COVID-19 and Glaucoma Management

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 by Ahmad A. Aref, MD, MBA on February 6, 2022.


Introduction

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.[1] The number of newly diagnosed patients and patients on regular follow-up declined as well as the number of trabeculectomies.[2] 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.

Clinical Examination

IOP Measurement

Recent advances in home monitoring of intraocular pressure (IOP) and visual fields have potential to expand teleglaucoma.[3] 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.[4] Types of visual field artifacts that may be mask-related include inferior visual defects, higher fixation losses, and false-positive errors.[5] 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.[6]

Teleglaucoma

Advantages

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.[7]

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.[8] “Digitally Integrated Visits” have been characterized, separating glaucoma testing performed by technical personnel from interactions with ophthalmologists at the same time.[7]  


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.[9]  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.[10] 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.

Drawbacks

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.[11][12] 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.[13]


Treatment

Medication Adherence

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.[14] Medication adherence may be improved with teleglaucoma to maintain the physician-patient relationship and motivation.

Surgical Practice

Trabeculectomy

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.[12] [15] In the UK, a shift towards transscleral diode lasers has been noted. [14] One study demonstrated potential efficacy for micropulse transscleral cyclophotocoagulation (MP-TSCPC) as a primary procedure for POAG during the pandemic.[16]


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.[15]

Future Directions

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. [8]


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.

  1. Liebmann JM. Ophthalmology and Glaucoma Practice in the COVID-19 Era. J Glaucoma. Jun 2020;29(6):407-408. doi:10.1097/IJG.0000000000001519
  2. Awwad MA, Masoud M. Influence of COVID19 on the Prognosis and Medication Compliance of Glaucoma Patients in the Nile Delta Region. Clin Ophthalmol. 2021;15:4565-4572. doi:10.2147/OPTH.S342682
  3. Mansouri K, Kersten-Gomez I, Hoffmann EM, Szurman P, Choritz L, Weinreb RN. Intraocular Pressure Telemetry for Managing Glaucoma during the COVID-19 Pandemic. Ophthalmol Glaucoma. Sep-Oct 2021;4(5):447-453. doi:10.1016/j.ogla.2020.12.008
  4. Gomez Mariscal M, Munoz-Negrete FJ, Munoz-Ramon PV, Aguado Casanova V, Jaumandreu L, Rebolleda G. Avoiding mask-related artefacts in visual field tests during the COVID-19 pandemic. Br J Ophthalmol. Feb 17 2021;doi:10.1136/bjophthalmol-2020-318408
  5. Bayram N, Gundogan M, Ozsaygili C, Vural E, Cicek A. The Impacts of Face Mask Use on Standard Automated Perimetry Results in Glaucoma Patients. J Glaucoma. Apr 1 2021;30(4):287-292. doi:10.1097/IJG.0000000000001786
  6. El-Nimri NW, Moghimi S, Fingeret M, Weinreb RN. Visual Field Artifacts in Glaucoma With Face Mask Use During the COVID-19 Pandemic. J Glaucoma. Dec 2020;29(12):1184-1188. doi:10.1097/IJG.0000000000001706
  7. 7.0 7.1 Gan K, Liu Y, Stagg B, Rathi S, Pasquale LR, Damji K. Telemedicine for Glaucoma: Guidelines and Recommendations. Telemed J E Health. Apr 2020;26(4):551-555. doi:10.1089/tmj.2020.0009
  8. 8.0 8.1 Powell S, Doolan E, Curtin K, Doyle A, O'Brien C. Audit of outcomes following attendance at the City West drive-through IOP glaucoma clinic during the COVID-19 pandemic. Ir J Med Sci. Jan 16 2022;doi:10.1007/s11845-021-02893-9
  9. Lam PY, Chow SC, Lai JSM, Choy BNK. A review on the use of telemedicine in glaucoma and possible roles in COVID-19 outbreak. Surv Ophthalmol. Nov-Dec 2021;66(6):999-1008. doi:10.1016/j.survophthal.2021.03.008
  10. Jayaram H, Strouthidis NG, Gazzard G. The COVID-19 pandemic will redefine the future delivery of glaucoma care. Eye (Lond). Jul 2020;34(7):1203-1205. doi:10.1038/s41433-020-0958-1
  11. Li JO, Liu H, Ting DSJ, et al. Digital technology, tele-medicine and artificial intelligence in ophthalmology: A global perspective. Prog Retin Eye Res. May 2021;82:100900. doi:10.1016/j.preteyeres.2020.100900
  12. 12.0 12.1 Parrish RK, 2nd, Higginbotham EJ. What Does Telemedicine Mean for the Care of Patients With Glaucoma in the Age of COVID-19? Am J Ophthalmol. Oct 2020;218:A1-A2. doi:10.1016/j.ajo.2020.07.038
  13. Odden JL, Khanna CL, Choo CM, et al. Telemedicine in long-term care of glaucoma patients. J Telemed Telecare. Jan-Feb 2020;26(1-2):92-99. doi:10.1177/1357633X18797175
  14. 14.0 14.1 Racette L, Abu SL, Poleon S, Thomas T, Sabbagh N, Girkin CA. The Impact of the Coronavirus Disease 2019 Pandemic on Adherence to Ocular Hypotensive Medication in Patients with Primary Open-Angle Glaucoma. Ophthalmology. Oct 19 2021;doi:10.1016/j.ophtha.2021.10.009
  15. 15.0 15.1 Holland LJ, Kirwan JF, Mercieca KJ. Effect of COVID-19 pandemic on glaucoma surgical practices in the UK. Br J Ophthalmol. Apr 30 2021;doi:10.1136/bjophthalmol-2021-319062
  16. Chang HL, Chao SC, Lee MT, Lin HY. Micropulse Transscleral Cyclophotocoagulation as Primary Surgical Treatment for Primary Open Angle Glaucoma in Taiwan during the COVID-19 Pandemic. Healthcare (Basel). Nov 17 2021;9(11)doi:10.3390/healthcare9111563
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