Glaucoma Suspect Monitoring: Can Telemedicine Bridge the Gap?
"A pilot program reveals how e-health solutions are keeping low-risk glaucoma suspects on track, reducing clinic burden and enhancing patient satisfaction."
For individuals suspected of having glaucoma, regular monitoring is essential. However, this can be time-consuming and costly for both patients and healthcare providers. Traditional diagnostic methods rely on a combination of subjective and objective ophthalmic testing, including clinical examinations and retinal nerve fiber layer (RNFL) measurements using optical coherence tomography (OCT). These tests help identify characteristic changes in optic nerve morphology, which are crucial for early detection and management.
Glaucoma suspects often present a unique challenge, as they exhibit an increased risk of developing the disease but do not yet show definitive signs requiring immediate intervention. These individuals may have suspicious optic nerve appearances, abnormal visual fields, and/or elevated intraocular pressure (IOP). Managing these patients requires careful monitoring, which can be resource-intensive, particularly when access to ophthalmologists is limited.
Telemedicine offers a promising solution to overcome these challenges. By extending healthcare delivery through digital channels, telemedicine can enhance routine screening and monitoring of ophthalmic pathologies. A pilot project was launched in 2013 at the Kaiser Permanente Eye Monitoring Center (EMC) to assess the feasibility and effectiveness of monitoring low-risk glaucoma suspects via telemedicine. This article delves into the program's initial two-year experiences, evaluating patient adherence, retention rates, and overall outcomes.
Telehealth’s Role in Glaucoma Care
Glaucoma management requires regular monitoring and active management to help prevent progressive vision loss. Traditional in-office ophthalmology visits can be difficult for patients facing accessibility limitations, transportation problems, or time constraints. Telehealth may improve access for high-risk and underserved populations, while home monitoring and artificial intelligence could increase the accuracy of remote screening and monitoring and support clinical decision-making.
From Remote Access to Teleglaucoma
Telehealth began with healthcare providers experimenting with telephone and radio transmissions in the 1950s and 1960s to reach patients in remote areas. In glaucoma, teleglaucoma screening developed as a way to screen high-risk individuals and assist ophthalmologists with diagnosis. After screening, newly diagnosed patients could receive further telemedicine evaluation or be referred for in-person care.
Telemedicine Monitoring Program
The Kaiser Permanente Eye Monitoring Center (EMC) initiated a pilot project in 2013 to monitor low-risk glaucoma suspects. The initial 2-year experiences of this program are described herein to evaluate patient adherence/retention and to demonstrate a proof of concept.
- In the program, patients could be enrolled if they had 20/40 or better vision, an IOP <25 mmHg, and a normal baseline visual field without evidence of glaucomatous optic nerve damage (and no sectors in the red color code) on OCT RNFL.
- Each patient's eligibility was evaluated by a glaucoma specialist and following approval they were enrolled in the program.
- Patients would receive an appointment at a local ophthalmology office where vision, IOP (via handheld applanation tonometer), and OCT RNFL were taken by a technician annually.
- These findings were forwarded to and screened by a trained technician at a centralized telemedicine reading center where they were compared to prior visits.
Evidence From Glaucoma Suspect Monitoring
The Kaiser Permanente Eye Monitoring Center conducted a 2-year telemedicine program to monitor low-risk glaucoma suspects. A separate pilot program in the United States used e-health to monitor low-risk glaucoma suspects and achieved high patient follow-up compliance. Together, these reports describe telemedicine as a promising approach for monitoring glaucoma suspects.
Limits of Current Monitoring Programs
A significant limitation of earlier glaucoma telemedicine studies is that they often lacked longitudinal follow-up. In one pilot program, visual fields were not obtained at follow-up, although serial OCT retinal nerve fiber layer measurements were used as a simpler monitoring strategy. The program involved low-risk glaucoma suspects, so its results may not generalize to other glaucoma populations.
Telemedicine Compared With In-Person Diagnosis
A 2024 comparison found that a simulated telemedicine approach had comparable agreement with in-person glaucoma diagnosis by fellowship-trained ophthalmologists. The result was reported across the study records describing the comparison. These findings position telemedicine as a complementary screening approach that may increase access, particularly in rural or underserved settings.
The Future of Glaucoma Care
Telemedicine programs offer a promising approach to alleviate the strain on the healthcare system amidst a growing demand for ophthalmic care, particularly as societies age. Early stages of glaucoma are well-suited for telemedicine due to the disease's slow progression, where small, incremental changes are less likely to cause significant visual impairment in the early phases. By leveraging technology and innovative care models, telemedicine can enhance access, improve patient outcomes, and optimize resource utilization in glaucoma management.
Expanding Access During Disruption
Teleglaucoma has expanded rapidly, with several large-scale screening programs operating worldwide and disease-management programs under study. The limited access to care during the COVID-19 pandemic highlighted the need to expand these programs. The SIGHT studies, or Screening and Interventions for Glaucoma and Eye Health Through Telemedicine studies, were developed by three universities, which adapted their protocols to reduce disruption during the pandemic.