Many of us thought that the COVID-19 pandemic was all going to be over in a matter of weeks or months. However, the pandemic has already made lasting impressions on glaucoma management, and its true impact has yet to be known (we may be reading this article 10 years later laughing at our naiveté as well). Nevertheless, here are our best guesses on changes that may persist after the pandemic in the way we care for our glaucoma patients, including telemedicine, home monitoring, office workflow, risk stratification, and practice management.

Telemedicine

The spikes in COVID cases, intermittent lockdowns and new telemedicine coding have led to a sudden exploration of telemedicine in glaucoma management after years of relative dabbling by the glaucoma community. There remains a broad range of opinion among both patients and doctors regarding the utility of virtual visits. However, telemedicine’s impact on glaucoma care may be greatly amplified by a hybrid model, home intraocular pressure (IOP) monitoring, and/or home perimetry.

Hybrid Telemedicine

Many practices have implemented hybrid telemedicine models. Patients come into the office (potentially an office that is closer or more convenient) for expedited testing and IOP checks with a technician, and then they are scheduled with a follow-up telemedicine appointment to discuss the results with their physician at a later date. When medically appropriate, this is a great option to reduce wait times and provide care at lower risk. Post-COVID-19, such a model could also allow for greater flexibility in connecting specialists with patients who are farther away and/or have limited availability during regular business hours.

Home Monitoring

The increased focus on home monitoring in all subspecialties, including ours, will be greatly beneficial to our patients. More frequent home perimetry could result in earlier detection of progression. Out-of-office IOP measurements could identify spikes in IOP that would warrant alterations in management or earlier surgical intervention. Several advances in these fields could enhance their availability and adoption: improved patient interfaces and instruction, enhanced repeatability and reliability, and appropriate reimbursement for the technology, as well as the monitoring.

Risk Stratification

Around the world, offices scrambled to create a system to deal with unprecedented numbers of cancellations and rescheduled appointments as COVID-19 numbers waxed and waned. A recent paper from the University of Michigan demonstrated the utility of an electronic medical record (EMR)-based risk stratification tool to recommend rescheduling of appointments by combining a glaucoma severity and progression risk score and a COVID-19 morbidity risk score.¹ Real-time risk stratification using EMR data would be ideal for future catastrophes or even snow days; if this is not possible, there is likely still a benefit of manually assigning a systematic risk score to each patient, to be able to automatically prioritize seeing those at greatest risk. Additional research on risk factors for progression, especially genetic and structural factors, will be instrumental to the development of objective risk scores that will guide the intensity of regular care, as well as the prioritization of patients during future crises.

Practice Management

Office Workflow

Many offices have redesigned their clinic workflow to minimize patient waiting room time and minimize close proximity among patients and between patients and staff. For our clinic, this led us to train each of our technicians to be able to take care of each patient's needs from start to finish (work-up, testing, closing the encounter, sending prescriptions, and making an appointment) according to the mantra of one patient/one tech/one room as much as possible. This has really improved our workflow and waiting room time and empowered our technicians.

Patient Communication

This pandemic has certainly taught us the importance of communication. Offices are often prescreening patients regarding COVID-19 exposure/symptoms or informing them of changes to appointments or protocols. Attending to preregistration details, insurance, and records issues prior to the day of the visit has further helped to reduce waiting time and potential exposures. Having a reliable method to reach patients is key, whether by phone, text, email, and/or patient portal. These improvements will continue to pay dividends in the future.

Office Visits and Procedures

Many physicians have moved toward recommending bilateral same-day procedures (laser peripheral iridotomy or selective laser trabeculoplasty) if the patients do not have any high risk characteristics. This minimizes the number of office visits for the patient and decompresses the waiting room as well.

Examinations have also become more focused, concentrating on gathering the data that is most important to the patient’s welfare and avoiding prolonged or close contact elements when possible. These streamlined interactions have improved patient, technician, and physician satisfaction. Since E&M coding guidelines for 2021 focus less on gathering often extraneous data, the move to more focused data collection is likely to continue after the COVID-19 pandemic.

Protective Equipment

Face masks, very frequent hand sterilization, slit-lamp and other shields, enhanced room cleaning, and other measures have all become the norm. So far this year, it appears that influenza and common cold numbers may be lower.² Perhaps some of these enhanced measures will remain with us after the pandemic.

Perimetry

Cleaning protocols for perimetry bowls have been discussed at length.³ Even with such protocols, the length of time between scheduled patients has been extended to decrease risk, and many practices have employed high-efficiency particulate air filters in their rooms. Scheduling visual fields remains an obstacle for many, but switching to faster algorithms has helped to alleviate scheduling issues. Head-mounted virtual visual fields are now available and offer several benefits: fewer surfaces to clean, as well as potential for more perimetry devices in a given office (due to their price and small footprint). Expansion of at-home perimetry in glaucoma patients has its obvious benefits, including the ability to repeat visual fields more frequently and to monitor glaucoma in a more continuous manner with potentially fewer office visits. Studies suggest that more frequent perimetric testing allows for earlier diagnosis of progression.⁴

Imaging

The cleaning protocols for imaging devices are less complicated than those for perimetry.³ Some have argued for the use of more frequent disc photos or optical coherence tomography scans to minimize the duration of slit-lamp examination for a routine nondilated follow-up exam.

Moving Forward

Overall, the ophthalmology community has shown itself to be creative, adaptive, and resilient during the COVID crisis. We expect that, when the pandemic subsides, many of these innovations will persist, given their additional value to patients and office workflow.

References

1. Bommakanti NK, Zhou Y, Ehrlich JR, et al; SOURCE Consortium. Application of the sight outcomes research collaborative ophthalmology data repository for triaging patients with glaucoma and clinic appointments during pandemics such as COVID-19. JAMA Ophthalmol. 2020;138(9):974-980. doi:10.1001/jamaophthalmol.2020.2974
2. US Centers for Disease Control and Prevention. Weekly U.S. influenza surveillance report. Accessed January 11, 2021. https://www.cdc.gov/flu/weekly/index.htm
3. Shabto JM, De Moraes CG, Cioffi GA, Liebmann JM. Review of hygiene and disinfection recommendations for outpatient glaucoma care: a COVID era update. J Glaucoma. 2020;29(6):409-416. doi:10.1097/IJG.0000000000001540
4. Wu Z, Saunders LJ, Daga FB, Diniz-Filho A, Medeiros FA. Frequency of testing to detect visual field progression derived using a longitudinal cohort of glaucoma patients. Ophthalmology. 2017;124(6):786-792. doi:10.1016/j.ophtha.2017.01.027