Teleoptometry beyond the pandemic

Optometry did adapt, though – and in some instances, even found effective ways to address both existing issues, and those that might not have been apparent pre-pandemic. Going remote, for many, was the key way they found to continue serving patients.

What of the future, though? Will teleoptometry endure, and will it become a staple part of day-to-day practice? If so, what is that likely to look like in practical terms?

OT and CooperVision asked a group of experts from across the industry about their experiences of the past 12 months, and what they think the future of teleoptometry will look like.

The landscape in January 2020

The panel described a landscape that was undeniably varied at the outset of last year – from practices that had been using aspects of remote consultation and care for years, to those that had never encountered the need for it.

Lynne Fernandes explained that pre-pandemic she “wasn't in the remote care mindset at all…I wasn't looking for any advances in technology.” At the same time, she was aware that there was often a reluctance for contact lens patients to visit the practice, especially if they didn’t feel they had any issues.

Teleoptometry at Lynne’s practice took the form of frontline staff being trained to run through a remote triage sheet, with the optometrist then contacting the patient to organise an appointment or referral if necessary. It’s something Lynne described as “remote care in its infancy.”

In Scotland, Julie Mosgrove believes that “remote triaging, to an extent, was already there.” As the first port of call for emergencies since October 2019, Julie and her colleagues had already grown used to triaging over the phone by the time COVID-19 hit.

The same was true of multiples, according to Helen Thompson at Boots: “We had triages over the phone, so our clinicians were already experienced at reviewing details taken down by colleagues,” she explained. “Anything else was kind of unheard of.”

Nick Rumney, owner of BBR Optometry, painted a more advanced picture of teleoptometry pre-pandemic. He described using “NHS.net, where we had been regularly asking for consultant opinions,” for eight or 10 years, something he categorises as different to a referral “because you're not referring the patient and you're not giving patient identifiable details.”

From a hospital perspective, Vijay Anand echoed the close collaboration that Nick describes: tests being carried out, virtual reviews by a clinician, and consultant optometrists reviewing the data. It’s something, Vijay said, that has been “happening quite considerably for a number of years in medical retina and in glaucoma clinics.”

He also identifies the Pando app, used by ophthalmologists, which allows photographs to be distributed to clinicians via a smartphone for a specialist to respond to. In January 2020, the app was being used at Moorfields to avoid consultants having to be called, and while staff were in urgent care clinics or A&E.  

Challenges of telemedicine

During the first national lockdown, an obvious issue for clinicians was whether patients would fully engage with a remote approach. Julie said: “When we first started, we were worried about how our patients would respond: would they want to do this over the phone? Would they tell us what was really bothering them? But it quickly came clear that the patient wanted to give us as much information as they could.”

Helen agrees: “When we first started our remote consultations, our patients were surprised to hear from us and surprised that we were willing to do something over the phone for them, which then turned into really grateful and understanding patients. It was a two-way conversation, and they felt really quite relaxed to talk about things.”

If you ask them the same things that you would if that patient was sitting in front of you, you're gathering the same

Vijay flags how much of a challenge a move to telemedicine can be for the clinician, even whilst it’s embraced by the patient. “In the hospital, anything that we do has to have either a standard operating procedure or we have to have the governance behind it,” he said, “and obviously all of this had to happen very, very quickly and get signed off very quickly. That was probably the biggest challenge to get over.

“And then, it was convincing the optometrists that they could actually do this. I think there was this feeling of, ‘oh no, what if I miss something? What if I don't ask the right questions?’ And reassuring them that actually, if you ask them the same things that you would if that patient was sitting in front of you, you're gathering the same data.”

Helen agrees that confidence is a hurdle for staff. She said: “Thinking about it is the worst part. Getting on and doing it is a lot easier.

“Right at the beginning, in March, we didn't consider that to be a suitable way to care for our patients. But when you look at the GOC guidance, and the guidance from the AOP and the College, actually it's a way that we should be looking after our patients where it's appropriate.”

Contact lens focus 

Helen said that Boots has been “able to keep a huge number of patients in contact lenses safely” through the use of teleoptometry.

“We all know that some of our contact lens patients aren't as compliant as we would like, or as they might say,” she told us. “So, if we had stopped lens supply because we were unable to see them, what would they have done?” She envisaged a situation where patients would dig out old glasses as a solution, use the wrong contacts, or go online and find a supplier outside the UK.

“I think it was vital for everybody to find a way to look after our patients so that they could safely wear lenses,” Helen said. “That was our biggest thing: to make sure we could look after them safely if we couldn't see them physically. That was our driving force.”

That was our biggest thing: to make sure we could look after patients safely if we couldn't see them physically. That was our driving force

In Bristol, Lynne had success implementing a remote aftercare clinic for her contact lens patients.

“We're using Advanced Ophthalmic Systems (AOS). Every single patient that's due has remote aftercare, in our remote aftercare clinic, where we have patient after patient after patient. We use the AOS system because they can send in images and videos of their eyes, which we can then grade, create a report, and send back. It's a 15-minute appointment…it's really streamlined.”

Whilst hugely useful, Lynne doesn’t believe that in-person contact lens care will ever disappear completely. “We'll still get them in every two years if they're not having any problems and we're not worried about anything,” she said. “For aftercare for those who have been fitted with contact lenses, rather than getting them in at the end of their trial, we'll use the AOS software instead.”

Julie said that the communication was key for contact lens patients at Duncan and Todd. “They were quite surprised to hear from us,” she said, “and delighted that they could speak to someone about their contact lenses. They were relieved to know that their supply wasn't getting stopped; that was a worry for a lot of people.”

Improving patient communication

Effective communication, Julie emphasises, can be as simple as making sure all patient email addresses are collected and stored in an organised way. By collecting email addresses from patients “on day one,” staff are able to communicate changes in practice “the minute there's another announcement.”

Vijay explained that, at Moorfields, the communication concern came from the complexity of cases that would usually be seen. With 70–80% of patients rigid gas permeable (RGP) wearers, there were worries that reduced corneal sensitivity would make patients less likely to notice irritations that soft lens wearers might pick up on immediately. “Those are the ones that you tend to find when they come in and say 'oh, but there's nothing on my lens,' and you look at the eye underneath and it's an unhappy eye,” Vijay said. “That was the sort of thing that we were worried about, that we weren't going to pick up.”

So, how was this risk mitigated? Vijay told OT that his department contacted 4000 of their contact lens patients over a four-month period, offering virtual aftercare and then triaging them into high, medium and low risk categories to determine how long it could be before they were seen again. A similar process was enacted for new referrals. He believes that aspects of the process will continue to be used in the future.

A positive of this new approach, Vijay said, “was the sense of gratitude that these patients had - that they didn't feel that they'd been lost in the system somewhere.”

Often, solutions to improve the management of contact lens patients remotely can be remarkably simple. Lynne, Julie and Helen all reported that follow up calls three to five days after a fit improved success in new contact lens wearers.

During the call, Lynne directs patients to video guides on the CooperVision website, as well as to her practice’s own YouTube channel, because “people just forget what they're doing almost instantly when they leave the practice.” She also recommends the use of My Lens Life, which offers daily reminders and advice so that patients are coached through the first few weeks of wear.

Helen emphasised the importance of a practice website, especially in the management of younger contact lens patients. “Lots of them would come in for their appointment knowing what to expect, having watched videos on how to apply and remove a lens, and be really confident with it,” she said. “And we've found that children are much better at learning that way than adults. We’ve had some real success stories through that.”

Benefits for practice teams 

Vijay believes that the principals of remote consultation can be hugely beneficial internally too, although he is realistic about the limitations of technology within the NHS: getting systems that integrate and having enough staff to perform Attend Anywhere consultations are both challenges that he anticipates.

Recent successes at Moorfields include the introduction of Microsoft Teams to aid communication within the optometry team.

Staff education and training is a rubber band

Incorporating this kind of system has worked within his multi-consulting room practice too, Nick said. Handovers at the end of examinations are sent through Microsoft Teams, creating what Nick called “a better business.”

It’s a gradual process, he said, to ensure that all staff are trained in the new ways of working and that adaptations are maintained. “Staff education and training is a rubber band,” he said. “You spend quite a lot of time stretching it out and keeping it to that level. And then it knicks back every so often, and then all of a sudden, something happens and it goes springing back to zero. And you've got to start all over again.

“We've had two members of staff leave and taken on two, so the new staff are being trained in an entirely different way of working.”

Opportunities from lockdown

Nick believes that the rollout of the COVID-19 Urgent Eyecare Service (CUES) scheme presented increased opportunities, particularly in practices “where there was little or zero experience of frontline staff being able to do any form of triage.” He now believes that triaging is well within the capabilities of most frontline practice staff.

Nick emphasises that the ability to provide real help, even if practices are closed, is the most important challenge – and something that teleoptometry can undoubtedly help with.

“I think as long as you're in a position to be able to intervene when somebody has a defined problem with vision, or pain, or whatever, then the remoteness of the aftercare makes absolute sense and is perfectly safe,” he said.

“What isn't safe is someone who develops a painful red eye, and then phones their eye care practitioner, and the doors are closed without any mechanisms put in place to get that person to the next correct individual. They end up going to A&E and getting diverted to us. I think eye care practitioners, in some instances, do have to lift their game.”

2021 and beyond

Safety is a continued priority in 2021, Lynne emphasised, with her perspective shifting from one that assumed “proper aftercare” only meant patients coming into the practice and optometrists measuring what they could see, “looking at eyes with a great big microscope.”

“Now,” she said, “we're very much of the mindset that COVID-19 is out there; it's a good idea not to go out and mingle with lots of people.”

There are still things to work out, she acknowledged: “It's not perfect, there are teething issues: we don't have a great big slit lamp, we don't have a letter chart that's nice and accurate. But it's safe, and it's secure, and you get that good two-way conversation. Patients love the convenience; they love the time saving.”

At Boots, Helen has also seen patients feeling increasingly comfortable with remote rather than in-person consultations. She noticed, she said, that “they felt relaxed enough to ask questions that they might not have done in practice, where they can feel intimidated or that they need to get on to the next thing.”

She added: “I think the quality of the conversations were different, but just as good, as if we were seeing them face to face. We had that opportunity too – if the patient is worried, or if we're worried about what they're telling us, we can bring them in. I think patients feel that they can be more honest; they aren’t feeling like they’re being judged.”

Remote consultations, Lynne believes, are likely to completely rewrite the system of contact lens patient care.

For new or lapsed patients, she said, “we need to be sending information before appointments, for example videos on what to expect when popping your lenses on and off your eyes. The appointments are going to be shorter, because we're trying to minimise contact time. You need as much information as you can beforehand.”

She listed clear communication on when and how patients will be contacted, the setting up of remote aftercare clinics across the practices, and using technology to keep close contact generally as key aims for the future.

Julie foresees huge benefits for patients in the longer term. She said: “The patients love remote consultations; I think we're going to really struggle to get them back into the test room.”

She also believes that dropouts will reduce, “because we're able to talk to them more, and get an understanding or tweak things.”

Vijay also envisages a future where certain contact lens patients can be seen in person less frequently than they currently are. He imagines patients, once stable with their lenses, having their appointments via videocall, with an in-person appointment booked if needed. He hopes that this system will increase appointment capacity, reducing the time patients might need to wait. “If you've got a daily disposable lens wearer that wears lenses for sports once or twice a week, for a couple of hours, then coming in on a yearly basis is probably not suitable,” he said. “Actually, a two-yearly check is probably fine for those individuals. That's where I would like to see it go.”

We've learned to lose the guilt that every piece of working time has to be spent in front of a patient

Nick thinks that a mindset shift is needed. “We've learned to lose the guilt that every piece of working time has to be spent in front of a patient,” he said. “There are things that you can do in terms of your planning, your staff, education processes, even down to getting to grips with your administration, that make a huge difference to the efficient running of the practice.

“But there are practitioners who think that all they have to do is turn up to see a patient for however many minutes they're going to allocate, do their normal examination, and everything will stay the same. Well, the only thing that's sure in this world is that nothing will stay the same. We will see some practices fade away because they can't cope with this. But we'll also see practices jump forward.”

Vijay also believes that optometry needs to step up its game in 2021. “I don't think we would have got as far as we will do without these last months having taken place,” he said. “It's going to be a real eye opener for people. I think everything's really changed.”

For practices that haven't taken on teleoptometry, he advises “take a step back and see the other things that the medical professions are doing. And see that you can do all of these things without actually physically being in front of the patient.”