With glaucoma, a leading cause of irreversible blindness, expected to rise in the coming decades and the ophthalmology workforce projected to decrease, there is a pressing need for innovations to make eye care more accessible and efficient. Teleglaucoma — a growing field where telehealth services like virtual appointments and home monitoring devices are used to detect and manage glaucoma — may offer useful solutions, though the field still faces limitations, explains ophthalmologist Cara Capitena Young, MD.
Capitena Young, an associate professor at the University of Colorado Anschutz Department of Ophthalmology, is a glaucoma specialist. She cares for patients at the Sue Anschutz-Rodgers Eye Center in Aurora, where she is the medical director of the operating room, and she is the clinical director of one of the eye center’s satellite locations in Lone Tree.
In her own practice, she has seen the benefits of teleglaucoma, particularly by facilitating care for patients who live far away from their ophthalmologist or subspecialist and by creating more comfortable methods to assess their disease. However, virtual eye appointments still cannot compare to in-person evaluations, she notes, and there are high costs associated with some teleglaucoma devices.
“I love the idea of teleglaucoma, though it’s still limited in its benefits,” she says. “The field continues to expand and improve, which is exciting, because in a world where we have a large shortage of ophthalmologists — let alone glaucoma specialists — it’s valuable for patients to access care virtually and not have to come into a clinic for every single visit.”
As an age-related disease, glaucoma primarily affects older adults, though it can affect any age group. Research suggests that an estimated 4.22 million people in the United States had glaucoma as of 2022, and that number is expected to increase given the rising aging population.
A major challenge of glaucoma is that many patients don’t notice they have the disease until it has become advanced, Capitena Young explains.
“Glaucoma is a disease characterized by optic nerve damage — the cord connecting the eye to the brain — and that damage typically starts as peripheral vision loss,” she says. “However, because you have two eyes working together and it starts slowly, most people don’t notice it until it starts to encroach near their central vision or another eye doctor catches it. That’s why it’s referred to as the sneaking thief of sight.”
Damage to the optic nerve cannot be undone, meaning that the vision loss patients experience is permanent. Although there is no cure for glaucoma, treatment aims to halt progression of the disease and stop further vision loss, highlighting the importance of getting an early diagnosis.
Optometrists are often the first to detect glaucoma during annual checkups, Capitena Young explains. When they conduct an eye exam on patients, they typically examine a patient’s optic nerve and check their eye pressure. Elevated eye pressure — which is different from blood pressure — is the main risk factor for glaucoma, as heightened pressure can cause damage to the optic nerve. However, there are some patients with glaucoma who do not have elevated eye pressure, she notes.
If an optometrist suspects a patient may have glaucoma, they will refer the patient to see a specialist like Capitena Young. There are two main tests that glaucoma specialists use to screen for the disease. The first is a visual field test that checks a patient’s peripheral vision. The second is an optical coherence tomography scan that uses light to measure the retinal nerve fiber layer, which is the part of the optic nerve that is damaged or thinned by glaucoma.
“These tests, along with the eye pressure levels and a number of other factors, all go into determining whether someone has glaucoma or is at risk of getting it. But to do all that requires access to eye doctors who are not always easily accessible, especially in certain areas,” Capitena Young says.
“Ophthalmic care, in general, is not prolific in some parts of southern Colorado, so I see a wide range of patients, from Castle Rock to Pueblo and beyond,” she adds. “For some of my patients, they have to travel several hours to see me, and given their vision issues, getting to their appointment may be difficult.”
Teleglaucoma spans a variety of different services, Capitena Young explains, but a primary goal is to make glaucoma monitoring and testing more accessible to patients.
“There are a number of ways that people are working on that,” she says. “One method is having virtual visits, but that can be difficult when it comes to assessing and taking photos of the eyes. There are some cameras that patients or other doctors, like primary care providers, can attach to their phone so they can take images of their eyes. It’ll be interesting to see how that develops and is used more over the next few years.”
Another teleglaucoma service that Capitena Young has used among her own patients is a small device called an iCare HOME tonometer. This device allows patients to measure their eye pressure levels multiple times a day from the comfort of their own home, and that data can be sent to an ophthalmologist for review.
“The benefit of home tonometry is wide,” she says. “Historically, there are some glaucoma patients who we would ask to come into the clinic just to check their eye pressure, or they would come back multiple times per day for pressure checks to assess for fluctuations. If they can do that at home instead, then we have more availability to care for other patients and we get more data to help care for them.”
This device is particularly useful for patients who have worsening vision despite having a normal eye pressure level when they get tested at the clinic. By having them monitor their eye pressure levels at home, Capitena Young can see if their levels fluctuate throughout the day, helping inform her treatment approach.
“I’ve also had patients use this device before and after they receive a laser procedure or therapy intervention, because it can help me see if the treatment worked or not,” she says.
A major challenge, however, is that the device is rarely covered by insurance, and with a four-figure price tag, it is cost prohibitive to many patients. It is possible to rent the device from some companies, Capitena Young explains, but she hopes to see more insurance coverage and accessibility for the device in the future.
However, for some patients, the price is worth it. That was the case for one of Capitena Young’s patients, a woman with aggressive glaucoma whose vision has been rapidly worsening and multiple interventions had failed.
“We’ve had a really hard time getting her disease controlled. She’s been through three surgeries in the last year, so right after her third surgery, she purchased the iCare HOME tonometer,” Capitena Young says. “It gives her a lot of peace of mind, and it gives me peace of mind, too, because I can’t have her come to the clinic every day, but I can see weekly updates from this device and decide based on the data when she should see me and how she is doing.”
Beyond helping glaucoma patients avoid unnecessary trips to the ophthalmologist, another teleglaucoma advancement has been improving the peripheral vision testing process.
“Currently, visual field testing is the gold standard for glaucoma patients, but to do this test, patients must come to the clinic, sit in a machine, and remain still as they stare straight ahead. When they see a flashing dot in their periphery, they click a button,” she says. “You do one eye at a time, and it usually takes about 5-10 minutes per eye. Patients usually hate taking the test.”
More recent updates and algorithms, however, have resulted in the creation of a virtual visual field machine. These machines are essentially eye or face masks that patients wear, allowing them to sit comfortably, and push a button when they see something.
“They don’t have to close one eye at a time because the machine does it for them. It’s like an arcade game,” she says. “It’s a huge improvement and really helpful for patients who have mobility issues and might struggle with the traditional test. One of my patients is in a wheelchair, and when she took the virtual field test, she said it was so much easier and therefore less stressful.”
These machines, however, are not widely available or adopted yet, she explains. At the Sue Anschutz-Rodgers Eye Center, for instance, there is currently one machine. Further scientific studies are needed to compare traditional field testing with the virtual test to prove that the tests are equivalent to one another.
Overall, though teleglaucoma services have some barriers and limitations, Capitena Young underscores the value of these efforts to help expand the accessibility, efficiency, and ease of care for glaucoma patients.
“Glaucoma can be really scary for patients,” she says. “That’s why it’s important to have a strong relationship with patients so they know that we have their back, and they can trust us to help them the best we can.”