The use of telehealth by glaucoma specialists was the focus of the symposium “Dipping Your Toes from a Distance: Telehealth in Glaucoma,” held at the 2024 American Glaucoma Society meeting. Six speakers brought their various perspectives and knowledge to the topic.
“Implementation is more important than efficacy,” said Dr. Yao Liu, who opened the symposium with an overview of telehealth in her talk “A Seagull’s Eye View of Telehealth in Ophthalmology.” She stated that tele-ophthalmology provides new options for improving quality of care, in a world where the population of older adults is ever-increasing and the number of glaucoma specialists remains small. Some of these options include virtual visits, home-based patient monitoring, smartphone apps, and programs to share remote and in-clinic photos in a “store-and-forward” approach with health care professionals.
For Dr. Liu, “the feasibility of patients taking visual field tests unsupervised at home is the greatest advantage of home perimetry.” Offering remote care for patients can improve access, convenience, and efficiency. It can also help doctors expand their practices (in volume and geographically) and can provide older ophthalmologists with a way to continue to contribute their wisdom, extending their career longevity. Home-based measurements, from a more diverse group of patients, may also help address some of the biases in AI and its algorithms by contributing to larger normative databases.
“A greater range of IOP can be measured at home than in the clinic,” noted Dr. Thomas Johnson in his presentation “Mercury Rising Under a Hot Sun: All You Need to Know on Patient-Assisted IOP!”, emphasizing that IOP is a highly dynamic and individual physiologic parameter. He discussed how home IOP measurements often show high variability, unlike measurements taken in the clinic. He asks why glaucoma specialists are basing medications on 1 or a few office visits over the course of a year, when more frequent measurements may be more representative of trends. He noted that fields such as cardiology and endocrinology fields are ahead with their more frequent measuring of blood pressure and glucose.
Potential new technologies for measuring IOP at home include remote tonometry that uses Bluetooth and no anesthetic. Dr. Johnson found that 88% of his patients trained on the iCare HOME remote tonometry system were able to take accurate, reproducible readings, which could appear more reflective of a patient’s condition than clinic-obtained measurements. One patient had a range of 8 to 11 mm Hg in clinic measurements and unexplained progression, while home tonometry revealed more than 20 daily pressure spikes. The advantages of home tonometry include more accurate data about treatment responses, potentially improved medication adherence when patients can see their own IOP responses, and improved access to care for patients who live far from the clinic.
Dr. Johnson acknowledged that there are limitations, including that we don’t understand the reasons for measurement spikes, and that the large amount of data being generated by the remote readings can be hard to interpret. There can also be substantial costs. Dr. Johnson lends out remote tonometry equipment to patients on a sliding scale. He saids telehealth works well in terms of population-level care: “In-clinic care is privileged care, but at-home care reaches more people.”
“Are we overtreating glaucoma?” asked Dr. Sanjay Asrani. In his talk “Scan Me, Scan Me Not: How Best to Use OCT for Glaucoma Screening or Establishing a Diagnosis,” he questioned whether OCT is an adequate measure for glaucoma screening and how to best use it. To establish a diagnosis, he says there is a need to look at disc symmetry and at the retinal fiber layer, including loss of total retinal thickness. When Dr. Asrani sees extreme asymmetry or extreme symmetry, it could mean that something “non-glaucoma” is going on. Eyes can show extreme symmetry in retinal nerve fiber loss or in their visual field that is not likely to be from glaucoma. Macular thickness measurements can be helpful in showing symmetry, but the raw OCT images are needed to see if the patient has cancer-associated retinopathy and not glaucoma. Some eyes show extreme symmetry retinal nerve fiber layer loss, but not all retinal fiber loss is glaucoma, and loss of visual field may not be evident, particularly if the patient is taking corticosteroids. Even visual field extreme symmetry is often also not likely to be a glaucoma case.
Additionally, changes in nerve fiber layer and macular thickness can be seen with other diseases, including hypertension, chronic kidney disease, diabetes, and small vessel diseases. “How are we to differentiate?” asked Dr. Asrani. In ischemic optic neuropathy there can be hypertension with non-progression and no changes, so glaucoma treatment is not needed. He noted that those changes do not show up on OCT in patients with low blood pressure. If OCT shows progression, that likely is a glaucoma case. He proposes that getting more people into trials and studies and using telehealth to develop better databases may help reveal answers to better diagnosis.
“There is a ton of work to do for this to be ready for prime time,” said Dr. Yvonne Ou, in her talk “Eyes Under Water: Is Home Perimetry Ready for Prime Time?” Dr. Ou said that home perimetry can improve diagnostic accuracy of fast progressors in glaucoma through more frequent readings. Standard tests to diagnose fast progressors can take 4 years for patients tested once a year, 3 years for those tested twice a year, 2.6 years for those tested 3 times a year, and 11 months for those tested daily. In her experience with remote tonometry, 63% of patients adhered to instructions for measuring themselves at home. She discussed in detail specific tools and apps for home perimetry that included online programs, iPad/tablet applications, and head-mounted reality devices.
While studies show that progression can be measured at home with fairly good correlation with Humphrey visual field results, she said “the device needs to be well-calibrated.” At-home patients testing weekly had 88% adherence, but 23% of patients preferred not to do weekly testing. Dr. Ou said that monthly testing appears may be the “sweet spot” for the frequency of home testing. There was a high preference for virtual reality visual field perimetry (71.7%), which provides measurements that are higher quality and more controlled, but it is more expensive than tablets. Tablets are more accessible to patients, but the quality of the output is lower—with 26% of patients in one study unable to map their blind spot. She added that it may be difficult to determine the right patients for a telehealth program, how generalizable it is to older adults and to worldwide populations, and how effective it will be for those for whom English is not their primary language.
“Smartphones help doctors take care of patients and help patients take care of themselves,” said Dr. Annette Giangiacomo in her talk “Riding the Smartphone Wave for Enhancing Patient Care in Glaucoma.” She explained how “the smartphone is a powerful tool that can help doctors choose better prescriptions and communicate with patients, measure perimetry, reduce IOP, and diagnose glaucoma.” Numerous uses of smartphones in the management of glaucoma include:
- Apps that find affordable prescription drugs, arrange delivery, and update patients with drug warnings
- Programs that measure tonometry or visual fields
- Software applications that provide text-to-speech and other low-vision assistance to offset accessibility and mobility issues
- Gonioscopy with magnifying IOLs for low-cost angle-imaging
Dr. Giangiacomo said that there is a need for AI in glaucoma care is great because there are few glaucoma specialists, and that technology including home-based testing can help fill the gap in demand. She noted that a bank of 3000 photos taken by patients were put into a deep learning algorithm and had a 90.9% correspondence with fundus photographs. Smartphones are a “game changer,” said Dr. Giangiacomo.
“Buy-in is the most critical activity in telehealth implementation” cautioned Dr. April Maa. In the final presentation, “Managing Glaucoma from Your Beach Shack: Practical Recommendations on Telehealth Implementation,” she discussed the key steps in making telehealth a reality. She practices comprehensive ophthalmology at a VA hospital, where she has extensive experience in setting up telehealth programs. She advises clinicians to ask the following questions before starting a program:
- What glaucoma problem are you trying to solve?
- What is the program goal – more screening?
- Why does the problem exist? Is it a problem that can’t be solved right now, or with a telehealth approach?
- What are the needs for equipment, training, space, and the personnel to gather the data?
- What method of delivery will you use: synchronous (audio/video), asynchronous (remote upload), or hybrid?
- What about equity and accessibility issues related to connectivity, portability, useability, location, and space?
Dr. Maa described the 3 phases of a telehealth program as pre-implementation, implementation, and post-implementation. In the pre-implementation phase, the first step is to determine the goal. Next is buy-in, which is the most important and time-consuming activity, which includes evaluating your stakeholders and finding your champions. The implementation phase requires project management and a coordinator who creates regular meetings, holds people accountable, and maps patient care and program implementation steps. Next is setting up the processes for the screening program, data transfer, and patient follow-up, and then you can start scheduling and seeing patients. During the post-implementation phase, check for quality metrics, review your setup, and make sure that the right people are doing the right jobs. Also create quality assurance and quality improvement cycles to continually and iteratively improve your program.
Dr. Maa encourages physicians to learn how to assess, market, and sustain a telehealth program. She concluded by saying that a program is sustainable when all the implementation stages are complete, and that it takes 2 years of being sustainable before the program can be called a success.