Conversations about COVID-19 For Eye Care Professionals

Telehealth: Practical Tips for Practicing Eye Doctors

Presenting sponsor

April 21, 2020

Practical TelehealthJason Brenner MDApril 21st 2020

I HAVE NO FINANCIAL DISCLOSURESRELATED TO THIS TALK

Part 1:Home Testing and Exam

Part 2:Case Examples

Part 3:The Future

Part 4:Tips for the Technically Challenged

AGENDA

PART 1: Home Testing

Checking Vision at Home

Printable Snellen Driver’s License Newspaper

Smart OptometryEyechart EyeCuity

Optic Neuropathy

ColorTest

Visual Field

Virtual Visual Field

Amsler Grid

• 20/40 vs 20/200 vs CF

• Large Field Cut

• Central Distortion

What Really Matters?

PART 2: Case Examples

Case Example: Red Eye

“I’m 75 and my right eye has been getting a little more red and blurry over the last week.

There is mild irritation and my wife says there is a spot on my eye”

DxD:Staph Marginal

PingueculitisCorneal UlcerForeign Body

Case Example: Red Eye

“No Contacts. I have had shingles in the right eye. I have been stressed about obtaining

PPE for a SNF that I serve on the board for.”

“Do you wear contact lenses? Do you recall getting something in your eye?

Have you had this before?”

“My vision with the eye chart you sent me was 20/70”

“Can you send me a photo of your eye?”

Cell Phone Camera

Slit Lamp Photo

“I think I need to take a better look in the clinic.”

Slit Lamp Camera

Neurtrophic Herpetic Ulcer +/- Superinfection

• Valacyclovir 1 Gram PO TID• Doxycycline 100 mg Daily• Moxifloxacin (PF) Q2H• PF AT Q2H• BCL• Collagen Plug RLL

This morning he was 20/40 and with a 0.5 mm epi defect

CASE Example: Glaucoma

• “Doc, I went to the pharmacy yesterday and they gave me a different drop instead of my Travatan. They said my insurance won’t cover Travatan anymore. Is this OK?

• “Well it depends, show me the new drop as well as every other bottle you have.”

Case Example: Post-op

“Hi Dr. Brenner. If you remember you did my cataract surgery about 2 months ago. Things

were pretty good but they my vision has gotten a little blurry and foggy in the last

week.”

DxD:Refractive Error

PCOCMEIritisRD

Case Example: Red Eye

“No, just blurry.”“Do you have any pain, light sensitivity, flashes or floaters?”

“Yes it seems to be the same with or without glasses. I can see the

most of the newspaper with reading glasses.”

“Is the vision blurry even with glasses and at every range? Can

you read the newspaper?”

Case Example: Post-Op

“Yes, let me go get them.”“OK. This is most likely late swelling in the back of the eye called CME. It responds very well to the same drops you used after surgery. Do you

still have them? Can you show them to me?”

“OK sounds good.”

“Great, lets use them 4 times per day for 1 month and then we will

reassess.”

Triage Tips• Va 20/40, 20/200, CF

• # Days of Symptoms = # Days to be Seen

• Risk of Vision Loss vs Risk of COVID• OK to empirically treat - Example CME• Especially the elderly

• Don’t be afraid to refer without seeing patient

• Now is not the time to be a stickler about refills

• Now is not the time to be a steward of judicious antibiotic use

• The diagnosis is usually in the HPI!Lancet, 3/30/2020

PART 3: The Future of Telehealth

.

Shifting Medicine out of the Clinic

Diabetic Screening• Testing Only Visits• Home IOP monitoring

• IOL

• SCL• Technician Check in on

Compliance

GlaucomaPre and Postoperative Visits• LASIK Consults• Cataract Consultations• 6 Week – 3 Month LPO• Cataract 1 week and 3

months• Blepharoplasty Post-op

Dry Eye and Blepharitis F/U• Post Lipiflow/Tearcare• After starting

Restasis/Xiidra

Globe Chek

• Visual Acuity• Refraction• IOP• OCT• Anterior and Posterior Photography

• Automated Slit Lamps are being developed to allow technicians to photograph.

• We are currently working with an MIT group on a 3D slit lamp camera that can be streamed in real time

3D Camera Technology

PART 4: Tips for the Technically Challenged

• Make sure content/apps are compatible on various platforms (Apple, Windows, Android)

• Cloud based is almost always easier (rather than downloading an app)

• Make GIFs for your patientwww.screentogif.com

• Avoid apps that need registration(HIPPA limiting)

• Ask patients to test before call

• Many devices require ”permission” to use camera and microphone

Zoolander: “The files are in the computer.”

Questions? Email me at:

Jason.Brenner@BostonLaser.com

TELEHEALTH: PRACTICAL TIPSCONTACT LENS EVALUATIONS

Anita Gulmiri, OD, FAAO

Determining EligibilityTelehealth During COVID-19

Ideal patients for contact lens evaluations– Established patients

• Last comprehensive exam date within 1 year– Compliance– Refractive Stability

Contact lens evaluations– Contact lens follow up– Contact lens renewals– Triage contact lens wearers

Pre-Visit Considerations• Provide clear

and concise instructions on platform use

Credit

Pre-Visit Considerations• Contact lens Questionnaire

• Visual acuity measurement

Pre-Visit Considerations

Tips:Photo & Video

VS.

Photos

Communicating with your Patient• HIPAA Compliant messenger• 1135-Waiver

– HIPAA compliant platform waived (through June 18,2020)

Patient ViewProvider View

Soft CL Evaluation

Soft CL Evaluation

Soft CL Evaluation

Soft CL Evaluation

Soft Toric CL Evaluation

Soft Toric CL Evaluation

Soft Toric CL Evaluation

Video: Soft Toric CL Evaluation

3-mo LASIK Post-OP

3-mo LASIK Post-OP

Scleral Lens Evaluation

Future Applications• On-call/Triage• Hybrid system

In-office care + adjunct/supplemental telehealth– Contact lens checks

– Compliance check

– Visual acuity monitoring• OrthoK VA check

– Peer-to-Peer Consults• Demonstration:https://vimeo.com/321528139

TIPS FOR IMPLEMENTING VISION THERAPY THROUGH TELEMEDICINEGayathri Srinivasan OD, MS, FAAOAssociate Professor of OptometryAttending Optometrist, NECO Center for Eye Care

FINANCIAL DISCLOSURES:• None

ACKNOWLEDGEMENTS:• Tim Bossie OD• Sari Schwartz OD• Sarah Miller OD• Office staff at NECO CEC• Gary Chu OD

Our Goal for Vision Therapy

• Provide continuity of care for those receiving vision therapy services prior to the clinic closure

Tips for implementation• Identifying patients

• Pre-appointment preparation

• Go with the flow

• Post-care follow-up

Identifying Patients• Review schedules to identify suitability of service

– Ex: Existing vision therapy patients vs existing patients with no prior in-office vision therapy

• At NECO CEC:– Phone consults– Telehealth– We are not providing:

• New evaluations• Follow up care• New vision therapy

Identifying Patients

• Conversation with the patient about:– The nature of service– Insurance/billing concerns– Consent/email release– Online platform for telehealth– Setting up patients on the platform

Pre-appointment Preparation• Chart review

• Compulink Remote Access • Chrome Remote Desktop

• Visual acuity• In-built VA tester through online platform• Printed paper charts (mail ahead)• Other applications are coming out

Go with the flow• Wifi capabilities• Smartphone or tablet with built-in camera

• Patient age– Adults– Children

• Duration of the session– 30-45 minutes

Go with the flow• During the session

• Activities with the patient’s existing equipment– Identifying ways to modify

• Activities with new equipment– Binovi™, Emergent VT, Neurovisual Trainer, Home Therapy

Systems 2(HTS 2), Bernell– Anti-suppression reading bars from Chrome web store

Emergentvt.com Binovi™ kit from bernell.com

Post-appointment follow up• Home therapy sheet

– Email to patients/Upload to patient portal– Documentation in online platform portal– Documentation in EMR

Helpful Resources• The visionhelp blog

• Facebook Remote Vision Therapy Forum

• https://vtworks.wordpress.com/2020/03/18/leaping-into-technology-part-one/

• https://vtworks.wordpress.com/2020/03/19/leaping-into-technology-part-two/

• https://vtworks.wordpress.com/2020/03/20/leaping-into-technology-part-three/