ptometry service, aligning with eyecare practices across the nation, has responded to the COVID-19 pandemic with numerous action steps targeted at protecting the visual welfare of our patients and to “flatten the curve” of infection in our beloved New York City. My optometry staff practices in Manhattan, Queens, Brooklyn, and Harlem. New York City and state, epicenters of infection, demanded swift and demonstrative barriers to infection spread.

Top of mind is that the coronavirus responsible for COVID-19 infection, has been isolated in the tear film and is responsible for viral conjunctivitis.1 Therefore, it is of the utmost importance to protect eyecare patients and providers from exposure.

Outlined are my team’s efforts to truncate infection spread in our centers and city.

All nonessential examinations and testing in the optometry department have been postponed. Doctors of optometry and seasoned ophthalmic technician staff individually review every patient scheduled for routine and follow-up care. Those appointments for interocular pressure (IOP) checks, retinal optical coherence tomography (OCT), epiretinal membrane progression, cataracts, macular degeneration, dry eye and select diabetic cases are postponed.

Each patient is counseled on ocular safeguards and follow up and receives recommendations on how to maintain eye health under our current pandemic restrictions.

All onsite visits have been designated to problem-based assessments to limit patient time within the centers. Those patients who attend in-person appointments are triaged based on the urgency of the reason for their visit. Video consultations are held whenever possible, via secure platforms, in order to reduce onsite visitations. These virtual appointments help to limit the risk of infection for patients and staff across multiple high-risk environments, including local and mass transit.

Accepted patients, once onsite, are screened with a battery of symptom questions, have their temperatures measured, are face masked, and are sent to the optometry suites where hand and spectacle washing are mandatory prior to sitting in the examination chair. Examination chairs are covered with full-barrier shields (head rests, arm rests, and seats are covered with plastic barrier sleeves). Patients are not permitted a companion in the exam room unless they are of pediatric age, need translation services, or require an aide for comprehension, impaired hearing, or other identified disabilities. Doctors and technicians are masked (surgical or KN95) and gloved.

All eye contact procedures (Goldmann applanation tonometry, gonioscopy, other) and non-contact tonometry (NCT), are not performed unless absolutely necessary for diagnosis or case management. Disposable tonometer tips, Tono-Pen (Reichert) or Icare tonometry is preferred. If used, tonometer tips are rotated and disinfected between use. Tonometer tips are covered after disinfection with a plastic shield.

Breath shields were added to all slit lamps and binocular indirect instruments.

Exam rooms are rotated between exams and thoroughly wiped down with commercial disinfectant wipes (desks, slit lamp and table, keyboards, phoropter, handheld instruments, occluders, and near cards). Barrier shields are changed. Indirect lenses are washed with mild soap and water and dried with a clean, soft, optical-grade cleaning cloth. Microscope oculars are cleaned. We are investigating, with our dental service, the use of electrostatic units to disinfect exam rooms between patients.

There is a plan to reduce clinician staffing in a way that rotates teams and minimizes exposure risks from public transport. While one team works from home, recharges, and recovers in quarantine, the other works onsite. This has made instant communication between colleagues paramount. To facilitate broad and rapid communication, colleagues were added to a secured messaging platform so that every team member can remain abreast of rapidly changing information, be it patient-centric or service-centric.

To transition to telehealth, physicians enrolled in Health Insurance Portability and Accountability Act (HIPAA)-compliant messaging and video platforms. Patients were encouraged to register on a patient portal for bidirectional communication and patient-uploaded-to-chart imaging. Online, telehealth, learning services prepared by optometry schools, state associations, private practices, and other eyecare outlets were consulted (thank you, optometry!) for best-practice tips for optometric/ophthalmologic telehealth examinations.

To offset the impact of staffing shortages and absences, team members expanded their normal responsibilities to support those areas needing additional support, such as pharmacy, nursing triage, calling COVID-19 isolated or quarantined patients, and monitoring for worsening or unresolved symptoms.

The opportunity for my team to offer care from home has granted respite to doctors and technicians during this stressful time. Our Member’s Health Assistant Program clinicians have been available throughout the crisis for personal mental health check-ins and Group Zoom consultation sessions. This service bonded staff across job functions and helped the organization unite in the common goals of our facilities, city, and state.

Willcox MD, Walsh K, Nichols JJ, Morgan PB, Jones LW. The ocular surface, coronaviruses and COVID-19. 

. 2020;103(4):418-424. doi:10.1111/cxo.13088

Articles

Managed patient flow, sanitizing, and HIPAA-compliant communication among new protocols

Committed to safety: One OD’s COVID-19 response

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institute of Health (NIH), established a network of clinical trials in hopes of enrolling thousands of volunteers to participate in early COVID-19 vaccine testing.

Related: Headache a key symptom of COVID-19

 has set up a secure method of volunteering for local studies. Anyone over the age of 18 may participate. If chosen, participants will be subjected to injections or infusions containing the study product or a placebo. Most studies require traveling to the research site for 10 or more visits over a span of 1 to 2 years.

The COVID-19 Prevention Trials Network (COVPN) consists of 4 existing NIAID-funded clinical trials networks including:

Infectious Diseases Clinical Research Consortium

Related: COVID-19 antibodies can disappear in non-symptomatic individuals

Together, they create a functional unit of “Operation Warp Speed,” an initiative led by the U.S. Department of Health and Human Services (HHS) to organize the development and distribution of COVID-19 diagnostics, therapeutics, and vaccines.

“Establishing a unified clinical trial network is a key element of President Trump’s Operation Warp Speed, which aims to deliver substantial quantities of a safe, effective vaccine by January 2021,” says Alex Azar, HHS Secretary, in a statement.

“Starting this summer, this new network will leverage existing infrastructure and engage communities to secure the thousands of volunteers needed for late-stage clinical trials of promising vaccines,” he says.

Related: Telemedicine in the face of COVID-19

The network is projected to operate more than 100 clinical trial sites throughout the United States and the world.

Interested persons can learn more about the different stages of vaccine research and the new network’s COVID-19 vaccine and monoclonal antibody studies by visiting 

https://www.coronaviruspreventionnetwork.org

Thousands of participants needed for research.

NIH launches clinical trials network: COVID-19 vaccine underway

requency doubling technology (FDT) has been around for decades with visual field testing.1 The science centers around frequency.2 The target of an FDT visual field has a low spatial frequency (the target is relatively large), and it undergoes a counterphase flicker with a high temporal frequency (the flicker happens rapidly).2

As the target is a grading of light and dark bars, the high temporal frequency flickering results in an illusion that twice as many bars are perceived as actually exist. One could say they are “doubled.” The magnocellular pathway of the visual system is responsible for this illusion.2,3 This pathway could suffer more damage in early glaucoma4 and isolating it with a targeted visual field may be of benefit.

A study5 published earlier this year lends credibility to FDT visual fields as good indicators of the presence or absence of glaucoma as measured in a large screening population. This retrospective cohort study had a large sample size (N=5076). Subjects consisted of people who participated in a “comprehensive health checkup service” during the course of a year.

Some 2024 participants completed an FDT visual field and also underwent fundus photography. In addition, 3052 patients underwent photography without completing a visual field. These subjects served as the control group. Subjects with a known diagnosis of glaucoma were excluded, and mean age of participants was the fifth decade of life. Those who had abnormal findings on their visual fields and/or photography were advised to undergo a complete eye exam. Subjects then reported (within 2 years of their first visit) if they had been diagnosed with glaucoma.

In the group with FDT testing and photography, 23 reported having been diagnosed with glaucoma during the 2-year time frame. That number accounted for 1.14 percent of that study group. Of those 23 individuals, 20 (or 87 percent) had abnormal findings on their FDT visual fields. Twelve of the 23 (or 52.2 percent) had abnormal results with photographs.

In the group having undergone fundus photography alone, 15 individuals reported having received a diagnosis of glaucoma within the 2-year follow up period. Of these individuals, 9 (or 60 percent) had abnormal findings on their fundus photographs. The age-adjusted glaucoma detection rate was significantly higher for the group who underwent FDT visual field studies and fundus photography as compared to the group of the study who only underwent fundus photography.

Investigators concluded that FDT field have the potential to improve glaucoma detection when performed in conjunction with fundus photography.

Admittedly, some results, such as history of glaucoma and results of a subsequent eye exam, were self-reported. As well, this study did not investigate FDT testing as compared to another modality of visual field testing.

The results are compelling that a quick test can improve the detection rate of a disease, even when administered by physicians who are not specialized in the human eye (authors point out that “nonspecialized physicians” conducted the FDT studies).

Literature over the last several years supports the use of FDT visual fields in patients who cannot complete a standard automated perimetry (SAP) study.6 There is also evidence that FDT studies may pick up defects missed on SAP studies.7 Further, visual field defects on FDT studies may be predictive of future defects as elicited by SAP.8

I have an FDT visual field analyzer, and I use it often. I cannot say from experience that it has picked up defects invisible to SAP, but I have not conducted a study. It does not take a long time to conduct an FDT study, and I find it useful for patients for whom SAP is difficult to administer. I look forward to the day (albeit with cautious optimism) when ODs no longer have to perform visual studies on glaucoma patients and suspects. That day does not seem to be coming anytime soon, but maybe I will still be practicing when it does.

Quigley HA. Identification of glaucoma-related visual field abnormality with the screening protocol of frequency doubling technology. 

Cioffi GA, Mansberger S, Spry P, et al. Frequency doubling perimetry and the detection of eye disease in the community. 

Giuffrè I. Frequency doubling technology vs standard automated perimetry in ocular hypertensive patients. 

Zhang P, Wen W, Sun X, He S. Selective reduction of fMRI responses to transient achromatic stimuli in the magnocellular layers of the LGN and the superficial layer of the SC of early glaucoma patients. 

Terauchi R, Wada T, Ogawa S, et al. FDT Perimetry for Glaucoma Detection in Comprehensive Health Checkup Service. 

Wesselink C, Jansonius NM. Glaucoma progression detection with frequency doubling technology (FDT) compared to standard automated perimetry (SAP) in the Groningen Longitudinal Glaucoma Study. 

Liu S, Yu M, Weinreb RN, et al. Frequency-doubling technology perimetry for detection of the development of visual field defects in glaucoma suspect eyes: a prospective study. 

Medeiros FA, et al. Frequency doubling technology perimetry abnormalities as predictors of glaucomatous visual field loss. 

Frequency doubling technology may become the new holy grail of glaucoma imaging.

Study finds FDT visual field studies are effective glaucoma detectors

With 2020 turning out to be the year of a pandemic, it seems nearly everyone’s plans have been turned upside-down and our new “normal” may be contributing to an influx of ocular problems.

An increased amount of time at home has meant a boost in hours of digital screen time and home improvement projects for millions of people across the globe. For some healthcare providers and essential workers, the pandemic has also meant an increased amount of time wearing a mask and frequent exposure to cleaning chemicals. In addition, heightened psychological and physical stresses due to sudden changes in routine schedules may play a role in the overall risk of some ocular pathologies seen during the pandemic.

Related: Homeostasis is the Holy Grail in dry eye disease

As an optometric provider partially available to emergency patients throughout the quarantine period (and full time since starting back in early May), I have noticed an interesting shift in ocular problems at my practice. Some of the common ocular “emergencies” have presented more frequently over the past several months, including dry eye disease (DED) associated with computer use and ill-fitting masks, corneal abrasions and foreign bodies due to home improvement projects, herpes simplex virus (HSV) and herpes zoster virus (HZV) flare-ups, along with episodes of central serous chorioretinopathy (CSC). 
 

Trying to avoid the virus that may be lurking on every doorknob, many companies and corporations have transitioned to work-at-home environments. This digital wave and virtual work world appears to be here to stay.

Related: Safe & effective ocular triage in the COVID-19 era

Considering the millions of people who now work on their computers and digital devices full time, it is not surprising to see increases in symptomatic complaints of burning, watering, ocular pain, eye strain, and intermittent blur.

Prolonged use of digital devices is likely associated with decreased blink rates and increased tear evaporation, which can lead to tear film instability and hyperosmolarity.1 This vicious dry eye cycle paired with computer use can eventually lead to a decreased tear break up time, worsening symptoms of 

.1To make matters worse, previous research suggests that subjective dry eye symptoms can be influenced by psychosomatic conditions including stress, anxiety, and depression.2

With an array of treatments, from artificial tears to punctal plugs to pharmacologic options that improve tear film stability, educating patients on the short- and long-term consequences of extended digital computer use can be helpful in stopping the cycle of DED.

Related: How one OD communicates with her team amid COVID-19

It may also be a great time to start sending dry eye questionnaires and information regarding DED associated with digital screen use to patients virtually before their exam. This can help toidentify potential DED factors or problems ahead of the appointment and decrease exposure time in office. 
 

With the addition of mask mandates across the world, dry eye signs and symptoms have also seemingly been on the rise since mid-March in my practice. Some patients, such as healthcare providers and essential workers, are now wearing masks or facial coverings for upward of 40 hours per week.

Especially worsened with ill-fitting masks, symptoms of mask associated DED is likely due to the constant flow of exhaled air on the exposed eye while breathing. Sometimes presenting with ocular pain and intrapalpebral corneal staining, the escaping air flow can create a windy obstacle affecting tear film stability. The frequency of mask-wearing seems to be correlated with increased frequency of DED recently seen in practice.

Mask-wearing is very effective in lowering the rate of viral transmission. It may be helpful to educate patients on the importance of a properly fitting mask to reduce airflow directed at the eyes. It may also be beneficial to ask questions regarding details of mask usage when considering overall risk factors for DED.

With additional time at home, more people than ever are completing projects and finishing up honey-do lists. Indoor and outdoor projects have resulted in more ocular injuries such as corneal abrasions and foreign bodies.

Ranging from “abrasion caused by mask” to “stick in eye while doing outdoor chores” to “metallic foreign body while grinding metal,” there seems to be an influx of ocular injuries since quarantines began.

As optometrists, it is especially vital to treat these ocular injuries and help keep these patients out of the emergency room, if possible. Of course, it is also important to discuss the importance of wearing safety glasses, but hindsight is 20/20. 


4. Herpes simplex virus (HSV) and herpes zoster virus (HZV)

Psychological and physical stresses associated with abrupt changes to daily life may play a role in the overall risk of some ocular pathologies seen in practice, especially in the midst of a pandemic.

Related: Optometry’s Apollo 13 moment during COVID-19

Stress has been thought to modulate an individual’s immune system through the release of certain molecules such as catecholamines, cytokines, and glucocorticoids.3,4 Such release signals other molecules to alter the host immune system, leaving it susceptible to a primary or recurrent viral infection.3,4

Stress is also thought to contribute to reactivation of latent herpes simplex virus (HSV) and has been considered a trigger for herpes zoster virus (HZV).4,5 This connection with stress and HSV/HZV has been supported by several, but not all, studies.3-5 It would be curious to investigate the effects of phycological and physical stress during a pandemic and its effect on HSV and HZV activation or reoccurrences.

Pre-pandemic, one clue to tip off the practitioner about increased risk for HSV-1 in the eye may have been the obvious fever blister noticed on the lip during an exam. For the time being, wearing a mask hides these important observational details; therefore, it may be important to ask about history of cold sores and fever blisters that may be hidden from view 
.

5. Central serous chorioretinopathy (CSC)

Predominantly, CSC affects young or middle-aged adults (25 to 50 years old) with men more frequently affected than women.6 Often presenting unilaterally with painless blurred vision and a shallow serous retinal detachment, some patients may even be asymptomatic.

Physiological stress is considered one of the most important risk factors for developing CSC.7 One study identified that stress scores, serum homocysteine levels, serum morning and evening cortisol levels, and systolic and diastolic blood pressure were all elevated in CSC patients.7

There have been several other independent studies over the past several decades concluding CSC occurs more frequently in “Type A” men with higher emotional stress, lower frustration tolerance threshold, and poor coping strategies for stressful events.6

The natural course of CSC is typically self-limiting with spontaneous resolution over many weeks or month and a good prognosis in 90 to 95 percent of cases.6 In addition to identifying the stressors, CSC patients should also consider a routine workup with stress score evaluation including measurement of blood pressure, serum homocysteine levels, and serum cortisol levels.7

In conclusion, our new “normal” during the midst of the pandemic may be contributing to an increase of ocular problems that optometrists should keep in mind as differentials.

Considering risk factors such as hours of digital screen time, mask wearing, and overall stress levels may be helpful in identifying those more susceptible to ocular problems.

Keep ocular emergencies that are presenting more frequently in mind—dry eye associated with computer use and ill-fitting masks, corneal abrasions and foreign bodies due to home improvement projects, herpes simplex virus (HSV) and herpes zoster virus (HZV) viral infections and central serous chorioretinopathy (CSC).

Post-pandemic, it will be interesting to seeretrospective data regarding the global incidence of ocular problems more frequently seen since quarantine. For now, it is of vital importance that optometrists treat patients and keep them out of the emergency room.

1. Kim KW, Han SB, Han ER, Woo SJ, Lee JJ, Yoon JC, Hyon JY. Association between depression and dry eye disease in an elderly population. 

2. Uchino M, Yokoi N, Uchino Y, Dogru M, Kawashima M, Komuro A, Sonomura Y, Kato H, Kinoshita S, Schaumberg DA, Tsubota K. Prevalence of dry eye disease and its risk factors in visual display terminal users: the Osaka study. 

3. Chida Y, Mao X. Does psychosocial stress predict symptomatic herpes simplex virus recurrence? A meta-analytic investigation on prospective studies. 

4. Sainz B, Loutsch JM, Marquart ME, Hill JM. Stress-associated immunomodulation and herpes simplex virus infections. 

5. Glaser R, Kiecolt-Glaser JK. Chronic stress modulates the virus-specific immune response to latent herpes simplex virus type 1. 

6. Semeraro F, Morescalchi F, Russo A, Gambicorti E, Pilotto A, Parmeggiani F, Bartollino S, Costagliola C. Central Serous Chorioretinopathy: Pathogenesis and Management. 

7. Agarwal A, Garg M, Dixit N, Godara R. Evaluation and correlation of stress scores with blood pressure, endogenous cortisol levels, and homocysteine levels in patients with central serous chorioretinopathy and comparison with age-matched controls

The pandemic is contributing to an influx of ocular problems.

5 common ocular problems seen during the pandemic

Vision Expo organizers, The Vision Council and Reed Exhibitions, announced the cancellation of the optometric conference Vision Expo West 2020 previously scheduled to take place in Las Vegas from September 23-26.

The decision comes after Vision Expo East and the American Optometric Association’s (AOA) Optometry’s Meeting 2020 were cancelled in March and June, respectively. Meeting organizers cite health and safety concerns as the main reason for the cancellation. Nevada Governor Steve Sisolak (D)announced Monday, June 26, that Nevada would remain in Phase 2 of reopening plans through the end of July due to current trends of the coronavirus infection.

“While certainly disappointing, the decision to cancel Vision Expo West 2020 is prudent and necessary following the announcement of the extension of Phase 2 in Las Vegas into the end of July,” says Fran Penella, event vice president, in a statement.

“Without having visibility on when the state of Nevada will be ready to roll into future phases or what the future phases will allow for, coupled with the unfortunate spiking of COVID-19 cases in the region, we know it is in the best interests of everyone in the vision community to not move forward.”

Attendees and exhibitors who had previously registered for the event may still take part in a digital platform that will virtually replace in-person experiences. Continuing education (CE) product showcases, and service and product sourcing will take place on the new platform.

More details on specific offerings and partners will be forthcoming, and personalized communications will be sent to each registered attendee this week from the Vision Expo team.

Related: AOA elects '20-'21 officer slate via virtual ballot

Vision Expo West 2020 cancelled due to COVID-19

most optometrists thought relatively little about ocular triage. Aside from an OD or staff worker fielding a phone call from a patient and deciding how urgently he needed to be seen, resources were typically greater than demand and there was little need to think deeply or systematically about principles of ocular triage.

Essentially, ODs’ doors were always opened, the welcome mat laid out, and the stakes relatively low.

However, COVID-19 turned the world, and eye care, upside down. With “routine” eye examinations suspended, ODs were forced to consider anew the practice of triage when a simple visit to the optometrist became a potentially lethal act for patients and the doctors and staff who care for them.

Although I am accustomed to triaging in my Department of Veterans Affairs practice where demand is often greater than resources, COVID-19 caught me flat-footed as well. Like everyone else, I scrambled to obtain personal protective equipment (PPE), institute new disinfection and screening protocols, and make plans for altered patient flow. What I have spent the most time doing is reviewing charts and deciding the “who, when, what, and how” of pandemic patient care.

I started the process with expectations of how I would proceed. In some cases, those expectations panned out; but the “new normal” also contained a few surprises.

Related: How doctors should handle crisis communication during COVID-19

This article is a summary of the lessons I have learned about ocular triage during the initial period of the COVID-19 epidemic and will cover four areas:

Defining triage and how the process applies to eye care

Discerning differences among “routine” eye care, ocular “urgencies,” and true ocular “emergencies”

Applying triage principles to surveillance of established ocular disease patients

Considering how COVID-19 impacts referrals to ophthalmology for secondary care and ocular surgery

The word “triage” is derived from the French word 

, which means “to choose, pick out, or separate from others, to sort” and was originally used in agriculture.

 Today, triage is almost exclusively used in a healthcare context and a formal definition is: allocation of a medical resource occurring under conditions of scarcity performed by a healthcare worker using an established system or plan.

 A simpler working definition is: the process of sorting through the sick and injured and choosing those with the best chance of benefiting from immediate care.

Historians trace the origins of triage to several ancient battlefield narratives, but they commonly place the first formal model in the early 19th century and attribute it to French military surgeon Baron Dominique-Jean Larrey, chief surgeon of Napoleon’s Imperial Guard.

Our conceptions of triage are shaped by culture and media, such as the popular TV shows “M*A*S*H*,” “China Beach,” and “ER” that depict triage under the stresses of acute battle injuries and the harried and demanding pace of the emergency department in an inner city public hospital. However, triage can apply to any specialty and setting, including inpatient or outpatient, in which demand is greater than available resources.

Triage carries a strong utilitarian connotation: to do the greatest good for the most and cause the least harm to the fewest.

 In the initial stages of the COVID-19 pandemic, public health officials decided the suspension of routine eye care and limiting face-to-face (F2F) care only to patients with ophthalmic urgencies and emergencies was necessary to “flatten the curve” of the pandemic to prevent overload of hospital critical care resources. Essentially, they considered slowing the spread of the coronavirus as the greatest good and the potential negative outcomes associated with delays in routine eye care as the least harm.

As of this writing, after an extended plateau in new cases and overall decline in the COVID-19 death rate for several weeks, the U.S. is experiencing a spike in new cases in 22 states located primarily in the Sun Belt and the West, as most state and local stay-at-home orders expire, businesses reopen, and public activities and gatherings increase. Public health officials point to pandemic “fatigue” and the desire to return to normal activities, recent street demonstrations and protests across the country, and poor compliance with wearing masks and social distancing as factors in this increase.

Related: Study brings fomites’ role in COVID-19 transmission to light

Routine eye care is also resuming but at a reduced volume and rate to allow for social distancing and disinfection. The pandemic’s ebb and flow will likely continue to impact our practices for an extended period. Reduced access to eye care because of the “speed bumps” of disinfection and screening protocols and/or the “throttle” of fresh spikes in new cases and more stay-at-home advisories or orders are optometry’s and ophthalmology’s “new normal” for the foreseeable future.

Decreased access has a domino effect, and what happens at the primary-care level also influences secondary care. For instance, ODs may discover that ophthalmologists may not as readily accept referrals for secondary treatment and surgery because MDs are also experiencing more constriction to patient flow and dealing with a larger-than-normal backlog of pent-up care created by the initial shutdown.

Principles of triage should continue to guide ODs’ thinking during the pandemic as they attempt to balance the vision needs and ocular health of their patients with public health concerns. This continuous process will involve deciding whether to see patients F2F or virtually, how long visits should last, what procedures and tests should be done in-office, and how far apart (or if) to schedule follow-up exams.

‘Routine’ versus ‘urgent’ versus ‘emergent’

Using the word “routine” to describe a comprehensive eye exam can be misleading. From experience, ODs know that they frequently detect and diagnose sight-threatening disease and life-threatening systemic conditions during a so-called “routine” exam. Patients often hesitate to speak up about “minor” symptoms until asked, and targeted follow-up questions often lead to an unexpected but timely diagnosis.

Patients vary in their tolerance of eye symptoms and blurred vision, and one’s occupation and activities of daily living (ADLs) can affect their perception of the urgency of their vision problems. ODs differ as well in how they triage and classify patient complaints and decide who should receive expedited care.

In the pandemic’s early stages, numerous ophthalmic organizations offered triage guidelines about which ocular conditions had a high enough risk of vision loss to outweigh the risk of virus transmission and thereby warrant F2F visits.

While most protocols were in general agreement, there were some differences in rankings and prioritization, and little distinction was made between ocular “urgencies” and “true emergencies.”

One way to distinguish between the two is to consider how quickly morbidity and/or mortality could occur without intervention. Based on that criterion, a true ocular emergency could be classified as a condition that results in irreversible blindness and/or death 

Endophthalmitis, intraocular foreign bodies, chemical injury, secondary glaucoma (for example, inflammatory, hyphema, etc.) with extremely high intraocular pressure (IOP), acute angle closure glaucoma (AACG), orbital cellulitis, and open globe trauma could all be correctly classified as true ocular emergencies. Possible additions to that list could include central retinal artery occlusion (CRAO) if diagnosed within hours of onset, extraocular muscle entrapment with muscle necrosis, and signs and symptoms of a cerebrovascular event such as sudden onset diplopia, cranial nerve palsies, and sudden vision or visual field loss.

The majority of acute conditions and symptoms that typically present to optometrists such as flashes and floaters, external ocular foreign bodies, retinal tears and detachments, uveitis, corneal ulcers, contact lens-associated red eye, acute conjunctivitis, vitreous hemorrhages, choroidal neovascular membranes (CNV), and even arteritic anterior ischemic optic neuropathy (AAION) may be more correctly classified as “urgencies” because they can usually be diagnosed and managed within a matter of days and not result in irreversible blindness and/or death.

Related: AOA Optometry’s Meeting 2020 cancelled

Regardless of these distinctions, ODs should continue F2F exams or expedited referrals for patients who have the above conditions, even amid strict “stay at home” orders and quarantine, provided proper PPE is used, screening and sanitation protocols are followed, and the patient has not tested positive for COVID-19 and has no signs, symptoms, or multiple risk factors for the disease.

For patients who have tested positive for COVID-19, or who are persons under investigation (PUI), most guidelines recommend that ocular urgencies or emergencies be managed in a hospital setting more equipped to provide the highly specialized care and strict disinfection controls needed, or if the condition allows (for example, acute conjunctivitis), remotely via telemedicine.

Diagnosing and managing acute conjunctivitis during COVID-19 deserves special mention. Because of reports of the presence of the novel coronavirus in tear secretion and follicular conjunctivitis associated with COVID-19 cases,9,10 ODs should take special caution in dealing with “red eyes” in F2F visits.

Because the majority of cases of acute conjunctivitis are self-resolving, most recommendations have been to provide ocular telehealth care if possible and supportive therapy such as artificial tears, cool compresses, and oral non-steroidal anti-inflammatory drugs (NSAID) and/or acetaminophen to avoid the risk of a F2F visit. Contact lens wear may complicate matters and tip the scale toward an in-person office visit. Both optometrists and ophthalmologists have often used telemedicine by means of traditional phone calls and live televideoconferencing platforms to treat conjunctivitis during COVID-19.

Related: Hypochlorous acid: harnessing nature’s germ killer

However, not all patients and their problems fit into neat categories and boxes. Clinical judgement and case-by-case evaluation are always paramount. While refractions weren’t regarded as “essential” during the acute phases of the pandemic, a -6.00 D delivery truck driver whose glasses break and does not have a backup pair or contact lenses can quickly jump in priority from “routine” to “urgent.”

Prioritizing surveillance of established patients with ocular disease

In addition to triaging acute conditions, ODs should prioritize follow-up care for established patients with existing ocular disease. Factors to consider are the practitioner’s knowledge of the individual patient, the natural course of the condition, previous treatment, existing vision impairment, and markers of progression.

While not all-encompassing, I found it useful to order my thinking around what I coined the “big four” causes of vision loss in my clinic: glaucoma, diabetic retinopathy (DR), age-related macular degeneration (AMD), and cataracts.

When I started reviewing charts to prioritize care and reschedule patients, I assumed that because about 40 percent of my patient load consists of the diagnosis, treatment, and surveillance of primary open-angle glaucoma (POAG) patients and glaucoma suspects, these would comprise the bulk of my F2F follow-ups.

Counterintuitively, this turned out not to be the case.

Related: Virtual conferences not filling the gap of in-person meetings

Instead, I discovered the majority of my POAG patients were, inasmuch as I could discern, stable enough to defer a majority of their follow-up visits judging from functional measurements such as progression analysis data from serial visual fields and structural information gained from serial optic nerve assessments and retinal nerve fiber layer (RNFL) optical coherence tomography (OCT). Very few were progressing rapidly enough to warrant the risk of keeping an upcoming F2F follow-up visit during the early phases of the pandemic when cases were rising exponentially, and the majority were rescheduled for 2 to 4 months later.

During chart review, I found I was already comanaging with or had permanently transferred care to glaucoma specialists in most cases of advanced and poorly controlled cases of POAG and secondary glaucoma. I have a handful of very elderly patients with advanced or end-stage glaucoma and multiple systemic comorbidities who have already received maximum medical and surgical treatment and whose IOPs are as low as reasonably possible and can no longer preform reliable visual fields. For the most part, I deferred their F2F follow-ups and instead talked by phone with them or their caretakers and hoped for the best.

Lengthening the interval between follow-up visits these past few months is a continuation of a practice I adopted in recent years as I reconsidered the traditional, every 3 to 4 month glaucoma follow-up protocol and looked for patients with milder glaucoma and good compliance whom I could safely monitor with fewer in-office visits. I have the advantage in my practice of being able to monitor if patients are refilling their drops, an indirect—but not foolproof—measurement of compliance. Reviewing that information, refilling their drops, talking with patients by telephone to reinforce compliance and explain why we were deferring their care reduced F2F visits, and most likely, virus transmission.

New devices are now enabling home IOP measurement, and while these would enhance the quality of remote care, unfortunately they are not yet scalable and affordable enough to use on a widespread basis.

 While glaucoma tends to progress slowly, ODs must remember progression can vary widely and occur in a sudden and non-linear fashion, even in the presence of low IOP.

 As always, case-by-case clinical judgement is important, and the maxim “know thy patient” has never been truer than in the current moment.

In contrast to glaucoma, I discovered the need to keep a tighter rein on my patients with DR and left in place more of their scheduled F2F follow-up visits for serial dilated fundus exams and macular OCTs. This was particularly true for patients with higher risk of progression, especially those patients with moderate and severe nonproliferative retinopathy (NPDR) accompanied by non-centered diabetic macular edema (DME) and good central vision whom I were closely monitoring or co-managing with retinal specialists.

I reasoned that during the pandemic, DR patients would likely see their primary-care providers (PCP) less often and might experience discontinuity in their systemic care and monitoring of their disease, be more prone to poor compliance with treatment and diet, perhaps from “stress eating” under conditions of isolation and quarantine, and also become less physically active.

Follow-up visits with these patients confirmed my suspicions as many of them have shown progression of their retinopathy and worsening of their DME. Retinal specialists generally performed only the most critical intravitreal injections (IVIs) in the early phase of the pandemic, and now many are scrambling to perform more such procedures to alleviate the pent-up demand that has developed.

When assessing diabetic retinopathy patients during the pandemic, ODs should triage using DR severity, evaluating the severity and location of DME, blood glucose control and HbA1c, and DR natural history.

 Monitoring less sight-threatening diabetic retinopathy via fundus photos and ultra-wide field imaging (UWF) is an evidence-based alternative to dilated fundus exams (DFE) when care is less accessible or when patients prefer to reduce F2F care to reduce their risk of viral transmission.

Like DR patients, delaying care and deferring routine F2F follow-ups of AMD patients during COVID-19 can contribute to poor visual outcomes. AMD can convert from dry to wet forms and progress rapidly. If possible, ODs should closely monitor with F2F exams those patients with high-risk characteristics such as “soft,” confluent drusen, calcified drusen, previous wet AMD with a history of treatment, and existing severe vision loss in one eye.

One study showed optometrists and ophthalmologists in primary eyecare settings equally underdiagnose AMD, especially in subclinical and early stages, misjudge the stage of severity, and are often too passive in management and treatment.

Additionally, one study demonstrated the importance of adherence to follow-up exams in patients with exudative AMD and documented worse visual outcomes associated with longer follow-up intervals.

While home monitoring via Amsler grid and newer automated methods may be valuable,20 even patients who are engaged and vigilantly monitor their vision sometimes miss clinically significant changes marking progression in disease severity. There is no substitute for F2F visits with serial OCTs and DFEs for monitoring AMD progression, even in the COVID-19 era.

Because IVIs are considered essential and still available even under stringent stay-at-home orders and isolation, ODs should monitor AMD patients with in-person visits assuming the visits can be conducted safely.

In most cases, cataract surgery was considered “nonessential” and suspended during the early stages of COVID-19. Although ophthalmic surgeons are performing this and other elective procedures again, patients with milder vision loss and less effect on their ADLs may receive less priority and experience delays in scheduling surgery.

During the pandemic, ODs should make an even greater effort to inform patients of the risks versus benefits of cataract surgery. For those patients who can reasonably wait, ODs can update prescriptions and use various coatings, tints, and other options to tide over patients until their cataracts can be removed.

Public health authorities and eyecare providers may have considered refraction to be “routine” in the initial stages of COVID-19. However, ODs performed some “urgent” refractions for patients whose cataracts were very symptomatic and who needed better vision to enjoy reading, watching TV, and perform other ADLs needed to better cope with increased stress associated with the pandemic and home isolation.

No guideline is a “one-size-fits-all” solution. ODs should always exercise professional judgement in deciding what actions are in the best interest of their patients and the public at large.

Related: Fashion advice from an OD on the frontlines of COVID-19

Ophthalmology colleagues and consultants also face backlog and pent-up demand that may slow their ability to receive OD referrals. As they reopen and increase the inflow of patients into their offices, ODs should strive to better communicate and coordinate care with them by determining the priorities they use to schedule patients whose care was deferred. Sharing and discussing cases and images via telemedicine platforms and negotiating comanagement strategies could lead to better coordination of care, improved handoffs, better outcomes, and higher patient convenience and satisfaction.

Optometry as a profession has been trending toward a more “medical mindset” for many years, and the increased opportunities to monitor and manage chronic eye disease patients afforded by altered referral patterns in response to the pandemic may further accelerate this movement. Patients, ophthalmology colleagues, and the entire healthcare system are counting on ODs to stretch their comfort zones, step up their game to an even higher level, and do their part as essential members of the healthcare team to defeat the virus.

The significant morbidity and mortality generated by COVID-19 will continue for the foreseeable future. As patients return to OD offices, ODs will inevitably discover ocular and systemic morbidity resulting from deferred ophthalmic care and delays in treatment caused by the pandemic.

However, revisiting and practicing sound principles of ophthalmic triage can enable ODs to help minimize these losses and decrease the causality count in the war on COVID-19.

This generational challenge gives ODs an exclusive opportunity to carry forward the new techniques, technologies, and mindsets they have been forced to adopt out of necessity and use them to reshape eyecare delivery systems for maximum efficiency and safety in the post-pandemic “new normal.”

More by Dr. Brown: Optometry’s Apollo 13 moment during COVID-19

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