Participants’ demographics

Of the 214 participating experts, 97 (45.3%) were women and 1 person (0.5%) preferred not to disclose his or her gender. Most participants were older than 40 years (n=140, 65.4%). Most experts practised in Western Europe (n=152, 70.7%), followed by South America (n=15, 7%) and North Africa (n=10, 4.7%) while Australian experts were least represented (n=2, 0.9%). Most of the participants were clinicians (n=158, 73.9%) or clinical academics (n=44, 20.8%) with over 15 years of experience in ophthalmology (n=120, 56.1%). All participants had expertise in medical retina, and 123 (57.2%) reported additional expertise in vitreoretinal diseases. Neither age nor the level of experience were associated with attitudes towards digital health or the extent to which it was implemented in institutions (table 1).

Setting and infrastructure

One hundred and thirty-eight experts (64.6%) were affiliated to a tertiary care institution and 102 (47.7%) were affiliated to a secondary care institution. Most experts were able to access patient records electronically (n=151, 70.6%). On a 5-point Likert scale, the information technology infrastructure was predominantly described as average (‘3’: n=70, 32.7%) or good (‘4’: n=74, 34.6%), as was the degree of interdisciplinary work among eye care professionals (‘average’ n=60, 28%; ‘good’ n=88, 41.1%). Reimbursement of teleophthalmology services was reported by 92 participants (43%), while home monitoring and other types of decentralised patient care were reimbursed in 12 (5.6%) and 22 (10.9%) of the institution experts reported on, respectively (table 2).

Patients with retinal disease at particular risk for permanent vision loss during the pandemic

Participating retinal experts identified wet age-related macular degeneration (n=118, 84.6%), retinal detachments (n=189, 88.3%), proliferative diabetic retinopathy (n=169, 79%), uncontrolled (posterior) uveitis (n=157, 73.4%), retinal vein occlusions with neovascularisations (n=156, 72.9%), myopic choroidal neovascularisation (n=147, 68.7%) and retinopathy of prematurity (n=114, 53.3%) as retinal diseases that may render patients particularly vulnerable to permanent vision loss during the pandemic.

Attitudes towards and opinions about digital health

Impact of the pandemic on the implementation of digital health

Teleophthalmology

In the majority of institutions, teleophthalmology was not used before the pandemic. More particularly, smart-history taking was used by 41 (19.2%), automated imaging analysis or decision-making by 21 (9.8%), triage by 60 (28%), virtual consultations or clinics by 25 (16.4%) respectively, 33 (15.4%), electronic referrals by 57 (26.6%) and the substitution of slit-lamp examinations by 54 (25.2%).

The use of teleophthalmology was significantly increased by the pandemic (n=46 vs n=105, p<0.001, see figure 1).

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Figure 1

Comparison of the levels of implementation of teleophthalmology (A), home monitoring (B) and other types of decentralised care (C) before and during the pandemic.

Main findings

This study found a significant increase in the implementation of teleophthalmology and home monitoring services during the SARS-CoV-2 pandemic. Of note, other types of decentralised patient care initiatives, such as intravitreal injections in non-medical settings, were infrequently adopted. The main driver for the implementation of teleophthalmology services in institutions that did not provide such service before the pandemic was reimbursement. The sceptical attitudes towards digital health found within an international group of retinal experts prior to the pandemic, however, stand in contrast to previously observed results in a general clinicians’ population.^{23 24}

Results in the light of the existing literature

This is the first study to investigate the impact of a global health crisis as an external disruptive force on digital health transformation in retinal care delivery. Indisputably, the SARS-CoV-2 pandemic has accelerated the transformation in a unique manner beyond previously described implementation strategies. In the United Kingdom, policymakers have even expressed enforcement discretion in regard to remote communication systems to empower healthcare providers.^{25 26}

Within the three evaluated areas, retinal specialists showed the highest short-term acceptance towards teleophthalmology, followed by home monitoring. However, attitudes towards decentralizsed care initiatives remained at a low level and did not change significantly due to the pandemic. We speculate that the availability of teleophthalmology and home monitoring technology, as well as initial experience with these technologies prior to the pandemic, may have allowed for short-term introduction, while decentralised care may have encountered regulatory and procedural obstacles that are more time-consuming and complex to overcome. Regardless, the availability of a robust evidence base for digital health is necessary to build sufficient trust within the community to facilitate the implementation of digital health. Li et al’s study, which compared the quality of routine care with a teleophthalmology service, showed no differences in the quality of care in terms of visual acuity in patients with age-related macular degeneration.²⁷ For some time now, a collaborative project of the Big Picture Medical Platform with the Moorfields Eye Hospital (National Health Service Foundation Trust, London, United Kingdom) has been in progress. In preliminary analyses, the project showed significant efficiency gains in the organisation of a virtual medical retina clinic, in which mainly patients with diabetic retinopathy were treated.¹⁷ In the field of home monitoring, the external validity of the Amsler Grid—although popular in clinic—has been questioned.^{21 28} At the moment, preliminary evidence is available for two smartphone-based tests approved by the United States Food and Drug Administration, the mVT (Genentec) and Alleye (Oculocare medical).^{29 30} Decentralised care of age-related macular degeneration by means of intravitreal injections at the patient’s home may prevent severe deterioration of vision in patients with little access to healthcare. In many countries, however, this form of care is still prohibited for regulatory reasons. It is therefore not surprising that activity in this area was hardly affected by the SARS-CoV-2 pandemic in our survey.

Limitations

The limitations of this study included the lack of validation of the survey prior to its application, which was reflected by the occurrence of incoherent answering patterns. Second, the selection process of experts was done in a non-random manner and is therefore likely to be non-representative of the diversity of the retinal expert community worldwide. Despite this limitation, it is a frequently conducted sampling method used in social science.³¹ The exclusive use of a Google product as a survey tool and the language restriction may have additionally limited representativeness. Another limitation to be considered is that we relied on participants’ reports about practice patterns of their respective institutions and asked for their attitudes in retrospect (memory bias). However, the survey questionnaire format is an accepted approach for gathering knowledge on expert opinions, attitudes and practice patterns.³² Moreover, some of the questions bore high face validity and therefore suggestive character. Lastly, we were not able to objectively quantify the degree to which retinal care delivery has been impeded to contextualise participants’ responses.³³

Implications for research

Further studies may investigate attitudes of upcoming generations of retinal specialists towards digital health. Moreover, since this survey predominantly represents a European perspective on digital health, other geographic areas may be highlighted. With regard to a long-term perspective, robustness of newly implemented service extensions during the SARS-CoV-2 pandemic may be investigated.

Implications for practice

In Great Britain, nearly eighty percent of the consultations in ophthalmology have been cancelled during the SARS-CoV-2 pandemic.³⁴ This disruption of retinal care delivery has expanded on the previous unmet need in eye care. Poorly prepared care structures necessitated hasty implementations of remote management systems, which offers now the opportunity to transform them into long-term solutions. A vital driver for this transformation, as identified by this expert survey, may be the reimbursement structure acknowledging the complementary role of digital care. Moreover, transferring care closely to the patient will require additional expertise coming from other areas than medicine. The development, maintenance and evolution of telemedical services require dedicated information specialists and engineers with sufficient insight into the clinical problem. Furthermore, particularly when implementing automated systems using artificial intelligence applications, staff with sufficient insight into the development and local adaptation of these algorithms should be available.