Optometrists phase back into ‘routine’ patient care during COVID-19
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Primary Care Optometry News reached out to doctors of optometry around the country to learn how they were dealing with the COVID-19 pandemic in their practices in late March/early April. Thirteen ODs provided details on how they initially reduced or canceled non-emergency consultations, with some unique approaches to safely see patients most in need. We talked with them again in May about continued practice changes and potential reopenings.
Richard Mangan, OD, FAAO, assistant professor in the department of ophthalmology at the University of Colorado and a PCON Editorial Board member, said that his office initially implemented telehealth training and maintained a skeleton staff for emergency patients.
“As news of the virulence and contagiousness of COVID-19 became a reality, our department had a faculty meeting in the middle of March to discuss the situation,” Mangan told PCON. “It was ultimately decided that in the best interest of our patients, staff and faculty, that the schedule be ‘scrubbed’ clear. This means that each doctor reviewed his or her clinic schedule and decided who could be moved. Patients who were considered high risk were seen as scheduled. These patients might have conditions like corneal ulcers, neovascular glaucoma, etc.”
Image: Joseph P. Shovlin, OD, FAAO
Beginning in late May, Mangan said he planned to begin phasing in patients to clinic. Each doctor will provide direct patient care approximately 4 half-days per week, with an additional half-day dedicated to virtual health exams and a half-day dedicated to triage calls.
“Unless the patient is elderly and needs assistance, we are encouraging patients to come alone,” he said. “If a family member is needed, they will be asked to wait in our waiting room.”
PCON blogger Margie Recalde, OD, FAAO, of Lifetime Optometric in Fresno, Calif., said that she is also hoping to make use of telehealth to minimize disruption. Her practice is also triaging urgent care patients over the phone to determine if they need to be seen in the office.
At first, Recalde did not have access to personal protective equipment and referred patients to other eye care practices if they were at high risk for COVID-19.
“I now have N95 masks, so when a patient is positive, I review the situation and decide on a case-by-case basis to see the patient or have them reschedule to a later date,” she said. “My husband is a nurse and still has to go to work at the hospital every day. Consequently, I need to be extra careful to minimize risk for exposure for the sake of our kids. Now, more than ever, we must all do our part to stay home to save lives and flatten the curve.”
While not all clinics have access to appropriate personal protective equipment (PPE), Joseph P. Shovlin, OD, FAAO, who practices at Northeastern Eye Institute in Scranton, Pa., is a PCON Editorial Board member and a former president of the American Academy of Optometry, said he and his colleagues have been able to use gloves, masks and shields while examining patients. He also said that they encourage patients to remain silent during the slit-lamp exam.
“Since conjunctivitis may be an early sign, we are committed to caring for these patients. This is the perfect incentive to get up and running with telemedicine for those who have not done so to date,” Shovlin said.
He noted that 15 of their offices opened mid-May. The few offices that remained closed were scheduled to see patients at the end of May. Previously, his offices were only seeing emergency and urgent care patients evaluated or triaged with telehealth assessment or seen via an e-visit. The offices are, however, still pushing back patients scheduled for routine exams with no pressing issues.
“It’s good to be back seeing patients other than true emergencies,” he said. “We have limited the number of patients each hour and the number of providers seeing patients at any one time. We continue to monitor at the door (temperatures only and brief history), avoiding any office crowding with a reduced schedule and having patients waiting in their car until we’re ready for them.”
In early February, Karen Perry, OD, FAAO, a PCON Editorial Board member who practices at the Vision Health Institute in Orlando, Fla., and colleagues instituted added precautions, including prescreening patients and posting signs at the front door and all high touch areas.
As of May 4, the institute opened its doors with normal working hours but continues with its original early protocol of having staff teams that work alternate days. They currently have N95 masks and face shields on order.
“We have found personal protective equipment and sanitization supplies difficult to access,” she said. “Vision Source now has supplies available, for which we are very grateful. Patients refusing to wear face coverings are asked to reschedule their appointment.”
Shane Kannarr, OD, from Kannarr Eye Care in Pittsburg, Kan., initially devised an altered working schedule with small teams working 30-minute blocks for each appointment and a limit of 10 people in the clinic.
As of April 27, the office reopened with a similar dynamic designed to see more patients. The main office remains open 7 hours, 7 days a week, with two teams of one doctor and staff splitting each shift and a third doctor in a satellite office working normal hours.
“If necessary, we will have patients wait in an exam room until the dispensary is open,” he said. “We are still trying to schedule dispenses and pickups, but it is not mandatory.”
During exams, Kannarr’s staff wear masks at all times and gloves with patient contact. Patients are encouraged but not required to wear masks and limit the people they bring with them to only necessary companions.
“This is an unprecedented and uniquely stressful time for our entire country,” he said. “Our practice, however, will continue to deliver the highest quality care possible to our patients, while monitoring the situation frequently, ensuring we are poised to change procedures as necessary. As soon as it is safe and prudent to do so, we will return to a normal schedule.”
Arthur B. Epstein, OD, FAAO, head of the Dry Eye – Ocular Surface Disease Center and director of clinical research at Phoenix Eye Care – the Dry Eye Center in Phoenix, said, “We have remained up and running for emergency patients throughout with limited hours and we have been surprisingly busy. “We have reduced employee hours and implemented other ways of reducing costs. Our goal is to keep the practice functioning to meet patient needs and keep our staff employed.”
Epstein said he and his staff conduct rigorous surface and instrument disinfection and wear procedure masks in the office.
“It’s obvious that airborne transmission is a primary vector for infection,” he said. “When we are in close proximity to patients for prolonged periods we wear N95 masks.”
They disinfect their scrubs as soon as they get home, he said.
As with other practices, only necessarily care givers are allowed to accompany patients, and everyone is asked screening questions, has their temperature taken and is required to use hand sanitizer upon entry.
“Worry about friends and family in heavily impacted places has added to the stress of what is already a stressful situation,” Epstein added.
He said they will be “cautiously resuming routine care while doing everything possible to reduce risk and keep our patients and staff safe and healthy,” after the Arizona stay-at-home order ended May 15.
John A. McCall Jr., OD, a PCON Editorial Board member who practices at Crockett Vision Source in Crockett, Texas, and is a former president of the American Optometric Association, said, at first, patients were invited into the clinic only if they had problems being able to see, eye pain, red eye, flashes or new floaters or had cataract surgery within the past week, with other routine appointments rescheduled for April 13 or later.
Starting May 11, his office began seeing patients every 30 minutes. All staff and patients wear masks – they are provided to patients if needed – and all exam lanes have breath plates on the slit lamps.
“We will schedule only one patient per hour to avoid any overlap and to keep within the guidelines of only 10 people or fewer in our clinic at any one time,” McCall said. “We have three areas to place patients in my clinic so we can keep social distance guidelines in order. Immediately after the workup and the exam, all areas where the patient has been are immediately cleaned and wiped down with a hypochlorous acid product. In addition, my staff will spray the outsides of their masks between patients.”
Damon Dierker, OD, FAAO, from Eye Surgeons of Indiana, said that after limiting patient visits to emergency care following the CDC guidelines early on, his practice would begin to offer routine services, including cataract surgery and management of chronic eye conditions, in late May.
“We have adopted telemedicine over the past 6 weeks, and this has become an important part of our practice,” he told PCON. “We expect this to continue and grow in the coming months. In addition to managing acute conditions and red eyes, we’ve incorporated preoperative cataract surgery counseling, management of new and established dry eye patients, and protocols for our glaucoma and retina patients into our telemedicine offerings. This has been incredibly rewarding for both our patients and our providers.”
Dierker said that during this time, they plan to keep clinic volume at about 70% as they adjust to new protocols and PPE requirements.
Similarly, PCON Editorial Board member Justin Schweitzer, OD, FAAO, from Vance Thompson Vision in Sioux Falls, S.D., transitioned during the week of May 11 back into performing evaluations for non-emergent or urgent cataracts, cornea, refractive and glaucoma cases. They continue to implement safety measures, including PPE, screening patients at the clinic entrance and limiting who accompanies patients.
“We continue to utilize telehealth evaluations and hybrid telehealth evaluations to limit the amount of time a patient is in the clinic,” he said. “It has been great for our team and doctors to be able to provide care that at least resembles pre-COVID times, and the feedback from our patients has been so encouraging to all involved.”
Eye care providers who practice within several hours of New York City, one of the most highly affected areas in the U.S., have followed similar precautions since the early days of the pandemic. As with others, however, some clinics are beginning to cautiously reopen.
“Being located in New York City, the epicenter of the U.S.’s COVID19 crisis, the University Eye Center (UEC) knew we needed to be creative in maintaining care for our patients, to help reduce the burden on the local emergency rooms of managing ocular emergencies and minimize risk to our community,” Jennifer Gould, OD, MS, FAAO, Dipl ABO, chief of advanced care services at UEC and assistant clinical professor at the State University of New York College of Optometry, told PCON.
Gould said that the center’s initial priority was urgent visits. Additionally, since the launch of a virtual care initiative, they have expanded to provide other high-quality patient care areas such as glaucoma, dry eye, myopia control and vision therapy.
“The breadth of services available also includes those offered by our social work team, who are providing virtual visits with our more atrisk patients to check on their wellbeing and current needs,” she said. “During a time when social distancing is imperative, being able to provide facetoface interactions between patients and providers remotely helps ensure the continuity of high-quality, compassionate and safe patient care during this time of crisis, as well as beyond.”
Christopher J. Quinn, OD, a PCON Editorial Board member, former American Optometric Association president and CEO of Omni Ophthalmic Management Consultants, a referral center that provides medical and surgical patient care, also expressed concern regarding the burden in the New York City area.
At the beginning of the pandemic, Quinn’s group, “in the epicenter of the outbreak here in New Jersey and New York,” remained open for urgent and emergency care, as they service the practices of hundreds of community optometrists, he said.
As of May 18, all Omni Ophthalmic offices in New Jersey, New York, Pennsylvania, Maryland and Delaware were scheduled to be open to provide essential medical care in addition to urgent and emergency care. Their safeguard procedures include remote patient check-in, daily employee screenings, pre-appointment patient screening, limitations on visitors, and PPE such as face-coverings for staff and patients.
“In New Jersey and New York we are still subject to a prohibition on performing elective surgical care in our ambulatory surgical facilities, but we have resumed medically necessary elective surgery in Pennsylvania and Maryland consistent with guidance from those respective states,” he told PCON. “We anticipate a slow build of patient volume as we adjust to what we know will become a ‘new normal’ in serving the referral needs of the optometric community.”
Doctors at Ophthalmic Consultants of Connecticut (OCC), which also provides medical and surgical patient care services in the New York City metroplex, responded to the COVID-19 pandemic with input from the CDC, state agencies and eye care associations, according to J. James Thimons, OD, medical director and founder of OCC, chairman of the National Glaucoma Society and PCON Editorial Board member.
“Our initial response was to condense our patient care activities from four offices to one and provide limited hours for true emergent conditions,” he said. “We have now transitioned to a staged reopening beginning the week of May 18 based on the state recommendations and following CDC guidelines. Initially the staff was reduced to provide support for doctors and patients, but we are now bringing back individuals in alignment with our staged opening.”
During the crisis, Thimons said that his staff was available for triage and referral 24 hours a day, 7 days a week, and the practice has had “a robust response from referring doctors and patients.” He felt that a positive aspect of the crisis was the response from patients and practitioners to the telehealth service in addition to their office emergency services.
“I anticipate this will be an ongoing aspect of our patient services,” he said. “At this juncture we are, like all practitioners, awaiting continued direction from state and federal officials as we will begin the process of reopening.”
James Deom, OD, with Hazelton Eye Specialists in Hazle Township, Pa., said he is seeing urgent and emergent cases in office 2 to 3 days a week and taking half days the remainder of the week for emergent calls if needed.
“The most exciting opportunity during this time is without a doubt telehealth,” he said. “I have spent hours with my staff, manager and partner doctors designing and implementing our telehealth approach. We have used mass communication techniques like text and email as well as traditional marketing techniques like newspaper outreach to let our patient base know we offer this.”
Deom found dry eye management lends itself well to telehealth. As patients spend more time indoors and “undoubtedly on their devices more, this spells disaster for the ocular surface,” he told PCON. “Letting patients know we are available for dry eye evaluations via telehealth is a great way to keep the practice viable in these tough times.
“With great assessment tools like easy questionnaires and high-quality videos, a continuation of care or even initial evaluation can be possible,” he added.
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