Telehealth for ophthalmology visits: What parents should know

By Dr. Rahul Bhola, pediatric ophthalmologist and medical director of ophthalmology at CHOC

Like many physicians continuing to offer care during the COVID-19 pandemic, I have transitioned many appointments to telehealth, so patients can still get the care they need while practicing social distancing. At CHOC, we adjusted our policies and practices to maintain a safe environment for our patients and families who need in-person appointments.

For in-person appointments, we require masks and practice proper hand hygiene to protect the health of everyone we serve. Before entering our building, CHOC nurses screen all visitors and staff. Screenings include a temperature check and asking symptom and exposure-related questions. In line with CHOC’s limited visitor policy during the COVID-19 pandemic, only one parent/guardian may accompany the child for their appointment. Our clinic is taking other necessary precautions such as thoroughly disinfecting clinical areas and rearranging seating in our lobby to ensure social distancing.

Since March, my office has successfully completed over 900 telehealth visits, on top of non-elective in-person appointments.

Dr. Rahul Bhola, pediatric ophthalmologist and medical director of ophthalmology at CHOC

Since telehealth is new to many families, here’s an overview of what parents can expect at their first virtual appointment, plus answers to parents’ most common questions on telehealth for ophthalmology.

A synchronous (live audio-video) CHOC ophthalmology telehealth appointment is divided into four components. I call them the four C’s: Contact, Connect, Consult and Care.


Our front desk reaches out to the family to confirm their contact information. We send a Zoom link to the family, along with information about how to connect to Zoom and download a Visual Acuity app that we use during appointments to check vision.


As the appointment day approaches, our technician connects with the family to resolve any technical issues before the physician consultation. The technician also goes over the at-home visual acuity check and evaluates basic medical history.


On the actual day of the telehealth appointment, the physician connects with the family to go over the relevant medical history and visual acuity and performs focused examination including external and ocular motility exam. If needed, pictures and videos from the family can be sent to the physician for further evaluation. This enables us to diagnose a majority of anterior segment ocular issues, visual acuity concerns like amblyopia, refractive errors and ocular motility disorders.


During the telehealth appointment, we discuss the treatment care plan and review any medical issues or concerns the patient is experiencing. Throughout this process, we can fulfill their needs ranging from prescription refills or broken glasses, without them having to step outside the comfort of their home.

Our office will then schedule a follow-up visit depending on the medical necessity.

How do your patients and families feel about telehealth?

I have found that many patients love telehealth! Our families feel supported and secure, since there was no interruption in their child’s care plan. I’ve also found that our families feel grateful that during this time of uncertainty, their physician was able to connect with them and address any urgent issues, and then follow them in clinic as needed.

Due to the positive response we have received from our families, we plan to continue offering telehealth appointments in the future.

Does telehealth compromise quality of care?

No. We carefully scrutinize the kind of visits that can safely be performed via telehealth without compromising on quality of care. If your ophthalmologist decides your child’s visit can safely be conducted via telehealth, rest assured your child will still receive the high level of care you’re used to receiving in person. After the telehealth appointment if we feel the need for an in-person appointment, we will work with our families to schedule that appointment promptly and safely.

Sometimes, an exam conducted via telehealth reveals something requiring an in-person appointment. In those cases, we work with our families to schedule appointments promptly and safely.

The benefits of an unplugged family vacation

Whether your family is jet-setting overseas or planning an epic stay-cation this summer, the concentrated family time and slower pace lent by an unplugged family vacation can do wonders to help a family reconnect and bond.

Read on for tips from CHOC Children’s experts, as well as an Orange County grandmother and CHOC supporter, on how to create an awesome family vacation that will surely create lifelong memories.

In an era where people of all ages are busier than ever, CHOC mental health experts stress the importance of letting kids be kids, and how “unplugged” time benefits everyone.

Dr. Harpreet Kaur, a pediatric psychologist at CHOC, says that children who face the pressures of adulthood may experience the ailments of it as well.

“Stress is linked to depression and anxiety,” she says. “Children who are stressed won’t have as much energy and can experience headaches and other physical ailments. Stress can surface in different ways; some children may experience pain, while others stop talking.”

Rising sources of stress on children comes at a time when they are exposed to more screen time than ever. School screen time coupled with at-home smart device usage can on average expose a student aged 8 to 18 years to media for more than 10 hours per day, says Dr. Rahul Bhola, a pediatric ophthalmologist at CHOC.

Janet Davidson, a member of CHOC Children’s board of directors, learned these lessons first hand during a recent overseas vacation with her extended family and close friends.

Janet Davidson, a member of CHOC Children’s board of directors,

“Despite the vast array of things to see and do in the area, the most treasured experiences were just hanging out with each other,” she says. “Early mornings in the kitchen with a cup of freshly-brewed Italian coffee, dinner outside, playing games, swimming in a pool and going for walks were all special times for our group. Although most of us had brought along smartphones and tablets, they were rarely used.”

Janet learned so much about the benefits of an unplugged vacation that she put her words to paper, recently publishing an insightful memoir “Meet us in Tuscany.”

“When I planned this trip, I had no plans to write a book, but when I came home I felt a need to do something to share lessons learned with others, so they could benefit no matter where they were in the world,” she says.

Unplugged family time ― whether you’re traveling or staying local ― opens the door for nutritional benefits as well.

CHOC clinical dietitian Shonda Brown stresses the importance of involving kids in the kitchen, exposing them to new flavors and letting them be involved in the process of preparing food.

“Exposing toddlers to a variety of foods and flavors increases the number of foods accepted in later childhood,” she says.

Shonda recommends having children help create a new meal or snack from a few healthy ingredients. In the kitchen, adults and kids can talk about how it smells, tastes, looks and feels.

“Children are more open to trying new foods if they have opportunities to explore and learn about the food before they eat it,” Shonda says.

On Janet’s trip, each family member or friend who came to stay at their villa was tasked with planning and making a meal for the group. They shopped from local vendors, used seasonal ingredients, and embraced the exposure to new ingredients and dishes.

“This activity turned out to be one of everyone’s favorite things,” she says. “The grandchildren on the trip tried everything they were exposed to, and they were involved in the kitchen as much as the adults.”

Just as Janet relearned the benefits associated with renewed personal bonds, we encourage you to drop the screens and unplug from time to time and to reconnect with family and friends.

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    Why You Should Add an Eye Exam to your Back-to-School Checklist

    By Dr. Rahul Bhola, pediatric ophthalmologist at CHOC Children’s

    Routine vision screening or eye examination at an early age is very important to detect risk factors, such as lazy eye, that can cause irreversible loss of vision or blindness. Fortunately, early detection and timely management of these issues can prevent permanent visual impairment.

    A majority of vision impairment issues go undetected, since young children with impaired vision are often unaware of their vision issues—it is, after all, how they’ve always seen things. It is on us as parents and educators to look for signs of visual impairment.

    How can you tell if a child has trouble seeing?

    Preschool children will most likely not be able to communicate their issues. Early signs that your child or student may need comprehensive vision exam include:

    • An eye appears to be misaligned (crossing or drifting out)
    • Squinting, closing, covering one eye or rubbing one or both eyes
    • Complaining of headache, nausea or dizziness during visual tasks such as reading
    • Excessive clumsiness or poor depth perception
    • Tilting head to one side
    • One or both eyelids droop down
    • Family members have been diagnosed with eye problems

    Without early detection and intervention, children with an untreated eye problem may suffer from serious irreversible vision loss or even blindness in some cases.

    The most common cause of visual impairment in children is refractive errors. This means the shape of the eye doesn’t bend light correctly, causing a blurred image. Children with refractive error need glasses, and without correction they are at risk for a lazy eye or irreversible vision loss.

    Correcting vision can improve social interaction for kids

    I recently treated a five-year-old boy who was referred by his pediatrician for an eye exam. When I met this patient, he was extremely shy and socially withdrawn. During his eye exam, which only took about 20 minutes, he was diagnosed with severe farsightedness. This explained what his parents had assumed was introvert behavior; if he got too close to something, it was blurry!

    His parents called my office a few days later. After wearing glasses for just a few days, their son was a totally different kid, interacting socially appropriately for the first time in his life. During his follow-up appointment, he was so excited to tell me that he had finally seen stars for the first time!

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    The Effects of Too Much Screen Time on Children’s Vision

    By Dr. Rahul Bhola, pediatric ophthalmologist at CHOC

    Technology has become an integral part of our daily lives. As we become increasingly more reliant on and absorbed in technology, many children are exposed to smart devices at less than 5 years of age. These devices have also become an integral teaching tool in classrooms—more than half of teachers in the United States use smart devices in elementary school. According to the U.S. Department of Education, 97 percent of classrooms in the U.S. have at least one computer. School screen time coupled with at-home smart device usage can on average expose a student aged 8-18 years to media for more than ten hours a day.

    As children’s exposure to screen time rises, many parents wonder how harmful excessive exposure to electronic media can be. While on one hand, an early exposure to technology might prepare children for future careers in technology-related fields, or jobs that require mastery of technology as a fundamental key to success. On the other hand, children overly immersed in this technology and not otherwise challenged can become socially stunted and ridden with health-related issues due to decreased physical activity.

    Dr. Rahul Bhola
    Dr. Rahul Bhola, pediatric ophthalmologist at CHOC.

    One of the biggest health issues related to smart devices are vision related. A recent study by the National Eye Institute found that the frequency of myopia, also known as near-sightedness, has jumped exponentially in Americans over the last few decades. Two clear reasons for this spike in myopia are an increased amount of time spent looking at things up close and also a lack of outdoor activities. Focusing on things too close to the eyes for a prolonged period puts excessive strain on the eyes and has been found to hasten the progression of myopia. Although genetic risks of myopia cannot be modified, limiting the amount of strain on eyes by avoiding excessive time spent looking at things up close can minimize environmental risk factors. It is imperative to prevent prolonged exposure of up-close work (such as reading) in children by allowing small breaks (during prolonged reading sessions, for example).

    The American Academy of Pediatrics (AAP) recently revised the recommendations for screen time in childhood.

    • 18 months and younger: no screen time is still best. The exception is live video chat with family and friends.
    • 18 months to 2 years: limit screen time and avoid solo use. Choose high-quality programming, and watch with kids to ensure understanding.
    • 2 to 5 years: limit screen time to an hour a day. Parents should watch as well to ensure understanding and application to their world.
    • 6 or older: place consistent limits on the time spent and types of media. Don’t let screen time affect sleep, exercise or other behaviors.
    screen time
    The American Academy of Pediatrics released new guidelines on how much screen time is appropriate for children.

    A separate study recently found that excessive screen time usage in adolescents was associated with development of acute onset esotropia, or crossing of the eyes, and that limiting usage of these gadgets decreased the degree of eye crossing in these patients. A portion of the patients in this study had to undergo surgery to correct esotropia.

    Excessive screen time can also lead to “Computer Vision Syndrome” which is a combination of headaches, eye strain, fatigue, blurry vision for distance, and excessive dry eyes. There’s a number of things you can do to help avoid these symptoms:

    • Check the ergonomics of the workstation. Placing the screens 20 to 28 inches away from the child’s eyes and aligning the top of the screen at eye level so that the children look down at the screen while they work.
    • Restrict entertainment-related screen time to two hours or less a day
    • Practice the 20-20-20 rule: After every 20 minutes of screen time, take a 20-second break and look 20 feet away.
    • Remind children to blink regularly to avoid excessive dry eyes.

    Meet Dr. Rahul Bhola

    CHOC Children’s wants its patients and families to get to know its specialists. Today, meet Dr. Rahul Bhola, an internationally recognized expert in pediatric ophthalmology.

    Dr. Bhola comes from a family of physicians. His parents practiced internal medicine for more than 40 years in India, and the empathetic and holistic care they provided to their patients inspired him to pursue a career in medicine.

    “Very early on in medical school, I developed a special interest in pediatrics, and the surgical finesse of ophthalmology later cemented my passion for pediatric ophthalmology. A gift of vision is the most important sense a child can have,” Dr. Bhola says. “Giving a ray of light to those who struggle with vision is very gratifying to me. Treating children is important to me because they have their entire lives ahead of them and improving their vision positively impacts their entire family.”

    Dr. Bhola attended medical school and completed an internship at University College of Medical Sciences in Delhi, India. He completed two residencies in ophthalmology at Maulana Azad Medical College in New Delhi, India and the University of Louisville, Kentucky. He pursued fellowships in pediatric ophthalmology at the University of California Los Angeles and University of Iowa.

    “The biggest reason I was inspired to join CHOC was the mission of the hospital. I feel that CHOC’s mission to nurture, advance and protect the health and well-being of children is in close alignment with my personal goals as a physician,” Bhola says. “I seek to nurture the healthcare of children by delivering state-of-the-art ophthalmology care to our fabulous community. CHOC has the resources, reputation and experience to provide great care.”

    At CHOC, Dr. Bhola will provide comprehensive eye care, treating patients with a variety of eye disease and disorders. In addition to treating refractive errors (the need for glasses), Dr. Bhola will provide more specialized care for diseases like amblyopia (lazy eyes), pediatric and adult strabismus (crossing or drifting of eyes), blocked tear duct, diplopia (double vision), pediatric cataracts, pediatric glaucoma, tearing eyes, retinopathy of prematurity, ptosis (droopy eyelids), traumatic eye injuries and uveitis.

    Dr. Rahul Bhola
    Meet Dr. Rahul Bhola, pediatric ophthalmologist at CHOC Children’s.

    The Need for Regular Eye Screenings

    Dr. Bhola is passionate about providing education on the need for regular eye screenings. For example, kids complaining of headaches may be taken to a neurologist. However, eye problems like refractive errors (the need for glasses), convergence insufficiency and strabismus can result in headache from excessive straining of the eyes, which may affect school performance and even social withdrawal in some children. These conditions are likely to be identified at regular vision screenings.

    Unique Approach To Treating Pediatric Glaucoma

    Dr. Bhola is among the very few surgeons nationally skilled in treating pediatric glaucoma surgically using the illuminated microcatheter. This highly-specialized, minimally-invasive approach of canaloplasty has been used for treating pediatric glaucoma only within the last five years. The onset of juvenile glaucoma often occurs between the ages of 10 and 20. It can be secondary to genetics, or traumatic.

    “Even though childhood glaucoma is an uncommon disorder, it often goes undetected and can eventually result in blindness, underscoring the importance of regular eye screenings,” says Dr. Bhola.

    As a Level II pediatric trauma center, and the only one in Orange County dedicated exclusively for kids, CHOC’s trauma team treats a variety of critically injured from across the region. This includes children who have sustained sports injuries, during which damage to the structure of the eye can cause glaucoma.

    Patient-Centered Care

    Dr. Bhola’s philosophy of care is to treat his patients as if they were his own children.

    “My main philosophy is to provide patient-centered care, delivered with compassion and excellence. I remember their life events, and celebrate their achievements with them. It’s important that a patient remembers and trusts you completely with their care. I love when my patients send me holiday cards and copies of their school photos and let me know how they are doing. They became part of my family. I always treat every patient of mine like they are my own child,” Dr. Bhola says.

    He also focuses on treating the whole person rather than the disease, and involving patients in their care.

    “I don’t treat the disease, I treat the individual. Healing is more than treating the disease. I want to be at their level so I always talk to them directly and not only talk to their parents. I involve their entire group during treatment,” he says.

    At CHOC, Dr. Bhola is eager to provide holistic eye care for his patients.

    “My practice will offer complete comprehensive vision care to all patients, which includes both medical as well as surgical care. Our patients come to us for glasses, contacts, regular vision screenings, and we also provide more specialized care like glaucoma, cataract and strabismus surgeries,” Bhola says. “Systemic disorders such as diabetes, sickle cell anemia, juvenile rheumatic disease and lupus, have coexisting eye issues that may go undetected if children aren’t seen for regular eye screenings. CHOC patients with systemic disorders such as diabetes now have better access to holistic care.”

    As division chief for CHOC Children’s Specialists ophthalmology, Dr. Bhola is passionate about providing state-of-the-art care to patients and training the next generation of pediatric ophthalmologists.

    “My main goal is to build a state-of-the-art ophthalmology division, not only delivering excellent patient care but also engaging in vital research and disseminating education to the next generation of ophthalmologists and referring providers,” Bhola says.

    When not treating patients, Dr. Bhola enjoys cooking, practicing yoga and meditation and spending time with his wife and two daughters.

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