Characterization and Utility of Remote Interpretation of Visual Field Diagnostic Testing in an Academic Center

The use of remote interpretation of data has risen in neuro-ophthalmology to increase efficiency and maintain social distancing due to the coronavirus disease-19 pandemic. The purpose of this study is to characterize the use and efficiency of remote interpretation of visual fields (VFs) in an academic center and to determine how often the VF interpretation was consistent with the patient's clinical history and imaging at the time of the consult

Original Contribution Section Editors: Clare Fraser, MD Susan Mollan, MD Characterization and Utility of Remote Interpretation of Visual Field Diagnostic Testing in an Academic Center Felix F. Kung, MD, Timothy T. Xu, MD, Jacqueline A. Leavitt, MD, Victoria I. Lossen, MD, Kevin E. Lai, MD, Melissa W. Ko, MD, M. Tariq Bhatti, MD, John J. Chen, MD, PhD Background: The use of remote interpretation of data has risen in neuro-ophthalmology to increase efficiency and maintain social distancing due to the coronavirus disease19 pandemic. The purpose of this study is to characterize the use and efficiency of remote interpretation of visual fields (VFs) in an academic center and to determine how often the VF interpretation was consistent with the patient’s clinical history and imaging at the time of the consult. Methods: This is a retrospective study at a single academic center that enrolled all patients receiving a remote interpretation of VF from January 1, 2012, through December 31, 2012. Data were collected regarding the referring department, indication for the VF, interpretation of the VF and comparison with any prior VFs, any associated interventions with the VF, and available follow-up VFs. The main outcome measures included 1) characterizing the use of remote VF interpretations and 2) how many remote VF interpretation results were consistent with the referring diagnosis based on the patient’s clinical history and imaging. Results: One hundred eighty patients received remote interpretation of VFs. The most frequent referring departments were endocrinology (79; 44%), neurology (51; 28%), and neurosurgery (43; 24%). The VF indications included parasellar lesion (107; 59%), seizure disorder (26; 14%), meningioma (19; 11%), vascular lesion (11; 6%), and others (17; 9%). There were 78 patients (43%) that had an intervention before the VF, whereas 49 (27%) were preoperative VFs. Eighty-seven (48%) of the VFs were interpreted as abnormal. Of all the 180 remote interpretation Mayo Clinic Alix School of Medicine (FFK, TTX), Mayo Clinic, Rochester, Minnesota; Departments of Ophthalmology (JAL, VIL, MTB, JJC) and Neurology (JAL, MTB, JJC), Mayo Clinic, Rochester, Minnesota; Circle City Neuro-Ophthalmology (KEL), Carmel, Indiana; Neuro-Ophthalmology Section (KEL), Midwest Eye Institute, Carmel, Indiana; Ophthalmology Service (KEL), Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana; and Departments of Ophthalmology (KEL, MWK) and Neurology and Neurosurgery (MWK), Indiana University School of Medicine, Indianapolis, Indiana. The authors report no conflicts of interest Address correspondence to John J. Chen, MD, PhD, Departments of Ophthalmology and Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; E-mail: [e-mail] Kung et al: J Neuro-Ophthalmol 2022; 42: e1-e7 of VFs, 156 (87%) had VF interpretations that were consistent with the clinical question posed by the referring provider based on clinical history and imaging. Among the other 24 remote VF interpretations (13% of total remote VF interpretations), there was no clear interpretation because of either additional unexpected VF defects (n = 5, 21%), VF defect mismatch (n = 6, 25%), or unreliable VFs (n = 13, 54%). The median wait time for patients receiving remote VF interpretations was 1 day. Conclusions: Remote interpretation of VFs was most often requested by endocrinology, neurology, and neurosurgery and could be performed very quickly. The most common indications were parasellar lesions, and just less than half of patients receiving remote VF interpretations had a prior intervention. A majority of remote VF interpretations were able to answer the clinical question, given the patient’s clinical history and imaging. Remote interpretation of VFs may thus offer referring departments a more efficient method of obtaining VF interpretations than in-office neuro-ophthalmology examinations. Journal of Neuro-Ophthalmology 2022;42:e1–e7 doi: 10.1097/WNO.0000000000001481 © 2022 by North American Neuro-Ophthalmology Society INTRODUCTION F or many years, neuro-ophthalmology has faced a shortage of physicians in the field that impedes access to patient care (1–6). A recent North American NeuroOphthalmology Society (NANOS) survey showed that new patients wait an average of 6 weeks to see a neuroophthalmologist, with more than 30% of patients reporting over 3-month wait times (6). In addition, changes to billing and reimbursement practices that prioritize procedural specialties place an increasing demand for neuroe1 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution ophthalmologists to develop more efficient clinical evaluation procedures (1,2,7,8). Strategies to address this mismatch in supply and demand of neuro-ophthalmologists include new care delivery models that expand access to patient care and improve efficiency (2,5). Tele neuro-ophthalmology, and teleophthalmology in general, is one such model that enables physicians to screen and triage patients on a wide scale level before seeing them in the office, facilitating more effective and efficient patient care as well as shifting the focus of in-office visits to patients with active disease requiring direct intervention or close monitoring (9). Some traditional barriers to increased telehealth adoption included cultural norms and substantially lower or lack of reimbursements compared with in-person patient visits, but in the setting of the coronavirus disease-2019 (COVID-19) pandemic, more equitable reimbursement changes and mandates for social distancing have caused telehealth use in neuroophthalmology to skyrocket (3,5,10,11). Remote interpretation of diagnostic testing is a telehealth modality in which a patient is referred to the consultant’s office for specific diagnostic testing, the office performs the test, and the consultant provides an interpretation based on clinical history/previous tests without any management recommendation and without seeing the patient (12). Because many questions posed to the neuro-ophthalmologist are narrowly defined test interpretation requests from other health care specialists, remote interpretation of diagnostic testing offers a way to improve efficiency of care by answering the referring question quickly in cases where an in-person examination is not necessary. The prevalence of remote interpretation of data in ophthalmology has increased since the start of the COVID-19 pandemic; however, there are limited studies describing their use and effectiveness (10). In this study, we will describe an implementation of remote interpretation of visual field (VF) diagnostic testing at a single academic institution, which was initially started a decade ago. We will also investigate how often the remote interpretation of VFs was able to provide an interpretation consistent with the referral diagnosis, given the patient’s clinical history and imaging. METHODS This study is in compliance with the Health Insurance Portability and Accountability Act (HIPAA), received retrospective approval from the Mayo Clinic Institutional Review Board, and adhered to the tenets of the Declaration of Helsinki. This retrospective study at a single institution enrolled all patients receiving a remote interpretation of VFs from January 1, 2012, through December 31, 2012. Data were collected by a chart review regarding the referring department, indication for the VF, interpretation of the VF, comparison with any prior VF testing, any associated interventions with the VF such as preoperative/ e2 postoperative surgeries or radiation, and any available follow-up VFs through March 2, 2021. At the study institution, physicians within a select list of departments were authorized to order remote interpretation of VFs. These included physicians within endocrinology, neurology, neurosurgery, medical and radiation oncology, the brain rehabilitation division of physical medicine and rehabilitation (PM&R), and other departments on a case-by-case basis. Each referring physician determined the appropriate patients for a VF without examination and placed an order through the electronic medical record (EMR). The remote interpretation of VF consisted of a Swedish Interactive Testing Algorithm standard 24-2 on the automated analyzer (Carl Zeiss Meditec AG, Jena, Germany), visual acuity, and color vision, which were collected by an ophthalmic technician and entered into the EMR for the neuro-ophthalmologist to review. During the remote interpretation of VF, visual information, indication for the test, any previous VFs, and pertinent neuroimaging were all reviewed by a neuro-ophthalmology consultant. The results of the remote interpretation included the field defect and severity. The MRI findings, if available, were not typically discussed, but they were reviewed to ensure the field defect made sense. These remote interpretation results were then documented in the EMR, where the referring provider could see the interpretation. There was no verbal communication. The encounter and visit were not billed for, but the patient was billed for the technician fee of performing the visual field and the physician fee of interpreting the visual field. The main outcome measures of the study included 1) characterizing the use of remote interpretation of VFs such as referral source, diagnosis, purpose of consultant, and wait time for consult read and 2) determining how many remote interpretations of VF results were consistent with the patient’s existing diagnoses given the patient’s clinical history and imaging. The secondary outcome measure included how often a follow-up VF result was performed, if available, and how it compared with the findings from the 2012 remote interpretation of VF. Statistical Analysis Categorical variables were presented with the frequency and percentage. Continuous variables were summarized using the median and interquartile range. All analyses and figures were completed using RStudio version 1.4.1106 and R version 4.0.4. RESULTS Characterization and Efficiency of Remote Interpretation of Visual Fields One hundred eighty patients were referred for 196 remote interpretations of VFs. For patients referred for multiple remote interpretations of VFs in 2012, only the initial remote interpretation was included, thus resulting in 180 remote interpretations from 180 patients. The referring Kung et al: J Neuro-Ophthalmol 2022; 42: e1-e7 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution departments included endocrinology (n = 79; 44%), neurology (n = 51; 28%), neurosurgery (n = 43; 24%), medical oncology (n = 2; 1%), radiation oncology (n = 2; 1%), the brain rehabilitation division of PM&R (n = 1; 0.6%), cardiology (n = 1; 0.6%), and community internal medicine (n = 1; 0.6%) (Fig. 1). The indications for obtaining remote VF interpretations included parasellar lesion (n = 107; 59%), seizure disorder (n = 26; 14%), meningioma (n = 19; 11%), vascular lesion (n = 11; 6%), and others (n = 17; 9%) (Fig. 2). There were 78 patients (43%) referred for a remote interpretation of VFs to evaluate postsurgical or postradiation visual field appearance, whereas 49 patients (27%) were referred to document VFs before an intervention. Of the 180 patients referred for a remote interpretation of VFs, 66 (37%) had a documented VF before the 2012 remote interpretation of VF. Sixty-two patients (34%) had a prior eye examination documented, and 143 patients (79%) received a refraction at the same time of the 2012 remote interpretation of VFs. The consult-to-visual field time was also evaluated. Of the 180 remote VF interpretations, 68 (38%) were prescheduled follow-ups to monitor a known disease process (e.g., a 3-month postop visit), and thus, the referral times for these remote VF interpretations were excluded. For the remaining remote interpretation of VFs, the median wait time from remote interpretation of VF order to the patient undergoing the VF test and read was 1 (interquartile range: 0, 6.75) day (Fig. 3). Patients who had longer waits (over 10 days) were often traveling from out of state, where they first came for initial visits with some providers, then went home and returned for a next round of tests. Remote Interpretation of Visual Field Results Eighty-seven (48%) of the 180 VFs were interpreted as abnormal. The types of defects included bitemporal hemianopia (n = 25; 29%), homonymous hemianopia (n = 22; 25%), nonspecific defect (n = 7; 8%), arcuate defect (n = 6; 7%), generalized constriction (n = 6; 7%), generalized depression (n = 5; 6%), junctional scotoma (n = 4; 5%), paracentral scotoma (n = 1; 1%), unreliable (n = 7; 8%), and others (n = 4; 5%). Of the 180 remote interpretation of VFs, 156 (87%) of the interpretations were consistent with the referral diagnoses, given the patient’s clinical history and imaging. Among the other 24 remote interpretation of VFs (13% of total remote VF interpretations), there was no clear interpretation due to either unreliable VFs (n = 13, 54%), VF FIG. 1. Ordering department for visual field remote interpretations. Visual field remote interpretations were primarily initiated by the endocrinology, neurology, and neurosurgery departments. BrainPMR, brain rehabilitation division of physical medicine and rehabilitation; CIM, community internal medicine; MedOnc, medical oncology; RadOnc, radiation oncology. Kung et al: J Neuro-Ophthalmol 2022; 42: e1-e7 e3 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution FIG. 2. Indications for visual field remote interpretations. Parasellar lesions, seizures, and meningiomas were the most common reasons for obtaining visual field (VF) remote interpretations. Many patients obtained VF remote interpretations for postintervention follow-up (n = 69; 38%), for a baseline VF before an intervention (n = 40; 22%), or for both (n = 9; 5%). Diagnoses in the “other” category included astrocytoma, visual changes, granulomatosis with polyangiitis, Paget disease, cognitive difficulty, migraine, hydrocephalus, papilledema, and optic atrophy, dermoid cyst, and arachnoid cyst. defects that were not consistent with the referring diagnosis (n = 6, 25%), or additional unexpected VF defects (n = 5, 21%). Follow-up Visual Fields Of the 180 patients receiving remote interpretation of VFs, 84 (47%) received a follow-up VF between the initial remote interpretation and March 2, 2021. The median (interquartile) time of the follow-up VF after the 2012 remote interpretation was 3.0 (0.80, 5.42) years. For the 87 patients with abnormal VFs in 2012, 45 patients (52%) received a follow-up VF. Of these follow-up VFs, 24 (53%) were stable, 6 (13%) worsened, 12 (27%) improved, and 3 (7%) were unreliable. Among the 6 VFs e4 that worsened, 4 patients (66%) worsened due to the referring diagnosis and 2 patients (33%) developed additional VF defects from pathology different than the referring diagnosis (coincident glaucoma and new stroke). For the 93 patients with normal VFs in 2012, 38 patients (41%) received a follow-up VF. Of these follow-up VFs, 35 (92%) remained normal, 2 (5%) worsened, and 1 (3%) was unreliable; the 2 patients with worsened VFs had progression of their referred diagnosis. CONCLUSIONS In the setting of the long-standing shortage of neuroophthalmologists, there is increasing interest in deploying telehealth to improve efficiency and expand access to neuroKung et al: J Neuro-Ophthalmol 2022; 42: e1-e7 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution FIG. 3. Time from referral to visual field remote interpretation. Over half of new visual field (VF) remote interpretations were completed within one day. ophthalmic care (1,6,10,11). Remote interpretation of data offers an efficient method to answer clinical questions for conditions that do not rely heavily on the physical examination (4). Since the start of the COVID-19 pandemic, the prevalence of remote interpretation of data has increased from 27% to 32% (10). This value does not fully reflect the growth of this modality though, since during the immediate peri-COVID period surveyed, 22% had to discontinue its use because of required shutdown of offices/ practices, and actually 15.6% of previous nonusers adopted this practice peri-COVID (12). There is limited literature describing the use and effectiveness of remote interpretation of data in ophthalmology and neuro-ophthalmology. In this study, we described the use of remote interpretation of VFs at a single academic center, which has been in practice long before the COVID-19 pandemic. Remote VF interpretations were most often requested by the endocrinology (44%), neurology (28%), and neurosurgery (24%) departments. The most common indication for VF was for parasellar lesions (59%), whereas seizure disorder (14%) and meningioma (11%) were other common Kung et al: J Neuro-Ophthalmol 2022; 42: e1-e7 indications. Nearly half (43%) of patients receiving remote interpretation of VFs had a prior intervention (surgery or radiation), whereas 27% of patients were referred for baseline VF before a subsequent intervention. More than half of new remote interpretation of VFs was completed within 1 day. About half (48%) of the VFs were abnormal, and the most common defects included bitemporal hemianopia (29%), homonymous hemianopia (25%), nonspecific defects (8%), and unreliable VFs (8%). When we correlated the remote interpretation of VF findings with the patient’s clinical history and imaging, most remote interpretation of VFs (87%) had interpretations consistent with the referring diagnosis. Among the 13% that did not, reasons included unreliable VFs (46%), VF defect mismatch (25%), additional unexpected VF defects (21%), and unsure if the defect was real (8%). Overall, most VFs had interpretations consistent with the referring diagnosis, which was sufficient to answer the clinical question posed by the referring provider. Unreliable VFs were a large reason for the VFs that could not be fully interpreted remotely. e5 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution Our results suggest that remote interpretation of VFs could be used as an efficient first-line method to adequately answer common clinical questions pertaining to VFs. Unreliable or inconsistent visual fields may be less common, and patients with these uninterpretable tests may benefit from additional examination. About half (47%) of the patients in our study received a follow-up VF between 2012 and March 2, 2021, with a median length of 3.0 years after the initial 2012 remote VF interpretation. If the patient initially had an abnormal VF, most patients had stable or improved VFs at followup (80%). For the 13% of patients with worsening VFs, most had progression attributed to the referring diagnosis. This supports the use of remote interpretation of VFs to monitor disease, but some patients may benefit from additional examination if there are unexpected VF findings. Our findings are similar to studies conducted in retinopathy of prematurity and diabetic retinopathy that report the ability of remote interpretation of data and e-consults to address specific clinical scenarios while expediting care (13–19). Of note, remote interpretation of VFs are not a replacement for routine eye examinations because patients can still develop other ocular diseases such as glaucoma or age-related macular degeneration, but they are helpful in monitoring known diseases, such as a pituitary macroadenoma. Limitations of this study include the retrospective study design and the smaller numbers. Some patients had unreliable VFs which made interpretation difficult. For our secondary outcome measure investigating follow-up, only about half of the study patients had follow-up VFs. At our institution, we continue to implement the same protocol and now perform about 300 remote VF interpretations a year. COVID-19 did not influence our numbers because our process was already in place beforehand. This study has confirmed its utility in our system and will be planned to be continued as a means of providing efficient interpretations of VFs. In conclusion, this study describes a practical implementation and effectiveness of remote interpretation of VFs in an academic neuro-ophthalmic practice. We propose that remote VF interpretations can be an efficient method of answering certain clinical questions that may not require in-person examination and may encourage further investigation and utilization of this modality to increase clinical efficiency and expand access to neuroophthalmic care. STATEMENT OF AUTHORSHIP F. F. Kung: conceptualization, methodology, formal analysis, investigation, writing—original draft, writing—review and editing, and visualization. T. T. Xu: conceptualization, methodology, investigation, writing—review and editing. J. A. Leavitt: conceptualization, methodology, investigation, writing—original draft, writing—review e6 and editing, and funding acquisition. V. I. Lossen: conceptualization, methodology, investigation, and writing—original draft. K. E. 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