The potential of video slit lamps in community optometry

How advances in telemedicine can further enable community eye care was the question presented to delegates by ophthalmologist Sunil Mamotra during the AOP’s Hospital and Specialty Optometrists Conference (HSOC) 2024.

Mamotra’s presentation focused on the use of slit lamp imaging – one of his favourite subjects, he told delegates.

HSOC 2024 was held at Emirates Old Trafford, Manchester on 21 and 22 September.

During his presentation, Mamtora acknowledged that using a slit lamp to diagnose and examine conditions is difficult, and can require a steep learning curve.

He noted, however, that ophthalmology is the NHS’ busiest outpatient department, making up 10% of the entire patient waiting list.

Ophthalmology also has the highest number of patients waiting for a follow up appointment, Mamotra said.

He hoped his presentation would bring a “fresh perspective” on referrals from primary care optometry to secondary care in the hospital eye service.

A unique specialism

Mamtora noted an ageing population, a high volume of patients, complex pathology, variation in commissioning, access to hospital eye service advice, a relatively low number of independent prescribing (IP) optometrists, and varied standards of training as reasons for the ophthalmology backlog.

Ophthalmology and optometry are in a position to work together to solve these challenges, Mamtora believes – although he added that a “hard reset” in how patients are managed is needed in order to do this.

Eye care practitioners must “redefine the ways that we are seeing these patients,” he believes.

Referrals with a few lines of text can be difficult to interpret in the hospital, Mamtora emphasised, adding that the hospital will always see these patients “because we are thinking about the worst-case scenario.”

There are clear opportunities to improve this situation, however.

If a slit lamp video was included in the referral, “we could see what it is that has caused the concern to the optometrist in the community, we could then be in a much better position to maybe even manage patients with advice and guidance.”

This detail could allow the hospital eye service to advise on treatments with a view to seeing patients for a follow-up if required further down the line, Mamtora said.

He added: “When you combine all this together, the aim is to really free up capacity in hospitals so that patients who have more complex needs, and who are at risk of losing vision, can get the appointments that they need.”

Mamtora used his presentation to show video case studies of patients who would have benefited if their slit lamp examination could have been shared with the hospital eye service.

“Thats the unique thing about our specialty, which we work in together: we’re doing the same thing,” he said.

“If we can improve our skills and expertise, and have pathways and guidelines on how we share that information and share those skills together, we’re in a unique position to take advantage of that.”

He also noted that ophthalmology is lucky to already benefit from the wealth of talent and clinical expertise in community optometry.

The NHS Long-term Workforce Plan, Mamotra believes, is “all about moving from hospital to community; all about moving from analogue to digital. It’s all about [moving] from treatment to prevention.”

He added: “Ophthalmology and optometry are probably best positioned, maybe more than any other specialty, to take advantage of this fundamental way in which we practice.”

A question of funding

Mamtora noted that there has been an increase in the amount of work in the decade that he has been an ophthalmologist.

Potential solutions to relieve the workload include increased funding for IP training, a digital first design for ophthalmology outpatient services, and increased use of the skills of community optometrists, Mamtora said.

He added that services should also be designed in conjunction with local secondary care providers.

However, “fundamentally, it comes down to funding," he said.

Mamtora noted the differences between hospital optometrists, who are likely to be working through patient lists, and High Street optometrists, who may be juggling patient care with other priorities.

“We have to have respect for the fact that optometrists are often running businesses,” Mamtora told delegates. “They’re not charities, and you can’t expect them to see lots of lots of patients with little gain for doing that.”

Embracing technology

The COVID-19 pandemic enabled certain technologies to be used more quickly than they might have been otherwise, Mamtora said.

However, he believes that, post-pandemic, “we forget that we can still do this.”

Frequent communication with the hospital eye service is the only way to avoid “double dipping” when care is provided in the community, Mamtora said.

In practical terms, Mamtora noted that in taking a video during an examination, using a phone is not always appropriate due to patient discomfort.

Using a phone also incurs the risk of it ringing, he said.

He also discussed the use of OCT video, and how patients could be managed in this scenario.

Mamtora advised delegates that he always asks patient permission to use videos of their examination on his YouTube channel, Slit Lamp Studios. 

No patient has ever said no, he shared.

“I love to come in and change things and do different things in the hospital,” Mamtora added.

Considering the role of technology in the hospital setting, though, he acknowledged that the “idea of doing something different seems overwhelming.”

He also noted the lack of time that can be allowed to think about how things might be done differently.

“We’ve got a cultural problem where we're all overworked, overburdened, and seeing too many patients,” he said.

However, time could be freed up and a significant number of patients currently being seen in the hospital could be seen in the community if hospital optometry was able to adopt a “digital first thought process,” Mamtora believes.

He also emphasised good cooperation with commissioners, as well as internally with managers and within departments in the hospital itself.

Good communication and cooperation could lead to extra time being set aside for referrals, leading to time being saved cumulatively in the longer-term, Mamtora suggested.

“We’re training people working in the community, who are taking on more qualifications. It’s all about freeing up time in the hospitals, so that patients who need hospital can access it,” Mamtora said.

Upskilling optometrists would mean more ophthalmologists could focus on sight-saving operations, he added.

“My dream, and my ambition, would be that every optometrist in the community could have access to a high-quality video slit lamp,” Mamtora said.

He noted that sending a slit lamp video alongside a written referral would allow the hospital to better triage the patient to the right person, at the right time.

Mamtora highlighted that health secretary, Wes Streeting, has referenced the use of slit lamps in the community as a potential technology that he would like to see implemented.