![Takeru Eye Clinic | Takatori Shopping Street, Sawara-ku, Fukuoka City [Nishijin Station / Fujisaki Station]](https://takeru-eye.com/wp-content/uploads/2022/10/takeru_logo_for-WP-header.png){kind=logo}
“I’m too busy with work to come to the clinic. Could you just prescribe my usual eye drops?”
We often receive this kind of request in the everyday setting of an eye clinic. Especially since online care spread after the COVID-19 pandemic, more patients expect to “just get the medicine” or “settle it easily online.”
I understand that feeling very well. However, in ophthalmology we cannot, in principle, prescribe medicine without an examination. This is not for the convenience of the medical institution but an important rule established by law and to protect patients’ safety.
The Medical Practitioners Act stipulates that “a physician must not issue a prescription without an examination,” and violations carry penalties.1 Also, because special examination equipment to examine the inside of the eye in detail is essential in ophthalmic care, strict limits are placed on online care as well.
In this article, from both legal and medical standpoints, I explain in detail why “just the medicine” is difficult in ophthalmology, what can and cannot be done in online care, and safe methods when coming to the clinic is truly difficult.
Article 20 of the Medical Practitioners Act: prescribing “without an examination” is illegal
The first thing I want you to know is that “giving medicine without an examination” is an illegal act clearly prohibited by Article 20 of the Medical Practitioners Act.1。
Article 20 of the Medical Practitioners Act reads: “A physician must not provide treatment, or issue a medical certificate or prescription, without personally examining the patient.”
A physician who breaks this is liable to a fine of up to ¥500,000, and may further face administrative dispositions such as suspension of the medical license and revocation of insurance-physician status.2。
You may think, “It’s a medicine I always use, so what’s wrong with just giving the same one?”
However, under the law, whether it is a new drug or one used continuously, “a physician’s examination” is required for every prescription.
This provision is the minimum safety device to protect patients’ lives and health.
The end of the COVID exception: why “they gave it to me back then”
From 2020 to July 2023, as a response to COVID-19, the rules for online care were temporarily relaxed greatly.3。
During this period, under a special measure called the “0410 Notice,” online care from the first visit, and even care by telephone only, were allowed as exceptions.
Some of you may have had the experience of “I used to get medicine by phone, but this time I was refused.”
This is because the COVID exception ended and the strict rules are now back to normal.3。
Under the current rules, online care is recognized as an “examination” only when it uses a real-time video call rather than mere phone or text exchange, and the physician judges that “sufficient medical information can be obtained.”4。
The special nature of ophthalmic care: you cannot tell by “looking from the outside”
Then, is an “examination” established simply by the physician checking the patient’s eyes on a screen by video call?
Unfortunately, in ophthalmology that alone is not enough.
This is because the diagnosis and treatment of eye disease absolutely require the special examination equipment available at a clinic.
A video call shows only the “surface”
What can be checked by video call in online care is limited to “visible changes” such as swollen eyelids and red eyes.
But what truly matters in ophthalmic care is the condition inside the eye.
Examinations essential to ophthalmic care include the following.
Intraocular pressure measurement: measures the firmness (pressure) of the eye. Indispensable for the diagnosis and management of glaucoma.
Slit-lamp microscopy: a special microscope used to observe corneal injuries, inflammation inside the eye, clouding of the lens and so on in detail.
Fundus examination: checks the state of the retina and optic nerve. Necessary for diagnosing diabetic retinopathy, glaucoma, retinal detachment and others.
All of these examinations can be done only by coming to the clinic.
The American Academy of Ophthalmology (AAO) also points out that online care has limits, such as being unable to perform slit-lamp examination, and that it is important for the physician to explain this point sufficiently to the patient.5。
Two especially dangerous cases: the fear of diseases without symptoms
The most difficult thing in ophthalmic care is thatthe patient’s subjective symptoms and the severity of the disease do not match.That is the point.
Just because “there is no problem with how I see” or “it doesn’t hurt” does not mean the eyes are healthy.
The following two cases are especially dangerous in online care.
Case 1: Steroid eye drops: one in three people is at risk of raised eye pressure
Steroid eye drops such as Rinderon® and Flumetholon® are very effective drugs for suppressing allergy and inflammation.
At the same time, however, they carry the risk of a serious side effect, “raised intraocular pressure.”
According to research, about 30% of the general population are people whose eye pressure rises in response to steroids (steroid responders), and 5–6% of them show a large rise of 15 mmHg or more.6。
The problem is that even when eye pressure rises, the patient has no subjective symptoms at all.
If high eye pressure continues without being noticed, the optic nerve is gradually damaged and in the end glaucoma may develop.
Also, visual field once lost does not recover.
The Japan Ophthalmologists Association and the Japan Glaucoma Society have jointly given a strong warning that “steroid eye drops must be treated in an ophthalmology clinic” and that “regular eye pressure measurement is important.”7。
Eye pressure cannot be measured in online care.
Therefore, prescribing steroid eye drops online without measuring eye pressure is a dangerous act that exposes the patient to the risk of blindness.
Case 2: Glaucoma medication: “using the drops” ≠ “being treated”
Glaucoma is a disease in which the visual field is lost little by little without subjective symptoms.8。
The purpose of treatment is to lower eye pressure and manage the disease so that visual field loss does not progress.
Glaucoma treatment requires regular eye pressure measurement, visual field tests, and evaluation of the optic nerve with optical coherence tomography (OCT).
Only with these tests can we judge whether “the current treatment is working” and whether “the disease is progressing.”
Even if a patient reports in online care, “I’m using the drops as usual” or “nothing has changed in particular,” that alone does not mean treatment is going well.
If eye pressure has not reached the target, the disease progresses quietly without the patient noticing.
From a legal viewpoint too, continuing to prescribe casually with emphasis only on the patient’s convenience leads to very large legal risk for the physician.
A known disease that worsens because regular tests were neglected makes a physician more likely to be held liable for medical malpractice than a misdiagnosis at the first visit.
The limited cases where online care “works”
Is online care in ophthalmology then meaningless?
Not at all.
Online care may work only when the condition is “mild” and can be judged by “observation from the outside,” as in the following.
Known allergic conjunctivitis (mild): already diagnosed, and the usual allergy eye drops (without steroids) are needed during hay fever season.10。
Early hordeolum (stye): at the stage when the eyelid has just started to become slightly red and swollen, and it can be clearly judged to be a stye by video call.
Subconjunctival hemorrhage: the white of the eye has turned bright red, but there is no pain or loss of vision.
Even in these cases, however, there is an important condition.
That is to keep the rule: “if symptoms do not improve within 2–3 days or if they worsen, receive in-person care immediately.”
Serious diseases hiding in “red eyes”: the danger of missing them
Symptoms such as “my eyes are red” or “bloodshot eyes” may seem at first glance to be a minor problem.
But redness can also be an early symptom of serious diseases that lead to blindness.
Redness in people who use contact lenses in particular needs attention.
This is because the risk of corneal ulcer, especially serious infections such as Acanthamoeba keratitis, is very high.12。
Uveitis too often starts with redness.
Eye inflammation due to herpes virus is also common.
The Japanese Ophthalmological Society also points out that “itching and redness of the eyes are seen in various diseases, and even specialists may find it difficult to tell whether the cause is allergic conjunctivitis.”10。
By video call, we cannot check for corneal injury with a slit-lamp microscope, confirm inflammatory cells inside the eye, or measure eye pressure.
If antibiotics or antiallergy drugs are prescribed on a simple judgment of “redness” without such tests, there is a risk of missing a serious disease.
Safe options when you truly cannot come to the clinic
“I understand the law and the safety issues. But what should I do if there are circumstances in which I really cannot come?”
For such patients, there are safe and legal options instead of the dangerous method of “just the medicine.”
Option 1: House calls / home-visit care
For patients who are bedridden or for whom the burden of visiting a clinic is very large, there is the method of house calls (home-visit care), in which the physician visits the home or facility.13。
Today, portable tonometers and compact slit-lamp microscopes exist.
When a physician brings these devices, an examination close to that at a clinic becomes possible.
Particularly for patients with dementia and others who find it hard to cooperate with an examination, a house call is far more effective than online care.
Option 2: Consultation between physicians (taishin)
For patients hospitalized at another hospital or residing in a care facility, rather than the patient and the ophthalmologist having a direct video call (the physician–patient model), the method called “taishin,” in which the local attending physician and the ophthalmologist cooperate, is appropriate.1。
The local attending physician examines the patient and provides the information (for example, “redness of the right eye and purulent discharge”) to the ophthalmologist.
The ophthalmologist gives specialist advice based on that information, and the prescription is issued by the attending physician who actually examined the patient on site.
With this method, the provision of Article 20 of the Medical Practitioners Act that “a physician must not prescribe without personally examining” does not apply.
Option 3: Emergency “bridge prescription”
This is an extremely exceptional response, but only when there is an imminent serious risk from interruption of medication, as in glaucoma, there is a method of prescribing only the minimum number of days as a “bridge” until the next in-person visit.
However, strict conditions must be met.
These include confirming the state of medication and any side effects through a phone or video call with the patient personally, securing an in-person appointment without fail, and limiting the prescription to the shortest number of days until the next appointment (for example, 7 days).
This is only an exceptional response permitted solely in emergencies to prevent optic nerve damage caused by interruption of the patient’s medication.
It is not a prescription for the sake of convenience.
How about having “only the family” come to get the medicine?
Some people wish, “I can’t go myself, so I’d like only my family to go to the clinic and get the medicine.”
However, this too falls under “without personally examining” in Article 20 of the Medical Practitioners Act, and is in principle not permitted.14。
Examining the patient in person is an absolute requirement under the law.
If coming is really difficult, it is necessary to consider safe methods such as the house calls and taishin described above.
Audits and administrative dispositions: risks on the side of medical institutions
The Ministry of Health, Labour and Welfare conducts fact-finding surveys and guidance through prefectures on inappropriate online care (text-only exchanges, first visits that violate the guidelines and so on), and takes administrative actions such as recommendations to suspend operations in malicious cases.15。
In fiscal 2023, 46 audits were carried out for improper claims of medical fees and the like, and 21 of them resulted in dispositions such as “revocation of insurance designation.”2。
A violation of Article 20 of the Medical Practitioners Act (prescribing without examination) goes hand in hand with a violation of insurance care rules (improper billing).
Billing online care fees and continuing to issue prescriptions without performing the necessary tests can become a serious finding in an audit.
From the patient’s side, a “convenient clinic that gives only the medicine” may at first seem welcome.
In reality, however, omitting the necessary tests carries the risk of delaying the discovery of a serious disease or failing to notice side effects.
Also, prescriptions that do not meet the requirements of an “examination” set by the Medical Practitioners Act are considered legally problematic.
Behind surface convenience, the important checks to protect both the patient’s own eye health and legal safety may be missing.
What a physician should record as an “examination”
When online care is provided, physicians are required to keep more detailed records than in ordinary in-person care.
This is not a mere medical record.
It is also a legal document needed to prove “why the physician judged online care to be possible.”
The record must include the following elements.
Explanation to and consent of the patient: explaining the limits of online care (that eye pressure measurement and slit-lamp examination cannot be done) and that the patient understood and still wished for it.
Identity confirmation: reliable identity confirmation with an insurance card or driver’s license.
Examination method: that a real-time video call system was used.
Visual findings: stating clearly both what could be confirmed by video call and what could not.
Basis of the physician’s judgment: why it was judged safe and what guidance was given.
Criteria for shifting to in-person care: that the patient was instructed to receive in-person care immediately if symptoms do not improve or worsen.
Such detailed records are the only means for a physician to prove that appropriate medical care was provided if trouble or an audit should arise.
Future outlook: balancing technological progress and the system
In the future, technologies such as devices that can measure eye pressure at home and fundus cameras that connect to smartphones may spread.
If so, online care may become able to obtain information with accuracy close to in-person care.
At present, however, such technologies are not yet common.
Even if technology develops, the standard of “examination” set by Article 20 of the Medical Practitioners Act will not change.
In other words, unless an environment is in place in which the physician can judge that sufficient medical information is obtained, medicine cannot be prescribed casually.
Online care is only a “complement” to in-person care and never a “replacement.”
This principle is very important for protecting patients’ safety.
Summary: balancing safety and convenience
In this article, I have explained from both legal and medical sides why “just the medicine, please” is difficult in ophthalmology.
Let me summarize the key points.
- Under Article 20 of the Medical Practitioners Act, prescribing without an examination is illegal. This is the same for new drugs and continuing drugs.
- Ophthalmic care requires examinations that can be done only at a clinic, such as eye pressure measurement and slit-lamp microscopy.
- Online prescription of steroid eye drops and glaucoma drugs carries a danger leading to blindness.
- In limited cases such as mild allergy and stye, online care may be possible.
- When coming to the clinic is truly difficult, there are safe options such as house calls, taishin and emergency bridge prescriptions.
A “convenient clinic that gives medicine without an examination” may seem kind at first glance.
But such clinics may be ignoring the law and neglecting patients’ safety.
Conversely, a clinic that explains “an examination is necessary” may feel inconvenient, but in fact it is sincerely trying to fulfill its responsibility to protect the patient’s eye health.
When we ophthalmologists say “an examination is necessary,” it is never because we want to inconvenience patients.
It is a necessary procedure, from both legal and medical standpoints, to protect your precious “right to see” and “eye health.”
References
- Ministry of Health, Labour and Welfare. Medical Practitioners Act. e-Gov Laws Search.
https://elaws.e-gov.go.jp/document?lawid=323AC0000000201 - Ministry of Health, Labour and Welfare. Fiscal 2023 (Reiwa 5) status of guidance and audits of insurance medical institutions.
https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/iryouhoken/shidou_kansa.html - Ministry of Health, Labour and Welfare. Guidelines for the appropriate implementation of online medical care.
https://www.mhlw.go.jp/content/000889114.pdf - Ministry of Health, Labour and Welfare. Q&A on the “Guidelines for the appropriate implementation of online medical care.”
https://www.mhlw.go.jp/stf/index_0024_00004.html - American Academy of Ophthalmology. Telehealth for Ophthalmology.
https://www.aao.org/clinical-statement/telehealth-ophthalmology - Armaly MF. Effect of corticosteroids on intraocular pressure and fluid dynamics. Arch Ophthalmol. 1963;70:482-491.
https://pubmed.ncbi.nlm.nih.gov/14078870/ - Japan Ophthalmologists Association / Japan Glaucoma Society. Awareness materials on steroid-induced glaucoma.
https://www.gankaikai.or.jp/info/20250401_steroid.pdf - Weinreb RN, Aung T, Medeiros FA. The pathophysiology and treatment of glaucoma: a review. JAMA. 2014;311(18):1901-1911.
https://pubmed.ncbi.nlm.nih.gov/24825645/ - Tham YC, Li X, Wong TY, et al. Global prevalence of glaucoma and projections of glaucoma burden through 2040. Ophthalmology. 2014;121(11):2081-2090.
https://pubmed.ncbi.nlm.nih.gov/24974815/ - Japanese Ophthalmological Society. View on over-the-counter drugs and others.
https://www.mhlw.go.jp/content/11120000/001509870.pdf - Lindsley K, Nichols JJ, Dickersin K. Non-surgical interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2017;1(1):CD007742.
https://pubmed.ncbi.nlm.nih.gov/28068454/ - Dart JK, Saw VP, Kilvington S. Acanthamoeba keratitis: diagnosis and treatment update 2009. Am J Ophthalmol. 2009;148(4):487-499.
https://pubmed.ncbi.nlm.nih.gov/19660733/ - Ministry of Health, Labour and Welfare. On the promotion of home medical care.
https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000061944.html - Medical Practitioners Act (Act No. 201 of 1948), Article 20 (Prohibition of treatment without examination). e-Gov Laws Search.
https://laws.e-gov.go.jp/law/323AC0000000201 - Ministry of Health, Labour and Welfare. Review of the regional medical care vision (2): creation of comprehensive provisions on online medical care
https://www.mhlw.go.jp/content/12201000/001442574.pdf
