Preparing for a New Landscape
How we will deal with the pandemic of neglected chronic eye disease following the COVID-19 lockdown
Hindsight is a cruel judge. When reflecting on the COVID-19 pandemic, a singular emphasis on infection and associated death rates provides an incomplete picture of the health, well-being and socio-economic impact this disease will have on populations globally. Inevitably, severe cutbacks in everyday medical care have led to disruption in provision for diseases that are the most frequent causes of morbidity and mortality outside a pandemic. Undersupply of care is also observed for many chronic diseases that do not lead directly to death, but to increased complications, more severe courses, a reduction in quality of life, and more complex and risky treatments.
In ophthalmology, the undersupply is particularly visible. During the pandemic, within only three months, we observed a 79 percent reduction in ophthalmic appointments in the UK – the most of any medical specialty (1). Disruptions in care for common chronic conditions, such as AMD or diabetic retinopathy (DR) that – if left untreated – can lead to irreversible vision loss and blindness, are particularly severe given that this patient population is at a high risk of serious illness from SARS-CoV-2.
Care structures are poorly prepared for the unprecedented challenges of a pandemic. In many places, new health delivery models have been launched under great time pressure and difficult conditions to offer at least minimal care. The focus of these initiatives was always on bringing medical care to the patient (and not, as usually the case, bringing the patient to the care center).
Although a large number of concepts were proposed and, in some cases, already implemented before the pandemic, digital health approaches, such as telemedicine, virtual clinics and home monitoring, are still a shadowy existence in the care landscape. These approaches have great potential to improve access to medical care and efficiency of care pathways even outside of pandemics.
Several organizational and political steps are necessary to effectively introduce these innovations into care. At the center of these activities is the involvement of non-medical specialists, such as opticians, optometrists, and medical-technical practice assistants, who can provide delegated services. Consequently, there is a need for more interdisciplinary and transdisciplinary collaboration. Robust evidence from implementation science will be essential to demonstrate the safety, efficiency and sustainability of such care pathway transformations. High-quality evidence generation is a time-consuming process, so such initiatives have to be launched quickly. The pressing need for minimizing vision loss during the pandemic justifies the rapid deployment of innovative care pathways on a pilot basis, providing preliminary evidence of their potential.
Shifting the provision of care for chronic eye diseases, such as AMD, DR and glaucoma, to non-medical practitioners requires training and direct access to professional input from hospital-based medical experts (2). Evidence already exists that shared care by hospital-based optometrists and specialist eye nurses to monitor chronic eye disease may be equivalent to ophthalmic care in certain circumstances (3). Telemedicine allows patients to be triaged remotely, reducing unnecessary and costly hospital visits, and optimizing access to medical care. It also enables referrals to be made by remote verification of the imaging performed close to the patient (for example, at the local optician or optometrist) by hospital-based experts. The technical requirements for this type of care already exist and have been implemented on a small scale in pilot projects (4, 5, 6, 7). Evidence from robust prospective validation research will guide meaningful implementation of such pathways at scale, and a small number of such initiatives are already underway (8).
Not unlike the search for a vaccine against SARS-CoV-2, further investment and prioritization of research in digitally-enabled eye care by national funders is needed to quickly and successfully redesign our services for the post-pandemic reality. In a further step, the time-consuming image evaluation by clinical experts can be partially replaced by AI-supported decision aids for the triage of referrals. Studies in this context have shown that automated classification of OCT scans and fundus images with new algorithms is equivalent to expert assessment for AMD and DR screening, but further validation and system-level transformation analysis of pathways will be needed to embed these tools in real-life care pathways (8, 9, 10, 11).
In the aftermath of the pandemic, collaborative care between community optometry and hospital-based eye services will be crucial when it comes to absorbing the expected capacity pressures – and telemedicine technologies can enable this link. During a pandemic, home monitoring of vision could provide the only remaining option for surveilling vision of vulnerable patients with AMD and DR who are self-isolating or cannot access hospital and community-based eye care. Two FDA-approved applications (mVT of Genentec and Alleye of Oculocare medical) are currently on the market to home-monitor visual functions of patients remotely, and recently, Notal Vision announced a home-monitoring OCT device (12, 13, 14).
Thanks to both technological innovations and miniaturization of examination equipment, completely new forms of ophthalmic care are now possible. The well-planned interplay of telemedicine, decentralized diagnostics, algorithmic processing of image data, and the automated triage of the patient group that requires prompt consultation and treatment makes it possible to transform eye care provision. This possibility, however, meets regulatory or organizational hurdles in many places, and often lacks robust evidence from validation and implementation science.
An important lesson we can learn from the SARS-CoV-2 pandemic is this: it is worth being prepared. The consequences of late intervention lead to suffering and patient harm that could be avoided with good planning. Now is the time to act – both by piloting new care pathways to minimize the impact of the pandemic on preventable vision loss; and by prioritizing research that will provide the evidence on efficiency and sustainability of an entirely new eye care landscape – probably bearing little resemblance to everything we knew as “standard care” just a few months ago.
- A Mehrotra et al., The Commonwealth Fund, “What impact has COVID-19 had on outpatient visits?” (2020). Available at: bit.ly/3gKKch2.
- K Balaskas, ISRCTN Registry, “Community care for neovascular age-related macular degeneration” (2019). Available at: bit.ly/3gJLyss.
- H Baker et al., “Effectiveness of UK optometric enhanced eye care services: a realist review of the literature”, Ophthalmic Physiol Opt, 36, 545 (2016). PMID: 27580754.
- C Kern et al., “Implementation of a cloud-based referral platform in ophthalmology: making telemedicine services a reality in eye care”, Br J Ophthalmol, 104, 312 (2020). PMID: 31320383.
- Opera, “Seamless referrals from optometrists”. Available at: bit.ly/3gCbVRf.
- Big Picture, “Empowering clinicians to change the delivery of healthcare. Completely”. Available at: bit.ly/2XlOOm5.
- ATA, “Ocular Telehealth” (2020). Available at: https://bit.ly/2TXSgBy.
- K Balaskas et al., NIHR, “Tele-opHthalmology-enablEd and ARtificial Intelligence-ready referral pathway for coMmunity optomEtry referralS of retinal disease: the HERMES study – a Cluster Randomised Superiority Trial with a linked Observational Diagnostic Accuracy Study” (2020). Available at: bit.ly/2zRe4rt.
- J De Fauw et al., “Clinically applicable deep learning for diagnosis and referral in retinal disease”. Nat Med, 24, 1342 (2018). PMID: 30104768.
- MD Abràmoff et al., “Pivotal trial of an autonomous AI-based diagnostic system for detection of diabetic retinopathy in primary care offices”, NPJ Digit Med, 1 (2018). PMID: 31304320.
- WD Heaven, MIT Technology Review, “Google’s medical AI was super accurate in a lab. Real life was a different story” (2020). Available at: https://bit.ly/2XnBHkA.
- YZ Wang et al., “Handheld shape discrimination hyperacuity test on a mobile device for remote monitoring of visual function in maculopathy”, Invest Ophthalmol Vis Sci, 54, 5497 (2013). PMID: 23860761.
- MK Schmid et al., “Reliability and diagnostic performance of a novel mobile app for hyperacuity self-monitoring in patients with age-related macular degeneration”, Eye, 33, 1584 (2019). PMID: 31043690.
- Notal Vision, “Notal Vision Announces FDA Grants Breakthrough Device Designation for Pioneering Patient-Operated Home Optical Coherence Tomography (OCT) System” (2018). Available at: bit.ly/2ZWLHTD.
Research Fellow, Moorfields Eye Hospital, London
Dawn Sim is a Consultant Ophthalmologist at Moorfields Eye Hospital, and Institute of Ophthalmology, University College London, United Kingdom, and Global Medical Lead of Big Picture Eye Health.
A specialist in in applied clinical imaging research, Pearse has a particular interest in optical coherence tomography. Now a consultant at Moorfields Eye Hospital, he previously carried out OCT research with some of the original inventors of the technology at the Doheny Eye Institute. As the first UK ophthalmologist to receive a Clinician Scientist Award from the National Institute of Health Research, his current work focuses on exploring the potential of new technologies and innovations in the treatment of visual impairment and blindness.
Consultant Ophthalmologist at Moorfields Eye Hospital, London, specialising in Medical Retina, and an Associate Professor at the UCL Institute of ophthalmology. Dr Balaskas is Director of the Morefields Ophthalmic Reading Centre & Clinical Artificial Intelligence Lab (MORC-AI), a research centre specialising in Ophthalmic Imaging, Digital Medicine and Artificial Intelligence.
Founder, Medignition Inc., Zurich, Switzerland