Teleglaucoma has tremendous potential to improve patient access to high-quality, cost-effective glaucoma care. A wide spectrum of teleglaucoma applications is currently used around the world. The growing body of literature on teleglaucoma will continue to inform further development and implementation of future teleglaucoma programs. The main modalities of teleophthalmology — store-and-forward and real-time consultation — each have distinct advantages and disadvantages. Several important studies have investigated the value of these methods of care delivery. Most recently, the coronavirus pandemic has fueled an immediate need for teleophthalmology. On March 18, 2020, the American Academy of Ophthalmology recommended that healthcare providers cancel all elective procedures and surgeries and delay all elective ambulatory provider visits, including routine eyecare visits in accordance with the American College of Surgeons and CDC guidelines. By early April, all but 7 state governors had issued stay-at-home orders to curb the spread of the COVID-19 virus. This situation hit the pause button on all glaucoma patients’ eye care, as they were unable to safely come to the office for routine visits. Teleglaucoma thus has come to the forefront of clinical practice during these trying times.

It is estimated that glaucoma affects 76 million people in 2020, and the prevalence will rise to 111 million in 2040 (a 46.1% increase);¹ further, at least 74% of patients with glaucoma are undiagnosed worldwide.² On the provider side, the number of glaucoma fellowship training positions in the United States has increased from 77 in 2014 to 93 in 2019 (a 20.8% increase) based on SF Match data. Clearly, there will be a worsening shortage of subspecialists in glaucoma for the growing burden. The question at hand is: How can teleglaucoma help improve the distribution of care?

Currently there are 2 main modalities of teleophthalmology: store-and-forward and real-time consultation.³ Using the store-and-forward model, patients are triaged at remote reading centers within opportunistic screening centers (nonophthalmologic settings, such as endocrinology or primary care offices), which provide ancillary screening, referrals to glaucoma specialists, and virtual visits with specialists for disease diagnosis and monitoring. In real-time consultation, live interaction between a clinician and patient allows for the ability to share diagnoses with patients, answer questions, and provide patient counseling and education. Each modality has its benefits and shortcomings.

Store-and-Forward Teleglaucoma

Store-and-forward teleglaucoma is ideal for large-scale, community-based screening, especially in high-risk areas. In a remote interaction between patient and clinician, the clinician relies on either a previous store-and-forward set of data (ie, prior visual acuity, intraocular pressure [IOP], and visual field) and/or simply the patient report of symptoms. Unfortunately, a critical challenge in teleglaucoma is the inability to check a patient’s IOP remotely. There are obvious shortcomings in both store-and-forward and real-time consultation for glaucoma care, but both have proved cost effective.⁴ In a recent study by Kapoor et al, GlobeChek was used to screen 326 patients in New York City (data have been accepted for publication in Asia-Pacific Journal of Ophthalmology). Technicians and trained medical and college students performed comprehensive eye history and screening exams with the help of a kiosk with visual acuity, IOP measurements, autorefraction, autokeratometry, pachymetry, anterior- and posterior-segment optical coherence tomography (OCT), nondilated fundus photography, and frequency doubling technology. These results were then transmitted to a secure virtual private reading center, where a clinician reviewed the images and data and emailed the results and recommendations for follow-up. This system of store-and-forward screening using the GlobeChek kiosk was found to be an effective way to identify the most common causes of vision loss in the community.

Real-Time Evaluation

Real-time technology does not rely on patient factors for follow-up. Real-time consultation is also helpful in limiting patient barriers to care, such as travel and cost, making these virtual teleglaucoma visits much more convenient for both patients and providers. These visits are time synchronous and allow for bidirectional conversations between the patient and physician via audio and video interaction. Real-time consultations are much more difficult to scale to cover a community-based screening, and they require some degree of technical proficiency to access the virtual platform. In 2017, one of the authors of this article, Dr. Al-Aswad, launched the first teleophthalmology mobile unit to screen for the 4 leading causes of vision loss in real time in high-risk and low-socioeconomic areas of New York City. Over 12 months, she screened 957 individuals, 26% of whom were identified as glaucoma suspects.

Turning to Telemedicine

Shortly after the COVID-19 pandemic emerged as a worldwide threat, the potential for teleglaucoma came to the forefront. Virtual visits allowed physicians to connect remotely to patients, addressing their needs and concerns while protecting patients, family members, staff, and doctors from possibly spreading the virus. Recognizing these important concerns, government restrictions, which previously stymied telemedicine from flourishing, were relaxed. Red tape, such as lack of codes for telemedicine, inability to practice telemedicine in different states, and stifling HIPAA restrictions, had made practicing telemedicine difficult. In the face of the COVID-19 pandemic, Medicare has even expanded its coverage to allow for telehealth visits during this state of emergency. For the time being, government restrictions have been eased to allow physicians to use various billing codes for telemedicine visits, including phone and live virtual visits. Additionally, patients who live in a different state from their provider can participate in virtual visits, even if the provider is not licensed in the patient’s state. HIPAA rules have been loosened to allow for other nonpublic facing audio and video platforms, such as FaceTime, Zoom, Skype, and several other popular applications, to be used for telehealth visits.

At New York University, virtual urgent care has been set up for patients to easily and seamlessly make video appointments with a qualified clinician for common nonemergency medical issues. With the advent of the coronavirus pandemic, this platform was expanded for use in the ophthalmology department.

Within 3 weeks from the launch, the department was able to perform 476 virtual visits, not counting telephone calls. To acquire data for IOP, iCare HOME rebound tonometer devices were sent to the patients’ homes 3 days prior to their scheduled virtual visits. An instructional video was also sent to the patient to learn from and begin acquiring IOP data points every 2-3 hours throughout the day. The glaucoma specialist then reviews the diurnal IOP curve at the time of the virtual visit. In addition, a new ophthalmology application was developed and sent to the patient to allow the patient to check his or her near visual acuity at 14 inches on the screen and gross central visual field with an Amsler grid. During the virtual visit, both the physician and patient log into a platform called the Epic Haiku mobile app, which was created by NYU in collaboration with Epic. This app allows for real-time voice and video communication and opens the patient’s chart for the physician to review the prior notes, visual fields, OCT, medications, and the iCare HOME IOP measurements. In this way, virtual glaucoma visits allow for a safe, collaborative, and informed encounter for both patients and providers.

When restrictions are lifted from the COVID-19 pandemic, it is likely that federal regulations will once again more tightly govern telemedicine encounters and limit the use of certain consumer applications for virtual visits. Nevertheless, the experiences of the glaucoma community during the less-regulated weeks of the pandemic have helped to demonstrate the utility of telehealth in modern medicine.

Teleophthalmology has the ability to reach across borders, time, and financial barriers to allow patients to be screened and monitored by qualified physicians and subspecialists. Store-and-forward modalities of teleglaucoma allow for broad public screenings to identify potentially blinding diseases in communities where people may lack easy access to glaucoma care. Teleglaucoma can also allow for real-time connection between patients and physicians via virtual visits for disease monitoring.

Glaucoma patients must deal with a chronic disease that sometimes leads to feelings of helplessness, particularly in times of uncertainty, such as the COVID-19 pandemic. Telehealth allows patients to connect with physicians for quality eye care and may alleviate the anxiety that patients feel during the pandemic. We believe that telehealth will continue to provide patients with access to care long after the pandemic ends. GP

Anna Do, MD, is a glaucoma fellow at NYU Grossman School of Medicine, NYU Langone Health in New York, New York. She reports no related disclosures.

Lama A. Al-Aswad, MD, MPH, is a professor of ophthalmology, vice chair for innovations, director of Teleophthalmology for Artificial Intelligence and Innovations, and associate director of the Glaucoma Fellowship at NYU Grossman School of Medicine, NYU Langone Health. She reports equity ownership in GlobeChek and grants from Topcon, Zeiss, and New World Medical. Reach her at lama.al-aswad@nyulangone.org.

References

1. Thomas SM, Jeyaraman MM, Hodge WG, Hutnik C, Costella J, Malvankar-Mehta MS. The effectiveness of teleglaucoma versus in-patient examination for glaucoma screening: a systematic review and meta-analysis. PLoS One. 2014;9(12):e113779.
2. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90(3):262-267.
3. Tang RA, Morales M, Ricur G, Schiffman JS. Telemedicine for eye care. J Telemed Telecare. 2005;11(8):391-396.
4. Thomas S, Hodge W, Malvankar-Mehta M. The cost-effectiveness analysis of teleglaucoma screening device. PLoS One. 2015 Sep 18;10(9):e0137913.