(Part 1) From ophthalmology’s lockdown to lasting change: Five Aprils ago

April 2020: A moment of stillness that reshaped everything. Five years on, ophthalmology continues to evolve from that turning point. (Image credit: AdobeStock/concept w)

Five years ago, in April 2020, ophthalmologists across the country were navigating shuttered offices, improvised personal protective equipment (PPE), and a cascade of unknowns. Just weeks earlier, the World Health Organization had declared COVID-19 a global pandemic—setting in motion a series of events that would redefine clinical care.

Now, in April 2025, we mark 5 years since that turning point—not just to remember the disruption, but to reflect on the transformation. In this Part 1 of a series, we asked a geographically diverse group of clinicians—including members of the Ophthalmology Times Editorial Advisory Board and Strategic Alliance Content Partners—to share how those early days shaped their practice, their priorities, and their perspective.

Part 2: From ophthalmology’s lockdown to lasting change: The pandemic habits that stuck

Reflecting on 2020

The early months of the COVID-19 pandemic brought unprecedented challenges to ophthalmology practices, from sudden lockdowns to navigating patient care amid evolving safety protocols. Clinicians were forced to make swift, defining decisions—often under pressure—that reshaped how care was delivered. The introduction of PPE, such as face masks and slit-lamp shields, became part of the new normal, altering daily routines and patient interactions. These early adaptations not only ensured continuity of care but also laid the groundwork for long-term changes in how ophthalmologists approach safety, efficiency, and resilience in clinical practice.

“It was clear that ophthalmologists were amongst the top three specialists to contract the illness, so protecting our people while they cared for their patients was a major concern.” — Peter J. McDonnell, MD

“It was clear that ophthalmologists were amongst the top three specialists to contract the illness, so protecting our people while they cared for their patients was a major concern,” said Peter J. McDonnell, MD, the director and William Holland Wilmer Professor of Ophthalmology at the Wilmer Eye Institute at the Johns Hopkins University School of Medicine in Baltimore, Maryland, and co-chief medical editor of Ophthalmology Times.

“While especially early on in the pandemic, when the fatality rate was uncertain and erroneously believed to be higher than it was, I would say there was some anxiety but that our doctors and staff felt very positive about their ability to care for the patients who needed them,” McDonnell said. “We faced a challenge when the availability of PPE was so limited that it was being reserved for workers in our ICUs, emergency room, and operating rooms.

“We improvised and quickly installed shields on our slit lamps, made our own face shields and (when construction workers were ruled ‘nonessential’ in our state) we were fortunately able to acquire 50,000 N95 masks,” he said. “This helped us very much to get through the pandemic with only one of our physicians experiencing a brief illness requiring a one-day hospitalization, and no prolonged hospitalizations or deaths.”

Additionally, at Wilmer Eye Institute, “we communicated with our patient population, emphasizing that we were remaining open for business and making sure our patients with time-sensitive problems, who would be at risk for permanent vision loss if their care was delayed, knew to come in as scheduled,” McDonnell continued.

Most ophthalmic practices in Maryland severely curtailed their hours or temporarily closed and furloughed their workers, he said.

“Because most patients with routine needs (eg, annual eye examinations) chose to put off their visits, we were able to remain open, fully staffed, and available to handle the needs of our established patient population as well new patients from elsewhere with urgent care needs,” McDonnell added.

"The most challenging aspect of COVID from the clinical perspective was navigating how to safely continue caring for our patients during a pandemic due to a virus that we didn’t know much about." —Nicole Bajic, MD

At the Cleveland Clinic’s Cole Eye Institute, “The most challenging aspect of COVID from the clinical perspective was navigating how to safely continue caring for our patients during a pandemic due to a virus that we didn’t know much about. And while some other specialties in medicine may have had an easier time with converting to virtual appointments, we are just not set up for that in a technology-reliant field like ophthalmology,” said Nicole Bajic, MD, Director of Communications at the Cole Eye Institute, and Assistant Professor of Ophthalmology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio.

Nicole Bajic, MD

“From a health perspective, as I was the least at risk from COVID, I volunteered to initially see all patients for the entire practice at the beginning of the pandemic,” she said. “Shortly thereafter, we made a plan with our retina specialist to risk stratify patients and coordinate our resources to prioritize the most at-risk patients. The use of PPE did not significantly interfere with patient care, but I would say that there was a looming anxiety about limited resources and the unknown about just how important certain aspects of PPE were.”

Oluwatosin “Tosin” Smith, MD, attending physician and surgeon, Glaucoma Associates of Texas in Dallas, noted the biggest challenge was one of immediate shut down which prevented access to care for patients.

"In the first few weeks, we had to quickly come up with a reduced schedule mostly for emergencies and postoperative patients.” —Oluwatosin “Tosin” Smith, MD,

“In the first few weeks, we had to quickly come up with a reduced schedule mostly for emergencies and postoperative patients,” she said, “but subsequently, with the evolution of visit models, increased availability of PPE and masks, we were able to increase the number of days that the office was open and see a higher number of patients after carefully triaging patients according to need and stage of disease.”

Rescheduling and making sure prescription refills were sent in was time consuming especially at a time when many offices were not working at full staff. Visual field testing was reduced due to concerns about the potential risks associated with the testing environment using the Humphrey visual field (HVF) machine, she noted.

For many ophthalmologists and practices, the biggest challenge was managing the fear of the unknown.

David Eichenbaum, MD

“In the office, the physicians and staff did not know how the pandemic would progress or who would become ill, and patients were fearful for their systemic health, which easily eclipsed their concern for their ocular health,” said David A. Eichenbaum, MD, director of research with Retina Vitreous Associates of Florida in Clearwater and St. Petersburg. “At home, my family was fearful I would return from clinic infected with COVID-19. I wore scrubs to the office and PPE daily, and when I returned home, I would remove my clothes in the garage and shower before contact with my family. Our clinic never closed, but we did defer elective visits for the first few months of the pandemic.”

"At home, my family was fearful I would return from clinic infected with COVID-19. I wore scrubs to the office and PPE daily, and when I returned home, I would remove my clothes in the garage and shower before contact with my family.” —David A. Eichenbaum, MD

For John Berdahl, MD, with Vance Thompson Vision in Sioux Falls, South Dakota, the early months of the COVID-19 pandemic felt like a ‘Super Bowl’ of leadership.

“In our practice, we pushed to balance quality patient care with the imperative to keep our team safe,” he said. “A smallish hurdle was rapidly implementing appropriate protocols—adopting PPE, using face masks, and installing protective shields on slit lamps. A bigger hurdle was the leadership decisions: how do we protect our staff with extra safety measures and support, do we require vaccination or you lose your job, how do we manage finances as government bailouts were uncertain. Ultimately, we chose to ensure no one was laid off, even before the bailout.”

Amid these high-stakes decisions, the unexpected value of slowing down became evident.

“Many of us discovered the joy of spending more quality time with our families and taking reflective walks with our spouses.” —John Berdahl, MD

“Many of us discovered the joy of spending more quality time with our families and taking reflective walks with our spouses,” Berdahl said.

These moments of personal reconnection became a counterbalance to the stress of crisis management, highlighting that leadership is not only about making difficult decisions but also about nurturing well-being, he added.

For Ehsan Sadri, MD, chief executive officer and founder of Visionary Eye Institute in Newport Beach, California, starting a new practice amid a global pandemic profoundly impacted his approach to ophthalmology.

“Starting my ophthalmology practice in October 2019, just before COVID-19 hit, was challenging.” — Ehsan Sadri, MD.

“Starting my ophthalmology practice in October 2019, just before COVID-19 hit, was challenging,” he said. “Implementing PPE like masks and shields became essential, altering daily routines to ensure safety. The challenges encountered fostered resilience and innovation, laying the foundation for a more adaptable and patient-centered practice in the future.”

RELATED: When the world went virtual: How ophthalmology’s conferences stayed on track

New York City quickly became the epicenter of the COVID-19 outbreak in the US, earning the dubious distinction of the nation’s “hot zone,” said James C. Tsai, MD, MBA, president, New York Eye and Ear Infirmary of Mount Sinai; Delafield-Rodgers Professor and Chair, Department of Ophthalmology; Icahn School of Medicine at Mount Sinai, Mount Sinai Health System.

New York City quickly became the epicenter of the COVID-19 outbreak in the US, earning the dubious distinction of the nation’s “hot zone.” —James C. Tsai, MD, MBA

“Infections climbed exponentially and overwhelmed our limited medical resources,” he said. “Nonurgent elective surgeries and procedures had to be temporarily postponed to preserve scarce resources and supplies while urgent ophthalmic conditions (eg, retinal detachment repair) were prioritized and performed with dedicated surgeons and staff.”

Telemedicine became a vital tool in the ability to render timely care and maintain the safety of our staff and facilities.

“We employed a tele-ophthalmology triage system, transforming our busy walk-in clinic into a virtual one,” Tsai said. “Teleconferencing was quickly adopted to maintain constant communication among our attendings, residents, and fellows. Lectures, microsurgical courses, and Grand Rounds quickly transitioned to virtual platforms.”

PPE was difficult to obtain, though essential, in keeping staff and physicians safe and maintaining their physical and mental well-being. New processes had to be implemented to minimize transmission of the virus during our day-to-day practice, he added.

Adaptation and change

Telemedicine played a pivotal role in maintaining patient care during the pandemic, offering a safe and accessible alternative when in-person visits were limited. Both clinicians and patients had to quickly adapt to this new mode of care, often requiring adjustments in technology use, communication styles, and expectations. Practices also made key operational changes—such as reworking scheduling systems, modifying staffing models, and enhancing patient communication—to better navigate the challenges. In the process, many teams developed new skills and protocols that not only addressed the immediate crisis but also strengthened their ability to deliver care in a more flexible, resilient way moving forward.

“We worked to streamline our visits, eliminating as much as possible the traditional wait in a waiting room full of old magazines and instead quickly putting patients into examination rooms and taking histories and performing examinations that were extremely problem focused,” McDonnell said. “Patients with time-sensitive problems that could not delay their visits took comfort in knowing that they were being seen as efficiently as possible and with stringent attention to cleaning and sterilizing surfaces between visits.”

Peter J. McDonnell, MD

An analysis of the Current Procedural Terminology codes associated with visits before and after the pandemic showed a major shift away from the routine (eg, cataract) and toward the more serious (malignancy, ocular inflammatory disorders and retinal diseases,¹ he noted.

Scheduling and back-office employees were already experienced with remote working, so our ability to handle calls, scheduling, or billing was not in the least negatively impacted, McDonnell continued.

“Our use of telemedicine increased 60-fold, but still this amounted to a small percentage of our overall practice,¹” McDonnell said. “I found the technology available for ophthalmic ‘telemedicine’ to be extremely limited, especially for the complicated tertiary and quaternary care-type patients that make up much of the population served by my faculty. Only about 3% of our overall practice converted to virtual visits. Clearly, there is a need for better instrumentation, and I believe when the next pandemic occurs, we will be able to increase that percentage.”

“One of my personal friends from residency, Chad Ellimoottil, MD, MS, is the Medical Director of Virtual Care for University of Michigan,” Bajic said. “He was a tremendous resource for getting our practice up to speed with how to functionally do telemedicine and also bill appropriately to mitigate losses. With respect to operational changes, we definitely did have to pare down the volume of patients we were seeing, but we had a fantastic support staff who we heavily relied on to carryout decisions and send out communications to patients.”

Smith said her practice introduced virtual visits using telemedicine either as a phone or video conferencing visit and performed some as a hybrid with portions of the exam and testing being done in-person and a follow-up visit by telemedicine.

Oluwatosin “Tosin” Smith, MD

Triaging emergencies also became necessary in deciding who needed to come into the office.

“Many of the older patients generally had a harder time with technology especially with video conferencing. We had to continue adapting with very fluid scheduling changes as we gained insight and learned from other colleagues,” she said. “Our staff was able to make changes and adapt and continue trying to figure out the best ways to serve patients.”

One big schedule change was the introduction of testing-only visits and the introduction of virtual reality visual field testing to our practice, Tosin added.

“We did not participate in telemedicine, and we never closed our traditional clinic,” Eichenbaum said.

As a field, everyone became a lot better at virtual meetings as well as the concept of some employees working from home.

“Retina congresses are a large part of my career, and everything became virtual overnight,” he said. “Both the virtual meeting providers and the virtual meeting participants improved rapidly over the first 6 months of the pandemic.”

For Berdahl, “telemedicine emerged as a useful tool that, while not central to our practice, prompted us to critically evaluate which patient visits were truly necessary,” he said.

John Berdahl, MD

The crisis forced us to reconsider our traditional model, and virtual consultations via platforms like Zoom became a stopgap measure that allowed us to continue offering care while minimizing in-person contact. Scheduling and staffing were restructured to ensure that essential services were maintained, adapting patient communication strategies to meet new safety standards. Operational changes included streamlining appointments and enhancing remote follow-ups, which not only reduced risk but also improved efficiency, Berdahl noted.

“This period of rapid adaptation saw our team developing new skills and protocols, making us more agile in the face of uncertainty,” Berdahl explained. “Overall, even though telemedicine was not our primary modality, it was instrumental in reshaping our approach to care and reinforced the importance of flexibility and continuous evaluation in healthcare delivery.”

Telemedicine became vital, allowing patient care to continue despite restrictions. “Both patients and I adapted to virtual consultations, which expanded accessible care,” Sadri said. “Operational changes, such as adjusting clinic schedules and enhancing digital communication, were implemented to maintain service continuity while adhering to safety protocols.”

“Telemedicine played a major role in allowing us to continue caring for patients during the pandemic,” Tsai added. “We shared our teleophthalmology implementation methodologies in one of the earliest publications² on virtual ophthalmology in response to the COVID-19 pandemic.”

Our practitioners, staff, and patients were willing to adjust to new technology if it meant that timely care could be continued to be rendered during the pandemic. There were certainly challenges in adjusting to virtual care and recognizing that certain subspecialties in ophthalmology (eg, oculoplastics, neuro-ophthalmology) were more amenable to telehealth visits than others (eg, retina, glaucoma).

Transformative operational changes were necessary to adopt to the pandemic. Virtual check-in exams required telephone calls with supporting documentation. Telehealth visits necessitated checking that broadband connectivity was intact and reliable. Care plan modifications and consenting for upcoming planned procedures needed to be made through virtual visits. Thus, providers and the clinical team had to be flexible and adaptable to meet these ongoing challenges.

"Virtual education platforms were quickly embraced to ensure continuity of education and training of our residents, fellows, and medical students," Tsai said. Lessons learned from the pandemic have help academic programs to transition into making lectures, microsurgical courses, and Grand Rounds more amenable to remote instruction.

References

1. Berkenstock MK, Liberman P, McDonnell PJ, Chaon BC. Changes in patient visits and diagnoses in a large academic center during the COVID-19 pandemic. BMC Ophthalmol. 2021;21(1):139. doi:10.1186/s12886-021-01886-7

2. Saleem SM, Pasquale LR, Sidoti PA, Tsai JC. Virtual Ophthalmology: Telemedicine in a COVID-19 Era. Am J Ophthalmol. 2020;216:237-242. doi:10.1016/j.ajo.2020.04.029