Eye telemedicine hits limits without home retinal imaging

A video call can carry a conversation. It cannot carry a retinal scan. That gap, between what a webcam transmits and what a retina specialist needs to see, is the line that decides how far telemedicine reaches in eye care, according to a commentary by T.Y. Alvin Liu, MD, Ferdinand K. Hui, MD, and Phillip H. Phan, PhD, published in Ophthalmology Times.

The piece dates from July 2020, written in the first months of pandemic-era telehealth, and its immediate context has passed. Its framework has not. The authors organized adoption around the patient's clinical journey rather than around the technology, and for a health system deciding where ophthalmology telehealth spending will actually shift visits, that remains a useful map, arguably a sharper one than most vendor decks offer.

Three kinds of eye patients, three different answers

The commentary sorts patients by how much a remote encounter can do for them. The first group is patients who are emotionally and cognitively ready for a video visit. The authors write that these patients are more likely to accept its inherent limits, such as losing body language from the encounter.

The second group needs high-fidelity diagnostics. The authors' example is patients with neovascular age-related macular degeneration, who require regular optical coherence tomography imaging. Those patients benefit less from telemedicine unless they have a device at home that can send the provider the information a clinic scanner would normally produce.

The third group needs invasive procedures, such as surgical repair of a retinal detachment. Telemedicine is unlikely to help them, the commentary says, unless a facility near home offers robotic surgical capability along with trained providers. That condition is a high bar, and the authors present it as one.

The second tier is where the planning decision gets hard. It is the only one of the three where a device purchase, rather than a software license, determines whether the patient can stay home. For a retina service line whose panel skews toward wet AMD and other conditions requiring repeat imaging, a video platform on its own would move few visits out of the building.

The minimum kit on each end of the call

On the provider side, the authors define the minimum viable product as a secured, HIPAA-compliant video communications platform. They note that these features were already built into large electronic medical record systems including Epic and Cerner. The authors call this the good news: for most providers, the core video capability already sits inside the record system they use every day.

The patient side is harder to guarantee. The commentary lists reliable internet with up and down bandwidth of at least 1.5 MB, a quiet and private location at home, and enough emotional and cognitive familiarity with the technology that it does not itself become the obstacle.

None of those three sits inside the health system's control. The bandwidth figure is a modest threshold, but the quiet room and the comfort level are the requirements a scheduler cannot verify from a chart. If a clinic is measuring telehealth readiness by whether its platform is live, the commentary suggests the more useful question is how many of its patients meet the home-side list.

Case mix is the deciding variable

The authors' central claim is that a productive telemedicine implementation depends on where, along the typical patient's journey, the provider creates the most value, and whether the technology can deliver at that point. That makes the provider's case mix the key input to the adoption decision, per Ophthalmology Times. A general ophthalmology practice and a retina subspecialty practice looking at the same video product would, by this logic, reach different conclusions.

The commentary also records the policy backdrop of its moment. The Centers for Medicare & Medicaid Services issued telemedicine CPT codes on March 6, 2020, to support its 1135 emergency waiver, and the authors wrote that they expected such measures to become permanent. The piece does not state how those codes reimbursed relative to an in-person eye exam, and none of the sources here establish the current payment picture. For a CFO signing off on home imaging devices, that missing figure is the one the framework cannot supply.

Home fundus cameras as the first route into retina

Using retina as the test case, the authors laid out two strategies for bringing telemedicine to patients. The first is widespread deployment of home-based posterior segment imaging. Their example is a modular color fundus photography system that can capture both posterior pole and ultrawide field images, can be self-administered by the patient, and integrates with a smartphone to collect and transmit the data.

The use case they name is monitoring progression in patients with non-proliferative diabetic retinopathy. That is a meaningful choice. It puts the nearer-term opportunity in diabetic eye disease, where a photograph may be enough to track change, and leaves wet AMD, where OCT is the standard, as the harder problem. The authors' text turns next to home-based OCT, which the piece had already identified as the technology gating the second patient tier.

For a health system with a large diabetic population and a retina clinic running at capacity, this ordering matters. The fundus camera route is the one the commentary describes as deployable with existing consumer hardware, a smartphone, at the transmission step. The OCT route is described only by its absence.

The adoption question has outlasted the pandemic

The barriers the ophthalmology authors were working through were not new in 2020. A systematic review led by Clemens Scott Kruse of Texas State University, published in the Journal of Telemedicine and Telecare and accepted in September 2016, had already catalogued barriers to telemedicine adoption worldwide before the pandemic forced the issue.

The question is still open in the current literature. A June 2026 open-access systematic review in Telematics and Informatics Reports, an Elsevier journal, by Faisal Binsar, Mohammad Hamsal, Sri Bramantoro Abdinagoro and Mohammad Ichsan, frames telemedicine's challenges and opportunities as tensions to be managed through what the authors call a dynamic equilibrium approach. The review tracks the annual growth of telemedicine publications and compares pre-pandemic work from 2018 and 2019 with what followed.

What the Ophthalmology Times commentary adds to that broader literature is specificity. The barrier has a name, OCT, and a location, the patient's home. Whether a self-administered home OCT device reaches wet AMD patients at scale is the single variable that would move them from the second tier into the first, and it is the device a retina service line's telehealth plan should be written around, conditional on it arriving.