European ophthalmology reshapes around COVID-19 pandemic
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Europe, for a long time at the center of the COVID-19 pandemic, is still struggling to flatten the curve of infections. As of April 21, 1,073,947 COVID-19 cases and 103,989 deaths had been reported in the European Union/European Economic Area and the United Kingdom. At different paces, governments are developing exit strategies and allowing partial lifting of coronavirus restrictions, while preventing a new wave of infections. Meanwhile, hospitals are still struggling, resources have been massively reallocated to deal with the COVID-19 influx, and all other medical and surgical interventions have been postponed and restricted to emergencies.
Guidelines from ophthalmology societies include master lists of urgent or emergent procedures. However, risk assessment is challenging when the chance of being infected in hospitals is part of the equation and when, as for several ophthalmic procedures, a clear-cut discrimination between what is and what is not deferrable is difficult to make if not on a case-by-case basis.
“Balancing the increased risk of contracting an infection with the severity of a progressing macular degeneration and vision loss is a dilemma we have been dealing with since the beginning of the outbreak. With the elderly patients that need intravitreal injections, it is a hard balance between life and sight. We decided that it was best to focus on patients for which the injections are really mandatory. However, many are too afraid to come,” Marta Figueroa, MD, PhD, head of the vitreoretinal unit at Ramón y Cajal University Hospital, Madrid, Spain, said.
A hard balance between life and sight
Shortly after Italy, Spain became the epicenter of the pandemic in Europe, and Madrid has recorded the most cases and deaths in the country.
“The amount of people who have died here is unbelievable. Our population has reacted responsibly to lockdown measures, although our people love being together, and gathering outside is such a great part of our life. Now the reopening has cautiously started, but we cannot let our guard down,” Figueroa said.
Patients who are asked to present for intravitreal injections are prevalently those who have AMD with monocular vision, patients who are in the loading phase or poor responders who need monthly injections.
“We make telephone contact with all our patients, check how they are doing, talk about the situation and try to convince only those who meet these criteria to come for the injection. Nevertheless, most of them don’t want to come. Normally, we perform about 80 injections per day in our hospital, and now we are down to approximately 15,” she said. “Many of these patients are aged between 80 and 90, and when they come to the office, I feel heavyhearted, thinking of the risk they run. I keep asking myself if I did the right thing, if it was really necessary to call them.”
On the other hand, there is serious concern for the many patients who are undertreated and will lose vision.
“AMD patients need regular monitoring and prompt treatment when necessary, and now this is not done,” she said.
Also, in private clinics such as Vissum Madrid, of which Figueroa is medical director, patient attendance is low. The risk there is minimal because it is a dedicated ophthalmologic clinic, but patients still prefer to stay at home.
Ophthalmologists volunteering in COVID wards
Like many hospitals in Lombardy, the Italian region worst affected by COVID-19, Melegnano Hospital has become a hub COVID hospital. All hospital departments were closed and converted into COVID-19 care units, with limited separate facilities for other emergencies.
“Most of our ophthalmology department staff have offered to volunteer for the COVID emergency. All over Italy, and particularly in the north where we had the largest outbreaks, many of us ophthalmologists are serving in ERs, helping colleagues in internal medicine, doing paperwork and administration, and communicating with the families of COVID inpatients,” Alfredo Pece, MD, head of ophthalmology at Melegnano Hospital, said.
Participation and engagement of health care workers at all levels in the fight against the coronavirus have been overwhelmingly high and generous in the country, he said.
“It has helped tremendously in coping with the sudden and exponentially escalating overflow of patients. Italy has been the frontline of the epidemic in Europe. We were unprepared for the size and severity of this epidemic. Very few health care systems in the world could be prepared for such a challenge,” he said.
The hospital has complied with national and regional guidelines, canceling all nonurgent elective surgical procedures, but has maintained an almost regular inflow for intravitreal injections.
“They are, by all means, an urgent procedure. If patients are not treated regularly as prescribed, the disease progresses toward blindness. We anticipated that the COVID-19 emergency would not be over soon, and since we could not let our patients miss their injections for several months, we got organized to maximize safety but maintain regular appointments. We space out the appointments, scheduling them over the entire day rather than half a day as we used to, to avoid contact in waiting rooms,” Pece said.
Concerns over pediatric eye care
Dominique Brémond-Gignac, MD, PhD, is head of ophthalmology at University Hospital Necker Enfants Malades in Paris, the oldest children’s hospital in Europe. Around mid-March, she saw the severity of the situation and equipped her department with protective plexiglass walls in the offices and a good supply of personal protective equipment (PPE), including goggles and specially made tissue masks with filters.
“Not everyone in the department had a realistic risk perception, and it took me a while to convince them of the need to implement COVID-19 safety measures. Then, quite rapidly, the situation evolved. On [March 20], all the operating rooms in my department were closed because all the respiratory and reanimation equipment was moved to COVID-19 hospitals. This happened in every hospital, so we were able in a short time to almost triple the intensive care capacity in the country,” she said.
Necker Enfants Malades adopted the guidelines of the French Society of Ophthalmology and French Society of Neonatology regarding mother and child and mothers affected by COVID-19. Pediatric eye care was restricted to urgent and emergent procedures, but delays in treating and detecting congenital disease such as glaucoma and cataract are a concern.
“Children with visual problems are usually referred to us by primary or secondary care centers, which now see very few patients. Understandably, parents are scared, and potentially severe problems may go unforeseen. For instance, strabismus may be a sign of congenital cataract, and if the child is not operated before 2 months old, this leads to irreversible visual impairment,” Brémond-Gignac said.
She is concerned about the consequences of late diagnosis and irregular monitoring of patients with severe eye disease.
“We are going to have a lot of nasty surprises when we get back to work regularly. There has been a significant drop in the number of cases of childhood glaucoma and cataract presenting at our hospital, and this is not normal. Many children will be seen when the disease is at a much more advanced stage,” she said.
The department has organized telemedicine consultations, and specialists are in contact with their patients via email and telephone, but more than 95% of regular follow-up consultations have been canceled, in many cases by the patients themselves.
“Moreover, movement restrictions are not so clear, and many patients don’t know if they are allowed to come for consultations,” she said.
Protective equipment
Eye emergency attendances, as well as other medical emergencies, have decreased in the U.K. as well. People who present are those with severe, highly symptomatic conditions, such as acute uveitis, acute glaucoma and retinal detachment with vision loss. Overall, retinal surgery is down by 70%, David Spalton, MD, FRCS, FRCOphth, emeritus consultant at St. Thomas’ Hospital, London, said.
“People are frightened to go to the hospital or want to avoid putting the hospital staff under more pressure. It is a huge concern because many of them might underestimate their problem and mistake, for instance, herpetic corneal ulcer for sore eye. A colleague told me that patients now don’t go with flashes and floaters and only appear when their vision deteriorates as the macula detaches,” he said.
Following an update of the Royal College of Ophthalmologists guidelines, all patients are now treated as potentially infected with COVID-19, using full PPE protection.
“This makes it simpler because we no longer have to try to determine if they are likely COVID-19 positive or not. We wear the same protective gear for everyone. Unless we are operating, we have single-use disposable gloves and gown, sessional-use fluid-resistant surgical mask and eye protection, and a breath shield on the slit lamp or any similar equipment we are using. We wear scrubs in the outpatient clinic and talk as little as possible whilst within 2 m of patients,” Philip Bloom, MB ChB, FRCOphth, FGS, glaucoma specialist and consultant at Western Eye Hospital and Hillingdon Hospital, London, said during a webinar organized by the United Kingdom and Ireland Society of Cataract and Refractive Surgeons.
Glaucoma surgery with precautions
In both centers, a color-coded risk stratification system is used, and face-to-face consultations are postponed whenever possible. The majority of glaucoma patients are elderly and therefore at a higher risk for more severe COVID-19 infection. On the other hand, treated glaucoma is usually a stable or slowly progressive disease, and this makes it easier to select and monitor the patients who need to be seen.
“For IOP measurement, we are using single-use, disposable, sterile tonometer heads for applanation tonometry. We avoid pneumotonometry, which might be an aerosol-generating procedure (AGP), whereas we think rebound tonometry is acceptable as it probably is not an AGP. When we operate on patients, we did not initially consider phacoemulsification or vitrectomy as AGPs, but the decision has now been made to do so. Similarly, in glaucoma surgery when we irrigate mitomycin C, there is a spray that comes off, so we have now classified all glaucoma surgery as AGPs. We feel that it is best to be cautious and err on the side of safety,” Bloom said.
The NHS has been managing the COVID-19 increased workload well, according to Spalton, who acknowledged the many junior residents who have been transferred to COVID wards. However, the shortage of PPE has been a problem, particularly in nursing homes and care homes, which are not set up for barrier nursing or controlling infection.
“In Scotland, about a quarter of COVID deaths have been in nursing homes and care homes because they haven’t had the right PPE. Notwithstanding the shortages and logistical difficulties in global supply chains, serious questions will need to be answered about political responsibilities,” he said.
Effective containment strategies
With 147,103 cases and 4,862 deaths as of April 21, Germany has one of the lowest fatality rates in the world. Widespread testing, early treatment and a high number of intensive care beds have allowed a more effective management of the COVID-19 outbreak, according to Gerd Auffarth, MD, PhD, head of the ophthalmology department at Heidelberg University Hospital.
“Here in Heidelberg, we created the corona taxis. Nurses and medical students drive to the homes of suspected COVID-19 patients and test them. The same is done with those who have been in contact with infected patients. We have performed 1.8 million corona tests, which is more than in South Korea. This allows us to treat positive patients early, and we have as many as 40,000 intensive care beds for ventilation, a huge number as compared with other countries,” he said.
There are hotspot areas in Germany, such as the Heinsberg district, where hospitals are working at full capacity, but elsewhere the situation seems to be under control. “We are very relaxed,” Auffarth said.
Ophthalmology departments have postponed elective surgery, but vision-threatening emergencies are regularly managed.
“We perform several RD cases, and we continue doing keratoplasty, though less than usual, because we have plenty of grafts available and don’t want to throw them away. Cataract surgery is performed in very few cases. We started with a few that had had one eye operated previously and needed surgery of the fellow eye. We also do some study patients who have a study lens implanted in one eye and another study lens in the other eye,” he said.
There is no shortage of PPE, which is regularly provided to everyone in the hospital, including patients. In addition, the ophthalmology team was split in two groups, one working at the hospital and the other sitting at home and doing office work.
“In this way, if someone gets infected, we have the substitutes,” Auffarth said.
However, many patients are reluctant to go to the hospital for fear of being infected. Cardiology and neurology departments are seeing an increased number of patients with myocardial infarction and stroke that could have been avoided with earlier monitoring of warning symptoms.
“In our department, we had the case of a lady that was in quarantine for COVID with minimal symptoms. For 1 week, she also had symptoms of vision loss but stayed diligently at home, and when she came to visit us, she had complete retinal detachment, which could have been prevented otherwise. We tested her twice in 3 days before we performed surgery, and she was still positive for COVID after 3 weeks. We operated on her using a strict safety protocol,” Auffarth said.
Three lessons learned
In the midst of the COVID-19 emergency, there are three lessons that must be learned while looking toward the future, according to Philippe Sourdille, MD, medical advisor of Elsan, a large private clinic group in France.
First is the need to establish and maintain clear and effective communication with patients.
“Our colleagues worldwide have competed creatively to adapt their offices and implement the best protective devices, and national scientific societies, including the SFO in France, have issued helpful recommendations. Even so, the fear of contamination still prevents many patients from visiting us. We need to communicate clearly and effectively to these people to ensure they understand and are fully aware of the additional precautions being taken to ensure their safety when they consult,” Sourdille said.
Hospital websites should provide links and contact numbers for patients to use if they need to get in touch with their ophthalmologists.
“They need to hear our voice to recreate a comforting human bond,” he said.
Telehealth, home-based monitoring devices and artificial intelligence hold the potential for continuous, effective remote care of patients. The pandemic has accelerated their growth and spread awareness of their importance for the future of medicine.
“Applications like the myopia.app by Norberto Lopez-Gil to measure VA and refraction is an answer to the technological challenge of direct communication. Myopia is a pandemic in the pandemic, which is likely to escalate due to reduction of outdoor activities and increased use of technology for online schooling,” Sourdille said.
Finally, the pandemic has shown that regulatory concerns are a source of slowness rather than safety. While the FDA has issued new policies to advance digital health innovation, Europe is more resistant to change, which puts constraints on innovative projects.
“We observed that global medical creativity, once no longer constrained by administrative burdens, has tremendously changed and developed. Scientific societies should use this opportunity to pressure the EU commission for medical devices to abandon needless layers of bureaucracy that put European research at permanent disadvantage compared to other continents,” Sourdille said.
“We are engaged in long, uncertain times. Like from every crisis, new opportunities arise, so let us hope that our brains will adapt faster than the virus to these new times,” he said.
- References:
- Alertes, avis et informations. www.societe-francaise-neonatalogie.fr.
- Allerta del presidente SOI inerente emergenza Corona Virus e conseguenti operatività. www.sedesoi.com/leggi_news.php?id=1878.
- Coronavirus COVID-19. www.dog.org/?cat=288.
- COVID-19 clinical guidance for ophthalmologists. www.rcophth.ac.uk/2020/04/covid-19-update-and-resources-for-ophthalmologists.
- Covid-19: Recommandations aux ophtalmologistes. www.sfo-online.fr/covid-19-infos.
- European Centre for Disease Prevention and Control. www.ecdc.europa.eu/en.
- Recomendaciones para la atención a pacientes oftalmológicos en relación con emergencia COVID-19. www.oftalmoseo.com/documentacion/comunicado_conjunto_oftalmologia_covid19v2.pdf.
- Statistics and research, coronavirus pandemic (COVID-19). ourworldindata.org/coronavirus.
- For more information:
- Gerd Auffarth, MD, PhD, can be reached at University of Heidelberg, Department of Ophthalmology, INF 400, Heidelberg, D-69120, Germany; email: gerd_auffarth@med.uni-heidelberg.de.
- Philip Bloom, MB ChB, FRCOphth, FGS, can be reached at The Western Eye Hospital, 153-173 Marylebone Road, London NW1 5QH, United Kingdom; email: philip.bloom@nhs.net.
- Dominique Brémond-Gignac, MD, PhD, can be reached at Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75743 Paris, France; email: dominique.bremond@aphp.fr.
- Marta Figueroa, MD, PhD, can be reached at Hospital Universitario Ramón y Cajal, Ctra. de Colmenar Viejo km. 9,100 28034 Madrid, Spain; email: figueroa@servicom2000.com.
- Alfredo Pece, MD, can be reached at Ospedale Vizzolo-Predibassi, Via Pandina, 20070 Melegnano (MI), Italy; email: alfredo.pece@asst-melegnano-martesana.it.
- Philippe Sourdille, MD, can be reached at email: philippe.sourdille86@gmail.com.
- David Spalton, MD, FRCS, FRCOphth, can be reached at The London Clinic Eye Centre, 119 Harley Street, London W1G 6AU, United Kingdom; email: dspalton@hotmail.com.
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