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An innovative ‘drivethrough’ clinic checks
Innovative assessments DURING COVID-19
An innovative ‘drive-through’ clinic in Ireland checks patients’ intraocular pressure. Priscilla Lynch reports
Adrive-through clinic in Ireland is being used to measure the IOP of glaucoma patients during the pandemic.
The emergence of COVID19 has wreaked havoc in almost every aspect of medical practice, but it has also created opportunities for innovation and different ways of doing things, including in the field of ophthalmology.
While initially used in a hasty effort to keep patients safe while maintaining essential care, more advanced telemedicine and low physical contact care has evolved to include new services that will likely continue after the pandemic has ended.
One such project is an innovative ‘drivethrough’ clinic set up by two hospitals in Dublin, Ireland, for patients with previously diagnosed glaucoma, where their intraocular pressure (IOP) is checked and assessed. HOW IT WORKS Glaucoma patients are invited for drivethrough testing based on clinical need, and once they arrive to the site at their scheduled appointment time, they remain seated in their cars while clinic staff, wearing PPE, undertake IOP testing using a handheld tonometer.
The patients are also asked four key questions; are they experiencing any problems with their sight; are they using their eye drops; have they started any new medications recently; and have they had any side-effects.
Patient results are recorded on handheld computer tablets and then reviewed by glaucoma specialists. Those with concerning results/raised IOP are invited for in-person review in the hospital, and then given corrective treatment if necessary. INSPIRATION Speaking to EuroTimes about the development of the service, project co-lead Dr Aoife Doyle, Consultant Ophthalmic Surgeon and Glaucoma Specialist, Royal Victoria Eye and Ear Hospital (RVEEH) Hospital, Dublin, explained that the RVEEH and the Mater Hospital, Dublin, were inspired by a similar service that was launched in Belfast during the first wave of the pandemic last year, which had received positive feedback.
Routine review waiting times for glaucoma patients had become unacceptably long in the two Dublin hospitals before the pandemic and then worsened during lockdown restrictions. Thus the creation of a drive-through service in Citywest, a large conference/ hotel site on the outskirts of Dublin, being operated by the national health service
during the pandemic, was seen as an innovative way to try to address the issue.
The two hospitals went through their glaucoma patient databases and identified about 2,000 hospital glaucoma patients who were overdue for review appointments: “We looked for people who had previously stable pressure measurements and were in the low-risk category of mild-to-moderate glaucoma, and ocular hypertension,” she explained.
Following careful review of these files, about 1,000 patients with mild-tomoderate glaucoma were deemed suitable to be invited to the drive-through clinic, which was launched last August.
NEW TECHNOLOGY Given that ophthalmology patient reviews depend heavily on in-person assessment using a range of devices in the clinic, this project was only really possible because of recent technological advancements, noted Dr Doyle.
“Part of the reason this project was possible was because of the existence of portable tonometers that give accurate IOP measurements, which is something that wasn’t available in the past. Goldmann applanation tonometry remains the gold standard for IP measurement, so portable tonometers are not in standard use in all clinics, but they have certainly increased in use over recent years, particularly for paediatric patients and those for whom mobility is a problem.
“They seem to be accurate in measuring a range of pressure from around 10-25mmHg, and a majority of our patients would be in that range, and even outside that, in the range that it becomes less accurate, it will overestimate, rather than underestimate pressure, so you won’t miss anything. So it is a good method of picking up glaucoma patients with high pressure and getting them back for urgent review, even if there is sometimes an overestimation of pressures in the very high range.”
The new portable tonometer devices do not need the use of a slit lamp or eye drops, and the patient doesn’t even have to get out of the car to be assessed. “So it was very appealing, during a time when community transmission rates of COVID19 were very high, and solved a lot of issues,” Dr Doyle told EuroTimes. AUDIT RESULTS In an audit of 195 RVEEH glaucoma patients whose IOP was assessed under the drive-through clinic, 85% were stable and no intervention was required.
The remaining 15% (29 patients) had IOP measurements that were significantly higher than their last assessment, so they were referred for a follow-up visit at the hospital’s specialist nurse-led clinic.
Of these 29 patients, 41% needed no change in treatment, 24% needed their eye drops changed/added, 10% (three patients) had laser treatment, one patient had glaucoma surgery (trabeculectomy) and one patient had cataract removal for angle closure glaucoma.
Since the drive-through clinic was launched last August, approximately 500 RVEEH glaucoma patients have attended appointments there. Patient feedback has been very positive, and it is seen as quick, convenient and safe, Dr Doyle said.
“It has been great, as all those patients [identified as needing follow-up] would have gotten worse and progressed and had further problems. In addition we didn’t have to bring a high proportion of patients seen back for early follow-up – that would have been pointless – so it was worthwhile.”
Initially the drive-through clinic operated a number of times per week but as numbers have reduced it now operates about once a fortnight. “Already that seems to be yielding a good result. So the model of running it at fixed intervals and maximising attendance seems to be a better approach, and we are being helped by the way that appointments for many of these patients have been considerably delayed as the pandemic has continued and Ireland went into a further lockdown at the start of the year so the uptake has improved.”
The project is funded to run until the
Dr Aoife Doyle
end of April, but Dr Doyle hopes that it can continue and be rolled out onsite in RVEEH itself, where it would be more convenient for staff managing bookings and local patients. In addition, she is hopeful the drive-through IOP model could be replicated in other ophthalmology units in Ireland, including the new emerging network of community-based public ophthalmic clinics.
INNOVATION Commenting on the project, leading Italian ophthalmologist and former ESCRS President Dr Roberto Bellucci said it was good example of innovative practice, and addresses the need for field control of glaucoma without relying on in-person ophthalmic visits during the pandemic.
“Rebound tonometers can be used by trained nurses or pharmacists, providing excellent care although with probably a high number of false positives.”
He said few if any such initiatives are currently implemented in Italy. “Italy has a huge number of ophthalmologists (>7,000) as compared with UK: patient access to the care is better, but not easy enough. However, there are campaigns to mitigate the difficulty of the patient to receive glaucoma checks. Commercial opticians usually have air puff tonometers. This was a good service although with false positives, but it was discontinued because of the COVID-19 crisis.”
Dr Bellucci said that many ophthalmologists, including himself, do not charge for simple tonometry and therapy check, to encourage patients to show-up. “However, this is not enough, and an initiative to legally empower pharmacists to measure IOP would be welcome.”
Aoife Doyle: aoife.doyle@rveeh.ie Roberto Bellucci: roberto.bellucci52@gmail.com
