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MAY 13, 2020 -- Ophthalmologists in small practices and large clinics are trying to protect their patients and themselves from COVID-19 while keeping their practices afloat.
Alice C. Lorch, MD, MPH, chief quality officer of ophthalmology, Massachusetts Eye and Ear, Boston, told Medscape Medical News that much of what they do in ophthalmology is elective, so the numbers of patients have "dropped sharply."
Many of her colleagues are dealing with similar issues, although the severity likely differs by region and population size as workforces are affected differently. In New York and Boston, for example, "some of our physicians are actually being redeployed to help with other things, and so as a result our workforce is lower, and I think that's probably not the case in other cities," she explained.
She added, however, that things are shut down throughout the United States, and that determining how to open things back up without increasing cases again will be an important problem to address.
Business Outlook Uncertain
John D. Dugan, Jr, MD, an ophthalmologist and cataract surgeon in private practice at Eye Physicians in Voorhees, New Jersey, told Medscape Medical News he closed his practice to "essentially all patients in the middle of March upon the advice of state and local governments, and it was really hard to do," he said. "We are an eight-ophthalmologist practice, and four equity partners have deferred compensation during this crisis."
Dugan has 40 to 50 employees and had to furlough "a large number" of them, saying it is not possible "to pay them and survive as a practice with no money coming in." Some employees who have been "instrumental" in working with patients, such as rescheduling appointments, refilling medications, and reordering contact lenses, are still working.
Some subspecialties have been somewhat buffered from the COVID-19 fallout, Abdhish R. Bhavsar, MD, president and director of clinical research, Retina Center of Minnesota, told Medscape Medical News.
"I think general ophthalmology practices are being hit harder since many patients have elective care. In a retina surgeon's office such as ours, many of our patients require acute emergent or urgent care, so we are still seeing those patients," Bhavsar explained, who is also a spokesperson for the American Academy of Ophthalmology (AAO).
"We are surviving, and we are keeping almost all of our employees still employed. We are applying for multiple programs including the payroll protection program and some state emergency funding as well," Bhavsar said.
To find out how the pandemic is affecting ophthalmologists in private practice, AAO surveyed 2500 members from April 9-13, 2020. Of those, 400 (16%) replied.
Overall, AAO reported that 89% of respondents are applying for payroll protection through the Coronavirus Aid, Relief, and Economic Security (CARES) Act and other sources. Most predict that their practices will be "smaller, financially unhealthy, or both by the end of the year" without significant federal grants and loans.
Only 6% of respondents believed they would be back to pre-COVID levels for size, volume, and financial health.
Elective Visits Canceled, Volume Down
Ophthalmologists are limiting patients they see in clinic to those with urgent and emergent situations and are honing new skills to help patients using telehealth technologies.
At the University of Iowa in Iowa City, for example, they reduced the number of patients they see in the ophthalmology clinic in mid-March and are seeing about 15% of their normal clinic volume, said Keith D. Carter, MD, professor of ophthalmology & visual sciences, University of Iowa.
Practices focused on surgical procedures have been particularly hard hit, according to Julia A. Haller, MD, ophthalmologist-in-chief at Wills Eye Hospital, Philadelphia, Pennsylvania.
"With all the restrictions, we're now only seeing patients for urgent and emergent issues or doing surgical procedures that are urgent or emergent, and that means we're putting off a lot of people who need surgery. Now that we're some weeks into the pandemic, we've got a whole cadre of people who really need to be seen even though they don't have frank emergencies, but the longer they're put off the more they become emergencies," Haller explained.
This is a trend that is being seen across numerous medical specialties, Haller noted. In ophthalmology, safety and quality of life also suffer for patients with impaired vision, and vision loss can become permanent, she said.
Operating room volume is similarly very low due to deferred procedures at Massachusetts Eye and Ear, Lorch said, though they too are treating emergent conditions, such as ruptured globes and urgent retinal detachment. They also are still seeing patients at risk for vision loss, but screening patients for potential symptoms of COVID-19 prior to seeing them and again when they arrive for their visit.
"The New Survival Is Face Shields and Masks"
Ophthalmology practices are employing a number of strategies to prevent infection transmission among patients and staff.
"The new survival is face shields and masks," University of Iowa's Carter said. Patients and staff will also likely be wearing masks to reduce droplet exposure, he added. "Because of social distancing and the equipment, we will not be back to normal levels any time soon."
Carter described several approaches clinicians and staff can take to protect themselves and their patients. First, staff and patients should keep their faces and mouths covered. Staff should limit the amount of time they are in close proximity with patients; therefore, if questions and concerns need to be addressed, this should happen after the procedure or exam is completed, and the patient and clinician should back away from each other to have that conversation.
"We also know that the virus is in the tear film," he said, which could raise the infection risk for staff and other patients. Ophthalmologists should suspect COVID-19 in patients with eye redness or conjunctivitis, as these may be early signs of infection, he added.
Other ophthalmologists interviewed said they've made similar modifications. For example, several said they have their patients call from the car to check in or they do pre-visit check-ins by telephone. Patients are asked to put on a mask and sanitize their hands at the door — some also are given gloves — and many clinics have patients go directly to their treatment room, bypassing communal waiting areas.
For higher risk procedures, Lorch's team ups their personal protective equipment (PPE) use, with staff switching from standard face masks to N95 respirators. For surgeries, they use standard precautions for low-risk patients, adding additional PPE as appropriate for droplet precautions in higher-risk procedures and situations, she added.
Haller said that at her institution patients "go up in the elevators by ones and twos, there is an attendant right there at the elevator who is armed with disinfectant and is sponging down the buttons...and that goes all the way through into the areas where they're being seen. And we're streamlining all visits and we have special isolation exam rooms and operating rooms for people who are under suspicion for being positive or who are positive. And we're testing very aggressively."
Telehealth Also Has Advantages
"We wouldn't have ever said ophthalmology is the perfect field for telemedicine but we're all making it work now through innovation and ingenuity," Dugan told Medscape Medical News.
Although it may take some patients and healthcare providers time to get accustomed to telehealth technology, it can be very effective in certain ways. "There are a number of concerns you can address over the phone. You can check to make sure they're taking their medications; you can check on their visual function and overall health, and clear up medical details about their diagnoses," Haller explained. "Then, too, simple emotional support and reassurance can also go a long way with patients, especially if they have a disorder that can take a while to improve," she added.
Lorch said reimbursement for telemedicine services was more problematic in the past but this appears to be evolving. "We in our clinic are ramping up virtual visits, both by telephone but also by video, and we're making that an opportunity...to see our established patients, but also we've set up hotlines so that new patients [with urgent issues can talk with a provider face-to-face]," she explained.
Helping Patients Feel Confident Returning to Clinic
Another big challenge will be getting patients to once again feel confident visiting their doctor, Carter said, and this is likely to be part of the "new normal" as well.
"The only way to do that is to don equipment and have [clear] social distancing in setting up our waiting rooms, to show them that we're very serious about this," Carter said.
Haller says they are now looking at how to work with all of the patients who have been put off during this crisis; how to communicate with them, how to prioritize who gets appointments and surgery first, and how to do all of these things in such a way that observes social distancing, as well as other public health prevention and containment measures.
Testing is an integral part of ophthalmology and imaging testing may shift to remote locations so patients need not travel to large cities and hospital settings where infection risks may be higher. This would allow medications and treatment plans to be ordered remotely and allow patients to avoid infection exposure, Lorch said, adding that a year's worth of progress in this area has been made in just a few weeks, "which has been exciting."
In talking with his colleagues, Carter said that many in academic medical centers — especially those in hard-hit New York, Washington, and California that experienced surges earlier — warned them about what to expect, which enabled them to prepare early.
Carter believes the lower density in rural areas may be allowing them to adjust more easily; although their "numbers are not as staggering" now, he said there will likely be a surge there as well.
The AAO and Centers for Disease Control and Prevention have provided resources on COVID-19, and one of the most important things for ophthalmologists to remember is to keep abreast of recommendations and to be aware that there is still much that is unknown about this virus. "Things will get better when we have adequate testing of everybody involved," Carter said.
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