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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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  Table of Contents 
Year : 2021  |  Volume : 28  |  Issue : 3  |  Page : 180-183  

Virtual consultation for red eye: Accuracy assessment in a primary care center

1 Department of Ophthalmology, Al Murabba PHC, Riyadh, Saudi Arabia
2 Department of Ophthalmology, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
3 Department of Ophthalmology, King Saud Medical City, Riyadh, Saudi Arabia
4 Department of Ophthalmology, Tabuk University, Tabuk, Saudi Arabia

Date of Submission28-Nov-2021
Date of Acceptance06-Dec-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Dr. Raseel A Awad
Al Murabba PHC, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/meajo.meajo_306_21

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PURPOSE: The purpose of the study was to evaluate the accuracy of teleexamination of red eye by a trained general practitioner (GP) compared to the gold standard (in-office consultation by an ophthalmologist).
METHODS: This was a study of diagnostic accuracy. We included consecutive male or female patients aged ≥6 months who presented to a primary care clinic in Riyadh, Saudi Arabia, with red eye. All the patients were initially evaluated by a trained GP using a standardized checklist and consulted virtually with an ophthalmologist. This was followed by an in-office eye examination conducted at a well-equipped ophthalmology clinic by a well-trained ophthalmologist. Data were analyzed using STATA 17.0 (StataCorp LLC, College Station, TX, USA).
RESULTS: A total of 54 patients with red eye presented to the primary care clinic during September–November 2021 and were initially examined virtually and then in-office. The mean age of the patients was 39.72 ± 21.70 years (range 5–90 years). Thirty-three patients (61.1%) were males. The most common cause of red eye was conjunctivitis (46.3%) followed by dry eye (31.5%). There was a significant association between viral conjunctivitis and age (P < 0.001), and between dry eye and age (P = 0.002). Tele eye examination accurately identified the etiology of red eye in all 54 patients.
CONCLUSION: Telemedicine has the potential to correctly diagnose patients with red eye and can result in a substantial decrease in the number of people visiting the health-care centers.

Keywords: Diagnostic accuracy, red eye, telemedicine

How to cite this article:
Awad RA, Sesma G, Neyaz SY, Ahmad K, Al Hemaidi SS, Awad AH. Virtual consultation for red eye: Accuracy assessment in a primary care center. Middle East Afr J Ophthalmol 2021;28:180-3

How to cite this URL:
Awad RA, Sesma G, Neyaz SY, Ahmad K, Al Hemaidi SS, Awad AH. Virtual consultation for red eye: Accuracy assessment in a primary care center. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2022 Jul 4];28:180-3. Available from: http://www.meajo.org/text.asp?2021/28/3/180/334629

   Introduction Top

Eye problems account for up to 3% of visits to primary care physicians and emergency facilities.[1] Of these, red eye is one of the most common presenting complaints in both primary and specialized health care.[2] In settings without an ophthalmologist, the decision of whether to refer a patient for further urgent eye care is a huge challenge.[1],[3] In the case of an eye injury, pain, vision loss, corneal involvement, or several other conditions, the patient should be seen by an ophthalmologist immediately.[1] There is a need to adopt alternative models to the traditional in-office eye examination that can effectively improve the delivery of quality services. In a study in Israel, 49 patients with complicated eye disease were seen during the night shift in the eye emergency setting. Eye images were taken using a slit-lamp connected to a video camera and transmitted to a senior physician by E-mail. A phone was used for real-time voice communication. The next day, each patient was reexamined by the same doctor. There was a 100% agreement between the diagnosis made by both methods.[4]

With a teledensity of over 60% and 40 million cellular subscribers in Saudi Arabia, mobile connectivity and economical broadband services present a unique opportunity for the continued provision of eye care through real-time audio and video communication. Such communication will help in effective triage of acute problems for referrals and management.[5],[6]

The present study aims to assess the accuracy of teleexamination of red eye by a trained general practitioner (GP) compared to the gold standard (in-office consultation by an ophthalmologist). This will help us understand the utility and effectiveness of virtual consultation in the country.

   Methods Top

This was a study of diagnostic accuracy. We included consecutive males or female patients aged ≥6 months who presented with red eye to the Al Murabba Primary Clinic in Riyadh, Saudi Arabia. The selection criterion was the inclusion of all the patients with red eyes with no known chronic eye problem or those on a regular follow-up by an ophthalmologist. The selected patients were not on any ophthalmic treatment, topical, or systemic medication.

The GP undertook a week-long training program (20 h) to learn how to recognize different aspects of the normal eye, the various etiologies of red eye, and how to take effective pictures using the smartphone. The patient's history, a close-up picture of their eyes by a smartphone, and a complete examination were done by the GP initially. The GP virtually consulted a senior ophthalmologist sitting at the King Khaled Specialist Hospital at the end of her evaluation of each patient. The senior ophthalmologist reviewed virtually the patient details and pictures. They (the GP and the senior ophthalmologist) reached a probable cause for the red eye that was recorded in a dedicated data sheet (virtual evaluation form).

The tools needed to perform the examination by the GP included Snellen's chart to test the visual acuity, a flashlight to examine the pupils, an ophthalmoscope, fluorescein paper, and a smartphone. The examination included the evaluation of all parts of both eyes, such as eyelids and eyebrows, and red eye criterion was the eye color changes and the apparent increase of conjunctival vessels engorgement that was determined by conducting the observation and examination with the flashlight. In addition, the patient's eye movements and eyesight were also examined.

The probable etiology of red eyes were studied in eight groups, including conjunctivitis (allergic, bacterial, or viral), degenerative conjunctivitis changes (pterygium and pinguecula), cornea inflammation (keratitis), sclera involvement (scleritis and episcleritis), iris involvement and angle involvement (glaucoma and uveitis), traumatic causes (foreign bodies and objects, chemical burns, and blunt trauma), eyelid diseases (blepharitis, hordeolum, chalazion, and eyelid deformation), and tear system involvement (dacryocystitis and eye dryness).

Bacterial conjunctivitis typically presents with mucopurulent or purulent discharge. Viral conjunctivitis often presents with sudden attacks of periocular lymphadenopathy, whereas allergic conjunctivitis presents with a history of itching, watery, and sticky secretion and involves both eyes. To diagnose acute glaucoma, the GP relied on the presenting symptoms, pupil assessment, and ocular pressure estimation by palpation.

Data collecting sheets (virtual and physical) included the patients' demographic information (age, sex, job, and living place) and factors concerning red eyes (exact red eye location, duration of eye redness from the symptom beginning to the diagnosis of the causes, manner of beginning, symptoms with red eyes, and ocular clinical findings and causes leading to red eyes and background diseases (diabetes, hypertension, lipid disorders, and thyroid disorder). Initial diagnoses (utilizing telemedicine) and final diagnosis (by an ophthalmologist who examined the patient physically in a well-equipped ophthalmology clinic) were recorded in a structured data forms.

The study was approved by the institutional review board, and the patients were assured that their personal information would be kept confidential. The study method was explained in detail to the patients. The clinical activities involved no risks to the patients.

Data were analyzed using STATA 16.1 (StataCorp LLC, College Station, TX, USA). Counts, percentages, and mean with standard deviation were computed to describe the data. The Chi-squared test or Fisher's exact test was used to compare proportions.

   Results Top

A total of 54 patients with red eye presented to the primary care clinic during September–November 2021 and were initially examined virtually and then in-office. The mean age of the patients was 39.72 ± 21.70 years (range 5–90 years). Thirty-three (62.5%) were males and 21 (37.5%) were females. Twenty-nine patients (46.9%) were aged ≥40 years, 18 (39.4%) between 12 and 40 years, and 7 (13.7%) <12 years [Table 1]. The etiology of red eyes was the following: conjunctivitis (46.2%), dry eyes (31.4%), inflamed pterygium (11.1%), trauma/foreign bodies (3.7%), blepharitis/chalazion (3.7%), keratitis (1.8%), and subconjunctival hemorrhage (1.8%) [Table 2] and [Figure 1].
Table 1: Characteristics of individuals presenting with red eyes (n=54)

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Table 2: Etiology of red eye (n=54)

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Figure 1: Causes of red eye among participants (n = 52)

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There was a significant association between viral conjunctivitis and age (P < 0.001) and between dry eye and age (P = 0.002). Among the etiology of red eyes, conjunctivitis was more often observed in patients >12 years of age, and viral etiology was more often encountered in this age group compared to bacterial etiology in the older age group (≥40 years) [Table 3]. Trauma was seen in patients <12 years of age, and dry eyes were more prevalent among patients ≥40 years of age [Table 3].
Table 3: Causes of red eye by the age group (n=54)

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   Discussion Top

The present study showed that the consultation by a GP correctly identified the etiology of red eye in all 54 cases. Dry eye was the most prevalent etiology of red eye in those aged ≥40 years, whereas conjunctivitis and trauma were the most prevalent etiologies in those aged <12 years and 12–40 years.

Our results add to previous research showing an excellent agreement between the in-office and other modes of diagnoses of red eye pathology. For example, in a study in the United States, Sink et al. found that the diagnosis of red eye based on smartphone images was comparable to in-office exams in 15 of 16 red eyes.[7]

A study of video consultations in the UK's Moorfields Eye Hospital (London) showed a greater than expected value of remote management of eye disease and resulted in a substantial decrease in the number of people visiting the hospital.[8] In the present study, the eye examination by an ophthalmologist was preceded by the virtual or remote exam by the trained GP which resulted in improved patient satisfaction. In the present study, the patients were examined by simple, yet reliable methods including the use of flashlights, ophthalmoscope, fluorescein paper, and smartphone. It is a cost-effective and time-saving method that is proving a boon to the patients during the current times of COVID-19. In recent years, telemedicine has become very popular in primary care as well as other parts of the health-care systems.[9] The emergence of COVID-19 as a global pandemic has made telemedicine even more relevant because it limits the spread of the virus and is a potential tool to diagnose eye problems in the majority of situations.[10]

The etiology of red eye may vary in different regions, different periods, and different age groups. The most common etiology for red eye in the present study was conjunctivitis followed by dry eyes. Other etiologies were inflamed pterygium, blepharitis, trauma, keratitis, and subconjunctival hemorrhage. On the other hand, the study by Sink et al. reported the main etiologies of red eye to be subconjunctival hemorrhage and pterygium followed by acute inflammation (13%), blepharitis (6.3%), uveitis (6.3%), corneal ulceration (6.3%), and episcleritis (6.3%).[7] The difference in underlying etiology can be attributed to the variation in study participants. In the present study, patients were included from Al Murabba PHC, Riyadh, Saudi Arabia. Therefore, based on the geographical background, the incidence of red eye lesions and pathologies may also differ from one population to another.

There are several limitations to telemedicine and to this study. First, although telemedicine is a critical component to improve patient care, it may become difficult for patients to come for a physical examination, if required. In such situations, further follow-up should be encouraged as some patients may require the medications and certain specific tests for treating the condition. Second, the use of smartphones and advanced optics will allow a more objective evaluation through video consultation. Simply using the flashlight is not an effective approach to diagnose various eye conditions. Third, the study has a small sample size. To adopt telemedicine on a wider scale, it is necessary to conduct clinical studies with a large number of participants so that the effectiveness can be adequately assessed. These factors should be considered before implementing telemedicine as a routine tool in ophthalmology.

   Conclusion Top

The study demonstrates the potential role of telemedicine in the current times. It works as an important means to diagnose red eyes without requiring the patients to physically meet the ophthalmologist. The study highlights the significance of video consultation that can serve as an important supplement to examine patients with red eyes remotely at the comfort of their home.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Pflipsen M, Massaquoi M, Wolf S. Evaluation of the painful eye. Am Fam Physician 2016;93:991-8.  Back to cited text no. 1
Pandey N, Srivastava RM, Kumar G, Katiyar V, Agrawal S. Teleconsultation at a tertiary care government medical university during COVID-19 Lockdown in India – A pilot study. Indian J Ophthalmol 2020;68:1381-4.  Back to cited text no. 2
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Bar-Sela SM, Glovinsky Y. A feasibility study of an Internet-based telemedicine system for consultation in an ophthalmic emergency room. J Telemed Telecare 2007;13:119-24.  Back to cited text no. 4
Cutler DM, Nikpay S, Huckman RS. The business of medicine in the era of COVID-19. JAMA 2020;323:2003-4.  Back to cited text no. 5
Nagra M, Vianya-Estopa M, Wolffsohn JS. Could telehealth help eye care practitioners adapt contact lens services during the COVID-19 pandemic? Cont Lens Anterior Eye 2020;43:204-7.  Back to cited text no. 6
Sink J, Blatt S, Yoo D, Henry M, Yang SD, Vasaiwala R, et al. A novel telemedicine technique for evaluation of ocular exam findings via smartphone images. J Telemed Telecare 2020. https://doi.org/10.1177/1357633X20926819.  Back to cited text no. 7
Kilduff CL, Thomas AA, Dugdill J, Casswell EJ, Dabrowski M, Lovegrove C, et al. Creating the Moorfields' virtual eye casualty: Video consultations to provide emergency teleophthalmology care during and beyond the COVID-19 pandemic. BMJ Health Care Inform 2020;27:e100179.  Back to cited text no. 8
Hammersley V, Donaghy E, Parker R, McNeilly H, Atherton H, Bikker A, et al. Comparing the content and quality of video, telephone, and face-to-face consultations: A non-randomised, quasi-experimental, exploratory study in UK primary care. Br J Gen Pract 2019;69:e595-604.  Back to cited text no. 9
Daruich A, Martin D, Bremond-Gignac D. Ocular manifestation as first sign of Coronavirus Disease 2019 (COVID-19): Interest of telemedicine during the pandemic context. J Fr Ophtalmol 2020;43:389-91.  Back to cited text no. 10


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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