Eyeworld

100 | EYEWORLD | SPRING 2025 G UCOMA Relevant disclosures Armstrong: Chart Biopsy, DynaMed, Kriya Therapeutics, McKinsey & Company, Ocular Technology, Optomed, Xenon Ophthalmics Maa: None Contact Armstrong: Grayson_Armstrong @meei.harvard.edu Maa: amaa@emory.edu field test out of the blue on one day and you're submitting an E/M visit on another day, but because it's a virtual visit, there isn't any clinical data linked to it. "I think insurance companies may get a little skeptical about higher billing codes if there's not data to support it, so this was important to make sure they saw that we were using a lot of data, like applanation tonometry, visual fields, and OCT, to make our determinations of the glaucoma state of the patient, for example." Dr. Armstrong also serves as director of Mass Eye and Ear's emergency room. "[We] always had a high throughput of patients, and even in the pandemic, it didn't slow down much. There were still real emergencies. We wanted to try to find a way to decompress, so we started using telemedicine for follow-up visits for patients," he said. This helped to keep in contact with the patient, while saving them travel time, as long as it was an appropriate condition to follow up with remotely. This telemedicine system was then rolled out for new patient encounters, but a system was put in place to make sure true emergencies still came for an in-person evaluation. "We've now set up a hotline that a patient can call in, and there's a series of questions that the nurse will triage the patient with to make sure they're appropriate, and we can set up a telemedicine appointment as their first visit before they even come in, assuming they need to come in at all," he said. Telemedicine took some adjustment for physicians, not just patients, Dr. Armstrong said. "We realized a lot of physicians weren't comfort- able, so we created a lot of tip sheets and educa- tional materials. We created a whole curriculum to train all the residents at Mass Eye and Ear in using telemedicine, so that curriculum has been through 4 years' worth of iterations," he said. Telemedicine is its own thing, but Dr. Armstrong predicts there will be a time when AI and support technologies are going to play a bigger role. "Right now, the only AI approved in the field of ophthalmology within the U.S. is to autonomously detect diabetic retinopathy using fundus photographs," he said. "Those tools have been on the market and are meant to be put in a primary care office so you can take a photo and diagnose DR in the office without an ophthal- mologist present." Work is also being done to help screen for glaucoma. "We're going to be using virtual reality visual fields and AI to try to screen for glaucoma in that same DR population, since they're already getting photos, and that's a population at higher risk," he said. "If the FDA approves tools like this, it would be helpful to use AI for screening for DR, glaucoma, AMD, and other diseases." There's also a move toward the use of phone cameras and images to perform AI, which Dr. Armstrong said is being looked at domestically and internationally. Tools exist where you can take a photo of the face and tell general health metrics and systemic issues, he said. There's been a lot of work in the space of systemic health based on a fundus photograph as well. Because the eye gives you access to the nerve tissue and the blood vessels of the retina, it can tell you things that are surprising but make sense, like risk of Alzheimer's, kidney sta- tus, systolic blood pressure, etc. "I think there's going to be a movement slowly toward this idea that instead of doing blood work, we can do this based on photographs," Dr. Armstrong said. "I think ophthalmology and the eye will play a bigger role in that space." Dr. Armstrong thinks virtual reality and augmented reality will someday enhance this space as well. If you have a patient with a virtual reality headset talking to an avatar of the physician, you can save a lot of time on counseling and education, he said. If you use a ChatGPT-style large language model, it could be trained to answer questions and walk patients through complex decisions. You could have a headset show patients what their vision would look like with different lenses. The last big technology piece is personal- ized medicine where you have all of the pa- tient's health metrics, alongside AI and other tools, and it's personalizing the decision, the medication, or the prognosis for each patient, Dr. Armstrong said. Dr. Armstrong stressed that telemedicine is up to the provider to offer and up to the patient to accept. While he recognized that it's still "not super widely utilized," he sees value. "It has a huge benefit for patient access, a huge benefit for practice efficiency, and people can get really creative with it," he said. continued from page 99

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