Tele-ophthalmology for age-related macular degeneration during the COVID-19 pandemic and beyond

Abstract

Introduction: COVID-19 has disrupted how ophthalmic practice is conducted worldwide. One patient population that may suffer from poor outcomes during the pandemic are those with age-related macular degeneration (AMD). Many practices are performing some form of tele-ophthalmology services for their patients, and guidance is needed on how to maintain continuity of care amongst patients with AMD using tele-ophthalmology.

Methods: A literature search was conducted, ending 1 August 2020, to identify AMD outcomes and telecare management strategies that could be used during the COVID-19 pandemic.

Results: 237 total articles were retrieved, 56 of which were included for analysis. Four American Academy of Ophthalmology and Center for Disease Control web resources were also included.

Discussion: Risk-stratification models have been developed that let providers readily screen existing patients for their future risk of neovascular AMD (nAMD). When used with at-home monitoring devices to detect nAMD, providers may be able to determine who should be contacted via tele-ophthalmology for screening. Telemedicine triage can be used for new complaints of vision loss to determine who should be referred to a retinal specialist for management of suspected nAMD. To increase access and provider flexibility, smartphone fundus photography images sent to a centralized tele-ophthalmology service can aid in the detection of nAMD. Considerations should also be made for COVID-19 transmission, and tele-ophthalmology can be used to screen patients for the presence of COVID-19 prior to in-person office visits. Tele-ophthalmology has additional utility in connecting with nursing home, rural, and socioeconomically disadvantaged patients in the post-pandemic period.

Keywords: COVID-19; age-related macular degeneration; coronavirus; pandemic; retinal disease; retinal specialist; tele-ophthalmology; telehealth; telemedicine.

Figure 1.

Flow algorithm to evaluate the complaint of vision loss due to nAMD during the COVID-19 pandemic. Initial telemedicine encounters with a primary care provider can determine the need for immediate treatment and generate referrals to tele-ophthalmology if no immediate threat to vision is present. For patients who have existing ophthalmic care, the initial tele-visit can take place via tele-ophthalmology directly. Tele-ophthalmology can determine the need for in-person testing and schedule COVID-19 RT-PCR testing for those in need of in-person testing. Positive titers should follow local protocols about how to proceed, before initiating in-office testing. PCP: Primary care provider, nAMD: neovascular age-related macular degeneration, COVID 19: Corona virus novel disease 2019, CDC: Centers for Disease Control and Prevention, AAO: American Academy of Ophthalmology, RT-PCR: reverse transcriptase polymerase chain reaction

Figure 2.

Flow algorithm of nAMD workup to maintain continuity of case for AMD patients during the COVID-19 pandemic. High-risk AMD patients and those with macular abnormalities detected via home monitoring should have initial encounters performed via tele-ophthalmology. Smartphone FP can also be scheduled to rule in the potential diagnosis of new onset nAMD. If nAMD is suspected, patients can be referred for COVID-19 RT-PCR testing in preparation for in-office testing and treatment. AMD: age-related macular degeneration, nAMD: neovascular age-related macular degeneration, COVID 19: Corona virus novel disease 2019, CDC: Centers for Disease Control and Prevention, AAO: American Academy of Ophthalmology, RT-PCR: reverse transcriptase polymerase chain reaction