Cheryl Guttman Krader is a contributor to Dermatology Times, Ophthalmology Times, and Urology Times.

Cheryl Guttman Krader, BS, Pharm

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Results of an email survey sent to the Glaucoma Research Foundation (GRF) Ambassadors when most states were poised to ease 

 restrictions showed that only three-fourths of the respondents had a plan in place for reopening their offices after stay-at-home orders were lifted.

Judging from write-in responses, whether or not the glaucoma specialists had developed strategies for returning to practice, they were interested in having colleagues share ideas for establishing safety and for optimizing practice efficiency and patient care delivery. They were also keen to receive post 

 patient education and support materials from GRF.

These topics and more were addressed in a virtual GRF Ambassador Round Table on managing a 

COVID-19 safety challenges accelerating welcome changes

​ 

Held on May 8, the discussion was moderated by Andrew Prince, MD, of Glaucoma Consultants of Greater New York & New Jersey, and Andrew Iwach, MD, of Glaucoma Center of San Francisco, and included input from several GRF Ambassadors that showed the clinicians were meeting the new challenges with different approaches; in part, these reflect variations in practice settings.

Recognizing that the pandemic situation will be evolving and that ideas about best practices are likely to change based on actual experience and changing circumstances, the group looked forward to reconvening to share their practical insights and take away new ideas.


Once stay-at-home orders were issued in California, only patients needing emergency care or a postoperative follow-up visit were being seen at the Glaucoma Center of San Francisco. 

In planning for reopening, staff had to review charts to identify patients who should be given priority for an appointment, according to Iwach.

Patients who have an upcoming visit are being contacted by phone and are being screened for 

 symptoms and informed about new processes in the office. The latter include requirements to wear a mask and enter alone unless they need to be accompanied by someone for language or other reasons.



A screening station has been set up at the entrance to the building where patients are checked for fever and 

 symptoms, asked to clean their hands with a hand sanitizer, and given a mask if they did not bring one. 

Changes were made in the office, including removal of magazines, removal and rearrangement of furniture in the waiting area to create proper social distancing, and installation of plastic shields at the front desks.

Iwach and his associate, Terri-Diann Pickering, MD, identified restaurant supply companies and neighborhood hardware stores as good sources for acquiring protective equipment, including plastic shields, hand sanitizers, gloves, and masks.

Prince mentioned that individuals with an Amazon business account can register as a health care professional; then, they will be put on the top of a queue for getting supplies. 

He also noted that in his practice, a solution containing 70% ethanol with hydrogen peroxide and glycerin that comes in large spray bottles is being used with paper towels for surface disinfection and offers a less expensive alternative to disinfectant wipes.



Transitioning back to ophthalmic care during a pandemic

Practices differed in their use of gloves for staff versus frequent hand washing and sanitizing, but all participants agreed that it was critical for patients to witness attention being given to hygiene.

Minimizing patient time in the office was a universal goal. In general, patients are undergoing necessary testing in the office. Oluwatosin Smith, MD, of Glaucoma Associates of Texas, said her practice is looking at establishing a dedicated center for glaucoma testing that would be separate from the rest of the clinic and might be opened for extended hours to meet the pent-up demand for services.

In-office physician–patient interaction is being limited. Patients are mostly being contacted following their visit once the provider has a chance to review the results from the diagnostic evaluations. 

Depending on the need for follow-up, the results may be discussed over the phone or patients may be offered a telehealth or subsequent in-office visit.



Capabilities of telemedicine for ophthalmologists during a pandemic: Part I


The participants agreed that home monitoring of IOP using a self-tonometer suffers from suboptimal accuracy. 

A few have reduced the use of Goldmann applanation tonometry except when they are not able to get an accurate or reliable measurement with other tonometers that are noncontact or involve minimal time up close with the patient.

Davinder Grover, MD, MPH, of Glaucoma Associates of Texas, said that his group is using a noncontact device to measure corneal-compensated IOP in most patients, but a Tono-Pen is used to check IOP of postsurgical patients during the first month of follow-up.

Visual field testing presents a particular concern, given the special care that needs to be taken to avoid damaging the perimeter bowl. Participants felt that guidance on disinfection from the manufacturer lacked clarity, and many were exploring alternative methods for checking visual fields.

Both Grover and Iwach mentioned that their practices are pursuing other methods of perimetry that can be performed with a low risk to the patient, such as virtual reality goggle-type visual field testing.



Putting to practice retina innovations amid a pandemic

Robert Feldman, MD, of the Robert Cizik Eye Clinic, Houston, Texas, said that visual field testing at his practice has been put on hold while the potential to use an ultraviolet (UV)-C lamp for sanitization is being investigated. He noted, however, that the perimeter manufacturer cautioned that UV-C light could damage the equipment.

Prince said that an air purifier was installed in his practice’s testing room.

“While there is no direct evidence yet that filtration works to reduce transmission of the novel coronavirus, it can be assumed from what we know of similar viruses that air purifiers might help in some situations,” he said.

Prince added that, theoretically, if an air purifier removes or reduces the viral load from the air, the potential for exposure is lessened.

“The novel coronavirus itself is 0.125 microns, but the droplets it travels in when people cough, talk, or breathe are around 1 μm,” he said. “That is a size easily captured by air purifiers with HEPA filters.”



In the GRF Ambassador survey, the majority of respondents indicated that they had been using a telemedicine approach to some extent.

Ambassadors participating in the discussion agreed that telemedicine has limitations for following patients with glaucoma.

Certain patient queries can be handled by phone, and a video visit can be helpful for reviewing medication use or for checking whether a red eye in a surgically treated patient is worrisome. 

Patients gain reassurance knowing that a physician has looked at their red eye, and the interaction itself can be a boost for patients who are socially isolated during the pandemic, Iwach said.



The eyes offer conjunctival clue to COVID-19


Steven Vold, MD, in private practice at Vold Vision in Fayetteville, Arkansas, noted that because of the conducive physical setting of his office building, his practice created a “curbside clinic” where patients could be quickly checked for possible progression of their glaucoma.

“We know that compliance with glaucoma medication is an issue, and the concern when patients are not being seen is that some who have moderate-to-advanced glaucoma could be having asymptomatic worsening,” Vold said.

In Vold’s “clinic,” patients remain in their cars and go from station to station for a “visit” that is completed within 5 to 10 minutes. 

After gathering insurance information and then a history, vision is tested with a device like that used at state motor vehicle departments, IOP is measured with a rebound tonometer, and anterior and posterior segment photographs are taken using a retinal camera through a 3-mm pupil.

Patients are contacted by a physician later in the day.

“I am not saying that it is ideal and I am not advocating this approach as a standard of care,” Vold said. “But I can say we have picked up numerous disc hemorrhages and elevated IOPs, and I think we have actually saved vision for some patients.”



Emerging opportunities — and risks — with telehealth in a pandemic



He added that the service has also been a practice builder. Patients who have seen its availability on the practice’s website have traveled as far as 1000 miles to get access to in-person care.

The encounter is charged as a telehealth visit. Before offering the service, the plan was reviewed with the Arkansas Department of Health and Arkansas State Medical Board.


The GRF Ambassadors’ focus is on patient education, and some of the write-in responses on the GRF Ambassadors survey indicated interest in materials that would give patients confidence about the safety of in-office visits and inform them about new processes.

The physicians continue to do their part.

Vold said that his practice has created some videos with those goals in mind, and Smith noted that she is currently working with the Cure Glaucoma Foundation to develop patient information.

Thomas Brunner, president and CEO of GRF, said that GRF is also collaborating with this effort to inform and educate patients.

“Starting in early April with financial support from Industry, GRF began hosting a number of patient webinars and we recently launched a new video series that includes steps doctors are taking to ensure the safety of their patients.” Brunner added. “GRF can play a unique role in supporting both doctors and patients during this extraordinary time.” 


Vold has no financial disclosures related to this content.

Articles

Glaucoma Research Foundation (GRF) Ambassadors webinar provides platform for idea-sharing by ophthalmologists

Pearls for practicing in the COVID-19 era

This article was reviewed by Sharmina Alauddin, MD



An artificial intelligence (AI)-based telemedicine platform for screening and early diagnosis of 

has been validated in a prospective trial, said Sharmina Alauddin, MD, at the 2020 Association for Research in Vision and Ophthalmology (ARVO) virtual meeting.

The deep learning algorithm’s (iPredict.health, iHealthScreen Inc USA) performance for classifying fundus images was evaluated using the gradings from expert human readers as the reference standard. 



Teaching AI algorithms to identify corneal pathology: The future is now



The analyses showed that the AI-based platform had 88.67% accuracy, 86.57% sensitivity, and 90.36% specificity.

“The results of our trial show that the tool is now ready for clinical use and potential deployment for remote telemedical use,” said Alauddin, a clinical research associate at the New York Eye and Ear Infirmary of Mount Sinai, New York, New York.

Alauddin and colleagues investigated the AI-based system’s performance in detecting and stratifying severity of 

 as a means of facilitating early diagnosis to improve patient prognosis.

“It is well known that AMD is a major cause of blindness among adults aged 50 years and older in developed countries,” Alauddin said. “If we are able to diagnose 

by screening in any clinical setting, we could start treating it early and thereby reduce the number of patients who become blind from their disease.”

The deep learning algorithm was originally developed and tested using images from the Age-Related Eye Disease Study (AREDS).



Cutting-edge neuro-ophthalmology: Combining artificial intelligence, eye tracking

“A deep learning algorithm teaches itself from massive datasets through artificial and neural networks. It mimics how our brain works to solve problems,” Alauddin said.

The validation study was performed using prospectively acquired, color fundus images obtained from 160 nondilated patients aged 50 years and older seen in New York Eye and Ear Infirmary-affiliated eye clinics.

After excluding patients who had another type of retinal degeneration, prior retinal surgery, diabetic retinopathy, or macular edema and images with poor quality, images from 290 eyes of 150 subjects were included in the analysis.

Based on the worst eye, patients were automatically classified by the software as referable AMD or nonreferable AMD. Referable AMD included intermediate AMD (drusen >125 μm and/or pigmentary abnormalities) and late 

 (geographic atrophy or neovascularization) while the nonreferable class included eyes with a normal macula or early AMD (drusen >63 to ≤125 μm). 



AI screening: Allowing physicians to see eye more clearly from afar



In addition, each image was independently reviewed and graded by two ophthalmologists. The performance of the AI-based system was evaluated by comparing its results with those of the expert human graders.

After adjudication of grading discrepancies, 66 images were classified as referable and 84 images as nonreferable. The AI-based program correctly identified 58 images of intermediate and advanced AMD and 75 images that were normal or early 

The investigators believe that for public health service, it is both warranted and feasible to create a more comprehensive, fully effective system trained on other retinal pathologies.



Alauddin has no relevant financial interests to disclose.

Algorithm detects, stratifies severity of disease, facilitates early diagnosis. 


Deep learning algorithm proven accurate for AMD classification

This article was reviewed by Jeremiah Brown Jr, MD, MS



A contemporary look at treatment patterns for proliferative 

 (PDR) shows that the vast majority of patients with PDR will receive an anti-VEGF injection regardless of whether they have 

), said Jeremiah Brown Jr, MD, MS, at the 2020 virtual meeting of the American Society of Retina Specialists.

Brown presented the findings from a retrospective review conducted using data from the American Academy of Ophthalmology’s Intelligent Research in Sight (IRIS) registry, the nation’s first comprehensive eye disease clinical registry.



Researchers advocate for intraoperative intravitreal steroid during cataract surgery in DME eyes

The study included 33,452 patients with PDR and new onset vitreous hemorrhage treated within 3 months who had a visit between June 2017 and June 2018.

Eighty percent of patients had a diagnosis of DME, and 84% of those patients received anti-VEGF treatment. However, 69% of patients with PDR alone also were given anti-VEGF therapy. 

In addition, anti-VEGF treatment was received by approximately one-half of patients who underwent panretinal photocoagulation (PRP) or vitrectomy if they also had DME, and by approximately one-third of those without DME who were treated with PRP or vitrectomy.




“The data from this study show that treatment patterns for PDR have undergone a dramatic shift since the advent of anti-VEGF medications,” said Brown, who is in private practice at the Brown Retina Institute in San Antonio, Texas. “Ophthalmologists are no longer relying on a foundation of repetitive peripheral laser applications to treat PDR but instead are taking care of patients using anindividualized mix of anti-VEGF injections, PRP, and vitrectomy.”

Brown also pointed out that the “research also highlights the enormous value of the IRIS registry, which contains information from hundreds of thousands of patient visits, for enabling us to look into our practices and evaluate trends to improve patient care.”



Clinical trial outcomes for macular edema don’t translate to ‘real-world’ settings

Providing context for undertaking the study, Brown noted there are some clear indications for treating DME with anti-VEGF medications, while the timing and the need for their use in the treatment of PDR are less clear.




“Our treatment for PDR was built on the foundation of the diabetic retinopathy study published in 1976 that established peripheral scatter laser photocoagulation as the standard of care,” he said. “More recently, Protocol S [NCT01489189] and the Clarity study showed similar visual outcomes could be achieved with anti-VEGF therapy. Our study sought to understand how the available options are being employed in the real world.”

Data on the use of PRP and vitrectomy showed that in the cohort of patients with PDR and DME, 30% were treated with PRP, 17% received PRP plus an anti-VEGF medication, and 20% underwent vitrectomy, of which approximately one-half also received an anti-VEGF injection.



Managing the challenge of cataract surgery in eyes with diabetic macular edema

Among those patients who had PDR without DME, 35% received PRP, while 11% received PRP plus anti-VEGF injection, and 29% underwent vitrectomy, of which 36% of those also received anti-VEGF therapy.



The study also analyzed visual acuity (VA) outcomes at 6 months following treatment, and the results showed that the percentage of patients achieving logMAR VA of 0.4 or better (approximately Snellen 20/50) was similar regardless of whether they received an anti-VEGF injection. Percentages of patients achieving logMAR VA of 0.4 or better were 59% in the anti-VEGF cohort, 65% among those treated with PRP alone, and 63% for patients who received both treatments.

Considering patients undergoing vitrectomy, approximately 50% achieved logMAR VA of 0.4 or better whether they had surgery alone or combined with anti-VEGF treatment.



Identifying biomarkers to predict diabetic retinopathy progression


Brown concluded that it is interesting to see that the VA results are similar with or without anti-VEGF therapy “if we consider that retina specialists would be more likely to use an anti-VEGF agent in patients with more severe proliferative disease, more severe vitreous hemorrhage, or more ischemic appearing retinas, along with the fact that patients with longstanding DME may reach a plateau in their VA improvement because of foveal atrophy or persistent edema.”

“Therefore, it is encouraging to note that patients treated with anti-VEGF injections were able to achieve the same level of vision as the patients treated with PRP or vitrectomy alone who likely had milder hemorrhage,” he said. 



Brown serves as an investigator, consultant, or member of speakers bureau for companies that market or are developing treatments for diabetic eye disease.

DME diagnosis plays no role in determining whether patients will receive injection.

Probe of IRIS registry: Anti-VEGF injections key treatment for PDR

​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 

This article was reviewed by Savak Teymoorian, MD, MBA

Early experience with the new intracameral bimatoprost 10-μg implant (Durysta, Allergan) in clinical practice indicates that it is a valuable addition for treating patients with ocular hypertension and 

, according to Savak Teymoorian, MD, MBA.

“Our aim in managing patients with ocular hypertension and glaucoma is to control their IOP so as to mitigate disease progression without adversely affecting quality of life,” said Teymoorian, a cataract and glaucoma specialist at Harvard Eye Associates in Orange County, California.



IOP homeostasis in glaucoma: Looking below the surface

“In deciding on our interventions to achieve that goal, it is necessary to balance the risks and benefits of each treatment option. It is clear to me that with its IOP-lowering efficacy and ability to address the drawbacks associated with topical drops, the benefits of the sustained-release prostaglandin significantly outweigh any risk associated with its administration.”

® that he implanted the bimatoprost product into approximately 55 eyes within the first month of using it. 

The satisfaction shared by patients is something novel in the glaucoma segment of his practice and is rewarding.

“Ophthalmologists who perform cataract surgery are used to seeing patients who are extremely happy because of the outcomes of their procedure, but gratification is rare among patients being treated for glaucoma. The recipients of the bimatoprost implant, however, are extremely happy because they have been able to eliminate or reduce their topical medications and the inconvenience, [adverse] effects, and cost associated with their use,” he said.


Study results show that surgical system decreases IOP in patients with POAG


Adherence with topical medications is well recognized as a key barrier to successful management of glaucoma. The issues underlying Adherence are multifaceted, Teymoorian said.

“Noncompliance can occur because of a plethora of factors. Some patients do not get their prescription filled, some don’t remember to use their medications, and some do not instill them properly,” he explained.

“The ability to take the responsibility for treatment away from the patient is one of the reasons why the minimally invasive glaucoma procedures have done so well. The value of the bimatoprost implant is similar in that regard,” he added.

The ability to reduce ocular surface toxicity from topical drops is another benefit of the bimatoprost implant.

“Minimizing or eliminating the number of topical medications a patient is using allows the ocular surface condition to improve. As a result, patients are more comfortable, their vision is better, and they can also eliminate or reduce their need for artificial tears and any other medications that they are using to manage dry eye signs and symptoms,” he said.


Examining ocular allergy, quality of life​ 


Patients who are on topical medications for IOP-lowering, regardless of where they are on the continuum of glaucoma severity, may be considered as candidates for the bimatoprost implant. 

However, Teymoorian noted that so far he has selected patients who are taking a topical prostaglandin analogue and who are pseudophakic in particular because they will likely have a deep anterior chamber, enabling safe and proper placement of the implant, and cataract development will not be an issue.

“My accumulating experience with the product is reinforcing its efficacy, safety, and benefits. The more I see how it allows me to discontinue all or some topical medications and how happy patients are, the more I am willing to offer the implant to patients,” he explained.



The implantation procedure should be done with the eye topically anesthetized and under aseptic conditions. 

Depending on their comfort level and facility, clinicians can choose to perform the procedure either in a surgery center using an operating microscope, or a slit lamp in an in-office procedure room.



Traditional glaucoma surgery in the era of MIGS procedures


When injecting the bimatoprost implant in the surgery center where the patient is lying under the microscope, Teymoorian said he has the patient’s head tilted up at about 30° and asks the patient to sit up immediately after the injection as these positions promote settling of the implant into its targeted location in the inferior angle.

“It has been remarkable to me that as soon as the injection is done, patients note how easy it seemed, tell me that they felt nothing, and ask when can they have the second eye procedure,” Teymoorian said. “I take these as signs that the procedure is well tolerated. The key is to make sure the patient is comfortable.”

Changes to existing topical medications and scheduling of the first postinjection follow-up visit are individualized, taking into account medication burden and glaucoma severity. 

Patients on a topical prostaglandin alone or a topical prostaglandin plus one adjunctive medication whose IOP has been well controlled may have both agents discontinued if they have mild-to-moderate glaucoma, and they will likely be asked to return 7 to 10 days postinjection.



Glaucoma drug delivery devices enter new frontier



Patients with more severe disease and on multiple medications are seen within a few days after the procedure and are weaned more slowly off existing topical drops according to the level of their IOP.

“Initially I thought the implant would be something that could simply replace a topical prostaglandin. However, as I treat more patients who are on multiple medications, I am realizing that some can do very well being taken off more than just the prostaglandin,” Teymoorian said. “The experience with patients who can stop multiple medications highlights the efficacy of the implant and also the problem of noncompliance for patients who are on topical drops. Clearly, even those individuals who are well intentioned may not be administering their medications properly.”



The implant is approved for one-time administration. Clinical trial experience indicates that the IOP-lowering benefit can last from 4 months to 2 years or more, and research is underway to collect data that will support FDA approval for repeat injections.

“Ongoing management for patients who begin to lose the IOP-lowering effect from the bimatoprost implant is something that we will need to address in the future,” Teymoorian said. “But while we think about what we might do tomorrow, we need to plan and execute for today. Even if I think it is a one-time treatment for now, I find no reason to hesitate using the implant in appropriate patients when I consider its many benefits and minimal risk.”



Glaucoma 360: Lowering IOP using the MIMS solution

Anticipating the opportunity for repeat injections, he noted it is exciting to think that early treatment with the bimatoprost implant holds promise for preserving vision and quality of life for glaucoma patients over the long term.

Teymoorian concluded that, in theory, disease control should be much better for patients who are being treated with the implant than for those who are on topical therapy because the implant ensures consistent medication delivery, while with topical treatment clinicians have to assume patient adherence.

“Consistently effective IOP control increases the likelihood that we will be able to slow or even halt glaucoma progression,” he said.


Teymoorian is a consultant, speakers’ bureau member, and investigator for Allergan.

Sustained release helps mitigate disease progression without impacting quality of life.


Cheryl Guttman Krader, BS, Pharm

Articles

Deep learning algorithm proven accurate for AMD classification

Probe of IRIS registry: Anti-VEGF injections key treatment for PDR

Long-acting prostaglandin implant creating shift in IOP-lowering therapy

Pearls for practicing in the COVID-19 era