Identifying serious eye conditions via telehealth

Evelyn Lewin

20/04/2020 4:53:02 PM

Patients with a red eye do not necessarily need an examination to rule out an ophthalmic emergency, an expert explains.

Dr Ehud Zamir conducting a telehealth consultation
Dr Ehud Zamir believes history taking is an important and under-utilised skill critical for diagnosing serious eye conditions.

‘You’re unlikely to miss something serious if you use it.’

Melbourne-based ophthalmologist Dr Ehud Zamir, a Clinical Associate Professor at the University of Melbourne, is talking about deyeagnose – a free-to-use, artificial intelligence program he created in 2014 to help clinicians pick up serious red eye conditions.

Even though Dr Zamir developed deyeagnose long before the pandemic, he believes it is of particular importance now as it can help clinicians categorise patients via telehealth into those who need to be seen face-to-face for an examination, and those who do not.

‘When someone rings you in normal times as an ophthalmologist about a patient, you go through a series of questions to try and more or less classify them into [a] relevant category, if not diagnosis,’ he said.

‘That’s what you would do even in normal times … it’s just more at the forefront now because of the popularity of telehealth consultations.’

Dr Zamir said the program can differentiate between ophthalmic emergencies and trivial causes of a red or painful eye via a ‘heavy’ reliance on history taking with targeted key questions.

These include questions such as:

  • Have you been working with power tools in the last 24 hours and could something have flown into your eyes?
  • Do you have a rash on your forehead and could it be zoster?
  • Do you have photophobia?
  • Is your vision down?
  • Do you have pain that wakes you up at night?

‘These are key junctional symptoms,’ Dr Zamir said. ‘And if you ask them systematically, you get a fair idea what you’re dealing with.’

Dr Zamir said further key questions include those regarding the nature of discomfort in the eye.

Pain on eye movement and photophobia, or pain when trying to focus on near targets, for example, are red flags and a pretty good indication of ‘something beyond trivial’.

He said such questions can help avoid misdiagnoses, which is a common occurrence with referrals to ophthalmologists.

‘We see it every day,’ he said.

‘As an ophthalmologist, you see patients coming in that have been taking Chlorsig for three weeks because they had a red eye, [but] the critical questions weren’t asked, and they in fact have something else, for instance, acute iritis.

‘By the time you see them, there’s a lot of damage that’s not that trivial and not that easy to recover from, and you know it’s preventable because you know if you treat those things early, often you come out of it in much better shape.’

However, other referrals are often overly-cautious, which he says could be avoided with the use of the tool.

‘We see a lot of referrals from concerned [doctors] – whether it’s GPs or emergency physicians – saying “rule out glaucoma”, “I don’t want to miss uveitis,” and so on,’ he said.

‘And again, the majority of those patients do not have the suspected diagnosis.’

According to Dr Zamir, the program excels at picking up serious conditions such as acute glaucoma, uveitis, scleritis, endophthalmitis and keratitis, but does not necessarily help diagnose ‘trivial’ causes.

‘In a series of 121 patients, we [achieved] a sensitivity of 90% and specificity of 98% for serious problems,’ he said. ‘So you’re unlikely to miss something serious if you use it.

‘On the other hand, you’re not likely to get a very refined diagnosis of something that’s not so serious. The program won’t be very good at telling you if it’s just dry eye or allergic conjunctivitis, but it really doesn’t matter that much for the purpose of your triage of patients with red eye.

‘Some of those diagnoses will usually take care of themselves even if you do nothing.’

Dr Zamir said the program is particularly useful right now as it has a lot of leeway, giving doctors the option to fill in ‘not sure’ in response to questions, including those regarding examination findings.

‘The program usually asks you many questions and if you don’t know the answer to some of them or you’re not sure if the patient has an epithelial defect for example, you can say “not sure”,’ he said.

‘So it lends itself to times like now, when you actually can’t do any examination over the phone or [videoconferencing].’

If the program concludes that an ophthalmic emergency is likely, the recommendation is made to seek urgent ophthalmology care.

‘The user can also access a condensed, practical monograph on each diagnosis considered, listing its key clinical features and likely urgency of referral,’ he said.

Dr Zamir notes while most common causes of a red or painful eye are trivial, it is pivotal for a primary clinician to identify potential ophthalmic emergencies early in order to improve long-term outcomes.

Since developing the program, Dr Zamir has retrospectively tested it with patients who originally presented to him with a misdiagnosis. He said that results point to the importance of history taking, especially now when patients may not be presenting to their doctor face-to-face.

‘You can often show that the answers to those questions would have made the diagnosis from day one,’ he said.

‘The history tool in general is really under-utilised in reaching our diagnoses, [yet] it’s a powerful tool, not necessarily much less powerful than examination.’

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