Distancing? But still I-care: Tele-ophthalmology during COVID-19 era

The COVID-19 pandemic has been a major blow to the healthcare sector worldwide. While all focus shifted to the management of the pandemic, patients with non-COVID-19 diseases suffer due to lack of health access. In search of practical solutions to this unique challenge, we have turned to teleconsultation, a hitherto under-utilized concept. Previously reserved for underserved areas, tele-health has become mainstream now because the pandemic has left a vast majority of people remote and underserved.[1] Cheap, accessible, fast internet connectivity, and improved tele-conferencing technology with ease of transferring documents and images, have made it a feasible interim option to connect patients with their physicians. The Telemedicine Practice Guidelines released by Ministry of Health and Family Welfare in March 2020 provides clarity to its application in India.[2] However, the Guidelines need to have further safeguards to insulate the providing doctor from unnecessary harassment. The doctors do everything in good faith but the perception of the legal system may not be the same. Though still in its nascent stages, telemedicine effectively minimizes barriers to healthcare accessibility. It helps the healthcare provider triage acute problems, follow-up chronic conditions, re-schedule appointments and procedures, re-assess treatment plans, prescribe medications, and provide reassurance.[13] It helps both patients and healthcare workers decrease their risk of exposure in the setting of the COVID-19 pandemic, while also cutting down healthcare expenditure. As pediatric ophthalmologists, it is important for us to decide which patients will benefit from virtual examination by teleconferencing. Sub-specialties like strabismus, oculoplasty, and lot of pediatric ophthalmology may benefit more since much of the examination can be performed externally. Besides evaluation of adnexa, corneal reflexes and pupil, the ophthalmologist can assess patients' near and distance visual acuity, refractive errors, ocular deviation, extraocular movements, and stereopsis through the use of mobile phone/tablet based applications like Eye handbook, 9-gaze, and Eye Test Charts, some of which also have pediatric fixation targets and pen lights essential for examining young children. Children are often more comfortable in the familiar setting of their homes and are cooperative for examination. Diagnosis of common eye problems like stye, chalazion, ptosis, squint, conjunctivitis, and follow-up of operated cases can be done through video consults. Unnecessary hospital visits can be avoided if patient education, for example, explaining Criggler's massage or patching for amblyopia can be done through virtual media. However, detailed anterior segment pathology is more difficult to address via tele-health since slit-lamp, gonioscope, and tonometers are integral part of anterior segment examination, unless the pathology is grossly obvious on external evaluation. Even the assessment of intraocular pressure is a hurdle. Due to the inability to perform posterior segment examination, the scope of tele-consultation in the diagnosis and management of retinal and optic nerve disorders is also limited. Moreover, it should be avoided in the management of emergency cases when alternative in-person care is available– its use should be limited to advising first-aid and triaging only.[13] Some patients, especially elderly may not be satisfied with tele-consultation because of the demand for technical knowledge[4] and the lack of physical presence of the doctor. Many clinical signs may be missed during virtual evaluation and no mobile application can be as accurate as in-office testing. Wherever possible it may be supplemented by a trained healthcare provider in the vicinity of the patient. It is important to understand that all professional and ethical standards apply to tele-consultations as for in-person care. Patient consent should be sought before starting a tele-consultation and patient should be explained about the risks of incomplete examination. The lack of communication or misunderstanding should be understood and soon be followed up by a trained healthcare provider in the proximity, whenever desired by the doctor at distance. The onus of any problem arising due to lack of compliance of these should be more on the care seeker rather than the provider. Also, the current guidelines do not allow us to provide consultations outside the jurisdiction of India.[2] However, there are certain concerns we would like to share keeping in mind our country with the legal system that we have! We need to have more safeguards for the distance care giver. The issues of liability and negligence; referrals for emergency services; maintenance of medical records; privacy and security of the patient records and exchange of information; prescribing; The onus of establishing a liability or misconduct needs to be on the patient or the seeking party and not that the provider is left to defend himself against the allegations. This is especially regarding the perception of treating an emergency and the reimbursement of fee for the services. Recently an ugly scene had erupted in Punjab regarding the latter, the doctor was given bad publicity and subjected to harassment, for nothing wrong on his part. Lack of valuation of tele-consultations is there in our country, where many people still get baulked by the idea of paying for the advice on a piece of paper! More so for tele-consults! This is a ready recipe for the mischievous media of exploiting the vulnerable doctors. In reality, there has to be sensitization and education of the society for the services provided by the doctor, which may appear simple and trivial but has been a distillation of years of toils and tribulations by the medical fraternity. On a lighter note, it may reduce the incidents of physical abuse of the care giver by violent mobs! Similarly the timing of providing such services should be as per the discretion of the provider. Regarding emergencies, the seeker may not be aware of the critical nature of work the provider may be involved at that time. We hope that the system will shape up better as doctors and patients become more tech-savvy. As we slowly limp back to “normalcy,” we believe that tele-ophthalmology can be used to ease patient load and reduce unnecessary hospital visits even in the post-COVID-19 times, but it can never substitute good clinical examination. Moreover the issue of valuation and monetization of the services and the issue of liability of the advice or treatment due to miscommunication or misunderstanding is a major challenge for all of us to solve. About the author Prof. Pradeep Sharma Prof. Pradeep Sharma is the Professor and Head of Section of Pediatric Ophthalmology, Strabismus and Neuro-Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Prof. Sharma completed his medical and specialty training - MBBS (1979) and MD (1982) from the All India Institute of Medical Sciences. He attained advanced subspecialty fellowship training in Strabismus at UCLA, Los Angeles, USA, Wills Eye Institute, Philadelphia, USA and Richmond Eye Institute, Richmond, USA, awarded by the International Strabismological Association (2001). He is the Fellow of National Academy of Medical Sciences and was the first Asian to deliver the prestigious Knapp Lecture at the American Association for Pediatric Ophthalmology and Strabismus, AAPOS at Vancouver 2016. Other awards to his credit include Col Rangachari Gold Medal (1984) and Dr Athavle Award (2002) of AIOS, iFocus Golden Apple in 2019, and named orations at several State Ophthalmological Societies. He is the visiting faculty and surgeon with Orbis International. His rich academic accomplishments include over 200 scientific publications and two books - Strabismus Simplified and Essentials of Ophthalmology. Prof. Sharma is an excellent teacher and a mentor and is elegantly balanced in work and life.

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