Eyeworld

104 | EYEWORLD | MARCH 2021 G UCOMA to maintain some form of telemedicine going forward, particularly for those patients who are stable. "I think telemedicine will help triage our patients better," Dr. Singh said. For example, he said that for post-surgery patients, it's help- ful to do a telemedicine visit if the patient is experiencing a complication to determine if the patient needs to be seen immediately, within a day, or later. "There's no doubt that because the regula- tions and coding have been improved, it makes it more palatable to offer telemedicine," he said. Visual field testing "While virtual visits offer an opportunity to connect with the patients, facilitate history taking, assist in addressing queries or concerns, and allow a limited anterior segment examina- tion, we are unable to measure IOP, assess the optic nerve, or perform perimetry," Dr. Salim said. "Home-based tonometers are limited by their suboptimal accuracy and cost. Portable alternatives to standard automated perimetry, web-based visual field programs, and virtual re- ality-based visual field testing have been devel- oped. However, additional data and experience are needed to further assess their reliability and feasibility before their use at home." Dr. Salim said her clinic still measures IOP using Goldmann applanation tonometer and evaluates visual function with a standard visual field analyzer. "Sometimes we offer testing on separate days to minimize the total contact time for patients in the clinic." Depending on the stage of glaucoma, she may order OCT and visual field on separate days and rely more on the clinical examination to tailor treatment. Telemedicine does not take the place of a physical exam, Dr. Singh said, though it helps when you can't see the patient. "We still have to do gonioscopy and look at the nerve physically," he said. Dr. Singh added that visual field testing at home should be more available in the future, which would "change the paradigm if we could evaluate the patient at home." Sustained drug delivery Dr. Francis said he is using sustained drug delivery devices more so because they are new technology rather than because of the pan- demic. "I wouldn't necessarily say that they helped patient management that much during the pandemic," he said. "If you're trying to control pressure and not have to do surgery, it can be helpful in that regard. Also, if you have a patient that relies on caregivers for medica- tion but may have this care disrupted due to the pandemic, a drug delivery system ensures they remain adequately treated. But in terms of patients getting medication, if they are able to use the medication properly, we've been able to easily get it to them due to home delivery," he said. Dr. Salim said that Durysta (bimatoprost implant, Allergan), the first FDA-approved sus- tained-release biodegradable implant, is a great addition and has the potential to overcome compliance issues, reduce the treatment bur- den, and minimize tolerability concerns. "This may be a good option for some patients who are uncomfortable coming to the office during the pandemic," she said. "At this point, we are still gaining more experience with this new implant, and I think its use should be tailored to each patient's clinical situation and social circumstances." Pandemic's impact on number of patients, time spent with patients, frequency of visits "Given the insidious and asymptomatic nature of glaucoma, delaying follow-up can be risky," Dr. Vinod said. Many New Yorkers rely on public transportation and have to take multiple trains/ buses to get to NYEE. "My patients were faced with what seemed like an impossible choice at the height of the pandemic when stay-at-home orders were in place: delay their glaucoma care and risk disease progression or keep their in-person appointments and risk exposure to SARS-CoV-2 while traveling to/from the office." Additionally, the fear of entering a hospi- tal (even a subspecialty one that did not treat COVID patients such as NYEE) contributed to the reluctance to attend office visits, she said. Increasing the intervals between visits is a consideration for glaucoma suspects or patients with excellent adherence and stable disease. However, Dr. Vinod said many of her patients have advanced glaucoma with multiple ocular comorbidities, requiring frequent and vigilant follow-up. continued from page 103

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