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Could telehealth help eye care practitioners adapt contact lens services during the COVID-19 pandemic?

Published:April 18, 2020DOI:https://doi.org/10.1016/j.clae.2020.04.002

      Abstract

      The COVID-19 pandemic has necessitated government-imposed restrictions on social interactions and travel. For many, the guidance has led to new ways of working, most notably a shift towards working remotely. While eye care practitioners (ECPs) may continue to provide urgent or emergency eye care, in many cases the travel restrictions present a unique challenge by preventing conventional face-to-face examination. Telephone triage provides a useful starting point for establishing at-risk and emergency patients; but patient examination is central to contact lens patient care.
      The indeterminate period over which conventional practice will be suspended, and the risk that resumption of ‘normal’ practice could be impeded by a potential secondary peak in COVID-19 cases, hastens the need for practitioners to adapt their delivery of eyecare. Specifically, it is prudent to reflect upon supportive evidence for more comprehensive approaches to teleoptometry in contact lens practice.
      Smartphone based ocular imaging is an area which has seen considerable growth, particularly for imaging the posterior eye. Smartphone imaging of the anterior eye requires additional specialised instrumentation unlikely to be available to patients at home. Further, there is only limited evidence for self-administered image capture. In general, digital photographs, are useful for detection of gross anterior eye changes, but subtle changes are less discernible.
      For the assessment of visual acuity, many electronic test charts have been validated for use by practitioners. Research into self-administered visual acuity measures remains limited.
      The absence of a comprehensive evidence base for teleoptometry limits ECPs, particularly during this pandemic. Knowledge gaps ought to be addressed to facilitate development of optometry specific evidence-based guidance for telecare. In particular, advances in ocular self-imaging could help move this field forwards.

      Keywords

      1. Introduction

      In response to the COVID-19 pandemic, governments across the world have announced measures which severely restrict social interactions and travel []. For many, the guidance has led to new ways of working, most notably a shift towards working remotely. While, at the time of writing, UK eye care practitioners (ECPs) may continue to provide urgent or emergency eye care [

      NHS England, Updates and guidance for optical settings; Optical letter: 1 April 2020, viewed 2nd April 2020 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0127-optical-letter-1-april-2020.pdf.

      ], the travel restrictions present a unique challenge by preventing conventional face-to-face examination of many patients.
      UK optometric professional bodies have worked at commendable speed to issue guidance on conducting telephone consultations [

      General Optical Council, Joint regulatory statement on remote consultations and prescribing: viewed 10th April 2020 https://www.optical.org/filemanager/root/site_assets/publications/covid_19/High-level-principles-for-remote-prescribing_.pdf.

      ,]. However, while this is useful for patient triage, contact lens practice is not a discipline which easily lends itself to such telehealth. Patient examination is central to clinical decision making; screening at-risk patients; and to the incidental detection of asymptomatic pathologies.
      Other healthcare professions, such as in medicine, are guided by a growing evidence base for conducting telephone and video consultations [
      • Mold F.
      • Hendy J.
      • Lai Y.L.
      • de Lusignan S.
      Electronic consultation in primary care between providers and patients: systematic review.
      ,
      • Al-Mahdi I.
      • Gray K.
      • Lederman R.
      Online medical consultation: a review of literature and practice.
      ,
      • Brown A.
      • Armstrong D.
      Telephone consultations in general practice: an additional or alternative service?.
      ], but there are comparatively fewer studies specific to primary care optometry particularly contact lens practice.
      At present, consideration of more comprehensive telecare may seem premature, particularly in view of the general expectation that more stringent social distancing measures will soon be relaxed. Timelines are, however, indefinite and the resumption of ‘normal’ practice could still be impeded by the potential secondary peak in COVID-19 cases [
      • Prem K.
      • Liu Y.
      • Russell T.W.
      • Kucharski A.J.
      • Eggo R.M.
      • Davies N.
      • et al.
      The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study.
      ].
      In the UK, the General Optical Council (GOC) along with other healthcare providers, have signed a joint regulatory statement acknowledging that during the pandemic, professionals may need to depart from established procedures [

      General Optical Council, Joint Regulators Statement: 3rd March 2020, viewed 10th April 2020 https://www.optical.org/filemanager/root/site_assets/publications/covid_19/covid-19_joint_regulators_statement_-_final.pdf.

      ]. The GOC have taken a pragmatic approach to contact lens wear and supply [

      General Optical Council, General Optical Council (GOC) statement on contact lens aftercare during COVID-19 emergency: 20th March 2020, viewed 10th April 2020 https://www.optical.org/filemanager/root/site_assets/publications/covid_19/statement_on_contact_lens_aftercare_during_covid-19_emergency.pdf.

      ]. In conducting remote consultations, ECPs are asked to exercise their professional judgement to decide the level of aftercare provided and how to provide it. This flexibility should support contact lens wearers by avoiding unnecessary anxiety, minimise non-compliance, and deter the use of non-prescribed contact lens products sourced online.
      To offer patients the best care under current circumstances, it is prudent to reflect and build upon ways of offering remote patient screening in the context of contact lens practice.

      2. Triage for anterior eye

      Telehealth can present in various forms, ranging from monitoring using mobile phone apps (mHealth), video consultations, to outreach clinics which forward test results for clinical interpretation.
      Advanced digital technology is not, however, the only method of optimising remote consultations. Improvements in history taking through use of validated questionnaires or adoption of patient-reported outcome measures may also help strengthen provision of care.
      ECPs can offer more comprehensive aftercares and improve differential diagnoses by revisiting some of the fundamentals of contact lens history taking [
      • Wolffsohn J.S.
      • Naroo S.A.
      • Christie C.
      • Morris J.
      • Conway R.
      • Maldonado-Codina C.
      • et al.
      Purslow C, of Contact TB. History and symptom taking in contact lens fitting and aftercare.
      ]. Adapting existing triage questions to focus on areas which represent key contact lens related symptoms e.g. eye pain, redness, glare, would help identify the presence and determine the urgency of anterior segment disease [
      • Woodward M.A.
      • Valikodath N.G.
      • Newman-Casey P.A.
      • Niziol L.M.
      • Musch D.C.
      • Lee P.P.
      Eye symptom questionnaire to evaluate anterior eye health.
      ].

      3. Enhancing compliance during the pandemic

      Non-compliance is common amongst contact lens wearers [
      • Wu Y.
      • Carnt N.
      • Stapleton F.
      Contact lens user profile, attitudes and level of compliance to lens care.
      ,
      • Morgan P.B.
      • Efron N.
      • Toshida H.
      • Nichols J.J.
      An international analysis of contact lens compliance.
      ]. While the current cessation of regular daily routines may exacerbate some non-compliance behaviours e.g. irregular lens replacement, improvements can be made in other areas such as the adoption of better hand hygiene. The current handwashing campaigns could lead to longer-term benefits, particularly for lens wearers, if habits are sustained beyond the pandemic.
      Typically, aftercare appointments provide an opportune time to reinforce messages about compliance, but in the absence of such interactions reliance on alternative approaches will inevitably increase. Patient education is generally advocated as the main method of addressing non-compliance, though behaviour modification techniques such as social influencing have also been suggested [
      • McMonnies C.W.
      Hand hygiene prior to contact lens handling is problematical.
      ,
      • Dumbleton K.
      • Richter D.
      • Bergenske P.
      • Jones L.W.
      Compliance with lens replacement and the interval between eye examinations.
      ,
      • Dumbleton K.A.
      • Spafford M.M.
      • Sivak A.
      • Jones L.W.
      Exploring compliance: a mixed-methods study of contact lens wearer perspectives.
      ,
      • McMonnies C.W.
      Improving contact lens compliance by explaining the benefits of compliant procedures.
      ]. The studies investigating efficacy of compliance-encouraging approaches have reported mixed results [
      • Cardona G.
      • Llovet I.
      Compliance amongst contact lens wearers: comprehension skills and reinforcement with written instructions.
      ,
      • Yung A.M.
      • Boost M.V.
      • Cho P.
      • Yap M.
      The effect of a compliance enhancement strategy (self‐review) on the level of lens care compliance and contamination of contact lenses and lens care accessories.
      ,
      • Claydon B.E.
      • Efron N.
      • Woods C.
      A prospective study of non-compliance in contact lens wear.
      ], but current supportive efforts by ECPs could include sending information or lens replacement reminders via SMS messages; providing written or verbal information (e.g. videos or patient information sheets); or making patients aware of lens care phone apps.
      Previously, the tracking of lens ordering patterns to identify non-compliant patients has been recommended [
      • Smith S.K.
      Patient noncompliance with wearing and replacement schedules of disposable contact lenses.
      ], but in view of the current changes to daily routines and online lens purchasing options, the validity of this approach may be compromised.

      4. Subjective refraction and visual acuity

      The potential for measuring visual acuity and refractive error using handheld electronic devices is a growing area of research [
      • Bastawrous A.
      • Rono H.K.
      • Livingstone I.A.
      • Weiss H.A.
      • Jordan S.
      • Kuper H.
      • et al.
      Development and validation of a smartphone-based visual acuity test (peek acuity) for clinical practice and community-based fieldwork.
      ,
      • Perera C.
      • Chakrabarti R.
      • Islam F.M.A.
      • Crowston J.
      The Eye Phone Study: reliability and accuracy of assessing Snellen visual acuity using smartphone technology.
      ,
      • Han X.
      • Scheetz J.
      • Keel S.
      • Liao C.
      • Liu C.
      • Jiang Y.
      • et al.
      Development and validation of a smartphone-based visual acuity test (Vision at home).
      ,
      • Tofigh S.
      • Shortridge E.
      • Elkeeb A.
      • Godley B.F.
      Effectiveness of a smartphone application for testing near visual acuity.
      ,
      • Jan-Bond C.
      • Wee-Min T.
      • Hong-Kee N.
      • Zu-Quan I.
      • Khairy-Shamel S.T.
      • Zunaina E.
      • et al.
      REST–An innovative rapid eye screening test.
      ]. Most studies have employed a healthcare worker to assist in taking measurements. Nevertheless, early evidence for unassisted visual acuity testing and subjective refraction is emerging [
      • Wisse R.P.
      • Muijzer M.B.
      • Cassano F.
      • Godefrooij D.A.
      • Prevoo Y.F.
      • Soeters N.
      Validation of an independent web-based tool for measuring visual acuity and refractive error (the manifest versus online refractive evaluation trial): prospective open-label noninferiority clinical trial.
      ,
      • Tousignant B.
      • Garceau M.C.
      • Bouffard‐Saint‐Pierre N.
      • Bellemare M.M.
      • Hanssens J.M.
      Comparing the Netra smartphone refractor to subjective refraction.
      ,
      • Yeung W.K.
      • Dawes P.
      • Pye A.
      • Neil M.
      • Aslam T.
      • Dickinson C.
      • et al.
      eHealth tools for the self-testing of visual acuity: a scoping review.
      ,
      • Rewri P.
      • Kakkar M.
      • Raghav D.
      Self-vision testing and intervention seeking behavior among school children: a pilot study.
      ].
      A validation study of a web-based refraction and visual acuity test (Easee BV Amsterdam, Netherlands) in adults (aged 18–40 years) showed excellent agreement with conventional subjective refraction (intraclass correlation coefficient 0.92); and did not find a significant difference in acuity measurements when compared to the ETDRS chart (p > 0.05). The study was limited to a refractive range of -6 to +4D and excluded individuals with diabetes [
      • Wisse R.P.
      • Muijzer M.B.
      • Cassano F.
      • Godefrooij D.A.
      • Prevoo Y.F.
      • Soeters N.
      Validation of an independent web-based tool for measuring visual acuity and refractive error (the manifest versus online refractive evaluation trial): prospective open-label noninferiority clinical trial.
      ].
      Other studies which have employed self-testing have shown less successful outcomes. Unassisted use of a smartphone-based refractor application (Netra, EyeNetra Inc., Somerville, MA, USA) in adults (aged 18–35 years, refractive range -9.25 to +0.50D) showed a significantly more median myopic overcorrection of 0.60D when compared to conventional subjective refraction. Median visual acuity estimates were also significantly lower with the app [
      • Tousignant B.
      • Garceau M.C.
      • Bouffard‐Saint‐Pierre N.
      • Bellemare M.M.
      • Hanssens J.M.
      Comparing the Netra smartphone refractor to subjective refraction.
      ]. The findings echoed previous work where the same app showed absolute differences in spherical error of more than 0.50D for approximately 60 % of eyes when compared to subjective refraction, and estimates of VA were also poorer (participant age range 20–90 years, refractive range −15.25 to 4.25D) [
      • Jeganathan S.E.
      • Valikodath N.
      • Niziol L.M.
      • Hansen V.S.
      • Apostolou H.
      • Woodward M.A.
      Accuracy of a Smartphone-Based Autorefractor Compared to Gold-Standard Refraction.
      ].
      A more intermediary approach to visual acuity estimation was found by using remote control of the computer based COMPlog test chart (Complog Medisoft Inc, UK) [
      • Srinivasan K.
      • Ramesh S.V.
      • Babu N.
      • Sanker N.
      • Ray A.
      • Karuna S.M.
      Efficacy of a remote based computerised visual acuity measurement.
      ]. Measurements were obtained in adults (age range 18–51 years), both with and without the physical presence of an optometrist. No significant difference in outcomes was noted between the two approaches (p > 0.05).
      To advance at-home vision screening, current vision testing apps require validation specifically for self-use. At-home vision screening tests may also offer parents and guardians the potential to assume a greater role in child vision screening [
      • Azis N.N.N.
      • Chew F.L.M.
      • Rosland S.F.
      • Ramlee A.
      • Che-Hamzah J.
      Parents’ performance using the AAPOS Vision Screening App to test visual acuity in Malaysian preschoolers.
      ,
      • Walker M.
      • Duvall A.
      • Daniels M.
      • Doan M.
      • Edmondson L.E.
      • Cheeseman E.W.
      • et al.
      Effectiveness of the iPhone GoCheck Kids smartphone vision screener in detecting amblyopia risk factors.
      ,
      • Dawkins A.
      • Bjerre A.
      Do the near computerised and non-computerised crowded Kay picture tests produce the same measure of visual acuity?.
      ]. Differences in device screen size, testing distance, and lighting conditions, are factors which need to be considered when evaluating home screening.

      5. Imaging

      One area of teleophthalmology which has seen substantial growth is smartphone ophthalmoscopy, particularly for posterior eye examination. In most cases, however, this approach requires additional specialised instrumentation which is generally unavailable to patients at home e.g. a macro lens or use of a slit lamp [
      • Russo A.
      • Morescalchi F.
      • Costagliola C.
      • Delcassi L.
      • Semeraro F.
      A novel device to exploit the smartphone camera for fundus photography.
      ,
      • Bastawrous A.
      Smartphone fundoscopy.
      ,
      • Ludwig C.A.
      • Newsom M.R.
      • Jais A.
      • Myung D.J.
      • Murthy S.I.
      • Chang R.T.
      Training time and quality of smartphone-based anterior segment screening in rural India.
      ,
      • Lord R.K.
      • Shah V.A.
      • San Filippo A.N.
      • Krishna R.
      Novel uses of smartphones in ophthalmology.
      ,
      • Chiong H.S.
      • Fang J.L.L.
      • Wilson G.
      Tele‐manufactured affordable smartphone anterior segment microscope.
      ,
      • Ye Y.
      • Wang J.
      • Xie Y.
      • Zhong J.
      • Hu Y.
      • Chen B.
      • et al.
      Global teleophthalmology with iPhones for real-time slitlamp eye examination.
      ,
      • Maamari R.N.
      • Ausayakhun S.
      • Margolis T.P.
      • Fletcher D.A.
      • Keenan J.D.
      Novel telemedicine device for diagnosis of corneal abrasions and ulcers in resource-poor settings.
      ].
      Thus far, research into smartphone ophthalmoscopy has largely concentrated on validation studies, screening of individuals through satellite clinics, and its potential utility for teaching [
      • Rajalakshmi R.
      • Arulmalar S.
      • Usha M.
      • Prathiba V.
      • Kareemuddin K.S.
      • Anjana R.M.
      • et al.
      Validation of smartphone based retinal photography for diabetic retinopathy screening.
      ,
      • Bolster N.M.
      • Giardini M.E.
      • Bastawrous A.
      The diabetic retinopathy screening workflow: potential for smartphone imaging.
      ,
      • Bastawrous A.
      • Giardini M.E.
      • Bolster N.M.
      • Peto T.
      • Shah N.
      • Livingstone I.A.
      • et al.
      Clinical validation of a smartphone-based adapter for optic disc imaging in Kenya.
      ,
      • Russo A.
      • Mapham W.
      • Turano R.
      • Costagliola C.
      • Morescalchi F.
      • Scaroni N.
      • et al.
      Comparison of smartphone ophthalmoscopy with slit-lamp biomicroscopy for grading vertical cup-to-disc ratio.
      ,
      • Fink W.
      • Tarbell M.
      Smart ophthalmics: a smart service platform for tele-ophthalmology.
      ,
      • Nagra M.
      • Huntjens B.
      Smartphone ophthalmoscopy: patient and student practitioner perceptions.
      ]. Nevertheless, there is some limited evidence showing that where the necessary equipment has been made available, successful self-imaging of both the fundus [
      • Ozerdem U.
      A simple nonmydriatic self-retinal imaging procedure using a Kowa Genesis-D hand-held digital fundus camera.
      ,
      • Swedish T.
      • Roesch K.
      • Lee I.H.
      • Rastogi K.
      • Bernstein S.
      • Raskar R.
      EyeSelfie: self directed eye alignment using reciprocal eye box imaging.
      ] and anterior segment is possible [
      • Kaya A.
      Ophthoselfie: detailed self-imaging of cornea and anterior segment by smartphone.
      ]. The pursuit of such self-imaging is, of course, only worthwhile if clinicians can draw accurate diagnoses from the images themselves.
      Use of teleophthalmology using retinal photography is well established, particularly for diabetic screening programmes [
      • Tozer K.
      • Woodward M.A.
      • Newman-Casey P.A.
      Telemedicine and diabetic retinopathy: review of published screening programs.
      ,
      • Sim D.A.
      • Mitry D.
      • Alexander P.
      • Mapani A.
      • Goverdhan S.
      • Aslam T.
      • et al.
      The evolution of teleophthalmology programs in the United Kingdom: beyond diabetic retinopathy screening.
      ], but studies investigating the anterior segment have yielded mixed results [
      • Kumar S.
      • Yogesan K.
      • Constable I.J.
      Telemedical diagnosis of anterior segment eye diseases: validation of digital slit-lamp still images.
      ,
      • Woodward M.A.
      • Musch D.C.
      • Hood C.T.
      • Greene J.B.
      • Niziol L.M.
      • Jeganathan V.S.E.
      • et al.
      Tele-ophthalmic approach for detection of corneal diseases: accuracy and reliability.
      ,
      • Woodward M.A.
      • Bavinger J.C.
      • Amin S.
      • Blachley T.S.
      • Musch D.C.
      • Lee P.P.
      • et al.
      Telemedicine for ophthalmic consultation services: use of a portable device and layering information for graders.
      ,
      • Shimmura S.
      • Shinozaki N.
      • Fukagawa K.
      • Shimazaki J.
      • Tsubota K.
      Real-time telemedicine in the clinical assessment of the ocular surface.
      ].
      A comparison between digital slit lamp images and conventional slit lamp examination found that while gross corneal signs, such as a corneal graft, could be detected using digital images (sensitivity 88 %; specificity 98 %), sensitivity to more subtle corneal and conjunctival signs was poorer, with some pathologies not being detected at all [
      • Kumar S.
      • Yogesan K.
      • Constable I.J.
      Telemedical diagnosis of anterior segment eye diseases: validation of digital slit-lamp still images.
      ]. Similarly, a comparison between conventional corneal examination versus digital images (obtained using the Apple iTouch 5 G, [Apple, Cupertino, CA] and Nidek VersaCam [Nidek, Fremont, CA] cameras), showed sensitivity with photographs was, in general, high for pathologies such as pterygium (sensitivity >90 %), but not corneal scarring (sensitivity <58 %) [
      • Woodward M.A.
      • Musch D.C.
      • Hood C.T.
      • Greene J.B.
      • Niziol L.M.
      • Jeganathan V.S.E.
      • et al.
      Tele-ophthalmic approach for detection of corneal diseases: accuracy and reliability.
      ]. Of particular relevance to contact lens work is a report which showed grading of corneal staining was underestimated when using digital images compared to live grading using a slit lamp [
      • Sorbara L.
      • Peterson R.
      • Schneider S.
      • Woods C.
      Comparison between live and photographed slit lamp grading of corneal staining.
      ]. Thus, the overarching indication is that subtle anterior eye changes are generally less discernible using photographs compared to direct observation. Improvements in sensitivity, though not necessarily specificity, to detection of anterior segment pathology using photographs may be achieved by considering the photos in combination with patient history and visual acuity information [
      • Woodward M.A.
      • Bavinger J.C.
      • Amin S.
      • Blachley T.S.
      • Musch D.C.
      • Lee P.P.
      • et al.
      Telemedicine for ophthalmic consultation services: use of a portable device and layering information for graders.
      ].
      Anterior eye imaging, particularly self-imaging, presents several additional challenges compared to fundus photography: the need to use diagnostic drugs (e.g. fluorescein sodium), to obtain cross-sectional images, and constraints around lid eversion. All these techniques are possible for an ECP in an outreach clinic, but impractical for a patient at home.
      Although the usefulness of anterior eye self-imaging can be extended by capturing images with the eye in different positions of gaze, the capture of digital anterior eye images using a smartphone camera has a number of limitations. The optical magnification without a macro lens is typically ∼2 times. At higher magnifications, the shorter depth of focus will render the image vulnerable to small camera movements and the closer working distance makes it harder for the user to judge the focus and positioning (due to the camera being off-set from the screen).
      For all types of anterior imaging, there will be variations in camera quality, image hue, and intensity, but whether such lack of standardisation will negatively impact clinical outcomes is less clear. Images of conjunctival hyperaemia obtained using different smartphone cameras and lighting conditions showed that although objective evaluation of images differed, clinician evaluations remained unaffected [
      • Otero C.
      • García-Porta N.
      • Tabernero J.
      • Pardhan S.
      Comparison of different smartphone cameras to evaluate conjunctival hyperaemia in normal subjects.
      ]. Nonetheless, it would be helpful to develop image standard references similar to those available for the posterior eye [

      Government Digital Service www.gov.uk, Diabetic eye screening programme: pathway for adequate or inadequate images and where images cannot be taken, viewed 5th April 2020 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/403107/Pathway_for_adequate_inadequate_images_and_where_images_cannot_be_taken_v1_4_10Apr13.pdf.

      ]. The introduction of objective image analysis software and other semi-automated image segmentation tools could then be used to further standardise practice [
      • Kunnen C.M.
      • Wolffsohn J.S.
      • Ritchey E.R.
      Comparison of subjective grading of lid wiper epitheliopathy with a semi-objective method.
      ,
      • Huntjens B.
      • Basi M.
      • Nagra M.
      Evaluating a new objective grading software for conjunctival hyperaemia.
      ,
      • Patel T.P.
      • Prajna N.V.
      • Farisu S.
      • Valikodath N.G.
      • Niziol L.M.
      • Dudeja L.
      • Kim K.H.
      • Woodward M.A.
      Novel image-based analysis for reduction of clinician-dependent variability in measurement of corneal ulcer size.
      ]. However, it is hard to envisage current smartphone technology being able to detect corneal pathology such as infiltrates and neovascularisation without accessories. In addition, the palpebral conjunctiva is not visible without specialised techniques [
      • Wolffsohn J.S.
      • Tahhan M.
      • Vidal-Rohr M.
      • Hunt O.A.
      • Bhogal-Bhamra G.
      Best technique for upper lid eversion.
      ].

      6. Contact Lens fitting

      With specific reference to contact lenses; there are various lens replacement reminder apps for patients and web-based tools to support practitioner prescribing, but patient driven teleoptometry is less well developed. The feasibility of lens fitting apps is likely to be limited by difficulties in visualising lenses, particularly soft lenses, against the non-uniform background of the ocular surface, without the magnification and illumination benefits provided by a slit lamp. The potential for future lens fitting assessment apps may be inferred from studies investigating video evaluation of lens fits.
      Smythe et al. (2001) reported an approximate 80 % agreement in fit reliability between live versus (electronically compressed) video evaluation of the RGP lens fits by ECPs [
      • Smythe J.
      • Yolton R.L.
      • LeRoy A.
      • Achong R.
      • Caroline P.
      • Van M.N.
      • et al.
      Use of teleoptometry to evaluate acceptability of rigid gas-permeable contact lens fits.
      ], although the agreement for estimation of refit parameters was slightly lower (67 %). Belda‐Salmerón et al. (2015) went further by comparing video evaluation of soft lens fits using objective analysis software to subjective lens evaluation by optometrists. Though, good concordance between subjective and objective approaches was reported for a range of parameters, objective analysis was deemed more reliable and sensitive [
      • Belda-Salmerón L.
      • Drew T.
      • Hall L.
      • Wolffsohn J.S.
      Objective analysis of contact lens fit.
      ],

      7. Summary

      There are, of course, many other vision related apps which show promising outcomes e.g. for the assessment of manifest and latent deviations; [
      • Pundlik S.
      • Tomasi M.
      • Liu R.
      • Houston K.
      • Luo G.
      Development and preliminary evaluation of a smartphone app for measuring eye alignment.
      ] visual field screening [
      • Johnson C.A.
      • Thapa S.
      • Kong Y.X.G.
      • Robin A.L.
      Performance of an iPad application to detect moderate and advanced visual field loss in Nepal.
      ]; and contrast sensitivity [
      • Habtamu E.
      • Bastawrous A.
      • Bolster N.M.
      • Tadesse Z.
      • Callahan E.K.
      • Gashaw B.
      • et al.
      Development and validation of a smartphone-based contrast sensitivity test.
      ]. The majority remain unvalidated for self-administration by patients.
      In addition to well researched and validated tools; usability, practitioner opinions, and medico-legal implications are likely to influence the uptake of teleoptometry.
      In summary, this unique period of global change has led to shifts in the way many professions work. While other health professions are transitioning to telehealth services, the absence of a comprehensive evidence base for teleoptometry somewhat limits ECPs. Given the uncertain duration over which conventional methods of practice will be suspended, gaps in the research ought to be addressed to facilitate development of optometry specific evidence-based guidance for telecare. Specifically, advances in ocular self-imaging and standardisation of such imaging would help to move this field forwards.

      Funding

      This work did not receive funding.

      Acknowledgement

      None.

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