COVID-19: What the reopening of ophthalmology could look like

Nearly two months after the American Academy of Ophthalmology issued a practice guidance urging ophthalmologists to cease providing “any treatment other than urgent or emergent care,” the group is now taking steps to consider the process of reopening ophthalmology care.

“Our efforts and the efforts of millions of our fellow citizens have succeeded in flattening the curve compared with the prognostications of many of our most thoughtful public health experts. Some parts of our country (most notably places like New York City, New Orleans and Detroit) have suffered horribly,” David W. Parke II, MD, CEO of the AAO, wrote in a letter posted on the Academy’s website. “Other areas, thankfully, have had a considerably more muted experience.”

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Parke noted that one observation from this experience is that the impact has been regional, but that Americans are all connected.

“A hot spot in one area can impact other areas if we do not take care to limit transmission,” he wrote.

According to Parke, while the Academy’s recommendation to curtail ophthalmic practice was national in scope, the decisions to return to more normal practice will be made on a local and regional basis.

“They will be based on local and state governments, on public health authorities interpreting local patterns of disease, on testing availability, on institutional policies and ultimately on individual ophthalmologists,” he wrote. “While we closed routine practice nationally, we will open locally.”

Parke stressed that ophthalmology is not “returning to normal.”

“The lessons learned from COVID-19 may mean that the normal of January 2020 may never approximate the normal of the future,” he added. “We will have the SARS-CoV-2 virus with us for years. We will always have the memory of what it means to shelter in place for weeks on end, to furlough staff and to defer patient care. What we must do now is develop the processes to provide patient care in a new normal.”

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Peter J. McDonnell, MD, chief medical editor of Ophthalmology Times,^® and director of the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, agreed that decisions will be complex and will depend on several variables from region to region, including the decisions of government officials (in some parts of the country there are executive orders preventing doctors from providing non-urgent care).  

“So legally, the governors or, in some cases mayors, would have to decide to allow practices to reopen,” he said.

McDonnell also noted that the degree of community spread varies widely, with some counties in the United States having zero cases and others heavily affected and not yet reaching their peaks.  

“For instance, right now in Baltimore we are approximately flat while in neighboring Washington, D.C., the curve is still up and their peak is not projected to occur for some time in the future,” he said.

According to McDonnell, many industry leaders are recommending that should only occur when a region has been on the downslope in terms of number of cases for two weeks.  

“So that is obviously a local and not a national data point,” he said.

Moreover, when clinics begin to reopen, precautions will be in place, including the use of protective masks, social distancing, and limiting the use of waiting rooms.  

“Some clinics might be better able to reopen sooner because they have better access to personal protective equipment and perhaps a larger physical plant allowing them to avoid having patients next to each other in waiting areas, etc.,” McDonnell said.

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McDonnell noted that the Wilmer Institute, in collaboration with the rest of Johns Hopkins, has a working group planning how best to reopen when the time comes.  

“The considerations include topics such as maximizing the safety of our patients and our clinical staff, maximizing the appropriate use of telemedicine, minimizing use of waiting areas and other common areas, limiting as much as possible the presence of companions who might wish to come with the patients, deciding on the appropriate use of testing (such as whether to test asymptomatic patients preoperatively), most wisely using personal protective equipment, and so on,” he said. “We will share our best thinking on these and other issues so that other practices around the country can see what we are doing and adopt similar practices (or not) depending upon their local situations and resources.”

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Arun C. Gulani, MD, founder of the Gulani Vision Institute in Jacksonville, FL, concurred that as different states are looking at individual situations, every ophthalmic practice is different. He said there will be two factors involved going forward, including necessity and safety.

“Necessity, meaning if the practice sees more emergent and glaucoma-retina patients that need to be seen, and also if that practice is only one in town so patients need help,” he said.

Safety relates to patient, physician and staff safety

Gulani said this, along with peripheral factors like how state and local areas are  impacted and whether hospitals are dealing with an influx of COVID-19 patients.

“With all this in mind, one can plan a step by step approach, of course following their governor's orders, and with keeping all AAO and CDC guidelines for prevention, detection and safety,” he said.

Practices also are relying on social media and websites to update patients.

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Cathleen M. McCabe, MD, chief medical officer, The Eye Associates in Bradenton and Sarasota, FL, noted her practice is continually updating its website with practical information such as hours of operation of its different clinics, what the screening process is and how patients can access the products they may need in the short term, such as contact lenses, glasses, and supplements.

The Academy in the coming weeks will issue guidance documents that will offer details on how to handle some of these key decisions that need to be made as ophthalmologists begin to move forward in practicing in the COVID-19 era.

Parke concluded that each practice and organization will need to make its own decisions based in part on local factors.

“The Academy will try to provide you with tools, resources and suggested options in the coming weeks,” he wrote. “We all want to get back to work, do what we were trained to do and fulfill our mission of protecting sight and empowering lives-while keeping everyone as safe as we can.”

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