As the novel coronavirus outbreak continues to spread in the United States, retina clinics—who often see older patients who are more at risk of virus complications—are making a number of adjustments.
Rishi P. Singh, MD, staff physician at the Cole Eye Institute at the Cleveland Clinic, where he is also Medical Director of the Clinical Systems Office, and an Associate Professor of Ophthalmology at Case Western Reserve University, told Eyewire News that ophthalmologists at his practice have canceled elective procedures such as cataract/refractive cases and cosmetic plastic surgery procedures.
This aligns with a policy statement issued by the AAO on Thursday, which said that it “strongly recommends that all ophthalmologists provide only urgent or emergent care. This includes both office-based care and surgical care.”
“For more complex diseases like glaucoma and retinal diseases, we’re doing the best we can,” Dr. Singh said. “It’s just a continual evaluation of where we are with things. It could change even further tomorrow, where we can’t do what we think are the less-acute but still need-to-be-done cases. And so we were just evaluating them on a day-to-day basis, each and every day.”
Dr. Singh said that retina patients are still being seen, but that Cleveland Clinic staff is adjusting treatment protocols.
“We’re seeing them, treating them, trying to defer their examination as much as possible,” he said. He added that the are being “aggressive about treating and extending [retina patients] so they don’t come back in a short period of time.”
John W. Kitchens, MD, of Retina Associates of Kentucky in Lexington, said that retina specialists may have to adjust expectations when it comes to getting patients with wet AMD completely dry.
“It should be safe for the majority of our patients to extend treatment intervals—at least according to the VIEW 1 and VIEW 2 studies—out to 8 weeks,” Dr. Kitchens told Eyewire News. “I’m using that to help reassure patients and reassure myself.”
Before the AAO’s statement that ophthalmologists should limit in-office care, Dr. Kitchens explained that his office is efficiently moving patients through the clinic so that they are not sitting in a waiting room too long.
“If a patient comes in at the end of a series of injections and we know they’re doing well with 8-week injection [intervals], we may choose to just image that patient and give them an injection and then do an exam the next time or the time following,” he said.
Dr. Kitchens said that his office considered extending hours and scheduling patients further apart to comply with social distancing guidelines, but that the issue partially took care of itself.
“It turns out that we’re having a pretty significant cancellation rate and rescheduling rate,” he explained. “It almost seems like our schedules are pruning themselves down to do that already.”
Retina Associates of Kentucky has also told three at-risk physicians to pause practice.
“Three of our physicians are over the age of 60 and we have just automatically said, ‘You guys are off. You’re going to continue to draw your salaries and your reimbursement, but we’re putting you off mandatory because we don’t want to see you get sick,’” Dr. Kitchens said.
Alan Kimura, MD, MPH, President of Colorado Retina, said that the changing conditions on the ground are difficult to keep up with.
“What’s throwing us for a loop is the volatility,” he told Eyewire News. Compared with normal conditions, Dr. Kimura said that “things are changing way too quickly.”
Dr. Kimura pointed to the importance of preparation.
“It’s given that we’re behind the curve in our thinking from where the reality is,” he said. “If it feels like we’re way too far ahead, then it is probably where it needs to be.”
“We’re going to have to become very creative,” Dr. Kimura said, emphasizing the role of telemedicine in the age of coronavirus. “We may be able to conduct some history by telemedicine, get paid for it, and document it. Some new EHRs are rushing to create software that can accommodate that.”
Considering business issues at a time like this is important when you consider the physician’s role as employer.
“There are discussions that need to occur at the administrative level,” Dr. Kimura said. “How a practice manages these slowdowns in relation to the staff is critical.”
He said that colleagues are a useful resource when making adjustments.
“I’ve been in close contact with my partners or peer colleagues across the country, which is a very valuable resource, because we’re all figuring this out on the fly ourselves.”
Dr. Singh agreed that professional camaraderie is an asset, and said that the organized ophthalmology has been useful during the coronavirus spread.
“The AAO has been fantastic about providing up-to-date information,” he said. “This is a moving target we’re all learning from about how best to take care of these patients. And we really rely on the guidance of what we learned from areas that are already had been affected, like in Italy and in China, that can help us better understand how best to take care of patients in our own practices, right now, in Ohio.”