The COVID-19 pandemic affected every aspect of Americans’ lives, including how we seek and provide medical care. In the eyecare field, services were halted except for urgent cases and necessary follow-up care. ASCs were, largely, handling only emergency surgeries. As restrictions are lifted and surgery centers ramp back up to full operation, ASCs are making the necessary adjustments to accommodate our new norm.

The Ophthalmic ASC hosted a panel of four leading eye surgeons to discuss the impact the pandemic disruption had on their business, and—more importantly—the key considerations and implications for the future of patient care and successful ASC operation.

Led by Cathy McCabe, MD, of Eye Health America and The Eye Associates in Bradenton, FL, panelists included Mark Kontos, MD, of Empire Eye Surgeons in Spokane, WA; Larry Patterson, MD, of Eye Centers of Tennessee in Crossville, TN; and Dee Stephenson, MD, of Stephenson Eye Associates, Venice, FL.

Faculty

Cathy McCabe, MD, is the chief medical officer of Eye Health America and medical director of The Eye Associates in Bradenton, FL. She is the president of OOSS and co-chief medical editor of The Ophthalmic ASC.

Mark Kontos, MD, is a senior surgeon and partner with Empire Eye Surgeons in Spokane, WA. He is also a director of the OOSS Board of Directors and co-chief medical editor of The Ophthalmic ASC.

Larry Patterson, MD, is the founding partner of Eye Centers of Tennessee and chief medical editor of Ophthalmology Management.

Dee Stephenson, MD, FACS, is the president of the American Board of Eye Surgery; founder and CFO of Stephenson Eye Associates in Venice, FL; and cataract section editor for AAO's Focal Points.

The webinar discussion was sponsored by The Ophthalmic ASC, Ophthalmology Management, EyePoint Pharmaceuticals, Ocular Therapeutix, and Santen.

Balancing Safety Factors With Efficiency

Cathy McCabe, MD: With your surgical centers and practices returning to relatively normal volumes—or heading in that direction—what, operationally, are you doing differently?

Larry Patterson, MD: For the office, we basically screen each patient as they come in. We ask the driver to stay in the car unless they are a caregiver. As far as the OR, we have surgery center staff sitting in the lobby, and when the patient comes in, the driver signs their paperwork and the patient goes in and the driver goes back to the car.

Dee Stephenson, MD: I’m in a multispecialty HCA Healthcare facility owned by a hospital. They have never closed. They do emergency surgeries. But my surgeries were limited. There is a mild wait time. They ask the patient family members to sit in the car. The ask a gamut of questions (travel history, exposure to anyone sick). Their temperature is taken. They wear a mask. The anesthesiologist and nurse anesthetist wear shields and a N95 mask.

Dr. McCabe: We all have backlogs of procedures and we’re trying to ramp back up safely and get ahead again. How do you keep in place all the mitigation necessary to keep patients safe and still do your normal or even additional volume?

Mark Kontos, MD: I think a lot of it comes down to the staff. We have a really motivated team that wants the surgery center to be successful and to get back to where we were. Before reopening, we did a lot of staff training in terms of moving patients through the center efficiently, calling them from their car, determining when we needed to have somebody with them, and when it was okay for a patient to be in by themselves. I think it made it a lot smoother once we got started. I was in surgery soon after we opened—we did 20 cases and it was just like a regular day. We did all of the things that we needed to do for the patients, but it didn’t take us any longer to get the cases done.

Dr. Patterson: Except for the fact that the PACU nurses and the CRNAs are wearing masks the entire time, our work is exactly the same because we’ve always used a stringent sterile process. We may now be a little more stringent about cleaning, but our cases per hour are the same. Working to get caught up on all these backlogged procedures, adding extra cases to the day and working longer days, staff had the attitude of, “we got a break for a few weeks and we need to get back up for it.”

Dr. McCabe: How do you reassure patients about your safety measures so that they feel comfortable coming to your surgery center?

Dr. Kontos: It’s not going to just go away, and we have to figure out ways to provide proper care to our patients with the virus in our midst. That’s the mindset that I’m trying to train my staff with, and the mindset we’re giving our patients. Within that, we do everything we can do. And then beyond that, it’s “life is what life is.”

Dr. Stephenson: Safety is of the utmost importance, and I think that how we talk to our patients to make them feel safe about signing on for surgery is the same conversation we have to have with them about the safety of our office. And when they come in, they see the extremes that we have gone to for safety. I have patients who have had family members pass away from coronavirus and it changes their whole aspect of how they look at things. So I think we have to be very sensitive and empathetic to everyone. If there’s a small chance of exposure, I’m shutting down for two weeks.

There’s also simple things like eliminating magazines and putting filters in every room. There’s all kinds of basic things that we did, and I won’t change them going forward.

Dr. McCabe: There were many weeks where we were getting just a small percentage of our normal revenue. Are you thinking of ways of augmenting the revenue you get per case, or adding new revenue streams?

Dr. Stephenson: We have extended our hours of operation, and we’ve also decided to work a couple Saturdays a month just to be able to catch up on our backlog of patients.

Dr. Patterson: The backlog of cataract surgeries will still be there, so it’s not really revenue lost—it’s more like revenue deferred. Through the shutdown we kept seeing the emergent and urgent cases. All of our retina patients still got their injections, things like that. Right now we’re not changing anything. We’re just getting caught up as best we can.

Preparing For What’s Next: Redefining Elective Surgery

Dr. McCabe: As we move into this next, post-COVID era, are you worried about another disruption happening again in the fall? And are you putting any plans in place for that?

Dr. Patterson: In my role as the chief medical editor of Ophthalmology Management, I’m encouraging everyone to have a little bit more cash on hand than they used to, just in case.

But I also think that we in the medical field have to start redefining “elective surgery” in terms of what we’re still allowed to do during emergency shutdowns. We think of elective surgery as: If you’re not going to die or go blind immediately, it’s elective. But we’ve pointed out for years that cataract surgery is an important thing. Not just to make people happier, but for their general safety. A study that was done several years ago showed that cataract surgery was associated with fewer hip fractures.¹

The Academy said if one eye was blind and the other eye needed cataract surgery, then that would be okay. What if both eyes are 20/100 or 20/200? We had lots of people like that. So, I think if this shutdown happens again, we need to redefine elective.

During the shutdown, one of my friends in town couldn’t get glasses in Walmart. He said, “Being able to see and move from one place to another, how is that considered elective?”

Preparing For What’s Next: Patient Independence

Dr. McCabe: What do you think about trying to maintain patient independence amid the possibility of future interruptions to their access to contact lenses, glasses, or even their glaucoma medications? Does that influence your choices when you’re looking at surgery and how you treat the patient now?

Dr. Stephenson: I think it comes down to “less is more.” We already have medications that allow us to give an antibiotic, a steroid, and a non-steroidal twice a day. In my surgery center, an HCA, I can’t use everything, but I can use some things. I can use every lens on the market, and I have every phaco machine, a femto laser, and an Optiwave Refractive Analysis system (ORA, Alcon). I have been able to use the Omidria phenylephrine and ketorolac injection (Omeros), but I have not been able to use the Dextenza intracanalicular steroid (Ocular Therapeutix).

I’m looking at a whole different regimen on how I do postoperative treatment, both in our ASC and in my office. I’ve been using Dextenza in my office for the last year, and it’s been very helpful to patients. So those are the kind of things that we have to have in place if there’s a resurgence of COVID-19 and we can’t do surgery. That would mean reducing the number of postoperative visits. Maybe you do same-day post-op visit or day 1, and then you don’t see them for 30 days because Dextenza lasts for 30 days.

Dr. McCabe: Is anyone else using any of the depot type of medications, or MIGS procedures, or things that can provide patients more independence? Do you think they take on a new importance now?

Dr. Kontos: We’ve been using MIGS from day one, really, and that’s been an expansive area for us. And we’ve also been using Omidria, and so those have been things that have been part of our ASC procedure for a while. That hasn’t really changed. Even before the crisis happened, there were reasons to look into using an intraocular steroid, or using the various products coming out now to try to get away from eye drops with our patients.

This upheaval is making us re-evaluate everything, which I think is a good thing. We’re looking at how we do everything now and whether we’ll ever have waiting rooms again or whether we’ll do this or that. And so looking at these new technologies that maybe have been a little bit slower to gain traction in the past might gain a little more traction now.

Dr. McCabe: We’ve been incorporating some of these things, such as Dexycu (EyePoint Pharmaceuticals), Dextenza, and Omidria. They actually give you a rebate, which is a nice thing for the surgery center when you’re looking at revenue as well, and it’s a win for everybody. It’s the same thing, I think, with other things that give more independence, such as premium lenses and MIGS.

Dr. Patterson: We were prepared for this ahead of time because we’ve been drop-free for three years now, using various modalities. And we also, based on some really good literature out there, stopped the day 1 post-op visit. We don’t do a same-day or day 1 post-op visit. I will if the patient has glaucoma and we’re doing a procedure or he’s got a compromised nerve, but if someone has two cataracts that need to be done, we do the surgery and we see the patient 1 week post-op. If everything’s good, we do the other eye the next week, and then 2 weeks later do a final post-op visit. We’ve got three years and about 6,000 cases and, really, it’s just the way to go. And the amount of time it’s freed up in the clinic—which is something for people to think about right now when they’ve got such backlogs—it’s eliminated a lot of unnecessary visits.

Dr. McCabe: What’s in your crystal ball for the future? Any new directions or permanent changes as we reopen and move out of this COVID-19 era?

Dr. Kontos: Even within all of the upheaval and everything that’s taken place, I’m really very optimistic about the future of our practice and the practice of ophthalmology in general. One thing that this has shown me is that our patients really value what we do. They really want our services and when they’ve been taken away for a period of time, it becomes pretty clear that our services are valued deeply by our patients. There’s a ton of work out there for us to do. Our clinics are showing that. Our practice is breaking ground on a new facility in Spokane, and when this all started happening I was worried that it was the worst timing in the world. And now I think it may be the best timing.

I think we’ll manage all these issues, and we’re going to learn a lot, and we’re going to get leaner in a lot of ways. It’s a wakeup call for some practices, and for others it’s just an affirmation that they’re doing really well at their job at this point. And I think a year from now we’ll look back on this and we’ll all be better for it.

Dr. Stephenson: I’m very optimistic. I think it will change some of the things we do, but what I’ve learned through this is that ophthalmology is an incredible field. We have had such great camaraderie with our groups, with industry all wanting the same thing: for us to be able to care for our patients and to find new ways to do it better. There are many changes to come, but I think that at the end of the day we will all be glad that we’re still ophthalmologists and that we have this industry that supports us. ■

REFERENCE

1. Tseng VL, Yu F, Lum F, Coleman AL. Risk of fractures following cataract surgery in Medicare beneficiaries. JAMA. 2012;308(5):493-501.