Advances in Ophthalmology

During the apex of the COVID-19 pandemic, Columbia and Weill Cornell Medicine ophthalmologists united in resourcefulness and collaboration to provide essential Ophthalmology services to patients at NewYork-Presbyterian Hospital, located in New York City, the very epicenter of the pandemic. With mounting concern that ophthalmologists may be at higher risk of infection because of their proximity to patients during clinical encounters, our ophthalmologists created new paradigms of care to protect physicians and staff while restoring eyesight and quality of life to our patients.

Initially, the Departments of Ophthalmology at Columbia and Weill Cornell Medicine were completely focused on increasing hospital and ICU capacity to meet the challenge. From mid-March through mid-May, the Departments were closed to all but urgent cases, with case volume greatly diminished.

“At a time of unprecedented need and amid incredible uncertainty, the COVID-19 pandemic required us to set aside all but our most essential work in patient care, research and teaching in order to focus on getting our patients, staff and community safely through the pandemic’s worst impact on the city,” recalled George A. (Jack) Cioffi, the Edward S. Harkness Chairman and Chairman of the Department of Ophthalmology at NewYork-Presbyterian/Columbia University Irving Medical Center. “We recognized that our national health care system had not been scaled to handle this sort of pandemic, but the NewYork-Presbyterian system - Columbia, Weill Cornell Medicine and NewYork-Presbyterian Hospital - was up to the challenge. Our colleagues, particularly in emergency medicine and critical care medicine, needed our help, and the system as a whole was under extreme strain and many roles needed to be filled.”

“As physicians on the front lines, we couldn’t help but be touched by the suffering and loss around us on an unimaginable scale, as well as our own fractured lives and our concerns for family, loved ones, and ourselves,” said Donald J. D'Amico, MD, the John Milton McLean Professor and Chairman of Ophthalmology at NewYork-Presbyterian/Weill Cornell Medicine. “The only sane starting point was to accept and confront our situation directly with honesty, knowledge, and savvy activity. And beyond that, to draw strength from the nobility that accompanies engaging the must-be-defeated enemy alongside trusted coworkers and organizational allies.”

“At Columbia, to protect our doctors and staff while meeting our patients’ needs, we implemented smart protocols and practices such as stopping elective surgery, restricting visitors, proper PPE use, decreasing outpatient clinical volumes, and increasing the use of telemedicine,” said Dr. Cioffi. “However, these precautions severely limited ophthalmic care to only emergent or urgent care situations.”

“At Weill Cornell Medicine, approximately 40% of the ophthalmologists, ophthalmologists in training, nurses, and other providers were redeployed to direct patient care in COVID-19–related areas, including the emergency department, the medical wards, intensive care units (ICUs), and related telemedical support,” said Dr. D’Amico. “Like most ophthalmology departments, ours had gone primarily virtual, but we still saw about 10% of our former outpatient volume each day and continued operating on patients with acute retinal detachments, ruptured globes, and the like. Vitreoretinal practice, with its complex diagnostics, is difficult to fully virtualize quite yet, but oculoplastics and some ophthalmic specialties were able to provide excellent care to patients.”

By the middle of May, the ophthalmologists at Columbia and Weill Cornell Medicine started seeing regular patients again, with thorough safety protocols that include repeated sanitizing of all spaces throughout the day, extensive use of personal protective equipment (PPE), and new screening personnel.

“By the end of July, we had reached approximately 90% of our regular case load,” said Dr. Cioffi. “We began catching up on postponements and delays, using extended hours to fit in all patients with sufficient social distancing.”

“During the height of the pandemic, we were asked, how will this end?” said Dr. D’Amico. “With all the newness and unanswered questions, no one knows, but it is clear that the situation will be marked by changes, and we have seen some already. In New York City, a frantic and remarkably coordinated scramble to double hospital and ICU capacity was completed in a matter of days. Like villagers adding rocks and sandbags to the top of a seawall in the face of an approaching tsunami, there was a palpable feeling of relief and elation when we realized that the seawall would hold and that hospital care, however strained and unconventional, would be available to all who needed it.”

“We will never forget how we all worked together with magnificent institutional leadership in a way that has revealed many creative opportunities for the future,” said Dr. D’Amico.

New COVID-era Eye Care Paradigm

By early fall, with the second wave of increased COVID-19 cases, the need for new COVID-era eye care paradigms was evident.

“Ophthalmologists, optometrists, and other eye care professionals remain at higher risk of infection because of the proximity to our patients during the physical examination, high patient volumes, and/or lack of personal protective equipment during the early phases of disease spread,” said Jeffrey M. Liebmann, MD, the Shirlee and Bernard Brown Professor, Vice-Chair, and Director of the Glaucoma Division of the Department Ophthalmology at Columbia University Medical Center. “Long before we reach a COVID-free future, we will need to think carefully and wisely about how we can safely care for our patients when there is still circulating COVID-19 virus with likely intermittent, more localized outbreaks (the ‘COVID era’).”

“Many of our colleagues in medicine are rushing to telemedicine applications to fill the immediate void, but the applications of teleophthalmology, while potentially impactful for data and image transfer, is not well suited at the present time for a detailed examination of intraocular structures and surgery,” added Dr. Liebmann. “Since we will still need to physically (not virtually) examine patients in our offices or clinic settings, creativity is required as we rethink our care models, beginning from the first point of patient contact to the moment the patient leaves our offices.”

These new models of eye care include:

• Each slit-lamp must be meticulously cleaned between use and better barriers ought to be created between the patient and the examiner.
• Both examiner and patient will need to be masked and many of us will wear gloves.
• The utility of reusable Goldmann tonometers may require reassessment, and more attention will be focused on disposable tonometers with single-use protective sleeves, which come in a variety of forms, some of which have not been adequately tested, limitations identified, or correlation to Goldmann tonometry clarified.
• Some institutions may require the use of single-use gonioscopy, laser and hand-held indirect lenses.
• Pneumotonometers and air-puff tonometry, both of which can presumably aerosolize the tear film and viral particles, may need to be avoided.
• New techniques for the sterilization of non-disposable equipment require elucidation and our most basic interventions and handling of instrumentation reinvented. Do we place the indirect ophthalmoscope on our heads first, with new gloves, or do we examine the patient, change gloves, and then don the instrument? Will multi-use eye drop bottles (dilating agents, for example) become obsolete? Seemingly simple actions require new forethought.
• Some form of physical distancing will need to be maintained and will affect the positioning of staff and patients and waiting times. Waiting rooms should be rearranged and reduced in capacity. Accompanying persons may be discouraged or be limited to one.
• General anesthesia protocols for intubation and extubation procedures to minimize aerosolized exposures will be adapted from our anesthesia colleagues.
• The trend away from trabeculectomy towards procedures with less intensive postoperative care, such as minimally invasive surgery and tube-shunts, may accelerate.
• The development of novel paradigms to diagnose and monitor glaucoma patients in the event that automated perimetry is not accessible (i.e. remains unsafe) or available for only limited patients.
• Routine postoperative care for cataract surgery in nonglaucomatous eyes could likely be cut further via teleophthalmology to allow us to have more time to examine sicker patients or those with new problems.
• Transfer of electronic data or digital pre-population of historical or present illness information could further reduce patient time in the office.