From Necessity Comes Invention

COVID-19 is a rapidly evolving situation – and our practices are having to evolve with it. Initially, when recommendations were first presented, we thought we’d have to reduce our clinical volume and maybe defer some appointments. Then the American Academy of Ophthalmology released a statement asking us to defer elective surgery all together to conserve personal protective equipment.

The only service still operating is glaucoma and retina. We are seeing patients with retinal detachments, proliferative diabetics, glaucoma patients who are uncontrolled and can’t be managed, patients with neovascular AMD or retinal vein occlusion where vision loss is pretty significant, but little beyond that. All other services have been shelved.

The Cleveland Clinic is a tertiary care referral center, which means we’re still operating pretty frequently as we receive patients from other ophthalmology offices that have had to close. In terms of retina, clinic volume is down, as is our surgical volume, but not by as much as I would have imagined – in part due to the nature of our practice, but also the nature of the providers in our region.

Unusual precautions

Any patient who is sent to us for surgery is triaged for COVID-19 symptoms – fever, cough, respiratory illness, fever, temperature or any kind of GI dysentery – and has their temperature taken before they enter the clinic. Unfortunately, Chinese literature has shown that one third of patients are asymptomatic, which is why we also offer masks. The proximity between ophthalmologist and patient is really quite intimate so risk of transmission is high. We invested in slit lamp guard shields when the pandemic started and we wear face masks, hats, and goggles in the clinic.

Of course, my concern is not only for my practice, but also for my family. My wife is an internist and has treated – and will continue to treat – patients with the virus. On top of that, we have three elderly people living with us – my parents and mother-in-law. We haven’t had any major issues so far, but I take precautions. I change my clothes before I come home, wash my hands multiple times a day and have hand sanitizer on me at all times.

Fortunately, our non-essential patients understand the limitations of what we can do right now, given our current status. They also are fearful of getting infected or infecting their loved ones, and are generally happy to defer surgery. Truth be told, it is called elective for a reason. Studies have shown that an epiretinal membrane can be peeled three months later without any significant detriment to vision. In fact, even in the anti-VEGF era, we know that deferring treatment for three months causes no significant detriment to visual acuity.

Virtual reality

With this in mind, we’ve focused our attention on retooling the practice and we now offer virtual appointments. These typically fall into two categories. The first is more of a routine check up to see if we could possibly defer the appointment for two to three months’ time; this is mostly for patients with intermediate AMD or patients with mild, moderate or severe PDR approaching their six-month check-up. During the video conversation, I ask the patient: how is your vision doing? Have you noticed any visual field changes? If everything looks okay, we defer the appointment.

The second category is follow-up cases, typically ones that have been referred to us. I’m able to see the patient’s electronic medical records – sent by my provider 50 miles away – review them and talk to the patient sensitively about what images have shown. I then discuss the surgical procedure in a preliminary fashion, with written consent to come later. The nice thing is that we’re able to have this discussion on the phone in a more private setting.

We typically use Amwell [telemedicine platform] for these appointments, but with the relaxation of professional guidelines, most patients prefer to use FaceTime or Google Duo. So far, everyone seems happy with this system. In fact, I was actually impressed at how receptive they have been – even our older patient population is willing to try and interact with us in a virtual manner. We don’t have a lot of tools available to us right now, but we’re looking to expand some of our capabilities in the future, including home OCT. 

Changing protocols

Times may be hard but they are also interesting for physicians, in that we are having to rethink the way we deliver care. In my mind, we’re going to be better physicians – and a better society – because of it. The pandemic has given us a unique opportunity to explore new technologies and evaluate patients in ways we once believed were not possible. This is our time to test the boundaries of medicine – so let’s be creative. Trial new ways of seeing your patients that aren’t totally virtual.

One of our pediatric providers is providing certain instructions as far as how pediatric patients might check their vision at home – a home chart for example – and testing them over the phone. These remote appointments could be applicable to other areas of the practice, too. Many of the complaints we receive at our ophthalmology office are not necessarily related to us at all. I get a lot of patients who come in with external post-operative issues, such as red eyes or irritation, which could easily be converted to virtual visits. I’ve seen 15–20 percent of my patients this way since the pandemic started. Two weeks ago, that number was essentially zero.

My only hope is we carry on with these practices once the pandemic subsides, as it is already proving to be an effective way of rapidly delivering care. Obviously, the issue is that there is no evidence base to support that yet, but I don’t know if there needs to be. The problem with much of Western medicine has been the need to test and retest things across large populations. While this is generally done for good reason, it is something that requires significant time, effort and money – things we just don’t have right now. A great deal of data might come from this pandemic that confirms we did really well with these virtual visits, with no patients suffering a significant visual detriment or loss as a result.

So where does that leave us? I am hopeful that while this is a trying time, it is also a time for us to be innovative in how we serve our patients. If anything, we’re going to sit back 10 or 15 years from now and be able to see what worked well, so that we can apply it to real clinical practice in the future. We will get through this pandemic – but only by doing something about it, not by sitting on the sidelines.