Novel Solutions to Maintain Glaucoma Care During COVID-19

The current pandemic has forced clinicians treating patients with chronic disease into a delicate balancing act. Although we must extend all efforts to minimize virus exposure through social distancing, these patients require a level of follow-up and monitoring that cannot always be replicated via virtual visits.

This is particular challenging for ophthalmologists treating glaucoma, which affects an estimated 3 million individuals in the United States, or approximately 2% of the national population. Most patients with glaucoma are routinely seen by their ophthalmologist two to four times a year. I personally monitor stable patients every 3-4 months. Such regularity became impractical beginning in mid-March, when guidelines calling for reduced crowding to avoid further spreading of COVID-19 led to hospital systems and private practice clinics restricting in-person visits. Thousands of appointments were cancelled.

The virtual visits that many physicians in other specialties turned to are particularly ill-suited to ophthalmology. It is not possible to accurately check a patient's vision or know their intraocular pressure (IOP) without an actual in-person visit. This information is the baseline for any ophthalmic exam, and especially for glaucoma, where IOP is a major data point for determining whether treatment is adequate.

There are minor efforts we can make. Patients can minimize their risk for glaucoma progression by reporting any vision changes. Reinforcing compliance with medications and keeping refills up to date is another way that physicians and patients can try to maintain glaucoma control. But eventually, these patients will require an accurate IOP measurement to dictate next steps.

Crises Can Bring Innovation and Change

If there is an upside to crises, however, it is that the unforeseen challenges they present us with are often met with innovation and change.

So it was with the idea of drive-through IOP check clinics, whereby patients with glaucoma have their pressure checked via portable devices while remaining in their car. Those who have relatively normal pressures have a follow-up conversation with the physician via phone or screen, but those with increased IOP are brought in for a face-to-face visit where further examination and testing are performed.

Although seemingly straightforward, establishing and coordinating these drive-through clinics requires many technical considerations, such as accessibility to medical records when outside of the office to accurately evaluate and document the target IOP for each patient. Also, given their outdoor location, the clinics must be sustainable in hot and cold climates.

We had hoped these drive-through clinics would serve as a temporary solution until normalcy resumed. Several months later, amidst another resurgence of COVID-19 cases with no clear end in sight, it is increasingly apparent that additional measures are required to keep patients from missing more appointments.

One form this might take is the increasing accessibility of at-home devices for monitoring glaucoma progression.

Phone apps, such as Vision Test, that can help to check visual acuity are already available, often at no cost. Vision test devices that attach to a smartphone, such as the EyeQue VisionCheck, are another option to measure refractive error.

Furthermore, more patients may be inclined to purchase machines, such as rebound tonometry, to check their IOP at home. Even perimetry testing could potentially be performed at home.

A mobile virtual visual field machine was recently developed, which many ophthalmologists have since incorporated into their practices. If it is possible to give patients home access to this technology through purchase or loan, data could then be transferred to a physician to review and evaluate. Far from a short-term fix, these solutions may yet revolutionize glaucoma care for the future.

In the present, however, we have to deal with the fact that COVID-19 has added a layer of confounding variables that may compromise the care of patients with glaucoma even when in-person visits are possible.

Ophthalmologists have tried to restrict such testing as visual fields because of the prolonged time required in a confined room and the intricacies of adequately sanitizing the machine. When perimetry testing was performed, physicians have commented that a poorly positioned mask may cause artifacts resulting from new nasal defects. And there is some anecdotal evidence to suggest that IOP may be increased by wearing a mask, especially a tight-fitting one.

We are fortunate that, for the majority of patients, glaucoma is a slowly progressive disease. For those who have been monitored routinely in the past and remained stable, this interruption in care will hopefully not prove to be severely detrimental.

There will inevitably come a point when COVID-19 is behind us. When that day comes, it will be interesting to compare the rate of glaucoma progression and in-person visits before and throughout this pandemic. This may validate our current practices or lead us to substantially change them.

The collateral damage COVID-19 has wrought upon ophthalmology is increasingly clear. Whether it can also impart lessons for us to improve remains to be seen.

Shuchi B. Patel, MD, is director of glaucoma services in the department of ophthalmology at West Palm Beach VA Medical Center in Florida. She explores the ever-changing glaucoma space for Medscape, including advances in diagnostics and treatments.

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