For more than a decade, Tom Poindexter managed his glaucoma with drops as routinely as brushing his teeth. Catching it early, he was diagnosed with open-angle glaucoma, the most common form, in his 50s.
Since his mother was diagnosed with glaucoma in her 40s, he’s always diligently cared for his eye health, but some unplanned eye surgeries and changes in his intraocular pressure (IOP) accelerated those efforts within the last year.
“I knew my pressure was increasing because if you have glaucoma and your pressure gets out of hand, your vision becomes rather poor. You get these halos and some other effects,” Poindexter says. “Oddly enough, you rarely feel any pain, so it's something you have to be aware of that might be creeping up and take care of it.”
Between surgeries to correct cataracts, glaucoma, and a detached retina, his journey to recovery required at least five emergency hospital visits over the summer and consistent pressure monitoring. Driving 40 minutes to and from the Sue Anschutz-Rodgers Eye Center at the CU Anschutz Medical Campus each way, he began searching for a more efficient solution to monitor his eye pressure.
“Being able to take my measurement at home and know my measurement right away would be a big game changer, especially for recovery patients that have to monitor their eye pressure carefully,” Poindexter says. “It's like taking your temperature or your blood pressure. You can easily take your temperature or your blood pressure to find out if you need to see your doctor.”
Eye care at home
Poindexter has his eyes on an iCare HOME tonometer, a small, portable device designed for patients to measure their IOP at home without anesthesia or eye drops. The CU Department of Ophthalmology is one of the first to implement this at-home technology as a one-week rental for patients.
Glaucoma is a disease resulting from damage to the optic nerve. It’s often asymptomatic, especially early, but can present through peripheral vision loss and increased intraocular pressure. Family history, high intraocular pressure and previous eye surgeries are risk factors, but glaucoma can affect any individual at any age. It is traditionally treated by eye drops, selective laser trabeculoplasty (SLT), or surgery if necessary.
“It’s similar to getting a heart monitor to track your heart over a 24-hour period. You come in, train with one of our techs, take it home, and then bring it back to the clinic,” says Leo Seibold, MD, associate professor of ophthalmology at the CU School of Medicine and director of the department’s glaucoma fellowship.
Patients check and log their pressure four times daily for seven days in their normal environment before returning the device by mail or in person. Seibold, who is Poindexter’s provider, believes this at-home approach offers a number of advantages to patients with glaucoma, including the ability to detect treatment responses missed by current standard-of-care IOP monitoring through in-office Goldmann applanation tonometry (GAT) measurements.
“Normally for glaucoma, we're monitoring pressure two to four times a year with patients coming in every three to six months for a pressure check in the clinic, and it's just a single spot reading,” Seibold says. “At home with this device, you get multiple readings over continuous days, so it's a more accurate representation of their pressure in real life. You can catch spikes in pressure that you might miss from that one in-office check.”
Although the iCare HOME is one of the most prevalent and accessible pressure monitoring products, according to Cara Capitena Young, MD, assistant professor of ophthalmology at the CU School of Medicine, there are some limitations.
“They are expensive. They are around one thousand dollars, and that's not affordable for most patients,” Capitena Young says. “Additionally, not all patients can use it. I have a few patients with tremors, which prohibits them from being able to check their pressure with this device.”
While this at-home monitoring can provide more data on patients’ pressure activity, it still doesn’t show the full picture.
“We know pressure fluctuates day to day, minute to minute, hour to hour,” Capitena Young says. “It tends to follow a 24-hour circadian rhythm, and pressures traditionally spike early in the morning when most people are sleeping. This means patients may not be measuring their highest pressure.”
Because Poindexter is interested in purchasing a device for longer-term monitoring, he’s experiencing his own obstacles.
“The availability of being able to take your pressure reading and not have to worry about putting anesthesia drops in your eyes first is amazing technology. Although the products on the market are somewhat expensive, there's no expense too high for keeping my vision as healthy as it can be,” he says. “But it's not as easy as you might think to go buy one of these devices. I have to have a doctor's prescription from my ophthalmologist just to rent. It would also be much more beneficial for me if I could actually see that pressure reading immediately.”
At this time, iCare HOME devices require measurement results to be uploaded into a secure cloud platform for a doctor to assess with the patient.
Cara Capitena Young, MD, demonstrates using an iCare HOME tonometer.
The future of glaucoma care is now
While teleglaucoma, or the application of telemedicine for glaucoma, has rapidly expanded in recent years, the COVID-19 pandemic highlighted the need to expand accessibility and care through innovative programs.
“We need to improve our screening of patients and get them to treating ophthalmologists sooner, and I think teleglaucoma plays a huge role in this area,” Capitena Young says. “That could mean organizing drive-up clinics across the state or country to check patients’ pressure and follow up with a telemedicine appointment to improve access.”
Studies show teleglaucoma screening reduces the rate of false-positive referrals, emergency room visits, and hospital exposure, especially during the ongoing pandemic. This not only reduces the burden on health care systems, but also offers some cost and travel relief for patients.
“At the University of Colorado, we are the only academic center for many miles. We take care of complex patients who come from Wyoming, Montana, Eastern Utah, all of Kansas, and a lot of Nebraska, so it's hard for those patients to get to us both timewise and financially,” Capitena Young says. “If I could get these patients to do a virtual visual field and iCare HOME twice per year instead of making them come into the clinic three times each year, it's cost effective for them and potentially cost effective for medical facilities so we can care for more patients.”
A virtual visual field is one of the emerging telemedicine technologies being used to conduct visual field testing that is typically done in clinic. Other teleglaucoma screening developments include portable fundus photography, which is already used in diabetic retinopathy and macular degeneration screening and can be used to take pictures of the optic nerve at the back of the eye.
“They’re not going to replace the visual field machines that we have in clinic here, but they are great screening and monitoring tools,” Capitena Young says. “These options also help when patients have mobility issues and can’t necessarily get into the machine. Patients with neck problems or who are wheelchair bound could continue testing with these new options.”
As at-home technology continues to develop and improve, Capitena Young says smartphones could be the next revolutionary adaptation for low-risk screenings, but the biggest benefit is increased ability to test early, prevent further damage, and improve long-term outcomes for patients like Poindexter.
“These emergencies last summer really drove a little bit of fear and anxiety into my life, knowing if I don’t get this under control, I may have some permanent vision loss,” he says. “I'd certainly like to avoid that as much as possible and keep the freedom and lifestyle that I have. That's important and possible with these home solutions."