When the final tally is taken of the toll of the COVID-19 pandemic, livelihoods, mental health and life itself will feature prominently on the list. But also on that dreadful ledger will be loss of vision. In this article, we’ll look at the impact of the delayed care caused by COVID on patient eye health.

REAL-LIFE VISION LOSSES

Case in point: Concerned about COVID, an elderly patient missed several appointments to care for a Descemet’s membrane endothelial keratoplasty that had been performed in 2019. When she finally visited the practice, her IOP had skyrocketed to the high 30s and she was unresponsive to a steroid decrease and pressure-lowering drops. The patient, in her 80s, suffered a significant loss of peripheral visual field, having incurred optic nerve damage. Ultimately, an Ahmed tube was placed, which reduced her pressure. Sadly, her overall vision suffered because of the delay.

Her physician, Sumit (Sam) Garg, MD, says that vision loss was “something that could have been prevented had we seen her.” Dr. Garg is professor of ophthalmology and medical director at the Gavin Herbert Eye Institute, University of California, Irvine. “Every practice has had some patients who have suffered” because of the pandemic, he says.

Consider another of Dr. Garg’s patients, a mother of four children who had a corneal transplant for a contact lens-related ulcer. She suffered from graft rejection but delayed a scheduled visit by roughly 2 months. Because a steroid challenge failed to reverse the rejection and her vision did not recover, she underwent a repeat corneal graft. Fortunately, she has not lost vision.

“We definitely had patients who lost vision, some permanently, due to delay in getting into the clinic, and ultimately a delay in getting the surgery or treatment they needed,” says Manjool Shah, MD, clinical assistant professor, medical director, glaucoma, cataract and anterior segment disease, glaucoma fellowship director, Kellogg Eye Center, University of Michigan, Ann Arbor. Dr. Shah notes that clinical operations did not restrict patients who needed care from receiving it, and the practice was able to continue operations and provide quality care.

Let’s look more closely at the extent of delays.

“NATURAL RESISTANCE”

As the pandemic began in March/April 2020, surgeries were delayed as practices closed or drastically reduced patient volumes. John DeStafeno, MD, Chester County Eye Care, West Chester, Pa., and clinical instructor, Wills Eye Hospital, says his practice cancelled elective cataract procedures and patient visits; in addition, non-vision-threatening retinal and glaucoma procedures were postponed. A significant number — perhaps 20% to 30% — of patients did not feel comfortable having surgery and “just didn’t want to do anything until everything was settled,” Dr. DeStafeno says.

Similarly, the patient load was severely reduced at the University of Michigan Kellogg Eye Center. From a caseload of 100 to 150 patients a day at its multiple sites, that number was reduced at times to fewer than five glaucoma patients a day, says Dr. Shah. With a skeleton crew of providers, the center only saw glaucoma patients with acute problems, post-surgical patients or patients who have unstable disease.

On the West Coast, a similar story was being played out at Oregon Health & Science University. “There was a natural resistance to proceed with a lot of elective procedures in the beginning of the pandemic. That led to an early backlog, both in clinic, in the patients we were evaluating, but also in surgeries that were scheduled,” says Winston Chamberlain, MD, PhD, Petti associate professor of ophthalmology, chief of cornea and refractive surgery division, Casey Eye Institute, Oregon Health & Science University, Portland.

That early backlog is something the practice is still experiencing, he reports. “Even after a year of going through this, we still have one of the largest backlogs that I can remember, but this may be partly affected by the complexity of cases we see at the University,” he says.

Some patients, notes Dr. Chamberlain, may have had concerns about going to a hospital setting, even though the institute is located in a building separate from the hospital. Patients have expressed concern that their risk for acquiring disease is higher in a hospital setting, Dr. Chamberlain says, “so I think there were probably some fears of patients associated with coming in for appointments and surgeries,

CATARACT PATIENTS: DIFFERENT SCENARIOS

Practices experienced different scenarios with cataract patients. Patients at some practices, like Sightline Ophthalmic Associates and Laser Eye Center, Sewickley, Pa., moved forward in spite of the pandemic. Other than after the initial closure at the start of the pandemic, cataract patients “did not want to wait,” says Paul Phillips, MD, of SightLine. His practice, near Pittsburgh, performs roughly 4,000 cataract surgeries per year.

“I was somewhat surprised that so many people simply came out and wanted to have their cataracts taken care of as soon as they could,” he says. “Once we got back up and running after we were shut down, there haven’t been a lot of people who wanted to hold off on surgery when they had a significant cataract. I do believe it is our job as physicians to create as safe an environment as possible for the patients, which involves, among other things, following CDC guidelines of screening for COVID symptoms and checking temperatures. Even with these extra measures, at times I was fairly shocked by the risk some would take coming out to be examined. It did reconfirm for me the importance of cataract surgery for these people.”

On the other hand, at the Kellogg Eye Center, cataract patients tended to delay their surgery more than glaucoma patients. Cataract surgery, Dr. Shah says, offers “a tremendous ability to make positive changes in people’s lives. But, in many situations, we believed surgery was not worth the risk of COVID-related issues when we were early in the COVID period and we didn’t know where things were going. We didn’t have really good COVID treatments and we certainly weren’t anywhere near a vaccine, so patients were understandably nervous.”

However, says Dr. Shah, “from a glaucoma surgical standpoint, we didn’t necessarily have to delay too much. When patients were in an emergent situation, we were able to go. We didn’t worry about it because the risks associated with COVID, even then, were real but theoretical, and the risks associated with vision loss from glaucoma were real and not theoretical.”

Dr. Shah participated in the development of a scoring algorithm, led by his colleague Joshua D. Stein, MD, MS, to help providers determine which clinic appointments to keep or postpone for glaucoma patients. It considered the risks of morbidity from glaucoma progression as a result of delayed care versus potential risk of acquiring COVID.

Some of Dr. Garg’s cataract patients have chosen to wait, he says, as have a couple of patients who have Fuchs’ corneal endothelial dystrophy and wanted to delay endothelial keratoplasty. Patients with dry eye conditions have delayed interventions such as Lipiflow (J&J Vision) or TearCare (Sight Sciences). However, by and large, on urgent cases, “I haven’t had a lot of pushback,” Dr. Garg says.

BACK TO THE DRAWING BOARD

Delaying surgery may entail complications for both patient and physician. For instance, while ultimately a benefit, patients who delayed cataract surgery due to COVID may be faced with more lens choices than when they first considered the procedure.

“If they made this decision 6 months ago and then decide to move forward with surgery after a new lens became available, we’re having more follow-up phone conversations or even follow-up in-clinic conversations to say, ‘We have some new lens technologies we want you to be aware of before we do surgery,’” says Dr. Chamberlain. “With the diversity of lenses available now, a patient almost needs to go to ‘lens school’ before making a decision. This creates a burden for the cataract surgeon and their staff to be able to clarify with the patient the variety of options available and the upsides and downsides to all these options, including costs, visual advantages and side effects.”

Dr. DeStafeno says that he treated cataract patients who returned to the office almost like new patients as there may have been examination changes, significant cataract progression and new IOL options available to them. While not a major challenge, for a progressive cataract patient who postponed surgery, the surgery might require more phaco energy than if the procedure had been done earlier, notes Dr. DeStafeno. The surgeon also may have to deal with more corneal swelling, delayed healing and possible macular edema.

On the scheduling side, some cataract patients who now feel comfortable getting surgery want the procedure done quickly, says Dr. Garg. In these cases, Dr. Garg tells the patient that “this was not an urgent surgery then, it’s not an urgent surgery now” and that it will be scheduled for the next available opening.

For high-risk glaucoma patients, Dr. DeStafeno repeats pressure measurement, visual fields and OCT diagnostic imaging to make sure there was no further progression. For retina patients, he repeats OCT imaging, looking for any increase in wet macular degeneration or macular edema.

Dr. DeStafeno’s staff contacted retinal patients who failed to appear for their monthly injections. “We did actively try to manage that and alert the patients with the highest risk of visual loss, and the majority of the time those patients did come in,” he says.

THE PATIENTS HAVE RETURNED

Today, Dr. DeStafeno, Dr. Chamberlain and Dr. Garg estimate that their patient volume has returned to 80% to 90% of pre-pandemic levels. Dr. DeStafeno attributes the comeback in volume to two factors: the return of referrals since practices in those networks reopened and an uptick in vaccinations increasing the comfort of patients.

Dr. Chamberlain notes that there has been an increased demand nationally for LASIK and PRK surgery. “In the last 6 months, I would say there’s probably been an increase over the previous several years’ volumes of up to 20% to 40% in our hospital system for demand for refractive surgery. This is interesting and was a little bit unexpected.”

The drivers for this increase, he notes, include patients engaging in more outdoor activities and wanting to be independent of contact lenses and spectacles; and mask wear, which can cause glasses to fog and may cause dryness in contact lens wearers. Some patients may also have more cash flow as they are not travelling or are collecting stimulus checks.

Dr. Shah says he is at “full scale” for glaucoma patients and is seeing some 10% to 20% more patients than 2 years ago. He attributes this to an increase in his practice’s efficiency.

What’s more, “there might be practices in the community that have either reduced capacity or basically closed their doors,” he explains. “The University of Michigan serves our community by being a resource to any and all, so that’s a huge number of patients who now become ours. We’ve seen that result in a major uptick in surgical referrals for our retina colleagues here at the University of Michigan. And I wonder if we’re starting to potentially see that happening on the glaucoma side as well.”

Although surgeons can attempt to get patients in the practice door, ultimately, they can exercise only so much control. “Practically speaking, care is something that is the patient’s responsibility and our responsibility,” says Dr. Garg. “Care is a two-way street.” OM