Battlefield Medicine Time: Ophthalmology in the Era of Coronavirus

We are in the midst of the Novel Coronavirus (COVID-19) pandemic. The numbers are scary and changing by the day and hour. Johns Hopkins University has a real-time dashboard where you can monitor global cases.

Cases in China have leveled off, while elsewhere in the world cases are on the rise. At the time of this writing, there are about a quarter of a million confirmed cases worldwide and almost 10,000 deaths. In the US, cases just surpassed 10,000 with 172 deaths.

Healthcare providers are scrambling since more is unknown than known. Without being able to test the entire population, the true disease prevalence remains unknown. As test kits are more readily available, more individuals will be tested.

But as more are tested, more will test positive, even if asymptomatic, driving the case numbers higher. On the other hand, with more positive tests in clinically unaffected individuals, the death rate will drop. It’s all a numbers game and the statistics depend in large part on who or what is being counted.

What does this all mean for ophthalmology? More than you think, but let’s first take a step back for some data and perspective.

For perspective, ten years ago we faced the H1N1, or swine flu, pandemic. That disease caused nowhere near the reaction that COVID-19 has, with closed schools and businesses, travel bans, and mass cancellation of sporting events, concerts, and sporting events.

Yet the H1N1 statistics were far worse compared to the current pandemic, at least to this point. In the US alone, H1N1 caused 61 million illnesses, 273,000 hospitalizations, and over 12,000 deaths. Worldwide, H1N1 may have killed up to 203,000 people, 20 times more to date compared to Coronavirus.

Regardless of statistics, medical providers are facing battlefield conditions. In Italy, there are not enough critical care beds or ventilators to accommodate all the ill patients in need, forcing physicians to choose who gets treated and who receives only palliative care.

Italy now has more Coronavirus deaths than China, overwhelming their healthcare system. US physicians fear we are only a few weeks behind Italy, and may soon be facing a similar catastrophe.

Masks, gloves, and other personal protective equipment is in short supply. Despite efforts by the Trump administration to ramp up the supply chain for medical equipment, the demand is here and now, while the supply chain is playing catch-up.

What specifically is happening in ophthalmology practices? Many are closing temporarily, seeing only emergency patients, or referring patients to a local academic center or emergency room.

In retina practices, especially large practices serving a major metropolitan area, demands are greater, and the patients have more urgent problems. Retina practices have another dilemma, based on conditions treated and their patient demographic.

Most patients in a retina practice are elderly, the most vulnerable population to Coronavirus. Most have concurrent medical conditions, adding to their vulnerability.

For this reason, these patients should self-quarantine, avoiding contact with individuals who may carry the virus and unwittingly transmit it to patients.

On the other hand, many of these patients receive intravitreal injections for macular degeneration, diabetic retinopathy, or vein occlusion, maintaining their vision. Forgoing a scheduled injection leaves them at risk for vision loss.

How can practices manage this dilemma? While there is no simple solution, my approach is based on battlefield medicine. Corners must be cut, although prudently, to strike a balance between good patient care and protection of the patient, physician, and office staff against Coronavirus.

It is important to screen patients for fever or viral symptoms before they enter the office and potentially infect some or all of the office staff. Patients who are unwell should be rescheduled or referred to their primary care physician for further evaluation.

Following the guidelines of the CDC and AAO mean that routine follow up appointments should be rescheduled to a later time. For example, those patients with a 3-6 month follow up appointment can be rescheduled in 4-6 weeks. Those with a 6-12 month follow up appointment can be rescheduled 2-3 months later.

This assumes the patients report stable visions and no new symptoms. Otherwise, consider whether they should be seen rather than rescheduled.

For injection patients, it would be reasonable to perform injection only, keeping the patient on their same injection interval. To further avoid virus exposure in either direction, visual acuity, intraocular pressure measurement, and imaging can all be deferred if the patient reports relatively stable vision.

Practices with a wide field imaging camera, such as Optos, may substitute a fundus photo for a dilated exam in the event an exam is needed. Further imaging, such as fluorescein angiography, can be omitted in most all patients.

Obviously, the physician has the prerogative to do more rather than less, based on their judgement, but this provides a way to maintain treatment of these chronic diseases, limiting potential viral exposure in clinic by moving the patients in and out as quickly as possible.

Patients on a fixed injection schedule will at least be covered for the duration of their current treatment interval, reducing the risk of vision loss from undertreatment.

Surgery should be restricted to urgent cases such as retinal detachment, endophthalmitis, retained lens fragments, trauma, and certain vitreous hemorrhages. The American Society of Retina Specialists provides guidance on emergent or urgent versus elective surgery.

This has gone from a suggestion to a mandate from the Centers for Medicare and Medicaid Services (CMS) to “Limit all non-essential planned surgeries and procedures, including dental, until further notice.”

It is important to document your shortcuts and provide a rationale for your actions. Once Coronavirus is a distant memory, personal injury lawyers will replace the virus, looking for a way to make your life miserable.

On the battlefield, or in an eye camp, we can’t practice as we would in our own clinic when our biggest concern is what we are having for lunch. We are in a brave new world, facing challenges and limits that many of us never encountered.

With thought and reason, it is possible to carve a path forward, walking the fine line between providing good patient care while minimizing risk of virus exposure to patients, physicians, and staff.

The next few weeks—hopefully not beyond that—will be battlefield medicine.