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Residents & Fellows Corner | Mar/Apr '21

COVID-19: An Opportunity to Forge a New Road Forward

Out with the old, in with the new.

One year ago, we had little idea that the world would soon come to a startling stop. It was an unprecedented day—Friday, March 13, 2020—when our high-volume county clinic shut down. In pre–COVID-19 days, our resident clinic easily saw more than 100 patients per day. Suddenly, our usually boisterous waiting room was empty. Busy overnight calls in our level 1 trauma center soon turned into “no-hitters.” Our pagers went deafeningly silent, and our Ophthalmic Knowledge Assessment Program examination was cancelled.

We secretly celebrated those first few days off. But soon enough, the solitude set in, with many of us confined to small city apartments. We had no access to the things that make free time valuable. For many of us, our loved ones were far away, across the country. Flights were grounded. Grocery stores were drained. Our anxiety was fed by the 24/7 onslaught of media reports on COVID-19. That was life in March 2020: fear and uncertainty.

Now, a year later, our world remains dramatically different. Many questions linger, with few key answers certain. A clear end is still nowhere in sight. Vaccination is thankfully well under way, and patients have come back in droves. But what about the patients who were lost amid last year’s cancellations?

UNTREATED BACKLOG

Experts are now predicting a “pandemic of pandemic-related disease.”1 Some argue that a large backlog of visits postponed due to the pandemic has left some patients untreated or undertreated. In our experience, delays in care can lead to irreversible vision loss.

It is the responsibility of physicians to call patients who have been rescheduled or self-cancelled. Devastating loss of vision and blindness ultimately have a snowball effect on the entire medical community. Patients with low vision are at high risk for falls, hip fractures, and loss of the ability to administer medications and injections.2,3 We should consider promoting health literacy and appropriately increased health care utilization within our communities, while continuing to adhere to safe social distancing and mask-wearing.

The American physicist and philosopher Thomas S. Kuhn, who introduced the concept of the paradigm shift, has argued that such shifts are essential for scientific progress. A paradigm shift occurs when a dominant theory is rendered incompatible with a new phenomenon. Whether gradual or sudden, this profound shift in the status quo forces the scientific community to adopt a new theory. Interestingly, Kuhn argues that the new replacement is always better than the old—not just different.4

FINDING A WAY FORWARD

How can we innovate ophthalmic care in 2021 to forge a new, more innovative road forward?

In March 2020, at the onset of the pandemic, the AAO recommended that ophthalmic practices limit care to patients with urgent or emergent ocular conditions. Suddenly we were tasked with triaging visits and sifting through our electronic records to locate these patients with urgent and emergent conditions. For the first time, many clinics turned to telemedicine for assistance.

In March and April 2020, approximately 60% of new and follow-up glaucoma and retina patients were postponed for several months.5 As one can imagine, lower socioeconomic groups were disproportionately affected by the move to virtual and telemedicine visits. Many older patients found themselves unable to use video conferencing modules. Those with language barriers were unable to communicate using English-only platforms.6 Minority groups were already known to have worse outcomes in glaucoma, and now were found also to have heightened levels of COVID-19 predictors.7

To move forward in this new world, we will need to adopt new tools. Studies over the past year have focused on identifying such tools. Drive-through IOP checks, mobile eye screening and testing, home tonometry, offsite visual field testing, and phone applications such as smartphone fundoscopy are just a few examples of proposed new and innovative devices. These instruments and techniques can improve our patient care by easing patient access to care, boosting patient engagement, and increasing the quantities of data points we have available to make management decisions.

A recent study looked at telemedicine utilization across Michigan in response to COVID-19.8 The study authors identified an initial rapid increase followed by a subsequent steep decrease in teleophthalmology use in the early phases of the pandemic. At its peak, telehealth accounted for 17% of total ophthalmology visits.8 Ophthalmology was reported as the lowest adopter of telehealth among all specialties.8

Several studies over the past year have explored how existing technologies can facilitate more effective and efficient mobile and virtual care.9-10 Development of mobile and home tonometry, OCT, and visual field testing may allow increased adoption of telehealth modalities for established patients in the glaucoma and retina spaces.

OPPORTUNITY FOR INNOVATION

A unique occasion for innovation is upon us. Out of this challenging time, we have gained a window of opportunity to improve outdated practices and provide better and more efficient care. Significant vision loss and permanent blindness are detrimental to our patients and ultimately to society. It is our responsibility to ensure that we forge a better path forward, while accounting for the obstacles and meeting the needs of our patients. This is our opportunity to redefine our practices and to become more determined patient advocates and ultimately more insightful, forethinking physicians.

1. Mahmoudinezhad G, Moghimi S, Weinreb RN. COVID-19 Pandemic: Are We Back to Normal? J Glaucoma. 2020;29(8):611-612.

2. Ivers RQ, Norton R, Cumming RG, Butler M, Campbell AJ. Visual impairment and risk of hip fracture. Am J Epidemiol. 2000 Oct 1;152(7):633-9.

3. McCann RM, Jackson AJ, Stevenson M, Dempster M, McElnay JC, Cupples ME. Help needed in medication self-management for people with visual impairment: case-control study. Br J Gen Pract. 2012;62(601):e530-e537.

4. Kuhn TS. The Structure of Scientific Revolutions. University of Chicago Press; 1962.

5. Williams AM, Kalra G, Commiskey PW, et al. Ophthalmology Practice During the Coronavirus Disease 2019 Pandemic: The University of Pittsburgh Experience in Promoting Clinic Safety and Embracing Video Visits [published online ahead of print, 2020 May 6]. Ophthalmol Ther. 2020;9(3):1-9.

6. Eberly LA, Kallan MJ, Julien HM, et al. Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(12):e2031640.

7. Geno Tai DB, Shah A, Doubeni CA, Sia IG, Wieland ML. The Disproportionate Impact of COVID-19 on Racial and Ethnic Minorities in the United States. Clinical Infectious Diseases. 2021;72(4):703–6.

8. Portney DS, Zhu Z, Chen EM, et al. COVID-19 and Use of Teleophthalmology (CUT Group): Trends and Diagnoses. Ophthalmology. 2021;S0161-6420(21)00118-4.

9. Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med; 2020.

10. Keesara S, Jonas A, Schulman K. Covid-19 and health care’s digital revolution. N Engl J Med; 2020.

author
Karine Shebaclo, MD, MSc
  • PGY-3 Resident Physician, Medstar Georgetown University Hospital/ Washington Hospital Center, Washington, DC
  • Kshebaclo@gmail.com
  • Financial disclosure: None
author
Malka Davina Kirschenbaum, MD
  • PGY-3 Resident Physician, Medstar Georgetown University Hospital/ Washington Hospital Center, Washington, DC
  • kirschenbaummd@gmail.com
  • Financial disclosure: None
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