Coronavirus update

AAO offers safety guidelines; Whistleblower ophthalmologist succumbs to COVID-19.

By René Luthe, senior editor

Updated March 23, 2020

COVID-19’s continued rapid spread prompted the AAO to tell ophthalmologists that it is “essential” they now offer only urgent and emergent care. According to the AAO, this step is necessary for two reasons. The first is to reduce the risk of person-to-person virus transmission, which is critical to avoid overwhelmingour nation’s medical infrastructure. “We have already hit that stage in a few hard-hit metropolitan areas,” notes the Academy in a press release. The second reason to restrict care is to help conserve needed disposable medical supplies for hospitals.
 
The recommendation applies to both office-based care and surgical care. However, the Academy also noted that “‘urgency’ is determined by physician judgment and must always take into account individual patient medical and social circumstances.”  
 
Similarly, CMS now recommends limiting “all non-essential surgeries and planned procedures … until further notice” to conserve critical resources and to limit exposure of patients and staff to COVID-19. CMS’ guidelines (https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures-recommendations.pdf) include recommendations on how to provide care to patients with conditions that require attention “to save a life, preserve organ function and avoid further harm from an underlying condition or disease.” The agency cited cataract surgery as an example of an outpatient surgery that does not qualify as something that addresses “life-threatening illness.”


Updated March 18, 2020

The AAO updated its ophthalmology-specific information related to the virus. Now referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the highly contagious virus can cause a severe respiratory disease known as COVID-19. Eye-care professionals should be aware that:

• Recent reports from Journal of Medicine Virology and New England Journal of Medicine suggest the virus can cause conjunctivitis and possibly be transmitted by aerosol contact with conjunctiva.
• Patients who present for conjunctivitis and who also have fever and respiratory symptoms as well as have recently traveled internationally, or have family members who have recently traveled internationally, could represent cases of COVID-19. Be sure to ask patients if they are experiencing symptoms, and about their recent travel history.
• The AAO and federal officials recommend protection for the mouth, nose and eyes with goggles or shields when caring for patients potentially infected with SARS-CoV-2.
• The virus that causes COVID-19 appears to be susceptible to the same alcohol- and bleach-based disinfectants that ophthalmologists commonly use to disinfect ophthalmic instruments and office furniture. Therefore, it is advisable to increase these disinfection practices before and after every patient encounter to prevent office-based spread of other viral pathogens.

As of March 17, three U.S. states are experiencing sustained community spread: New York (1,717), Washington (1,014) and California (718), according to Johns Hopkins University. Though no vaccine against SARS-CoV-2 currently exists, Kaiser Permanente began enrolling for mRNA coronavirus vaccine trials on March 5 in the Washington State area. 
 
For more information and updates from the AAO, go to https://www.aao.org/headline/alert-important-coronavirus-context.

Original story

The coronavirus claimed the life of the Chinese ophthalmologist reprimanded by local police for sounding the alarm about its outbreak.

Li Wenliang, 34, was one of eight people reproached by authorities in Wuhan, the virus’ epicenter, in January for “spreading rumours” about the budding epidemic. He had sent a warning on the WeChat messaging app advising his former medical school classmates, many now in practice, to wear protective clothing to avoid infection after several patients from a local seafood market exhibited symptoms similar to SARS.

Dr. Li reported on Chinese social media platform Weibo on Feb. 1 that he had tested positive for the coronavirus. In interviews with Chinese media while he was hospitalized, he said he was infected by a female patient he treated for glaucoma in the second week of January. She had developed a fever and a CT scan showed an unknown virus in her lung.

Dr. Li passed away on Feb. 7. He leaves behind a pregnant wife and a child.

At press time, there are 89,197 cases of coronavirus worldwide and at least 3,048 deaths, according to the Johns Hopkins Whiting School of Engineering’s Center for Systems Science and Engineering. The majority of both cases and fatalities have occurred in mainland China.
 
The AAO notes that conjunctivitis is a possible symptom of the virus, so patients with conjunctivitis who also show respiratory symptoms should be evaluated for exposure, particularly if they recently traveled internationally. Additionally, ophthalmologists should notify both their individual health-care facilities and their local or state health departments immediately of any concerns. For complete AAO guidelines for ophthalmologists, visit https://www.aao.org/headline/alert-important-coronavirus-contex OM

Compounding pharmacies and glaucoma

Advantages include increased adherence and affordability.

By Robert Stoneback, associate editor

For ophthalmologists who have glaucoma patients struggling with compliance and medication prices, compounding pharmacies may offer a solution.

For Inder Paul Singh, MD, of The Eye Centers of Racine & Kenosha in Wisconsin, compliance is “the number one issue we face.” Glaucoma patients may need to use several different drops to treat their condition, which can be a huge hurdle, he explains. Not many brand name combinations use more than two medications in one bottle, but that’s where compounding pharmacies can be so helpful, Dr. Singh says.

ADVANTAGES OF COMPOUNDING

Compounding pharmacies offer multi-agent compounded therapies, combining medications like latanoprost, timolol, brimonidine and dorzolamide in a single bottle. These combination drops make patients much more likely to comply with their treatment regimen, Dr. Singh says.

He recalls a patient who could not remember to take all of her prescribed glaucoma medications. Instead of advancing to surgery, though, he prescribed a combination treatment from a compounding pharmacy: one bottle of timolol, brimonidine and dorzolamide to use in the morning and another, comprised of the same three medications plus latanoprost, at night. The patient’s compliance increased on the simpler regimen, and her IOP went down dramatically.

George Tanaka, MD, of Vold Vision in Fayetteville, Ark., agrees that compounded medications greatly improve patient compliance when a patient “can just take one bottle.” They also address the problem of availability. “There’s a lot of combination medicine available overseas that are not FDA approved in the U.S.,” he says, and compounding pharmacies offer a way to provide these.

PRICE

The cost to patients of compounded medicine is also competitive compared to retail pharmacies, Dr. Tanaka says. He’s found that using compounded medicine has saved some of his patients, using multiple medications, $50 to $100 a month.

“You’ve got the convenience of having one bottle, but the price of that convenience is not exorbitant compared to what patients would pay through their insurance at a retail pharmacy,” Dr. Tanaka says.

Jason Bacharach, MD, of Sonoma County, California’s, North Bay Eye Associates and San Francisco’s California Pacific Medical Center, found similar cost benefits for his patients, with some saving hundreds of dollars within a month. Buying medications individually may cost $200 to $300, but switching to a compounded eyedrop comprised of three or four medicines might cost $100 to $140.

While his clinic initially requests the medication from the compounding pharmacy, the financial exchange is handled directly between the pharmacy and the patient. This more direct relationship between manufacturer and end user “cuts out a lot of red tape and a lot of expense” for both the patient and clinical practice, Dr. Bacharach says.

CHOOSING A PHARMACY

“There’s more science behind these compounded drops” than some might be aware, Dr. Singh says. Compounding pharmacies typically disclose their inactive ingredients, unlike many generics. For instance, he says, “the vehicle for the compounded glaucoma drops by one of the largest pharmacies contains a surfactant that allows the individual molecules to remain equally distributed. Since the vehicle of drops plays an important role in bioavailability and tolerability of a medication, it is comforting to know where the compounding pharmacies outsource the ingredients and that the inactive ingredients are consistent.” These pharmacies can also provide potency and sterility data, he adds.

Dr. Singh advises any doctor concerned about using drops from compounding pharmacies to try them on a small number of patients, about five to 10, and monitor their effectiveness.

Another factor in choosing a pharmacy is quality and regulations. The compounded drugs themselves are not FDA-approved, but Dr. Singh says that 503B compounding pharmacies are inspected by the FDA, unlike traditional 503A compounding pharmacies. In addition, Dr. Bacharach advises using a pharmacy accredited by the Pharmacy Compounding Accreditation Board. OM