Introduction

The current health care crisis due to the SARS-CoV-2 coronavirus pandemic has made it necessary to consider new methodologies for ophthalmologic evaluation. The Centers for Disease Control and Prevention now recommend telemedicine, rather than on-site clinic visits, in anticipation of a prolonged period of social distancing (¹).

Telehealth is defined as the provision of medical care at a distance using information technologies and telecommunication services, with the objective of improving access to medical care, quality, resolution and patient satisfaction. Telehealth includes activities such as tele-counseling, tele-medicine and tele-support (¹,²).

Telemedicine, in turn, is defined as the provision of health services at a distance in the components of promotion, prevention, diagnosis, treatment, and rehabilitation, by health professionals using information and communication technologies (¹). Within it are categories such as:

In Colombia, these modalities of care are contemplated under the legal framework of Law 1419 of 2010, according to which the guidelines for telehealth are presented; Resolution 2654 of 2019, which deals with the enabling of telemedicine, and Resolution 521 of 2020, which adapts the Action Plan for the Provision of Health Services during the containment and mitigation stages of the covid-19 pandemic (²).

However, in ophthalmology, the use of telemedicine is infrequent, because it has not been widely accepted by specialists, even though the standards required to improve the provision of health services in this modality have already been established (³,⁴).

Meanwhile, it has been reported that telemedicine services can be used for screening and follow-up of ocular pathologies in both outpatient and emergency departments (⁵,⁶). Similarly, studies have been published on the advantages of teleophthalmology in patients diagnosed with diabetic retinopathy (⁷-⁹), follow-up of patients with glaucoma (³), and in postoperative oculoplastic procedures (¹⁰), which confirm its usefulness in the timely diagnosis and appropriate management of these patients.

Despite innovations and advances, telemedicine continues to be a challenge due to the usual obstacles faced by the technology in terms of access, quality of service and safety (⁶,¹¹-¹³). These limitations mean that in developing countries such as Colombia there may be barriers to the implementation of telemedicine in specialties such as ophthalmology.

This article presents the results of the experience of implementing teleophthalmology, expressed in the number of consultations attended (access) and resolved through the practice of telemedicine during the covid-19 pandemic in a high complexity ophthalmology center (Oftalmosanitas) in Bogota (Colombia). It aims to propose this model of care as another tool in the ophthalmology consultation service, with application in times of contingency, since it can reduce access times to specialized consultation and manage to serve isolated or vulnerable populations.

Materials and methods

This was a descriptive cross-sectional study that included information from consultations with pediatric and adult patients who attended telemedicine consultations for ophthalmologic pathologies at Oftalmosanitas between April 15 and August 31, 2020.

Selection criteria:

Data collection strategy. The medical records of patients who attended telemedicine consultation for ophthalmologic pathologies between April 2020 and August 2020 in the general ophthalmology, retina, glaucoma, cornea, pediatrics, and uveitis services were reviewed. The main investigator and co-investigators collected data of interest from the digital medical record within the clinic facilities. The data were entered into an Excel database for the exclusive use of the investigators and, thus, the principle of confidentiality was maintained. Table 1 describes the variables included in the study.

Table 1 Description of variables 

A successful consultation was defined as one in which communication with the patient was achieved and which allowed an anamnesis to be performed and, if possible, some findings to be obtained by means of a photo, video call or the interpretation of paraclinical examinations. And, from this, a diagnosis and management plan has been provided.

Information collection techniques. All patients had to verbally and voluntarily accept the consultation scheme using a consent form before the beginning of the consultation. The purpose of the consultation was proposed as an alternative to provide a solution to the reason for the patient's current consultation or complaint, as well as to identify warning signs that merit urgent or priority attention, following the recommendations given by scientific societies.

Data analysis plan. Subsequently, the information recorded was reviewed to avoid possible inconsistencies or duplicates. We also verified that the data recorded corresponded to the type of variable, its definition, the corresponding unit and the coding, if applicable. With the data collected from the variables characterizing the population, the distribution of frequencies and percentages was obtained for the categorical variables, and for the continuous variables, measures of central tendency and dispersion were obtained. The statistical software STATA version 15 was used for data analysis.

Ethical considerations. The protocol was approved by the Research Committee and the Research Ethics Committee of the Fundación Universitaria Sanitas.

Results

Characteristics of patients seen

The sample collected was 23,629 consultations performed by telemedicine to pediatric and adult patients, with one of the 16 Oftalmosanitas specialists, between April 15 and August 31, 2020. Most of the patients assessed by this virtual consultation modality were located in the country's capital city (Table 2).

Table 2 Description of the telemedicine experience 

The mean age of the patients was 53.6 ± 21.3 years, with a standard deviation of 21.3 years. In terms of sex, the percentage of women was 62.29 % (n = 14,718). Of the patients seen, 92.52 % (n = 21.3) were of legal age and 43.55 % (n = 10,290) of them were seen for first-time assessment (Table 3).

Table 3 Description of patients seen in consultation 

When analyzing the ophthalmologic diagnoses recorded in the clinical history, the most frequent was glaucoma, with 21.01 % (n = 4966); followed by external pathology, represented by 13.38 % (n = 3162), including pathologies of the lacrimal apparatus and eyelids. The least frequent diagnosis was neurological pathology, with only 0.70 % (n = 166) (Table 4).

Table 4 Description of comorbidities 

In 77.46% (n = 18,302) of the cases it was recorded that the consultation had been resolved. In 13.39% (n = 3165) of the patients, it was not recorded in the database whether the consultation was resolved or not, because the data was not correctly migrated from the medical record to the database (see Table 3).

With regard to the management plan, 56.93% (n = 13,452) of the cases were indicated to continue monitoring by the specialty in virtual mode; 24.09% (n = 5692) were discharged by the specialty, and 4.05% (n = 956) of the cases were sent for priority evaluation in person. Only 0.58% (n = 136) of cases were referred to the emergency department (see Table 3).

Information on comorbidities was obtained in 2,864 patients. The most frequent were: Arterial hypertension, reported in 2041 patients (71.26 %); hypothyroidism, in 773 patients (26.99 %); hyperlipidemia, in 676 (23.60 %), and diabetes mellitus, in 527 patients (18.4 %) (see Table 4). Most of the consultations made corresponded to referrals from general medicine for retinopathy screening, which were performed by taking posterior pole photographs and, in some cases, by angiography or tomography, which were subsequently reviewed by the physician and the result was reviewed in a control, where the findings were explained and the conduct to be followed, in addition to giving recommendations to prevent ophthalmologic complications derived from the patient's underlying pathology.

The importance of the interpretation of different paraclinical tests that helped physicians to define behaviors should be emphasized. Some of them are: visual fields, coherent optical tomography of the optic nerve, anterior segment or macula, pachymetry, standardized ocular ultrasound, ultrasonic biomicroscopy (UBM), computed axial tomography or nuclear magnetic resonance of the skull or orbits, retinal angiography, posterior pole and anterior segment photographs, Pentacam, optometry, biopsies or conjunctival impression cytology.

Discussion

Due to the covid-19 pandemic, the practice of medicine has had to adapt and the use of technology has been necessary to continue the evaluation of patients by different specialties, including ophthalmology. In the last year, different articles have been published on the experience of teleophthalmology in several countries and they have agreed that this modality of consultation has an invaluable utility in this type of contingency (¹,⁶,⁸,⁹).

The virtual consultation modality has proven to be cost-effective in countries of the region, such as Brazil, where it has made it possible to speed up access to specialized consultation and avoid preventable blindness secondary to delays in care; likewise, the unit cost per evaluation has been reduced (¹⁴). In Chile, telemedicine allowed greater detection of diabetic retinopathy and in Iran, it demonstrated that this model can avoid unnecessary referrals in patients with diabetic retinopathy (¹⁵,¹⁶).

In a descriptive study published in Spain, where they wanted to show the results of the experience during the covid-19 pandemic, they concluded that the number of teleconsultations performed was low due to the novelty of the service and the lack of knowledge on the part of the patients. This result is the opposite of our experience, from which we obtained a massive acceptance by patients (¹⁷).

Experience with the use of teleophthalmology during the covid-19 pandemic had not been published in Colombia. This study describes the results of 23,629 consultations made during the contingency in Oftalmosanitas, of which 77.46% of the cases resolved the reason for which the patient was consulting. This suggests that this modality of care is effective in generating a diagnosis and a management plan for patients who are evaluated virtually.

The largest percentage of patients were located in Bogotá. However, we also saw people located in some rural or remote areas, where access to specialized ophthalmology care is limited or non-existent. For this reason, we believe that the virtual consultation service was useful for the resolution of some eye diseases and also provided education regarding recommendations and warning signs of different pathologies.

The reduced number of visits in the pediatric population may be related to the fact that most of the consultations in this age group are for eyeglasses prescription or strabismus evaluations, reasons why a face-to-face appointment is required. Glaucoma was the most frequent ophthalmologic diagnosis in the patients who participated in this study. These data correlate with the percentages of the specialties, where glaucoma and general ophthalmology were among the most requested. The specialty with the lowest number of patients seen was oculoplastics, with 0.8%, which was related to the fact that this specialty was only available for one month (see Table 3). These results are different from those presented in a Spanish publication, with a similar experience to ours, where the most frequent reason for consultation was inflammatory conditions of the ocular surface and eyelids, with 79.4 % (¹⁷).

For glaucoma management and follow-up, patients are scheduled for periodic visits for diagnostic tests that are reviewed by the treating physician to adjust the treatment plan. Such tests can be reviewed virtually, as occurred in our study. This experience is similar to that reported by Gan et al. (¹⁸), who report that this methodology reduces the number of in-person provider visits while ensuring oversight of patient care.

Regarding the perception of teleophthalmology by patients, in January 2020 the results of a study conducted in a low-income urban population with a history of type 2 diabetes mellitus in the United States were published, which reported a general acceptance of this consultation modality, except for older adults, who prefer an assessment by their ophthalmologist of choice (¹⁹). Telemedicine at Oftalmosanitas was very well received, to such an extent that it became currently part of the portfolio of services offered by the institution, due to the great demand from physicians and patients.

Regarding age groups, in our study more than 90 % of the patients were adults, and of these, 16.26 % were older than 75 years. For this group of patients, teleophthalmology has become increasingly important to detect or follow up pathologies such as glaucoma, diabetic retinopathy, and age-related macular degeneration. This modality of consultation has proven to be both cost-effective and efficient in reducing the burden of visual disability resulting from these diseases (²⁰). In addition, elderly or chronically ill patients are more aware of its usefulness, as they now use it to reduce their exposure (²¹).

Although the technology for remote ophthalmic monitoring is neither scalable nor ready, it appears that our patients are willing to adopt this approach. This crisis is likely to spur innovation that will transform the delivery of care, improving different tools such as a close focus on smartphone cameras, self-photography accessories, and the application of scalable and more accurate home tests. We can see teleophthalmology finding a more permanent role in the near future (²¹).

One year after starting the use of teleophthalmology in our institution, we can conclude that the experience of physicians and patients has been satisfactory, by reducing the time of attention, which has allowed early and timely detection of priority and urgent pathologies. This has reduced severe ophthalmologic complications that could lead to irreversible blindness, in addition to reducing the risk of infection by coronavirus, due to the close contact that occurs during the ophthalmologic consultation. Due to the results obtained and to the request of the patients themselves, we are currently continuing with the practice of telemedicine to provide assistance to patients who live in isolated populations or have difficulty in traveling, improving the time of attention to those patients who require an urgent or priority consultation and providing health education through the virtual consultation.

It is important to define the goals to be achieved with teleophthalmology. There are several methods of non-face-to-face consultation (video, synchronous video, photographs, or audio only), and each one with its advantages as well as disadvantages, sought to fulfill one of the following purposes: 1) to give continuity to the treatment of already diagnosed ophthalmologic pathologies, 2) to reduce the number of patients in face-to-face consultations to respect health restrictions and 3) to refer patients with situations/pathologies considered as urgent to provide timely treatment.

In the non-face-to-face consultation, the ophthalmologist performs an interrogation, and based on his or her clinical judgment, initiates the follow-up required by the patient. This is why the teleconsultation model in ophthalmology is a practice that should continue. At the moment, it is required by health authorities to prevent the spread of SARS-CoV-2; but once this emergency is over, telemedicine will continue to be relevant: scheduling consultations to review requested examinations, observing tolerance/adherence to medications, and even triaging patients (²²). More studies of this type should be conducted and financed to promote timely ophthalmologic care and reduce preventable visual disturbances.