Managing Dry Eye and Ocular Allergy Using Telemedicine

The current pandemic has forced clinics to kick their telemedicine services into high gear. What were once experimental rollouts reserved for rural mission trips and the like are now helping keep ophthalmic practices afloat. Eye clinics, particularly those with a surgical focus, have been among the most affected as rates of elective procedures, such as cataract removals, have declined sharply since the first lockdowns in March 2020.¹ In fact, ophthalmology was the hardest hit of any medical specialty in the early days of the pandemic, with an estimated 81% drop in revenue, according to a February 2021 article in Ophthalmology.² But since social distancing measures were put into place, many ophthalmology patients still required routine and follow-up care for chronic, anterior segment issues, such as dry eye disease (DED), ocular allergies, “pink eye,” and allergic conjunctivitis. In fact, some research suggests that the extended time spent indoors due to quarantining may have actually increased exposure to some allergens (such as dust mites), although other research shows it has reduced exposure to others, such as pollution.^3,4 

Telemedicine (also known as telehealth and remote visits) helped those patients receive care, with the Centers for Medicare and Medicaid Services relaxing regulations around it, allowing for the same reimbursement rates for telehealth as in-person visits.⁵ The use of telehealth services in ophthalmology was highest between April 2020 and November 2020, when it represented 17% of all ophthalmology encounters.⁶ And the most telemedicine visits by eye condition were for corneal and external disease diagnoses.² 

These new tech options, jump-started by tough circumstances, have given ophthalmologists and optometrists the ability to assist these patients remotely. As the viral threat continues, some clinicians have honed the technology in ways that are changing how they manage DED and ocular surface disease patients now — and likely will well into the future, even beyond this pandemic era. 

Here, we look at ways clinics in the United States have used telemedicine to reach these patients, and how it can become a part of everyday practice. 

Diagnosing With Telehealth

Just how much chronic DED and ocular allergy can be managed via telemedicine? According to a study published in The Ocular Surface, quite a bit.⁷ In the article, researchers outlined a framework for telemedicine in DED that first employs a “teleconsultation,” where a “patient initiates contact via teleconsultation platforms.” The next step is “telemonitoring,” when a “patient [was] previously diagnosed and started on treatment by the specialist.” Finally, it discussed “telecollaboration,” where healthcare professionals work together in an online system to deliver care. 

“Teleophthalmology platforms for DED are necessary in a modern healthcare system,” according to that research team. “Given the relatively limited number of specialists, an increasing patient load, and a need to maintain safe distancing in this COVID-19 pandemic, this may be the only option to deliver quality healthcare.”

Take diagnosis, for example. For Susan Watson, MD, an ophthalmologist who specializes in ocular surface disease at her Raleigh, North Carolina-based Watson Dry Eye Center, telemedicine has changed her process. Since COVID-19 struck, all of her new DED patients are now seen in a 45-minute telemedicine visit — a sharp contrast to her former rushed visits before the pandemic hit, when she might have had less time to spend with patients in the office. People seek her out when other DED options have failed, so she often treats more complex cases. Telehealth visits give them new options to see her, from the comfort of their own homes.

To start the first telehealth visit process, her staff sends new patients intake paperwork, including the Dry Eye Questionnaire (DEQ-5), a validated screening questionnaire recommended by the landmark TFOS DEWS II Report.^8,9 Patients are asked to submit photos of their eyes and any products they might use for DED already. Then, when the initial telehealth visit occurs, Dr. Watson has her technician assist patients in setting up the technology, walking them through how to use the virtual “waiting room” for the visit. When she enters the real exam room, which is presently being used exclusively for telehealth visits, Dr. Watson can remove her mask to let patients see her face, and starts the visit. 

As the TFOS DEWS II report outlines, the best clinical approach to DED is to use triaging questions and risk-factor analysis as part of a traditional patient history and perform a detailed anterior eye examination and differential diagnosis based on the responses. Dr. Watson does just this with her telehealth visits for new patients, going over their DEQ-5 responses and taking a full “story” of that person’s DED journey. As Dr. Watson listens to the patient’s history, she observes their full facial expressions through the screen, and how they blink. She can also see their living area and circumstances, including if, say, a cat walks across their computer keyboard — information which can help her later if they have ocular allergy or allergic conjunctivitis issues. 

“They don’t have to have a mask on, so we can learn so much about them and their story, yet still satisfy the DEWS II diagnostic criteria for dry eye disease,” she explains. 

Remote Testing 

Once she suspects DED, she moves on to the next stage, which the DEWS outlines as determining: 1) tear break-up time (non-invasive methods preferred), 2) tear film osmolarity, or 3) ocular surface staining (that includes the cornea, conjunctiva and lid margin) with fluorescein and lissamine green.⁹ Since tear film osmolarity determination and ocular surface staining cannot be conducted until a patient’s in-office follow-up appointment (a visit that happens in all of her cases), those are performed in person. She also points out that not all 3 exams must be completed to reach a DED diagnosis, according to the report. But she can do tear break-up time via telemedicine — here’s how:

“We’ll say [to the patient] ‘Okay, we’re going to do a little test here, we’re going to have you close your eyes, feel your eyelid margins together. Open up. We’re going to ask you to do that same thing again. And when we ask you to open up your eyes, we want you to stare at the camera.’ So at this point, we’ve had them take their glasses off [if they wear them] and get a little closer to the camera. So they close the second time, they open and then we count stare 1, stare 2, stare 3, and then we can see them blink. And then we ask them, what did you feel?” 

Normal tear breakup time is between 15 and 20 seconds, she points out. If she sees the patient blink in 5 seconds, or 6 seconds, for instance, she can make a DED diagnosis based on the questionnaire, history, and tear break-up time.

“We’re ready to start treating almost even before we start to do the in-office diagnostic tests,” she explains. “That’s the way the disease is. It’s a perfect telemedicine disease.”. 

Follow-Up Care 

For both diagnoses and follow-up care, a “hybrid” telehealth model can be helpful, according to Anat Galor, MD, MSPH, who specializes in cataract and refractive disease, cornea and external disease, and uveitis care at the University of Miami Health System. She’s also a clinical spokesperson for the American Academy of Ophthalmology (AAO). 

The hybrid visit she describes requires patients to present in person for  Schirmer’s tests, corneal staining, and other exams that cannot be done remotely. Patients then receive follow-up consultation via telehealth to track their response to therapy and to change treatment plans if necessary. Hybrid visits can reduce the time patients spend in-person in the waiting room (especially in more challenging cases), as well as allow those who need to travel long distances or who are without access to transportation to reach her and maintain continuity of care. 

“I think we’re not only providing better care to our existing patients, but we’re also able to have new patients who wouldn’t have necessarily had access, now have access to services,” Dr. Galor says.

Beware of Masqueraders

Ocular allergies and conjunctivitis can be caused by many factors, so taking a full history is important for diagnosis and ultimately, treatment, Dr. Watson says. But that conversation isn’t the limit of what can be evaluated using telehealth platforms. You can also see presentations such as swollen lids and redness, she explains. Patients with allergic complaints should be seen in the office as soon as possible for further examination and testing that cannot be done through a screen.

First, it is important to note that there are no real DED emergencies, Dr. Galor says. However, some eye problems can masquerade as DED and need to be seen right away, she says, to rule out potential issues such as infection. Signs and symptoms that constitute eye emergencies include, but are not limited to, eye pain, redness, and changes in vision.¹⁰  

Ocular allergies and ocular conjunctivitis are a little different from DED care in that they often present during a flare-up, Dr. Galor points out, so signs can include red eyes and tearing. “Our general philosophy is red eyes, tearing, we generally like to see those patients in-person to make sure that there’s not a visually threatening complication or condition,” she says. That’s especially the case with new patients. If you’re concerned about allergy and patients have redness and discharge, “that’s really something that should be seen. Maybe the follow-up can be managed by telehealth, but certainly not as a primary visit.”

An exception? If the person is already a patient in her practice and has well-established seasonal conjunctivitis, because that’s generally not associated with vision loss, their treatment and care can be usually be followed via telehealth.

Implementation Tips

If you’re not already doing a lot of telehealth visits for the right DED and ocular allergies cases, this is a good time to start, Dr. Galor says. 

“I think we should all not just fall back to our old routines, but think about how we can optimize delivery of care,” she says. “I would get started by setting up the infrastructure to provide telehealth now, and work with your staff to figure out which patient is most amenable, which patients are most interested.” 

Clinicians may wonder how to get started incorporating a telehealth protocol into their daily practice. While the precise technology implemented will guide some of that, a practice consultant can also offer some advice, particularly with regards to billing and coding issues. But some aspects of the setup are entirely in the clinicians’ hands. Consider these 3 key questions when setting up telehealth services:

1. When are you going to schedule them? Do you want to dedicate whole days exclusive to telemedicine visits, or work them into your daily schedule, along with in-person visits? 
2. Who is going to be in charge of communicating with the patient and troubleshooting? Consider dedicating a member of your staff to preparing patients for telehealth visits, and acting as a coordinator who runs the visits, troubleshoots any technical problems, and schedules any follow-up, virtual or in-person, as necessary.

3. What technology do you want to use? Look into the options available, and decide which telehealth platform you’re most comfortable with.

Physician, Manage Thy Own Expectations

Telehealth can be a great option in many areas of medicine, explains Tanvi M. Shah, MD, a general ophthalmologist at the Eye Center at GBMC Healthcare in Towson, Maryland. But they can prove challenging for some ophthalmology subspecialties. For doctors who treat the posterior segment — fundus imaging, anti-VEGF injections, and other posterior segment exams and treatments cannot yet be performed over a screen. In DED, this extends to not only those exams and tests, such as Schirmer’s testing, that must be conducted in-person, but also some treatment options, such as placing punctal plugs or using intense pulsed light treatments.

“There is only so much that telemedicine can give us, and it gives us a lot, but it doesn’t give us all of what we need,” she advises.

As this technology becomes standard practice, the addition of things like translation services in real-time and formal vision testing could help enhance the telehealth experience for all, Dr. Galor says. 

For herself and her patients, Dr. Watson hopes to continue reaping the telemedicine benefits of more time and greater access to her patients into the future. “I’ll never go back,” she says, “especially for what I do.”

References

1. StrataSphere. The 2021 National Patient and Procedure Volume Tracker. Published online February 8, 2021.
2. Portney D, Zhu Z, Chen E, BS. COVID-19 and utilization of teleophthalmology: trends and diagnoses (CUT Group). Ophthalmol. Published online February 10, 2021. doi:10.1016/j.ophtha.2021.02.010
3. Gelardi M, Trecca E, Fortunato F, et al. COVID‐19: When dust mites and lockdown create the perfect storm. Laryngoscope Investig Otolaryngol. 2020;5(5):788-790. 
4. Gallo O, Bruno C, Orlando P, Locatello L. The impact of lockdown on allergic rhinitis: What is good and what is bad? Laryngoscope Investig Otolaryngol. 2020;5(5):807-808.
5. U.S. Centers for Medicare & Medicaid Services. Medicare telemedicine health care provider fact sheet. CMS Newsroom. Published online May 17, 2020.
6. Starr M, Israilevich R, Zhitnitsky M, et al. Practice patterns and responsiveness to simulated common ocular complaints among us ophthalmology centers during the COVID-19 pandemic. JAMA Ophthalmol. 2020;138(9):981-988. doi:10.1001/jamaophthalmol.2020.3237
7. Nga S, Ong HS, Tong L. A practical framework for telemedicine in dry eye disease. Ocul Surf. 2020; S1542-0124(20)30165-8. doi: 10.1016/j.jtos.2020.10.007. Online ahead of print.
8. Chalmers R, Begley C, Caffery B. Validation of the 5-item dry eye questionnaire (DEQ-5): discrimination across self-assessed severity and aqueous tear deficient dry eye diagnoses. Cont Lens Anterior Eye. 2010;33(2):55-60. doi:10.1016/j.clae.2009.12.010
9. Wolffsohn J, Arita R, Chalmer R, et al. TFOS DEWS II diagnostic methodology report. Ocul Surf. 2017;15(3):539-574. doi:10.1016/j.jtos.2017.05.001.
10. Mukamal R. Eye Care During the Coronavirus Pandemic (COVID-19). American Academy of Ophthalmology. Published online January 6, 2021.