While the global pandemic has brought about certain overarching changes to daily life such as hypervigilance, quarantine, social distancing and the resulting decline in patient volume and elective surgeries, it’s also caused several more mundane, but no less important, problems that you might not have been expecting: Have your oculars been getting foggy with all the mask-wearing, for instance? In this article, we’ve rounded up some creative solutions for 10 common problems you may run into in the clinic and the OR as a result of the pandemic.
1. Maintaining social distancing in the clinic. Standing six feet away from everyone else doesn’t come naturally for most people and is easy to forget in the absence of reminders to maintain physical distance. In order to comply with social distancing and reduce the chance of viral transmission, practices have had to reduce patient volume and find new ways to keep those who do visit the office safe and separated from others. Here are some ways doctors are helping their patients maintain social distance.
—Pre-filling forms. “We’ve started having people fill out their history and medications over the phone beforehand,” says Joshua Frenkel, MD, MPH, of the Wang Vision Institute in Nashville. “We have staff calling our patients to fill out as much information before they arrive as possible,” he says. “It cuts down on wait times and improves the efficiency of our clinic.”
—Musical chairs. Sometimes all it takes is a simple solution. “For social distancing, we’ve moved our waiting room chairs six feet apart,” says John Jarstad, MD, FAAO, a professor of clinical ophthalmology and director of cataract and refractive surgery at the University of Missouri Mason Eye Institute. Some practices have also put upholstered furniture into storage and are using plastic chairs instead, which can more easily be sanitized after patients use them.
—Restaurant buzzers. Michele C. Lim, MD, professor, vice chair and medical director of ophthalmology at the University of California Davis in Sacramento, uses restaurant reservation buzzers to help limit the number of people crowding the waiting room. “If the waiting room looks busy, patients will be given buzzers so they can roam around our outpatient building or go back to the parking lot [while they wait],” she says. She points out that this method works well for the elderly, who may not be able to use or receive text message alerts. Additionally, the restaurant buzzers operate on a radio frequency, which works in a parking garage, unlike Wi-Fi.
—Drive-thru exams with video follow up. Dr. Lim has begun offering drive-up visits to decrease the number of people in the office. “Video visits on a phone camera don’t allow us to see the detailed structures of the eye, but with a drive-up exam, we can obtain some objective data,” she says. Patients drive into the parking lot and sit in their cars while Dr. Lim checks vision and pressure. Then patients return home and a doctor follows up with a video visit to go over their care.
2. No-visitor policies aren’t always ideal. Many hospitals and offices have instituted no-visitor policies to help cut down on the number of people in a health-care setting, but this often means that patients are left without the assistance they need for emotional support, translating or remembering important information. Amir H. Marvasti, MD, of Coastal Vision Medical in Orange County, California, says this is especially true for the elderly. “We almost never allow another person to come in with the patient,” he says, “but if I feel like they’ll forget the information, or if the patient needs help with translating or decision-making, we have a phone call with their trusted support person.”
Dr. Jarstad adds that “no HIPAA laws are violated in this instance if the support person is a family member and you obtain permission. We have family members wait in the car, but they can also talk to us on the phone or come in if the patient insists on it. But they must wear a mask and are screened at the door before they come in.”
3. Telehealth technology challenges with some patients. A large percentage of ophthalmic patients are elderly and may have trouble with the technology required for their virtual exam. Here are a couple of ways you can help ensure the virtual visit runs smoothly, tech-wise.
—A simple checklist. Sending patients a simple tech checklist along with the usual instructions for accessing the telemedicine virtual video visit can help your patients be more prepared for their exams and can save you valuable time. Some checklist items might include testing the video camera and microphone settings with a website program, guidelines on how to position or hold the camera, and ensuring good lighting.1
—A run-through with a staff member. Nikola Ragusa, MD, FACS, of the Bronx Eye Center in New York, says, “Since this is still a relatively new way for doctors to see patients, it’s good to have a staff member call prior to the video visit to go over the nuances of the telemedicine service that’s being used. Some are more intuitive than others, and for some patients nothing is intuitive enough. Camera and microphone access is critical for these encounters. Knowing how to log onto a call and ensuring that lighting, as well as video and audio quality, are adequate are key to a successful and frustration-free video visit. Most of these elements can be handled by a staff/technician prior to the call. Having said that, a good script is important for the staff member along with a checklist for the patient.”
He adds that having a back-up plan, such as FaceTime or Google Duo, is important in case your telemedicine service doesn’t function. “It’s better to overprepare and let the patient know ahead of time that a backup service may be used for the encounter,” he says.
4. Lens fogging. With mandatory masking in place, lens fogging has become a major problem for ophthalmologists during the pandemic. Not only do eye glasses fog up with most masks, but oculars and diagnostic imaging tools also fall victim to lens fogging.
“Doing a good dilated fundus exam has been tricky,” says Dr. Marvasti. “My oculars get foggy with my mask, and then as I’m holding the lens close to the eye of the patient who’s also wearing a mask, the lens fogs up. Unless there’s a tight seal on the mask, there will be fogging. For routine visits, this isn’t a major problem, but if I’m trying to find a small tear or if I really need the best visualization and need to take my time, the lens fogging can be frustrating.” Here are three ways you can cut through the fog.
—Paper tape or gentle finger pressure. If you don’t have the type of mask that can make a tight seal, such as an N-95 mask with a metal piece that molds to the shape of the nose, Dr. Marvasti recommends putting surgical tape over the top of the mask to prevent fogging of the lens. This approach can be time-consuming, he admits. “If you have 20 patients, doing this for every one of them might take too long,” he says. He says that for larger patient volumes, “I press my ring finger gently on the mask to push it against their skin, which mechanically creates a tight seal so their breath doesn’t come up toward the lens. I’ve had some success with that.”
—Dishwashing liquid. “I just ran into a brick wall when I was trying to do delicate YAG lasers on posterior capsules,” says R. Bruce Wallace III, MD, FACS, founder and medical director of the Wallace Laser and Surgery Center in Alexandria, Louisiana, and a clinical professor at Louisiana State University and Tulane University School of Medicine. “I couldn’t see anything because the lenses for the slit lamp, the laser and the lens on the patient’s eye had all fogged up,” he says. Dr. Wallace went online and discovered that dishwashing liquid might hold the answer. “You spread the soap on the surface of the oculars and then wipe or buff it off,” he explains. “Suddenly, it’s clear. No more fogging. It makes a huge difference.”
Soap can prevent fogging because the surfactants reduce water’s surface tension. Otherwise, water molecules clump together in tiny droplets on the lens surface, creating lens fog. Leaving behind a thin surfactant film on your lenses will reduce any water surface tension and allow the water molecules to disperse evenly across the lens surface in a transparent layer.2
—Anti-fog sprays. Dr. Jarstad, a former competitive downhill skier, says that anti-fog sprays are widely available at ski shops, sporting goods stores and online to prevent lens fogging. Small, portable bottles of anti-fog spray run in the $8- to $15-dollar range online.
5. Many slit lamp shields aren’t large enough. “We have clear plastic Zeiss shields that measure 10 by 12 inches on our slit lamps now, but simulation studies have suggested that if a patient were to sneeze or cough with this size shield, about 50 percent of the aerosol would pass around the shield,”3 says Michael Colvard, MD, of the Colvard-Kandaval Eye Center in Encino, California. “That’s a bit of a concern, but the problem is that slit lamp shields that are much larger begin to interfere with the clinical exam, especially indirect ophthalmoscopy with hand-held 78- or 90-diopter lenses, or gonioscopy.”
Larger slit lamp shields are available for purchase, but if you prefer the DIY route, Dr. Jarstard says you can buy quarter-inch thick, clear plexiglass sheets from your local hardware store to make your own. “Slit lamp shields can be made at home by anyone with a bandsaw or jigsaw and a power drill with a two-inch bit,” he says. “The Zeiss-donated shields have two-inch holes, placed 0.75 inches apart for the oculars. The shields fit easily over the oculars with enough room to adjust the oculars for proper individual interpupillary distance.”
6. Obtaining IOP. Concerned with contamination, many practices have stopped using Goldmann applanation to monitor patients’ pressures. “We use the Tonopen with a sterile cover for each patient,” Dr. Jarstard says.
“We’re leaning on the Tonopen for most routine visits,” adds Dr. Marvasti. “If I’m trying to get accurate measurements for a glaucoma patient or assessing whether MIGS or drops will be sufficient, I’ll make an exception and check the Goldmann applanator. If I need to use the Goldmann, I try to use it on only one patient per day and clean it very well afterward.”
7. Potential diagnostic artifacts. This is another problem resulting from mask-wearing. The ASCRS Glaucoma Clinical Committee made a cautionary statement to its members on May 29 about this new potential concern. David Palmer, MD, of Northwestern University, found that condensate on perimeter lenses could create visual field changes that could be interpreted as a sign of progression. ASCRS suggested applying hypoallergenic tape to seal the top of the mask during perimetry to prevent condensate, repeating visual fields if disease progression is suspected and to be aware of possible errors due to fogging during other ocular diagnostic tests such as OCT and autorefraction.
8. Risk of viral transmission in the clinic. Good sanitization and cleaning procedures have always been important for practices, but these concerns are front-and-center during the pandemic. Here are some reminders for playing it safe.
—Sanitize everything. Steve Charles, MD, of the Charles Retina Institute in Germantown, Tennessee, says that disinfecting equipment, using face shields and slit lamp shields, washing 90-D lenses and indirect lenses with soap and water can all help reduce transmission.
“For some in-office procedures like YAG and SLTs, there’s a lens that comes in contact with patients’ eyes,” Dr. Marvasti says. “I’m trying to limit those procedures to one a day, and I use a particular lens on a particular patient. Even if I clean it properly, I’m worried that I may still cause transmission of a virus.” Leaving the lenses overnight to allow any residual virus to die off takes extra time, but Dr. Marvasti says he prefers to play it safe.
Dr. Jarstard says he washes his YAG and SLT lenses with soap and water and then wipes them down with peroxide or alcohol wipes and leaves them to dry.
—Check manufacturer guidelines. Not all instruments and devices can be disinfected the same way. Checking with instrument manufacturers on the best ways to clean and disinfect is advised. For example, Zeiss has published specific guidelines on its website for disinfecting instruments like Humphrey perimeters. The company recommends cleaning this device with a fine mist of 70% isopropyl alcohol, without rubbing and without any use of UV-C light.
—Rely on other imaging. “I don’t think any of us would be keen to do direct ophthalmoscopy now, which involves being virtually face to face with the patient,” says Dr. Colvard. “I don’t imagine that the patients would be very happy with this kind of exam either. But even with indirect ophthalmoscopy the physician is no more than a foot and a half away from the patient, and a thorough exam means prolonged exposure. For this reason, we’re finding ourselves doing more posterior photographic imaging and OCTs than we were doing before the pandemic.”
9. Risk of viral transmission in the OR. Many states require COVID-19 testing prior to surgery, but Dr. Frenkel says that at this point, it isn’t terribly useful. “I think it’s a great idea in theory,” he says. “But we’re having trouble testing right now, nationally, and there are many logistical hurdles. It would be more useful if we could get same-day results. A test will only tell you whether or not your patient was negative or positive at the time of the test. If your patient tested negative, by the time they come in for surgery, they could have become infected.”
Dr. Charles shares some of his basic COVID safety requirements for surgery. “These are necessary to reduce risk to staff, but they’re not sufficient to eliminate the risk,” he cautions:
—Airway management. SARS-CoV-2 poses a risk to staff through aerosolization. Dr. Charles says that “endotracheal intubation is safer for anesthesia staff than laryngeal mask airways. Additionally, oxygen masks and nasal cannula tubes must be handled with gloves after use, as they pose a high risk to staff. We’ve always used oxygen masks on all monitored anesthesia care cases and vacuum lines under drapes to prevent CO2 retention under the drape and to reduce aerosol spreading of viral particles.”
—Nasopharyngeal swab. It’s important to determine whether or not your patient has active infection. However, as Dr. Frenkel notes above, the timing of the test before surgery and the time it takes to get results can present problems. Additionally, Dr. Charles says, “There are many non-validated tests on the market.”
Dr. Colvard adds that testing requirements vary by state and can change from week to week. “When we began to do elective cataract surgery again, the general standard of the community was to require all elective surgery patients to undergo COVID testing three days before the procedure,” he says. “More recently in Los Angeles, most eye surgery centers have changed the requirements so that cataract surgery patients don’t need testing unless they’re likely to require airway support. So cataract patients in our community who are afebrile, asymptomatic and have no history of COVID exposure aren’t required to undergo preoperative COVID testing. Patients who are undergoing some oculoplastics procedures who are likely to need airway support, however, are required to undergo preop testing.”
—Serology for previous infection. This presents similar problems to nasopharyngeal swab testing, says Dr. Charles. “There’s a delay between infection and positive serology, and it takes a while to get results,” he says.
—Drape the microscope. Asymptomatic infected staff are at the highest risk of transmitting COVID-19 to the patient. Dr. Charles always drapes the microscope on every case. He adds that it’s important to “disinfect the bottom of the microscope optical head after each case and clean the objective without damaging the AR coating.”
10. Plume from phacoemulsification. “The ultrasonic vibration of the phaco tip causes cavitation and bubbles in the anterior chamber,” explains Dr. Colvard. “The recent concern has been that this cavitation might create a spritz of viral organisms that might leave the eye around the phaco tip and enter the OR environment.”
A group at the Bristol Eye Hospital used special photography techniques to better visualize aerosolized particles in their investigations on a plume during phaco. You can view video at youtu.be/8LGwI9LIYmU. Here are some of the group’s findings and recommendations:
—Povidone-iodine. Povidone-iodine reduces any theoretical viral load on conjunctiva, says the Bristol group.
—A smaller incision size. In the study, a 2.2-mm wound reduced visible aerosol, whereas a 2.75-mm wound allowed aerosols to escape. Ike Ahmed, MD, of the University of Toronto and the Prism Eye Institute in Ontario, also demonstrated that there was no evidence of visible aerosolization with a 2.2-mm incision. (You can view his video at youtu.be/GHH_rvyarCI). Commenting on Dr. Ahmed’s video, Douglas Wisner, MD, of Wills Eye Hospital in Philadelphia, says he “recorded a case under high magnification with a 2.4-mm incision to look at the same thing . . . No aerosolization was noted.”
—Hydroxypropyl methylcellulose. The Bristol group found that applying HPMC every minute during active phaco prevented aerosolized particles from escaping a 2.75-mm wound. “Does this impair visualization?” asks Dr. Colvard. “In surgery the other day, I put methylcellulose on the cornea just to test it,” he says. “You need to smooth it out a little bit, but it doesn’t impair visualization. You can see quite well through it. So if one uses a 2.75-mm incision and has concerns based on the 2.75-mm incision demonstration by the Bristol group, then the use of topical methylcellulose seems reasonable. The only caveat is that one needs to wash all the methylcellulose off the cornea before taking ORA measurements.”
—Irrigation and aspiration for at least six seconds. The group found that performing I/A for at least six seconds before starting active phaco helped to reduce aerosols.
Dr. Frenkel notes that many of the Bristol group’s recommendations, such as using small incision sizes and doing I/A prior to the procedure, are already routinely done by eye surgeons. “More studies are needed before everyone undergoes a massive change in practice and starts applying HPMC to the wound every minute,” he says. “I also think it’s important to have more studies done in human eyes.” The Bristol group performed their investigations using a human corneoscleral rim mounted on an artificial chamber. The phaco device was kept in a fixed, static configuration to reduce variables.
Uday Devgan, MD, of Devgan Eye Surgery in Los Angeles, says some of his colleagues from the University of Toronto also did experiments to determine whether cataract surgery posed a risk of viral exposure. The Toronto group used trypan blue to simulate viral aqueous in a human cadaveric eye. You can view the video at youtu.be/epcDtNN-PkI.
In the first technique, I/A was done to replace the AC volume, prior to filling the AC with dispersive OVD. No aerosolized trypan blue dye was observed during torsional, torsional-longitudinal or longitudinal phaco. In the second technique, the ‘viral’ trypan blue aqueous was replaced with OVD prior to phaco. Dr. Devgan says that replacing the AC contents with OVD effectively evacuates the virus. No aerosolized trypan blue was observed during phaco. In the third technique, an open-sky model, performing phaco in BSS confirmed an aerosol plume. Dr. Devgan suggests removing the aqueous with I/A or evacuating the AC with viscoelastic at the beginning of the procedure. Neither longitudinal nor torsional phaco generates significant aerosols in a closed procedure, he says.
Dr. Colvard wonders about the clinical impact of such findings. “The overarching question is what significance do these experiments have?” he says. “Most surgeons use 5% Betadine to sterilize the surface of the eye prior to cataract surgery. This concentration of Betadine kills 99 percent of organisms, including, as I understand, the COVID virus. Then most of us empty the anterior chamber volume completely and fill the anterior chamber with OVD. So it’s hard to imagine that a lot of organisms, even if a patient were infected, would end up entering the OR from this source. If one has the bad luck of operating on a patient with an active COVID infection, it seems logical to assume that the risks of aerosolization from the patient’s own respiratory system would constitute a far greater risk.” REVIEW
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