How COVID-19 can impact your practice: Ophthalmologists respond

As COVID-19 continues to spread in the United States and internationally, the disease increasingly is becoming a cause for concern throughout the healthcare field, including the ophthalmology community.

This week, the World Health Organization (WHO) officially declared COVID-19 a pandemic, meaning it has spread to more than 100 countries.

The coronavirus can cause respiratory infections, including pneumonia. Symptoms can include respiratory illness, fever, cough, shortness of breath and conjunctivitis. In the office, the virus can be spread by respiratory droplets. As a result, it is imperative for ophthalmologists to wear eye and nose protection. This can include goggles or an N-95 mask.

Ophthalmologists respond

William W. Culbertson, MD, professor of ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, said his office is trying to screen patients by phone contact, at the check-in desk, and when the technician sees them.

“If they have flu-like symptoms they are given a mask, and the doctor and other staff wear masks,” he said. “Sanitizer is used on the exam rooms furniture after seeing each patient.” Dr. Culbertson added that there are more no-shows for both clinic exams and surgery.

As for concern, he said he has a high level of concern for the virus becoming a prolonged, endemic threat for doctors and staff.

“It appears to be extremely contagious and potentially lethal to older people with existing pulmonary problems,” he said. “There is no natural barrier or end in sight. Not since World War II has there been such potential for disruption of everyday existence.”

Dr. Culbertson noted that the University of Miami has prohibited foreign and domestic academic travel for the foreseeable future.

“I will probably not be traveling to ARVO, ASCRS and the World Corneal Congress this spring, or to Europe this summer,” he said.

Fluid situation

According to Michael Raizman, MD, Massachusetts Eye and Ear, Harvard University, Boston, a lot has changed in recent weeks and continues to change daily.

“Because Boston has an increasing number of COVID-19 cases there, restrictions are multiplying rapidly,” he said. “We are in the process of installing plastic barriers on our slit lamps that will provide some increased protection from droplet spread.”

Dr. Raizman also is screening patients by phone for symptoms of upper respiratory infections, and he has seen a decine in patient traffic. During a recent day, he had about 15% of patients cancel appointments for exams.

”Some patients are calling and asking to postpone elective surgery that had been scheduled,” he said.

Moreover, as physicians, Dr. Raizman noted that the profession interfaces with educational and governmental institutions and the restrictions imposed on them by those groups are increasingly stringent.

“Hospitals are restricting elective surgery,” he said. “Meetings of groups are restricted. A week ago it was no more than 200 people. Now, in some cases, it is no more than 10 people.”

Dr. Raizman added that some medical centers are canceling patient office visits entirely, unless the visits are urgent and cannot be rescheduled at a later date.

“Grand rounds and other educational activities are canceled or converted to video-conferences,” he said. “Medical centers are prohibiting any air travel for doctors, including domestic flights.”

Rapid changes

According to Laura M. Periman, MD, an ocular surface disease expert and director of Dry Eye Services and Clinical Research in Seattle, the situation continues to change rapidly, and on a recent day, her office did several things differently.

“The waitlist for the Dry Eye Services clinic is four months long, so most patients are still showing up, except for the ones that fly in to see us,” she said. “We have a sign on the door, ask screening questions at check in and wipe down all surfaces, handles, equipment with Cavicide wipes in between patients.”

Dr. Periman noted that every physician and technician has a full hand-washing session before and after each patient encounter as well as frequent Purell touch ups in the lane when touching equipment.

“We use a no-touch technique for instilling drops and examining the eye,” she said. This can include the use of a cotton swab to check the lids, meibomian gland dysfunction, etc. New patients are greeted warmly but handshakes are skipped.

Dr. Periman noted that COVID-19 is now endemic in Washington.

“I have several friends from medical school on the front lines and the contagiousness and seriousness of infection and severity of illness is very concerning,” she said. “Several physicians are out on quarantine.”

In her region, Dr. Periman noted that the Gates Foundation and the Fred Hutchinson Cancer Research Institute have been pivotal in making COVID-19 testing available for healthcare workers.

Given the medical systems and staffing overwhelm seen in Italy, these proactive measures are wise. Dr. Periman also has noted an increase in travel-related issues.

“Our high-attendance annual Washington Academy of Eye Physicians and Surgeons (WAEPS), scheduled for the end of March, has also been postponed,” she said. “I am limiting travel. I practice excellent hand-washing hygiene, avoid touching my face and eyes, and carry disinfecting wipes with me.”

Rescheduling appointments

According to Uday Devgan, MD, FACS, is in private practice at Devgan Eye Surgery in Los Angeles and Beverly Hills. He also is clinical professor of ophthalmology at the Jules Stein Eye Institute at the UCLA School of Medicine and Chief of Ophthalmology at Olive View-UCLA Medical Center. He noted that most of what his office does in ophthalmology is elective, particularly in his cataract and refractive surgery practice.

“This means that any patients who are feeling a bit under the weather and encouraged to stay home and reschedule both clinic and surgery center appointments,” he said. “Your systemic health is more important than the cataract surgery-if you may be sick, whether it is covid-19, the flu, or even a garden variety sore throat, then please let us reschedule your elective surgery for a future date when you are back to feeling 100%.”

As a result, Dr. Devgan said his practice has seen about 15% of its scheduled cataract and refractive surgery patients elect to reschedule their procedures for a future date.

As for his level of concern, Dr. Devgan said his offices are cautious and taking it day by day.

“We are heeding the guidance of our trusted colleagues and leaders and using the same high level of hygiene that we always do,” he added. “Keys are hand-washing, disinfecting the equipment thoroughly for each patient, and using gloves when touching near mucous membranes such as the ocular surface.”

Dr. Devgan also is keeping a watchful eye on current restrictions as he looks toward future travel plans.

“A few local ophthalmology meetings have been cancelled or postponed, but it seems like the upcoming ASCRS in Boston in May is still on,” he said. “We don't have any family vacations planned in the next month, but perhaps we will need to cancel our trip in May if COVID-19 gets out of control. Maybe that's a good thing because I could use a ‘staycation’ to relax and home and finally clean-out the garage.”