Glaucoma Management Plans during COVID 19

Our Royal College has issued guidelines for the management of glaucoma during the COVID 19 outbreak. The idea is to strike a pragmatic balance – looking to maintain care where it is essential and to defer care for patients who can safely wait.

Assessing risk

Many glaucoma patients fall into the most at-risk categories for acquiring COVID-19, including age and existing co-morbidities. Hence, the priority will be patients lives in the first instance. When making decisions about how to manage glaucoma patients, we assess the risk of imminent visual loss in the patient, the risk of COVID-19 spread by attending hospital and the potential loss of life of glaucoma patients if they contract COVID-19.

Prioritising surgery

Clinical details of each patient will be stratified to identify who needs immediate surgery and whose treatment can be deferred. In short, glaucoma surgery requires careful attention to detail, lots of follow-up and tweaking, whether it be from laser, injections, taking out stitches, etc. Hence undertaking surgery is not an easy decision in this environment. Factors that will be considered includes:

  • The level of vision
  • Extent of visual field loss in the affected eye
  • Whether it’s an only seeing eye
  • The rate of visual deterioration
  • The level of intraocular pressure.

Treating new patients

Doctors are reviewing all referrals and making difficult decisions based on the referral letter. The initial information from the referral source and medical history via community care is used to stratify the likelihood of glaucoma and the extent of the disease. If deemed high risk and no contra-indications, empirical treatment with a topical prostaglandin via a prescription through the GP is being commenced. The follow-up face to face assessment is subsequently scheduled for some months later.

Where possible, it is important to explain to the patient the nature of their condition, how to apply drops, receiving repeat prescriptions and assess side effects via a video or telephone consultation. The patient should be advised that the treatment is a protective measure and may change after a formal assessment.

Similarly, patients with advanced glaucoma can receive a remote consultation and be offered primary intervention, often medically.

Outpatient follow-up reviews

Doctors are working through lists of thousands of patients to stratify patients into low, medium and high-risk categories based on their disease severity and underlying pathology. Low risk patients will be written to in order to inform them of the delay in their appointments and give them details of what to do if they feel their condition has deteriorated.

Medication changes can be arranged remotely or face-to-face if there are serious concerns a condition may be worsening. Note: high risk patients may be offered face-to-face depending on the severity of the conditions. As with all face-to-face consultations at this time, the RCOphth guidance on minimising risk will be followed.

This blog is contributed by Gurjeet Jutley.