key: cord-0702086-flvh9wmb
authors: Vinod, Kateki; Sidoti, Paul A.
title: How glaucoma care changed for the better after the pandemic
date: 2021-10-25
journal: Curr Opin Ophthalmol
DOI: 10.1097/icu.0000000000000812
sha: 6f5f99a897d0bc720f956e357e75a69599b76aec
doc_id: 702086
cord_uid: flvh9wmb

PURPOSE OF REVIEW: The current article reviews enhancements to the delivery of glaucoma care that developed in response to the coronavirus disease 19 (COVID-19) pandemic and are likely to persist beyond its resolution. RECENT FINDINGS: Literature from the review period (2020–2021) includes reports highlighting contributions of the ophthalmology community to global health during the pandemic. Glaucoma practices worldwide have instituted more robust infection control measures to mitigate severe acute respiratory syndrome coronavirus 2 transmission in the outpatient setting, and many of these modifications will endure in the post-COVID era. Operational adjustments have led to the provision of more efficient glaucoma care. A hybrid care model involving technician-based diagnostic testing and subsequent virtual consultation with a glaucoma specialist has evolved as a useful adjunct to traditional face-to-face encounters with patients. SUMMARY: Glaucoma specialists, patients, and staff have adapted to a ‘new normal’ of glaucoma care delivery during the COVID-19 pandemic. Although innovation has propelled several improvements to glaucoma care during this global health crisis, significant barriers to more widespread implementation of teleglaucoma still exist. Whether, and in what capacity, the pandemic has permanently altered glaucoma practice patterns remains to be seen.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in 198 227 874 infections and 4223 255 deaths worldwide and 34 997 105 infections and 613 223 deaths in the United States as of 1 August 2021 [1] . The coronavirus disease 19 (COVID-19) pandemic has caused unprecedented devastation, not only in the toll of lives lost and enduring morbidity among survivors, but also its impact on the economy and society at large. The magnitude of this global health crisis is likely not yet fully realized. Fortunately, public health measures, including universal masking, hand hygiene, social distancing, and, more recently, vaccinations against COVID-19, have significantly reduced the rates of infection, hospitalization, and death in the United States.

While sanguinity in the face of such widespread tragedy is nearly inconceivable, the pandemic has redefined the role of the ophthalmologist in medicine and transformed the delivery of ophthalmic, and specifically glaucoma, care. Herein, we highlight the ophthalmology community's contributions to the global fight against COVID-19 and review those aspects of glaucoma care that may have changed for the better after the pandemic.

]. Shortly thereafter, healthcare systems throughout the world rapidly became overburdened by soaring SARS-CoV-2 infection rates and shortages in hospital capacity, personal protective equipment (PPE), and ventilators. Healthcare workers, among them trainees, retired healthcare professionals, and specialists, including ophthalmologists, were called upon to bolster the front lines. At the height of the pandemic, some ophthalmologists were redeployed to emergency departments, ICUs, and medical wards, whereas others continued to provide urgent and emergent eye care [4 & -10 & ]. Collectively, our varied experiences as ophthalmologists, and in particular glaucoma specialists, during the pandemic have likely increased our resilience, deepened our empathy, and heightened our vigilance toward our most vulnerable patients, preparing us to provide better care to our patients with glaucoma in the post-COVID era.

The COVID-19 pandemic has exacerbated existing challenges to the delivery of glaucoma care. Extended lockdowns and suspension of routine outpatient visits limited access to care among a population in which nonadherence to treatment and follow-up was already prevalent [11 & ]. Patients, particularly those whose age and systemic comorbidities increased their risk for complications from COVID-19 [12 & ], were forced to weigh their fears of glaucomatous progression and blindness due to missed appointments against concerns of contracting SARS-CoV-2 during in-person visits. Survey- ] identified SARS-CoV-2 ribonucleic acid in a sample obtained from a slit-lamp breath shield and another sample from a phoropter following the ophthalmic examinations of 22 asymptomatic patients. Notably, investigators wiped the forehead and chin rests of the slit-lamp with 70% isopropyl alcohol, a common practice in the pre-COVID era. Although patients were wearing masks, efforts were not made by staff to enforce their proper usage. While infectivity of viral samples was not assessed in this study,

Major modifications implemented by glaucoma practices worldwide, ranging from enhanced disinfection protocols to implementation of single-use diagnostic instruments, will continue to optimize safety for patients, physicians, and staff in the post-COVID era.

Reorganization of patient flow in the outpatient setting has streamlined in-person visits for patients with glaucoma.

Hybrid models of glaucoma care harness the advantages of teleglaucoma by combining techniciandriven data acquisition and virtual consultation with a glaucoma specialist.

its results reinforce the need for the improved disinfection protocols (in addition to masks and breath shields) that are now a part of our ' [42] [43] [44] and are more reliable than alternative methods of contact tonometry, including Icare (Icare Finland Oy, Vantaa, Finland) and Tono-Pen (Reichert, Inc., Buffalo, New York, USA) [44] , which employ disposable probes and tip covers, respectively. Icare and Tono-Pen exhibit wider 95% limits of agreement (À8.18-9.06 for Icare versus À8.55-5.21 for Tono-Pen) than disposable GAT (À3. .96) when comparing each modality with standard GAT [44] . Icare and Tono-Pen are also more likely to overestimate the IOP in eyes with greater central corneal thickness (CCT > 555 mm) [45] . Glaucoma specialists who routinely use Icare or Tono-Pen should therefore exercise caution in eyes displaying extremes of IOP and/or CCT, as their results may erroneously influence clinical decision-making.

Ultrasound pachymeters with disposable tip covers are also commercially available (PalmScan Pachymeter, Micro Medical Devices, Inc., Calabasas, California, USA), as are single-use gonioprisms, laser iridotomy lenses, and selective laser trabeculoplasty lenses (Katena Products, Inc., Parsippany-Troy Hills, New Jersey, USA; Lombart Instrument Co., Norfolk, Virginia, USA; Volk Optical Inc., Mentor, Ohio, USA). Disposable ultrasound probe covers also exist for ultrasound biomicroscopy (ClearScan, ESI, Inc., Plymouth, Minnesota, USA).

Several aspects of glaucoma care delivery have become safer for patients, physicians, and staff as a result of the pandemic. Such efforts will remain essential indefinitely in reassuring patients that their health and safety are being prioritized during visits to glaucoma practices [15 & ,46 & ]. In addition, the use of disposable GAT tips and lenses will eliminate the need to perform high-level disinfection of reusable instruments and thereby confer ongoing benefits with regard to streamlined workflow, efficiency, and cost.

Although minimizing wait times for patients was relatively straightforward when in-office censuses were low, maintaining efficiency became challenging as glaucoma practices returned to their prepandemic volumes. Patients are no longer willing to tolerate crowded waiting rooms and extended wait times [15 & ]. The need to incorporate new safety measures has demanded more time and effort from staff, and practices have had to develop more efficient models of glaucoma care to streamline inperson visits.

Multiple approaches have been adopted to reorganize patient flow and reduce the total amount of time patients spend in the office. Streamlining glaucoma care can begin prior to the appointment date by mailing new patient questionnaires to patients for completion at home or making forms available online. When scheduling in-person appointments by telephone, staff may also prescreen new and established patients by collecting a history of present illness, medical and ophthalmic history, ]. This strategy also minimizes the number of times patients must return to the waiting room between different aspects of their glaucoma evaluation. Patients can be offered separate appointments for testing and in-person consultation with their glaucoma specialist to minimize the amount of time spent in the office on a given day and utilize resources more efficiently. Technician-based testing can be performed on a day on which the physician is in the operating room or performs administrative duties.

Prior to the pandemic, some large, multispecialty practices, such as those based in a hospital or an academic setting, had imaging suites and diagnostic equipment on different floors of a given building. The pandemic compelled reorganization of such arrangements, such that equipment needed for a given subspecialty like glaucoma was consolidated onto one floor, limiting patient traffic between floors and saving time. Having administrative staff perform the check-out process and schedule the next visit while the patient is still in the examination room may avoid queues at the discharge desk. Planning in advance for any ancillary testing that will be required at the next appointment may also improve flow. In addition to these modifications, some practices have expanded office hours to include evenings and weekends, further minimizing wait times and helping to avoid crowded waiting

. Glaucoma specialists may consider widening follow-up intervals for glaucoma suspects and patients proven to have stable disease for many years, contributing to overall practice efficiency. Ninety-day medication prescription refills, where permitted by insurance companies, may help safeguard medication availability and decrease the number of phone calls to the office, thereby reducing demands on staff [37 & ]. Finally, collaboration among administrative staff, ophthalmic technicians, and physicians, sometimes expanding duties beyond one's typical responsibilities, has been instrumental in streamlining in-person visits for patients.

Use of telemedicine burgeoned during the early months of the COVID-19 pandemic, particularly when routine outpatient visits were suspended. Its implementation was supported by relaxation of regulatory barriers, including the removal of penalties for Health Insurance Portability and Accountability Act violations, elimination of geographic restrictions, and reimbursement parity during the Public Health Emergency (which, after several renewals, remains in effect as of this writing). However, ophthalmologists were among the least frequent users of telemedicine during the early pandemic when compared with other physicians providing chronic care. In a database analysis of telemedicine use among 16.7 million beneficiaries with commercial insurance and Medicare Advantage over the first 13 weeks of the pandemic, Patel et al. ]. Kotecha et al. described a stable monitoring service that provided hybrid glaucoma care to 1575 low-risk patients (i.e., glaucoma suspects and those with early-to-moderate glaucoma) between March 2014 and April 2015. Technicians assessed visual acuity, performed visual field testing, measured IOP, instilled dilating eye drops, and obtained optic nerve imaging before discharging a patient home. Within 2 weeks, a glaucoma specialist remotely reviewed data and made clinical decisions regarding follow-up. Total average time spent by patients in the hybrid clinic was 51 min, compared with an average of 92 min in the conventional glaucoma outpatient clinic [72] . Clarke et al. [73] observed infrequent disagreement between clinical decisions made by attending glaucoma specialists during virtual glaucoma visits and in-person visits, reporting misclassification events in two of 204 (0.98%) patients. Both patients who were inappropriately deemed to be stable via virtual visits but whose disease was found to be progressing during in-person visits in this study had advanced visual field loss, suggesting that teleglaucoma is best reserved for patients with early-to-moderate disease. A 2016 NHS survey of clinical and glaucoma leads found comparable patient acceptability, safety, and efficiency between virtual glaucoma clinics and standard outpatient visits [74] .

In the COVID-19 era, the hybrid model has been adopted in various forms by glaucoma practices worldwide [ & ]. Glaucoma practices have since continued to use a more sustainable strategy in which patients undergo any indicated diagnostic testing in-person with a trained technician and then review results by telephone or video visit on a later date with their glaucoma specialists. In some regions of the world, testing centers established in more remote areas have been used for the initial technician-based evaluations. Tham and associates recognized that 40% of patients within the Singapore National Eye Center's glaucoma clinic had stable disease and could benefit from a hybrid model of care. The authors established Investigative Units in the Community at which patients with stable glaucoma and low-risk glaucoma suspects underwent testing by technicians. Data were reviewed remotely by a glaucoma specialist within 1 week. Patients requiring a change in management were scheduled for a video visit and those whose management was to be continued were informed via short message service or e-mail. A majority of patients agreed that the new model provided efficient (90.2%) and satisfactory (94.8%) glaucoma care [70 & ].

In its current state, teleglaucoma is best reserved as a supplement to, rather than a replacement for, in-person visits. Its future expansion and sustainability will rely on numerous factors including favorable reimbursement structures, ease of use, acceptance by physicians and patients, and further validation of home monitoring devices. During the pandemic, both patients and providers have recognized the challenges inherent in providing completely virtual glaucoma care without the availability of ancillary testing [15 & ]. A hybrid model, which permits acquisition of critical data that cannot be gleaned virtually and reduces the amount of time patients spend waiting in the office, may represent a viable strategy for incorporating teleglaucoma in the post-COVID era if supported by payers.

The COVID-19 pandemic has supported a paradigm shift in the delivery of glaucoma care. Glaucoma practices worldwide have adopted innovative modifications to optimize safety and streamline in-person visits, many of which will persist indefinitely. Teleglaucoma has enabled the implementation of a hybrid model of care while tools for home-based glaucoma monitoring undergo further refinement and validation. Beyond the pandemic, these developments in care delivery will allow for improved access to services and a reduction in existing disparities within our communities.

Many unanswered questions remain regarding the long-term impacts of the pandemic on glaucoma care. Patients who have been unable to follow-up for extended periods continue to reestablish care today, often presenting with uncontrolled IOP and disease progression. As more data become available supporting the efficacy of selective laser trabeculoplasty, microinvasive glaucoma surgery, and sustained drug delivery devices, glaucoma specialists may shift their practice patterns toward earlier intervention to mitigate such adverse outcomes. Interestingly, reports from countries including India, Italy, and the United Kingdom have demonstrated a significant decrease in the number of trabeculectomies performed during the pandemic in favor of less invasive procedures, including & ], with a continued emphasis on safety and efficiency during in-person visits.

None.

Financial support and sponsorship None.

There are no conflicts of interest. In a telephone survey of 363 patients, the authors identified barriers to follow-up during the pandemic including fear of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), local lockdowns, finances, and transportation, and barriers to medication adherence including lack of availability, finances and poor health literacy/lack of perceived benefit. 

Patient perceptions of SARS-CoV-2 exposure risk and association with continuity of ophthalmic care

This survey-based study found a four-fold higher rate of loss to follow-up among patients fearful of exposure to SARS-CoV-2 at the eye clinic

Transmission of SARS-CoV-2: a review of viral, host, and environmental factors

SARS-CoV-2 and surface (Fomite) transmission for indoor community environments

Sustainability of ophthalmology practice and training during and post the pandemic of coronavirus (COVID-19): a review

The authors report various approaches to optimizing safety used by ophthalmology practices during the COVID-19 pandemic

Proposed measures to be taken by ophthalmologists during the coronavirus disease 2019 pandemic: experience from Chang Gung Memorial Hospital

The authors report infection control measures utilized within the Department of Ophthalmology at the Chang Gung Memorial Hospital in Taiwan during the COVID-19 pandemic

Guidelines and recommendations for tonometry use during the COVID-19 era

This review summarizes evidence regarding the ocular surface as a route of SARS-CoV-2 infection and provides recommendations regarding the use of tonometry during the pandemic

Preferred practice guidelines for glaucoma management during COVID-19 pandemic

This article summarizes consensus-based guidelines for glaucoma care in India during the COVID-19 pandemic

Current trends in tonometry and tonometer tip disinfection

In a survey of the American Glaucoma Society membership that preceded the pandemic, the authors observed that 98% (193 of 197) of glaucoma specialists preferred goldmann applanation tonometry (GAT) over other methods of intraocular pressure (IOP) measurement, and 55% (109 of 197) were exclusively using disposable GAT tips

Applanation tonometry: interobserver and prism agreement using the reusable Goldmann applanation prism and the Tonosafe disposable prism

A comparison of applanation tonometry using conventional reusable goldmann prisms and disposable prisms

Comparison of disposable Goldmann applanation tonometer, ICare ic100, and Tonopen XL to standards of care Goldmann nondisposable applanation tonometer for measuring intraocular pressure

Comparison of intraocular pressure measurements with different contact tonometers in young healthy persons

What does telemedicine mean for the care of patients with glaucoma in the age of COVID-19?

This editorial summarizes the utility and limitations of telemedicine in glaucoma care, including its potential to exacerbate inequity in access to care

Teleophthalmology in COVID-19 era: an Italian ophthalmology department experience

The authors describe their experience using tele-triage for diagnosis of ophthalmic conditions during the pandemic

Impact of teleophthalmology during COVID-19 lockdown in a tertiary care center in South India

The authors report results of a cross-sectional, hospital-based study of teleconsultations performed in Tamil Nadu, India between

Utility of mobile application-based teleophthalmology services across India during the COVID-19 pandemic

The authors report use of a smartphone-and web-based application to provide remote ophthalmic care to 2452 patients

New digital models of care in ophthalmology, during and beyond the COVID-19 pandemic

Telemedicine for glaucoma: guidelines and recommendations

Experiences with developing and implementing a virtual clinic for glaucoma care in an NHS setting

Virtual clinics in glaucoma care: face-toface versus remote decision-making

Acceptability and use of glaucoma virtual clinics in the UK: a national survey of clinical leads

How to restore medical services in the ophthalmic department in the postpandemic period of COVID-19

The authors summarize infection control strategies to mitigate SARS-CoV-transmission in ophthalmology practices

Jayaram H, Strouthidis NG, Gazzard G. The COVID-19 pandemic will redefine the future delivery of glaucoma care. Eye (Lond) 2020; 34:1203-1205. The authors report the use of telemedicine for glaucoma care at Moorfields Eye Hospital in the United Kingdom. 58.

The authors report results of a telephone survey of 232 patients and caregivers, in which blind patients (defined as those with best corrected distance visual acuity of 3/60 or worse or visual field less than 10-degrees in the better-seeing eye) were significantly more likely than those with no or mild visual impairment to perceive vision as a risk factor for acquiring COVID-19 (P ¼ 0.045) and to have concerns about access to care (P < 0.001). The authors describe the results of an online questionnaire exploring the impact of eye disease on individuals' mental health and ability to cope with the pandemicrelated lockdown in the United Kingdom.

Liu J, Wang AY, Ing EB. Efficacy of slit lamp breath shields. Am J Ophthalmol 2020; 218:120-127. In a series of experiments evaluating the efficacy of six different breath shields, the authors found that those with larger surface areas (i.e., 513 and 924 cm 2 ) conferred greater protection, especially when placed on the objective lens arm rather than the oculars of the slit-lamp biomicroscope. This retrospective analysis reports an overall 80.9% decrease in the number of outpatient glaucoma visits to a tertiary eye center during the lockdown period, but a 62.4% increase in the number of true emergency visits for glaucoma. 80.