Ophthalmology Practice During the Coronavirus Disease 2019 Pandemic: The University of Pittsburgh Experience in Promoting Clinic Safety and Embracing Video Visits

Prevalence, correlates, and network analysis of depression and its associated quality of life among ophthalmology nurses during the COVID-19 pandemic

Background

Nurses in Ophthalmology Department (OD) had a high risk of infection during the novel coronavirus disease 2019 (COVID-19) pandemic. This study examined the prevalence, correlates, and network structure of depression, and explored its association with quality of life (QOL) in Chinese OD nurses.

Methods

Based on a cross-sectional survey, demographic and clinical data were collected. Depression was measured with the 9-item Self-reported Patient Health Questionnaire (PHQ-9), and QOL was measured using the World Health Organization Quality of Life Questionnaire-brief version (WHOQOL-BREF). Univariate analyses, multivariate logistic regression analyses, and network analyses were performed.

Results

Altogether, 2,155 OD nurses were included. The overall prevalence of depression among OD nurses was 32.71% (95%CI: 30.73-34.70%). Multiple logistic regression analysis revealed that having family or friends or colleagues who were infected (OR = 1.760, p = 0.003) was significantly associated with higher risk of depression. After controlling for covariates, nurses with depression reported lower QOL (F(1, 2,155) = 596.784, p < 0.001) than those without depression. Network analyses revealed that 'Sad Mood', 'Energy Loss' and 'Worthlessness' were the key central symptoms.

Conclusion

Depression was common among OD nurses during the COVID-19 pandemic. Considering the negative impact of depression on QOL and daily life, regular screening for depression, timely counselling service, and psychiatric treatment should be provided for OD nurses, especially those who had infected family/friends or colleagues. Central symptoms identified in network analysis should be targeted in the treatment of depression.

Establishment of a clinical nurse specialist-led, virtual aneurysm surveillance clinic

BACKGROUND

The COVID-19 pandemic has necessitated significant changes to the manner in which healthcare is delivered. Chief among these has been the need to rapidly adopt virtual, or telephone clinics as a means of reducing unnecessary patient exposure to hospitals and clinical care settings. We were greatly aided in our adoption of virtual clinics by our experience in the establishment and maintenance of a Clinical Nurse Specialist-led, virtual clinic for both abdominal aortic (AAA) and extra-aortic aneurysm (EAA) surveillance within our department since 2016. Patients undergoing surveillance for abdominal aortic aneurysm (AAA) require frequent and lifelong clinical review. Previous studies have shown that post-operative surveillance in particular is critical in prolonging survival in AAA patients and in the early detection of late complications particularly following endovascular repair (EVAR). Poor compliance with EVAR surveillance has been shown to result in worse outcomes.

AIM

The aim of this study was to evaluate the success of a nurse-led virtual clinic programme in terms of the safe management of patients undergoing AAA surveillance in a nurse-led virtual clinic.

RESULTS

Over the course of the 4-year period from 2016 to 2019, 1352 patients were enrolled in the virtual aneurysm surveillance clinic. The majority of patients each year were male, ranging from 78.2% in 2016 to 85.2% in 2017. The majority of patients encountered the service owing to pre-operative surveillance of an AAA, with this group comprising at least 65% of the total cohort of patients each year.Over the course of the 4-year period of the virtual clinic there were 1466 patient encounters. Each ambulatory day care centre (ADCC) attendance normally costs the hospital €149. Therefore, a total saving of €218,434 resulted from this initiative alone. No patient presented as an emergency with a ruptured aneurysm during the time period studied.

CONCLUSION

Patients with AAA can be safely kept under surveillance in a nurse-led virtual clinic. Our experience with this model of care proved to be particularly advantageous during the period of the early COVID-19 pandemic.

The Impact of the COVID-19 Pandemic on Emergency Department Visits Resulting in Ophthalmology Consultations

Introduction The aim of this study is to determine the characteristics of eye-related emergency department (ED) visits resulting in ophthalmology consultation during the COVID-19 pandemic and compare them against an equivalent period from the previous year. Methods In this study, we reviewed the charts of patients who were admitted to ED with ocular complaints between March 11th, 2020 (the date of the first COVID-positive case in our country) and March 11th, 2021 (Study period 1; SP1) and those who were admitted to ED within the equivalent period of the previous year (Study period 2; SP2). The frequency of eye-related cases, the urgency status of complaints, diagnosis, treatment applied, and hospitalization status of the patients were compared. Results The proportion of ophthalmology consultations among all medical departments decreased from 4.52% to 4.04% (p<0.001). There was a 40.5% reduction in eye-related ED admissions during the pandemic, and the top three ocular diagnoses were foreign bodies of the ocular surface (24.3%), corneal abrasion (18.7%), and blow-out fractures (6.2%) during SP1. The proportion of urgent eye-related emergency visits increased during the pandemic year (80.7% of total cases) compared to the year prior to the pandemic (66.0% of total cases) (p<0.001). Although the number of ophthalmology consultations per day decreased during lockdown periods, this decrease was not statistically significant. Conclusion During the first year of the COVID-19 pandemic, the number of eye-related ED visits decreased in comparison to the year which preceded the pandemic. However, the proportion of urgent visits increased during the pandemic. Understanding the circumstances under which patients seek eye care in EDs is critical to rendering the optimal level of service of available resources.

Loss to Follow up among Glaucoma Patients at a Tertiary Eye Center over 10 Years: Incidence, Risk Factors, and Clinical Outcomes

PURPOSE

To assess the incidence, risk factors, and clinical consequences of loss to follow up (LTFU) among glaucoma patients at our institution over a 10-year period.

METHODS

This retrospective study examined LTFU among a cohort of glaucoma patients with a clinical encounter in 2010. LTFU was defined as 52 weeks or more without an encounter and without alternative reason for discontinued care, such as discharge, documented move, or death. Baseline demographic and clinical characteristics were collected and compared between LTFU and non-LTFU groups using a logistic regression model to identify risk factors for LTFU. Odds ratios (ORs) are reported with 95% confidence intervals. Clinical outcomes were documented for LTFU patients who returned after a lapse in care.

RESULTS

Among the 395 included patients, 132 (33%) were LTFU over the 10-year study period. Characteristics associated with LTFU in a logistic regression model included greater disease severity (OR = 1.03 [1.01-1.05], p = .023, for each worsening decibel of mean deviation) and in-state rather than out-of-state residence (OR = 2.76 [1.12-6.80], p = .027). Other potential risk factors that did not reach significance included male gender (OR = 1.39 [0.92-2.13], p = .124), Black race (OR = 1.40 [0.91-2.16] p = .123), and legal blindness (OR = 1.58 [0.91-2.76] p = .107). Among the 132 patients who were LTFU, only 23 (17%) later returned to care, two-thirds (15/23) of whom returned with disease progression or complication.

CONCLUSION

One-third of glaucoma patients became LTFU over a 10-year period, and LTFU may be associated with poor clinical outcomes. More research is needed to understand reasons for LTFU and to promote regular glaucoma care.

Accuracy Assessment of Outpatient Telemedicine Encounters at an Academic Ophthalmology Department

Purpose We assess the clinical accuracy of direct-to-patient real-time outpatient video visit encounters at our eye center.

Design This was a retrospective longitudinal study.

Subjects and Methods Patients who completed a video visit over a 3-week period between March and April 2020 were included. Accuracy assessment was determined by comparing diagnosis and management from the video visit with subsequent in-person follow-up over the next year.

Results A total of 210 patients (mean age 55±18 years) were included, of whom 172 (82%) were recommended a scheduled in-person follow-up encounter after their video visit. Among the 141 total patients who completed in-person follow-up, 137 (97%) had a diagnostic agreement between telemedicine and in-person evaluation. Management plan agreed for 116 (82%), with the remainder of visits either escalating or deescalating treatment upon in-person follow-up with little substantive change. Compared with established patients, new patients had higher diagnostic disagreement following video visits (12 vs. 1%, p=0.014). Acute visits trended toward more diagnostic disagreement compared with routine visits (6 vs. 1%, p=0.28) but had a similar rate of management change on follow-up (21 vs. 16%, p=0.48). New patients were more likely to have early unplanned follow-up than established patients (17 vs. 5%, p=0.029), and acute video visits were associated with unplanned early in-person assessments compared with routine video visits (13 vs. 3%, p=0.027). There were no serious adverse events associated with the use of our telemedicine program in the outpatient setting.

Conclusions Video visits had high diagnostic and management agreement with subsequent in-person follow-up encounters.

The Impact of the First COVID-19 Lockdown Period on the Inpatient and Outpatient Volume of a University Based Tertiary Referral Center with Corneal Subspecialization in Germany

Background/Aims

To determine the impact of COVID-19 on the number of in- and outpatients surgical and diagnostic procedures performed at a southwestern German university hospital with corneal subspecialization.

Methods

A retrospective examination of the number of inpatients, several outpatients subunits, in- and outpatient surgeries as well as diagnostic procedures at the Department of Ophthalmology, Saarland University Medical Centre during the COVID-19 pandemic "lockdown period" from 18 March until 8 May 2020 in comparison with the corresponding period in 2019 (source: SAP database and electronic patient record FIDUS).

Results

The year 2020 showed a significant decrease in the number of inpatient surgeries with a total number of 285 vs 412 in 2019. However, the number of corneal transplantations increased significantly (60 in 2020 vs 54 in 2019, p=0.0089). In the various outpatient units of our department, we observed a significant decrease in the number of consultations (1.711 in 2020 vs 3.194 in 2019), especially for cataract surgery consultations (34 vs 137, p<0.0001). The number of outpatient surgeries was significantly reduced in 2020, especially for cataract surgery (64 vs 216, p=0.007) and intravitreal injections (577 vs 768, p<0.0001).

Conclusion

Despite taking all the necessary precautions to ensure that our medical care can continue to be available reliably and completely safe during the "Corona lockdown period", the number of in- and outpatient surgeries and the number of outpatient consultations decreased significantly. However, the number of corneal transplantations still increased.

Addressing Social Determinants of Vision Health

Social determinants of health encompass the quality of an individual’s social and physical environment and its effect on health outcomes. Disparities in these social and environmental factors have a significant role in vision health disparities and inequity in eye care. In this review, we discuss how disparities in visual impairment and eye care utilization are affected by each of the five core domains of social determinants of health, namely economic stability (income, employment, and food security), education (education level and health literacy), health care access (insurance and medical costs), neighborhood environment (housing conditions, home ownership, pollution, and crime), and social context (race and racism). Moreover, we describe a framework by which ophthalmologists can take action to address social determinants of vision health. These actionable strategies are guided by recommendations from the National Academies of Sciences, Engineering, and Medicine and have five complementary components to address social needs: awareness (screening for social needs), assistance (connecting patients with social care resources), adjustment (altering clinical care in recognition of social needs), alignment (understanding social assets and collaborating with community organizations), and advocacy (promoting policies to address social needs). Addressing social determinants of health is complex but achievable through collaborative strategies. Ophthalmologists have an important leadership role in addressing eye care disparities by taking action on underlying social determinants of vision health.

Urgent Virtual Eye Assessments During the COVID-19 Pandemic

Purpose

We aimed to evaluate the effectiveness and safety of a virtual eye assessment triage system implemented in response to COVID-19.

Patients and Methods

We conducted a retrospective cross-sectional study using a consecutive sample of all virtual assessments conducted from March 24 to June 7, 2020 at a single ophthalmology center in Toronto, ON, Canada. Visual acuity and smartphone photographs were uploaded to an electronic assessment website. All patients were virtually triaged to an email or phone consult. Patient outcomes and satisfaction were assessed with a quality assurance survey. Primary outcome measures were the incidence of unplanned additional in-person visits and changes in treatment.

Results

We performed 1535 virtual assessments. Of the triage pathways, 15% received an email consult only and 85% received a phone consult. Subsequently, 15% required an in-person assessment, 3% were referred elsewhere, and 0.1% were sent to the emergency. Presentations were most commonly cornea (52%) and retina (25%). They were non-urgent in 68% of cases and no pharmacologic treatment was required for 49%. Of 397 patients that responded out of 653 patients surveyed, 4% had an unplanned additional visit to the emergency, after which two patients underwent urgent retinal surgery and one patient underwent urgent glaucoma surgery. Two patients (0.5%) had a minor change in treatment.

Conclusion

As routine regular in-person visits were not possible during the COVID-19 lockdown, virtual eye assessments provided an opportunity to triage patients. Virtual assessments have the potential to reduce in-person visits, but caution must be exercised to not miss vision-threatening conditions.

Clinical Utility of COVID-19 Real Time-Polymerase Chain Reaction Testing of Ocular Tissues of Non-COVID-19 Cornea Donors Deemed Suitable for Corneal Retrieval and Transplantation

PURPOSE

The purpose of this study was to evaluate the prevalence of SARS-CoV-2 in human postmortem ocular tissues of asymptomatic donors and its implications on our eye banking protocols.

METHODS

The expression of SARS-CoV-2 RNA was assessed by reverse transcription-polymerase chain reaction in corneal rims and conjunctival tissues from 100 donors who were found suitable for transplantation as per the donor screening guidelines of the Global Alliance of Eye Bank Associations. The donor's clinical history and cause of death were assessed for secondary analysis.

RESULTS

Of 200 ocular tissues (100 corneal and 100 conjunctival) from the same 1 eye of 100 surgical-intended donors, between September 2020 and April 2021, the overall positivity rate for SARS-CoV-2 was ∼1% (2/200). Both the ocular samples that tested positive were conjunctival biopsies (2/100, 2%), whereas corneal samples were negative (0/100, 0%) in both donors. The causes of donor death were trauma in 51 donors, suicide in 33, cardiac arrest in 7, electric shock in 5, metabolic cause in 2, malignancy in 1, and snake bite in 1. None of the donors had a medical history suggestive of COVID infection or possible contact. None of the recipients from the donors were reported to have any systemic adverse event after keratoplasty until the follow-up of 6 weeks.

CONCLUSIONS

The overall prevalence of SARS-CoV-2 was 1% (2% for conjunctival and 0% for corneal samples, P value = 0.5) in the donors who were found suitable for cornea recovery and transplantation. The findings of exceptionally low positive rates in our samples validate the criticality of history-based donor screening and do not support the necessity of postmortem PCR testing as a criterion for procurement and subsequent use for corneal transplantation.

Socioeconomic and Demographic Disparities in the Use of Telemedicine for Ophthalmic Care during the COVID-19 Pandemic

PURPOSE

To identify disparities in the use of telemedicine during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

A cross-sectional study of completed clinical encounters in an academic ophthalmology center from March 2020 through August 2020.

PARTICIPANTS

A total of 5023 patients comprising 8116 ophthalmic clinical encounters.

METHODS

Medical charts were abstracted for demographic information. We identified zip code-level socioeconomic characteristics, which were drawn from the 2019 American Community Survey 5-year estimates.

MAIN OUTCOME MEASURES

The completion of a synchronous video encounter, the completion of a telephone (audio-only) encounter in the absence of any video encounters, or the completion of in-person encounters only.

RESULTS

During the study period, 8116 total clinical encounters were completed for 5023 unique patients. Of these patients, 446 (8.9%) participated in a video encounter, 642 (12.8%) completed a telephone encounter, and 3935 (78.3%) attended clinical appointments in person only. In adjusted analysis, patients who were Black (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52-0.80; P < 0.001) or Hispanic/Latino (OR, 0.65; 95% CI, 0.49-0.85; P = 0.002) were significantly less likely to complete a video or telephone appointment. Older patients (OR, 0.99; 95% CI, 0.98-0.99; P < 0.001), patients whose primary language was not English (OR, 0.49; 95% CI, 0.28-0.82; P = 0.01), Black patients (OR, 0.45; 95% CI, 0.32-0.62; P < 0.001), and Hispanic/Latino patients (OR, 0.56; 95% CI, 0.37-0.83; P = 0.005) were significantly less likely to complete a video encounter. Finally, among patients completing any type of telemedicine encounter, older age, (OR, 1.02; 95% CI, 1.01-1.03; P < 0.001), Medicare insurance (OR, 1.55; 95% CI, 1.11-2.17; P = 0.01), and Black race (OR, 1.97; 95% CI, 1.33-2.94; P < 0.001) were associated with using only phone visits.

CONCLUSIONS

Ethnic/racial minorities, older patients, and non-English-speaking individuals were significantly less likely to complete a video telehealth encounter. With the expansion of telemedicine and the need to reduce the disparate impact of COVID-19 on minorities, it will be increasingly important to identify barriers to telehealth use and opportunities to improve access.

Application of the Quadruple Aim to evaluate the operational impact of a telemedicine program

Background

In response to the COVID-19 pandemic, telemedicine utilization has increased dramatically, yet most institutions lack a standardized approach to determine how much to invest in these programs.

Methods

We used the Quadruple Aim to evaluate the operational impact of CardioClick, a program replacing in-person follow-up visits with video visits in a preventive cardiology clinic. We examined data for 134 patients enrolled in CardioClick with 181 video follow-up visits and 276 patients enrolled in the clinic's traditional prevention program with 694 in-person follow-up visits.

Results

Patients in CardioClick and the cohort receiving in-person care were similar in terms of age (43 vs 45 years), gender balance (74% vs 79% male), and baseline clinical characteristics. Video follow-up visits were shorter than in-person visits in terms of clinician time (median 22 vs 30 min) and total clinic time (median 22 vs 68 min). Video visits were more likely to end on time than in-person visits (71 vs 11%, p < .001). Physicians more often completed video visit documentation on the day of the visit (56 vs 42%, p = .002).

Conclusions

Implementation of video follow-up visits in a preventive cardiology clinic was associated with operational improvements in the areas of efficiency, patient experience, and clinician experience. These benefits in three domains of the Quadruple Aim justify expanded use of telemedicine at our institution.

Implications

The Quadruple Aim provides a framework to evaluate telemedicine programs recently implemented in many health systems.

Level of evidence

Level III (retrospective comparative study).

The Role and Views of Ophthalmologists During the COVID-19 Pandemic

Purpose

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic forced ophthalmologists to adjust their working conditions to ensure patient and staff safety, while still providing effective and timely treatment. This international survey among ophthalmologists was initiated to capture what actions ophthalmologists were taking and what their opinions were on the risks of infection in their workplace, the delay in treatment, the use of telemedicine and telephone for appointments, and the regional specifications and measures implemented by the respective authorities.

Methods

An open-source web tool was used to develop an online survey, to which ophthalmologists worldwide were invited via e-mail using international mailing lists (Media Mice, Singapore; Texere Publishing Inc, USA; CGO Gerling) and incentivized using a lottery. The physicians provided their level of agreement relating to the offered statements and gave free answers to the questions regarding the actions taken (conducted November 5th 2020 to December 20th 2020).

Results

After 91,000 invitations, responses were collected from 1122 ophthalmologists. Despite the use of large international mailing lists, mainly doctors from Europe participated. Half of the participants expressed great concern about possible SARS-CoV-2 infection in their patients. A significant number of younger ophthalmologists (≤50 years: 76.9%, n = 313; >50 years: 69.6%, n = 181) feared the delays that COVID-19 could cause to treatment. Reductions in patient numbers were broadly observed, with more ophthalmologists of younger age reporting greater declines. Nearly all ophthalmologists indicated that they provided disinfectant and the majority also used masks and questionnaires for screening. For 60.3% (n = 412) of ophthalmologists, telephone calls reduced the risk of ‘no-shows’; 71.6% (n = 497) disagreed that telemedical evaluation is possible without slit lamp findings and fundus photos; and 57.0% of participants felt content with the governmental measures during the COVID-19 pandemic.

Conclusion

The COVID-19 pandemic has significantly influenced the work of ophthalmologists. Based on the limited response rate, certain statements were only possible to evaluate for the European Union: with a noticeable reduction in patient numbers, delay in treatment was a major worry. Measures to protect and reassure patients should be undertaken, especially regarding those with vision-threatening diseases requiring treatment.

Use of Teleophthalmology for Evaluation of Ophthalmic Emergencies by Ophthalmology Residents in the Emergency Department

Background: Utilizing telemedicine is one approach to reduce the ever-increasing burden of patients on emergency departments (EDs) and consulting physicians. Utilization of telemedicine services in the ED may also benefit resident education. Materials and Methods: Ten first-year ophthalmology residents were trained to use a Topcon 3D Optical Coherence Tomography (OCT)-1 Maestro to capture OCT images and fundus photos in patients presenting to the ED with urgent ophthalmic concerns. Findings were communicated to the supervising ophthalmologist. Retrospective chart review was conducted to obtain patient characteristics and final ophthalmologist diagnosis. Residents rated ease of use, technical reliability, and educational value through a survey. Results: From December 1, 2019, to December 1, 2020, the device was used in 109 patient encounters, capturing 887 images (average 8.1 images per encounter). Patients on whom the device was used were on average 48.5 years old (±17.2, range 17-90) and 59.6% were female. The imaging device was utilized most commonly for evaluating papilledema (n = 21, 18.6%), new-onset visual acuity/visual field defects (n = 12, 10.6%), retinal detachment/tear (n = 8, 7.1%), and ophthalmic trauma workup (n = 8, 7.1%). Eight residents completed the survey and most (n = 7) agreed or strongly agreed that the device helped them diagnose patients more accurately. Technical issues such as machine malfunction, image artifacts, and problems syncing with the electronic health record and computer were noted by survey respondents. Conclusions: The most common use of teleophthalmology in the ED setting was evaluation of papilledema; the majority of residents perceived an educational benefit from this tool. Efforts should be made to address the technical challenges to increase the utility of this device.

Assessment of a novel ophthalmology tele-triage system during the COVID-19 pandemic

Background

In response to the COVID-19 pandemic, a web-based tele-triage system was created to prioritize in-person clinic visits and ensure safety at the University of Illinois at Chicago Department of Ophthalmology and Visual Sciences during a statewide shelter-in-place order. The aim of this study is to evaluate the impact of the tele-triage system on urgent visit volume and explore the characteristics of acute visit requests at a tertiary referral eye center.

Methods

This retrospective study analyzed acute visit requests between April 6, 2020 and June 6, 2020. Descriptive statistics, chi-square tests, ANOVA, and bivariate logistic regression were used to compare variables with a p-value of 0.05.

Results

Three hundred fifty-eight surveys were completed. Mean age was 49.7 ± 18.8 years (range 2–91). The majority of requests were determined as urgent (63.0%) or emergent (0.8%). Forty-nine patients had recent eye trauma (13.7%), and the most common reported symptoms were new onset eye pain (25.7%) and photophobia (22.9%). Most patients were self-referred (63.7%), though provider referral was more common in patients with symptoms of new onset lid swelling (p < 0.01), diplopia (p < 0.01), flashing lights (p = 0.02), or droopy eyelid (p < 0.01). Patients presenting with symptom onset within 48 h tended to be younger (45.8 years) versus those with symptom duration of 48 h to 1 week (49.6 years), or more than 1 week (52.6 years; p < 0.01).

Conclusion

This novel tele-triage system screened out one-third of acute visit requests as non-urgent, which limited in-person visits during the initial shelter-in-place period of the pandemic. Tele-triage systems should be implemented in eye care practices for future emergency preparedness.

Systematic review: SARS-COV-2 contagion prevention measures in vision health professionals

The disease, which originated from the SARS-CoV-2 virus, is primarily transmitted by direct contact with infected individuals. Visual healthcare professionals perform clinical practices that pose a significant risk of infection due to their proximity with patients during the examination. This systematic review aims to identify preventive measures that will aid in reducing the risk of infection during standard appointments between patients and visual health professionals. A systematic review was done for articles published in indexed journals from December 2019 to December 2020. The search for these articles was done in 3 electronic databases. As part of the search criteria, articles were selected if they had the keywords (SARS-CoV-2), (COVID-19), and coronavirus combined with ophthalmology, optometry, eye care, and the eye. Once duplicated and unrelated items were eliminated, 36 articles of interest were selected. Seven sections were described in detail: telephone screening, (COVID-19) triage, decreasing transmission within shared spaces, hand washing, use of personal protective equipment Personal Protective Equipment (PPE), cleaning of diagnostic instruments, and use of telemedicine. This paper helps healthcare professionals to better understand the context of the "new normal" clinical practice. Visual health professionals and their patients must adhere to norms and use the indicated PPE during the consultation to safeguard each other.

Patient generated aerosol in the context of ophthalmic surgery

OBJECTIVE

To assess the patterns of patient generated aerosol in the context of ophthalmic surgery and ophthalmic examinations. To inform medical teams regarding potential hazards and suggest mitigating measures.

METHODS

Qualitatively, real-time time videography assessed exhalation patterns from simulated patients under different clinical scenarios using propylene glycol from an e-cigarette. Quantitatively, high-speed Schlieren imaging was performed to enable high resolution recordings analysable by MATLAB technical computing software.

RESULTS

Without a face mask, the standard prior to COVID 19, vapour was observed exiting through the opening in the drape over the surgical field. The amount of vapour increased when a surgical mask was worn. With a taped face mask, the amount of vapour decreased and with inclusion of a continuous suction device, the least amount of vapour was seen. These results were equivocal when the patient was supine or sitting upright. High-speed Schlieren imaging corroborated these findings and in addition showed substantial increase in airflow egress during coughing and with ill-fitting face masks.

CONCLUSION

Advising patients to wear a surgical mask at the time of ophthalmic interventions potentially contaminants the ocular field with patient generated aerosol risking endophthalmitis. Surgeon safety can be maintained with personal protective equipment to mitigate the increased egress of vapour from the surgical drape and taping, with or without suction is advisable, whilst meticulous hygiene around lenses is required at the time of slit lamp examination.

The impact of COVID-19 related national lockdown on ophthalmic emergency in Italy: A multicenter study

Purpose:

To assess ocular pathologies admitted to Italian Emergency Eye Departments (EEDs) during the COVID-19 pandemic national lockdown in 2020 in comparison with the same period in 2019.

Methods:

Electronic records of all patients presenting at EEDs of two tertiary-care Eye Centers during the COVID-19 national lockdown in Italy (March 10–May 3, 2020) were compared with the equivalent period in 2019. Main outcomes were patient age, gender, and diagnoses. Statistical analysis included unpaired Student t-tests, Poisson regression, and chi-square test.

Results:

Overall EED visits significantly decreased by 54.1% during the 2020 lockdown compared to 2019 (851 vs 1854, p < 0.001). During lockdown, patients showed comparable mean age (52.8 years in 2020 vs 53.3 years in 2019, p = 0.52) and significant male gender bias (61.1% in 2020 vs 55.8% in 2019, p < 0.0001). The most frequent pathologies were eye inflammations, trauma-related incidents, and spontaneous acute vitreous detachment. Patients with inflammation, headache/hemicrania, and spontaneous subconjunctival hemorrhages were significantly less, whereas those with trauma-related diagnoses were significantly higher during the lockdown as compared with 2019 (p < 0.05). The proportion of non-urgent visits decreased from 17% in 2019 to 8% in 2020 (p < 0.001).

Conclusions:

During the 2020 lockdown, there was a significant reduction of accesses to EED, especially for non-urgent pathologies. Potentially visual function threatening conditions, such as trauma-related pathologies, retinal detachment or ruptures, and wet AMD, showed lower number of cases but higher or stable proportion relative to the total caseload, suggesting a correct and efficient access to ophthalmic health care during the pandemic period.

Evaluation of a Home-Printable Vision Screening Test for Telemedicine

Importance

Many ophthalmology appointments have been converted to telemedicine assessments. The use of a printed vision chart for ophthalmology telemedicine appointments that can be used by people who are excluded from digital testing has yet to be validated.

Objectives

To evaluate the repeatability of visual acuity measured using the Home Acuity Test (HAT) and the agreement between the HAT and the last in-clinic visual acuity.

Design, Setting, and Participants

This diagnostic study was conducted from May 11 to 22, 2020, among 50 control participants and 100 adult ophthalmology outpatients who reported subjectively stable vision and were attending routine telemedicine clinics. Bland-Altman analysis of corrected visual acuity measured with the HAT was compared with the last measured in-clinic visual acuity on a conventional Early Treatment Diabetic Retinopathy Study logMAR chart.

Main Outcomes and Measures

For control participants, repeatability of the HAT and agreement with standard logMAR visual acuity measurement. For ophthalmology outpatients, agreement with the last recorded in-clinic visual acuity and with the International Classification of Diseases and Related Health Problems, 11th Revision visual impairment category.

Results

A total of 50 control participants (33 [66%] women; mean [SD] age, 36.0 [10.8] years) and 100 ophthalmology patients with a wide range of diseases (65 [65%] women; mean [SD] age, 55.3 [22.2] years) were recruited. For control participants, mean (SD) test-retest difference in the HAT line score was -0.012 (0.06) logMAR, with limits of agreement (LOA) between -0.13 and 0.10 logMAR. The mean (SD) difference in visual acuity compared with conventional vision charts was -0.14 (0.14) logMAR (range, -0.4 to 0.18 log MAR) (-7 letters) in controls, with LOA of -0.41 to 0.12 logMAR (-20 to 6 letters). For ophthalmology outpatients, the mean (SD) difference in visual acuity was -0.10 (0.17) logMAR (range, -0.5 to 0.3 logMAR) (1 line on a conventional logMAR sight chart), with the HAT indicating poorer visual acuity than the previous in-clinic test, and LOA of -0.44 to 0.23 logMAR (-22 to 12 letters). There was good agreement in the visual impairment category for ophthalmology outpatients (Cohen κ = 0.77 [95% CI, 0.74-0.81]) and control participants (Cohen κ = 0.88 [95% CI, 0.88-0.88]).

Conclusions and Relevance

This study suggests that the HAT can be used to measure visual acuity by telephone for a wide range of ophthalmology outpatients with diverse conditions. Test-retest repeatability is relatively high, and agreement in the visual impairment category is good for this sample, supporting the use of printed charts in this context.

Global Ophthalmology Practice Patterns during COVID-19 Pandemic and Lockdown

Aim: To assess the impact of practice patterns amongst global ophthalmologists during severe acute respiratory syndrome Coronavirus 2 (SARS Cov2) causing Corona virus disease (COVID-19) and understand the various modifications made to address emergency surgeries and practice needs.Methods: An online survey was sent to practicing ophthalmologists around the world through email, Whatsapp™ ListServ17.0™ (for pediatric ophthalmologists), WeChat™ (China) and ophthalmology associations (Indonesia, Philippines, Ireland). All queries were collected and categorized. Responses to the queries were given according to the recommendations by the Ophthalmology association. Practices ability to deal with the COVID were also classified according to country and type of access to PPE. Statistical analyses of the association between these data and queries, where appropriate were carried out.Results: One thousand nine hundred sixteen ophthalmologists were invited to participate in a survey between April 10^th and April 30^th, 2020 of which 1207 responded, which is a response rate of approximately 63%. The majority of respondents were from India, Indonesia, China, Singapore and the USA. Our study indicates a precipitous drop in surgical procedures with 46% (n = 538) ophthalmologists ceased to operate on their patients and almost 40% (n = 486) were doing less than 25% of their original number of surgeries. The intent to resume elective surgeries was a consideration in 41% (n = 495) after an evaluation of the situation and in consultation with professional bodies. More than 2/3 of the respondents (n = 703) made it a priority to use and mandate their patients to practice physical distancing, wearing masks, and hand dis-infection for protection to limit the spread of infection.Conclusion: This global survey provides a real-world assessment of diverse practices that were in various forms of "shut down mode" and circumstances with varying capabilities to deal with COVID. It is unprecedented that the collective wisdom for a curtailment of practice has had an enormous immediate and far reaching implications on the livelihoods of ophthalmologists, their staff, and their families. Nevertheless, ophthalmologists and their staff remain resilient and have adapted to these changes pragmatically.

Progression and Trends in Virus from Influenza A to COVID-19: An Overview of Recent Studies

Influenza is a highly known contagious viral infection that has been responsible for the death of many people in history with pandemics. These pandemics have been occurring every 10 to 30 years in the last century. The most recent global pandemic prior to COVID-19 was the 2009 influenza A (H1N1) pandemic. A decade ago, the H1N1 virus caused 12,500 deaths in just 19 months globally. Now, again, the world has been challenged with another pandemic. Since December 2019, the first case of a novel coronavirus (COVID-19) infection was detected in Wuhan. This infection has risen rapidly throughout the world; even the World Health Organization (WHO) announced COVID-19 as a worldwide emergency to ensure human health and public safety. This review article aims to discuss important issues relating to COVID-19, including clinical, epidemiological, and pathological features of COVID-19 and recent progress in diagnosis and treatment approaches for the COVID-19 infection. We also highlight key similarities and differences between COVID-19 and influenza A to ensure the theoretical and practical details of COVID-19.

Home vision monitoring in patients with maculopathy: Real-life study of the OdySight application

INTRODUCTION

The goal of the present study was to analyze the implementation and clinical efficacy of OdySight, a mobile medical application for the remote monitoring of patients with maculopathy.

MATERIALS AND METHODS

In all, 60 patients with edematous maculopathies receiving traditional clinical treatment (PRN or Treat & Extend) were provided with OdySight to detect changes in visual acuity from home. To determine both the feasibility and reliability of the application, its use by patients (both testing and game play), as well as the processing of alerts by the clinical team, were analyzed during the first year.

RESULTS

The female-to-male ratio was 3:2, with a mean age of 64 years. 52% of patients presented with age-related macular degeneration, 31% with high myopia, 11% with retinal vein occlusion, and 6% with diabetic maculopathy. The conversion rate (defined as the percentage of patients completing at least one test following prescription) and the nine-month retention rate (percentage of active patients) were 61% and 24% respectively. Patients aged 50 to 70 years and those whose use of the app included game play represent 75% of active patients at 9 months. The 22 active patients performed 483 visual acuity tests, completed 1,667 game sessions, and underwent 77 in-person consultations. During the trial period, the clinical team processed 19 alerts, on average in fewer than 6 days. Decreases in visual acuity were detected with a sensitivity of 92% and specificity of 99%.

DISCUSSION

The use of connected and mobile devices today is widespread, as is interest in mobile medical applications. Long-term treatments for maculopathies can be a difficult burden to bear, both for patients and healthcare practitioners. Overcoming the challenges associated with the successful remote detection of recurrences thus represents a significant opportunity for improving patient care. The implementation of novel digital tools requires the cooperation of the clinical team as a whole, to both inform and motivate patients. OdySight demonstrates satisfactory detection rates, thanks to reliable and reproducible home testing, and can thus serve as a supplementary tool for patients whose consultations are often spaced several months apart. Implementation can be nonetheless improved by facilitating alert processing, a goal which necessitates active adaptation of clinical practices. In general, active patients were very satisfied with this personalized service.

CONCLUSION

Improved medical support, plus the amusing nature of the tests and games, both bolster long-term use of the OdySight app. The application allows for the remote monitoring of changes in visual acuity and affords patients and practitioners an added level of protection, particularly during long intervals between treatments and at the end of a treatment course. To ensure proper implementation, clinics should focus on reinforcing and modernizing the clinical pathway, from patient intake to the injection room.

Live teleophthalmology avoids escalation of referrals to secondary care during COVID-19 lockdown

CLINICAL RELEVANCE

Following the COVID-19 lockdown, uptake of slitlamp-enabled live teleophthalmology increased. Its use contributed to a reduction of referrals escalated to secondary care during-lockdown (avoided: 64% pre-lockdown vs 86% during-lockdown).

BACKGROUND

Live teleophthalmology using video conferencing allows real-time, three-way consultation between secondary care, community providers and patients, improving interpretation of slit lamp findings and potentially reducing referrals to secondary care. NHS Forth Valley implemented live teleophthalmology in March 2019. In March 2020, the COVID-19 pandemic created urgency to deliver ophthalmic care while minimising the risk of contracting or spreading the disease. We aim to compare the uptake and two outcomes (number of avoided secondary care referrals; pattern of presenting conditions) of live teleophthalmology consultations in NHS Forth Valley before and during the COVID-19 national lockdown.

METHODS

An NHS secure video conferencing platform connected the video slit lamps of optometrists, or an iPad mounted on a slit lamp and viewing through the eyepieces, to a secondary care ophthalmologist via a virtual live clinic/waiting area. Data about avoiding a secondary care referral were extracted from a post-consultation ophthalmologist survey for 14 months of data. Pre- and during-lockdown intervals were before/after 23 March 2020, when routine eyecare appointments were suspended. Numbers of avoided referrals to secondary care and patterns of presenting conditions were compared for pre- and during-lockdown periods.

RESULTS

The COVID-19 pandemic markedly increased use of live teleophthalmology in NHS Forth Valley. Surveys were completed for 164 of 250 (66%) teleophthalmology consultations over the study period. Data from 154 surveys were analysed, 78 and 76 for the pre- and during-lockdown periods, respectively. Significantly more during-lockdown (86%) than pre-lockdown (64%; difference 21%, 95% CI 8-34%, p = 0.001) surveys indicated that referrals to secondary care were avoided.

CONCLUSION

Survey data from ophthalmologists suggest significantly fewer escalations to secondary care due to teleophthalmology use.

Assessment of infection prevention and control measures adopted by eye care practitioners in Ghana and South Africa against COVID-19

This study investigated the infection prevention and control measures adopted by eye care practitioners in Ghana and South Africa during the lockdown phase of the COVID-19 pandemic.

A descriptive, cross-sectional study was used to investigate infection prevention and control measures by eye care practitioners in Ghana (n = 189) and South Africa (n = 92) during the extended lockdown phase (01 April-30 June 2020) by both countries, immediately following the WHO declaration of COVI9–19 as a pandemic. Participants from both countries included Ophthalmologists, Optometrists, Ophthalmic nurses, and Opticians who were invited via email and social media platforms to complete an online questionnaire. The questionnaire assessed practitioners’ general knowledge on the COVID-19, viral exposure, infection prevention and control measures adopted during eye examinations.

The majority of the practitioners from Ghana 140 (74%) and 43 (47%) South Africa reported COVID-19 screening at their facilities before the commencement of eye examinations. Few practitioners 77 (41%) and 9 (10)% from Ghana and South Africa, respectively had received any form of training (seminars and workshops) in COVID-19 infection prevention and control measures. Practitioners frequently practiced hand washing - Ghana (125, 66%), South Africa (70, 76%) -, wearing of nose masks - Ghana 126 (67%), South Africa 51 (55%), alcohol-rub on equipment - Ghana 115 (61%), South Africa 45(49%) as a means of sterilizing the hand and equipment against COVID-19 during close contact examinations.

The majority of practitioners from the two countries adhered to basic safety protocols despite receiving no additional training on COVID-19 infection prevention. Maintenance of universal safety precautions in eye care facilities is key to preventing nosocomial infections.

Smartphone-Acquired Image Photogrammetry for Detection of Shallow Anterior Chamber

Purpose

This study aimed to explore the role of smartphone imaging of the eye using two perspectives — anterior and temporal — in the detection of a shallow anterior chamber (AC). The AC depth (ACD) of an eye can be used as a surrogate marker for identification of eyes at risk of developing angle-closure disease.

Methods

A prospective observational study was conducted at a university teaching hospital in South India. Each eye was photographed with a smartphone using the two perspectives, followed by quantitative measurement of ACD using optical biometry. The percentage of nasal iris illuminated was measured from the image acquired using the flashlight method (anterior perspective), whereas pupil position relative to the cornea was measured from the image acquired using the temporal perpendicular method (temporal perspective). The receiver-operating characteristic curve and area under the curve (AUC) were studied for both perspectives independently for overall predictive accuracy in detection of shallow AC (ACD <2.7 mm, obtained by IOL Master).

Results

A total of 275 eyes were examined, of which 77 (28%) had an ACD <2.7 mm. The accuracy of detection of shallow AC was found to be 95.2% for both perspectives when used alone or in combination. AUC of the anterior perspective was 0.99 (95% CI 0.982–0.997). The AUC for the temporal perspective was 0.993 (95% CI 0.988–0.999).

Conclusion

Smartphone-acquired image photogrammetry of an eye with anterior and temporal perspectives independently and in combination provided accuracy nearing 95% in the detection of shallow AC (ACD <2.7 mm).

Registration

This trial was registered with the Clinical Trial Registry of India (CTRI/2018/09/015867, September 28, 2018).

COVID-19 and ophthalmology: A scientometric analysis

PURPOSE

Coronavirus disease pandemic has impacted global healthcare tremendously and ophthalmology is one of the high-hit specialties. An increasing number of research items are upcoming with COVID-19-related research in ophthalmology and this report aims at performing a scientometric analysis of all the available research pertaining to COVID-19 and ophthalmology.

METHODS

A Web of Science (https://webofknowledge.com) query TS = ("novel coronavirus 2019" OR "coronavirus 2019" OR "COVID 2019" OR "COVID 19" OR "nCOV" OR "SARS-CoV-2" OR "COVID-19") AND WC = ("Ophthalmology") was deployed on February 22, 2021, to retrieve all research items on the topics of interest. R software (v4.0.1) with Bibliometrix library was deployed to visualize metrics to quantify geographical distribution, source metrics, author metrics, document metrics, and keyword metrics.

RESULTS

A total of 616 research items appeared in our search results that were drafted by 2398 authors and published in 63 sources. India, USA, UK, and China had the greatest number of research items among others. Indian Journal of Ophthalmology, Eye, and Graefe's Archive for Clinical and Experimental Ophthalmology were sources with greatest number of research items. Documents per author were 0.257 and authors per document were 3.89. The collaboration index was noted to be 4.28.

CONCLUSION

Our scientometric analysis presents descriptive quantitative metrics for COVID-related research in the field of ophthalmology and provides evidence for the increased global collaboration that global researchers have fostered to fight this pandemic.

Safety of video-based telemedicine compared to in-person triage in emergency ophthalmology during COVID-19

BACKGROUND

the need for social distancing midst the COVID-19 pandemic has forced ophthalmologists to innovate with telemedicine. The novel process of triaging emergency ophthalmology patients via videoconsultations should reduce hospital attendances. However, the safety profile of such services were unknown.

METHODS

in this retrospective cohort study, we reviewed case notes of 404 adults who used our videoconsultation service from 20/04/2020 to 03/05/2020. We compared these to 451 patient who attended eye casualty in person at the same time who were deemed not to require same day ophthalmic examination.

FINDINGS

patients seen by videoconsultations tended to be younger (Median = 43 years, Inter-quartile range = 27 vs Median= 49 years, Inter-quartile range = 28)'. More males used the face-to-face triage (55%) while more females used videoconsultation (54%)%. Fewer patients seen by videoconsultations required specialist review compared to face-face triage [X ² (1, N = 854) = 128.02, p<0.001)]. 35.5% of the patients initially seen by videoconsultation had unplanned reattendance within 1 month, compared to 15.7% in the group initially seen in person. X ² (1, N = 234) = 7.31, p = 0.007). The rate of actual harm was no different (at 0% for each method), with perfect inter-grader correlation when graded independently by two senior ophthalmologists. 97% of patients seen on the video platform surveyed were satisfied with their care.

INTERPRETATION

we demonstrate comparable patient safety of videoconsultations at one-month follow-up to in person review. The service is acceptable to patients and reduces the risk of COVID-19 transmission. We propose that videoconsultations are effective and desirable as a tool for triage in ophthalmology.

FUNDING

the research supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology who fund PT and DS's time to conduct research. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

Changes in patient visits and diagnoses in a large academic center during the COVID-19 pandemic

Background

To minimize the risk of viral transmission, ophthalmology practices limited face-to-face encounters to only patients with urgent and emergent ophthalmic conditions in the weeks after the start of the COVID-19 epidemic in the United States. The impact of this is unknown.

Methods

We did a retrospective analysis of the change in the frequency of ICD-10 code use and patient volumes in the 6 weeks before and after the changes in clinical practice associated with COVID-19.

Results

The total number of encounters decreased four-fold after the implementation of clinic changes associated with COVID-19. The low vision, pediatric ophthalmology, general ophthalmology, and cornea divisions had the largest total decrease of in-person visits. Conversely, the number of telemedicine visits increased sixty-fold. The number of diagnostic codes associated with ocular malignancies, most ocular inflammatory disorders, and retinal conditions requiring intravitreal injections increased. ICD-10 codes associated with ocular screening exams for systemic disorders decreased during the weeks post COVID-19.

Conclusion

Ophthalmology practices need to be prepared to experience changes in practice patterns, implementation of telemedicine, and decreased patient volumes during a pandemic. Knowing the changes specific to each subspecialty clinic is vital to redistribute available resources correctly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01886-7.

Impact of teleophthalmology during COVID-19 lockdown in a tertiary care center in South India

Purpose:

The aim of this study was to describe the experience of teleconsultations addressed at our hospital in India during the ongoing coronavirus (COVID-19) lockdown.

Methods:

This cross-sectional hospital-based study included 977 teleconsultations presenting between April 1^st and May 31, 2020. A two-level protocol was implemented to triage the calls.

Results:

Overall, 977 teleconsultation were addressed. Of the 621 teleconsultation addressed the most common queries were related to redness/pain/ watering/blurred vision/itching/irritation (52.49%), followed by queries related to medications (28.01%), appointments (18.84%) & 0.64% cited an emergency need to visit the hospital due to sudden loss of vision. The majority of the queries were directed to the department of cornea (58.93%) followed by retina (16.26%), cataract (13.04%), glaucoma (10.14%) & pediatric ophthalmology (1.61%). The most common advice given to the patient was related to medications (47.66%) followed by appointment-related queries (31.72%) & fixing of surgical appointment (20.61%). Among the 356 preterm babies that were screened, 57 (16.01%) were diagnosed with retinopathy of prematurity (ROP). Of them 3 required laser and 3 were given injection.

Conclusion:

Teleconsultation is here to stay beyond the pandemic. WhatsApp was the preferred modality of communication for us. Teleophthalmology has given us insights to use this evolving technology to reach out to the population at large to provide eye care services. We believe that this mode of teleophthalmology has helped us in providing feasible eye care to the patients.

A virtual COVID-19 ophthalmology rotation

The coronavirus (COVID-19) pandemic temporarily suspended medical student involvement in clinical rotations, resulting in the need to develop virtual clinical experiences. The cancellation of clinical ophthalmology electives and away rotations reduces opportunities for exposure to the field, to network with faculty, conduct research, and prepare for residency applications. We review the literature and discuss the impact and consequences of COVID-19 on undergraduate medical education with an emphasis on ophthalmic undergraduate medical education. We also discuss innovative learning modalities used from medical schools around the world during the COVID-19 pandemic such as virtual didactics, online cases, and telehealth. Finally, we describe a novel, virtual neuro-ophthalmology elective created to educate medical students on neuro-ophthalmology foundational principles, provide research and presentation opportunities, and build relationships with faculty members. These innovative approaches represent a step forward in further improving medical education in ophthalmology during COVID-19 pandemic and beyond.

Glaucoma care during the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

The current article reviews the impact of the coronavirus disease 2019 (COVID-19) pandemic on the delivery of ophthalmic, and specifically, glaucoma care.

RECENT FINDINGS

Literature from the review period includes case series demonstrating the presence of severe acute respiratory syndrome coronavirus 2 RNA in the conjunctival secretions of patients with laboratory-confirmed COVID-19. The global ophthalmology community published reports outlining the enhanced infection control measures undertaken by different institutions around the world to mitigate transmission of the novel coronavirus. Telemedicine has been increasingly implemented in glaucoma practices to reduce in-office patient volume. New data regarding the efficacy and feasibility of tools for home monitoring of intraocular pressure, virtual visual field testing, and remote disc photography are reviewed.

SUMMARY

COVID-19 has posed a global public health threat due to the severity of its contagion and associated morbidity and mortality. Glaucoma specialists have responded to the pandemic with innovative modifications to reduce viral transmission and optimize patient and staff safety in the office and operating room. The role of teleglaucoma has expanded and will continue to evolve as remote diagnostic devices undergo further refinement and validation.

Initial Results and Patient Survey of Virtual Inpatient Ophthalmology Consultations During the COVID-19 Pandemic

Purpose: To examine the uptake, results, and patient assessment of virtual inpatient ophthalmology consultations at our academic medical center during the COVID-19 pandemic.Design: Retrospective review, pre and post COVID analysis, and teleophthalmology patient survey in the inpatient and emergency setting.Participants: Adult patients at our medical center for whom ophthalmology consultation was requested from February 24 through April 19, 2020.Methods: Patient encounters were retrieved and coded for all inpatient and emergency room ophthalmology consultations over a 4-week period before and a 4-week period after our department first offered virtual ophthalmology consultations. Theseconsultations took place over real-time video, audio, or photography between the on-call ophthalmologist and the patient and/or patient's primary physician. A four-item questionnaire was offered to patients who completed a virtual consultation.Main Outcome Measures: Virtual consultation diagnoses and management outcomes; patient assessment of virtual inpatient and emergent ophthalmic care.Results: Of all 423 included encounters, 258 (61%) occurred during the 4 weeks before offering virtual consultations and 165 (39%) encounters occurred during the subsequent 4-week period, indicating a 36% decrease in ophthalmology consultations over this pandemic period. A total of 120 (28%) encounters were conducted remotely during the 8-week period. In-person emergency department (ED) encounters (as percent of total encounters) decreased from 60% to 36% (p < .01) between the first and eighth weeks of the study period. In the 4 weeks since their implementation, virtual inpatient ophthalmology consultations were utilized in 34 of 165 (21%) consultations. Of those, 20 (59%) were high acuity and 1 (3%) was escalated to the ED for in-person evaluation. Most common management decisions made included medication prescription in 46 (55%) patients and scheduling follow-up for 44 (30%) patients. In a survey administered to all 120 patients who were managed over phone or video, 56 (47%) responded. Respondents were in general agreement (Cronbach's alpha = 0.92) and expressed satisfaction with phone and virtual encounters. Specifically, 42 (49%) of 86 patients who had phone encounters noted a mean weighted satisfaction score of 4.6 out of 5 and 14 (41%) responders of 34 virtual consultation encounters noted a mean weighted satisfaction score of 4.9 out of 5. The difference between the average weighted satisfaction scores favored virtual consultation over telephone encounters (p < .01).Conclusions: Virtual inpatient ophthalmology consultations are feasible and have reported high patient satisfaction. Implementing video-based technologies to deliver high-acuity ophthalmic triage and management may help to promote patient and provider safety. In our experience, patients favored virtual consultation over telephone encounters.

Restructuring Wet Age-Related Macular Degeneration Services During the COVID-19 Pandemic to Allow Social Distancing Outpatient Clinics (SDOC)

Background

COVID-19 has had a major impact on health-care provision. Social distancing will impact the organization of outpatient clinics (OCs) and require general restructuring of health care.

Methods

Our retinal team participated in a structured fact-finding session to implement social distancing of patients and staff in wet age-related macular degeneration (wAMD) clinics. Clinic flow and performance were continually reviewed and improved. A retrospective audit of all wAMD follow-up appointments was conducted for 4 weeks from the start of the UK lockdown. A search for clinical guidance regarding retinal services was performed on the homepages of international professional bodies. The guidelines were compared to the implemented changes in our wAMD social distancing OCs (SDOCs) and potential risk examined.

Results

The changes in clinic setup to achieve SDOCs are described. The average total time spent in the clinic area by each patient has reduced by 27%. The audit concluded that 65% of patients needed a treatment interval of 4–7 weeks after their appointment, 17% at either 8 or 9 weeks, and 18% at 10 weeks or beyond. The UK, Australian–New Zealand, US, and German professional ophthalmology bodies have published divergent guidelines, but all recommended a continuation of anti-VEGF injections.

Conclusion

Health-care provision will change and hospitals and outpatient facilities will have to adapt to the COVID-19 epidemic. We describe a clinic setup (SDOCs) that minimizes risk to patients and staff, while maintaining the ability to treat each patient and their disease individually.

Ocular surface assessment in times of sanitary crisis: What lessons and solutions for the present and the future?

PURPOSE

To describe the immediate consequences of SARS-CoV-2 and the COVID-19 pandemic on the ocular surface and eye-care professionals, and to discuss the need for a mandatory switch from currently performed tele-screening to true teleconsultation for remote ocular surface assessment.

MAIN FINDINGS

Ophthalmologists have been largely impacted by the COVID-19 sanitary crisis, due to both the ocular manifestations of SARS-CoV-2 and to the high contagiousness of the virus. The proximity of ophthalmologists to their patients have pushed eye-care providers to readapt their practices and develop alternatives to face-to-face consultations. However, teleconsultation has some major limitations and drawbacks, especially for ocular surface assessment that relies on high-quality graphic data for adequate diagnosis. Tele-screening, on the other hand, emphasizes on the importance of history-taking and listening to the patient in order to adequately prioritize appointments based on the presumed degree of emergency.

CONCLUSION

Despite all the enthusiasm, tele-screening as currently performed with the available tools is still not capable of completely replacing a standard ophthalmic examination for the assessment of ocular surface diseases. While waiting for new emerging technologies and future implementation of imaging modalities and artificial intelligence, decision making algorithms can help eye-practitioners remotely screen their patients to assess the optimal time for follow-up appointments.

Rethinking Elective Cataract Surgery Diagnostics, Assessments, and Tools after the COVID-19 Pandemic Experience and Beyond: Insights from the EUROCOVCAT Group

The progressive deterioration of the visual function in patients on waiting lists for cataract surgery has a negative impact on their quality of life, especially in the elderly population. Patient waiting times for cataract surgeries in many healthcare settings have increased recently due to the prolonged stop or slowdown of elective cataract surgery as a result of coronavirus disease 19 (COVID-19). The aim of this review is to highlight the impact of such a "de-prioritization" of cataract surgery and to summarize some critical issues and useful hints on how to reorganize cataract pathways, with a special focus on perioperative diagnostic tools during the recovery phase and beyond. The experiences of a group of surgeons originating from nine different countries, named the European COVID-19 Cataract Group (EUROCOVCAT), have been combined with the literature and recommendations from scientific ophthalmic societies and healthcare institutions. Key considerations for elective cataract surgery should include the reduction of the number of unnecessary visits and examinations, adoption of precautionary measures, and implementation of telemedicine instruments. New strategies should be adopted to provide an adequate level of assistance and to guarantee safety conditions. Flexibility will be the watchword and regular updates would be necessary following scientific insights and the development of the pandemic.

Diagnostic and Interventional Radiology Case Volume and Education in the Age of Pandemics: Impact Analysis and Potential Future Directions

RATIONALE AND OBJECTIVES

To assess the immediate impact of the COVID-19 pandemic on Diagnostic and Interventional Radiology education, and to propose measures to preserve and augment trainee education during future crises.

MATERIALS AND METHODS

Diagnostic Radiology (DR) studies and Interventional Radiology (IR) procedures at a single tertiary-care teaching institution between 2015 and 2020 were reviewed. DR was divided by section: body, cardiothoracic, musculoskeletal (MSK), neuroradiology, nuclear medicine, pediatrics, and women's imaging. IR was divided by procedural types: arterial, venous, lymphatic, core, neuro, pediatrics, dialysis, cancer embolization or ablation, noncancer embolization, portal hypertension, and miscellaneous. Impact on didactic education was also assessed. ANOVA, t test, and multiple comparison correction were used for analysis.

RESULTS

DR and IR caseloads decreased significantly in April 2020 compared to April of the prior 5 years (both p < 0.0001). Case volumes were reduced in body (49.2%, p < 0.01), MSK (54.2%, p < 0.05), neuro (39.3%, p < 0.05), and women's imaging (75.5%, p < 0.05) in DR, and in arterial (62.6%, p < 0.01), neuro IR (57.6%, p < 0.01) and core IR (42.6%, p < 0.05) in IR. IR trainee average caseload in April 2020 decreased 51.9% compared to April of the prior 5 years (p < 0.01). Utilization of online learning increased in April. Trainees saw significant increases in overall DR didactics (31.3%, p = 0.02) and no reduction in IR didactics, all online. Twelve major national and international DR and IR meetings were canceled or postponed between March and July.

CONCLUSION

Decreases in caseload and widespread cancellation of conferences have had significant impact on DR/IR training during COVID-19 restrictions. Remote learning technologies with annotated case recording, boards-style case reviews, procedural simulation and narrated live cases as well as online lectures and virtual journal clubs increased during this time. Whether remote learning can mitigate lost opportunities from in-person interactions remains uncertain. Optimizing these strategies will be important for potential future restricted learning paradigms and can also be extrapolated to augment trainee education during unrestricted times.

Optimising telemedicine in ophthalmology during the COVID-19 pandemic

Ophthalmology, an outpatient surgical specialty, depends on regular in-person encounters to manage complex eye disease. The coronavirus disease 2019 (COVID-19) pandemic has brought about unprecedented challenges in how we take care of our patients. At Vanderbilt University Medical Center, we have gone to great lengths to implement expeditiously a telemedicine platform for safely and securely evaluating our patients during the pandemic. Since implementing live videoconference appointments in late March, 840 patients received ophthalmic care during a 12-week period among all subspecialties at the Vanderbilt Eye Institute. Of these, the majority (79.6%) were either return or postoperative visits. Live telehealth visits were more amenable to certain ophthalmic subspecialties, with paediatrics, neuro-ophthalmology and oculoplastics encounters making up 80.5% of all telemedicine visits. As demonstrated through this care model and our initial experience, live video telemedicine is a sustainable and safe care delivery approach to extend ophthalmic care delivery during the COVID-19 pandemic and even post pandemic.

Artificial intelligence and deep learning in glaucoma: Current state and future prospects

Over the past few years, there has been an unprecedented and tremendous excitement for artificial intelligence (AI) research in the field of Ophthalmology; this has naturally been translated to glaucoma-a progressive optic neuropathy characterized by retinal ganglion cell axon loss and associated visual field defects. In this review, we aim to discuss how AI may have a unique opportunity to tackle the many challenges faced in the glaucoma clinic. This is because glaucoma remains poorly understood with difficulties in providing early diagnosis and prognosis accurately and in a timely fashion. In the short term, AI could also become a game changer by paving the way for the first cost-effective glaucoma screening campaigns. While there are undeniable technical and clinical challenges ahead, and more so than for other ophthalmic disorders whereby AI is already booming, we strongly believe that glaucoma specialists should embrace AI as a companion to their practice. Finally, this review will also remind ourselves that glaucoma is a complex group of disorders with a multitude of physiological manifestations that cannot yet be observed clinically. AI in glaucoma is here to stay, but it will not be the only tool to solve glaucoma.

To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute

Purpose:

To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute.

Methods:

Records of all the patients who presented from March 25^th to May 3^rd, 2020 were scanned to evaluate the details regarding the presenting complaints, diagnosis, advised treatment and surgical interventions.

Results:

The number of outpatient department visits, retinal laser procedures, intravitreal injections and cataract surgeries during this lockdown decreased by 96.5%, 96.5%, 98.7% and 99.7% respectively compared from the corresponding time last year. Around 38.8% patients could be triaged as non-emergency cases based on history alone while 59.5% patients could be triaged as non-emergency cases after examination. Only eighty-four patients opted for video-consultation from April 15^th to May 3^rd, 2020. Nine patients presented with perforated corneal ulcer, but could not undergo penetrating keratoplasty due to the lack to available donor corneal tissue. One of these patients had to undergo evisceration due to disease progression. Two patients with open globe injury presented late after trauma and had to undergo enucleation. Around 9% patients could not undergo the advised urgent procedure due to logistical issues related to the lockdown.

Conclusion:

A significant number of patients could not get adequate treatment during the lockdown period. Hospitals need to build capacity to cater to the expected patient surge post-COVID-19-era, especially those requiring immediate in-person attention. A large number of patients can be classified as non-emergency cases. These patients need to be encouraged to follow-up via video-consultation to carve adequate in-person time for the high-risk patients.

Teleconsultation at a tertiary care government medical university during COVID-19 Lockdown in India - A pilot study

Purpose:

COVID-19 related pan- India lockdown brought teleophthalmology to the forefront. The study ventures to understand the relevance of this modality in a government setup. The objective is to understand the feasibility, clinical profile and addressability of patients using teleconsultation in ophthalmology at a tertiary care government medical university during the COVID-19 Lockdown in India.

Methods:

An online survey targeting faculty members and resident doctors in a tertiary eye center in a government medical university in north India was conducted. Various aspects of teleconsultation were analyzed including the number and preferential mode of consultations, commonest complaints and diagnoses made. Frequency and factors mandating physical examination of patients was also analyzed.

Results:

The questionnaire was sent to 40 ophthalmologists of whom 38 responded. A total of 4880 teleconsultations were given. The commonest mode of communication was by WhatsApp messages (65.6%) and E-mail was the least preferred medium. More than 80% consultations were from previously seen patients. Red eye was the commonest presenting complaint (22.8%), followed by watering (18.7%) and foreign body sensation (14.5%). Computer vision syndrome was the commonest diagnosis (25.9%) followed by conjunctivitis (17.7%) and refractive error (17.7%). About 40% required physical examination, mostly due to uncertain diagnosis (22%) or inadequate response to prescribed treatment (19%).

Conclusion:

Teleconsultation was feasible in a government medical university for providing ophthalmic services during lockdown. WhatsApp was the preferred communication modality, computer vision syndrome was the most frequent tentative diagnosis and approximately 60% did not require in-person physical examination.

COVID-19 pandemic and lacrimal practice: Multipronged resumption strategies and getting back on our feet

The aim of this review was to propose multi-pronged resumption strategies for lacrimal practice in an effort to plan a sustainable recommencement of elective surgeries after we emerge from the peak of COVID-19 pandemic. The strategies for lacrimal practice were classified into 7 subtypes, and each of the blueprints were reassessed based on existing information on resumption strategies of elective surgeries from other specialties in COVID-19 era. The specific needs of lacrimal practice were then added to construct algorithms summarizing the resumption strategies. The basic principle of 'primum non nocere' needs to be followed. The overall proposed plan advocates the transition to a more sustainable health care reality in a world where we would still co-exist with COVID-19. A comprehensive effort involving screening, laboratory testing, appropriate triage, effective personal protection and specific precautionary measures for lacrimal clinics and operating room are needed to be able to safely resume elective surgery when the pandemic peak declines. To predict the timing of the resumption of elective surgeries is quite complex and influenced by several geographic, political and economic factors. It is equally important to remember that COVID-19 crisis is a dynamic situation and constantly evolving, hence the strategies provided are subject to change. Strict adherence to standard COVID-19 guidelines combined with effective testing and personal protection strategies can ensure slow yet smooth and safe return to full lacrimal practice after the COVID-19 pandemic calms down. The local government directives, individual and institutional discretion are advised.

Incorporating Video Visits into Ophthalmology Practice: A Retrospective Analysis and Patient Survey to Assess Initial Experiences and Patient Acceptability at an Academic Eye Center

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has led to rapid adoption of teleophthalmology to deliver eyecare remotely. The purpose of our study was to assess the implementation and patient acceptability of video consultation for outpatient ophthalmic care at our institution.

METHODS

We conducted a retrospective, cross-sectional analysis and patient survey of adult patients who completed a virtual video visit at our institution from 18 March 18 through to 27 April 2020. All video visit encounters were assessed for patient characteristics, diagnoses, management, and follow-up outcomes. Patients were surveyed for their feedback on acceptability and utility of their virtual video consultation.

RESULTS

A total of 219 patients (mean age 55 years; range 21-89 years) completed 231 video visit encounters at our department over a 6-week period, of whom 118 were women (54%). About half of these encounters were acute visits (102 visits, 47%). The most common diagnosis of these visits was postoperative state (20 visits, 9% of the total), followed by conjunctivitis (16 visits, 7%), and keratitis (14 visits, 6%). The most common management decisions were medication prescription (102 visits, 46%) or reassurance (86 visits, 39%), while 17 video visit patients (8%) were escalated to an urgent, in-person evaluation. Ninety-two patients completed a follow-up survey (42% response rate), of whom 45 (49%) indicated that they might have delayed seeking care during this pandemic in the absence of a virtual video option. Seventy-two (78%) reported that they would consider participating in a video visit as an alternative to an office-based encounter in the future, and the overall video visit experience was rated highly, with a weighted mean Likert scale rating of 4.3 out of 5 (Cronbach's α = 0.88).

CONCLUSION

Virtual video visits may be used to manage a range of ophthalmic complaints. Patients participating in this survey found such video visits acceptable and timesaving, and the majority would consider using video consultations for future eyecare encounters.