The COVID-19 pandemic has dramatically changed the delivery of glaucoma care since 2020. In addition to the cancellation of non-urgent outpatient visits, social distancing and fear of COVID-19 infection led to a decrease in the number of new diagnoses, regular follow-up visits, and trabeculectomy procedures.
Many ophthalmology societies recommended avoiding elective care 1), and telemedicine was rapidly introduced as an alternative to in-person visits. However, essential components of glaucoma management such as intraocular pressure measurement, visual field testing, and fundus evaluation are difficult to perform remotely, and telemedicine was discontinued in many facilities within a few months 1).
Liu et al. (2023) conducted semi-structured interviews with 20 glaucoma specialists in New York City and organized the introduction, challenges, discontinuation, and future prospects of telemedicine during the pandemic into four themes 1).
Intraocular pressure monitoring is the foundation of glaucoma management. During the pandemic, the use of Goldmann applanation tonometers was limited due to infection transmission risk. The use of disposable tips was recommended, but some facilities discontinued use altogether.
Devices for home intraocular pressure measurement (e.g., rebound tonometer Icare HOME) are approved, but adoption is limited due to device cost and reliability of self-measurement. The telemetric intraocular pressure sensor (Eyemate) is a permanently implantable device approved in Europe, holding potential for future remote monitoring.
Artifacts in visual field testing due to mask wearing have become a new issue.
The pandemic also affected adherence to visual field testing. However, the impact on adherence was limited in glaucoma suspects and patients with a history of laser trabeculoplasty.
Wearing a mask can cause artifacts such as inferior visual field defects (due to obstruction by the upper edge of the mask), increased fixation loss, and fogging of glasses. These may be mistaken for true visual field damage from glaucoma progression, and measures such as taping the upper edge of the mask are recommended.
Tele-glaucoma was rapidly introduced during the pandemic. Main components include history taking, fundus photography, RNFL imaging, intraocular pressure measurement, corneal thickness measurement, and anterior segment imaging.
Advantages
Improved access: Provides eye care to patients in remote or underserved areas.
Efficiency: A “digital integrated examination” method that separates testing from physician consultation has been developed.
Adherence support: Maintaining the doctor-patient relationship is expected to improve medication adherence.
Infection control: Methods to minimize contact, such as drive-through intraocular pressure clinics, have been attempted.
Disadvantages
Inability to measure intraocular pressure: Reliable intraocular pressure measurement cannot be performed remotely1).
Limitations of objective data: Cannot replace in-person tests such as visual field testing and OCT1).
Digital divide: Barriers to internet access and digital literacy exist among the elderly and low-income populations1).
Unsuitability for new patients: While suitable for monitoring already diagnosed patients, it is not appropriate for initial diagnosis.
In interview surveys, telemedicine was useful for addressing subjective complaints (checking symptoms and side effects), but many facilities discontinued it due to concerns about patient safety because objective data collection was impossible1).
There is evidence that the pandemic worsened adherence to intraocular pressure-lowering medications. Elderly patients, those with multiple eye diseases, and those with lower education levels had lower resilience and more pronounced decreases in adherence.
Trabeculectomy requires frequent postoperative visits and procedures (suture lysis, needling, etc.), so the number of procedures decreased significantly during the pandemic.
There was a shift toward surgical procedures with relatively simpler postoperative management.
Shorter surgical time and minimization of postoperative interventions greatly influenced surgical choices after the pandemic.
Telemedicine is useful for checking symptoms and supporting medication adherence, but it is currently difficult to perform essential objective tests for glaucoma management such as intraocular pressure measurement, visual field testing, and fundus evaluation remotely 1). It plays a certain role in monitoring existing patients but is not a complete substitute for in-person visits.
Development of home intraocular pressure measurement (rebound tonometer, telemetric IOP sensor) and home visual field testing devices is underway. Theoretically, if all of IOP, visual field, and OCT can be measured at home, the need for in-person visits could be significantly reduced 1).
A survey by Liu et al. (2023) found that many glaucoma specialists are optimistic about future implementation of telemedicine, and with technological advances, telemedicine could become the frontline of glaucoma care delivery 1).
The pandemic left the following lessons 1).
The pandemic has disproportionately affected populations at high risk of blindness from glaucoma, such as African American and Hispanic communities 1). The digital divide may further limit these groups’ access to telemedicine.
Many facilities discontinued telemedicine introduced early in the pandemic within a few months due to patient safety concerns 1). However, with the development of home monitoring technology, reintroduction of telemedicine is expected and is also positioned as a preparation for future pandemics.
