Lessons learned from pandemic will have long-term impact on ophthalmology
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COVID-19 has challenged ophthalmology, like every other sector of health care, to rapidly develop strategies to respond to the crisis.
It has brought changes that have profoundly reshaped the present and future of medical education, patient care, clinical practice and practice management. It has opened unforeseen opportunities and catalyzed technological innovations. Last but not least, it has been an eye-opener, calling attention to the urgency of making health care more equitable and more sustainable.
Source: Cynthia Matossian, MD, FACS
“A cataclysmic event forces you out of your comfort zone. It forces you to think out of the box and be creative and nimble,” OSN Cataract Surgery Board Member Cynthia A. Matossian, MD, FACS, said. “The pandemic has taught us lessons that are making our practice better; many of the positive changes that we have made should become embedded in our everyday routine to improve patient care.”
Lesson 1: Teleconsultations
Telehealth has been available for some time, but during the pandemic, when offices were mandated to be closed in most states except for emergencies, virtual visits became essential to offer care to patients.
“The utilization of telehealth is not as widespread as it was during the first stages of the pandemic, but it has become more commonplace in many practices to prescreen patients for refractive or cataract surgery,” Matossian said. “We can collect information on medical history, coexisting diseases, patients’ lifestyle and their desire to be less dependent on spectacles and inform them of options we can offer.”
Dry eye disease is another field in which remote consultation is effective and time-saving.
“For dry eye, we have to ask a long battery of questions with either the OSDI or the SPEED questionnaire, and this takes time. Completing this step, in advance, online, with someone who is not necessarily an MD, can really expedite the office visit because all the information will be available when the patient arrives for their appointment,” she said. “Obviously, we must see the patients for in-office diagnostics and treatment decisions, but every other visit can be a telehealth visit where we can discuss symptoms, monitor improvement, review medications and reevaluate if patients are using them properly.”
Communicating with patients in their home environment can reveal aspects that would not emerge during office visits. In two cases, Matossian found this to be key to understanding why symptoms persisted despite treatment.
“One was a woman who continued to come to me with red, itchy eyes and fluctuating vision. She was on many different treatments, and I could not understand why those symptoms persisted. When we did our first telehealth visit, I saw she was surrounded by a whole army of cats, 12 of them, climbing on her desk, lap and shoulders. The other case was a university lecturer who was doing remote teaching because the class had been closed due to COVID. I saw she had a big fan above her desk, and it was whirling around while she was sitting right under it for 10 hours a day. By making those observational notes, I was able to help both these patients a lot better with their dry eye disease,” she said.
Shortly after the onset of the pandemic, the U.S. federal government supported the increased use of telehealth by expanding Medicare coverage of remote patient monitoring from just patients with chronic conditions to those with chronic and/or acute conditions.
“We now have codes for several types of exams and get paid for a telehealth visit similar to what we get paid if a patient comes to our office,” Matossian said.
Lesson 2: Digital equity
Beyond the pandemic, telemedicine has the potential to broaden access to care, reducing the costs and burdens that patients and their families encounter, such as transportation issues.
On the other hand, telehealth requires owning and being able to use a digital device and having access to the internet. For homebound and elderly patients and for people living in rural areas, the opportunity to rely on communication technologies can be both an asset and a limitation.
In the U.S., the average rate of broadband availability per county is currently 76%: 71% for nonmetropolitan counties and 85% for metropolitan counties, according to a study reported by Tufts University. In some counties, there is still no access to a broadband network.
“Connectivity is getting better. There are initiatives, such as Internet for All and the American Connection Project, aimed at providing access to high-speed internet for all Americans, including the rural areas. These projects became accelerated because of COVID,” Matossian said.
Lesson 3: Online learning
COVID prompted the development of new forms of medical education that proved valuable and will continue to be available alongside in-person programs.
“I think COVID just accelerated what probably needed to happen anyway. Although most people would agree that in-person learning is superior because it allows for more engagement and interaction, having the virtual option is a nice alternative for everybody,” Tanner Ferguson, MD, a fellow at Vance Thompson Vision in Sioux Falls, SD, said.
The various forms of virtual learning, including classes, webinars and meetings, are here to stay because they offer the advantages of reduced cost, more flexible scheduling and enhanced accessibility.
“Doing things on demand, in your own time, when you have other responsibilities at home or at work, is an attractive option,” Ferguson said. “I also think the format of hybrid meetings is nice because you have the opportunity to catch up on sessions or presentations you missed, and a virtual option allows those unable to attend in person to tune in from home.”
At the start of the pandemic, Ferguson was a resident at the Cleveland Clinic Cole Eye Institute, and he is now a fellow at Vance Thompson Vision.
“Speaking from a trainee perspective, in Cleveland, COVID was bad, but we weren’t as severely impacted as other places, and fortunately my training was not significantly impacted. We halted clinical duties for a short while, but a silver lining for me personally was that it freed up time to concentrate on clinical research,” he said.
Lesson 4: Home monitoring technologies
COVID has given momentum to the development of home-monitoring technologies through which patients can monitor their own eye disease-related parameters. One of them is the iCare Home tonometer.
“Instead of the typical once every 3 months nanosecond pressure check, we can have an accurate view of the patient’s diurnal IOPs performed by the patient over time. In this way, the disease is regularly monitored and progression, hopefully, prevented through an alert system that warns the clinician in the event of sudden changes,” Matossian said.
Heru, among other companies, has produced a wearable, portable device for virtual reality visual field testing. Eyenovia has created the Optejet dispenser, designed to deliver the necessary amount of medication to the eye, while smart electronics track compliance.
In the retinal landscape, the Notal Vision ForeseeHome and Notal Home OCT provide timely assessment of the state of the macula in patients with age-related macular degeneration, alerting the treating physician if there are changes and monitoring the effects of treatments. The Zeiss Velara teleretinal screening system has also been developed for remote diabetic retinopathy and fundus screening.
“There are devices or smartphone applications for self-assessment of vision, for anterior segment photography and for assisting in the treatment of amblyopia in children. New applications are cropping up regularly, including one for retinopathy of prematurity, that allow for remote scanning of the retina for premature babies,” Matossian said.
Lesson 5: Safety
“The pandemic has made us aware of the need to contain the spread of infections. More than most medical specialties, ophthalmology relies on examinations that involve close contact with the patient. We did not appreciate this before, but having shields mounted on the slit lamp and other diagnostic equipment was very helpful and should be maintained as a habit,” OSN Cataract Surgery Board Member Audrey Talley Rostov, MD, said.
The same applies to face masks, which she believes should be maintained in clinical areas.
“Although the CDC rules may change, we are planning to wear a mask in the clinical area pretty much indefinitely. This will reduce the spread of not just COVID, but cold and flu and all airborne viruses. I may take the mask down if I am having a conversation with my patient but wear it during exams. And at the slit lamp, patients are required to wear a medical-grade mask,” she said.
Hand hygiene and equipment disinfection in between patients are also good commonsense habits to maintain. Before the pandemic, thorough disinfection was performed after examining infectious cases, but it should now be a good general precaution.
“Similarly, universal precautions for handling body fluids were introduced in the ’80s when the AIDS epidemic started. Before, we did not use gloves routinely to handle body fluids, but now it has become routine to protect from HIV but also other infections,” Talley Rostov said.
What is no longer done, she said, is the excessive cleaning of the waiting room, and temperature checks and questionnaires have been abandoned.
“We used to ask about traveling, even when the highest number of cases were in our country, and that was silly,” Talley Rostov said.
Lesson 6: Sustainability
COVID-19 has highlighted the complex interplay among ecosystem degradation, climate change, globalization and increased risk of pandemics. It has been a wake-up call for sustainable health care, and health care providers as well as manufacturers are beginning to examine how they can reduce their environmental footprint.
“The pandemic caused supply chain interruptions that forced us to reuse things that we would normally discard after a single procedure, such as masks, hats and gowns,” Talley Rostov said.
During her mission trips to India, she had the opportunity to work at the Aravind Eye Hospital and to see its A-to-Z approach to environmental sustainability.
“They demonstrated that reuse does not increase infection rate and endophthalmitis rate. Here in the U.S., we are bound down by so many cumbersome regulations, and a lot of them are not based on evidence. We can reuse hats and masks over several procedures during the day — it is safe. The supply chain interruption made us more aware of what could be sterilized and reused,” she said.
In her practice, Talley Rostov uses reusable blades and reusable IOL insertion devices for surgery. She is careful to order only supplies that are needed and to save whatever is not used for other purposes.
“There are instruments that are single use in this country, such as certain types of insertion cannulas for DMEK grafts and trephines, which can have more than one life. I sterilize them and use them for teaching and training in my mission trips. And I save supplies that are leftover, like Weck-Cel sponges, triangular spears and sutures, for wet lab training,” she said.
The American Society of Cataract and Refractive Surgery has been organizing several meetings with industry leaders to discuss strategies to reduce waste in the supply chain.
“We are trying to have an emphasis on sustainability. ASCRS and the European Society of Cataract and Refractive Surgeons together, we met at the American Academy of Ophthalmology meeting with all the top companies and formed a committee. We talked about the different regulations in the U.S. and EU and were admired by the sustainability policies adopted at the ESCRS meeting, like lunches with reduced packaging, sustainable choices of food, the use of compostable or recyclable materials, and reduced energy consumption,” Talley Rostov said.
A survey sent to ASC surgeons and managers showed that 90% are concerned about the increasing amount of OR waste, and some are taking action to reduce it.
“Is there something we can do to make it a win-win for companies, owners, surgeons and our planet? To create not just awareness but a call to action? We are committed to answering these urgent questions,” Talley Rostov said.
Lesson 7: Task delegation
A possible physician shortage is part of the staff shortage continuum fueled by the pandemic.
“COVID led people to put lifestyle as a priority in their career plan, a trend we have seen for a number of years. Trainees in particular want to put lifestyle first, and their willingness to work long hours is not as strong as it used to be. They are smart, educated, well trained and very capable when they come out of their respective programs, and most of them have a great attitude, but generationally they are looking for different priorities,” OSN Associate Medical Editor John A. Hovanesian, MD, FACS, said.
Demographics also play a role. There are fewer people coming out of training than physicians that need to be replaced; meanwhile, the population that needs to be cared for is growing.
“Probably the first and most important change that practices need to do is look at nonphysician providers, an old story that becomes more important now for this reason,” Hovanesian said.
With some specific training, optometrists could have their role expanded to include ocular surface disease. Physician assistants have generally not been involved in ophthalmology practices because they are not allowed to do refractions and prescribe glasses, but they could make a real change in retina practices by running injection clinics supervised by a physician.
“They could also help oculoplastics practices, both on the clinic side and operating room side. They could see preop and postop patients, perform simple office procedures such as chalazion removals and Botox injections, and in the operating room, they could close the incisions after blepharoplasty and other procedures,” Hovanesian said.
Lesson 8: Psychological safety
Besides safety in terms of protection from disease, the pandemic has highlighted the importance of psychological safety in the workplace.
“The pandemic crisis highlighted and reaffirmed the importance of cultivating a positive culture in your practice. I am very proud of the way we handled all the challenges of COVID. At the beginning, when we were forced to close our doors, we treated our staff like family and did everything we could to protect their job and income and to take good care of them. Many businesses had a hard time attracting and retaining employees, and for us it was also challenging but much easier because of the good relationship we had with them at all levels,” Hovanesian said.
Creating a positive culture and keeping it alive, empowering individuals to express their ideas, wishes and concerns, make people feel valued.
“Little things like celebrating anniversaries, bringing in a cake to share or inviting everybody out to something like a roller skating rink are impactful in bringing people together and making them feel like a team,” Hovanesian said.
“In our practice, we continually invest time and energy into our team. Providing people with relevant and consistent training and taking time to acknowledge performance and growth positively impact self-confidence, engagement and, ultimately, productivity,” Ferguson said. “And, most importantly, we find ways to show appreciation to one another and have an egalitarian, inclusive approach. I think that helps foster an enjoyable place to come to work.”
When staff members feel psychologically safe and happy, they will show kindness and provide loving care to patients.
“There is a silver lining of COVID, despite its disruption. It has been a positive accelerant for change and innovation and has made us more socially and environmentally conscious as health care professionals and people,” Ferguson said.
- References:
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- The impact of internet access on Covid-19 mortality in the United States. https://sites.tufts.edu/digitalplanet/the-impact-of-internet-access-on-covid-19-deaths-in-the-us/. Published June 22, 2022. Accessed Oct. 19, 2022.
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- For more information:
- Tanner Ferguson, MD, can be reached at Vance Thompson Vision, 3101 W. 57th St., Sioux Falls, SD 57108; email: tannerferg@gmail.com.
- John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Laguna Hills, CA 92653; email: drhovanesian@harvardeye.com.
- Cynthia A. Matossian, MD, FACS, can be reached at Matossian Eye Associates; email: cmatossianmd@icloud.com.
- Audrey Talley Rostov, MD, can be reached at Northwest Eye Surgeons, 10330 Meridian Ave. N., Suite 370, Seattle, WA 98133; email: atalleyrostov@nweyes.com.
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