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Disclosures: No products or companies that would require financial disclosure are mentioned in this article.
March 23, 2020
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At Issue: How ophthalmologists are handling COVID-19

Source/Disclosures
Disclosures: No products or companies that would require financial disclosure are mentioned in this article.
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As the COVID-19 pandemic stretches across the country, physicians have had to modify schedules, evaluate patient needs and change the way their businesses are run.

The American Academy of Ophthalmology and the American Society of Retina Specialists have recommended ophthalmologists restrict seeing patients to urgent or emergency cases, as well as screening any patients coming into their offices for symptoms of the novel coronavirus.

Healio/OSN spoke with some of the leading ophthalmologists in the United States to see how they are dealing with the outbreak.

Laura M. Periman, MD
Healio/OSN Board Member
Seattle, Washington

Laura M. Periman

Our practices and our lives have changed dramatically from early to late March and continue to rapidly evolve. With the prime directive of “do no harm,” I canceled all elective procedures and nonurgent visits. I agree with the strongly worded March 18 letter from the AAO calling for postponement of all elective procedures and nonurgent visits. Doctors are concerned about the rate of spread, the high contagion factor and the high mortality rate in the vulnerable population. Additionally, we now know that infected patients do not always have a fever (thus, temperature screening is insufficient for protecting our other patients in the clinic), and we now know that healthy people well younger than age 70 years are vulnerable and dying (thus, age screening is insufficient). The rate of viral shedding and infection from asymptomatic individuals is much higher than previously estimated. While I appreciate the creativity behind the idea of repurposing plastic folders as makeshift slit lamp shields, this provides a false sense of security because newly published research indicates that the COVID-19 virus lives on plastic for 5 days and lingers in the air for hours.

Doctors are also concerned with conserving resources. Washington State Department of Health is calling for inventory of equipment in our ASCs in case we need to convert to makeshift critical care facilities. I have enormous respect for our Italian colleagues who have come together and leaned into the crushing workload of the hospitalized and critical care patients.

As the COVID-19 pandemic stretches across the country, physicians have had to modify schedules, evaluate patient needs and change the way their businesses are run.

I am glad to see we have some relief on telehealth and HIPAA requirements. This will help us continue nonurgent care. The AAO has posted excellent guidelines on how to implement and bill for telehealth. I am finding patients respect and appreciate the decision to postpone elective and nonurgent visits. I am also finding that patients very much appreciate my personal phone call rather than simple postponement of their nonurgent visits for an undetermined period of time.

These are unprecedented times, and we all need to shoulder into the workload of the COVID-19 response. While the massive yet necessary changes are indeed painful for our patients and our colleagues, it is also an opportunity to lead, pivot and reinvent how we serve our patients. With collegiality, innovation and persistence, I am optimistic that we can contain and defeat this viral foe that unites us.

Eric D. Donnenfeld, MD
OSN Cornea/External Disease Board Member
Long Island, New York

Eric D. Donnenfeld

The world of ophthalmology has changed dramatically over the past several weeks with the COVID-19 pandemic. We closed 80% of our offices Friday, March 13, and we are only doing emergency surgery. A couple of second eyes in patients with significant anisometropia had cataract surgery the following week, and that is the end of cataract surgery. Our OR is open only for emergent cases such as retina corneal perforations and glaucoma.

We have opened four regional emergent offices that are staffed by a skeleton crew of office staff, a retina doctor and a glaucoma doctor. We have a cornea person on call but not seeing routine cases. All of our offices are being cleaned several times a day, family members stay outside in their cars, and only the patient is allowed in the waiting or examining room. We have outfitted many of our slit lamps with homemade splashguards.

We are still following up with some postops from the last few weeks, but the busiest part of the practice is anti-VEGF retina injections. Our main OR does around 100 cases a day. March 19, there were two cases.

We have taken any physician older than the age of 68 years and are not allowing them to see patients for any reason. There are six people affected. We have about 100 ophthalmologists in the practice, and on any given day, only 10 are seeing patients. We have seven ODs in the practice, and they are not working at all.

Our biggest problem is we have had to close three offices because a staff member was exposed to someone at home with COVID-19 and we were forced to move to another office. The only offices that are open have retina capability.

We have had to furlough many of the staff. Partners are not taking a paycheck, and associates are continuing to be paid based on productivity, which is not a lot.

We are continuing health insurance for all.

Our management is doing an exceptional job, and they could write a book about how to respond to a crisis.

As a managing partner, I have an update twice a day with our management leadership, and we keep our lines of communication open with physicians and staff through frequent emails and personal calls when needed.

New York is exploding with new cases, and there is a sense of dread as hospitals are being overrun with new cases. Keeping the subways, theaters and schools open so long was in my opinion a bad decision that is now affecting the entire population.

We are taking draconian steps, but I believe they are necessary, and we are confident we will come out the other side stronger than ever, but there is a good deal of pain right now. Most importantly, none of our staff or physicians has tested positive yet.

In summary, this is a time of concern in ophthalmic practices and the key to our success is to limit exposure and continue our vigilant action plan to stay abreast of CDC and local department of health guidelines as they are released. My best to my colleagues is to stay home as much as you can with your family.

Steven Silverstein, MD
Kansas City, Missouri

Steven Silverstein

Had you asked me 1 week ago about life, health care and my practice in Kansas City, Missouri, I would have told you that it is business as usual. However, as each of you know, the unchartered circumstances are changing hourly. We have decided to remain open and accessible to patients. We will practice every manner of precaution and have given our staff the option of either maintaining proper hygiene or staying at home. If they choose to remain at home, they can use PTO or time off without pay, and their job will be secure.

In the end, we are in the health care business. I would not ask my patients nor my staff to face risk I am not prepared to accept for myself.

This is yet another, albeit more virulent, virus, but a virus just the same, and I am concerned about the precedent this will set for future, more virulent strains.

I wish each of you and your families good health and happiness.

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Marjan Farid, MD
OSN Cornea/External Disease Board Member
Irvine, California

Marjan Farid

There is a daily shift in the COVID-19 climate here at University of California, Irvine. The undergraduate campus has now shut down all face-to-face classes and has gone to an online system for an indefinite length of time. The university campus and UCI Medical Center are taking every precaution in terms of isolation of patients at risk. We are seeing more testing happening on site and the hospital is prepared for large numbers of COVID19 positive patients. UCI has closed to all non-urgent cases at this time.
There has been a mandate from the campus leadership that all business-related travel be held until further notice and a strong recommendation to stay home if there are any signs of fever or illness for any of the faculty or staff. The overall climate is one of strong vigilance and preparedness without panic and premature halting of services for patient care.

Uday Devgan, MD
Healio/OSN Section Editor
Los Angeles, California

Uday Devgan

Recently, California enacted a statewide stay-at-home order in an effort to limit the spread of COVID-19. This means canceling all elective ocular surgery as well as nonurgent clinic visits. My private practice, which specializes in just cataract and refractive surgery, is closed for now, and our surgery center is only doing the rare urgent case. At our large teaching hospital, Olive View-UCLA Medical Center, we have taken similar measures, and we are only seeing urgent or emergency patients and performing required emergency surgeries such as retinal detachment repair, ruptured globes and certain glaucoma cases.

This pandemic is likely going to be more severe than many are expecting, and we want to minimize the risks to our patient population, which is largely elderly. Initial statistics show about a 10% mortality rate in people older than age 70 years, such as our cataract surgery patients. There is no need to expose our patients to this potential risk when the cataract surgery can be delayed without consequences. Now, we must focus our attention on limiting the severity of COVID-19 transmission and trust our leaders and infectious disease specialists.

Terrence P. OBrien, MD
OSN Cornea/External Disease Board Member
Palm Beach Gardens, Florida

Terrence P. OBrien

The pandemic attributed to SARS-CoV-2, previously known as 2019-nCoV, is caused by a highly contagious enveloped, single-stranded RNA virus that is readily transmissible and can result in a severe respiratory disease known as COVID-19. More importantly, following the death of  a reportedly healthy ophthalmologist in China and subsequently four of his close medical colleagues, this current global pathogen represents a potentially lethal occupational hazard for ophthalmologists worldwide that necessitates heightened awareness, increased surveillance and strict precautions with adherence to general principles of infection control as well as specific guidelines from public health and ophthalmological organizations.

The current pandemic, now in the phase 4 acceleration interval, is also an infodemic that has affected every avenue of ophthalmic life in the United States as we know it, from Main Street to Wall Street. As ophthalmologists, we already know this story, albeit as a new chapter with a different leading character. Collectively, we can therefore be leaders on the front lines in avoidance of panic, while demonstrating proper practices protecting our patients, ourselves and the global community. Studies from large clinical series indicate that conjunctivitis is a rare clinical manifestation with COVID-19. However, in confirmed patients having conjunctivitis, SARS-CoV-2 has been recovered infrequently from conjunctival secretions, posing a unique potential route of ocular transmission. As eye care providers, we have long been aware of potential contamination of tears/ocular secretions with transmissible and highly contagious pathogens (eg, HIV, adenovirus, enterovirus 70, etc). Thus, universal precautions that should be programmed into our standard routine apply more than ever. Based on the much higher recovery of SARS-CoV-2 from nasopharyngeal samples in COVID-19 patients, the respiratory droplet route of transmission is considerably more likely. With routine ocular examination, we are in close proximity, and with direct ophthalmoscopy, literally “in the face” of our patient. Therefore, appropriate deployment of personal protection equipment (N95 masks, eye shields/goggles, gloves, gowns, slit lamp breath shields, etc) is essential to avoid contamination and propagation. Recovery of SARS-CoV-2 from stool samples also suggests a potential fecal-oral route of transmission. Preliminary data indicate that SARS-CoV-2 may survive on hard surfaces for a considerable period of time, thus presenting a contact risk for transmission in the environs of the ocular clinic. Fortunately, the virus seems susceptible to conventional alcohol- and bleach-based disinfectants already widely utilized in standard decontamination efforts.

Prevention of exposure altogether is preferred to containment after exposure. Ophthalmologists should cancel all but urgent or emergent patients in both the clinic and operating rooms. Utilize telehealth applications to interact electronically with non-urgent patients experiencing problems in order to provide instruction and reassurance. For any urgent or emergent patients that must remain on schedules, active screening to detect common symptoms such as fever, cough, runny nose, headache, malaise, as well as recent travel to hyperendemic high risk areas or on cruise ships via telephone, at an external “Checkpoint Charlie” outside the clinic/hospital facility and in pre-clinical screening areas should prevent entry of high risk patients. Of significant concern are reports of transmission from asymptomatic patients, making universal precautions essential and treating every patient as a potential carrier a priority.

Some current practical tips: Adjust schedules to eliminate all but urgent and emergency patients and space accordingly to avoid overlap and reduce congestion of waiting room areas. Limit accompanying individuals to none or one as absolutely necessary per patient. Reduce and remove all non-essential staff and employees from clinics and operating rooms. Maintain social distancing as much as possible while avoiding social isolation. Wash hands with soap and water before and after every single encounter and wear gloves as part of personal protective equipment (PPE). Apply alcohol-based hand sanitizer during ocular examinations as indicated. Use sterile cotton-tipped applicators to touch eyelids and avoid direct hand-to-eye contact. Wear goggles or eye shields as PPE.  Monitor staff and provider health as well as patients with universal screening at entry points. Have a low threshold for laboratory testing of any and all suspected individuals as capacity permits. Report any highly suspect patient contact to local infection control and regional public health agencies. For the moment, remain calm and practice prior proper planning to prevent propagation and provide personal and patient protection. - by Rebecca L. Forand and Robert Linnehan

 

References:

Alert: Important coronavirus updates for ophthalmologists. American Academy of Ophthalmology. www.aao.org/headline/alert-important-coronavirus-context. Updated March 22, 2020.

Coronavirus disease 2019 (COVID-19) situation summary. Centers for Disease Control and Prevention. www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fsummary.html. Updated March 21, 2020.

Reviglio VE, et al. Med Hypothesis Discov Innov Ophthalmol. 2020;9(2):71-73.

Disclosure: No products or companies that would require financial disclosure are mentioned in this article.