Teleophthalmology

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Article initiated by:
Albert S Khouri, MD, Ashley Ooms, Ben Szirth PhD
All contributors:
Helia Ashourizadeh, Koushik Tripathy, MD (AIIMS), Albert S Khouri, MD, Neelakshi Bhagat, MD, FACS, Jennifer I Lim MD, Grayson W Armstrong MD MPH
Assigned editor:
Review:
Assigned status Update Pending
 by Neelakshi Bhagat, MD, FACS on September 19, 2025.


Significance

Anterior segment photo showing wheel-spoke pattern of cataracts.

Teleophthalmology is evolving into an integral clinical tool in the American healthcare system. It allows clinicians to provide quality health care outside of clinics, thus improving access to medical care, patient outcomes, and overall patient satisfaction. Eye screenings are conducted within the community, often in schools, health fairs, and places of worship.[1] Bringing the clinic directly to the patients allows health professionals to capture more vision threatening diseases (VTD) such as diabetic retinopathy, glaucoma, age-related macular degeneration, and cataract.[2] By detecting VTD’s early on, teleophthalmology allows for timely referral to appropriate experts and consequently, earlier treatment.[1][3] This tool is actively being used in the US army to support the accessibility of ophthalmic care for military personnel, and allied forces worldwide.[4]

Screening sites may not have the comprehensive eye examination equipment that is readily available in a permanent clinical facility, such as slit lamps, phoropters and other imaging equipment.[3] On-site screenings may utilize smaller footprint equipment including an automated refractor, non-contact tonometer, non-mydriatic retinal camera, and optical coherence tomography. Often, screenings are advertised to the local community via email, newsletters, or by word of mouth. A qualified ophthalmologist, known as the reader, is available either in person or remotely to interpret the data collected and develop an assessment and treatment plan for the screened patient.

Teleophthalmology may potentially provide health services to underserved and remote rural populations who otherwise may not have access to specialized eye care.[3][5] Tele-ophthalmology has the potential to improve ophthalmic care and diagnose VTDs.[1][6] Ultimately, the goal of tele-ophthalmology is to decrease the global burden of vision threatening disease and improve the quality of life for patients with eye diseases worldwide. Environmental benefits have been demonstrated by decreasing carbon emissions as a result of reduced patient travel. [7]

Ophthalmic Telemedicine Models of Care

Telemedicine in ophthalmology has adapted to accommodate various care delivery models, evolving with technological advancements and changing needs of patients and providers. To optimize these programs, defining clear objectives for visits—such as screening, triage, follow-up, and management—is crucial, ensuring they align with the selected care model.[8]

  1. Physician to Patient (Direct Care): This model involves direct interaction between the ophthalmologist and the patient via video or audio calls, allowing for real-time consultations. This synchronous communication can be supplemented with asynchronous data review, where physicians assess patient-provided images or previous records at a different time.
  2. Physician to Physician (Consultation and Second Opinions): This model facilitates inter-professional collaboration, where ophthalmologists can consult with peers or other specialists to discuss complex cases or seek second opinions. This can be synchronous, or asynchronous.
  3. Hybrid Models: Combining in-person visits with telemedical consultations, such as testing-only visits followed by remote interpretations, provides a balanced approach that maximizes the benefits of both direct and remote care.

Components of an Ophthalmic Telemedicine Visit

Conducting an effective ophthalmic telemedicine visit involves a structured setup that begins with pre-visit preparations, ensuring that patients are equipped with the necessary technology and environment to facilitate a thorough examination. This includes access to a stable internet connection, high-quality audio/video capabilities, and telecommunication software that adheres to HIPAA compliance for safeguarding patient data.

Patient History

A focused patient history is acquired prior to screening using a standardized intake form. Demographic data including age, gender, and ethnicity, as well as medication use and a brief medical ocular and surgical history is obtained. Additional data may be collected particularly if the ophthalmic evaluation is conducted as a part of a health fair where other medical specialties are conducting health screening (for example: Body Mass Index, blood pressure, pulse oximetry, smoking status, dietary habits). Additionally, patients are asked if they have a family history of pertinent medical conditions like hypertension, hyperlipidemia, diabetes, cardiovascular disease, and eye conditions.

Visual Acuity

Assessing visual acuity is critical in teleophthalmology, and many digital applications and web-based tools exist for this purpose. Simple options include websites like farsight.care with Snellen-style near acuity charts, and distance acuity tools that pair with a phone camera like Myeyes.ai and Easee.online. For patients with limited digital literacy, printable visual acuity charts with instructions can facilitate remote assessments by caregivers. The visual acuity outcome then has to be placed in the context of the eye evaluation to help identify the cause of blurred vision.[9]

Community screening showcasing the use of an automated refractor and non-contact tonometer.

Automated Refractor

Tele-refraction can be performed through web-based assessments, hybrid models with in-person technicians, or portable autorefractors. There are multiple commercially available autorefractors, some of which integrate with smartphones, while others function as standalone units.[10]

Automated refractors are key in measuring the eye’s refractive state in sphere, cylinder, and axis. These measurements are then fine tuned in order to be translated into an eyeglasses corrective prescription for the patient. Because these measurements are automated, this measurement requires minimal communication. Autorefractors are particularly useful when there is a language barrier between provider and subject as well as with younger children and those with disabilities.[11] [12] Automated refractors generate an estimate of the refractive error of the eye and are then fine tuned with an actual refraction by a health care provider prior to being dispensed.

Non-contact Tonometry

Non-contact tonometry, as in "air-puff" tonometry, is used to measure intraocular pressure in a noninvasive manner. These instruments are easy to handle and do not require anesthetic eye drops or fluorescein administration, making it especially useful in a field setting and with less cooperative patient groups such as young children and disabled persons.[13] This is a critical test in screening for eye diseases like glaucoma, a leading cause of blindness in people over 60 and one of the leading causes of blindness globally.[14] Non-contact tonometry correlates well with other contact measurements (as in Goldmann applanation tonometry) yet may over or under-estimate intraocular pressure in some individuals and may need to be interpreted in the context of a screening test and be rechecked in the office by an ophthalmologist for confirmation. The iCare Home tonometer provides reliable home-based IOP readings comparable to Goldman applanation tonometry, making it suitable for glaucoma monitoring[15]. Contact lens biosensors like the FDA-approved Sensimed Triggerfish can continuously monitor IOP fluctuations by measuring changes in ocular shape.[16]

Anterior Segment Assessment

A variety of telehealth technologies exist for anterior segment imaging, ranging from slit lamp-based modalities to smartphone and webcam-based approaches.[17] Slit lamp imaging, including robotic slit lamps and smartphone/digital camera attachments, can provide high-fidelity images akin to in-office exams, though robotic options are costly and require longer examination times. [18]

External Periorbital examinations

Smartphones and webcams have significantly enhanced the examination of the external eye and periorbital area. Smartphones are particularly effective due to their wide availability, enabling both synchronous and asynchronous assessments. They have proven valuable in diagnosing conditions like red eye and postoperative eyelid complications, as well as aiding in emergency department consultations, reducing unnecessary ER visits[19][20]. Additionally, video-based visits have been shown to be feasible and successful in the remote diagnosis and management of adnexal and peri-orbital lesions.[21]

Ocular Surface

There are numerous reports and widespread implementation of managing ocular surface disorders via teleophthalmology.[22][23] Conditions like corneal ulcers, scars, pterygia, conjunctivitis, chalazion, hordeolum, and scleritis are regularly evaluated using virtual platforms. Smartphones, equipped with accessories like the SmartEye Camera, provide enhanced capabilities for diagnosing corneal conditions, matching over 90% sensitivity of traditional slit lamp examinations[24]. These devices can also be adapted with blue filters and macro lenses to improve diagnostic imaging of fluorescein staining.

Lens

Accurate assessment of lens structure plays an important role in assessing cataract as one of the important causes of blindness in the world. Both handheld digital slit lamps[25] and smartphone cameras with the addition of a macro lens and augmented LED illumination have been shown to yield good image quality [26]. More recently, advancements in artificial-assisted screening, diagnosis and referral of cataract have been implemented as well. [27]

Posterior Segment Assessment

Fundus Photography

Digital non-mydriatic retinal cameras allow for imaging of the retina, retinal vasculature, optic disc, and macula. It is a vital tool in evaluation as it allows diagnosing disease processes like diabetic retinopathy, age-related macular degeneration, glaucoma, and hypertensive retinopathy.[28] Cataracts may also be suspected when fundus image quality is limited by media opacities. Low light conditions are used to induce physiological pupillary dilation, foregoing the need for dilating (mydriatic) eye drops and thus making fundus photography a more accessible tool to be used within the community.[5] Additionally, fundus autofluorescence (FAF) has been successfully integrated in community based ocular screening programs. Some retinal camera models can perform nonmydriatic 45 degree color imaging and FAF imaging, allowing the convenience of a single instrument needing to be transported. FAF significantly improves the screeners’ abilities to characterize retinal changes and highlights certain ocular pathology more predominantly than color fundus photography alone.[29]

Top right: Color fundus photo of healthy right eye. Top left: Color fundus photo of the optic nerve head with advanced cupping and loss of neural retinal rim, indicative of glaucoma. Bottom left: Color fundus photo of healthy left eye. Bottom right: Red free photo of the same left eye showing no abnormalities with a healthy appearing macula.

Optical Coherence Tomography

Optical Coherence Tomography (OCT) is a noninvasive imaging test that allows screeners to obtain high resolution, cross-sectional images of the retina, retinal nerve fiber layer, optic nerve head, and anterior segment. The OCT is an invaluable tool in ocular screenings, especially in the cases of age-related macular degeneration, glaucoma, and diabetic retinopathy.[30][31] Anterior segment OCT can also be used to identify narrow angle at risk for potential glaucoma.

Documentation and Billing

Teleophthalmology visits require documentation similar to in-person appointments, plus telemedicine-specific records such as patient consent, doctor and patient locations, and consultation duration. These details are essential for meeting varying insurance requirements and ensuring virtual visits match traditional care standards.

Initially, during the COVID-19 pandemic, telemedicine visits were often reimbursed at rates comparable to in-person consultations, with simplified billing protocols. However, billing practices have since evolved. Now, reimbursement considers factors like time spent, medical decision-making processes, and specific eye codes. Additional billing considerations include the use of modifiers and accurately documenting the place of service.

To ensure accurate billing and proper reimbursement for telemedicine services, it is crucial for ophthalmologists to stay updated with the latest guidelines from relevant ophthalmic associations.

Ethical Considerations

All telemedicine visits require adherence to ethical guidelines, including maintaining patient confidentiality and recording clinical data for continuity of care. It is also crucial to be aware that telemedicine can inadvertently exacerbate health disparities among populations with limited access to technology or lower health literacy.[32] Ethical practice also involves obtaining informed consent and providing patients with clear information about the nature of telemedicine consultations and associated costs. By addressing these ethical challenges, telemedicine can be a tool that enhances, rather than compromises, the fairness and quality of ophthalmic care.

Future Directions and Challenges

The major challenges of tele-ophthalmology revolve around patient retention and pursuing follow up appointments after ocular disease detection. Additionally, regulatory challenges restrict the wide use of tele-ophthalmology as a viable option for health care throughout the United States. Future initiatives need to focus on engaging policies to regulate telemedicine applications in ophthalmology. Challenges also remain regarding cost and reimbursement for tele-ophthalmology services, thus limiting a more widespread adoption of tele-ophthalmology. The American Academy of Ophthalmology and other societies have recognized the value of tele-ophthalmology in providing valuable ocular services especially to subjects in remote and under-served communities. The Veteran Administration has also initiated landmark initiatives in tele-ophthalmology to enhance the care of veterans. In India, a tele-ophthalmology model, KIDROP has been successful in detecting retinopathy of prematurity and delivering care to underserved areas. In the settings epidemics and pandemic like COVID19 infection (2020), tele-ophthalmology can become a preferred mode for delivering initial contact with the patient. Tele-ophthalmology can reduce healthcare costs, increase access in underserved areas, and improve DR screening and detection; however, reimbursements by insurance companies and failure to implement the technology and much needed areas remain barriers to the use of this technology.

Artificial intelligence (AI)-Human hybrid based Teleophthalmology is being evaluated as an alternative improved means of DR screening. [33][34]

Additional Resources

References

  1. ↑ 1.0 1.1 1.2 Sreelatha, O. K. & Ramesh, S. V. Teleophthalmology: improving patient outcomes? Clin. Ophthalmol. Auckl. NZ 10, 285–295 (2016).
  2. ↑ Szirth, B., Khouri, A., Bhagat, N. & Shahid, K. New Concepts in Screening for Vision Threatening Disease. Invest. Ophthalmol. Vis. Sci. 48, 1578–1578 (2007).
  3. ↑ 3.0 3.1 3.2 Rural and Remote Health. Available at: https://rrh.org.au/. (Accessed: 27th June 2018)
  4. ↑ Anthony CM, Altman AH, Otte B, Mines MJ, Mazzoli RA, Lappan CM, Legault GL. Teleophthalmology in the United States Army: A Review From 2004 Through 2018. Mil Med. 2023 Jan 4;188(1-2):e182-e189.
  5. ↑ 5.0 5.1 Shahid, K. et al. Ocular Telehealth Screenings in an Urban Community. Telemed. E-Health 18, 95–100 (2012).
  6. ↑ Sangani R, Henry RK, Shah MK, Szirth B, Bhagat N.  Use of Resident Tele-Ophthalmic Diagnosis to Aid in Management of Vision-Compromising Retinal Pathology.  ARVO . May 2022.
  7. ↑ Dullet NW, Geraghty EM, Kaufman T, Kissee JL, King J, Dharmar M, et al. Impact of a university-based outpatient telemedicine program on time savings, travel costs, and environmental pollutants. Value Health. 2017;20:542–6.
  8. ↑ Armstrong GW, Liebman DL, Ashourizadeh H. Implementation of anterior segment ophthalmic telemedicine. Curr Opin Ophthalmol. 2024;35(4):343-350. doi:10.1097/ICU.0000000000001052
  9. ↑ Holladay, J. T. Proper Method for Calculating Average Visual Acuity. J. Refract. Surg. 13, 388–391 (1997).
  10. ↑ Blais N, Tousignant B, Hanssens JM. Tele-refraction in tele-eye care settings. Clin Exp Optom. 2022;105(6):573-581. doi:10.1080/08164622.2021.2009736
  11. ↑ Pesudovs, K. & Weisinger, H. S. A Comparison of Autorefractor Performance. Optom. Vis. Sci. 81, 554 (2004).
  12. ↑ Saw, S. M. et al. Near-Work Activity and Myopia in Rural and Urban Schoolchildren in China. J. Pediatr. Ophthalmol. Strabismus 38, 149–155 (2001).
  13. ↑ Raina, U. K., Rathie, N., Gupta, A., Gupta, S. K. & Thakar, M. Comparison of Goldmann applanation tonometer, Tono-Pen and noncontact tonometer in children. Oman J. Ophthalmol. 9, 22–26 (2016).
  14. ↑ Parihar, J. K. S. Glaucoma: The ‘Black hole’ of irreversible blindness. Med. J. Armed Forces India 72, 3–4 (2016).
  15. ↑ Takagi D, Sawada A, Yamamoto T. Evaluation of a New Rebound Self-tonometer, Icare HOME: Comparison With Goldmann Applanation Tonometer. J Glaucoma. 2017;26(7):613-618. doi:10.1097/IJG.0000000000000674
  16. ↑ Zhang J, Kim K, Kim HJ, Meyer D, Park W, Lee SA, et al. Smart soft contact lenses for continuous 24-hour monitoring of intraocular pressure in glaucoma care. Nat Commun 2022;13:5518. https://doi.org/10.1038/s41467-022-33254-4.
  17. ↑ Armstrong GW, Liebman DL, Ashourizadeh H. Implementation of anterior segment ophthalmic telemedicine. Curr Opin Ophthalmol. 2024;35(4):343-350. doi:10.1097/ICU.0000000000001052
  18. ↑ Nankivil D, Gonzalez A, Rowaan C, Lee W, Aguilar MC, Parel J-MA. Robotic Remote Controlled Stereo Slit Lamp. Transl Vis Sci Technol 2018;7:1. https://doi.org/10.1167/tvst.7.4.1.
  19. ↑ Gosalia H, Chandrakanth P, Verghese S, Rammohan R, Narendran K, Narendran V. Rapid Office-Based Diagnosis of Demodex Using an Innovative Smartphone-Aided Intraocular Lens Tool. Eye & Contact Lens: Science & Clinical Practice 2022;48:306–7. https://doi.org/10.1097/ICL.0000000000000881.
  20. ↑ Awad R, Sesma G, Neyaz S, Ahmad K, Al Hemaidi S, Awad A. Virtual consultation for red eye: Accuracy assessment in a primary care center. Middle East Afr J Ophthalmol 2021;28:180. https://doi.org/10.4103/meajo.meajo_306_21.
  21. ↑ Kang S, Thomas PBM, Sim DA, Parker RT, Daniel C, Uddin JM. Oculoplastic video-based telemedicine consultations: Covid-19 and beyond. Eye 2020;34:1193–5. https://doi.org/10.1038/s41433-020-0953-6.
  22. ↑ Cao B, Vu CH V., Keenan JD. Telemedicine for Cornea and External Disease: A Scoping Review of Imaging Devices. Ophthalmol Ther 2023;12:2281–93. https://doi.org/10.1007/s40123-023-00764-3.
  23. ↑ Komal S, Radhakrishnan N, Vardhan S A, Prajna NV. Effectiveness of a Tele-Ophthalmology Vision Center in Treating Corneal Disorders and Its Associated Economic Benefits. Cornea 2022;41:688–91. https://doi.org/10.1097/ICO.0000000000002784.
  24. ↑ Andhare P, Ramasamy K, Ramesh R, Shimizu E, Nakayama S, Gandhi P. A study establishing sensitivity and accuracy of smartphone photography in ophthalmologic community outreach programs: Review of a smart eye camera. Indian J Ophthalmol 2023;71:2416–20. https://doi.org/10.4103/IJO.IJO_292_23.
  25. ↑ Kumar S, Yogesan K, Constable IJ. Telemedical diagnosis of anterior segment eye diseases: validation of digital slit-lamp still images. Eye 2009;23:652–60. https://doi.org/10.1038/eye.2008.11.
  26. ↑ Sanguansak T, Morley K, Morley M, Kusakul S, Lee R, Shieh E, et al. Comparing smartphone camera adapters in imaging post-operative cataract patients. J Telemed Telecare 2017;23:36–43. https://doi.org/10.1177/1357633X15625400.
  27. ↑ Wu X, Huang Y, Liu Z, Lai W, Long E, Zhang K, et al. Universal artificial intelligence platform for collaborative management of cataracts. British Journal of Ophthalmology 2019;103:1553–60. https://doi.org/10.1136/bjophthalmol-2019-314729.
  28. ↑ Kolomeyer, A. M., Baumrind, B. R., Szirth, B. C., Shahid, K. & Khouri, A. S. Fundus Autofluorescence and Colour Fundus Imaging Compared During Telemedicine Screening in Patients with Diabetes. J. Telemed. Telecare 19, 209–212 (2013).
  29. ↑ Kolomeyer, A. M., Nayak, N. V., Szirth, B. C. & Khouri, A. S. Fundus Autofluorescence Imaging in an Ocular Screening Program. International Journal of Telemedicine and Applications (2012). doi:10.1155/2012/806464
  30. ↑ Adhi, M. & Duker, J. S. Optical coherence tomography – current and future applications. Curr. Opin. Ophthalmol. 24, 213–221 (2013).
  31. ↑ Shah MK, Henry RK, Szirth B, Bhagat N.  Utility of Remote Point-Of-Care Tele-Retinal Imaging for Screening and Diagnosis of Diabetic Retinopathy: A Pilot Study.  ARVO.  May 2022
  32. ↑ Haimi M. The tragic paradoxical effect of telemedicine on healthcare disparities- a time for redemption: a narrative review. BMC Med Inform Decis Mak 2023;23:95. https://doi.org/10.1186/s12911-023-02194-4.
  33. ↑ Dow ER, Khan NC, Chen KM, Mishra K, Perera C, Narala R, Basina M, Dang J, Kim M, Levine M, Phadke A, Tan M, Weng K, Do DV, Moshfeghi DM, Mahajan VB, Mruthyunjaya P, Leng T, Myung D. AI-Human Hybrid Workflow Enhances Teleophthalmology for the Detection of Diabetic Retinopathy. Ophthalmol Sci. 2023 May 12;3(4):100330.
  34. ↑ Kuklinski EJ, Henry RK, Shah M, Zarbin MA, Szirth B, Bhagat N. Screening of Diabetic Retinopathy Using Artificial Intelligence and Tele-Ophthalmology. J Diabetes Sci Technol. 2023 Nov;17(6):1724-1725. doi: 10.1177/19322968231194041.
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