COVID-19 & New Discoveries About Glaucoma
The COVID-19 pandemic has presented several insights into the practice. At the peak of the pandemic, when we were only allowed to see urgent cases, we adopted video-based telemedicine visits with patients.
We could not conduct any meaningful eye examination for glaucoma purposes, but the ability to speak with patients without time pressure, to talk about their quality of life, to discuss their medication use, and to see inside their homes was extremely gratifying.
The gratitude those patients showed in return made us realize how much a physician’s attention matters to them. Patients appreciate the check-in, even if nothing practical (eg, IOP measurements) can be accomplished. We never realized before how much they relied on our reassurance.
Something else the pandemic has highlighted for us is the brazen practice we had of making our patients wait for hours in the office during their appointments. We used to make no apologies for this.
Necessity Is The Mother Of Invention
As the saying goes, necessity is the mother of invention. With the changes introduced to our practice patterns to minimize patient visits and contact during the COVID-19 pandemic, that certainly seemed to be the case this year.
During the pandemic, we have learned that we need more options for sustained drug delivery and more methods of monitoring patients with glaucoma outside the clinic. Currently, one sustained drug delivery option is available, but access to an option that is longer-lasting or repeatable would go a long way for patients.
As for monitoring patients outside the clinic, we simply need more available solutions, whether it be a take-home tonometer, an implantable IOP-monitoring device, or perhaps even an automated method similar to the blood pressure cuffs located in many stores and pharmacies.
Diagnostic devices such as these could provide physicians with substantially more information about their patients’ conditions and could alleviate patients’ anxiety about their disease and/or access to their physicians.
The Rising Star of Telemedicine
Through the COVID-19 pandemic, we learned that physicians will always find a way to provide care to their patients. Telemedicine has been a topic of discussion for years without reaching implementation.
Although it continues to have significant limitations for our field, telemedicine certainly served a purpose at the height of COVID-19 closures.
We found the practice of telemedicine to be particularly and surprisingly useful with new patients. Some individuals had been waiting a few weeks for a new patient appointment with our practice, only to have that appointment canceled due to COVID-19.
Most of our new glaucoma evaluation patients have undergone fairly recent examinations and testing by their referring ophthalmologists. Therefore, the telemedicine appointments allowed us to meet these patients, evaluate currently available data, discuss their glaucoma status and potential next steps (pending confirmation on examination), and answer any questions they had.
Many of these new patients are told that they are being referred because their glaucoma is advancing and may require surgery. Therefore, the telemedicine visits seemed to have a reassuring effect on these individuals. Many expressed gratitude to our team for holding these appointments.
Additionally, we were able to combine telemedicine appointments with quick IOP checks or testing in the office when needed. When we reopened, this practice allowed us to hit the ground running.
In terms of glaucoma management, it became obvious during the pandemic that there is a true need for an affordable way for patients to measure their IOP at home. Glaucoma care has seen so much innovation in the past few years that we wonder if an all-inclusive diagnostic machine, instrument, or application could become a reality in the future.
As the volume of clinical visits returned to equilibrium, we actively gauged each patient’s comfort level regarding therapy in light of COVID-19. Although some were conservative and preferred a minimal approach, others were quite comfortable with the intervention (especially after they met the yearly deductibles).
Depending on each patient’s circumstances, we backed off somewhat if patients had several medical comorbidities of old age if they had a conservative attitude toward COVID-19, and if their disease progression was slow. For others, interventions continued with a few adjustments.
Overall, 2020 has been a challenging year that will have a lasting impact. Despite these challenges, many promising solutions have emerged. At its heart, interventional glaucoma will continually evolve and adapt to the situation at hand so that 2021 can be brighter for glaucoma patients.
Education, Communication, Empathy & Reassurance
The COVID-19 pandemic brought to light the importance of education, communication, empathy, and reassurance. It also emphasized the need to remind patients of the chronicity of glaucoma and its nature as a slowly progressive neurodegenerative disease.
Glaucoma specialists play an important role in the doctor-patient relationship to allay patients’ fear of going blind. Irrespective of disease severity, several clinical trials spanning the disease spectrum from ocular hypertension to advanced disease enable us to counsel patients that, in general, glaucoma can be kept under control.
During the temporary ban on elective surgeries due to COVID-19, glaucoma management took on a new meaning for nonurgent cases. The optimization of medical therapy in our practice was twofold. First, we utilized fixed-combination medications to enhance compliance.
Second, we emphasized the role of proper drop instillation with either eyelid closure or nasolacrimal occlusion to increase ocular absorption and drug efficacy while minimizing systemic absorption to avert side effects.
The slogan “an educated consumer is our best customer” pays dividends by placing the onus on patients to take their drops properly. We remind patients, “It’s not what you take but how you take it.”
For elderly individuals who live alone or for those with involuntary hand tremors or arthritis, nasolacrimal occlusion may be impractical. Given the challenge of eye-hand coordination in properly placing an eye drop, we simply ask patients to close their eyelids for 3 to 5 minutes.
This approach is particularly important in patients with thick corneas on pachymetry. Looking at a given patient’s IOP clinical data spanning several years, We have observed a sustained reduction in IOP of as much as 4 to 5 mm Hg not seen in prior visits.
For patients who are intolerant of multiple glaucoma medications or who quickly run out of their drops due to excessive bottle squeezing, we have offered preservative-free alternatives, necessitating the use of individual vials for each drop not only to enhance tolerability but also to avoid waste, respectively.
For patients who require surgical intervention, the pandemic has emphasized the importance of being patient-centric when selecting a procedure. This entails minimizing the frequency of postoperative visits while achieving an acceptable level of IOP.
A report from the AAO showed that among patients with medically controlled glaucoma who needed cataract surgery and had not undergone prior incisional surgery, cataract surgery alone resulted in a sustained IOP reduction out to 1.5 to 3 years in those with primary open-angle glaucoma (13%), pseudoexfoliative glaucoma (20%), and chronic angle-closure glaucoma (30%).
Patients with chronic angle-closure glaucoma were found to have an additional 58% decrease in medication burden. During the pandemic, we have offered select patients the option of cataract surgery as a standalone procedure, with the understanding that they may need additional glaucoma intervention in the future.
This approach provides peace of mind to both the doctor and the patient that, until the pandemic is brought under control with the distribution of FDA-approved vaccines, cataract surgery alone also plays a role akin to a MIGS procedure in lowering and controlling IOP.