COVID-19 and Glaucoma Management
Glaucoma is the leading global cause of preventable and irreversible blindness. The current COVID-19 pandemic has drastically altered the landscape in which glaucoma care must be delivered. Cancelations of clinic visits, deemed non-urgent, were compounded by social distancing measures and potential fear of COVID-19 infection. The number of newly diagnosed patients and patients on regular follow-up declined as well as the number of trabeculectomies. To replace sudden and unexpected cancelation of in-person visits, virtual clinics were opened with their own advantages and drawbacks. Here we present the evolving challenges of glaucoma management during the COVID-19 and lessons for the future.
Recent advances in home monitoring of intraocular pressure (IOP) and visual fields have potential to expand teleglaucoma. Rebound tonometer (Icare HOME) is an approved device, but not widely adopted due to issues with cost of the device and patient-self monitoring. Recently approved for use in Europe, the Eyemate telemetric IOP sensor acts as a permanent implantable monitoring device for use in patients with open-angle glaucoma.
Visual Field Examination
Mask-related artifacts in VF examination seem to be more common, potentially mistaken for glaucoma progression damage. Types of visual field artifacts that may be mask-related include inferior visual defects, higher fixation losses, and false-positive errors. Fogging of eyeglasses before standard automated perimetry is a strong predictor of low reliability. Taping the upper edges of face masks is a suggested alternative technique. However, while fogging can induce artifacts and reduce test reliability, it may also conceal true VF defects.
Glaucoma requires regular follow-up to avoid its potentially blinding effect. Teleglaucoma is a growing field increasing patient access and decreasing the need for long-distance travel for patients in adherence with social distancing concerns during the pandemic.
Teleglaucoma programs can be used for long-term treatment monitoring and diagnostic consultations. Key components include patient history, equipment, fundus photography, retinal nerve fiber layer imaging, IOP measurement, pachymetry, anterior chamber imaging, gonioscopy, and imaging software. Various models exist including screening, diagnostic consultation, and home monitoring. In addition, drive-through IOP clinics have been shown to be a safe way to monitor glaucoma patients during COVID-19. “Digitally Integrated Visits” have been characterized, separating glaucoma testing performed by technical personnel from interactions with ophthalmologists at the same time.
Because glaucoma management requires frequent monitoring of glaucoma progression in existing patients, teleglaucoma may be beneficial to assess in treatment compliance, to increase efficiency of follow up, and to monitor clinical parameters such as IOP. Cases have been reported during the pandemic of permanent and severe vision loss as a consequence of delayed follow-up due to insufficient capacity within hospital eye services. Teleglaucoma, therefore, can improve access to eyecare for those in underserved or remote areas. Its rapid nature allows patients to be seen quickly and conveniently, giving patients more control over their time.
Glaucoma is diagnosed according to consensus findings from IOP measurements, fundus photographs, VF exams and OCT. There are clear limitations to certain modalities of teleglaucoma, for example, consults over the phone. IOP measurements cannot be checked remotely. Thus, teleglaucoma may be more suited towards the monitoring of patients with an established diagnosis, rather than new patients. Ultimately, not all patients are well-suited candidates for teleglaucoma may be better seen in person.
Teleglaucoma can provide healthcare access to patients in less resourced areas, however, there may be a tradeoff for the most vulnerable patients who may have barriers accessing the internet and certain digital platforms for patient-physician communication. Cultural attitudes and languages may also pose additional challenges. Furthermore, there is no valid VF or IOP measurement method through telemedicine that meets HIPAA guidelines. Overall, the consensus from current literature does not recommend remote assessment alone to monitor glaucoma.
Poor compliance and adherence to medications are well-known drawbacks for glaucoma patients. Evidence suggests that the pandemic has worsened adherence to ocular hypotensive medications which appears to be related to patient resilience, notably lower in patients of older age, greater number of eye diseases, and lower education level. Medication adherence may be improved with teleglaucoma to maintain the physician-patient relationship and motivation.
The frequency of trabeculectomies has decreased during the COVID-19 pandemic in part due to the number of postoperative visits and procedures required. Conventional and micropulse diode laser, glaucoma drainage devices, deep sclerectomy and Preserflo appear to be alternatives as the postoperative care for these procedures is typically less intensive.  In the UK, a shift towards transscleral diode lasers has been noted.  One study demonstrated potential efficacy for micropulse transscleral cyclophotocoagulation (MP-TSCPC) as a primary procedure for POAG during the pandemic.
Desires to minimize patient contact during surgery and simplify postoperative care in order to reduce the risk of COVID-19 transmission have had a large impact on the type of surgery offered after the outbreak with a tendency for less post-operative follow up, interventions, and shorter surgical time.
The COVID-19 pandemic has created a new landscape in which ophthalmic care and glaucoma care will be delivered in the future. Telemedicine, including phone consultations and virtual clinics rose to prominence as means of providing effective ophthalmic care. However, telemedicine has clear drawbacks in glaucoma where measurements obtained at in-person patient visits play a pivotal role in treatment decision-making. 
Many patients have had their access to healthcare curtailed and follow-ups canceled due to the heavy burden that the pandemic has placed on healthcare systems globally. In the case of follow-up appointments, certain populations are disproportionally impacted. Furthermore, the COVID-19 pandemic has disproportionally impacted patients of older age and Black and brown communities, particularly vulnerable to glaucomatous disease. More planning is required to ensure medication and treatment adherence and address the challenges in managing glaucoma care during subsequent waves of the pandemic.
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