Using Telemedicine to Prevent Blindness in an At-risk Rural Alabama Population
Phase: NA
Conditions: Glaucoma, Diabetic Retinopathy, Refractive Errors, Cataract, Behavior, Health
Sponsor: University of Alabama at Birmingham

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
1 
 
 
 
 
Department of Ophthalmology & Visual Sciences 
 
July 7, 2025 
Manual of Procedures 
 
Title of Project:  Alabama Screening and Intervention for Glaucoma and Eye 
Health through Telemedicine (AL-SIGHT) 
Project dates: 9/30/2019 – 9/29/2024 
 
Funding Agency: Centers for Disease Control and Prevention (1U01DP006441) 
Date of this Document: June 18, 2025 
Principal Investigators: 
9/30/2019 – 4/30/2023: Lindsay A. Rhodes MD (contact PI), Christopher A. 
Girkin MD (PI) 
5/1/2023 – 9/29/2024: Christopher A. Girkin MD (contact PI) 
9/30/2024 – 7/1/2025: Cynthia Owsley PhD (contact PI) 
 
Investigative Team: 
Lindsay A. Rhodes MD, Christopher A. Girkin MD, Cynthia Owsley PhD, Gerald 
McGwin Jr. PhD, Massimo Fazio PhD, Irfan M. Asif MD, Shilpa Register OD, Van 
Thi Ha Nghiem PhD, Ellen K. Antwi-Adjel OD, Thomas Swain PhD  
 
Clinical Research Staa Resources: 
Angela McCombs BS (pre-award), Dylan McDonald MBA and Jennifer America 
MBM (post-award), Karen Searcey MSPH (regulatory), Mark Clark M.Eng 
(imaging manager), Liyan Gao PhD (Database designer/manager), Mitzi Swift 
BS, COT and Tara Sloan COT (clinical coordinators) 
 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
2 
Table of Contents 
 
 
 
 
 
 
 
 
 
 
 
 
Page # 
 
1.  Aims of the Study  
 
 
 
 
 
 
 
 
   3 
 
2.  Background 
 
 
 
 
 
 
 
 
 
   4 
 
3.  Protocol 
 
 
 
 
 
 
 
 
 
 
   9 
 
4.  Statistical Analysis Plan  
 
 
 
 
 
 
 
 13 
 
5.  References 
 
 
 
 
 
 
 
 
 
 14 
 
6.  Data Collection Forms 
 
 
 
 
 
 
 
 
  20 
 
 
 
 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
3 
 
1. Aims of the Study 
 
Aim 1: Implement and evaluate a remote optic nerve assessment (RONA) protocol using 
telemedicine to identify glaucoma-associated disease in at-risk rural 
patients using portable multimodal structural and functional assessment of the optic 
nerve and retina. Also assess for diabetic retinopathy, cataract, visual acuity impairment, 
and refractive error. 
 
Aim 2: Identify and evaluate remediation strategies for the barriers to patient adherence 
with referral and follow-up appointments by comparing the eRectiveness of ﬁnancial 
incentives along with a validated patient education program versus a validated patient 
education program alone.  
 
Aim 3: Investigate the cost-eRectiveness of the telemedicine program in diagnosing 
glaucoma using RONA versus usual in-person care from a glaucoma specialist.  

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
4 
2.  Background 
 
Prioritizing Vision Health. Vision health is an important public health concern aRecting 
Americans of all ages. The 2016 report from the National Academies of Sciences, 
Engineering, and Medicine (NASEM) elevated the importance of a population health action 
framework that would transform “vision impairments from common to rare and eliminate 
correctable and avoidable vision impairments in the U.S. by 2030”.1 The report also called 
on the Centers for Disease Control and Prevention (CDC) to develop a research agenda to 
provide evidence on eRective policies, practices, and interventions that could delay the 
onset and progression of eye diseases and “achieve eye and vision health equity by 
improving care in underserved populations”.2 Improving the “visual health of the nation 
through prevention, early detection, treatment, and rehabilitation” is also a Healthy People 
2020 goal.3  Speciﬁcally, this research plan focuses on a novel telemedicine-based care 
delivery model for the detection and management of the eye diseases of glaucoma, 
primarily, as well as other eye diseases such as diabetic retinopathy (DR). The public health 
challenge is that if eye conditions such as glaucoma and DR had been detected early in the 
disease course, vision impairment would be preventable, and sometimes reversible, with 
currently available ophthalmic treatments.  
 
Epidemiology of Glaucoma. Glaucoma is one of the most common eye diseases of aging 
and is the leading cause of irreversible vision loss and blindness in older African 
Americans. Primary open angle glaucoma (POAG), the most common form of glaucoma, is 
a chronic progressive optic neuropathy traditionally characterized by changes in the optic 
disk, thinning of the retinal nerve ﬁber layer, and gradual loss of vision, with both peripheral 
vision and central vision aRected depending on disease severity. The prevalence of POAG 
increases with age, aRecting more than 1.8% of the population over 40 but increasing to 
23.2% among African Americans and 9.4% among non-Hispanic whites over the age of 75.4 
With the rapid growth in older populations, the number of POAG cases will increase 250% 
by 2050, directly aRecting over 7 million lives.5 These numbers are speciﬁcally for POAG 
and do not include those who are monitored and treated for elevated intraocular pressure 
or for glaucoma suspect status, which along with POAG can all be considered glaucoma 
associated diseases (GAD). While the number of patients with glaucoma will nearly double 
over the next 20 years, the number of US ophthalmologists is expected to grow only 
0.67%.4,5 The at-risk population for glaucoma in the U.S. is large, with older age as the 
primary risk factor as well as African Americans or Hispanics ≥ 40 years old, Asians, non-
Hispanic whites ≥ 50 years old, older persons with diabetes, and those with a family history 
of glaucoma. POAG is at least 4-5 times higher in African Americans, progresses more 
rapidly and appears about 10 years earlier as compared to those of European descent.6,7 
Fortunately, vision loss from glaucoma can be prevented by early detection, consistent 
follow-up, and control of intraocular pressure with medication or surgery. 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
5 
Epidemiology of Diabetic Retinopathy. Diabetes, and its ocular complications, is the 
leading cause of new cases of blindness in adults age 20-74 years in the US.8,9  African 
Americans are 2 times more likely to have DR than whites.10 In 2005-2008, 4.2 million 
(28.5%) Americans with diabetes ≥ age 40 had DR and of these, 655,000 (4.4%) had 
advanced DR that often leads to severe vision loss.11 The number of people with DR is 
expected to increase more than 3-fold by 2050, creating an immense, costly public health 
problem.9,12-14 Despite the risk of vision loss, only 50-60% of people with diabetes follow the 
recommendation to receive an annual dilated eye exam and this is even less in low-income 
and minority populations.15-17  Successful management of DR includes early diagnosis, tight 
glycemic and blood pressure control, and medical or surgical treatment to prevent vision 
loss.18-20 
 
Epidemiology of Cataract and Refractive Error. Cataracts are a major cause of 
preventable visual impairment and blindness, especially in African Americans, with over 24 
million people in the US having cataracts.10 A major risk factor for cataracts is aging and 
thus there is an expected 50% increase in cataracts by 2030.21 Additionally, studies have 
shown that African Americans have a reduced likelihood for curative cataract surgery, 
highlighting possible racial disparities in access to care for a reversible cause of visual 
impairment.22,23 Refractive error is another major cause of preventable visual impairment in 
the US. Over 48 million people over age 40 in the US have refractive error, with the majority 
having myopia. Uncorrected refractive error has also been found to be associated with 
racial disparities.24  
 
Personal Burden of Eye Disease. The personal burden of eye disease and its 
accompanying visual impairment is undisputed and widely documented. Adults with 
glaucoma experience reductions in health-related quality of life and mobility problems 
including ambulatory and driving diRiculties and limitations in physical activity.25-41 Persons 
with vision impairment, regardless of etiology, are at increased risk for depression, social 
disengagement, employment challenges, and problems accessing health care.40,42-45 
Several studies have demonstrated an association between vision impairment in adults 
and increased mortality risk, including studies focused on persons with glaucoma, 
cataract, and refractive error.46-52    Thus, interventions to improve early detection, eRective 
follow-up and implementation of evidence-based treatments for glaucoma, and patients’ 
adherence to medication plans will improve the health and well-being of persons with this 
condition and at-risk for the condition. 
 
Economic Burden of Eye Disease. The economic burden of eye disease in the U.S. is 
staggering. Analyses commissioned by the Centers for Disease Control and Prevention and 
Prevent Blindness America estimate the annual cost of adult vision problems in the U.S. at 
about $139 billion.53 In Alabama, the cost of vision problems is $2.2 billion.53 This includes 
U.S. economic factors such as direct medical costs, other direct costs (e.g., nursing home 
care stemming from vision impairment), and productivity losses (i.e., lower wages for 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
6 
visually impaired), as well as the ﬁnancial burden incurred by the individual, caregivers, 
and other healthcare payers. The direct medical costs of glaucoma are $5.8 billion/year, 
which does not include indirect costs such as incremental nursing home placements and 
productivity losses.53 For people aged 40- 64 years, the annual medical costs of glaucoma 
are $1490/person and for those aged ≥ 65 years, they are $2580/person.53 The annual 
medical costs of blindness and low vision per person from all causes, including glaucoma, 
are $5870 and $10,020 for people aged 40-64 years and ≥ 65 years, respectively.53 Cost-
eRective beneﬁts to quality of life have been reported for early detection and treatment of 
eye conditions such as glaucoma.54,55  Given projected Medicare shortfalls and potential 
reductions in Medicaid coverage, developing high quality and eRicient means to provide 
care for these individuals will become increasingly important. 
 
Barriers to Eye Care. Inadequate access to eye care delays diagnosis and increases the 
personal and economic burdens of eye disease and visual disability.56 Problems accessing 
eye care are the most commonly cited barrier to care by African Americans in Alabama and 
elsewhere.57-59 Older African Americans are less likely to receive routine comprehensive 
eye care, when damaging eye conditions could be detected and treated early, and less 
likely to adhere to prescribed glaucoma therapies, thus contributing to higher rates of eye 
disease.10,60-63 The lower rate of receiving routine eye care may be contributing to higher 
rates of disability from eye disease. Factors underlying lower utilization include inadequate 
knowledge of basic symptoms, risk factors and available treatments; reduced ﬁnancial 
resources; limited transportation; low trust in health care providers; and high cost.57,64,65 
Ophthalmologists rarely practice in rural areas where African Americans represent the 
majority of the population in Alabama.66 This produces a problem accessing 
ophthalmological care, especially subspecialist care.  
 
Alabama’s Black Belt Region, named for its rich black soil, is a rural area with one of the 
highest poverty rates in the US. The Birmingham News has characterized it as America’s 
Third World.67 It has one of the highest concentrations of African American residents of any 
region of the country, representing over 50% of the population. In addition to having 
widespread poverty, the region is characterized by inadequate education, transportation, 
community resources, and a shortage of healthcare providers including a shortage of 
ophthalmologists and optometrists.66  
 
To summarize, glaucoma is a blinding eye disease and a leading cause of irreversible vision 
loss in Americans, and THE leading cause in African Americans. In many rural counties in 
Alabama and the rest of the South, the majority of the population is African American. 
African Americans are less likely to receive routine, dilated comprehensive eye care that 
would facilitate early detection and thus prognosis. The number of cases of glaucoma and 
DR are expected to increase in the US. The personal burden of glaucoma, DR, cataract, 
refractive error, and vision impairment is heavy, with numerous negative implications for 
quality of life, and the economic burden is dramatically large. Ophthalmologists 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
7 
specializing in glaucoma and retina are centered in urban areas, particularly in and around 
academic medical centers. Thus, all the factors we have discussed above -- the shortage of 
ophthalmologists in general but especially in communities with high concentrations of 
African Americans, the rising cost of care, and rapid growth in glaucoma prevalence in the 
population -- clearly necessitates an alternative model of care for these individuals. 
 
Given the barriers to implementation of population-based screening for glaucoma, 
telemedicine is a potential strategy to improve disease detection and management as well 
as to improve eRectiveness, access, and adherence with routine eye care. Telemedicine 
refers to the electronic communication of medical information from one site to another to 
improve a patient’s clinical health status.68 It has already been utilized in many healthcare 
ﬁelds and can improve health outcomes, increase accessibility to specialty care, and 
increase patient satisfaction.68,69 By utilizing current technologies, telemedicine transmits 
patient data from a primary care clinic to another remote site for review by specialist 
physicians and thus, the standards of specialty care are more accessible to patients who 
live where no specialists practice. Telemedicine is well suited for the detection and 
management of certain eye conditions since there have been great strides made in the 
development of non-invasive ocular imaging devices that provide high levels of diagnostic 
reliability, ease of training of testing personnel, and electronically transmissible results. 
Telemedicine has been implemented in some areas of eye care but the vast majority of the 
literature on telemedicine for the chronic eye conditions of adulthood is focused on DR 
screening. Acceptance of telemedicine for DR using digital fundus photography has 
increased steadily around the world over the years stemming from its proven eRicacy, cost-
eRectiveness, and ability to reach underserved populations.70-72  
 
Applying Previous Experience in a New Way. This project focuses on the development 
and implementation of a community-based detection model for the two most common 
vision-threatening eye diseases in the African American population, POAG and DR. This will 
be achieved through a novel telemedicine program using RONA, based on integrated and 
collaborative partnerships, to improve both the quality of and access to eye care. The 
program will use advanced eye imaging technology to remotely assist in the detection and 
management of POAG, DR, cataract, and refractive error in a predominantly African 
American community receiving primary care through FQHC’s in rural counties of Alabama, 
where African Americans represent 56% of the population.73 Many of these rural counties 
are in Alabama’s Black Belt Region that was described in detail above. Compared to many 
other states, Alabamians, particularly African Americans, have a disproportionately high 
prevalence of many risk factors for POAG and DR. Alabama has a higher prevalence of 
diabetes than any other state (~13%), and African American Alabamians have a diabetes 
mortality rate 2.5 times greater than white Alabamians.74 The relative lack of specialists in 
communities with high concentrations of African Americans, combined with the rapid 
growth in glaucoma and diabetes prevalence, clearly necessitates an innovative and 
community-based approach to eye care. 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
8 
 
Achieving high levels of adherence to recommended health interventions has long been a 
challenge, particularly in rural, underserved populations. One method to try to increase 
adherence levels has been through ﬁnancial incentives. Previous research in rural 
populations with improving adherence to preventive services such as mammography and 
inﬂuenza vaccination has shown that ﬁnancial incentives are the only method to increase 
adherence compared to other behavioral interventions.75 In addition to showing 
eRectiveness of ﬁnancial incentives, there are ethical considerations as to the 
appropriateness of incentivizing health behaviors through ﬁnancial means. Shea et al. 
found that patients were willing to engage in incentive programs and had a positive 
experience without impact on the relationship with their physician.76 In relation to eye care, 
Tan et al. found improved adherence to tertiary eye care services after community-based 
screenings in low socio-economic areas with the addition of an incentive care scheme.77 
That study provided a one-time transportation allowance to the appointment and a subsidy 
for the ﬁrst tertiary eye care consultation.77 In our proposed study, in addition to providing 
the eye health education program, ﬁnancial incentives will also be used in the study sites in 
order to encourage patient adherence to referral and follow-up appointments.   
 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
9 
2.  Protocol 
 
Source Population.  This consisted of patients seeking healthcare at three FQHCs in north 
central Alabama. The three FQHCs are part of the Cahaba Medical Care Foundation, an 
Alabama-based FQHC. They care for a population of approximately 16,000 patients per 
year, including 58% who are African American, 38% White, and < 3% Hispanic. Among the 
active patients in these FQHCs, health insurance status is 25% Medicaid, 30% Medicare, 
25% private insurance, and 20% uninsured. The study clinics are in rural Alabama towns: 
Centreville (Bibb County), Maplesville (Chilton County), and Marion (Perry County). This 
region of Alabama borders or is part of the region known as the Black Belt named for its rich 
black soil that supported cotton agriculture. In the 19th century, the agricultural workers 
were enslaved African Americans. The Black Belt consists of 9 of 10 of the poorest counties 
in the state. Poverty is directly link to health disparities in the Black Belt.78 Today this 
region’s population is over 50% African American. 
 
Inclusion criteria.  Patients presenting at these clinics were eligible to participate if they 
had one or more risk factors for GAD79 and volunteered to participate: (1) African American 
or His-panic ≥40 years of age; (2) White ≥50 years of age; (3) anyone ≥18 years of age with 
diabetes, (4) anyone ≥18 years of age with a GAD; and (5) anyone ≥18 years of age with a 
family history of glaucoma. All participants spoke and understood English. 
 
Exclusion criterion: If patients did not complete written informed consent to participate, 
they did not participate. 
 
Study Design. This study had two arms. The protocol, as described below, was identical in 
both arms, except for the following.  One arm consisted of participants not receiving any 
ﬁnancial incentive for attending recommended follow-up care with an optometrist or 
ophthalmologist based on positive eye screening results. The other arm had a ﬁnancial 
incentive, that is, participants recommended to attend a follow-up care exam with an 
optometrist or ophthalmologist received $50 for attending the appointment. In the second 
arm, we conﬁrmed with the eye care provider through the optometrist’s or 
ophthalmologist’s electronic medical records (EMR) whether the participant attended the 
follow-up appointment. We considered randomizing patients to each of the two arms. We 
decided not to use this approach because we were concerned that patients may talk 
among themselves (they live in small rural communities) about some receiving a ﬁnancial 
incentive to attend recommended follow-up visits versus others not receiving a ﬁnancial 
incentive. This was viewed as causing a potential conﬂict for patients in terms of their 
participating in the study and viewed as potentially unfair by patients.  Thus, our approach 
was to ﬁrst enroll half of the total number of patients in the non-ﬁnancial incentive arm, 
and then when that was complete, to enroll the second half of the total number of patients 
in the ﬁnancial arm. The goal was to enroll 500 patients in each arm.  
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
10 
Protocol Measurements.  These are each described below. All were completed in a single 
visit to the FQHC. All eye and visual function measurements were performed on each eye 
separately. The clinical coordinators (certiﬁed ophthalmic technicians) collected all data 
including questionnaires. 
 
Demographic review.  Questionnaires obtained information on birthdate, gender, race, 
ethnicity, marital status, medical insurance status, transportation availability, education 
level, employment status, whether they received an eye examination in the past two years, 
reasons for not seeking an eye examination in the past two years, and contact information 
(address, phone number). 
 
Self-reported clinical characteristics. Questionnaires obtained information on the 
following: smoking status, family history of glaucoma or blindness, and ocular history of 
major chronic eye diseases or conditions. Family history of glaucoma was considered 
positive if a participant reported a glaucoma diagnosis for a ﬁrst degree relative (parent, 
sibling, child). 
 
Ocular screening. All measurements were completed under undilated conditions, as 
follows.  (1)  Distance visual acuity was assessed using a Snellen chart presented at 20 feet 
while participants wore whatever correction (if any) they were habitually wearing for 
distance. (2) Autorefraction was carried out with the QuickSee (PlenOptika Inc) or 
Retinomax (Nikon). (3) Intraocular pressure (IOP) was measured with the iCare portable 
rebound tonometer (iCare USA). A second measurement was taken if the IOP was > 21 mm 
Hg. If these 2 IOPs diRered by more than 2 mm Hg, a third measurement was taken. If IOP 
was measured twice, the mean value was used as the IOP; if it was measured 3 times, the 
middle value was used. Participants with IOP ≥30 mm Hg were referred to an optometrist or 
ophthalmologist in our fast-track protocol: IOP > 30 mm Hg within 2 weeks; IOP > 35 mm 
Hg, within 1 week; and IOP > 40 mm Hg, an urgent referral within 1 day. (4) Visual ﬁeld was 
assessed using three methods: the Humphrey Field Analyzer 3 (HFA3) using the Swedish 
Interactive Threshold Algorithm Fast screening strategy (Carl Zeiss Meditec), the Melbourne 
Rapid Fields, a tablet-based perimetry test (M&S Technologies), and the Alleye test 
(Oculocare Medical). 
 
Retinal imaging.  Spectral domain optical coherence tomography (SD- OCT) was 
performed using the Maestro2 (Topcon Medical Systems), measuring the thickness of the 
retinal nerve ﬁber layer of the optic nerve head and of the macula by a single wideﬁeld OCT 
scan measuring 12 ×9 mm (512 ×128 pixels). This encompassed both the macula and disc. 
The Maestro2 also provided high-resolution fundus photographs encompassing both the 
optic nerve and macula.  
 
Telemedicine. All the above ocular screening data and retinal imaging, as well as the 
medical and ocular history and demographics (age, gender, race, ethnicity) were 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
11 
electronically transferred to a remotely located glaucoma-fellowship-trained 
ophthalmologist for reading and interpretation. With respect to visual ﬁeld data, only HFA3 
data were transferred since the other two ﬁeld tests are not routinely used in standard of 
care in glaucoma assessments. The ophthalmologist made the following diagnostic 
judgments based on the screening in terms of the presence of the following conditions: 
glaucoma, glaucoma suspect, ocular hypertension, diabetic retinopathy, cataract, 
refractive error, or any other ocular conditions identiﬁed through the above screening data. 
 
Diagnoses for GAD conditions are as follows. Ocular hypertension is deﬁned as no 
glaucomatous appearing disc changes (described below), a normal visual ﬁeld (described 
below), and statistically elevated IOP ≥23 mm Hg. Glaucoma suspect is deﬁned as the 
presence of glaucomatous-appearing disc changes (de- scribed below), normal visual ﬁeld 
(described below), and statistically normal IOP < 23 mm Hg. Glaucoma refers to the 
presence of glaucomatous appearing disc changes (de- scribed below) and an abnormal 
visual ﬁeld (described be- low). A glaucomatous appearing optic disk is deﬁned as 
evidence of excavation, neuroretinal rim thinning or notching, localized or diRuse retinal 
nerve ﬁber layer (RNFL) defect, or a between-eye asymmetry of the vertical cup disc ratio > 
0.2. A glaucomatous visual ﬁeld defect is deﬁned as a reliable SAP Humphrey 24-2 ﬁeld 
(deﬁned as < 33% false- positives results, false-negative results, and ﬁxation losses) that 
exhibits a pattern standard deviation outside of the 95% normal limits, or a glaucoma 
hemiﬁeld test outside of the 99% normal limits consistent with an RNFL defect pattern 
based on clinical review. A normal eye that meets none of these deﬁnitions of GAD is 
deﬁned as not having glaucomatous-appearing disc changes and having a normal visual 
ﬁeld and statistically normal IOP < 23 mm Hg (both described above). Diagnoses of DR 
were made based on the National Health Service Grading Classiﬁcation System.80 
 
Each participant, the FQHC primary care provider, and their eye care provider (if they had 
one) received the ﬁnal report about the ophthalmologist’s screening-based diagnoses.  
These were sent out electronically within 14 days of the participant’s screening visit date. 
The report contained diagnostic information on the conditions mentioned above plus visual 
acuity, IOP, recommended treatment, and whether a follow-up exam was recommended. 
 
Recommendations from the telemedicine ophthalmologist.  Participants whom the 
ophthalmologist clinically judged as normal were recommended to undergo an annual 
comprehensive eye examination on a routine basis. The following participants were 
recommended for a follow-up examination visit with an optometrist who was partnered 
with the FQHC (located in a separate oRice), or an ophthalmologist at the Glaucoma 
Service at UAB, the Lions Eye Clinic at UAB, or an ophthalmologist whose clinic was 
located in the FQHC geographic area: participants with 20/40 or worse visual acuity and/or 
with an IOP ≥23 mm Hg in either eye, as well as those with GAD (glaucoma, glaucoma 
suspect, or ocular hypertension), DR, and/or other ocular condition that the 
ophthalmologist viewed as needing to be examined in per- son. The FQHC staR scheduled 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
12 
the appointment and communicated the details to the participant. The study coordinator 
followed up with the clinic where participants were scheduled for the follow-up 
examination to determine whether they actually attended the appointment by contacting 
the eye clinic and getting conﬁrmation through the EMR. 
 
Vision-Speciﬁc Health-Related Quality of Life.  This was assessed using the National Eye 
Institute Visual Function Question – 9.81 
 
Satisfaction with the RONA screening.  Following the ocular screening, participants’ 
satisfaction with the telemedicine screening was evaluated by a questionnaire using Likert 
scales. Questions address satisfaction with the vision screening and the time that it took to 
complete it (very satisﬁed/satisﬁed/dissatisﬁed/very dissatisﬁed), as well as how 
convenient the venue was (very convenient/convenient/inconvenient/very inconvenient). 
Participants were also asked whether they would recommend the ocular screening to 
others, whether they could return to the same venue in 12 months for another screening, 
and whether they could make a follow-up visit to an optometrist or ophthalmologist if 
referred for a problem identiﬁed by the screening (very likely/somewhat likely/not very 
likely/not at all likely)  
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
13 
4. Statistical Analysis Plan 
 
Demographic, socioeconomic, medical, and ocular factors were compared across groups 
who did and did not receive incentives for obtaining follow-up care using unpaired t-tests 
for continuous data and using the Fisher’s exact test for categorical data. The proportion of 
individuals in each group who were recommended for a follow-up comprehensive eye 
exam and, among those individuals, the proportion who attended that exam was compared 
using chi-square tests. Given the demographic diRerences in the study groups, the impact 
of incentivization was evaluated using a subset of incentivized and non-incentivized 
patients matched on age, sex and race. The impact of COVID-19 on follow-up attendance 
was estimated by correlating the rate of COVID-19 deaths in Alabama obtained from the 
Alabama Department of Public Health and the average number of daily hospitalizations per 
month with the proportion of those attending follow-up referrals during each month of the 
study.  P-values ≤ 0.05 (two-sided) were considered statistically signiﬁcant.  
 
 
 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
14 
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Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
19 
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Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
20 
6.  Data Collection Forms 
 
Data collection forms are appended to this document. 
 
 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
21 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
22 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
23 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
24 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
25 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
26 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
27 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
28 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
29 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
30 
 

   
Source: Rhodes LA, Girkin CA, Owsley C. Manual of Procedures, Alabama Screening and Intervention for 
Glaucoma and Eye Health through Telemedicine (AL-SIGHT), Funded by Centers for Disease Control and 
Prevention (1U01DP006441), Department of Ophthalmology & Visual Sciences, University of Alabama at 
Birmingham, Heersink School of Medicine, 2024, Version 1.0. 
 
31