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 Table of Contents  
Year : 2020  |  Volume : 58  |  Issue : 4  |  Page : 288-292

Tele-eye care models during COVID-19 pandemic: A systematic review

1 Department of Optometry, Netra Jyothi Institute of Allied Health Science, Udupi, Karnataka, India
2 Department of Optometry, Manipal College of Health Profession, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission01-Aug-2020
Date of Acceptance04-Aug-2020
Date of Web Publication16-Dec-2020

Correspondence Address:
Mr. Siddharth K Karthikeyan
Department of Optometry, Netra Jyothi Institute of Allied Health Science, Udupi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_101_20

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Coronavirus disease 2019 (COVID-19) pandemic has affected eye care practices in several ways. To reach out to people who need eye care services during this pandemic, eye care practitioners started tele-eye care (TEC) practice worldwide. This review aims to describe the methods, including protocols, regulations of TEC, and its usefulness during the COVID-19 pandemic. Articles relevant to the aim were searched from various databases such as “PubMed, Scopus, Wiley Online Library, ProQuest, CINAHL, and Web of Science.” The last date of the search was June 16, 2020. Retrieved articles underwent screening process against the predefined inclusion and exclusion criteria, and the irrelevant articles were excluded. Data extraction was done using excel sheets. Quality assessment and risk of bias were assessed. The results of the included articles were summarized and tabulated. A total of 188 articles were retrieved from database screening, of which only two articles met the inclusion criteria. Results of the included studies reported that TEC practice was favorable to patients in saving their time, money, and was easy to use. Patients would like to continue TEC practices in future as an alternative to an in-person consultation. TEC practice mainly benefited people in rural areas and people living far from the hospital. The percentage of patients utilizing TEC practice has been increasing.

Keywords: COVID 19, remote consultation, tele-eye care, virtual consultation

How to cite this article:
Kharvi RK, Padmashali S, Poojary S, Karthikeyan SK, Nandagopal P, Acharya M. Tele-eye care models during COVID-19 pandemic: A systematic review. TNOA J Ophthalmic Sci Res 2020;58:288-92

How to cite this URL:
Kharvi RK, Padmashali S, Poojary S, Karthikeyan SK, Nandagopal P, Acharya M. Tele-eye care models during COVID-19 pandemic: A systematic review. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2022 Dec 7];58:288-92. Available from: https://www.tnoajosr.com/text.asp?2020/58/4/288/303665

  Introduction Top

In early December 2019, the first case of SARS-CoV-2 originated in Wuhan, Hubei province, in China.[1],[2] SARS-CoV-2 had spread throughout the world within a few months of its appearance. On February 11, 2020, the disease was officially termed as coronavirus disease 2019 (COVID-19) and was declared as pandemic on March 11, 2020, by the World Health Organization.[3],[4] Coronavirus transmits from person-to-person by inhaling the discharge of infected person or by direct contact with droplets, fomites, or the surface containing the virus which enters through the mouth, nose, or eyes.[5]

The human eye is rarely involved in COVID-19 infection.[6] Williams et al.,[7] reported that about 12 of 38 (31.6%) COVID-19-positive patients had ocular anomalies such as conjunctival hyperemia, follicular conjunctivitis, chemosis, or epiphora.[7] Few patients with signs of conjunctivitis had detected a viral RNA in their tears.[8]

The rapid spreading of COVID-19 infection has led to the downfall of the world's economy and health-care services.[9] The act of social distancing and lockdown for people's safety has reduced the patient's visit to hospitals worldwide. Eye care practitioners (ECPs) are more prone to infection due to proximity with the patients.[10] Increased risk of transmission may occur due to increased time spent in the hospitals or clinics for the completion of multiple ocular examinations.[11] Thus, to reduce the risk of infection and to improve patient's health status, ECPs around the world had started tele-eye care (TEC) practices.[12],[13]

This review aims to discuss the available methods of TEC practice, its usefulness during the COVID-19 pandemic, along with protocols and regulations followed with respect to each described model.

  Methods Top

The protocol of this systematic review was registered in International Prospective Register for Systematic Reviews (PROSPERO– Registration number: CRD42020191998). Results are reported using Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines.[14]

  Search Strategy Top

Relevant articles were searched from various databases such as “PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest, Wiley Online Library and Web of Science” using the following keywords: (eye or ophthalmic or ocular) and (COVID 19 or coronavirus or SARS-CoV-2) and (telemedicine or telehealth or teleophthalmology or tele optometry or TEC). The last date of the search was June 16, 2020.

  Study Eligibility Top

Original articles describing the models used for TEC during COVID-19 pandemic published from November 1, 2019, to June 16, 2020, were included. Only the articles published in the English languages were included, but the inclusion of the articles was not restricted to study designs. All ophthalmic patients who had undergone TEC practice regardless of the age group, location, gender, ethnicity, or religion were included.

Publications in books, gray literature, conference abstracts, review, opinion pieces, and letters to the editor were excluded.

  Study Selection Top

On search completion, the articles were imported to Rayyan Qatar Computing Research Institute.[15] Duplicates were identified and removed. The titles and abstracts were examined on inclusion criteria by three independent reviewers, and the articles unrelated to research questions were excluded. Then, the full-text of included articles were assessed for eligibility. At each stage, the disagreements that arose were discussed and were solved by the fourth reviewer. A manual search of reference lists of included articles of the full-text was checked for possible inclusion in the review.

  Assessment of Methodological Quality and Risk of Bias Top

The quality and risk of bias of the articles included in the full-text review were assessed using the National Institute of Health study quality assessment tool.[16] Questions with an answer “yes” were scored as 1 and answer “no“/”not reported“/”cannot determine” as 0. Any conflict was resolved by mutual discussion.

The total score for each study = (the total number of questions with “yes” as answer/the total number of questions) ×100 (Note: If the answer to a question was “Not Applicable,” the question was excluded from both the numerator and denominator). Studies were graded as good (80%–100%), fair (60%–80%), and poor (<60%).

  Data Extraction Top

The relevant information from the final included articles were extracted in Microsoft excel by two independent reviewers. The key data such as author name, year and country, aim of the study, study design, quality of the study, number of participants, age group, inclusion and exclusion criteria, intervention, comparison, outcome measures, results, and limitations of the included studies were recorded. Disagreements between reviewers were resolved by mutual discussions.

  Results Top

A total of 188 articles were identified from various databases. After the removal of duplicates, 103 articles remained. Among these, 18 articles were included for full-text screening after screening the titles/abstracts. After the full-text screening, one non-English and 15 full-text articles that do not obey inclusion criteria were excluded. Finally, two articles were included in the review [Figure 1].
Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart for study identification

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The study details of the included articles are described in [Table 1].Kalra et al.,[17] described the 219 patient survey who had completed the video consultation at their institution from March 18, 2018 to April 27, 2020. Whereas, Das et al.,[18] had presented, 7.008 teleconsultations between March 23, and April 19, 2020. The comparisons between ocular sub-specialty services are described in [Figure 2]. The majority of services were on Cornea and least on uvea in both of the included studies.
Figure 2: Comparison of sub.specialty services of both the included studies

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Table 1: Study details of included articles

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  Protocol Followed Top

The protocols followed by Kalra et al.,[17] and Das et al.,[18] are demonstrated in [Figure 3]. In the TEC practice by Das et al.,[18] the consultations were free of cost. A standard list of frequently answered questions were provided to the tele consultants to manage nonclinical queries. This study had triaged the phone calls into three levels. About 3738 patients were addressed in Level 1 and 3270 patients in Level 2 and 3. Of these, 2,805 calls addressed and completed were included in their analysis. Kalra et al.,[17] grouped the patient into three based on the urgency and need of the patient, thus reducing the in-office patient flow.
Figure 3: (a) Protocol followed by Kalra et al., and (b) Protocol followed by Das et al.

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  Patient Feedback Top

The patient's feedback was collected by Kalra et al.,[17] and Das et al.,[18] after the survey [Table 2]. High positive ratings were found on TEC practice. Patients reported that TEC practice is time and money-saving, convenient, effective, telephone calls gave clarity about their next visits and addressed their issues completely.
Table 2: Description of patient feedbacks of the included studies

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  Discussions Top

This systematic review is aimed to discuss the methods and usefulness of TEC practice during the COVID-19 pandemic. Only two articles were included that qualified our inclusion criteria. Both the included studies by Kalra et al.,[17] and Das et al.,[18] were a survey describing patient's experiences and feedback, modes of TEC practice, and outcome measures.

The effect of the COVID-19 pandemic has modified the routine of ECPs. The onset of COVID-19 has maximized the rate of adaptation to TEC practice.[19] In a survey of 219 video visit patients, 45 (49%) indicated that, if video-consultations were not been an option, there might have a delay in delivering the health-care system. Whereas 62 (67%) stated that the video visits have decreased patients fears about potential vision loss. The triage acuity level was reported as low: 33 (15%); moderate: 151 (69%); high: 35 (16%). Among 87 different diagnoses, the most common was a prospective state (20 visits, 9%), followed by conjunctivitis (16 visits, 7%), and keratitis (14 visits, 6%).[17]

Das et al.,[18] reported that feedbacks taken from the patients were favorable to TEC practice. About 65.71% of patients could reach the examiners in the first attempt itself. In the weekly overview, the answered calls were increased regularly from week 1 to week 4. In these 4 weeks, increasing trends were seen in calls from new patients, whereas decreasing trends in lower socioeconomic patients. This reports that patients of the lower socioeconomic class had certain issues on consultation. The majority of 31.52% of patients' queries were related to the symptoms of redness/watering/blurred vision/pain.[18]

Previous times, the “store-and-forward” telemedicine was used to collect and to send the clinical information of the patient's electronic to another site for evaluation.[7],[20] During the COVID-19 pandemic, video conferencing was used to test the patient's vision at the clinic. By this mode, ECP's communicate with the patients through the video link sent to the computers placed in the assessor's and patient's rooms. This method was acceptable, maintains social distancing, and thus preserves the patient's vision.[21]

Nowadays, visual functions are measured using webpage available charts, which include a Rosenbaum-style near acuity card, an Amsler grid, and a red dot for color desaturation.[7] While the accuracy of the charts requires validation. The ECP's guide the patients about the webpage via smart apps. Printed charts are the easier method, as the ECP's can see the figures and the patients can read the figures displayed on the screen. Virtual videos are beneficial in the evaluation of anterior segments (iris, cornea, pupillary light reflexes, external adnexa, psychological or neurological defects, ocular motility, and the alignment of the eye).[12]

Jayadev et al.[22] reported that to evaluate strabismus in children, parents were asked to perform the basic eye movement examinations using “9” Gaze application. The Hirschberg tests were also performed by directly looking into the camera. These techniques were unreliable due to calibration and validation issues.[22] Saleem et al.,[12] stated that finger tension tests were also performed at home to measure the intraocular pressure. The iCare home tonometer and the sensimed triggerfish contact lens can also be used in TEC practice, but are expensive and are not accurate in the home environment.[12]

ECPs can directly observe the signs and symptoms of the patient's disease and can prescribe required medications through virtual videos.[22] Many conditions, such as conjunctivitis, corneal ulcer, subconjunctival hemorrhage, dry eye syndrome, filamentary keratitis, recurrent corneal erosion, corneal abrasions, episcleritis, or scleritis, can be ruled out using TEC practices. ECP's were utilizing TEC methods to avoid unnecessary hospital visits.[17],[23]

The TEC method practiced before the pandemic had not gained much importance compared to present consultations. Saleem et al.[12] reported that about 74% of patients were unaware of the TEC method in their routine eye care practice, but due to pandemic, its use has been increased between 257%-700%.[12] This pandemic has raised the usage of TEC practice and has reached maximum patients.[18] Though the TEC practice relying on online tools needs validation and thus cannot replace in-person consultations.[17]

TEC practice is developing rapidly, providing the best medical examinations through telephone calls, virtual videos, smart apps such as WhatsApp or E-mails, or through other modes.[24] TEC practices are increasing as the resources needed to deliver virtual consultations are comparatively less expensive than traditional mode of consultation.[25]

  Limitations of Described Studies Top

The limitations are the usage of non validated tools for teleconsultation and the possibility of skewness in the result due to survey bias.

  Conclusions Top

The COVID-19 pandemic has altered the lifestyles of patients and ECPs. They are adapting to these digital systems. Patients in underserved and remote populations were benefited more. Interest in Virtual Video consultations in the ophthalmic sector has been increasing. The use of smart apps to get connected with ECPs is also increasing. ECPs are striving to fulfill the needs and demands of the patients, thereby improving TEC practice.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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