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Editors Selection IGR 22-2

Telemedicine: Expanding Virtual Glaucoma Clinics

Anja Tuulonen

Comment by Anja Tuulonen on:

94554 Expansion of patient eligibility for virtual glaucoma clinics: a long-term strategy to increase the capacity of high-quality glaucoma care, Nikita E; Gazzard G; Sim DA et al., British Journal of Ophthalmology, 2021; 0:

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In 2016, the UK Royal College of Ophthalmologists issued a recommendation for virtual clinics, for glaucoma suspects and patients with early glaucoma, to better meet demand. In response, technician-led virtual clinics were implemented in Moorfields, representing 14% of glaucoma attendances prior to the beginning of the COVID pandemic. In 2020, the UK Healthcare Safety Investigation Branch recommended further streamlining of clinical care due to the continuous backlog of delayed visits. In response, eligibility for virtual clinics was expanded most glaucoma phenotypes and more advanced disease. This pilot study evaluated the safety, efficacy, and patient experience of virtual clinics with expanded criteria.

Out of 8000 reviewed patient records, 25% fulfilled the expanded criteria for attendance at virtual clinics of which 27.5% were new appointments and 72.5% follow-up visits. After three visits at 6 month intervals, 25% of these patients were discharged, 32% remained in virtual clinics, and 42% were referred for face-to-face visit, the latter mainly due to need for gonioscopy, ineligibility for virtual clinics and unreliable diagnostic tests. Eleven percent were rebooked due to progression.

Online surveys were completed by 118 out of 193 invited patients (61% response rate), and the majority evaluated the service as either 'excellent' or 'satisfactory'. Over 70% of patients clearly understood that they would not see a doctor during the visit and preferred virtual visits in future if given a choice.

Over 70% of patients preferred virtual visits in future if given a choice

The authors reported no evidence of quality issues in virtual clinics model and emphasized more efficient use of specialist time enabling rapid decision making and reduced mismatch between capacity and demand.

The first seeds for virtual glaucoma care with favorable outcomes were sown almost three decades ago in several countries, including the UK,1-4 and was recently reviewed by Simons et al.5 An economic evaluation and randomized-controlled trial of virtual care reported reduced costs with no difference in quality of care.6

In asynchronous clinical decision making models (or virtual care/shared care/teleophthalmology), the ophthalmologist 'sees' the patient through the test results and designs the care protocol. For patients, not needing to see the doctor represents good news. Simultaneously the model ensures that unstable and high risk cases will have prompt access to face-to-face consultation.7


  1. Hume J, Abbott F. Setting up a shared care glaucoma clinic. Nurs Stand. 1995 Dec 6-12;10(11):34-6. doi: 10.7748/ns.10.11.34.s38. PMID: 8546927.
  2. Oster J, Culham LE, Daniel R. An extended role for the hospital optometrist. Ophthalmic Physiol Opt. 1999 Jul;19(4):351-6. doi: 10.1046/j.1475- 1313.1999.00427.x. PMID: 10645392.
  3. Tuulonen A, Ohinmaa T, Alanko HI, Hyytinen P, Juutinen A, Toppinen E. The application of teleophthalmology in examining patients with glaucoma: a pilot study. J Glaucoma. 1999 Dec;8(6):367-73. PMID: 10604295.
  4. Rathod D, Win T, Pickering S, Austin M. Incorporation of a virtual assessment into a care pathway for initial glaucoma management: feasibility study. Clin Exp Ophthalmol. 2008 Aug;36(6):543-6. doi: 10.1111/j.1442-9071.2008.01831.x. PMID: 18954317.
  5. Simons AS, Vercauteren J, Barbosa-Breda J, Stalmans I. Shared Care and Virtual Clinics for Glaucoma in a Hospital Setting. J Clin Med. 2021:19;10(20):4785. doi: 10.3390/jcm10204785. PMID: 34682908; PMCID: PMC8538177.
  6. Holtzer-Goor KM, van Sprundel E, Lemij HG, Plochg T, Klazinga NS, Koopmanschap MA. Cost-effectiveness of monitoring glaucoma patients in shared care: an economic evaluation alongside a randomized controlled trial. BMC Health Serv Res 2010;10:312; PMID: 21083880
  7. Tuulonen A, Kataja M, Syvanen U, Miettunen S, Uusitalo H. Right services to right patients at right time in right setting in Tays Eye Centre. Acta Ophthalmol 2016 Nov;94(7):730-735. doi: 10.1111/aos.13168. Epub 2016 Jul 16. PMID: 27422769.

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