The management of glaucoma remains a significant clinical challenge. Regular monitoring and active management are required to prevent progressive vision loss. Traditional in-office ophthalmology visits can be difficult for patients, particularly those with accessibility limitations, transportation issues, and time constraints. 

Telehealth, the delivery of health care services and information through digital communication technologies, has the potential to revolutionize glaucoma care, offering numerous advantages through remote monitoring, improved patient convenience, enhanced treatment adherence, and earlier detection.¹ Telehealth can be administered with the patient either in their home or in a remote health care setting. 

Teleophthalmic care is particularly helpful for high-risk or underserved, vulnerable patient populations.^1,2 It allows high-risk patients to undergo more frequent evaluation without the burden of frequent office visits, allowing for earlier detection and intervention of uncontrolled intraocular pressure (IOP) or disease progression. Virtual medicine also bridges geographical gaps by providing access to specialists for patients in remote or underserved areas, facilitating screening, diagnosis, and monitoring of ophthalmic conditions regardless of location. This approach helps reduce disparities in eye care access and may improve overall patient outcomes. 

How does it work? Remote monitoring, a cornerstone of telehealth for glaucoma management, requires access to remote tonometry and/or visual field testing and a platform for virtual communication. This article will focus on in-home options for telehealth.

Remote Tonometry

Remote tonometry allows patients to measure IOP remotely while transmitting the data to a health care provider for analysis. These technologies enable frequent, even continuous monitoring and rapid detection of uncontrolled IOP, ideally spurring more timely intervention.^3,4

This technology allows health care to be more accessible to patients who have mobility limitations or who reside in remote areas, thereby helping to improve broader health care access. Remote monitoring allows physicians to intervene punctually and treat dangerous pressure changes more quickly than waiting for scheduled office visits, thereby improving long-term outcomes and reducing the risk of vision loss.^3,4 This not only strengthens clinical decision-making but fosters greater patient participation. Patients become more engaged in their care, improving treatment adherence.⁵ These technologies continue to make great strides. 

Several studies have illustrated that remote monitoring of IOP has demonstrated comparable accuracy to conventional in-office measurements, validating its effectiveness as a distance-based glaucoma management tool.³ It provides longitudinal data by capturing trends and patterns in IOP that may be missed during sporadic in-office measurements. This aids in tailoring individualized treatment plans for patients. Remote tonometry continues to transform the field of ophthalmology by addressing clinical and systemic challenges in glaucoma care. 

The first device for home monitoring approved for the US Food and Drug Administration (FDA) is the iCare Home tonometer. This rebound tonometer enables patients to perform self-measurements, facilitating the collection of longitudinal data that can reveal important IOP patterns over time. Studies show that measurements taken with the iCare Home device correlate well with Goldmann applanation tonometry, demonstrating a mean IOP difference of only 0.5 mmHg.^3,6 Patients can use this device at home with minimal training, and its noninvasive nature makes it ideal for frequent, self-administered measurements, contributing to a more comprehensive understanding of pressure fluctuations over time. The iCare Home device can be rented or purchased directly by the patient once prescribed; the cost may be covered by the patient’s insurance. Billing codes are available for device setup, monitoring, and telehealth programs. 

Another option for remote monitoring is the Sensimed Triggerfish, an FDA-approved soft, silicone prescription contact lens that continuously records dimensional changes at the corneoscleral junction over a 24-hour period. The contact is placed in the office, worn for 24 hours, and then removed in the office, offering insight into diurnal IOP, even during sleep.⁷ Data are collected on a small wearable device and transmitted via Bluetooth. The lenses do not measure IOP directly, only IOP fluctuation in the form of millivolts, but this can provide helpful information on periods of maximum IOP and pressure fluctuation. 

A potential future option for remote IOP monitoring is the implantable Eyemate systems being developed by Implandata Ophthalmic Products.^8,9 The Eyemate-SC device can be implanted in the suprachoroidal space, typically during nonpenetrating glaucoma surgery, whereas the Eyemate-IO is positioned in the ciliary sulcus during cataract surgery. Both devices provide real-time, continuous IOP data via a telemetric system, which can be accessed remotely by ophthalmologists. These devices represent an advancement in long-term glaucoma management, by providing continuous monitoring to aid in personalized treatment plans.⁶ Although the Eyemate systems received breakthrough device designation from the FDA in 2021, they are not yet fully approved for market use in the United States.

Visual Fields

Perimetry has also undergone rapid advancements that are amenable to remote testing. Specifically, online perimetry tools offer accessible options via computers, tablets, and virtual reality glasses. The Peristat Online Perimetry test provides a quick and efficient assessment using a standard computer monitor.¹⁰ This 5-minute test generates a comprehensive report, including reliability indices and a grayscale visual field image, which is then emailed to the prescribing physician.¹⁰ The Melbourne Rapid Fields (MRF; Glance Optical) is a web-based program utilizing touchscreen tablets with multilanguage voice prompts and a user-friendly interface. MRF delivers a concise 3- to 4-minute test per eye, and results include detailed maps of sensitivity values, total and pattern deviations, and a visual field grayscale, offering a thorough analysis comparable to traditional standard automated perimetry (SAP).¹¹ 

Virtual reality (VR) headsets are increasing in popularity within eye care practices and represent the cutting edge of perimetry. By leveraging gyroscopes and gaze trackers, these devices create an immersive 3D environment that adapts to the user’s head and eye movements. The Radius XR visual field system, a virtual reality–based perimetry device, has demonstrated similar sensitivity and specificity, high concordance in glaucoma staging accuracy, and faster test times when compared to SITA-Standard HFA testing.¹² The Radius XR device is primarily used in the clinic setting, but its lightweight and portable design is amenable to remote use. 

Other advanced VR systems include the Virtual Field device (Virtual Field), the VisuALL VR platform (Olleyes), the wearable VF2000 visual field analyzer (Micro Medical Devices), and the Easyfield VR (Oculus). These systems are pushing boundaries by detecting multifocal steady-state visual evoked potentials, possibly eliminating the “human factor” in testing reliability.¹³ This paradigm shift in visual field assessment promises enhanced accuracy and efficiency, potentially surpassing the current SAP standard, all done with a device small enough to be portable.

Consultations

After data gathering is complete, virtual consultations enable patients to interact with providers through video, phone, or secure messaging. These remote interactions improve treatment adherence by increasing patient-provider contact. A 2-year cohort study of 500 patients showed a 15% improvement in adherence rates for those using telehealth services.¹⁴

Implementing virtual consultations for glaucoma management requires a comprehensive approach. Physicians must establish a telehealth infrastructure, including HIPAA-compliant platforms and necessary equipment for both clinics and patients. Patient enrollment and education are imperative. This involves careful selection of eligible participants and thorough training on home tonometry devices and telehealth platforms. 

Virtual consultations also require efficient scheduling systems, standardized protocols, and secure communication channels. For example, Doxy.me is an option for virtual consultations offering easy, secure access to onboard patients without software downloads. Providers can share a direct link with simple instructions and Doxy.me’s HIPAA compliance builds trust between the physician and the patients.¹⁵

Benefits and Limitations

Economic analyses consistently report cost savings associated with reduced travel burden and fewer missed appointments. These savings are primarily due to decreased transportation costs and time off work. In 1 economic evaluation, patients saved approximately $200 annually in transportation expenses alone by avoiding multiple in-person visits for routine glaucoma follow-ups.¹⁶ These savings stem from reduced travel to ophthalmology clinics, which is especially beneficial for patients living in rural or underserved areas where access to specialized care may require long-distance travel. The reduction in travel also leads to fewer missed appointments, as telehealth allows patients to consult with their health care providers from the comfort of their own homes. Additionally, decreased reliance on transportation services (eg, public transport or private vehicles) lowers indirect costs such as fuel, parking fees, and travel time.¹⁶ These individual savings contribute to broad economic impacts, including reduced health care system costs and improved long-term health outcomes due to better patient compliance. These economic benefits, coupled with clinical advantages, present a compelling case for the continued expansion of telehealth services in glaucoma management. 

Several studies have indicated improvements in quality-of-life metrics among those using telehealth services. Patients reported higher satisfaction scores related to convenience and perceived control over their health management.¹⁷ This is largely due to increased convenience and user-friendly platforms. Telehealth also provided patients with a greater sense of control over their health management, fostering proactive engagement and better compliance with treatment plans. Quality of life improvements were evident in reduced anxiety and stress, as well as better health outcomes due to consistent follow-up care and early detection of issues.¹⁷ 

The success of remote monitoring depends on the patient’s ability to use home tonometry devices correctly, which can be challenging for older adults or individuals with limited technological proficiency.^3,4 A cohort study involving 400 elderly patients with glaucoma, limited technological proficiency, and assistance needs found that only 60% could successfully use home tonometry devices without assistance.⁴  Studies have also identified issues such as the digital divide, where there is unequal access to digital technologies. Patients in rural or underserved areas may lack reliable internet access or the necessary devices to participate in telehealth programs.⁴ Thus, approaches that consider disease severity, patient preferences, access, and technological literacy are essential for the success of telehealth programs. This highlights the need for comprehensive education and support programs to help patients become comfortable with the technology. 

At the highest level, effective implementation of telehealth for glaucoma management also requires supportive policies and regulations. Advocacy must work to remove barriers to telehealth adoption, such as restrictive reimbursement policies and licensure regulations. Community-based programs that provide digital literacy training and access to devices and internet services can help bridge the digital divide and enable more patients to benefit from telehealth interventions.¹⁸

Conclusion

Telehealth presents a viable option for managing glaucoma by facilitating remote monitoring and improving adherence rates without compromising clinical outcomes. However, its implementation should be carefully tailored based on disease severity and patient capabilities. Addressing technological barriers is crucial for broader adoption. High-quality research is needed to optimize these interventions and ensure equitable access across diverse populations. Ensuring that all patients, regardless of technological proficiency or geographic location, can benefit from telehealth will require coordinated efforts from health care providers, policymakers, and community organizations. GP

Imani Nwokeji, , is a third-year medical student at the City University of New York School of Medicine/ Sophie Davis Biomedical Education Program in New York City. She reports no disclosures. Ms. Nwokeji can be reached at inwokej000@citymail.cuny.edu.

Lorraine M. Provencher, MD, is a glaucoma specialist and refractive cataract surgeon at Vance Thompson Vision in Omaha, Nebraska. She reports the following disclosures: Radius speaker, advisory board member. Dr. Provencher can be reached at lorraine.provencher@vancethompsonvision.com.

References

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