Refractive Recovery and COVID-19

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What impact has COVID-19 had on your practice – and what did re-opening your practice look like?

Denise Visco: I work at a small (two-surgeon) practice. We are based in central Pennsylvania, USA, and we employ three supporting optometrists. We closed around March 16, but we were able to reopen on May 2. Although we are fully open at this point, our guidelines for seeing patients have definitely changed. Our goal was to try to get back up to 100 percent of the throughput we had prior to COVID-19, and we were able to reach that target around the end of June, but with very different processes in place.

Following the changing curve of COVID-19 cases and working out new safety guidelines has been a challenge for me as the main decision maker.

Maria Scott: It has been a very interesting time for my practice, and it has really made us much more innovative. Vision Innovation Partners in Maryland, USA, closed down its offices on March 16. We have 23 offices, 13 practices and employ around 70 ophthalmologists and optometrists. We started gradually reopening our practices around May 18, and since late June we have fully opened all of our centers.

Sheraz Daya: We were instructed to lock down on March 23, but we had a few transplants that we didn’t want to lose, so we continued surgery with full precautions, locked down on March 25, and saw only emergencies every week throughout the lockdown period. Retinal surgeons in our setting were still operating on retinal detachment patients, and dealt with a couple of vitreous hemorrhages, ensuring there were no holes and tears that would need attention later. We re-started on June 1, but we started very slowly to ensure we got used to the “new normal:” enhanced cleaning, making sure our staff understood the processes of checking patients’ temperature and getting specific questionnaires filled out, and so on. All this preparation made patients a little more vigilant, which can only be a good thing under current circumstances. It’s amazing how quickly you get up to speed – we are now ready to see all our patients back, and our schedules are back to normal volumes.

Ben LaHood: In New Zealand, we have done pretty well with containing the virus. We initially had a lockdown period for a month, when we weren’t doing anything except taking care of emergencies. Then we gradually moved from serious restrictions over a few weeks to having very vague guidelines about when it would be safe to return to refractive surgery and elective cataracts. And that’s why we got together as a group of ophthalmologists across the country; together, we decided that it was safe for us to carry on with procedures. We got back to practically 100 percent of elective cataract surgery and laser surgery.

Did you make use of telemedicine during the lockdown period, and are there any elements of it you’re keen to retain? 

Maria: In some locations, such as our Annapolis center, our retina surgeons continued to deal with emergencies and carry out injections – that was one area where telemedicine would obviously not work. Our oculoplastics specialist was easily able to switch to telemedicine, and other specialists used it a little in their practices. I used it for all the surgical patients I had already scheduled to make sure nothing had changed. For those patients, it was a wonderful way of making them feel like we were still connected.

In the US, you are required to have an eye exam within 90 days ahead of surgery, so the telemedicine visit served that purpose – we didn’t have to bring the patients in another day. We’re continuing to do telemedicine now: we have our optometrists rotating on a weekly basis using telemedicine. They’re doing a lot of triage, so the sub-conjunctival hemorrhage, conjunctivitis, and sty patients can be seen remotely. Our one-week post-op second eye visits are also being conducted through telemedicine.

Sheraz: We did indeed try telemedicine. In my experience, it took a lot of time trying to get our elderly patients to understand how to use it, so we got them to use our portal for uploads instead. We gave them clear instructions on how to take photographs, put them on their computer screen and measure the distance to check their vision. We quickly abandoned it. We didn’t have to see any emergencies as a result of telemedicine consultations. Usually in the triage process we knew which patients had to be seen in person and we just brought them into the office. They were, without fail, all true emergencies.

I think telemedicine works great for oculoplastics, but I’m not sure it’s a good solution for refractive surgery. And yet, colleagues around the world are talking about doing their consultations online! I don’t know how they can do that, without obtaining a diagnosis in person first. I find it very hard to be convincing and reassuring to a surgery candidate without important, solid data in front of you. I have also found that it takes longer to see a patient using telemedicine, so I didn’t think it was very efficient. Given my recent experience, I’d describe it as quirky and gimmicky.

Arthur Cummings: I’ve always been very optimistic about telemedicine, and have been keen to try it out based on the experience of colleagues of mine, notably the Zaldivars in South America. I have used a system that allows me to examine the eye on a slit lamp. We started using telemedicine mostly for emergencies. I have found that it was possible to build a rapport with a patient using telemedicine, which has been reassuring. Some of those patients came into the clinic afterwards, and we felt like we had met each other in person already.

When COVID-19 is no longer active, my colleagues and I want to look back and think we never played any part in spreading the virus – and that’s why we’re trying to make our clinic consultations as short as possible. Patients come in for their scans and for a refraction, and for the part of the examination that has to be done in person, but we have also introduced a process using telemedicine, where nurses or technicians go through an online form with the patient around four days before the visit. They check the patient’s preferences, hobbies, and they create a relationship that is important when the patient comes into the clinic in person. When they arrive, they’ve already thought about different options, so the conversation I have with them is much more focused. Before the lockdown, our conversion rate after the visit was around 55 percent; now, if a patient is suitable, they simply make a plan to go ahead with the surgery. They are less likely to shop around – once they’ve made up their mind about the procedure, they just want to get on with it.

What protective measures have you used to ensure staff and patient safety?

Maria: Keeping patients safe has been our priority from the very beginning of the pandemic. The safety of our staff has also been paramount: they all have families that they want and need to protect. There is also a financial aspect to it: if one of your surgeons or other specialists cannot work for eight or 10 weeks, it has serious financial implications. We’ve done most of the things that the AAO recommended. Everyone is given the option of wearing an N95 or a surgical mask, but we try to stress that technicians and doctors should wear N95s because of their close contact with patients. We developed our own slit lamp shields.

When I’m dressing for work, I look like I’m going into battle: I wear goggles, a surgical cap, scrubs, an ENVO N95 mask, and a surgical mask on top of that. I also have protective shields in front of my desk. As we don’t have any family members coming with patients, it feels much more intimate. Patients come in and very soon they’re ready to leave. My schedule is much more reasonable now; I’m happier and I cherish the fact that I can spend much more time with my cataract consults.

Sheraz: We wear N95 masks, patients are given a mask if they don’t come in wearing one. I think the mask is now a fashion accessory, so we have found that all patients come in with masks on. We don’t allow relatives in unless they come with elderly patients or they act as an interpreter. We schedule elderly and vulnerable patients earlier. We measure patients’ temperature; we have a COVID-19 checklist with a consent form. We physically distance within the clinic. One thing I have found difficult was wearing goggles, so I started using a pair of clear glasses to shield instead.

How have you managed to get through this period financially?

Sheraz: Half of our staff were furloughed, with the UK government paying 80 percent of their wages. The ones that stayed on were a skeleton crew. In this way, we cut down our salary bill, but that only saved us a small amount. We managed to get a capital break on the mortgages on our properties: we paid interest, but not capital. We also managed to defer equipment loans, to mixed reactions from our vendors. I think some of them genuinely wanted to help, but it wasn’t always easy to agree terms with them, so I basically told them I would pay the bills when I had cash coming in again, which is what is happening now. Thankfully, we have been able to keep all of our staff.

We have taken out an interest-free loan from the government, around £50,000 (~$65,000). I’m really worried about a second shutdown, and in anticipation of that I’m going to preserve as much cash as possible. Even if we’re profitable, we’re going to learn the lessons of being lean and mean, and will keep it that way for a long while to come. There won’t be any major capital expenditures – I’m not going to upgrade our equipment until we’re on an even keel for a good period of time.

Some patients are deferring their treatment as they are worried about COVID-19, and I completely understand that, but there are also those who are ready to undergo procedures now. I expect we are going to break even, but our profits will suffer.

Maria: We brought almost all of our staff back after the lockdown. I was pleasantly surprised with how the government handled the situation in the US, giving businesses with fewer than 500 employees loans and grants. We were not eligible because we have over 500 employees, but many of my ophthalmology friends who had slightly smaller practices managed to secure help. The payment we received from the Centers for Medicare & Medicaid Services was a wonderful surprise. American Express deferred their bills for two months, and almost all of our rentals and mortgages were deferred. It was great to see how everyone worked together in this crisis. However, I am worried about what is coming in the autumn; I don’t think this story is over, by any means.

Arthur: We have had very similar experience: we also deferred or extended loans and even tax bills, which has been great, but it does mean that at one point in the near future we’re in for a big hit.

I have noticed a demand for laser refractive surgery at the moment, and for refractive lens exchange or custom lens replacement. And that helps us quite a lot because these patients are self-payers, so we don’t have to wait for the insurer to pay, and they are also mostly younger and less fearful of COVID-19. And it has resulted in us bringing younger patients in quicker; patients aged 75+ are very happy to wait another three months. Not only is it safer, but it has also helped us with the cash flow.

Maria: I was concerned that the economy wasn’t going to be doing as well and patients would go for basic options, but it seems that patients have reassessed their financial priorities and have decided that their eyesight is important for their lifestyle, so many of them are actually choosing multifocals. Some have money available that would otherwise be spent on holidays, for example.

In terms of spending, we have a big reception and waiting room area, which is not being used right now, so we might think about changing it in six months or so, to make better use of the space.

Sheraz: One of my recent patients, when asked why they wanted surgery now, replied, “Life is short.” This pandemic is certainly giving people a new perspective: they want to enjoy their lives because you never know what’s around the corner. For our patients, this might make the decision about surgery a lot easier.

Arthur: Yes, there’s an element of “Seize the day” in patients’ decisions now. And, as Maria said, there’s not so much for people to spend their disposable income on (assuming they have any).

Denise: We have been very diligent about planning for when COVID-19 strikes again, so that we can continue to see patients. Having those plans in place, making sure that the surgery center doesn’t run out of PPE, and putting systems in place for potential employee sickness are how we have tried to protect ourselves. Barring the government telling us that we can’t perform elective procedures or routine examinations again, we should be able to sustain our practice.

We have used the post-lockdown period as an opportunity to differentiate ourselves from our competition. As our patients are younger, and have busy schedules, we bring them in for a slit lamp exam with an optometrist when it suits them, and record it for the surgeon, who can then arrange a telehealth visit with the patient at a suitable time – sometimes in the evening – to go over appropriate laser vision correction options. Patients really appreciate this “higher level of service” – we make it easier for them to fit the surgery into their busy lifestyles, with extras, such as prescriptions delivered to their house, for example. And it has made a difference; we have seen numbers of LASIK, SMILE and PRK up this year compared with the same time last year.

Ben: Everyone at our practice decided to take a pay cut so that we could retain staff. We have seen a big demand for surgery, but I can’t tell whether it will continue, so we have been making sure we communicate clearly that it is safe for patients to come and see us – we use social media, clips on Facebook, and let people know we are using the correct PPE and have updated our procedures. We will have to focus more on encouraging the Chinese community to come back; they are usually a big part of my practice, but the numbers of those patients have dropped significantly.

How will the world look in a year’s time?

Maria: COVID-19 will be with us for longer, and with the upcoming election in the US, there is a lot of uncertainty. By 2021, we will be living a much more normal life, but it will be different from what we have been used to. I can’t see another longer lockdown happening in the USA.

Sheraz: Human beings are amazingly resilient. In the last two centuries there have been major wars, the GDP has shrunk considerably, and we had the 1918 pandemic. But people fight back and change things for the better. Having said that, with a huge loss of GDP, many people are going to lose their jobs and livelihoods. We all live in one community and we are all part of one society, so we need to work together and help each other. Our businesses might sometimes take a hit, but it’s OK to have less money in your pocket – the most important thing is to avoid civil unrest and suffering. We all need to be in this together.

Arthur: Ophthalmologists have always looked forward to the year 2020 for all the obvious reasons, and it’s been a damp squib so far. Nevertheless, 2020 has made us see the world differently. I think we’ll look back and say that it was the year we started seeing things for what they really are. I’ve always known I had an amazing, independent team, but they have never worked the way they are now. You’re right, Sheraz, there’s a strong, palpable energy and vigor at work.

Denise: I am an optimist, and I do feel that healthcare in general, and ophthalmology in particular, will come out stronger, as people focus more on their well-being. Not having your glasses fog up or being able to see first thing in the morning may sound like a trivial thing, but for us, who fix these issues for a living, it’s definitely not trivial, and it won’t be for our patients. I believe what we give to our patients will have greater value than before COVID-19.

Ben: New Zealand is a country that does team up together well – we talk a lot about being a team of 5 million people. We are getting through this, but my concern is that, with a lot of financial boosts (like six-month mortgage holidays), we have simply shifted all our worries into the future. We rely a lot on overseas travel, imports and exports, and I think that once we get through this period of widespread support, there will be a downturn that will affect the whole economy, including ophthalmology. Nevertheless, I believe that the team mentality will get us through this and next year.

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