For David Parke, II, MD, the COVID-19 pandemic recalls the day 25 years ago when he stepped out of an operating room in Oklahoma City and found out that the Federal Building there had just been bombed. He was met by the hospital CEO who put an arm band on Dr. Parke and said, “You’re now the hospital triage officer, because you’re the first doctor I found.”Dr. Parke, a retina specialist, spent the next hour and a half seeing about 80 critically injured patients. “Times like this remind us that whether we're retina surgeons or we're cataract surgeons, we're all physicians first,” said Dr. Parke, now CEO of the AAO, in a recent episode of the Retina Podcast. As it sweeps through the world, swamping some emergency rooms, COVID-19 is transforming daily life for nearly everyone, and retina specialists are no exception. Most are deferring all but the most urgent and emergent patient visits, and many are suffering financial losses as a result. Others are standing ready to back up colleagues whose specialties put them on the front lines. All are being called upon as medical leaders in their communities.
To slow the spread of the virus, public health officials in most of the United States have recommended that people stay apart from each other. For retina specialists, this means reducing encounters among physicians, staff, and patients. Not only does this cut the risk of contagion, it minimizes the use of resources, such as gowns, gloves, intravenous tubing, and anesthesia machines that are in short supply because of the demands of COVID-19 patients.
No Longer “Business as Usual”
“That has dramatically reduced volumes for almost everyone in retinal practice,” said Peter K. Kaiser, MD, the Chaney Family Endowed Chair in Ophthalmology Research and a professor of ophthalmology at the Cole Eye Institute, Cleveland Clinic Lerner College of Medicine in Cleveland, Ohio. Clinics there have reduced their volume by 70% to 80%, he said.
Patients usually respond well when their physicians tell them, “I don't want to expose you unnecessarily by bringing you in,” said Jayanth Sridhar, MD, an assistant professor of clinical ophthalmology and vitreoretinal surgery at the Bascom Palmer Eye Institute in Miami, Florida. Likewise, he is usually able to persuade patients to come in when necessary, despite their fears of infection. He tells them, “It’s a personal decision. I understand your concern, but I really recommend treatment.”
The most immediate challenge for many retina specialists is determining which patients to see and which to defer.
“Practices are doing this a number of different ways,” said Dr. Parke. “The first is that they're calling patients as we typically do anyway, a couple of days to the evening before, but the call is different. It's not just reminding patients of their visits and asking them to reconfirm; it is going through a programmed series of questions to help the patients decide whether they really should be coming.”
The AAO has published a list of urgent and emergent ophthalmological procedures. But some decisions, such as whether to defer treatment of a macular hole, can be “murky,” Dr. Parke acknowledged. He recommended thinking in terms of a grid that balances the patient’s risk factors, including age and underlying conditions, such as diabetes, along with logistics, such as transportation, against the importance of the procedure.
“You can't use blanket rules for your patients,” agreed Dr. Sridhar. “The difficult decisions are for patients who fall in the in-between zones — patients who don't necessarily have an urgent or emergent need for treatment or a visit. What happens if their visit is now delayed 2 weeks or 4 weeks or 6 weeks or 8 weeks and this extends out?”
No one knows how long social distancing recommendations will remain in place. So, Dr. Sridhar is rescheduling patients who fall in the gray zone for about 2 weeks. After that, he evaluates whether to reschedule them for another 2 weeks later or bring them in if their risk of vision loss is likely to increase significantly.
Taking Advantage of Telemedicine
In some cases, retina specialists can take advantage of new telemedicine opportunities. The Centers for Medicare and Medicaid Services (CMS) is reimbursing for more telemedicine procedures than in the past (see “2020 Ophthalmic Telemedicine and the CMS 1135 Waiver” for more). Also, the U.S. Department of Health and Human Services is temporarily allowing clinicians to communicate with their patients through commercially available video conferencing and texting applications such as Whatsapp and FaceTime, not just technology developed specifically to protect patients' confidentiality.
Using remote video, retinal physicians can triage postoperative complications, such as reports of redness. And they can bill not only for these video examinations but for answering questions by phone or email as well as second opinions and consultations with colleagues, said Ranya Habash, MD, medical director of technology innovation and assistant professor of clinical ophthalmology at Bascom Palmer, in a recent webinar hosted by the American Society for Cataract and Refractive Surgeons. “We’re already doing this 20 million times a day, but now we’re going to get paid for it, which is a game changer.”
More cutting-edge devices for telemedicine include the Drone robotic remote-controlled stereo slit lamps being developed at Bascom Palmer, and the ForeseeHome monitor by Notal Vision that analyzes changes in age-related macular degeneration, said Dr. Habash.
A Change in Protocol, Operations
When patients do come into the clinics at Bascom Palmer, they are asked to wait in the car rather than the waiting room. The staff then phones the patients when they can be seen.
For some patients, Bascom Palmer is also foregoing elements of the examination that would otherwise be typically included with treatments, such as checking visual acuity and intraocular pressure or performing an OCT, said Dr. Sridhar. This, too, minimizes exposure to other patients and to staff. For each patient visit, he considers whether these diagnostic findings are likely to influence treatment plans.
During procedures, the AAO recommends mouth, nose, and eye protection (such as N-95 masks and goggles) as well as slit-lamp barriers or breath shields.
Deferring so many procedures comes with a steep cost, especially for retinal physicians in private practice, acknowledged Dr. Kaiser. “In general, retinal practices have a little bit of leeway, a little bit of reserve, that they are able to use to survive. Some practices will need to lay off people. It’s something that nobody wants to do, but it’s necessary for the practice to survive.”
Some retinal physicians are foregoing their own compensation to support their staff, Dr. Sridhar said. “I think that it's really important to remember the people who are living paycheck to paycheck, and to take care of them.”To assist affected health care providers, CMS has accelerated its advance payment program. And under the US Coronavirus Aid, Relief, and Economic Security (CARES) Act, Economic Injury Disaster Loan, and Paycheck Protection Program, practices can take out emergency small business loans. Also Allergan, Genentech, Novartis, and Regeneron have announced that they will temporarily extend payment terms.
Joining the Fight
In the meantime, retinal physicians can make use of the time they are not seeing patients, Dr. Kaiser said. In the hospital setting, they can prepare for a surge of COVID-19 patients. When that happens, they may be called upon to treat the non-COVID-19 patients that would otherwise be treated by pulmonologists and others on the front lines.
Alternately, retinal physicians might staff emergency hotlines for people who think they might have COVID-19 illness. “So, a refresher course would be a beneficial thing to do,” Dr. Kaiser said. “We can’t say where we’re going to be deployed, but there is no question that we will be deployed where we can best serve.”
Retinal physicians in private practice meanwhile can offer leadership in their communities, Dr. Parke said. “Our families, our friends, our staff are looking to us for real scientific distillations, recommendations, and just plain old-fashioned advice.”
That requires staying up to date on the research and recommendations of public health authorities. Above all, it requires calm. “The first thing is to take a deep breath,” counseled Dr. Sridhar. “There is a light at the end of the tunnel. We just don't know how long that tunnel is yet.”Editor’s note: This article was published online April 8, 2020, ahead of print in the May 2020 issue of Retinal Physician.