Teleglaucoma Using a New Smartphone-Based Tool for Visual Field Assessment.

PRCIS: COVID-19 underlines the importance of telemedical diagnostics. The smartphone-based campimetry (Sb-C) is a newly developed digital application allowing visual field testing using a head-mounted device and a smartphone. It enables visual field screening remotely from a clinic. BACKGROUND: Sb-C is a newly developed tool for functional ophthalmic diagnosis. This study aimed to examine the comparability of the Sb-C and Octopus 900 to ensure ophthalmological care in times of social distancing. METHODS: Total 93 eyes were included in the study. After an ophthalmological examination, the visual field was tested by the Octopus program G1 and by the smartphone-based campimeter. The Sb-C was performed using VR glasses and an iPhone 6. The software Sb-C was downloaded and installed as SmartCampiTracker app and is examining the 30-degree visual field with 59 test positions corresponding to the G pattern of Octopus G1. Sensitivities were recorded and saved on the app. In addition, test-retest reliability was tested on 6 ophthalmologically healthy participants. RESULTS: The group comprised 48 women and 45 men (mean age: 62.52±12.2 y) including 19 controls, 17 patients with ocular hypertension, 11 preperimetric glaucomas, and 46 perimetric glaucomas. The mean sensitivity (MS) of all points of G1 perimetry was 23.13 dB (95% CI, 22.08-24.18). The MS of the Sb-C was 21.23 dB (95% CI, 20.37-22.08). The correlation between the mean MS measured by G1 perimetry and the Sb-C was strong ( r =0.815, P <0.05). The test-retest reliability showed a correlation of r =0.591 ( P <0.05) . CONCLUSIONS: With some technical adjustments, the Sb-C shows promise for screening glaucoma and monitoring disease progression remotely from an ophthalmologic clinic.

Visual fields in glaucoma: Where are we now?

Visual fields are an integral part of glaucoma diagnosis and management. COVID has heightened the awareness of the potential for viral spread with the practice of visual fields modified. Mask artefacts can occur due to fogging of the inferior rim of the trail lens. Fortunately, the risk of airborne transmission when field testing is low. The 24-2c may be useful to detect early disease and the 10-2 more sensitive to detect advanced loss. The SITA faster test algorithm is able to reduce testing time thereby improving clinic efficiency, however, may show milder results for moderate or severe glaucoma. The technician has an important role of supervising the visual field performance to achieve reliable output. Home monitoring can provide earlier detection of progression and thus improve monitoring of glaucoma as well as reduce the burden of in-clinic assessments. Artificial Intelligence has been found to have high sensitivity and specificity compared to expert observers in detecting field abnormalities and progression as well as integrating structure with function. Although these advances will improve efficiency and guide accuracy, there will remain a need for clinicians to interpret the results and instigate management.

IMPULSE Study: Impact of COVID-19 in the present of ophthalmology focusing on ocular surface and future trends.

INTRODUCTION AND OBJECTIVE: Digital evolution represents an opportunity for ophthalmology to adapt to new care models. This study aimed to find out how the pandemic has modified the clinical practice and training activities of the ophthalmologist specialised in ocular surface, as well as to analyse emerging trends and needs. MATERIALS AND METHODS: This study was carried out through an online survey. A committee of 3 specialists developed a questionnaire of 25 questions structured in: 1) Participant profile; 2) Impact of the pandemic on patient management and professional activities; 3) Trends and needs. RESULTS: 68 clinical ophthalmologists participated. There was a high degree of agreement (90%) that the pandemic has delayed ophthalmological follow-up visits and diagnosis. The participants agreed that the frequency of patients with dry eye disease (75%), stye/chalazion (62%) and blepharitis (60%) has increased. According to 28%, remote monitoring of pathologies such as dry eye, glaucoma, diabetes, conjunctivitis, hyposphagmas, styes, etc., will be common, especially in the young population. This will be especially relevant in chronic or mild pathologies of the ocular surface, and in the follow-up of patients after cataract and diabetic retinopathy interventions. CONCLUSIONS: During the pandemic, an increase in the incidence of certain ocular surface diseases has been perceived. The telematic follow-up of chronic or mild pathologies of the ocular surface entails the need to provide specific training for both the patient and the healthcare professional, in addition to screening and referral protocols that would optimise the flow of care.

Patients' Perception of COVID-19 Preventive Measures in Ophthalmology: Satisfaction and Impact on Glaucoma Care and Follow-up.

PURPOSE: In response to the spread of COVID-19 in Switzerland, ophthalmology practices implemented a variety of preventive measures in order to minimise the risk of contamination to their patients and staff. Yet, some studies suggested that over a quarter of all glaucoma patients never returned to the clinic after the first lockdown eased. This raises the question of the factors influencing Patients' likelihood to keep their appointments in this COVID-19 era. The aim of this study was therefore to assess ophthalmology Patients' perception of COVID-19 preventive measures, as well as their impact on glaucoma Patients' clinic attendance and follow-up. METHODS: This was a prospective study based on primary data collected from 12 private ophthalmology clinics in French-speaking Switzerland. A web-based patient experience questionnaire was designed to assess Patients' appreciation of the preventive measures in place at their eye care provider as well as their intention to attend further follow-up appointments. These measures were made on modified 10-point Likert scales. Every patient who attended an appointment at one of the participating clinics on randomly selected dates in October 2020 was offered voluntary enrolment into the study. RESULTS: In all, 118 surveys were completed and analysed. The mean age of respondents was 57.8 ± 18.0 years, 59.3% were female, and 71.2% were Swiss nationals. Fifty-four (45.8%) of them suffered from glaucoma. Overall, patients were highly satisfied with the measures in place to safeguard them from COVID-19 infection, with a mean score of 9.29 ± 1.35. This was higher amongst Swiss nationals (9.55 ± 0.77) than foreigners (8.65 ± 2.09). On average, responders expressed a 90.2 ± 17.5 percent likelihood to keep their follow-up appointment. The figure went down to 88.5 ± 19.9 percent amongst glaucoma patients (p = 0.58), and 86.3 ± 22.1 percent amongst glaucoma patients aged 65 and over (p = 0.29). Interestingly, older glaucoma Patients' satisfaction with preventive measures in place strongly correlated with their likelihood to keep follow-up appointments (r = 0.72). The correlation was moderate amongst all glaucoma patients (r = 0.46) and weak amongst all respondents (r = 0.38) and those over 65 (r = 0.44). CONCLUSIONS: The present research highlights the importance of Patients' perception on COVID-19 preventive measures in place in ophthalmology clinics, which was directly associated with their likelihood to keep follow-up appointments. Vulnerable subgroups of patients were more likely to miss their follow-up appointments altogether, and their decision to attend was more strongly influenced by their perceived risk of contracting COVID-19. This suggests a role for telemedicine in more vulnerable patients suffering from progressive diseases such as glaucoma.

[Attitude of patients to possible telemedicine in ophthalmology : Survey by questionnaire in patients with glaucoma]. / Einstellung von Patienten zu möglicher Telemedizin in der Ophthalmologie : Erhebung mittels Fragebogen bei Glaukompatienten.

BACKGROUND: The COVID-19 pandemic in 2020 and 2021 severely restricted the care of ophthalmology patients. Teleophthalmological services, such as video consultation or medical telephone advice could, at least partially, compensate for the lack of necessary controls in the case of chronic diseases; however, teleophthalmological options are currently still significantly underrepresented in Germany. OBJECTIVE: In order to determine the willingness of patients to use telemedicine and the virtual clinic, we conducted a survey using a questionnaire on the subject of teleophthalmology in university medicine patients with known glaucoma as a chronic disease during the first wave of the COVID-19 pandemic. METHODS: A total of100 patients were interviewed. The questionnaire contained 22 questions with multiple choice possible answers. The inclusion criterion was the presence of glaucoma as a chronic disease, age over 18 years, and sufficient linguistic understanding to answer the questions. The data were collected, analyzed and anonymously evaluated. RESULTS: In the patient survey it could be shown that the respondents with glaucoma are very willing to do teleophthalmology and that this would be utilized. Of the patients surveyed 74.0% would accept telemedicine and virtual clinics. Of the ophthalmological patients surveyed 54.0% stated that their visit to the doctor/clinic could not take place due to SARS-CoV­2 and 17.0% of the patients stated that the SARS-CoV­2 pandemic had changed their opinion of telemedicine. DISCUSSION: The acceptance of telemedicine in patients with chronic open-angle glaucoma seems surprisingly high. This has been increased even further by the SARS-CoV­2 pandemic. These results reflect a general willingness of patients with chronic eye disease but do not reflect the applicability and acceptance and applicability from a medical point of view; however, this form of virtual consultation is accepted by the majority of patients with glaucoma and could be considered for certain clinical pictures.

Case Report: Steroid-induced Ocular Hypertension in a 6-year-old Boy.

SIGNIFICANCE: Systemic corticosteroid use in children is rare because of known risks of adverse effects. The increased prevalence of multisystem inflammatory syndrome associated with COVID-19 may change this. It is critical for eye care providers to be aware of potential severe and rapid ocular hypertensive response to prevent irreversible vision loss. PURPOSE: The purpose of this study was to report the importance of early monitoring of intraocular eye pressure in pediatric patients on systemic steroid medication. CASE REPORT: A 6-year-old White boy presented with a complaint of headache for 2 weeks. He was on his 19th day of treatment for acute lymphoblastic leukemia with oral dexamethasone and chemotherapy. IOP at presentation was 65 mmHg in both eyes measured with iCare tonometry. Treatment with maximum topical glaucoma therapy reduced IOP to normal levels and eliminated the symptom of headache. CONCLUSIONS: This case reminds eye care providers to be aware of the potential ocular hypertensive response to systemic steroid treatment and the importance of establishing early monitoring. With the emergence of multisystem inflammatory syndrome in children during the current COVID-19 pandemic, eye care providers may encounter more pediatric patients on systemic corticosteroid treatment than previously and should adjust their examinations appropriately.

Accuracy of Using Generative Adversarial Networks for Glaucoma Detection: Systematic Review and Bibliometric Analysis.

BACKGROUND: Glaucoma leads to irreversible blindness. Globally, it is the second most common retinal disease that leads to blindness, slightly less common than cataracts. Therefore, there is a great need to avoid the silent growth of this disease using recently developed generative adversarial networks (GANs). OBJECTIVE: This paper aims to introduce a GAN technology for the diagnosis of eye disorders, particularly glaucoma. This paper illustrates deep adversarial learning as a potential diagnostic tool and the challenges involved in its implementation. This study describes and analyzes many of the pitfalls and problems that researchers will need to overcome to implement this kind of technology. METHODS: To organize this review comprehensively, articles and reviews were collected using the following keywords: ("Glaucoma," "optic disc," "blood vessels") and ("receptive field," "loss function," "GAN," "Generative Adversarial Network," "Deep learning," "CNN," "convolutional neural network" OR encoder). The records were identified from 5 highly reputed databases: IEEE Xplore, Web of Science, Scopus, ScienceDirect, and PubMed. These libraries broadly cover the technical and medical literature. Publications within the last 5 years, specifically 2015-2020, were included because the target GAN technique was invented only in 2014 and the publishing date of the collected papers was not earlier than 2016. Duplicate records were removed, and irrelevant titles and abstracts were excluded. In addition, we excluded papers that used optical coherence tomography and visual field images, except for those with 2D images. A large-scale systematic analysis was performed, and then a summarized taxonomy was generated. Furthermore, the results of the collected articles were summarized and a visual representation of the results was presented on a T-shaped matrix diagram. This study was conducted between March 2020 and November 2020. RESULTS: We found 59 articles after conducting a comprehensive survey of the literature. Among the 59 articles, 30 present actual attempts to synthesize images and provide accurate segmentation/classification using single/multiple landmarks or share certain experiences. The other 29 articles discuss the recent advances in GANs, do practical experiments, and contain analytical studies of retinal disease. CONCLUSIONS: Recent deep learning techniques, namely GANs, have shown encouraging performance in retinal disease detection. Although this methodology involves an extensive computing budget and optimization process, it saturates the greedy nature of deep learning techniques by synthesizing images and solves major medical issues. This paper contributes to this research field by offering a thorough analysis of existing works, highlighting current limitations, and suggesting alternatives to support other researchers and participants in further improving and strengthening future work. Finally, new directions for this research have been identified.

Quantitative assessment of retinal changes in COVID-19 patients.

CLINICAL RELEVANCE: The SARS-COV 2 virus, which is responsible for the COVID-19 pandemic, acts on the angiotensin converting enzyme 2 (ACE-2) receptor in the host cell. Ocular effects may occur because of the ACE-2 receptor in the retina. BACKGROUND: To investigate the impact of COVID-19 on the retinal layers and optic disc parameters in previously confirmed COVID-19 patients using spectral domain optical coherence tomography (SD-OCT). METHODS: This study included 60 eyes of 60 subjects; 35 of them were in the COVID-19 group and the remaining 25 were in the control group. Patients with the diagnosis of COVID-19 that had a negative result after treatment were included in the study. Macular and peripapillary retinal nerve fiber layer (RNFL) thickness measurements, each retinal layer thickness of all participants were done 14-30 days after COVID-19 symptom onset, following the negative result of real time reverse transcriptase-polymerase chain reaction test using SD-OCT. RESULTS: The mean value of central macular thickness was significantly higher in the COVID-19 group than the control group (p = 0.02). The mean values of the ganglion cell layer and inner nuclear layer thickness in the COVID-19 group were significantly thinner than control group (p = 0.04 and p = 0.04, respectively). Even though mean RNFL thickness measurements in all sections in the COVID-19 group was thinner than controls, there were no significant differences between groups (p > 0.05 for all). CONCLUSION: In the early recovery phase, changes in the macula, ganglion cell layer and inner nuclear layer could be seen. These patients should be followed up closely for the recognition of new pathologies that could be seen in the late recovery phase.

Acceptability of a home-based visual field test (Eyecatcher) for glaucoma home monitoring: a qualitative study of patients' views and experiences.

OBJECTIVES: To explore the acceptability of home visual field (VF) testing using Eyecatcher among people with glaucoma participating in a 6-month home monitoring pilot study. DESIGN: Qualitative study using face-to-face semistructured interviews. Transcripts were analysed using thematic analysis. SETTING: Participants were recruited in the UK through an advertisement in the International Glaucoma Association (now Glaucoma UK) newsletter. PARTICIPANTS: Twenty adults (10 women; median age: 71 years) with a diagnosis of glaucoma were recruited (including open angle and normal tension glaucoma; mean deviation=2.5 to -29.9 dB). RESULTS: All participants could successfully perform VF testing at home. Interview data were coded into four overarching themes regarding experiences of undertaking VF home monitoring and attitudes towards its wider implementation in healthcare: (1) comparisons between Eyecatcher and Humphrey Field Analyser (HFA); (2) capability using Eyecatcher; (3) practicalities for effective wider scale implementation; (4) motivations for home monitoring. CONCLUSIONS: Participants identified a broad range of benefits to VF home monitoring and discussed areas for service improvement. Eyecatcher was compared positively with conventional VF testing using HFA. Home monitoring may be acceptable to at least a subset of people with glaucoma.

A review on the use of telemedicine in glaucoma and possible roles in COVID-19 outbreak.

We review the use of telemedicine in glaucoma and its possible roles in the COVID-19 outbreak. We performed a literature search of published human studies on teleglaucoma on May 12, 2020, using search terms including "telemedicine" and "glaucoma" that were in English and published over the prior 10 years. This search strategy yielded a total of 14 relevant articles after manual curation. Of the 14 articles, 4 were from the same randomized control trial, 7 were prospective studies, 2 were retrospective studies, 1 was descriptive analysis, and 1 was cost-effective analysis. Seven discussed the common ophthalmologic measurements used in teleglaucoma. Four demonstrated the cost effectiveness of the use of teleglaucoma, and 3 articles investigated patient satisfaction with the use of teleglaucoma. Three articles investigated the correlation between teleglaucoma and face-to-face clinics. Five articles discussed the current use and opportunities of teleglaucoma. When compared to in-person care, teleglaucoma is more time and cost-effective, shows high patient satisfaction and fair to good agreement with in-person care; however, there is great variation in the reported sensitivity of glaucoma screening, warranting further studies to establish its efficacy. For glaucoma management, both the sensitivity and specificity must be further improved before it could be put into extensive use. Nevertheless, it is worthwhile to explore the possible extensive application of teleglaucoma in monitoring "glaucoma suspects" and maintaining glaucoma follow-up during a pandemic outbreak to reduce the risk of transmission of infection.

Home Monitoring for Glaucoma: Current Applications and Future Directions.

Technological advances provide a number of options for glaucoma monitoring outside the office setting, including home-based tonometry and perimetry. This has the potential to revolutionize management of this chronic disease, improve access to care, and enhance patient engagement. Here, we provide an overview of existing technologies for home-based glaucoma monitoring. We also discuss areas for future research and the potential applications of these technologies to telemedicine, which has been brought to the forefront during the ongoing COVID-19 pandemic.

The Impacts of Face Mask Use on Standard Automated Perimetry Results in Glaucoma Patients.

PURPOSE: The coronavirus disease 2019 (COVID-19) spread rapidly worldwide, causing a severe outbreak. Because the disease is easily transmitted, face masks are a vital tool to slow the spread. The aim of this study is to investigate the impacts of face mask use on standard automated perimetry (SAP) results in glaucoma patients. MATERIALS AND METHODS: All follow-up glaucoma patients who underwent SAP between May and October 2020 were enrolled in this study. In patients with low test reliability and/or visual field changes, SAP was repeated after repositioning and taping patients' face masks. RESULTS: A total of 127 patients (59 female and 68 male) with a mean age of 59.8±10.3 years were included in the study. While 101 patients (79.5%) wore surgical face masks, 26 patients (20.5%) wore cloth face masks. Low SAP reliability appeared in 23 patients (18.1%), and inferior visual field defects were present in 3 patients (2.4%). The main effects of poorly fitting face masks on SAP reliability were increased fixation losses and false-positive errors (for both, P=0.001). Low SAP reliability was significantly higher in patients wearing cloth face masks than in those wearing surgical face masks (47.8% vs. 9.9%; P=0.0001). The face mask-related fogging of eyeglasses before SAP is a strong predictor of fogging of the trial lenses-related low SAP reliability (odds ratio: 27, 95% confidence interval: 5.48-132.92, P=0.0001). In all repeated SAPs, the patients' reliability parameters improved, and inferior visual field artifacts disappeared. CONCLUSIONS: Unsuitable face masks can cause either visual field artifacts, which may be interpreted as glaucoma progression or low test reliability. Taping the face masks' upper edges is an effective technique to prevent visual field artifacts and obtain good test reliability.

Intraocular Pressure Telemetry for Managing Glaucoma during the COVID-19 Pandemic.

PURPOSE: To evaluate in glaucoma patients the feasibility and use of remote monitoring of intraocular pressure (IOP) with an implanted telemetry sensor during the coronavirus disease 2019 (COVID-19) lockdown. DESIGN: Cross-sectional study. PARTICIPANTS: Patients previously implanted with a telemetric IOP sensor (Eyemate; Implandata GmbH) were included. METHODS: Intraocular pressure measurements acquired by the patients during the lockdown were collected by physicians who were located remotely. A questionnaire was sent to 10 participating study centers to evaluate the clinical impact of remote monitoring of IOP via the IOP sensor system. MAIN OUTCOME MEASURES: Number of patients who obtained home IOP measurements. RESULTS: Data were available from all centers and from 37 eyes of 37 patients (16 patients with a sulcus-based sensor and 21 patients with a suprachoroidal sensor). Thirty-four patients obtained IOP measurements during the lockdown. Mean age of the patients was 69.3 ± 9.6 years, and 48.6% were women. A total of 8415 IOP measurements from 370 measurement days were obtained. Based on remote IOP measurements, treatment was changed in 5 patients. In another 5 patients, treatment change was considered when physicians received the IOP measurements after the lockdown. Nine of the 10 study centers judged remote IOP measurements to have a clinical impact. CONCLUSIONS: These results show the feasibility of patient-acquired measurement of IOP in conjunction with remote IOP monitoring by physicians with an implantable sensor. The data obtained impacted clinical decision making, including adjustment of ocular hypotensive therapy and avoiding unnecessary office visits during the COVID-19 pandemic.

Digital Ophthalmology in the UK - Diabetic Retinopathy Screening and Virtual Glaucoma Clinics in the National Health Service. / Digitale Ophthalmologie in Großbritannien ­ Diabetische-Retinopathie-Screening und virtuelle Glaukomsprechstunde im National Health Service.

The customary doctor and patient interactions are currently undergoing significant changes through technological advances in imaging and data processing and the need for reducing person-to person contacts during the COVID-19 crisis. There is a trend away from face-to-face examinations to virtual assessments and decision making. Ophthalmology is particularly amenable to such changes, as a high proportion of clinical decisions are based on routine tests and imaging results, which can be assessed remotely. The uptake of digital ophthalmology varies significantly between countries. Due to financial constraints within the National Health Service, specialized ophthalmology units in the UK have been early adopters of digital technology. For more than a decade, patients have been managed remotely in the diabetic retinopathy screening service and virtual glaucoma clinics. We describe the day-to-day running of such services and the doctor and patient experiences with digital ophthalmology in daily practice.

Drive-through Intraocular Pressure Checks During the COVID-19 Pandemic.

PRECIS: A drive-through clinic was created to obtain intraocular pressure measurements before a virtual visit with their provider, in order to provide care for patients in the Kellogg Glaucoma Clinic while minimizing risk of COVID-19 transmission. PURPOSE: The aim of this study was to establish a drive-through clinic model to provide glaucoma care for patients while minimizing the risk of COVID-19 transmission. PATIENTS AND METHODS: A drive-through clinic was created by adapting a 1-lane, 1-way driveway adjacent to the Kellogg Eye Center building entrance. Patients were physicianselected from the Glaucoma Clinic at Kellogg Eye Center as existing patients who required intraocular pressure (IOP) checks and therapeutic management and were chosen based on their ability to be managed with an IOP measurement primarily. The entrance was otherwise closed to the public, allowing staff to utilize an adjacent vestibule with glass walls and sliding doors as a staffroom. Patients were instructed to arrive within a 15-minute time window at which time they would drive through the lane and stop their cars under an awning over the driveway. Ophthalmic technicians wearing appropriate personal protective equipment then approached each car, confirmed patient information, and measured IOP. Once the data were recorded using a mobile workstation, the physician was able to complete each visit by discussing the findings and therapeutic plan with the patient, either in-person in real time or virtually by phone or video visit at a later time. RESULTS: A total of 241 visits were completed over 14 half day clinic sessions, with number of drive-through visits ranging from 5 to 45 per session. CONCLUSIONS: It is possible to institute a drive-through model of IOP checks for glaucoma patients which is efficient and minimizes the risk of exposure to COVID-19 for patients and staff.

Guidelines and Recommendations for Tonometry Use during the COVID-19 Era.

The novel coronavirus disease COVID-19 caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has resulted in a substantial change in eye care and clinical practice. There has been conflicting information and weak evidence on the virus's transmission through tears. Yet, virus detection on cornea and conjunctiva surface as a gateway for infection is not well-studied. Moreover, there have been no reported cases of SARS-CoV-2 transmission through tonometry to date. Thus, this uncertainty has urged this review on evidence-based guidelines and recommendations on tonometer use in the COVID-19 era. The aim of this article is to provide ophthalmologists with recommendations for tonometry practice based on current evidence and best practice guidelines.