Rethinking Glaucoma Treatment – Safety & The Covid-19

Rethinking Glaucoma Treatment – Safety & The Covid-19

December 06, 2020

In every sense of the word, the pandemic has set a new reality for all of us. We, physicians, are all living in a new reality. Every day, doctors are being called on to do incredible, creative things in increasingly complex conditions.

The situation is changing in real-time and the impetus is on them to make sound decisions that keep themselves and their patients safe – all while providing the best possible care.

Doctors must do more than simply take precautions; they must find innovative treatment approaches as well – and glaucoma is no exception.


While hospitals and surgical centers are reopening, many continue to experience major backlogs as there is a lack of OR time available for incisional glaucoma treatments.

In many places, equipment is unavailable as resources are being reallocated for emergent care. The fear of COVID-19 exposure also continues to be a major concern, particularly for the elderly and vulnerable.

This unavailability is compounded by many nursing homes and long-term care facilities still being in mandatory lockdown, which prevents patients from getting to the doctor or the pharmacy.

How The The Covid-19 has forced physicians to focus on glaucoma treatment – starting with updated tools and protocols for safety-conscious encounters & Safety Comes First

In light of overcoming these challenges, there are a few ideas to consider such as; implementing office-based procedures to move the patient from the OR backlog to the front of the line; choosing procedures that are safe and durable with minimal post-op care to reduce follow-up visits; and incorporating new office operating procedures to keep yourself, your staff, your patients and your business safe.

Health care providers have a principal responsibility in these new normal conditions and it is not being vectors for disease. The responsibility is to help people, not put them at risk. Given that, the doctors’ practice has reimagined everyday logistics and implemented a series of thorough safety protocols.

These new operating procedures begin well before a patient arrives, with intake paperwork, patient history, and prescreening completed over the phone where possible. Patients are also triaged virtually to see if they have been out of the country or to any hotspots recently, and to make sure they haven’t had a fever or exposure to a COVID19-positive patient.

During the time of appointment, a staff member – wearing a face shield and other appropriate PPE – greets the patient at the door with sanitizer and a mask, if one happens to be needed, and a temperature check is performed. Since a patient passes the pre-screening and temperature check, they wait outside or in their vehicle until they are called to be seen.

Check-in, temperature, and IOP checks could be performed by the car-side as well. Patients only have to wait inside our waiting room in extenuating circumstances. Even then, the waiting room gets


arranged to allow for proper distancing. It is free of all magazines and reading materials and thoroughly sanitized regularly. The patient ratio within the practice is also optimized for efficiency and linearity.

Patients come through one door and exit through another, creating unidirectional flow. Planning a completely different logistical fashion is a big change, but it is critical to the economics of the practice.

Years ago, we would bring the patient into the exam lane, maybe take some history, then escort the patient to another room for testing and then back to the exam lane to see the doctor. Now, every room the patient visits remains empty until these rooms have been resterilized, which requires extra time and labor.

Presently, most testing is performed before the patient entering the exam lane. This decreases patient movement around the office, contributes to a linear flow, reduces the need for unnecessary sanitation, and keeps exam lanes open.

Also, hybrid models have experimented with it. For example, after a patient is tested and leaves the clinic, we speak to them over the phone to discuss their test results. Indeed, the combination of telehealth with an in-person component has become very useful for doctors. During all face-to-face patient interactions, proper PPE is maintained, as well as some additional precautions.

We developed our shields for protection that fit over the slit lamps as an extra barrier early on in the pandemic. Currently, we have switched to commercially available shields that are specifically designed to reduce exposure for slit lamps.

Staff also try to limit conversation as much as possible to prevent any viral transfer during close interactions, with the overall goal of keeping facetime to six minutes or less. Those logistical alterations have reduced facetime by 25-30 percent, but the key is to not make patients feel rushed or neglected.

Doctors help them understand that these amendments are designed to reduce the risk for them and our staff. Having said that, we have received nothing but positive feedback so far – not a single complaint or negative review – as patients are generally appreciative of the protocol changes to reduce exposure.

Once they’ve experienced the safety precautions medical personnel implemented, they feel extremely gratified and, in many cases, are more inclined to return feeling more comfortable and are less concerned about exposure to COVID-19.

Rethinking Treatment Options

After being severely restricted for several months, surgery centers are left with a backlog of cases – it has never been more valuable to have safe and durable treatment options which could be performed in the clinic.

When safety is ensured and when flexibility and durability are key, MicroPulse transscleral laser therapy (TLT) with the MicroPulse P3 Delivery Device (Iridex) is an excellent tool. Doctors used it in


both the office and the surgical center for many years. Many patients, especially seniors, are scared to come to the hospital or clinics.

So, when we tell them we can treat their glaucoma with an efficient procedure that can be performed in the office with no cutting and reduced risk of infection, they are all ears. We make sure they understand that MicroPulse TLT does not decrease the success of subsequent procedures, so it can be considered earlier on the glaucoma continuum.

As the procedure is quick and standardized to 100 seconds per eye, this relatively short procedure time allows us to reduce facetime and move patients through the clinic efficiently. More than that, the durability of MicroPulse TLT allows us to push out follow-ups, further reducing face-to-face interaction – a boon in COVID-19 times.

Also, the other benefit of MicroPulse TLT is the reduced impact on activity level after the procedure. We patch the eye and send patients home with a topical steroid; the next morning, they remove the patch and resume normal activities. In these times, patients are understandably reluctant to invest in any procedure that requires a great deal of follow-up or restricts their activity or exercise.

We’d say the revised design has reduced the learning curve for quick implementation into practice. Although it may not be right for every patient, it is a useful tool to have in your armamentarium, especially if you have no access or limited access to an ASC.

At this point, telehealth and online pharmacies help reduce patient burden and unnecessary exposure, especially for high-risk patients. That’s why a variety of mechanisms for patients are employed to get their medications directly.

Even before COVID-19, we transitioned to a considerable number of mail-order acquisition modalities, rather than making patients go to a brick-and-mortar pharmacy. We’ve also opened new accounts with online pharmacies to reduce the office burden of ensuring patients get their medications directly.

Normally, we are quite strict about requiring patients to come in for a visit before renewing their glaucoma medication. Doctors need to make sure that a person’s IOP is well controlled; however, circumstances have forced them to become more flexible on their rigid posture on refills.

Let’s think of a patient who’s been stable for several years but is running low on medications and can’t physically come to the office because they are in lockdown. This patient could be considered an excellent candidate for a telemedicine visit.

We have a phone or video chat, review their medications, reinforce compliance, and then forward their prescription refill to their local pharmacy or online pharmacy, extending the length between visits.

In addition to expanding to mailorder and online pharmacy options, they have also employed larger bottles where possible or more refills to reduce patient visits to physical pharmacies. They have also sought partnerships with other eye care practitioners who are in closer proximity to the patient for more timely care when needed.


This type of cooperation has become even more important than ever and will continue to be in the coming months. As the COVID-19 situation gradually subsides, some of these approaches may start to disappear and our practices will gradually return to normal.

The telehealth component, however, will most likely stay. It’s become an incredibly valuable tool and though it will never fully replace in-person visits, there is certainly a place for it in today’s world. So, where does that leave us now?

This pandemic indeed has forced everybody to adapt our practices and protocols in creative ways – for the better. Let’s take these new lessons and tools with us into the future, so we may strive to continually evolve and offer our patients the best possible treatment options – and the best possible care.