Telemedicine Evaluations in Neuro-Ophthalmology During the COVID19 Pandemic: Patient and Physician Surveys

Background: The novel coronavirus 2019 (COVID-19) pandemic has transformed healthcare. With the need to limit COVID-19 exposures, telemedicine has become an increasingly important format for clinical care. Compared to other fields, neuro-ophthalmology faces unique challenges given its dependence on physical examination signs that are difficult to elicit outside the office setting. As such, it is imperative to understand both patient and provider experiences in order to continue to adapt the technology and tailor its application. The purpose of this study is to analyze both neuro-ophthalmology physician and patient satisfaction with virtual health visits during the time of the COVID-19 pandemic. Methods: Across three institutions (NYU Langone Health, Indiana University Health, and Columbia University Medical Center), telemedicine surveys were administered to 159 patients. Neuro-ophthalmologists completed 157 surveys; each of these were linked to a single patient visit. Patient surveys consisted of five questions regarding visit preparation, satisfaction, challenges, and comfort. The physician survey included four questions that focused on ability to gather specific clinical information by history and examination. Results: Among 159 patients, 104 (65.4%) reported that they were satisfied with the visit, and 149 (93.7%) indicated that they were comfortable asking questions. Sixty-eight (73.9%) patients found the instructions provided prior to the visit easy to understand. Potential areas for improvement noted by patients included more detailed preparation instructions and better technology (phone positioning, internet connection, software). Over 87% (137/157) of neuroophthalmologists surveyed reported having performed an examination that provided enough information for medical decision-making. Some areas of the neuro-ophthalmologic exam were reported to be easy to conduct (range of eye movements, visual acuity, Amsler grids, Ishihara color plates, and pupillary exam). Other components were more difficult (saccades, red desaturation, visual fields, convergence, oscillations, ocular alignment, and smooth pursuit); some were especially challenging (vestibulo-ocular reflex [VOR], VOR suppression, and optokinetic nystagmus). Clinicians noted that virtual health visits were limited by patient preparation, inability to perform certain parts of the examination (funduscopy and pupils), and technological issues. Conclusions: Among virtual neuro-ophthalmology visits evaluated, most offer patients with appointments that satisfy their needs. The majority of physicians in this cohort obtained adequate clinical information for decision-making. Even better technology and instructions may help improve aspects of virtual health visits

Tele-Neuro-Ophthalmology During the Age of COVID-19

This article is made available for unrestricted research re-use and secondary analysis in any form or be any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.In this article, we present possible “best practices” for neuro-ophthalmologists to design and implement tele-neuro-ophthalmology during and following this national and international crisis. We review the previsit, intravisit, and postvisit steps in a practical manner that we hope will be of value to practicing neuro-ophthalmologists. We include sections on how to appropriately implement telemedicine and patient selection, focusing on different types of visits, determining eligible patients, and triaging patients. In addition, we outline the software and hardware requirements for the electronic medical record (EMR), including Epic and non-Epic platforms. We also describe the nuts and bolts of how to get started, including descriptions of the multiple useful applications and software available. As with any medical encounter, privacy regulations, billing, and coding can be significant hurdles to implementation, and we discuss each in detail. We hope that this article will be of use for neuro-ophthalmologists, comprehensive ophthalmologists, and general neurologists because we deal with effects and aftereffects of this COVID-19 pandemic. We believe that this current disruptive innovation will drive the future of telemedicine in neuro-ophthalmology

Localization of the Site of Abnormality in Papillo-Renal Syndrome

To investigate the origin of the visual field defects in two patients with papillo-renal syndrome by recording multifocal electroretinograms (mfERG)

Neuro-Ophthalmic Complications of Radiation

Ionizing radiation - Radiation capable of transferring enough energy to electrons to separate them from their orbitals, thus producing ionized atoms or molecules which are chemically unstable

The Multifocal VEP Is Abnormal in Regions of the Field Affected in Optic Neuritis

Multifocal visual evoked potentials (mVEP) and visual fields were obtained from patients who had experienced unilateral, acute optic neuritis. Although the traditionally recorded VEP generally shows reduced amplitude and delayed timing in such patients; it can be relatively normal in more than 20% of the cases. However, a mix of affected and unaffected regions can generate the traditional VEP. Here we examine local VEP changes

Adaptive Optics Ophthalmoscopy, Autofluorescence Photography and Microperimetry

Recently, technologies that have captured the attention of the subspecialties of retina and glaucoma, such as optical coherence tomography, multifocal electroretinography and multifocal visual evoked potentials, have been adapted for use in Neuro- Ophthalmology. The purpose of the this talk is to point out some other technologies which have attracted interest mostly outside of Neuro-Ophthalmology that have been used by a few early adaptors, and call attention to possible neuro-ophthalmologic uses

Ocular Myasthenia

A disorder of neuromuscular transmission recognized clinically by varying muscle weakness which is characterized by worsening with fatigue.RSmyastheniagravi

Cases (Slides)

OCT is capable of the highest resolution images of the retina and optic nerve clinically available of the eye, yet when clinicians examine its output, they frequently rely upon a few quantitative measures to determine whether the nerve fiber layer or ganglion cell complex is thinning or thickening. Reviewing the automated segmentation, signal strength and centering of the study and how they may compare to prior studies is critical, as is looking at where the retinal vessels enter the disc when trying to understand local nerve fiber layer thickness as the nerve fiber layer follows the retinal vessels embryologically. The examination of the visual field side by side with the OCT of the nerve fiber layer and ganglion cell complex lends authority to conclusions when they reinforce one another. The recognition of papilledema from its OCT appearance and its separation from other causes of disc swelling e.g. drusen, NAION, optic nerve menigioma and hypotony will be addressed and the importance of the peripapillary RPE Burch's membrane conformation on axial OCTs and the recognition of folds on in face images. Upon completion of this session, participants should be able to: 1) read an OCT like a radiologist reads an MRI 2) distinguish amongst swollen discs when interpreting an OCT and 3) recognize retinal patterns in an OCT

Cases

OCT is capable of the highest resolution images of the retina and optic nerve clinically available of the eye, yet when clinicians examine its output, they frequently rely upon a few quantitative measures to determine whether the nerve fiber layer or ganglion cell complex is thinning or thickening. Reviewing the automated segmentation, signal strength and centering of the study and how they may compare to prior studies is critical, as is looking at where the retinal vessels enter the disc when trying to understand local nerve fiber layer thickness as the nerve fiber layer follows the retinal vessels embryologically. The examination of the visual field side by side with the OCT of the nerve fiber layer and ganglion cell complex lends authority to conclusions when they reinforce one another. The recognition of papilledema from its OCT appearance and its separation from other causes of disc swelling e.g. drusen, NAION, optic nerve menigioma and hypotony will be addressed and the importance of the peripapillary RPE Burch's membrane conformation on axial OCTs and the recognition of folds on in face images. Upon completion of this session, participants should be able to: 1) read an OCT like a radiologist reads an MRI 2) distinguish amongst swollen discs when interpreting an OCT and 3) recognize retinal patterns in an OCT