Dr. Wong is a Diplomate of the American Board of Optometry and a member of the AOA Ethics committee and ASCO Ethics SIG. He is a past president of the Maryland Optometric Association, and an appointee to the American Medical Association’s Physician’s Cons
Anupam Laul, OD, FAAO is an assistant clinical professor at SUNY College of Optometry.
Gary Y. Chu, OD, MPH, FAAO is senior director of public health and community collaborations at New England College of Optometry.
ODs who utilize technology will advance modern optometric care.
As optometric practices re-open from COVID-19 shutdowns, it is essential that workspaces remain healthy and safe for all employees, consumers and the communities they serve. Advancements in technology, including screening, tracking, decontamination and telehealth measures will allow ODs to take successful next steps.
As ODs battle the COVID-19 pandemic and redesign modern, clinical optometric care, they should pay attention to scientific principles and utilize innovative technologies.
Gene sequencing is one to watch for because it gives ODs growing insights into the biology of SARS-COV-2, the virus that causes COVID-19. A better understanding of COVID-19’s transmission through droplets (aerosol, fomites) can help practitioners control it. Additionally, it gives the modern optometric practice novel ways to safeguard offices and provide important medical services to communities.
Although current Centers for Disease Control and Prevention (CDC) guidelines suggest droplets, not surfaces, are the most likely vehicle for transmission, scientific insights are constantly changing, and new data is emerging.
Innovative technologies can lead to improvements in care and decreased disparities.3,4 Social distancing between doctors and patients is often thought to more accepted by Asian communities than by Latino or other population groups.5,6
The use of online device applications for communications like patient registration, history appointment confirmation, payment, recall, and follow up has helped many ODs transition to emergency-only services during the pandemic. For others, however, this technology can pose challenges, especially for those patient populations with limited technological resources and lower incomes and elderly patients.7
Increased WiFi access at healthcare facilities, libraries, and nursing homes can go a long way toward helping patients register with practitioners and limits exposure time in optometric offices.8-10 Temperature checks have become commonplace in medical offices; however, new methods of screening for COVID-19 and contact tracing offer approaches to move past walk-in appointments and facilitate safer patient flow models.11,12
The care ODs provide necessitates close contact. Social distancing measures, wearing masks, disinfection, hand hygiene, and wearing face shields and goggles have shown to be effective in mitigating infection.13 Other personal protective equipment (PPE), namely ophthalmic PPE, has not been as top-of-mind and therefore, poses more prominent contamination risks if not careful.
We have all seen sneeze guards at checkout counters and registration desks throughout various businesses. Little research has been conducted on their efficacy, but the concept makes sense.
Evidence suggests the airborne nature of the virus is at the crux of its risk. Initially, sneezing and coughing were the greatest concern; however, epidemiology case studies have pointed to microdroplets as higher risk because they linger in the air for longer periods of time.14,15 Air circulation is critically important.
As businesses begin to re-open, the health and wellness of employees, staff, and the general public is a priority. As such, many practices are implementing advanced screening protocols in order to prevent the spread of the virus.22
Temperature screenings are becoming common practice. This is especially true for healthcare workers. Many state and local departments of health require healthcare workers to undergo daily temperature screenings.23-25
Current volume restrictions during phased re-opening allows temperature screenings to be quick and easy. However, as we approach later phases of re-opening, and as patient volume increases, manual temperatures can become a daunting task that can lead to long lines and bottlenecks. This has garnered interest in infrared thermal imaging systems as seen in international airports, worldwide.26 Infrared systems can be used to screen staff and patrons quickly and efficiently. Those with increased temperatures will be flagged and undergo additional screening.5
Although controversial, cell phone data can be used to track individuals and warn them if they have been exposed to someone with the SARSCoV2 virus.27 This technology has been used in Europe and China, although there are concerns about privacy. Developers of this technology use anonymized data to track the disease while ensuring individual privacy.28
A major key in preventing the spread of infectious diseases like COVID-19 is the ability to quickly and efficiently test individuals.29,30 Laboratory testing is expensive and can take days to deliver results. In recent years, there has been a major push for point-of-care testing and self-testing.
Abbott recently released a system that detects SARS-CoV2 when swabs are taken from the nose or throat and often produces results in under 15 minutes.31 Taking it a step further, the U.S. Food and Drug Administration (FDA) recently approved an at-home COVID-19 test by the Rutgers Clinical Genomic Laboratory.32 Two major benefits of at-home testing are that tests can be mailed to patients so they do not have to travel to a testing site (potentially infecting others) and at-home tests save the PPE that would otherwise be used during sample collection.
Another tool used in early detection of COVID-19 lies in wearable technology. Many ODs already wear Apple Watches or FitBits to track health goals. As many of these devices already monitor heart rate, it is not a stretch to think they may be able to monitor temperature and oxygen saturation (oximeter).33 This data is useful when tracking infected persons.
Telehealth and telework
Global telehealth and telework trends have forever changed. Data shows that the ability of employees to work from home could make businesses more profitable through reduced overhead and improved productivity.34 Optometry and medicine had been reluctant to embrace telehealth for many reasons including patient safety, limits of technology, training of staff, and conflicts of interest.35 However, the emergency policies of the CDC and FDA have greatly expanded the availability of telehealth.36
There are continual questions about standards of care and the suitability of telehealth for eye exams, refractions, and ocular and systemic disease management.
However, telehealth is now becoming an integral part of all health care, including primary eye care.37
In a COVID-19 environment, the use of telehealth can greatly reduce the time patients spend in offices, lessening the spread of the virus in optometric settings.38 The American Optometric Association (AOA), CDC, American Academy of Ophthalmology, and major academic institutions (State University of New York [SUNY] Optometry, New England College of Optometry, and Johns Hopkins Universities) have begun to research and utilize telehealth in patient care.39-44 Lastly, state optometric associations, including the New York State Optometric Association (NYSOA), Massachusetts Society of Optometrists (MSO), and California Optometric Association (COA) have created major resources to aid the clinical optometrist for their return to patient care.45-47
Apple and other technology companies are collaborating as Centers for Medicare & Medicaid Services (CMS) continues to roll back Medicare and telehealth regulatory restrictions allowing ODs and other clinicians to be reimbursed for their services through the COVID-19 pandemic. Tech giants Apple and Google underwent unprecedented collaborations with the CDC for COVID-19 contact tracing.48 Risk assessment is setting the stage for a much more connected and patient-driven healthcare system, which is establishing the use of telehealth in much of health care, including optometry.
Clinical research goals
With the lack of scientific knowledge about SARSCoV-2, clinical research will focus on several priorities. First is understanding if the virus will be transmitted through ocular mucous surfaces. This is important in directing the use of goggles and in understanding the ways to treat and manage COVID-19 ocular infections. Second, the effectiveness of ophthalmic PPE, such as shields for slit lamps, phoropters, and visual fields. Studies may include how flow of air is redirected by shields through technologies such as Schlieren imaging techniques or culturing shields for the coronavirus as a way to understand the protective properties such shields may provide.49 Third, the practice of optometry requires close contact with patients.
Will optometry be considered a high-risk profession, and what PPE is most effective in mitigating risks? Last, aerosol of the virus is a risk factor for infection. Studies may look to determine if instruments such as non-contact tonometry pose a risk to optometrists and patients.50
The use of science and technology (PPE, medical imaging, biotechnology, nanotechnology, intelligent machines [smartphones, autonomous drones and artificial intelligence algorithms]) are already present in daily life and optometric practices.51 I contend that innovations in technology offer the best hope to make optometric offices safer for patients, doctors, and staff. They also offer significant long-term hope to improve patient flow, improve patient outcomes, and reduce healthcare disparities.
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21. New England College of Optometry. Infection Control for Optometrists and Staff. Available at: https://www.neco.edu/ academics/continuing-education/online-ce. Accessed 6/15/20.
22. Considerations for Return to Patient Care. American Academy of Optometry. Available at: https://www.aaopt.org/docs/defaultdocument-library/aao-012-return-to-patient-care-considerationsversion 1.pdf?sfvrsn=c7d3bdb9_0. Accessed 7/9/20.
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29. Mandavilli A, Edmondson C. This is not the hunger games’: National testing strategy draws concerns. NY Times. Available at: https://www.nytimes.com/2020/05/25/health/coronavirustesting-trump.html. Accessed 7/9/20.
30. Harvard School of Public Health. Analysis: More than half of US states aren’t doing enough COVID-19 testing. Available at: https://www.hsph.harvard.edu/news/hsph-in-the-news/analysis-morethan-half-of-u-s-states-arent-doing-enough-covid-19-testing/. Accessed 7/9/20.
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35. Karpecki PM. COVID-19: Uncharted optometric territory. PECCA. Available at: https://www.pecaa.com/2020/03/18/ optometry-telehealth/. Accessed 7/9/20.
36. Ross C. ‘I can’t imagine going back’: Medicare leader calls for expanded telehealth access after COVID-19. STAT. Available at: https://www.statnews.com/2020/06/09/seema-vermatelehealth-access-covid19/. Accessed 7/9/20.
37. Lawenda K, Moses R. Telehealth care/ Telemedicine. American Optometric Association. Available at: https://www.aoa.org/ about-the-aoa/ethics-and-values/ethics-forum/telehealth-care/telemedicine. Accessed 7/9/20.
38. Byrne J. Telemedicine predicted to play a larger role in optometry’s future. Healio. Available at: https://www.healio.com/news/optometry/20120225/telemedicine-predicted-to-play-largerrole-in-optometry-s-future. Accessed 7/9/20.
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