key: cord-0754348-riggkfo2 authors: Grossman, Scott N.; Calix, Rachel; Tow, Sharon; Odel, Jeffrey G.; Sun, Linus; Balcer, Laura J.; Galetta, Steven L.; Rucker, Janet C. title: Neuro-Ophthalmology in the Era of COVID-19: Future Implications of a Public Health Crisis date: 2020-05-07 journal: Ophthalmology DOI: 10.1016/j.ophtha.2020.05.004 sha: dfda24b7fd47b8c33ba4fa67d6323e02592a72dd doc_id: 754348 cord_uid: riggkfo2 nan The COVID-19 pandemic has disrupted neuro-ophthalmic care, research, and education across the globe. Neuro-ophthalmology faces unique challenges, given our dependence on aspects of the physical examination and on immediate diagnostic testing. Impaired access impedes our ability to differentiate benign conditions from vision-and life-threatening neurological emergencies. Detailed history and some examination components, such as visual acuity and pupillary examination, are feasible; however, visual field testing and ophthalmoscopy, are difficult or impossible to perform remotely. Decisions regarding diagnostic testing and therapeutic interventions must weigh urgency versus COVID-19 exposure risk. We review changes precipitated by COVID-19, emphasizing those with the potential to outlast the immediate pandemic. Video Visits: A central strategy for neuro-ophthalmic clinical care has been rapid implementation of virtual visits except for emergencies. 1 At NYU Langone Health (NYULH), institution-wide data show that over 5,000 video visits were conducted daily within one month of pandemic onset, a time-frame that included institutional roll-out of an Epic telehealth platform with physician onboarding. 2 At Columbia University Irving Medical Center (CUIMC), 2,000 virtual visits were performed daily after establishing Epic as the medical record in February 2020. At the Singapore National Eye Centre (SNEC), plans are underway for video consultation clinics for several subspecialties, including neuro-ophthalmology. Remotely capturing the neuro-ophthalmologic examination has been a major challenge. In the US, a Neuro-Ophthalmology in COVID, 3 multi-institutional physician working group meets weekly to discuss examination techniques and digital applications. Visual acuity can be tested with a printable near card or EyeHandbook application and afferent pupillary defect (APD) testing can be successful with a patientperformed swinging flashlight test. Ocular motor range and detection of nystagmus can also be easily assessed virtually. Telemedicine has many challenges and several benefits, including protection of patients, physicians, and the general public from virus exposure 3, 4 as well as patient and physician convenience. 2 Notably, variable access to technology has the potential to worsen health disparities. Despite this concern, we anticipate virtual visits will be integral to future practice, including for assessment of evaluation urgency. Long-term impact: Initial patient encounters likely will remain in-person, but virtual visits may play an important role for follow-up. In the US, it remains to be seen if current reimbursement policies from Medicare/Medicaid and private insurance will remain in force once the pandemic subsides. 5 We are piloting remote automated visual fields with the Melbourne Rapid Fields (MRF) Neural Lite program, shown to strongly reflect results of Humphrey Visual Fields with good test-retest reliability. 6 This technology may enable remote monitoring of visual field defects between in-person visits. In Person Visits: Essential exam components such as ophthalmoscopy and ocular alignment quantification can only be evaluated reliably in person. Techniques are being explored to perform these maneuvers remotely, but are not ready for implementation. [7] [8] [9] Recent studies have used artificial intelligence for optic disc analysis. 10, 11 Optical coherence tomography and visual fields can be done remotely, but the technologies are in early stages of deployment. Long-term impact: 'Combined visits' in which patients have in-office testing and a physician virtual visit may evolve, as they may improve access to neuro-ophthalmologic care. Consultation: Teleneurology consultation has been most thoroughly explored in stroke. 12 However, new technologies engendered by the pandemic have future applications. For example, NYULH now has access to Epic functionality allowing direct clinician-to-clinician video connection at the bedside for real-time subspecialty consultation. Long-term impact: Video conferencing may facilitate our involvement in complex neuroophthalmic cases. Reimbursement models will be key in determining whether this strategy thrives. Some existing models are the "teledizzy" services in early development in the US and Europe. 13 Although clinical trial enrollment has been impacted by minimal in-person evaluation, researchers have pivoted toward data analysis from home while maintaining HIPAA standards. Investigators have adopted online work management platforms for team members. Long-term impact: Online work management platforms will remain useful. Observational studies have been inspired by implementation of virtual visits, e.g., the inter-institutional "Telemedicine Experience in Neuro-Ophthalmology in the Era of COVID-19 Pandemic" study captures patients' and physicians' perspectives to optimize this model and identify symptoms easily addressed virtually. In SNEC, the ongoing study "The Epidemiology of Neuro-Ophthalmic Disorders in Asians," will capture patients presenting with neuro-ophthalmologic manifestations of COVID-19 and also allows patients to consent for data to be used for future research. Education: All conferences and lectures have transitioned to remote learning. Although this poses challenges, it opens new vistas for educational innovation. For instance, virtual visits allow for simultaneous evaluation by fellow and attending. Virtual divisional business meetings, conferences and happy hours to bolster morale have been critical. Having no choice but to adopt virtual platforms has taught us that, while there is no replacing face-to-face interaction, we can successfully unite educationally and socially while maintaining distance. Long-term impact: We anticipate instituting video-based bedside neuro-ophthalmology teaching. If a neuro-ophthalmic patient is admitted to any hospital within one of our health systems, we can connect to residents at the bedside for integrated teaching during predetermined didactic sessions. "Virtual curriculum" in the pre-clinical years has been operational in the US since at least 1997, and the time is now to bring virtual teaching into resident education. 14 This virtual platform would be useful in the future for residents rotating at other hospitals, due to travel constraints, as well as grand rounds sessions that could be broadcast to satellite locations adjacent to or remote from the primary teaching hospital. Transition to life in the era of COVID-19 has been challenging, but out of this difficult period arise many opportunities to improve on our practices from "before." Neuro-ophthalmology is a unique and anatomically-based subspecialty at the intersection of two fields and is wellpositioned to implement innovative changes to clinical practice and the education of future COVID-19 is catalyzing the adoption of teleneurology How NYU Langone Health Grew its Telemedicine Program Virtually Perfect? Telemedicine for Covid-19 In-Person Health Care as Option B Coding in the World of COVID-19; Non-Face-to-Face Evaluation and Management Care Six-month Longitudinal Comparison of a Portable Tablet Perimeter With the Humphrey Field Analyzer Ophthalmoscopy in the 21st century Development and Preliminary Evaluation of a Smartphone App for Measuring Eye Alignment High-Resolution Direct Ophthalmoscopy With an Unmodified iPhone X Artificial Intelligence to Detect Papilledema from Ocular Fundus Photographs Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus Photographs Teleneurology and mobile technologies: the future of neurological care University of Pennsylvania School of Medicine