COMMENTARY

As Ophthalmology Clinics Reopen, New Questions Abound

Sumit (Sam) Garg, MD

Disclosures

July 24, 2020

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As the COVID-19 pandemic continues to upend our professional and personal lives, predicting what the future may hold has become an increasingly difficult task.

In March, when I last wrote about how the pandemic might impact ophthalmology, my questions largely revolved around the ramifications of temporarily shuttering practices. Those were soon answered, as my practice shut down everything except for urgent and emergent care. As a corneal/cataract surgeon, the vast majority of my practice came to a standstill. I dabbled in telehealth but found that most of my effort was spent trying to get the patient to navigate the technology rather than discussing their ocular condition. Even though I found it to be a frustrating exercise on the whole, most of the patients I interacted with were happy and found value in the visit.

We are now back to clinical practice, often face-to-face with our patients again, yet the uncertainty remains. What will our new normal look like?

Some aspects are already apparent: first, that our day-to-day practice requires new protocols. We administer questionnaires and temperature checks for all those entering the clinic (eg, patients, staff, physicians). Masks are mandatory. Examination rooms and equipment are wiped down between each patient. Nonessential patient visitors are asked to remain outside. Social distancing is strictly enforced, with more than half of our waiting chairs blocked off.

Another effect of COVID-19 on my practice is the delay of care for patients. Some are eager to come back to the clinic and proceed with surgery, but several other patients have postponed visits, which I fear may lead to untoward morbidity.

I recently saw a patient who, after undergoing Descemet membrane endothelial keratoplasty, had noted a slow drop in vision. Being elderly and wanting to avoid possible exposure to the virus, she decided to wait to visit our practice until 2 months after the onset of symptoms. Unfortunately, upon presentation her intraocular pressure was 45 mm Hg, probably secondary to a steroid response, and she exhibited an afferent pupillary defect in the affected eye. I can't help but think that she would have presented earlier if she didn't fear that visiting a doctor's office would potentially expose her to COVID-19.

Overall, the majority of patients scheduled for surgery pre-COVID-19 have responded positively to our reengaging with them, but some remain reluctant. The worrisome part is that it has been hard to track who has come in, who needs to come in, and who may have been missed. At this point, we are working through our backlog and trying to accommodate those routine and urgent patients as they present.

In California, where I practice, we were on a relatively early timetable to resume elective surgeries. After years practicing in an academic system and suffering through the seemingly endless bureaucracy and compliance mandates, this may be the first time that we are actually better off than private ambulatory surgery centers in regard to the effect of rules and regulations on our workflow. With the exception of COVID-19 testing being required for all patients 48-72 hours prior to surgery, masking of patients, and limiting family members in the pre- and post-op areas, our surgical workflow has been minimally impacted. We are also doing our best to slow our burn of personal protective equipment by limiting how many cases students can scrub in and reducing surgical technician swap-outs during cases.

Our academic meetings have also been notably affected by COVID-19. Many have postponed, transitioned to virtual meetings and/or hybrid meetings, or have opted to cancel. After canceling its annual in-person meeting, the American Society of Cataract and Refractive Surgery (ASCRS) was able to pivot to a well-received virtual meeting in May. Our largest meeting, the American Academy of Ophthalmology, just announced that it too will be held virtually later this year.

It's unclear how clinician education will function in a world of virtual congresses. I was impressed, and frankly surprised, by the quality of education and the viability of the virtual format at ASCRS. Will this be emblematic of what's to come or an exception? Although many high-quality meetings are occurring virtually, I'm concerned that attendees are getting Zoom fatigue. I also wonder how long industry will be willing to support virtual meetings as their ability to interact with attendees is certainly limited.

It will be several years before we fully understand the economic impact of COVID-19 on our practices and on our field as a whole. Certainly, the short-term loss is evident. What will the long-term loss be? Will we ever make up the losses? How many practices will be forced to shut down? How many patients suffered morbidity because they were scared to seek care due to COVID-19?

On the flip side, some positive developments may come out of these difficult times. One clear advantage is found in the streamlining of patient care and possibly even implementing procedures like same-day bilateral sequential cataract surgery on a more wide-scale basis.

Many have also espoused the benefits of investing in and improving telehealth. Even though I am currently not a huge fan of it, I do think there is a role for telehealth in ophthalmology, but only after significant changes are put in place to make the visits more than a social check-in. This would entail additional improvement in the process (eg, patient interface and login as easy as FaceTime, improved integration with our electronic health records), home testing options, and examinations that can be conducted remotely with high fidelity. I am a believer that ophthalmic telehealth, when executed correctly and efficiently, will be a part of our practices in the future.

Of course, just because we're returning to our clinics and a slightly more familiar version of how we practiced in the past, it doesn't mean that we can say with confidence what will come about in the next few months, let alone the next few years. That disorienting state of uncertainty is perhaps the only thing we can count on being consistent in our new normal.

Sumit (Sam) Garg, MD, is the vice chair of clinical ophthalmology and an associate professor in the Department of Ophthalmology at the Gavin Herbert Eye Institute, University of California, in Irvine. He specializes in corneal and cataract surgery, as well as laser refractive surgery.

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