Cornea Specialist Perspectives During the Pandemic

Cornea specialists share how they’re coping with the novel coronavirus pandemic.

Like many other much-anticipated events, the World Cornea Congress, a once-in-five-year convention scheduled to take place in May 2020 in Boston, will be rescheduled. But that’s not the worst of concerns for cornea specialists right now. The mitigation and containment efforts to battle the novel coronavirus have hit practices hard, reducing patient volume and revenue.

“Most cornea practices—whether consulting, private, hospital-based or university employed—are facing the same challenges faced by physicians in general, and ophthalmologists in particular,” says Sadeer B. Hannush, MD, attending surgeon with the cornea service at Wills Eye, professor ophthalmology at Jefferson University, medical director of the Lions Eye Bank of Delaware Valley and founder of Oxford Valley Laser Vision Center in Langhorne, Pennsylvania. “Our goals are three-fold,” he explains. “We want to care for patients with urgent and emergent needs, protect and retain our employees and salvage our practices in the absence of a revenue stream.”

In this special perspective piece, we’ll see how cornea specialists are dealing with the pandemic and how it’s impacted their practices.

Dr. Hannush examines a patient, equipped with a protective slit lamp shield.

At the Front: The Conjunctiva

“From an ophthalmology standpoint, it seems that the coronavirus can cause mild follicular conjunctivitis similar to other viral causes of conjunctivitis,” says Thomas John, MD, clinical associate professor at Loyola University at Chicago and medical editor of Review’s Cornea/Anterior Segment column. “The transmission in this case is possibly via aerosol contact with the conjunctival tissues. Conjunctivitis when present has to be combined with other systemic symptoms to raise a suspicion of coronavirus infection.” Dr. John adds that hand dryers are ineffective against the coronavirus, as are hot baths. Neither provides any protection against this virus.

It’s important to be vigilant when looking for possible coronavirus infection. Before deciding to see a patient during the pandemic, consider the following:

• Recent history of fever, dyspnea, cough or possible conjunctivitis.
• History of recent travel to countries with a high concentration of coronavirus or hotspots within the United States.
• Family members or close contacts who’ve been sick or recently traveled to those areas mentioned above.


Emergency Cases

On March 18, 2020, the AAO recommended that all ophthalmologists cease providing treatment other than urgent or emergency care. The definition of an emergency, however, varies from patient to doctor, and among doctors, says Dr. Hannush. This ambiguity has created some confusion over what counts as “urgent,” and many practices have adopted their own policies for seeing patients during the pandemic.

Dr. Hannush wears an N-95 mask and gloves as his personal protective equipment (PPE) in addition to the slit lamp shield. He tries to minimize verbal communication as well, to reduce droplet transmission.

Ultimately, emergency visits, immediate postoperative patients and any other patients that the physician feels are important to be seen might be included in this limited category, says Dr. John. “Clearly, the postoperative patient pool will decrease the soonest, since most, if not all, surgical facilities are currently closed for elective surgical procedures,” he notes. “Cornea specialists may be following post-corneal transplant patients, and they may have to be seen, especially if they have a postoperative, adverse healing phase.”

The American Academy of Ophthalmology has also published a list of conditions that may reasonably be considered urgent or emergent. “In our corneal subspecialty, we have a short list of conditions we consider true emergencies,” says Dr. Hannush. “Those include, but are not limited to, corneal lacerations, ruptured globes, melts, impending perforations, perforations, graft wound dehiscences, hypopyon ulcers and some severe scleritis. Some of these cases may need urgent medical care or a trip to the operating room.”

Kathryn Colby, MD, Louis Block professor and chair of the department of ophthalmology and visual science at the University of Chicago Medicine & Biological Sciences, says that her institution had canceled all elective cases before the Academy issued its guidelines. She’s seeing only emergency and urgent cases where delay of care would negatively impact patient outcomes. “We have a finite list of surgeries that can be done that are time-sensitive,” she says. “These all have to be approved by me, as the department chair, and then by the OR executive committee. But if someone comes in with an eye injury or an open cornea, we’ll do those.”

When an established patient calls with a perceived urgent concern, Dr. Hannush says he reviews their electronic chart, establishes their status on their last exam, asks them about the nature of their emergency and may ask for a selfie of the eye. “In most instances,” he says, “these cases may be handled remotely without seeing the patient. In rare instances, I’ll ask the patient to meet me at my office or head down to our eye emergency room at Wills Eye Hospital to be seen by one of our residents or fellows. I specifically discourage patients from seeking eye care at an urgent care center or a hospital emergency room. This may not yield results and may also unnecessarily occupy the time of health-care workers—precious time that may be needed elsewhere, not to mention taking the risk of exposing others or being exposed to infectious elements.” Dr. Hannush adds that “More likely in a tertiary practice, the call will come from a comprehensive ophthalmology colleague, who’s seen the patient needing urgent care. The need for further acute treatment is more easily determined in those cases and triaged appropriately.”


Patient Care in the Office

“In the absence of an effective antiviral drug against coronavirus and a vaccine that’s possibly a year away, we have to use social distancing of the recommended six feet,” says Dr. John. “This clearly impacts the way we see patients in our offices. When seeing patients in the office, the physician and staff need to protect themselves with masks, gloves and head gear that can shield the face and eyes. Also ensure your office has proper ventilation, especially if a suspected coronavirus patient happens to visit the office.

“Most concerning are those patients who may be infected, but aren’t showing symptoms of the disease,” continues Dr. John. “In ophthalmology, we come into very close quarters with the patient, especially when using the slit lamp. Try to limit exposure by shortening the encounter time and take precautionary steps during examinations. Hand washing is a must with soap and water for at least 20 seconds, as the soap destroys the virus’ lipid molecule membrane. When using an alcohol-based hand sanitizer, the alcohol content should be at least 60%.”

Wills Eye Hospital in Philadelphia is allowing only urgent procedures during this time. Rules for entering the building have changed as well to include querying patients about fevers, respiratory and other symptoms, risk factors and temperature checks. Masks, hand sanitation and wristbands are also used for patients. Elevator buttons are wiped down by an attendant and patients are spread out in a waiting room with minimal staff.

Dr. Hannush’s practice went into lockdown on March 20. He expects to be closed at least through May 4, but he still sees urgent and emergency cases on a limited basis, one at a time, usually on Mondays or Thursdays. To limit the number of people in the office at any one time, Dr. Hannush rotates his staff. “I go in with my senior technician and one other employee, who uses their time to call patients, reschedule office visits and renew prescriptions,” he says. “Our bookkeeper comes in on a separate day, and our surgical scheduler comes in on another day. We’ve told our team that we’ll continue to pay their salaries as long as possible, and ask for two things in return: to stay at home and observe maximal social distancing and to make every effort, once we’re back, to make up for lost time.

Some practices have decided to take advantage of Medicare's advanced payment plan. (The Centers for Medicare and Medicaid Services recently expanded the current Accelerated and Advance Payment Program on a temporary basis to include a broader group of Medicare Part A providers and Part B suppliers in order to increase cash flow to those impacted by the coronavirus. CMS will provide accelerated payments up to a three-month period, based on prior billing history.¹

“For patients we need to see, we’re allowing only one patient in the office at a time,” Dr. Hannush says. “The patient is interviewed by phone to make sure they have no upper respiratory symptoms or fever. When they arrive in the parking lot, they text or call our technician, who will either come out to get them from their car if they’re not able to walk by themselves, or open the front door for them. The patient is encouraged to arrive wearing a mask or face covering and is offered a hand sanitizer and gloves upon entry. They walk straight into the examination room—not the waiting room. The technician screens the patient, then I examine them.
“I wear an N-95 mask, gloves and use a slit lamp shield,” he says. “Hands are washed before and after each patient examination, and I have only minimal verbal communication with the patient. The equipment and surfaces, computer keyboard, phones, and such, are cleansed after each examination. We try to answer questions, give recommendations and complete the EMR note from another room.”

At the University of Chicago, providers and residents are split into teams. “We did this about a month ago to reduce the chance of knocking out a whole service if there’s an exposure or an infection,” says Dr. Colby.
“The next few months will really depend on how individual cities and regions are able to control their outbreaks,” Dr. Colby continues. “It sounds like New York has peaked. I’m concerned about New Orleans. We’re hopeful in Chicago—everything’s canceled and we’re sheltering in place through the end of the month, though I think it’s likely that the shelter-in-place order will extend into May. We’re in a situation where we reevaluate every day, so it’s almost impossible to say what the next two weeks will look like. I’m hopeful, and I think people who are more knowledgeable about the epidemiology believe we could start getting back to normal in June, but that could all change at a moment’s notice, if hospitals are suddenly overwhelmed.

“When you work at an academic medical center, if your whole hospital is filled with COVID patients, then you’re not going to be doing elective cataracts,” she says. “We’re looking into other options in terms of taking cases off-site, but even when you do cases at an off-site surgical center, you still have postops, and patients won’t want to come into a hospital full of COVID patients. The next two weeks will be critical, and we also need to have testing available to demonstrate immunity. Once a certain percentage of our population is immune, there’ll be fewer hosts for the virus to spread though, and that will give people more peace of mind.”


Telemedicine

Dr. John says that the pandemic has brought telemedicine to the forefront. Though it has its limitations in ophthalmology, he believes that telemedicine is here to stay. “This is a very good time for ophthalmologists to embrace this technology,” he says.

Kendall Donaldson, MD, MS, professor of clinical ophthalmology and medical director of cornea, external disease, cataract and refractive surgery at Bascom Palmer, says she’s received training for telemedicine, but hasn’t used it yet (as of our interview). “I’ve been doing so many patient calls, but have been concerned about billing issues,” she says. “The requirement for patient video has held me back a bit,” she adds.

In Dallas, Jeffrey Whitman, MD, chief surgeon at the Key-Whitman Eye Center, also hasn’t used telemedicine before, but is now “slowly…getting going” using Doxy.me. “It’s an excellent interface for practices,” he says.

Dr. Colby says the University of Chicago is rolling out Zoom visits for telemedicine. “The RVUs for phone visits are kind of low, so [billing for phone calls] isn’t going to help much,” she says. “CMS is giving practices and hospitals payments based on prior Medicare billings, but it’s going to be a rocky time. When we roll out video visits, those can be billed at a regular E/M level. Obviously there’s a limit to what you can do in ophthalmology in terms of exams, but you can still keep tabs on patients. Someone sent me a picture of their eye recently, and I was able to diagnose subconjunctival hemorrhage from the photo. We’re not checking eye pressure remotely or doing fundus exams, but we’re trying to keep in contact with patients—especially those who are in a situation where they might have lost vision due to a delay.”

With video calls to patients, don’t forget to stay in touch with colleagues too. The six ophthalmology programs at Chicago have been connecting on Zoom with weekly chair calls with the program directors. “We’re very collegial,” says Dr. Colby, “Our program directors set up virtual learning that we’re all collaborating on. My department is giving a Zoom lecture that residents and other departments can join. We’ve expanded the Chicago programs to include some of the other Midwest programs. It’s a nice thing, because it allows residents to have access to education beyond their own institution. It also increases collegiality, and while residents seeing each other on Zoom isn’t the same as grabbing a drink together, it still creates a feeling of community.”

“Even during this pandemic we have to look at the positive horizon and recognize this too will pass,” says Dr. John. “In the interim, let us all take preventive, recommended measures to help facilitate this period of clinical setback.”



^{1. Fact sheet: Expansion of the accelerated and advance payment program for providers and suppliers during covid-19 emergency. CMS.gov.https://www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf.}