When I was a junior resident, one of the first cases I presented for Grand Rounds was that of a patient who had previously undergone ruptured globe repair, who noticed that he was having a harder time with near vision in the fellow eye that had not experienced ocular trauma. Difficulty in reading is often a vague symptom reported by many patients. However, this individual (an engineer by training) was meticulous about testing his accommodative range at the exact same time each day, with the same lighting conditions, and with the same reading material. Over the course of a couple of weeks, he measured the increasing distance to his near focal point in fractions of an inch. The precision of his data gave us confidence that he was experiencing a real phenomenon, and his documentation of accommodative difficulties, in combination with mild intraocular inflammation and focal chorioretinal abnormalities, led to the diagnosis of sympathetic ophthalmia.
This case was the first and perhaps one of the most successful examples of home monitoring that I’ve seen for retinal disease. Thanks to this patient’s early diagnosis and subsequent treatment, he had an excellent visual outcome. However, his degree of meticulousness is rare, and I’ve never had another patient spontaneously quantify their home vision changes to the same level.
There is randomized clinical trial evidence to suggest that implementing a successful strategy for home monitoring improves visual outcomes in patients with age-related macular degeneration. In the Age-Related Eye Disease Study 2 (AREDS 2), patients at high risk of developing neovascular age-related macular degeneration who were successful at using a self-monitoring device to detect metamorphopsia at home had less visual acuity loss than those who were not randomized to use the device. This was owing to the earlier detection and treatment of new choroidal neovascular membranes in the device-using group.
Despite these encouraging results, the ForseeHome device used in AREDS 2 has not been adopted routinely by all patients who might benefit from its use. Some of the barriers to its use include affordability and out-of-pocket costs for patients, the inability of some patients to use the device effectively, and the need to set up communication with ophthalmic care clinicians who would be alerted if testing results are abnormal.
In this age of smartphones and so many other means of readily accessible technology, many ophthalmologists wonder why we haven’t developed even better, easier, and more reliable means to track changes in visual function outside our ophthalmology clinics for all types of ocular disease. There are an increasing number of smartphone apps and electronic devices being made available. However, although several of these are appealing in their ease of use or accessibility, there have not been widespread efforts for rigorous validation and comparative effectiveness testing across home-monitoring methods. Thus, for many retinal diseases, we lack level 1 evidence that self monitoring is an effective strategy for driving treatment or follow-up recommendations.
I have no doubt that the day will come when home monitoring of visual function becomes an essential part of ophthalmic treatment. This will allow patients to more effectively participate in their own care and should enable us to implement treatment strategies that are geared towards earlier intervention and optimizing the preservation of vision. In the meantime, it is incumbent on us to design and implement rigorous clinical trial testing of a diversity of monitoring options. It is only through carefully performed clinical studies that we can guarantee that patients choose the best home-monitoring options wisely, with evidence-based understanding of how these strategies may help improve visual outcomes over the long term.