Eye to the Sky: Ophthalmologists Aided Hurricane Response

Caroline Helwick

November 17, 2017

NEW ORLEANS — Eye care is one of the most common acute medical needs after natural disasters. After recent hurricanes devastated Houston, Texas, and Puerto Rico, ophthalmologists were quick to respond, but having a plan in place speeds aid. Several groups are now developing plans that can be shared and modified for particular settings.

In Houston, specialty eye care clinics were promptly established within shelters, as the city had an eye care disaster plan in place. Puerto Rico, lacking such a plan, relied on a dedicated group of ophthalmologists on the mainland to bring order to the chaos.

At the American Academy of Ophthalmology (AAO) 2017 Annual Meeting, these dedicated ophthalmologists told their stories.

Hurricane Maria, Puerto Rico

Eduardo C. Alfonso, MD, chairman and director of the Bascom Palmer Eye Institute at the University of Miami, Florida, described how US ophthalmologists became critical to the relief mission in Puerto Rico after the aftermath of category 4 Hurricane Maria on September 19.

"In preparation for hurricanes, we have plan of action in Miami. As soon as I heard that Maria would hit Puerto Rico, I started texting my colleagues there to see what plan of action they had in place for safety and recovery. It soon became obvious that plans were not firmly laid out on the island," Dr Alfonso said at a press briefing.

Given that information, Dr Alfonso and colleagues jumped in to provide support. Michael Kelly, director of strategic operations at Bascom Palmer, lent his experience from previous disaster relief to help organize the mission there, and Dr Alfonso set up a WhatsApp conversation. The mobile app allows up to 250 people to join a single conversation on a phone or computer. He named the group Eye Care Puerto Rico.

Kelly developed a template of "status indicators" as a way to communicate about facility and transportation issues, patient care needs, and requests for staffing, and he created a hotline through which US ophthalmologists could accept patient transfers from the island.

Dr Alfonso and Kelly flew to Puerto Rico to get a close-up look at what was needed and to determine what more they could do, bringing with them coolers stocked with much-needed ophthalmic medications.

WhatsApp Critical for Communication

To form the Eye Care Puerto Rico WhatsApp group, Dr Alfonso added the names of many US physicians and others "who we felt could help," and the president of the Puerto Rican Society of Ophthalmology uploaded the telephone numbers of that society's members. The group held daily 6 pm conference calls to discuss the day's accomplishments and to craft a plan for the following day.

WhatsApp participants used the chat room to let others know how they were faring and to make requests. Many asked for medications. One messaged, "You can help us by sending us large quantities of anti-VEGF. I can coordinate the logistics....People could go blind...That would be really sad...With all my heart, in anticipation..."

Representatives of the ophthalmic industry were included in the group and quickly stepped up to contribute. For one, Regeneron messaged the doctors, "Don't throw out your Eylea. We will replace all that was damaged."

Getting fresh medications into damaged areas became a priority. For this, Dr Alfonso and his team enlisted airlines, cruise lines, and nongovernment organizations traveling from the United States to the island.

Untangling the Red Tape

Aside from bringing eye care to residents, a big need, and challenge, was untangling the red tape that hindered the medical treatment of evacuees to the US mainland. Although many Puerto Ricans have Medicaid and Medicare insurance, it is not directly transferrable to US practices. "We needed to make this insurance work for patients evacuating," Dr Alfonso said. This required regulatory flexibility from the Centers for Medicare & Medicaid Services. The AAO helped iron out these kinks and also worked with the Federal Emergency Management Agency to secure transportation to the mainland for neonates needing surgery for retinopathy of prematurity and other pressing conditions.

The US ophthalmology relief mission is ongoing, and it is not confined to that island but extends to other Caribbean islands that also were affected, Dr Alfonso said.

Hurricane Harvey

Hurricane Harvey made landfall as a category 4 storm on August 25 some 180 miles south of Houston. Flooding in downtown Houston began a day earlier, creating complete loss of access to most medical care for the city. Damage to nearly 135,000 homes sent thousands of residents to 250 shelters, with 10,000 ultimately consolidating into the George R. Brown Convention Center and the NRG complex.

But the Houston ophthalmology community was ready to go. The city had learned much from Hurricane Alicia, which hit the city in 1983, and from housing Hurricane Katrina evacuees in 2005.

"This was not our first rodeo," said Amy G. Coburn, MD, vice chairman of Prevent Blindness Texas and director of community outreach for the Houston Ophthalmological Society.

Dr Coburn described how disaster relief planning facilitated the rapid, nimble delivery of critically needed eye care for a large population. Houston ophthalmologists stepped right up, even including some who lost their own homes. "In Texas, everybody helps. It's almost an inspiring situation to be in," she said.

Disaster Plan Already in Place

As a result of experience and planning, the Houston ophthalmology community had an eye care disaster plan template and bank of resources organized even before Harvey threatened the city. This was the second hurricane shelter-based ophthalmology relief effort Dr Coburn had organized as an executive board member of Prevent Blindness Texas. Ten years ago, she had coordinated the eye relief effort for Katrina evacuees housed in the Astrodome and the Convention Center.

In 2007, she spearheaded the development of the Eye Care Emergency Disaster Response Plan, which covers various disaster scenarios likely for Houston and customizes operations and clinic plans for these situations. The mission of that plan is to support and maintain vision to allow victims "to recover their lives," she said.

Booting up the Plan

Volunteers from the Houston Ophthalmological Society were on deck immediately, tending not only to eye concerns but also to emergencies and any other health issues.

"Within 4 days, we opened up fixed eye clinics in two locations," she said. These clinics were soon delivering large-scale comprehensive eye care 7 days a week for the 10,000 evacuees in the shelters. In the early aftermath, these shelter clinics averaged 250 to 350 visits a day.

The team was a multidisciplinary mix of ophthalmologists, optometrists, ophthalmic assistants, opticians, screeners, equipment repair vendors, city health workers, and ophthalmic industry representatives. They provided comprehensive eye exams, screenings and diagnosis, free prescription glasses, free readers, and a full selection of commercial eye medications.

As in any other flood, the primary problems were lost glasses and medications. Contaminated flood water and trauma set the stage for infections, and many evacuees needed to be managed for chronic health issues as well. Because most victims were from underserved areas, the team diagnosed many new cases of diabetic retinopathy, cataracts, and glaucoma. One individual sustained an open globe with endophthalmitis resulting from trauma from a floodwater-contaminated air conditioning coil and foreign bodies.

"The long list of our diagnoses shows the breadth of the problems that you must be prepared for, most of which the emergency care doctors and other providers were unable to diagnosis and treat," she said.

Eye care and dental care were the health services most in demand in the shelters. Within the first 3 weeks of September, more than 1650 patients were treated for ophthalmic conditions, 1850 were triaged, and 1587 received glasses. The team was actually able to grind lens on site in some cases. Others received vouchers for glasses from local outlets.

What's Next

Hurricane Harvey provided some new lessons about disaster response that Dr Coburn will consider in the updates to her Disaster Response Plan. She said they learned the importance of understanding regional infrastructures, of having protected generators in clinics and hospitals, of getting accurate weather forecasts and recognizing shifting timelines, and of appreciating that the mission may change, depending on the disaster scenario.

For the future, she and her colleagues hope to have access to more equipment that is portable, simple, accurate, and not dependent on electricity. They also aim to improve communication with patients through portals, to make better use of electronic analytics for triage and data management, and to incorporate real-time communication. She believes that operations can also be streamlined to reduce redundancy of staff and make better use of resources and supplies.

"We also need to be at the table with [the Federal Emergency Management Agency] in planning for future disasters," she added.

Dr Coburn and colleagues will be updating their Disaster Response Plan with input from the AAO, and ideally the military, to create "a template that could be an algorithmic disaster response plan," she said. This will be detailed down to the type and number of medications that should be stocked for a given scenario in a given locale. The aim is to have all options predetermined to eliminate "the stress of thinking through a disaster response on the fly."

The plan will be modifiable according to scenarios (weather, industrial accident, mass casualties, etc), be attentive to regional infrastructure, and consider the perspectives and roles of all types of staff, vendors, and referral facilities.

Although their ophthalmic disaster plans have been copied by other cities, Dr Coburn believes most US cities remain frighteningly underprepared.

Future Response Will Be Even More Portable

Richard K. Lee, MD, also from Bascom Palmer, described how the institute's Vision Van Mobile Eye Clinic provided a myriad of services when Hurricane Irma hit the Florida Keys on September 10, 2017. The Bascom Palmer response team has also provided emergency eye care in Haiti after the earthquake of 2010, and in Japan after the Tohoku tsunami in 2011.

"While disaster medical assistance teams are brought into these areas, ophthalmologists are among the specialties that [disaster medical assistance teams do] not cover," he said. "We offer something outside of their comfort zone and are one of the few medical groups allowed into disaster areas."

His team, he said, has learned these lessons: be personally prepared and keep yourself safe and secure, customize the response to the type of disaster, anticipate needs and bring the necessary resources, and help in any way possible.

Portable technology and the harnessing of the latest smart phone technology are becoming part of an effective disaster response. "We can now do many things that replicate what we do in the office. We can quickly diagnosis and offer treatment. I can fit most of the tools I need into a backpack that's been around the world," he said.

Dr Alfonso, Dr Coburn, and Dr Lee have disclosed no relevant financial relationships.

American Academy of Ophthalmology (AAO) 2017 Annual Meeting. Presented November 13, 2017.

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