Biography: Singh is a staff surgeon at the Cole Eye Institute, Cleveland Clinic and Associate Professor of Ophthalmology at the Lerner College of Medicine in Cleveland Ohio. He also currently serves as the medical director of informatics at the Cleveland Clinic.
May 05, 2020
3 min read

BLOG: Going beyond the curve: Restarting eye practices following the COVID-19 pandemic

Biography: Singh is a staff surgeon at the Cole Eye Institute, Cleveland Clinic and Associate Professor of Ophthalmology at the Lerner College of Medicine in Cleveland Ohio. He also currently serves as the medical director of informatics at the Cleveland Clinic.
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Social distancing, reducing our clinical volume and canceling elective surgeries have led nationally and in Ohio to a significant flattening of our curve. Locally we are currently trending at a model of social distancing between 60% and 80% and have blunted the curve such that our health care organization can now get back to elective patients while not being overwhelmed with COVID-19 inpatients.

In particular, ophthalmologists were the hardest hit surgical specialty, experiencing a drop in 79% of clinic visits, according to a recent evaluation.

And we are about to embark on probably the greatest national experiment: What happens to the pandemic as we open our doors to our patients again? How do we start our practice knowing that potential flares of COVID-19 might exist in the future? With no vaccine in the near term, how do we best protect patients and caregivers? And are the changes we’ve experienced during this time temporary or here to stay? Here are some ways in which we will strategically open our doors and stay safe.

1. Virtual visits are here to stay. We will continue seeing patients virtually whenever possible, reducing their exposure to our health care organizations. We covered in a recent article how we retooled our providers and practice to accommodate telehealth appointments. We are experimenting now with hybrid visit types, involving limited contact expedited appointments within the office with a diagnostic device and then performing a virtual visit afterward. This has already shown promise in glaucoma and retina clinics, and now we see almost 30% of our eye patients virtually.

2. We will promote current remote eye options and encourage innovation for future devices. Many forget that we do have a remote device approved already for monitoring dry age-related macular degeneration. The ForeseeHome monitoring system (Notal Vision) can be fully integrated into EMR with the ability to order the test and see the results. The findings were supported by a randomized clinical trial that showed significant benefit. And we have many companies working on home OCT devices to detect activity in those with age-related macular degeneration, diabetic retinopathy and retinal vein occlusion. An additional benefit of these home OCT devices will be in how they streamline office workflow. For example, our practice on average has a patient wait of 45 minutes to get an OCT due to the sheer volume of patients using the device. Imagine that we had patients doing these tests at home and coming in with their results for interpretation and treatment to our offices.

Virtual visits have already shown promise in glaucoma and retina clinics in Ohio.
Credit: Rishi P. Singh, MD

3. Our waiting rooms and exam rooms will have to evolve. The average ophthalmologist sees between 40 and 60 patients per day. Social distancing in offices can be difficult given the footprint. We will have to check the temperature of a patient entering our offices, offer masks if they are not wearing them, reduce patient movement between rooms, omit diagnostic testing unless necessary for clinical decision-making and opt for skipping seats between patients in the waiting room. Lastly, providers will be seeing patients at a slower rate to properly space them apart on a schedule with longer office hours, and thus this could lead to a lower overall clinical volume than we saw before this pandemic.

4. Our ambulatory surgery centers will have to adapt. We will see changes in how our buildings are structured, with improved filters and ventilation if needed. Physical barriers such as clear plastic guards will reduce transmission. The centers will have to incorporate COVID-19 testing before any surgical procedure. And this is complicated because even if the patient has a negative test, between the time of their test and the time of surgery there is a risk they could be exposed. And what about cases of bilateral surgery like cataracts separated by 2 weeks? Patients would have to undergo COVID-19 testing twice to ensure they are negative for both surgeries. This will be complicated by the backlog of cases that 2 months of no surgery has created. Any interruption in the supply chain from adequate testing, surgical supplies and personal protective equipment materials will delay cases further.

5. We will establish the “new normal.” Americans will continue to contract COVID-19 without a vaccine. The measures we have established in our personal lives at places like the grocery store will become part of our work lives. This will include patients and providers wearing masks in the clinic, reducing social gatherings and likely medical education meetings, and using hand hygiene as routinely as we possibly can. Ultimately the “new normal” will never make us feel like we did 6 months ago, and we will adapt and understand that there are many decisions, big and small, that will need to take place at all levels of society for us to overcome this pandemic.

Like what you are reading? Follow me on Instagram, Facebook and Twitter @drrishisingh.

Disclosure: Singh reports he is a consultant to Zeiss, Novartis, Regeneron, Genentech and Alcon and receives grant support from Apellis and Graybug.