A Place for House Calls in Optometry

As optometrists, we stand at the forefront of eye care, uniquely positioned to significantly affect our patients’ lives. I had one experience that I will never forget, and it all began when a gentleman came in for his annual eye exam. After going through my pre-testing room, he asked me if the office was wheelchair-accessible, to which I replied in the affirmative. He explained that his father is in a wheelchair and that they were just at an eye clinic where they were told he couldn’t be seen. He asked if I would see his father and I of course said yes. I could not imagine a situation where a patient would be told they could not be examined, simply due to their mobility issues. Fast-forward to the day of his father’s appointment.

THE CASE

A 70-year-old male patient with progressive supranuclear palsy (PSP) presented for a comprehensive eye exam with no complaints. He arrived in a wheelchair, although I was informed that most of the time he was bedbound. He was nonverbal, wearing medical safety mittens, and was fully dependent on caretakers. His eyes were firmly closed during the entire visit. He was not using any ophthalmic medications and had no prior ocular surgeries. His medications included carbidopa 10 mg, levodopa 100 mg, escitalopram 10 mg, doxazosin 4 mg, levetiracetam 1,000 mg, and oxybutynin 10 mg.

EXAMINATION FINDINGS

Examination of this patient was challenging. The assistance of his son and aide was required to hold him in place and open his eyelids. His IOP was within normal limits OU, performed with an iCare IC200 Tonometer (Revenio Group). Slit-lamp examination was performed using a 20 D lens and a direct ophthalmoscope. The patient’s lids and lashes showed meibomian gland dysfunction OU, and his conjunctiva was mildly injected OU. Evaluation of the cornea was performed with use of proparacaine, fluorescein strips, and a cobalt blue light keychain. This revealed three centrally located 1-mm circular areas of positive staining with trace surrounding corneal filaments and an instant tear breakup time (TBUT) OU. Dilated retinal evaluation was performed with an indirect ophthalmoscope, and the results were within normal limits.

Based on these findings and the limited views, I considered the differentials of filamentary keratitis, herpes simplex keratitis, neurotrophic keratitis, and corneal abrasion. Out of an abundance of caution, I started the patient on moxifloxacin eye drops three times daily OU and eyelid hygiene wipes at bedtime OU.

The patient displayed noticeable discomfort throughout the examination, which ended in an emesis event and subsequent visit to the ER. It was clear that in-office visits required excessive physical effort and caused pain for the patient. His son shared that they only lived two blocks away, and together, we decided that any follow-up visits would take place at the patient’s home.

AT-HOME CARE

Follow-Up Visit No. 1

The first follow-up visit took place 2 weeks later, after I had confirmed the patient’s insurance covered at-home visits (see Coding for House Calls). I packed my tonometer, a bottle of proparacaine, fluorescein strips, a cobalt blue light keychain, a direct ophthalmoscope, a 20 D lens, cotton-tipped applicators, tissues, and gloves, and walked the two blocks to his home.

The patient’s room was set up like an in-patient hospital room. His eyelids were closed due to apraxia, but I noticed an intermittent slow blink, which allowed a more detailed examination. It was clear now that no other corneal processes were occurring, so we were dealing with filamentary keratitis. I removed the corneal filaments with a proparacaine-soaked cotton-tipped applicator, had the patient’s caregivers discontinue moxifloxacin, and prescribed cyclosporine ophthalmic emulsion 0.05% (Restasis, AbbVie) once daily OU. Eyelid hygiene wipes were to be continued at bedtime OU, and I scheduled another follow-up visit.

Follow-Up Visit No. 2

At the second follow-up visit 2 weeks later, I noted no signs of filamentary keratitis, and instant TBUT had increased to 10 seconds OU. However, most surprising was finding that the patient’s eyes were no longer closed. He demonstrated a normal blink rate and was now watching television during the day, which he had been unable to do for many years. At present, he has continued to do well on cyclosporine twice daily and eyelid hygiene wipes at bedtime. An upcoming 6-month follow-up visit is scheduled, at which point I will recommend continuing the indicated treatment if his ocular surface remains stable.

MORE ON PSP

PSP is a “prime of life” disease, meaning it affects patients around 40 to 50 years of age. It is a Parkinsonian syndrome, and diagnosis is based on clinical characteristics and lack of a positive response to traditional therapies for Parkinson disease. Of note to optometrists: A hallmark diagnostic characteristic of PSP is abnormal eye movements, including square wave jerks, slow vertical saccades, vertical supranuclear gaze palsy, “round the houses” sign, decreased blink rates, blepharospasm, and apraxia of eyelid opening.¹ It is referred to as PSP because it affects the supranuclear part of the brain responsible for these eye movements.¹ Typically, the eyelid apraxia seen in PSP is not a true apraxia,¹ as was the case for this patient; he developed a protective ptosis due to his underlying ocular surface disease.² Once that was resolved, his eyelids opened.

DISABILITY SHOULD NOT STAND IN THE WAY OF NECESSARY EYE CARE

In our careers, we will inevitably encounter patients who present with different types of mobility and cognitive issues, and it’s our duty to adapt our examination methods to collect meaningful findings. Many of our instruments are portable by nature and easy enough to take to a patient’s home, and most insurances offer coverage for at-home visits. I don’t mean to say that you should make a complete transition to exclusive house calls. Rather, consider my experience as a gentle reminder that you possess the tools to have a positive influence on each patient’s life—especially those with mobility issues that prevent clinic visits, who are nevertheless in need of eye care. House calls can serve as a valuable solution for reaching patients who would benefit from this more accessible form of care.

I discovered someone in my community who could derive immense benefit from house calls. I challenge you to explore similar opportunities in your area to have a transformative effect on a patient’s life.