From the Editors of Review of Ophthalmology:

Managing Glaucoma During the COVID-19 Pandemic

As with every subspecialty in ophthalmology, doctors managing glaucoma have particular challenges to deal with during this crisis. Here, several glaucoma specialists discuss some of their experiences in the current situation.

• The problem with postponing less-critical visits. Peter Netland, Vernah Scott Moyston Professor and ophthalmology department chair at the University of Virginia in Charlottesville, Virginia, notes that managing glaucoma without regular visits is inherently dangerous. “We’re concerned about missing patients who are progressing,” he explains. “In normal times, a certain percentage of patients having routine follow-up turn out to have elevated pressure or optic nerve damage. Glaucoma can be asymptomatic, so patients may not pick this up. This means that if we defer routine care for a long time, we’ll be missing patients who should have been treated within a month or so at the most. The longer routine care is delayed, the more patients will need care that they’re not receiving.”

• Deciding which patients to see. Brian Flowers, MD, who practices at Ophthalmology Associates in Fort Worth, Texas, a 15-doctor multispecialty practice with 110 employees, points out that every glaucoma patient’s situation is unique. “Each doctor in our practice is reviewing every patient’s chart carefully,” he says. “If someone with moderate to advanced glaucoma had uncontrolled IOP at the previous visit and just changed medications, that patient would need to be seen. If someone had mildly uncontrolled pressure with a relatively healthy nerve and not too great a risk for vision loss, we’d postpone seeing them but make an appointment. Patients who are very stable will be called to set up an appointment after the crisis is over.”

“We’re minimizing visits to urgent and emergent patients only, and urgent and emergent surgery,” says Paul A. Sidoti, MD, a professor of ophthalmology and Deputy Chair for Clinical Affairs in the Department of Ophthalmology at the Icahn School of Medicine at Mount Sinai in New York City. “Urgent means you need to be seen within a few weeks or it will potentially be problematic, and we have a lot of patients who fit into that category. We’ve postponed all elective visits and surgery.”

Malik Y. Kahook, MD, a professor of ophthalmology, The Slater Family Endowed Chair in Ophthalmology, chief of the Glaucoma Service and vice chair of clinical and translational research at the University of Colorado School of Medicine in Aurora, says his institution stopped seeing non-urgent patients in mid-March. “This includes non-urgent clinical visits as well as non-urgent surgical cases,” he says. “We continue to see patients who require urgent care, including emergency surgery when preservation of vision requires immediate attention.”

In addition to the urgency of care that’s required, doctors are also having to weigh the patient’s safety. “When deciding who should come into the office, you have to think about what’s best for the patient,” notes Dr. Flowers. “If it’s an average 80-year-old patient, the question we ask ourselves is, is this in their best interest? Is the risk-benefit ratio worth the patient coming out of the house? Can it wait a month? That’s the standard we’re applying.”

Malik Kahook, MD's glaucoma fellow, Monica Ertel, MD, wearing a standard surgical mask over an N95 mask. Dr. Kahook says this is done to prevent soiling the underlying and more difficult to obtain N95 mask.

• Surgical dilemmas. “Like many places, we’ve classified surgeries as tier 1, 2 or 3,” Dr. Netland says. “Tier 1 would be routine elective care, such as a routine cataract. Tier 2 is something that has to be done with days or weeks, which is fairly common in glaucoma. Tier 3 is urgent medical care. The patients we’re seeing for glaucoma surgery are tier-2 and -3 patients. We have a state mandate to postpone elective tier-1 care, so that’s what we’re doing. We plan to reevaluate the situation on April 24th.
“Treating tier-2 patients is somewhat of a gray zone with glaucoma,” he notes. “Tier 3 might mean neovascular glaucoma, and no one questions our treating that. But many patients need surgery because they’re progressing or have pressures that are too high for the condition of their optic nerve. We have to treat those patients within a reasonable period of time. So, we’re still checking those patients in clinic and doing surgery if we need to.”

Dr. Kahook says his team is still performing urgently needed surgical cases. “For the Glaucoma Service, this includes cases such as sight-threatening hypotony; intraocular pressure that’s too high on maximal tolerated medical therapy, with expectation of vision loss within weeks; device exposure; and bleb leak and/or infection.”

Dr. Netland notes that the new rules make it difficult to decide how to proceed in some situations. “What if your cataract patient has an intraocular pressure of 25 or 30 mmHg?” he asks. “Normally, you’d do a combined surgery, possibly adding a MIGS procedure to the cataract surgery. Now, a red flag is raised when you set up the cataract surgery, because that’s considered elective. But having the patient undergo glaucoma surgery and come back later for the cataract surgery isn’t ideal. So for many of those patients we’ve decided to go ahead with the combined surgery. If urgent glaucoma surgery is part of the equation, we’re considering it a tier-2 situation.”

• Impact on the practice. Dr. Flowers notes that the impact of the pandemic differs from practice to practice. “The rules only allow urgent and emergent care,” he points out. “As a result, general ophthalmologists and LASIK doctors will have almost no patients. In a retinal practice, up to 70 percent of patients might qualify as urgent or emergent; patients who need injections for macular degeneration are still getting them. But for a glaucoma or cornea practice, a much smaller percentage of the patients meet that criteria.”

Dr. Flowers notes that medical practices are set up to have limited funds in the bank. “Having a lot of money in the bank at the end of the year results in a corporate tax bill, so medical practices avoid that,” he explains. “That means most practices can only go without income for a number of weeks before they have no money to pay their bills. To deal with that reality, you have to cut costs. In our case, we had to furlough 55 of our 110 employees when the crisis got underway, and 13 more employees a week later. They’re still employees, so we continue to fund their benefits, but without a paycheck.

“We decided to pay our employees for two weeks to make sure no one would miss a paycheck before unemployment kicked in,” he continues. “With the new rules that Congress passed, unemployment should pay them their full salary. None of our doctors are taking salaries. Obviously we’re worried about supporting all of our employees so they can get through this, but we have to do it without bankrupting our practice.”

• Talking to patients. Dr. Sidoti says that explaining to patients the reason for postponing appointments was more difficult at the outset. “Now everyone is acutely aware of the situation,” he says. “At this point patients are reluctant to come in. We’re telling them that for their safety as well as ours, we’re trying to minimize all nonessential visits, and patients are pretty understanding of that.”

Dr. Netland says the doctors in his group are making sure that patients understand that appointments aren’t being canceled, just postponed. “We let them know we’ll resume care as soon as we’re able to do that,” he says. “We make sure they know that we want to see them.”

• Switching to telemedicine. Being unable to see many patients face-to-face has abruptly put a spotlight on the use of remote visits. “The problem with using telemedicine in glaucoma is that our disease management is very dependent upon the examination,” says Dr. Netland. “Right now, telemedicine doesn’t work well for us. Patients need to come to us for an OCT or visual field, and for the most part you can’t see the eye well enough for a visual evaluation over a phone. That makes it hard to catch a problem that needs to be addressed without actually bringing the patient into the clinic.”

Despite its limitations, Dr. Netland admits that there still is some role for remote patient contact. “Some patients have issues with basic things like getting their medications,” he says. “And sometimes patients do notice that a problem is getting worse. Or, we may need to work with a patient preparing for an upcoming surgery. So there are a number of things we can do pretty effectively via telemedicine.”

Some groups are jumping into telemedicine in a big way. “Virtual health has been a big focus for our clinic over the past three weeks,” says Dr. Kahook. “We use EPIC electronic health records, and we’ve moved many of our red eye, medication allergy and some postoperative follow-ups—postoperative blepharoplasty, for example—to video-based visits, with great success. This was a monumental undertaking by our hospital; 1,000 doctors were trained on virtual health workflow in a matter of seven to 10 days.

“The key aspect of our success with getting our entire department up and running with ‘Virtual Health’ was the early formation of a committee dedicated to this work,” he continues. “The committee is composed of our medical director, Sophie Liao, MD; my glaucoma colleague Cara Capitena-Young, MD; our practice administrator, Eimi Rodriguez-Cruz; and myself. This has been one of the best working relationships I’ve had in ophthalmology. I'm so proud of this group for all of the sleepless hours they’ve spent and their dedication to making sure we’ll continue to care for patients despite a major active pandemic.

“All of our residents, fellows and attendings are now trained to care for patients using video-based communication,” he concludes. “We intend to keep this as a big part of our practice even when the current pandemic ends.”

Not surprisingly, the sudden importance of telemedicine has raised questions regarding reimbursement. “Using available coding, we can do a telemedicine visit and either charge for a standard outpatient visit—which the patient has to agree to—or use an inpatient format, in which we charge for the time that we spend on the phone with the patient,” says Dr. Netland. “We’ve been able to incorporate this into our EMR system. That not only enables accurate billing but also documents the telemedicine consultation. Of course, this is still new to us, so our experience is limited.”

• Preparing for possibilities. Dr. Netland says his group understands that some doctors could be called upon to help care for COVID patients. “We know that we may lose some of our providers to COVID care if needed—particularly trainees,” he says. “So far we haven’t had to do that. But we have a prioritized list of providers to be deployed should the need arise.”





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