The ophthalmologic exam

Introduction

A comprehensive ophthalmic exam can be critical to the diagnosis and management of neurological conditions. Composed of eight different parts, certain components of a complete ophthalmic exam are easily adapted to telemedicine and others are quite challenging. In this chapter, we will discuss the current options available to the clinician as it relates to examining the eye, current practices, and future adaptions specific to ophthalmology.

Telemedicine can be broadly divided into two broad categories: asynchronous (data are collected and discussed at a later time) and synchronous (data are exchanged in real time). We will discuss asynchronous telemedicine in what the author refers to as the hybrid model of ophthalmology. Historically the hybrid model has been the one most often applied to ophthalmology.

Patient selection

The physician and practice should select patients appropriate for telemedicine visits based on objective clinical criteria (e.g., established vs. new patients, age) and subjective patient-specific criteria such as ability to access and use technology. Some physicians find that establishing relationships with new patients is more difficult than maintaining or following up chronic conditions using telemedicine.

Scheduling visits

Telemedicine visits can either be scheduled as a separate clinic or integrated into a traditional clinic. In ophthalmology, the average dilated patient exam lasts 1.5 h, whereas the average nondilated patient exam lasts 30 min. Synchronous and asynchronous telemedicine exams usually only require 15–20 min of physician and patient time, given that dilation is often not possible. Many of the time-consuming aspects of the exam have already been completed.

Prior to the day of the visit, staff members send the patient information about how to prepare for the telemedicine visit through electronic mail (email), phone call, or secure messaging. Consent for the visit is obtained verbally and documented in the electronic health record (EHR), or some telemedicine software programs include consent. The patient is asked to test the internet connection and their device’s compatibility with the software solution that will be used. Virtual visits can be converted to a telephone call if there are technological problems on either side during the call.

Software and hardware technology solutions

Often the physician will have a separate telemedicine software platform that allows for a secure HIPAA-compliant system that allows the physician to schedule patients, interact through video conferencing, and share screens. The physician will also have a separate EHR system that is most often used for in-person visits.

Internet bandwidth and computers with sufficient processing speed are essential to a high-quality telemedicine visit. Many physicians also find it more helpful to use large screens to visualize the patient rather than small devices such as a cell phone or tablet.

The traditional ophthalmic exam

Technicians will often perform a standard medical interview and gather details of the patient’s chief complaint, history of present illness, past medical history, past ocular history, surgical history, current medications, allergies, family history, social history, and review of systems. This can be done either prior to the virtual visit or during the visit. Once this information is recorded in the medical record, the physician may embark upon a specific ophthalmologic exam that consists of:

• visual acuity, near and far, with and without glasses;

• pupil exam;

• ocular motility;

• visual field;

• intraocular pressure;

• external exam (eyelids and globe position in the orbit);

• anterior segment exam; and

• fundus or retina exam.

With a cooperative patient in a well-equipped ophthalmic office, the exam is often completed quickly and efficiently, usually including the 20-min dilation time needed to examine the fundus adequately. Most often the exam requires many pieces of specialized equipment, including:

• phoropter to refract and find the best corrected vision;

• bright focused light to test the pupils;

• tonometer to test intraocular pressure;

• slit lamp to examine the translucent structures of the front of the eye: cornea, anterior chamber, lens, and anterior vitreous; and

• direct or indirect (more commonly) ophthalmoscope for dilated fundus exam ( Fig. 5.1 ).

  

Often ophthalmologists will use very specialized machines in the office to:

• formally standardize and quantify visual fields;

• photograph the optic nerve and fundus through either undilated or dilated pupil;

• measure the retina nerve fiber layer or the retina layers and fovea via optical coherence tomography;

• carry out fluorescein angiography to evaluate the perfusion of the retina; or

• evaluate the shape of the cornea and topography.

There are many textbooks that carefully explain traditional methods of ocular exam. Here, we will explore each major part of the ocular exam and consider adaptations for telemedicine.