Continuity of ophthalmology education during a pandemic by combining video conferencing application with a slit-lamp camera.

The on-going coronavirus disease 2019 (COVID-19) outbreak has dramatically changed the way of work and communication in health care. As of March 22, 2020, public hospitals in Israel have ceased to provide nonurgent office-based visits and surgeries, and the presence of faculty and residents is kept to a minimum. Clinical departments’ staff is commonly divided into separate teams, to diminish their vulnerability in case of exposure to COVID-19 carriers. Worldwide, quarantine and social distancing regulations have now put new barriers between ophthalmologists, their patients, and their colleagues. ,

As a result of COVID-19 epidemic, video conferencing tools have become crucial for remote worker collaboration, as well as for social and family communication. In Israel, physicians are currently using video conferencing applications for the purpose of conducting country-level professional tele-conferences and department- and hospital-level staff meetings. We report a technique that allows sharing high-resolution real-time slit-lamp video with multiple viewers simultaneously, by combining a slit-lamp camera with a video conferencing application.

The free version of Zoom cloud meeting application (Zoom Video Communications, Inc, San José, CA), which allows meetings of up to 100 attendees, was installed in 2 different ophthalmology departments in university hospitals in Israel, onto standalone computers with WiFi capability, connected to Righton MW50D LED slit-lamp (Right group, Tokyo, Japan) and to the Elite SL9900 slit-lamp (CSO, Florence, Italy) cameras. The screen sharing option in the application allowed remote viewers to see a real-time high-resolution video feed using a desktop computer or a smartphone, which displays the slit-lamp ophthalmic examination. Importantly, it enables the remote viewers to guide the examiner in adjusting slit-lamp properties (focus, magnification, location, slit aperture, etc.) to produce a desired image of the area of interest (Fig. 1 and Video 1).

Fig. 1

Slit-lamp examination transferred via video conferencing application. (A) The screen of a slit-lamp camera computer is shared as seen in the adjacent laptop. The examiner can speak with a consultant using the computer speakers, while adjusting the slit lamp to show the area of interest. (B) Slit-lamp video feed as seen via Zoom video conferencing application. The examiner and 2 consultants are online.

The technique is currently used by residents in 2 different university hospitals in Israel for the purpose of conducting consultations with one or more remote-based specialists. In our experience, this technique allows a much more reliable presentation of the clinical status than verbal description or static compressed smartphone pictures sent via WhatsApp application (Facebook, Inc, Menlo Park, CA). This technique can also allow the presentation of special and difficult cases by senior ophthalmologists to their peers, in lieu of specialist clinical meetings and grand rounds that are now impossible to perform. Additionally, video conferencing applications can be combined with smartphone-based examination using smartphone directly or with an adapter, for the basic examination of patients in corona-dedicated wards.

Naturally, the acquired video is limited by the optical properties of the imaging device, and although this technique allowed us to produce superb video images of the anterior segment, images of the posterior segment were of lower quality, contained reflections even with dilated pupil, and demonstrated a relatively small area of the ocular fundus. We believe that the same technique can be applied to fundus cameras better suited for this purpose, as well as to optical coherence tomography or other imaging devices. That being said, with clear media, and a small slit aperture, the optic nerve and the posterior pole could reliably be seen even through a nonmydriatic pupil (Video 2).

Although many video conferencing applications are available, notably the Zoom software offers HIPPA (Health Insurance Portability and Accountability Act)/PIPEDA (Personal Information Protection and Electronic Documents Act) compliant plans (priced at $200 a month), and use end-to-end encryption.

In conclusion, although escalating isolation and quarantine measures are implemented worldwide, and the end is nowhere to be seen, it is our hope that our initial experience with this simple and affordable technique can help ophthalmologists to communicate reliably and efficiently, while minimizing the exposure of patients and medical personnel to COVID-19.