COVID-19 shows ‘virtual is possible’ in ophthalmology
Although COVID-19 triggered widespread disruption in medical care across all specialties, ophthalmologists had to overcome unique challenges.
For instance, many ophthalmologists faced the added burden of communicating what constitutes essential care regarding ocular diseases after the American Academy of Ophthalmology issued its recommendation to cease providing treatment for nonurgent patients in March 2020. Further, telemedicine, conventionally considered less than ideal in ophthalmology, became a staple of clinical practice during the pandemic. However, ophthalmologists rose to the occasion by employing technology to treat patients and by viewing the pandemic as an opportunity for research, according to Rishi P. Singh, MD, staff surgeon at the Cole Eye Institute, Cleveland Clinic, and associate professor of ophthalmology at the Lerner College of Medicine in Cleveland.
In an interview with Healio, Singh discussed problems posed early in the pandemic, the benefits of telemedicine, caring for vulnerable populations in the COVID-19 era and the need for more advanced technology moving forward.
Healio: What were the challenges facing ophthalmologists early in the COVID-19 pandemic?
Singh: Some of the challenges we faced stemmed from confusion around the AAO recommendation that we do not see patients for routine visits or nonurgent care. Many patients misinterpreted this to mean that they should not see their ophthalmologists because they thought all eye-related issues were not considered urgent. They likely didn’t understand that treatment for conditions such as age-related macular degeneration, diabetic macular edema or retinal vein occlusion falls under the umbrella of essential care, and they probably struggled to understand why they needed to be seen. I have stories of patients who experienced significant vision losses during the pandemic because they thought missing a few visits would not have much of an impact.
Many mandates were also state-dependent, with some states remaining open, meaning physicians in one state may have continued to see patients while others in a different state did not. So, recommendations could not be applied in the same way across the board.
We also had no objective information — from research studies or otherwise — on what the impact of short lapses in treatment might be. Actually, when the COVID-19 pandemic began, we were in the process of doing a study, which has since been published in Retina, assessing the effect of treatment lapses in AMD. Even before the pandemic hit, we had patients who would miss maybe 2 or 3 months of appointments for various reasons. For AMD, we found that when they resumed treatment, there was almost a line of difference in vision at the end of the time period.
Overall, many people misinterpreted the AAO recommendation, and we probably needed more messaging around what counts as an urgent or emergent visit to an ophthalmologist.
Healio: How did ophthalmologists overcome these barriers?
Singh: Some of the simplest strategies involved the telephone. We connected with patients over the phone for simple things, such as diagnosis of less complex symptoms or changing drop regimens. This is not perfect for ophthalmology, obviously, because an in-person visit is required to really gather that information, but it works in some cases.
We also did virtual visits using FaceTime on iPhones, which were sufficient for some external complaints that were visible to us, and we had a lot of uptake by oculoplastic and comprehensive ophthalmologists who were able to diagnose or at least triage patients.
We’re actually in the process of publishing two studies, one of which is evaluating virtual visits as a whole across the Cole Eye Institute. In that study, we found that not only was uptake good but metrics of what we did with our patients afterward were similar to what we observed when we were doing inpatient visits, regarding writing prescriptions, developing a referral to another provider and more. Further, we have preliminary data showing that rates of patient satisfaction with virtual appointments were on par with those for in-person visits. These studies validated the fact that virtual is possible in ophthalmology, even though many people thought otherwise.
Healio: Patients with AMD fall within the spectrum of patients who are at higher risk for severe COVID-19 disease. Has this complicated diagnosis and treatment of these patients?
Singh: Yes, it has, and this is true for other diseases as well as COVID-19. The AMD patient who comes in and out of care, at least anecdotally, is more severe and has more visual issues than a patient who just walked in off the street before the pandemic. This has been a real concern for us because clearly, we want to catch patients at the earliest possible point in the disease with the best possible vision so that we can achieve a good outcome. When a patient comes in late in the disease state, there is a potential inability to improve over their baseline.
In terms of COVID-19, we have addressed this problem by adopting a lot of precautions for our offices to ensure that we can do in-person visits safely and effectively. Patients need to know that now is the time to come in, get evaluated and receive treatment. With vaccination rates increasing and with our offices having vaccinated all employees at this point, the chance of contracting COVID-19 from an office visit is very low.
Interestingly, we have looked at the rates of COVID-19 across our institution. In our ORs, we test patients preoperatively for COVID-19 and the positivity rate is only 0.37% among our patients. This could be hugely impactful from the standpoint of understanding the disease and how to risk-stratify people. But the bottom line is that we feel there are very few patients with COVID-19 who obviously need actionable care at this point in time. We’re finding that patients who have COVID-19 tend to present with symptoms and do not necessarily need formalized testing to determine if they have the disease or not.
Healio: Has there been research on novel treatment strategies, such as extended treatment intervals for patients with AMD, that have been introduced during the pandemic?
Singh: Again, this has been a validation of what we have already learned from some peer-reviewed literature — there is an ability to extend treatment to significant intervals for these patients. However, we clearly need more evidence and guidance. The biggest issue, though, is that we have a lack of remote monitoring in our system right now. Monitoring patients for these disease states would be immensely helpful and could solve many issues. Store-and-forward technology, where we essentially image a patient remotely and then interpret the image, would facilitate clinical decision making. This is particularly applicable to ophthalmology in several ways, including with management of AMD, DME, RVO or diabetic retinopathy. These are all things we could do that would make a huge difference.
Healio: Have ophthalmologists been employing other technologies in addition to telemedicine?
Singh: We have looked at using a variety of different technologies. For instance, we have seen significant uptake in use of ForeseeHome, which is an FDA-approved AMD management system, for patients with non-neovascular AMD. Essentially, you send the machine to a patient’s house and it tests them each day. This testing has been able to show time of conversion to wet macular degeneration without doing an OCT. However, we still need other technologies such as remote OCT devices. Currently, we don’t have formalized remote vision tracking, which is a real problem if you’re relying on vision to make clinical decisions for treatment.
Healio: Are there any special considerations for treating patients with AMD who have COVID-19?
Singh: First, the rate of transmission of COVID-19 in a hospital or office setting is very low provided the appropriate precautions are taken. Therefore, the message for our patients should be that we’re open for business, we’re happy to see them and the office or inpatient setting is a safe place. Second, I would tell practitioners to try to spend time and explain to their patients when they do return for care that in-person visits are necessary because a big part and parcel of good visual outcomes is seeing their ophthalmologist on a regular basis. Otherwise, there will be serious issues with continuity of care and sufficient outcomes.
Healio: Do you think there will be any permanent changes to care after the COVID-19 pandemic ends?
Singh: It’s hard to say. There needs to be more development in technology, whether it’s asynchronous, meaning they enter information and we read it offline, or synchronous, meaning we’re having an active discussion with our patients. That investment needs to occur because we’re struggling and will be struggling during the next pandemic to come up with strategies that will make a difference for our patients. That’s the real issue we’re facing.
Beyond that, the bigger ask is going to be can we develop effective models of care that will continue and persist beyond this pandemic? Even before the pandemic, we had a volume issue. We have too few practitioners and too many patients — the boomers are still growing older, which leads to a lot of insufficiencies in care and potential gaps in care. That’s our next endeavor — developing more of these technologies that will help with the ability to spread ourselves across many different patients and care groups.