Teleophthalmology Apps Extend Care in Combat Zones

William Gensheimer, MD

Teleophthalmology mobile phone apps may improve and extend ophthalmic care in combat zones.

Telehealth consultations could help patients access care while decreasing in-person visits to protect patients and healthcare workers during the current coronavirus disease 2019 (COVID-19) pandemic.

To learn about the efficacy of such technology, William Gensheimer, MD, and colleagues beta tested a secure teleophthalmology mobile app at military treatment facilities in Afghanistan. US or coalition military or civilian personnel in the US Central Command area of responsibility providing medical care were eligible to participate, including medics, corpsman, physician assistants, and physicians.

The mobile eye care app was downloaded on participants’ cell phones. Users placed new consults in the app by importing information for response time needed (urgent: less than 1 hour; priority: less than 4 hours; routine: less than 24 hours), demographics, history, and examination. The app had the ability to capture photographs on the ocular adnexa, external eye and cornea, and anterior segment. Users could include text of relevant examination information, draw pictures of critical findings, and check boxes for common examination findings. The HIPAA-compliant, encrypted software directed users through how to input data and gave detailed instructions for some steps including visual acuity testing.

Expeditionary ophthalmologists were notified of a new consult by an email alert on their cell phone. Consults were responded to by logging into a secure computer portal. During the consult response, teleophthalmology diagnosis, treatment and management plan, the need for ophthalmology evaluation, and the need for aeromedical evacuation were determined.

Users could log into the app on their phone to view the response from their ophthalmologist with management recommendations. They were able to ask more questions or close the consult. When the consult was complete, the user completed a satisfaction survey using a 1-5 rating scale with 1 being very dissatisfied and 5 being very satisfied.

The primary outcomes were the initial response time, agreement between the teleophthalmology diagnosis and final diagnosis, treatment and management, prevention of the need for aeromedical evacuation, user satisfaction, and HIPAA compliance. Additional outcomes included response within the requested time, visual acuity tested in both eyes, downgraded category of aeromedical evacuation precedence, return to duty rate, and consult record uploaded to medical records.

Overall, 28 consults were received and responded to by the expeditionary ophthalmologist at role 3. The mean patient age was 30.3 years old and a majority of them were male (93%) and active duty US military (78%). The requested response time was routine (57%), priority (14%), and urgent (29%).

Red-eye with or without pain was the most common chief complaint (36%). Disease and non-battle injury (79%) were more common than battle injury (21%). External disease and cornea (50%), uveitis (7%), retina and vitreous (18%), neuro-ophthalmology (11%), strabismus (4%), and orbit and eyelids (11%) were all among teleophthalmology diagnoses.

The investigators noted the mean initial response time was just under 4 minutes (95% CI, 2 minutes 30 seconds-5 minutes 26 seconds). All consults were responded to within the requested time. Ophthalmologists tested visual acuity in both eyes in 64% of the consults (95% CI, 46-83). Treatment and management followed proper recommendations in all consults and the teleophthalmology consults prevented the need for an aeromedical evacuation in 4 consults (14%; 95% CI, .7-28) and downgraded from urgent or priority to routine in 4 consults (14%; 95% CI, .7-28).

All users completed the satisfaction survey. The median satisfaction was 5 (minimum, 3; maximum, 5), median satisfaction with ease of use was 5 (minimum, 3; maximum, 5), median satisfaction with treatment and management plan was 5 (minimum, 4; maximum, 5), and median satisfaction compared with other teleophthalmology methods was 5 (minimum 3; maximum, 5).

Such apps have the potential to be used for virtual screening, examination, and treatment of patients during COVID-19 and other infectious disease outbreaks. The technology may also be useful in other remote settings.

In an accompanying editorial, Kimberly Winges, MD, and colleagues supported the use of telehealth in ophthalmology.

“We believe the role of telehealth and teleophthalmology will continue to expand even as in-person limitations decrease after COVID-19,” Winges and her team wrote.

The study, "Military Teleophthalmology in Afghanistan Using Mobile Phone Application," was published online in JAMA Ophthalmology.