Implementation of Teleretinal Screening Using Optical Coherence Tomography in the Veterans Health Administration

Abstract

Background:

The Veterans Health Administration (VHA) has an existing teleretinal screening program that uses nonmydriatic fundus photography to screen for diabetic retinopathy in primary care clinics. Concurrently, optical coherence tomography (OCT) has become a routine screening modality in eye clinics for the diagnosis and management of retinal diseases.

Introduction:

This study aimed to evaluate the first year of a pilot tele-OCT program that used existing resources within the VHA. Without the tele-OCT program, all patients would have been referred to retina clinic for an in-person evaluation.

Materials and Methods:

This is a retrospective chart review study of patients evaluated by a retina specialist through asynchronous tele-OCT evaluation in 2019. Electronic medical records were used to assess patients' demographic and clinical characteristics, tele-OCT consult results, and patient adherence to tele-OCT follow-up plans.

Results:

There were 158 tele-OCT consults originating from optometry and nonretinal ophthalmology clinics in 2019. After tele-OCT evaluation, 113 (71.5%) patients were recommended to be monitored in their originating eye clinic, 27 (17.1%) were referred to intravitreal injection clinic, and 12 (7.6%) were referred to retina clinic for in-person evaluation. Patient adherence to tele-OCT follow-up plans was 76.4%. Patients with decreased central vision (p = 0.007) and patients referred to intravitreal injection clinic (p = 0.043) were most adherent to follow-up.

Discussion:

The tele-OCT program reduced unnecessary in-person clinic visits and enabled more retina clinic availability. Follow-up adherence was greatest among symptomatic patients and those requiring treatment.

Conclusions:

Tele-OCT can extend tertiary care resources and improve patient care in a large multidisciplinary eye care practice.

Introduction

The Veterans Health Administration (VHA) is the largest national health care organization, serving more than nine million enrolled Veterans each year.¹ Veterans are considered a vulnerable and underserved population, and the VHA has been at the forefront of technological advancements to constantly improve Veteran health care, including being one of the first to adopt electronic medical records in 1997 and teleretinal screening for diabetic retinopathy (DR) in 2006.^2,3

Since its inception 15 years ago, the VHA teleretinal screening program has improved screening and management for DR as well as detecting other treatable and preventable causes of blindness such as cataract, glaucoma, and age-related macular degeneration (AMD).^4

–7 Nonmydriatic color fundus photographs are taken in primary care clinics, images are read remotely by eye care professionals (i.e., optometrists and ophthalmologists), and patients are referred to the eye clinic for further evaluation when appropriate. Similar teleretinal screening programs that use digital fundus images have since been implemented at other health care settings to improve access to care, to increase cost-effectiveness, and to identify which patients have immediate need for retinal evaluation.⁸

After referral to the eye clinic for pathology detected on fundus photography, the next step is often optical coherence tomography (OCT) to better evaluate the macula. First widely available as time-domain in 2005 and then as spectral-domain in 2010, OCT has revolutionized the detection and management of diabetic macular edema (DME). Instead of treating clinically significant macular edema as was done in the age of fundus photography and laser, treatment with anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections is currently recommended for center-involving macular edema determined by OCT.⁹ Besides facilitating management decisions for DR/DME, macular OCT is also essential for the management of AMD, retinal vein occlusion, central serous chorioretinopathy, epiretinal membrane, macular holes, and other macular diseases.^10,11

Within VHA eye clinics, OCT is used routinely by both optometrists and ophthalmologists. This tele-OCT program was established to enable general eye care providers to consult a retina specialist remotely to evaluate the macula and potentially reduce the number of unnecessary in-person retina clinic visits. The purpose of this study was to assess the first year of this newly established program.

Methods

Tele-OCT Program Model

Teleretinal consults originated from three eye clinic locations within the Greater Los Angeles VHA System (West Los Angeles, Sepulveda, Downtown Los Angeles) and were requested by optometrists and nonretinal ophthalmologists. Subjects were evaluated in optometry and ophthalmology clinics and received OCT imaging as part of their standard care. At the providers' discretion, tele-OCT consult requests (Fig. 1) were entered into the electronic medical record and automatically placed in the retina specialist's queue for remote asynchronous retinal evaluation of the patient's OCT scan.

Fig. 1.

Tele-OCT consult request template. Tele-OCT consult requests were entered by optometrists and nonretinal ophthalmologists in the electronic medical record system. Consult requests were automatically placed in the retina specialist's queue for asynchronous evaluation of patients' OCT scans. N/A, not applicable; OCT, optical coherence tomography.

As all consults originated within the VHA, the retina specialist had access to the patients' full electronic medical records and imaging. The retina specialist provided a management plan that included each patient's follow-up clinic location and follow-up time interval, which was automatically queued in the original eye care provider's electronic medical record system. This management plan was then communicated to the patient by the original eye care provider. Patients were educated to return sooner if symptoms worsened or if new symptoms developed. However, patients with stable or improving symptoms in the setting of a nonworrisome eye examination were instructed to follow-up at a clinically appropriate interval.

Electronic Medical Record Review

The study protocol was approved by the VA Greater Los Angeles Healthcare System Institutional Review Board and conformed to the tenets of the Declaration of Helsinki. Informed consent was waived due to the retrospective nature of this study. All study investigators were compliant with the U.S. Health Insurance Portability and Accountability Act.

We performed a retrospective chart review to identify patients who had a tele-OCT consult during 2019. All consults made through the tele-OCT program between January 1, 2019 and December 31, 2019 were included in the study. No exclusion criteria were used. The Computerized Patient Record System (CPRS), the VA electronic medical record system, was used to identify eligible patients and for chart review.

Demographic data including age, gender, race, and homelessness were documented. Zip code was collected to estimate travel distances to the retina clinic or their appropriate follow-up eye clinic. Past medical history, psychiatric history, substance use disorders, and nonretinal ocular history were also documented. For each tele-OCT consult request, the laterality of the retinal pathology, best corrected visual acuity (BCVA), consulting retinal diagnosis, ocular symptoms, reason for tele-OCT consult, and originating eye clinic were documented for each patient. From the consult notes documented by the retina specialist in CPRS, the new or confirmed retinal diagnosis, recommended follow-up location, and recommended follow-up interval were collected. Response time for each tele-OCT consult was calculated as the number of days between the tele-OCT consult request and the date of the consult note from the retina specialist. The shortest driving distances from each patient's zip code to the retina clinic and to their respective follow-up clinic were estimated in kilometers using an online trip calculator (Google Maps). A patient was considered to be compliant with the recommended follow-up plan after tele-OCT consultation when they attended an appointment at the appropriate follow-up location within twice the recommended referral interval.

Statistical Analysis

Study data were collected and managed using Research Electronic Data Capture tools hosted at the VHA.¹² Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS 24; IBM Corp., Armonk, NY).

Data describing utilization of the tele-OCT program were summarized using descriptive statistics. Binary logistic regression analyses were performed to identify patient characteristics associated with patient adherence with their follow-up plan after tele-OCT consultation. For variables with a small sample size, Fisher's exact test or a continuity correction were used to calculate significance.

Results

A total of 158 tele-OCT consults were placed in 2019. Most patients were male (154/158, 97.5%). The mean patient age was 70.6 ± 11.3 years. Approximately 70 patients (44.3%) were white, 55 (34.8%) black, 16 (10.1%) Hispanic or Latino, 6 (3.8%) Asian, 4 (2.5%) Native Hawaiian or other Pacific Islander, 2 (1.3%) American Indian or Native Alaskan, and 11 (7.0%) did not report race. Six (3.8%) patients identified with more than one race. The average distance from patients' zip codes to the retina clinic was 52.6 kilometers. Twenty-one (13.3%) patients were experiencing homelessness. Patient demographic information is summarized in Table 1.

Table 1.

Patient Demographics

CHARACTERISTIC	n (% ^a )
Males	154 (97.5)
Females	4 (2.5)
Age, mean (range), years	70.6 (34–94)
Race^b
White	70 (44.3)
Black	55 (34.8)
Hispanic or Latino	16 (10.1)
Asian	6 (3.8)
Native Hawaiian or other Pacific Islander	4 (2.5)
American Indian or Alaska Native	2 (1.3)
Unknown	11 (7.0)
Distance from patient to retina clinic, median^c (interquartile range), kilometers	30.9 (49.5)
Homelessness	21 (13.3)

Percentage was calculated with a total of 158 subjects.

Six patients identified with more than one race.

Three patients were excluded due to having an out-of-state zip code in their electronic medical record.

Cardiometabolic conditions were common, with 119 (75.3%) of patients having hypertension, 111 (70.3%) having hyperlipidemia, and 73 (46.2%) having diabetes mellitus. In addition, 53 (33.5%) patients had post-traumatic stress disorder and 50 (31.6%) patients had depression. Patients' medical and nonretinal ocular history are summarized in Table 2.

Table 2.

Past Medical and Ocular History

CATEGORY	DIAGNOSIS	n (% ^a )
Cardiometabolic history	Hypertension	119 (75.3)
	Hyperlipidemia	111 (70.3)
	Diabetes mellitus	73 (46.2)
Psychiatric history	Post-traumatic stress disorder	53 (33.5)
	Depression	50 (31.6)
	Anxiety	14 (8.9)
	Schizophrenia	8 (5.1)
	Dementia	8 (5.1)
	Psychosis	7 (4.4)
	Bipolar	5 (3.2)
	Schizoaffective	5 (3.2)
Substance use disorders	Tobacco	40 (25.3)
	Alcohol	13 (8.2)
	Cocaine	9 (5.7)
Nonretinal ocular history	Refractive error	129 (81.6)
	Cataract	109 (69.0)
	Dry eye	73 (46.2)
	Glaucoma	48 (30.4)
	Pseudophakia	39 (24.7)

Percentage was calculated with a total of 158 subjects.

Most consults originated from optometry clinics, with 110 (69.6%) originating from the optometry clinic at the same location as the retina clinic and 36 (22.8%) originating from a satellite location optometry clinic. In addition, three (1.9%) consults originated from the nonretinal ophthalmology clinic at the same location as the retina clinic, and nine (5.7%) consults originated from a satellite location nonretinal ophthalmology clinic. Among all tele-OCT consults, 5 (3.2%) consult requests were for the diagnosis of a retinal condition, 66 (41.8%) were for recommendations on management, and 87 (55.1%) were for both diagnosis and management recommendations.

The most common consulting diagnoses were AMD (26.6%), DR/DME (18.4%), structural macular changes (13.9%), retinal vein occlusion (11.4%), and epiretinal membrane (10.8%). The consulted eye(s) had a BCVA better than 20/70 in 119 (75.3%) patients, had low vision (20/70 or worse but better than 20/200) in 25 (15.8%) patients, and were legally blind (20/200 or worse) in 14 (8.9%) patients. Fifty percent of patients were experiencing one or more ocular symptoms at the time of the tele-OCT consult, including decreased central vision, metamorphopsia, or scotoma. Tele-OCT consult details are provided in Table 3.

Table 3.

Tele-Optical Coherence Tomography Consult Summary

CHARACTERISTIC	n (%)
Laterality of retinal issue
Right eye	48 (30.4)
Left eye	59 (37.3)
Both eyes	51 (32.3)
BCVA in consulted eye(s)
Better than 20/70 in consulted eye(s)	119 (75.3)
Low vision in at least 1 consulted eye (20/70 or worse but better than 20/200)	25 (15.8)
Legally blind in at least 1 consulted eye (20/200 or worse)	14 (8.9)
Consulting diagnosis^a
AMD	42 (26.6)
DR/DME	29 (18.4)
Structural macular changes	22 (13.9)
RVO/CME	18 (11.4)
ERM	17 (10.8)
CSR	14 (8.9)
CME, other etiology	13 (8.2)
Other diagnosis	24 (15.2)
Reason for teleretinal consult
Diagnosis	5 (3.2)
Management	66 (41.8)
Both diagnosis and management	87 (55.1)
Ocular symptoms^b
Asymptomatic	79 (50.0)
Decreased central vision	61 (38.6)
Metamorphopsia	15 (9.5)
Scotoma	6 (3.8)
Other	11 (7.0)
Originating clinic^c
Same location optometry	110 (69.6)
Same location ophthalmology	3 (1.9)
Satellite location optometry	36 (22.8)
Satellite location ophthalmology	9 (5.7)
Tele-OCT response time in days, mean (SD)	2.7 (3.3)
Diagnosis changed after tele-OCT consult	46 (29.1)
Recommended follow-up location
Original clinic	113 (71.5)
Retina clinic	12 (7.6)
Injection clinic	27 (17.1)
Other	6 (3.8)
Recommended follow-up interval
<1 week	7 (4.4)
1 week to <4 weeks	34 (21.5)
1 month to <3 months	47 (29.7)
3 months to <6 months	39 (24.7)
6 months to 12 months	31 (19.6)
Adherence to follow-up plan after tele-OCT consult^d	120 (76.4)

Patients may have more than one consulting diagnosis.

Patients may have more than one ocular symptom.

Same location refers to optometry and ophthalmology clinics that were in same building as the retina clinic.

One patient was excluded due to passing away during the recommended follow-up interval.

AMD, age-related macular degeneration; BCVA, best corrected visual acuity; CME, cystoid macular edema; CSR, central serous retinopathy; DME, diabetic macular edema; DR, diabetic retinopathy; ERM, epiretinal membrane; OCT, optical coherence tomography; RVO, retinal vein occlusion; SD, standard deviation.

On average, tele-OCT consults were evaluated by the remote retina specialist within 2.7 days. All of the OCT scans were deemed gradable. After remote evaluation, 113 (71.5%) patients were recommended to follow-up at their original eye clinic, 27 (17.1%) were scheduled directly into the intravitreal injection clinic for treatment, 12 (7.6%) were scheduled into the retina clinic for further evaluation, and 6 (3.8%) were referred to a different clinic location.

Patient adherence with the recommended follow-up plan from the tele-OCT consult was 76.4%. Patients who had ocular symptoms (p = 0.002) and those who were referred to the injection clinic for treatment (p = 0.043) were significantly more likely to be adherent to their recommended follow-up plan after the tele-OCT consult. Among the ocular symptoms collected, having decreased central vision was associated with patients being significantly more likely to adhere to their follow-up plan (p = 0.007). Experiencing metamorphopsia, scotoma, or other ocular symptoms (i.e., floaters/flashes, fluctuating vision, and nonspecific blurry vision) was not associated with significantly greater adherence to follow-up (p = 0.196, p > 0.99, and p > 0.99, respectively). Patients who were white (p = 0.047), who had no change in their diagnosis after tele-OCT consultation (p = 0.002), or who were recommended to follow-up at their original eye clinic (p = 0.007) were less likely to be adherent to their recommended follow-up plan.

Discussion

The Veteran population is often marginalized in society with high rates of psychosocial comorbidities such as post-traumatic stress disorder and homelessness. The current study on a tele-OCT program implemented at the Greater Los Angeles VHA is among the first teleophthalmology initiatives to integrate remote OCT evaluation into patient eye care. This program was implemented at a large multidisciplinary health care system with multiple feeder site eye clinics that share an electronic medical record system. It was possible because the VHA already had a large infrastructure for e-consults not only in ophthalmology but in all medical and surgical subspecialties as well, making communication and workload credit streamlined and user-friendly. As per all other e-consults, the original provider with an established relationship with the patient received immediate notification of results and was responsible for communicating results and next steps.

The main purposes of establishing this tele-OCT program were to improve retina clinic utilization, improve patient convenience, and reduce loss to follow-up. Indeed, the majority of patients (71.5%) did not require intervention and were recommended to continue being monitored by their original eye clinic with instructions on a follow-up time interval. The most common diagnoses were AMD (26.6%) and DR (18.4%).

Patient adherence with tele-OCT management recommendations was 76.4%, which is better than or comparable with the follow-up rates after 1 year for non-OCT teleretinal screening programs in other studies, which range from 51.0% to 75.5%.^13
–15 Not surprisingly, our study found that patients were more likely to follow-up when they experienced loss of central vision or when an intravitreal injection was recommended. We speculate that having activities of daily living affected motivated patients to adhere to follow-up eye care and the need for intravitreal injections was associated with greater disease severity, also leading to patient adherence.

In the Greater Los Angeles VHA, both retina clinic and intravitreal injection clinic are located in West Los Angeles. Our retina clinic has a large catchment area in southern California, serving five counties: Los Angeles, Ventura, Kern, Santa Barbara, and San Luis Obispo. Even if patients return to the nonretina clinic that the OCT originated from in the same West Los Angeles location for follow-up, the tele-OCT program reduces patient travel burden since same-day retina clinic appointments are not available given the high clinic volume. Thus, being able to space out their next appointment (i.e., patients do not need to return for a retina specialist to review their OCT) is of great value for improving patient convenience and health care utilization. On average, patients in our study lived an estimated round-trip distance of 105.3 kilometers from the West Los Angeles retina clinic. The two other sites that entered consults are located 23.8 kilometers and 24.5 kilometers away, which during peak traffic hours can take an addition 1-h drive. Utilizing tele-OCT consults thus considerably reduced patient travel burden as well as eliminated clinic visits with dilation that typically lasts 1–3 h. In addition, patients were often elderly with multiple comorbid conditions and required a family member or friend to accompany them to dilated fundus examination visits.

Limitations of this study include its setting at a single VHA health care system, which may not be generalizable to other populations, and its lack of a control group. Although the tele-OCT program enabled patients with retinal pathologies on OCT to be evaluated by a retina specialist, without a control group, we do not know if patients would have been more or less compliant with subsequent in-person follow-up after seeing a retina specialist. Nonetheless, we were able to show the feasibility and utility of using tele-OCT in a large multidisciplinary eye care practice.

Although this study was carried out in 2019, telemedicine programs in ophthalmology have further developed and become increasingly utilized globally during the COVID-19 pandemic of 2020.^16
–18 Eye care centers have made efforts to reduce unnecessary eye care visits to enable adherence to social distancing guidelines, particularly for elderly and high-risk patients in clinic.¹⁹ Given the advantages of telemedicine, remote eye care delivery will likely continue to some degree even after the COVID-19 pandemic ends. This tele-OCT program may serve as a model for other eye clinics for asynchronous remote evaluation by a retina specialist.

Conclusion

Given the success of the VHA's existing teleretinal screening program and the ubiquity of OCT in optometry and ophthalmologist clinics, a tele-OCT program in a vulnerable population was a natural extension of existing e-consult infrastructure. Benefits of the program included increased access to retina care, increased patient convenience and adherence, and improved clinic utilization. Future studies can consider the impact of COVID-19 on this pilot program.

Footnotes

Authors' Contributions

Concept and design, acquisition of data, and drafting of the article by S.A. and I.T. Statistical analysis by B.S.G. Interpretation of data and critical revision of the article for important intellectual content by all authors. Supervision by I.T.

Acknowledgments

The authors thank the UCLA Clinical and Translational Science Institute Summer Fellowship for their support of this research project. The authors also thank the optometrists and nonretinal ophthalmologists who utilized the tele-OCT program.

Disclosure Statement

The authors report no competing financial interests. The views expressed in this study are those of the authors and do not necessarily reflect the position of the Department of Veterans Affairs or the United States government.

Funding Information

This study is supported by an Unrestricted Grant from Research to Prevent Blindness, Inc. to the Department of Ophthalmology at UCLA.

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