Katherine M. Mastrota, MS, OD, FAAO, Dipl ABO

home

authors

katherine-m-mastrota-ms-od-faao-dipl-abo

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

Asking patients to disclose occupation information should be standard in any OD’s practice. Why? A person’s occupation discloses a lot of useful information, such as level of education, socioeconomic status, potential lifestyle habits, occupational hazards, and most importantly, probable causes of disease.

For me, dry eye history is at the core of developing a profile for my ocular disease patients.  One of the most important questions I ask is about the patient’s occupation.  How and where does the patient spend his waking, work hours? Inside, outside, office, operating room, art studio, classroom, nail salon, supermarket, kitchen, health club, airplane, factory, laboratory, hair salon, arena, fire station?


	I care for housekeepers, cooks and bartenders, doormen and concierges, executives and dishwashers, desk agents and room servers. My patients work in the hospitality industry in the finest venues in New York City. Each environment impacts their ocular surfaces in different ways. The dryness of the hotel room, the heat in the kitchen, the hours on the computer, the cleaning agents and particles from linen, rugs and towels are elements to be considered as challenges to tear film integrity.

6 steps to establish an OSD advocate in your practice

An electronic medical records-driven, data analytics report was built to understand the incidence, demographics, types, and risk factors of dry eye disease (DED) in patients presenting to an ophthalmology hospital network in India.

 This observational study of 1,458,830 patients presenting between 2010 and 2018 included patients with recent onset of symptoms as defined by TFOS Dry Eye Workshop. Study results indicated that age, gender, residence, occupation, and socio-economic status have significant impact on development of DED.


	Odds ratios (OR) are a measure of association between exposure and outcome. The OR represents the odds that an outcome will occur, given a particular exposure. When compared to the odds of an outcome occurring in the absence of that exposure, an OR >1 indicates increased occurrence of an event. Other high-risk factors for DED include age (OR 3.7 to 13.5), urban residence (OR 1.6), professional work (OR 1.5); homemaking (OR 1.42), retirement/unemployment (OR 1.24) and socio-economic affluence (OR 1.6 to 3.2) were identified as high risk-factors for developing DED.

How to create an ocular surface disease treatment protocol


	A separate study in the Netherlands proposed that environmental factors play an important etiological role in dry eye and investigated the relationship between types of occupations and symptomatic dry eye.

 Some 40,501 employed people working ≥8â¯hours a week were included from the population-based cohort. Logistic regression was used to determine the association.


	The results of this study suggest professionals (e.g. legal, health, and business and administration professionals), OR 1.14, and clerical support workers, OR 1.14, had the highest risk of dry eye of all 10 major occupation groups. Building workers and metal and machinery workers, also showed elevated risk of dry eye with OR 1.12. Skilled agricultural workers (OR 0.57) and elementary occupations carried the lowest risk.

Your glaucoma patients also have ocular surface disease


	More specific occupational dry eye risk studies exist. For example, a recent study describes ocular surface and tear film changes in workers exposed to organic solvents used in the dry-cleaning industry.

 Such workers are commonly exposed to different occupational hazards and chemicals that may affect their eye health in particular. Organic solvents used in dry cleaning are associated with changes in ocular surface and tear film, generating irritation symptoms commonly present in evaporative dry eye. Study authors speculate that eye symptomatology was stimulated by the organic solvent exposure.

Sick Building Syndrome (SBS) is important to consider for patients who are based in particular working locations. There are physical, biological, chemical, and psychosocial contributors to SBS. These factors facilitate the emergence of SBS symptoms, creating negative effects for occupants including nasal, ocular, oropharyngeal, and cutaneous irritation. On the contrary, healthy building concepts, or those that are built for workers’ well-being, sidestep working condition concerns because they maintain internal air quality and thermal control, maximize the use of daylight, and provide a workplace that is compliant with the occupants’ ergonomics.

Better manage nocturnal lagophthalmos for dry eye patients


	Strategies to improve SBS concerns include proper ventilation system design, careful room layouts arrangement, sanitation frequency, mold/dampness reduction, installation of external devices on openings such as sunshades, development of green buildings, and visual/physical access to nature.

New guidelines in OSD evaluation before surgery


	A green building refers to both a structure and processes integrated into the building’s lifestyle that are environmentally responsible and resource-efficient: from planning to design, construction, operation, maintenance, renovation, and demolition. The Green Building practice expands and complements the classical building design concerns of economy, utility, durability, and comfort.


	These studies underline the importance of asking about patient occupations when accessing for dry eye. Screening forâ¯symptomaticâ¯dry eye in high risk occupations such as building workers and indoor occupations with high screen use is relevant from an occupational health and work productivity perspective. Environmental modifications and palliative therapies should be discussed and introduced to these patients as part of dry eye management strategies.

Why OAB should be considered before cataract removal

1. Donthineni PR, Kammari P, Shanbhag SS, et al. Incidence, demographics, types and risk factors of dry eye disease in India: Electronic medical records driven big data analytics report I. Ocul Surf. 2019 Apr;17(2):250-256.
	2. Bazeer S, Jansonius N, Snieder H, Hammond C, Vehof J. The relationship between occupation and dry eye. Ocul Surf. 2019 Jul;17(3):484-490.
	3. JimÃ©nez Barbosa IA, RodrÃ­guez Alvarez MF, DussÃ¡n Torres GA, Khuu SK. Ocular surface and tear film changes in workers exposed to organic solvents used in the dry-cleaning industry. 3. PLoS One. 2019 Dec 9;14(12):e0226042.
	4. Ghaffarianhoseini A, Alwaer H, Omrany H, et al. Sick building syndrome: are we doing enough? Arch Sci Rev. 2008 May; 61(3):99-121.
	5. Wikipedia. Green building. Available at: https://en.wikipedia.org/wiki/Green_building. Accessed 4/1/20.

Asking patients about occupation can lead ODs into new diagnosis territory

Why patient occupation matters with dry eye disease

 cases was that of a 65-year-old hospice nurse who suffered from debilitating dry eye symptoms. My patient had seen two or three doctors prior to myself, one a corneal specialist at top New York City hospital. She had tried the usual palliative therapies, punctal plugs, and cyclosporine therapy. She had given up on her contact lenses.

She did admit to working long hours, drinking little water (so she could avoid running to void frequently during working hours) and lots of coffee to keep her alert in the evening hours of her demanding shift.

She also was taking oral medication to temper her over-active bladder (OAB). Discontinuation of the OAB medication dramatically improved the signs and symptoms of dry eye in my nurse-patient. 

Related: Modern-day techniques for diagnosing dry eye disease

Overactive bladder (OAB) is a prevalent condition in both men and women. It may have a significant impact on overall quality of life, sexual function, sleep, and mental health. OAB consists of urinary urgency with or without urge incontinence, often accompanied by frequency and nocturia (nighttime urination).

Every time I examine a women, I think of my patient and her OAB. However, OAB is common in both men and women with equal prevalence. 

The coexistence of benign prostatic hyperplasia (BPH) with OAB can worsen quality of life in men. BPH-also called prostate gland enlargement- is a common condition as men get older. The prostate gland is located beneath the bladder and if enlarged, begins to block urine flow. 

An enlarged prostate gland can cause uncomfortable urinary symptoms such as a weak, slow urinary stream; a hesitancy and straining to urinate; prolonged voiding; dribbling at the end of urination; an inability to empty the bladder completely; the frequent passage of small amounts of urine; and nocturia. Other symptoms of BPH maybe the uncontrollable need to void, symptoms of urinary urgency, frequency, and incontinence. 

Anticholinergic drugs that slow the bladder’s contractions, such as oxybutynin, are the mainstays of therapy for OAB. In men, it may be used in combination with BPH medication. 

Related: Explore the relationship between dry eye and sleep

Anticholinergic drugs however, are notorious for the side effect of provoking 

. Male dry eye patients, especially those with BPH, should be queried regarding their use. 

Lifestyle changes can reduce the need to therapeutically manage OAB.

 These changes include reducing fluid intake, especially alcohol and caffeine; avoiding medications that stimulate muscles in the bladder neck and prostate such as pseudoephedrine and other decongestants; and reducing or changing diuretic medication use for treating high blood pressure. 

Another strategy is timed urination (following a bathroom schedule instead of “urge”). Excercises to strengthen the pelvic floor (Kegel excercises) are also beneficial in controlling OAB symptoms. Biofeedback is another option. Botox (onabotulinumtoxin A, Allergan) bladder treatments are another alternative to control OAB symptoms. Botox works for the bladder by relaxing the muscle of the bladder wall to reduce urinary urgency and incontinence: it can help the bladder muscles from squeezing too much. The effects of Botox last up to six months. 

Another potential treatment is neuromodulation therapy. This type of treatment sends electrical pulses to nerves that share the same path for the bladder. In OAB, the nerve signals between your bladder and brain do not communicate correctly. These electrical pulses help the brain and the nerves to the bladder communicate so the bladder can function properly and improve OAB symptoms. 

Related: How to address the three aspects of dry eye disease

 patient’s medical history and medication list. Be equipped with suggestions or alternatives to modify those pathologies that prompt other colleagues to prescribe medications that thwart our best dry eye therapies. 

Empower your patient to have important conversations and be involved in decision-making with every member of their healthcare teams to limit or avoid oral therapies that impact the ocular surface system.

More by Dr. Mastrota: Dry eye signs may signal risk for diabetic foot ulcers

1. Eapen RS, Radomski SB. Review of the epidemiology of overactive bladder. Res Rep Urol. 2016 Jun 6;8:71-6.
	2. Urology Care Foundation. What Is Overactive Bladder (OAB)? Available at: https://www.urologyhealth.org/urologicconditions/ overactive-bladder-(oab). Accessed 1/17/20.

Discontinuation of OAB medication dramatically improves the signs and symptoms of dry eye in a 65-year-old patient.

Consider a patient’s case history when conducting assessments for potential diagnosis

I practice in a multidisciplinary setting where professional collaborative engagement of all medical specialties is highly valued and practiced on a daily basis.

I learned about a new test from podiatrists on staff in our health centers called the Semmes-Weinstein 5.07 (10-gram) monofilament test for loss of protective sensation of diabetic/neuropathic feet. 

The Semmes-Weinstein monofilament test (SWM) is a nylon filament calibrated so that it takes 10 grams of force to bend it when touched on the skin of the foot. An inability of the patient to detect this degree of force indicates that the client has a loss of protective sensation in the foot.

In 2008, a task force was built to consider the elements of a comprehensive foot and risk assessment of the patient with 

The task force was comprised of the Foot Care Interest Group of the American Diabetes Association (ADA), with endorsement by the American Association of Clinical Endocrinologists (AACE).

Explore the relationship between dry eye and sleep 

The lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25 percent, whereas the annual incidence of foot ulcers is < 2 percent.

The most common triad of causes that interact and ultimately result in foot ulceration has been identified as neuropathy, foot deformity, and foot trauma.

For the foot exam, case history is a pivotal component of risk assessment. A patient cannot be fully assessed for risk factors for foot ulceration based on history alone; a careful foot exam remains the key component of this process. 

Noteworthy aspects of the patient history include previous foot ulceration or amputation. Other important assessments in the history include neuropathic or peripheral vascular symptoms, impaired vision, or renal replacement therapy. 

Tobacco use should be recorded, as cigarette smoking is a risk factor not only for vascular disease but also for neuropathy.

Eyecare providers know that beyond the associated retinal pathology, 

 has been demonstrated to impact corneal nerve morphology and ocular surface integrity. 

 is associated with progressive damage to corneal nerves and epithelial cells. Corneal nerve length and corneal nerve thickness changes are evident even in the early stages of diabetes mellitus (DM).

Corneal neuropathy can lead to loss of corneal sensation and ultimately result in neurotrophic ulcers and significant visual morbidity. 

The epithelial fragility and poor wound healing that result from reduced epithelial adhesion to the underlying basement membrane in diabetes-together with corneal neuropathy-are thought to increase the susceptibility to

, persistent corneal erosions and infection, as well as to increase the risk of post-surgical complications.

To parallel, loss of corneal sensation (corneal hypoesthesia) can be quantified by the use of the handheld Luneau Cochet-Bonnet Aesthesiometer. The device, akin to the monofilament foot test, contains a thin, retractable, nylon monofilament. Variable pressure can be applied to the cornea by the device-quantifying corneal sensation-by adjusting the length. The monofilament ranges from 60 mm to 5 mm. As the length is decreased, the pressure increases from 11 mm/gm to 200 mm/gm.

As guardians of a patient’s wellbeing-and in the current outcomes-driven medical environment-should ODs have patients with 

take off their shoes and socks for the Semmes–Weinstein test? 
	
	

1. Bolton AJM, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman SM, Lavery LA, LeMaster JW, Mills JL, Mueller MJ, Sheehan P, Wukich DK. Comprehensive foot examination and risk assessment: a report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. 

 2008 Aug; 31(8): 1679–1685.
	2. Singh H, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. 

2005 Jan 12;293(2):217-28.
	3. Reiber GE, Vileikyte L, Boyko EJ, del Aguila M, Smith D, Lavery LA, Boulton AJ. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. 

 1999 Jan;22(1):157-62.
	4. Clair C, Cohen MJ, Eichler F, Selby KJ, Rigotti NA. The effect of cigarette smoking on diabetic peripheral neuropathy: a systematic review and meta-analysis.

 2015 Aug; 30(8): 1193–1203.
	5. Reiber GE, Vileikyte L, Boyko EJ, del Aguila M, Smith DG, Lavery LA, Boulton AJ. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. 

. 1999 Jan;22(1):157-62.
	6. Markoulli M, Flanagan J, Tummanapalli SS, Wu J, Willcox M. The impact of diabetes on corneal nerve morphology and ocular surface integrity. 

Author | Katherine M. Mastrota, MS, OD, FAAO, Dipl ABO

Articles

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

Why patient occupation matters with dry eye disease

Why OAB should be considered before cataract removal

Dry eye signs may signal risk for diabetic foot ulcers