Care in the Clinic post COVID-19

As many countries begin to emerge from lockdown, health care providers and patients eagerly anticipate the re-opening of clinics, which will allow for the widespread provision of essential care to re-commence. This is certainly the case within the ophthalmic community as many retinal conditions are time-sensitive, and thus rely on early and accurate diagnosis and therapy administration to be effectively managed. In order to facilitate this safe transition back to the healthcare setting, appropriate and necessary precautionary measures must be formalised to ensure the safety of patients and staff, and thus prevent the spread of COVID-19 through the clinic.

According to a MedRxiv preprint study conducted in the New York City district, ophthalmology is one of the top three health disciplines at greatest risk of COVID-19, and contradicts the view that ophthalmology is a low-risk and outpatient specialty¹. The very nature of the profession requires patients and eye care professionals to be in very close proximity to each other, much less than the World Health Organisation’s 1 metre social distancing recommendation during general eye examination procedures, such as the slit lamp exam, although these recommendations do vary among different countries². Therefore, it is essential that evidence-based procedures and risk mitigation protocols are in place to manage patient flow through the clinic, and that there are clear instructions for using personal protective equipment and proper instrument cleaning.

There is also evidence emerging from studies carried out in China which suggests that the COVID-19 infection can be asymptomatic in some people who have contracted the virus, and thus poses a serious and previously unknown risk to both patients, staff and the general public^2,3. This is particularly concerning for people in the “at risk” category with respect to COVID-19, such as those living with age-related visual impairments, and who attend the clinic for regular treatment.

The Irish College of Ophthalmologists (ICO) made a recent statement urging the Irish government to make available appropriate resources which will allow for the provision of eye care services to resume for non-COVID patients⁴. Ophthalmology is one of the busiest outpatient specialties in Ireland, with latest figures from the National Treatment Purchase Fund (NPTF) indicating that of the 50,000 people waiting for an ophthalmology appointment, 41,401 of these are outpatient consultations, an issue which requires urgent attention⁵.  According to Dr. Patricia Quinlan, Consultant Ophthalmologist, “never before has the importance of a sustainable and cost effective eye care model, accessible to all patients, been more pressing as we adapt to the COVID-19 pandemic environment”.

Clinicians in the UK have highlighted the dramatic decrease in patient volume to their clinics, many of whom require urgent care and without which they will likely experience irreversible damage to their vision⁶. Many patients experience anxiety and worry at the prospect of using public transport to attend their appointment, while others are uncertain about their respective clinic’s preparedness to provide care and simultaneously abide by recommended social distancing and hygiene practices. The establishment and implementation of standardised guidelines at a national and international level will help to alleviate many of these fears and will provide greater clarity for patients who urgently need clinical care so that they can continue to manage their retinal condition.

Continuing to avail of telemedicine, which has developed into an integral part of the healthcare system, will also allow patients to carry out visual function tests remotely and maintain clear lines of communication with their eye care professionals, so they can continue to provide consistent care and counsel.

By taking action now and forming a unified plan for the provision of ophthalmic services globally, we can achieve greater transparency for patients, eye care professionals and the general public about how ophthalmic care will be delivered in the clinic, so we can overcome the challenges presented by COVID-19. Additionally, this preparation will benefit and improve our capacity to treat and manage retinal diseases, should similarly disruptive events occur in the future.

References:

1. Breazzano, M.P., Shen, J., Abdelhakim, A.H., Glass, L.R.D., Horowitz, J.D., Xie, S.X., de Moraes, C.G., Chen-Plotkin, A. and Chen, R.W., 2020. Resident physician exposure to novel coronavirus (2019-nCoV, SARS-CoV-2) within New York City during exponential phase of COVID-19 pandemic: Report of the New York City Residency Program Directors COVID-19 Research Group. medRxiv.
2. World Health Organisation. Coronavirus disease (COVID-19) advice for the public. Available at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Accessed June 2020.
3. Pan, X., Chen, D., Xia, Y., Wu, X., Li, T., Ou, X., Zhou, L. and Liu, J., 2020. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. The Lancet Infectious Diseases, 20(4), pp.410-411.
4. Luo, S.H., Liu, W., Liu, Z.J., Zheng, X.Y., Hong, C.X., Liu, Z.R., Liu, J. and Weng, J.P., 2020. A confirmed asymptomatic carrier of 2019 novel coronavirus. Chinese medical journal, 133(9), pp.1123-1125.
5. Eye Doctors Call for Action as they Mark Significance of 6/6 2020. Available athttps://www.eyedoctors.ie/press-release/May-29-2020/Eye-Doctors-Call-for-Action-as-they-Mark-Significance-of-6%7C6-2020/125.html. Accessed June 2020.
6. Outpatient waiting lists. Available at https://www.ntpf.ie/home/outpatient.htm. Accessed June 2020.
7. The Telegraph. People going blind as they are ‘too scared’ to see a doctor or optician. Available at https://www.telegraph.co.uk/news/2020/05/23/people-going-blind-scared-see-doctor-optician/. Accessed June 2020.