Issue: June 25, 2020
Source/Disclosures
Disclosures: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.
June 19, 2020
6 min read
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Post-lockdown paroxysm

A 'nonessential' dry eye physician learns otherwise once his patients return to the office.

Issue: June 25, 2020
Source/Disclosures
Disclosures: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.
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It is now a full week since the COVID-19 lockdown has begun to be lifted in Ohio. I am sitting at my table looking back over my first week kinda sorta back at work. You will read this at a slightly different time, having been back in the saddle in some way for almost a month.

Whereas I am still trying to figure out how to keep the Department of Health from knocking at my door (man, are there a lot of nebulous rules to figure out), as you sit down for a good read you (and I) are now running up against the end of the Paycheck Protection Program forgiveness window. If they have yet to make the whole loan go away, we (or your department chair or that slick 28-year-old MBA running your PE-owned shop) will now have to figure out how to pay back that loan even though we are unlikely to be running near enough to full steam to pay our regular bills.

Darrell E. White, MD
Darrell E. White

Tough gig, this nonessential business.

Just as symptoms matter to our patients so, too, do the words chosen to guide us during a crisis. Now that I have had a chance to resume at least a part of my practice life, the essential folly of designating eye care as nonessential (and the resulting unthinkable and unthinking shutdown declaration by the American Academy of Ophthalmology making “essential” existential) has quickly become evident. Care to guess which patients were most desperate to see me and my associates? Our dry eye disease patients, of course. Don’t get me wrong, my cataract patients were thrilled to be back on the schedule; all of their family members riding shotgun in cars driven by patients a couple of months overdue for their surgery were even happier, as you can imagine.

But it was our medical patients in general, and our DED patients in particular, who had been placed in the most precarious position when we eye doctors were told to head to the bench in support of so-called “front-line” caregivers treating COVID-19. I am not knocking those folks in the ER and ICU; a quick viewing of my video relating how COVID-19 affected SkyVision will make it quite clear that I do not equate what we do in the clinic or the OR with what was happening in the viral trenches. Still, even a 3-day week (we are using A/B teams to prevent a full shutdown if someone gets sick) seeing 40% of a usual schedule is a sample big enough to know that many of our patients needlessly suffered while we were locked out. Let me share a couple of examples.

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Even though I predicted our DED patients would look and feel terrible when they started to emerge from their screened-filled cocoons, it was still a shock to encounter just how bad it had become for some. Each half-day session brought in one or two patients who were on the brink of despair. Their symptoms had failed to respond to our most recent interventions, or they had become so despondent in their solitude that they had fallen off the treatment wagon in whole or in part. A couple of them had reached out by phone, one or two even agreeing to a telemedicine session, neither of which allowed us to make any meaningful change in their treatment without an exam. Those who seemed to still be functioning we scheduled on the first day we were open. Sadly, the ones we offered to see on an emergent basis were too frightened to venture out of their homes, even to come to the office.

There were a couple of surprises awaiting us during that first week back in the saddle. Like good soldiers, we had pushed almost all of our symptom-controlled DED patients’ follow-up appointments out during the lockout. One or two, sometimes three, months longer than the usual interval between visits, as long as they were comfortable. For sure, we checked their charts looking for possible landmines or ambushes. After all, we have a very large population of DED patients who thankfully are doing quite well on chronic treatment regimens. Because we see so many moderate and severe cases, there are quite a few folks who take multiple drops, including steroids. Those charts were reviewed very carefully; only those patients with a long history of safe use (read: no elevated IOP) were pushed out.

You can see where this is going.

Every half-day session brought in at least one DED patient who had a significant IOP elevation. I mean big time, 30- and 40-plus IOP significant, with all kinds of different steroid products. In order to make physical distancing easier, we acquired an Ocular Response Analyzer from Reichert. Our first instinct was that we were getting false IOP elevation with an instrument we were just learning how to use. Nope. Applanation confirmed the ORA values within a point or two. (As an aside, a couple of those patients also had a low corneal hysteresis, prompting us to initiate a formal glaucoma evaluation.) Each of these would have been identified earlier had we seen them on schedule. Thankfully, every OCT we did to rule out damage was normal. A blessing for all involved.

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Of course, it was not only DED patients who had essential care delayed. I can see you nodding your heads as you think of your own patients. That elderly glaucoma patient who had borderline pressures you were bringing back for an early OCT? Yup, she came in on Wednesday, 2 months later than planned, with a new notch on her optic nerve and nerve fiber layer loss. Or the 50-year-old guy with “pink eye” who got a telemedicine visit with pellucid marginal degeneration and a prescription for Ciloxan (ciprofloxacin, Alcon)? He followed up at a Minute Clinic a week later after driving up and seeing the “closed” sign on our front door. The clinic changed him to Tobrex (tobramycin ophthalmic ointment 0.3%, Alcon). When he called this week for the first time, we asked him about other medical problems. Turns out he has ankylosing spondylitis. It took oral steroids in addition to Pred Forte (prednisolone acetate ophthalmic suspension, Allergan) every hour to turn him around. We lost count of the number of corneal infiltrates we saw in patients who just decided they would ride out the lockdown by using their 2-week disposable contacts for 2 months.

Think maybe a pair of glasses is essential for that –6 D myope with a corneal ulcer?

Words matter. In a crisis, the words that our leaders use matter even more. Declaring eye care “nonessential,” and furthermore having local, state and national leaders of both government and our profession demand that we all but close, will be shown to have caused significant suffering that was avoidable. Here is a heads-up to all of those leaders: Unfortunately, you are going to get a mulligan. There is going to be another outbreak of COVID-19 this fall. Some of the overreach will be easy to avoid; hopefully you have enough personal protective equipment stored up so that this time you do not need to crib the stuff we use to do cataract surgery. For the rest, how about stating up front and out loud that we have learned from the lockout that medical care, including eye care, is essential on an ongoing basis if we are to avoid unnecessary suffering and loss.

Here is some free advice from a “words guy” to help us when the COVID-19 cases start to rise again: “Essential” is meaningless when the electrician wiring the $2 million vacation home under construction is essential and the pediatric ophthalmologist seeing the 4-year-old with accommodative esotropia is not. How about safest, safer, safe, less safe and safety at risk instead. Get to work now on what it takes to be closest to “safest” for both eye care givers and our patients when together we go to the office, the laser suite and the OR.

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When we do the essential work of preserving and enhancing our patients’ vision and their health.