responders required in-person evaluation for problems not fully addressed in video visitAll questions about patient satisfaction regarding telehealth use had positive responses (mean response between “good” and “excellent”), with higher ratings for repeat patients358 of 2,330 (15%) visits were for neuro-ophthalmology problemsMost common neuro-ophthalmology diagnoses were cranial nerve palsy/diplopia (93/358, 26%), visual disturbance (88/358, 25%), and migraine/headache (29/358, 8%) Al Owaifeer et al,33 2022 Survey 71 Reported opinions of general ophthalmologists and ophthalmology subspecialists regarding their experience with telemedicine during COVID-19 56.3% were satisfied with using telehealth (most respondents were age 40 years or younger)Respondents were generally satisfied with communication and rapport but concerned about patient privacyRespondents agreed that telehealth provides desirable results in patient management but had on diagnostic were satisfied with the of service provided by telehealth but did not as for using telehealth for follow-up visits Moss et al,18 2023 Survey survey of NANOS members 1 year after COVID PHE to continued utilization of telemedicine, to and sentiments regarding tele-neuro-ophthalmology video visit utilization was pre-COVID among increased to during early COVID but decreased to 1 year of video telemedicine increased from pre-COVID to early 1 year later visit utilization was higher in neuro-ophthalmologists than respondents in all respondents to continue using video of video telemedicine most included increased to care of care and patient efficiency barriers for video visits were limitations in and of data patient technology barriers and of and of remote and eConsults grew after COVID but not as dramatically as video to continue perform remote sentiments for and visits were not that there was in telehealth barriers would et 2020 Prospective and diagnoses of the first patients emergency ophthalmology during COVID-19 lockdown (March 2020 to 2020) in and reported time to rates to in-person and rates of and care emergency telehealth of of all of those to in-person of patients for neuro-ophthalmology evaluation were by telehealth before in-person patient did not as a of et 2020 Retrospective Description and analysis of telehealth in the of and neuro-ophthalmology at a eye care from 2020 to were from whereas cranial nerve were included age 7 years 1 to of store-and-forward of of were with cranial nerve 7 of were of were of were of were surgery of were to or that telehealth services could as a et 2020 Retrospective virtual evaluation of patients to a between and 2019 in those clinical information and diagnostic testing was by neuro-ophthalmologists to the of the with the or in-person evaluation of had and were by the neuro-ophthalmologists to a of were most of these cases were on virtual by the neuro-ophthalmologists and of did not have nerve but reported at the visit and found a requiring that a telehealth model for could be a safe and effective for neuro-ophthalmology Moss et 2021 Retrospective visits, patients Description of vs tele-neuro-ophthalmology visits during the first 3 months of COVID-19 PHE (March 2020 to June 2020) with to in 2019 in 3 practices in the United States There was a in all neuro-ophthalmology visits during early COVID compared with the previous in telemedicine adoption in 2019 to in patient during early COVID established in 2019, established in visits were more to be for established patients and efferent compared with visits et 2022 Retrospective Description of telemedicine utilization within a care academic medical ophthalmology from March 2020 to June 2020 of telemedicine visits were within the neuro-ophthalmology in-person visits in neuro-ophthalmology decreased from in 2019 to during early COVID et 2022 Retrospective of remote interpretation of visual fields with of visual color previous visual and at a care academic neuro-ophthalmology clinic years before COVID described and of visual field interpretation with and were most for remote visual field interpretation were for of had visual fields as of (87%) of had visual fields with of of visual fields were with 25%), or had that remote visual field interpretation is and effective for clinical questions et Retrospective patients of eConsults for neuro-ophthalmic conditions at a care from to described of eConsults able to management of eConsults in-person and of on patient care time from to was questions were field and had sufficient data at the time of for the to provide a management without testing in-person neuro-ophthalmology diagnostic provided diagnostic treatment (15%) treatment and had that eConsults with and to neuro-ophthalmic care direction to and sentiments on tele-neuro-ophthalmology have been Conway et reported in a 2021 survey of patients and using telemedicine for neuro-ophthalmic that most patients were satisfied with their visit (65.4%) and questions whereas neuro-ophthalmologists reported adequate data in more than of the Conway et al reported that the neuro-ophthalmologists found that visual acuity of and of eye movements of were to whereas ocular oscillations (21.7%), ocular alignment (21.7%), smooth pursuit (21.7%), and visual fields of were among the examination elements that were not to the early COVID neuro-ophthalmologists felt that for conditions more reliant on clinical history, diagnostic and external evaluation were more amenable to synchronous year into the neuro-ophthalmologists increased patient care of 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