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Established in other areas, telemedicine implementation slow in glaucoma treatment
Improved knowledge about glaucoma and a high intent to pursue eye care may lead to improved detection of early disease, thus lowering the risk of blindness among patients.
Reviewed by Lindsay Anne Rhodes, MD
Traditional in-office glaucoma screening and treatment approaches fail to reach many patients in the population, resulting in an increase of significant visual deterioration or even blindness. Community models that provide accessible, convenient, and efficient care to high-risk populations could be part of the solution, said Lindsay Anne Rhodes, MD, assistant professor, Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham.
“If we can make it easier and more convenient for patients to get to their appointments and have regular checks, maybe we will do a better job of finding them before their condition gets worse,” said Dr. Rhodes, who is participating in one teleglaucoma initiative, known as EQUALITY (Eye Care Quality and Accessibility Improvement in the Community).
Telemedicine is well established in the diagnosis of diabetic retinopathy and retinopathy of prematurity, but implementation has been slower for glaucoma, she said. Reasons include the need for a combination of structural and functional testing, often conducted with sophisticated, expensive instruments, and challenges such as image readability, and follow-up adherence.
A community model holds promise for improving the management of glaucoma, particularly in small towns, rural areas, and inner cities where specialized medical services are often limited or nonexistent.
Goals include providing accessible, convenient, and efficient care; using improved imaging and diagnostic modalities (portable fundus cameras, smartphone cameras, tablet- or virtual reality-based visual field testing, and spectral-domain optical coherence tomography); increasing rates of diagnosed and treated glaucoma; and allowing glaucoma specialists to focus on advanced disease and surgical work.
Projects being tested
Teleglaucoma projects are being tested in a number of areas, most falling into either of two categories. One is population-based detection targeting high-risk populations.
“Checking everybody for glaucoma is not a good way of finding the disease,” Dr. Rhodes explained. “If we can isolate high-risk populations based on age, race, and family history of glaucoma, it improves our ability to find and treat glaucoma.”
In this model, screening can take place in numerous types of locations such as primary-care settings, federally qualified health centers, Veterans Administration clinics, retail locations, rural areas, and community centers or churches. Some screening projects reach out to at-risk urban communities, partnering with community organizations to provide eye exams on mobile units, offer treatment on-site, and arrange follow-up care.
One example of this approach is TECS (Technology-Based Eye Care Services), funded primarily by the Department of Veterans Affairs. Nearly 39% of the patients screened received a glaucoma-related diagnosis, as reported in a 2017 study, which is far higher than the prevalence of glaucoma in the general population, Dr. Rhodes noted.
Another approach is the vertically integrated network. This approach taps into a network of primary eye care providers such as optometrists-more likely to be found in small towns, rural areas, or underserved urban communities than glaucoma specialists-to perform comprehensive dilated eye exams. Optical coherence tomography image, visual field tests, and optic nerve head photography are then sent to a reading center for remote subspecialist review.
The EQUALITY project, in which screening and follow-up take place in retail-based, primary-care settings serving communities with a large percentage of African Americans, follows this particular model. Walmart Vision Centers were chosen as partners for the EQUALITY program because in the rural areas of Alabama, where the project is based, Walmart stores are often the largest, or only, retail centers and therefore provide a convenient central point of access for the target population, Dr. Rhodes explained.
Since the screenings are conducted at a regularly staffed clinic, patients know that they can readily return for follow-up visits, while the optometrists can bill for their services, making the project more sustainable. In a 2016 study conducted at two EQUALITY sites, Dr. Rhodes reported that a total of 56% of the patients screened had a glaucoma-related diagnosis.
Based on a review of teleglaucoma programs, the keys to success that Dr. Rhodes has identified include targeting high-risk populations; choosing imaging modalities based on budget, convenience, and portability; engaging community partners to spread awareness and increase attendance; and utilizing patient navigators, social workers, and technology to increase follow-up adherence rates.
Future directions that could enhance the success of teleglaucoma include comparisons of emerging imaging devices such as smartphone cameras and tablets and application of artificial intelligence in the reading of optic nerve photos. Additional research on effectiveness and cost-effectiveness is also needed to improve reimbursement rates.
Lindsay Anne Rhodes, MD
This article is adapted from Dr. Rhodes’ presentation at the American Glaucoma Society 2019 annual meeting. Dr. Rhodes has received funding and support for the EQUALITY project from the Centers for Disease Control and Prevention, Research to Prevent Blindness, EyeSight Foundation, Carl Zeiss Meditec, and Heidelberg Engineering.