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HomeminewsCommunication Critical to Overcome Challenges Amidst Pandemic

Communication Critical to Overcome Challenges Amidst Pandemic

COVID-19 is putting the vision of many patients with chronic eye disease at risk, as attending clinics becomes increasingly challenging for both their physical health and financial well-being.

Modified practices have been implemented to minimise the risk of spreading COVID-19, including the provision of telehealth services, COVID exposure screening prior to and at clinic attendance, physical distancing, reduced appointment frequency, extra hygiene practices and the use of personal protective equipment.

Ophthalmologists say communication by optometrists, ophthalmologists and patients is more critical than ever right now, to minimise patient anxiety, advise them of service availability/special arrangements, and remind them of the need to attend appointments for disease management.

“Eye disease doesn’t go into lockdown just because we do,” said Associate Professor Colin Chan from Vision Eye Institute. “It’s not just about emergencies. For example, what happens to a patient with recurrent herpes keratitis who is on topical steroids if she/he is not seen? How about rapidly progressive young keratoconics, and patients with wet AMD?”

In addition to treating his patients’ existing conditions, A/Prof Chan said he is emphasising the need for chronic dry eye and allergy sufferers to, “more than ever, observe hand hygiene. I have not seen any data on this but theoretically they may be more susceptible to Covid-19 because of habits like eye rubbing and mucous fishing which increases face touching,” he explained.

 EXTRA CHALLENGES FOR PATIENTS AND CARERS

Associate Professor Andrew Chang from Sydney Retina highlighted the complexity of ensuring continued treatment for macular diseases at a time when elderly patients and those with diabetes must physically distance themselves in an effort to avoid unnecessary exposure to COVID-19.

“Attending clinics can be more challenging than usual for these patients who need to avoid travel on public transport and minimise their time spent in waiting rooms. Some carers are also finding it more challenging than usual to accompany patients to clinics due to their own health vulnerabilities,” he said. Additionally, he observed, “many workers (carers and patients) have lost jobs and are facing more intense financial challenges, which will also affect their ability to maintain treatment regimens”.

A/Prof Chang said in spite of the challenges presented by COVID-19, clinics need to maintain a stable service for patients. “To reduce the risk of cross-transmission of infection in elderly and vulnerable patients, we may attempt to reduce the frequency of injections by extending the intervals between injections in those patients managed on a treat-and-extend regime. It is important for patients to attend for assessment and treatment. We can make arrangements for patients to contact the clinic, such as by telehealth, so that we can detect and treat recurrences or a leak in the fellow eye. This is necessary to maintain their sight.”

NAVIGATING THE LESS OBVIOUS

In the case of cataract and glaucoma patients, the situation is a little less black and white, says Associate Professor Simon Skalicky from Eye Surgery Associates.

“Most cataract surgery can be deferred in the majority of cases, with the exception of a) advanced cataracts in patients who are monocular (ie. blind in the other eye), and b) eyes for which cataract surgery will treat intractably high IOP (eg. angle closure). In comparison, glaucoma management cannot always be safely withheld. Glaucoma services must continue but in a reduced format and with modified practises to ensure risk minimisation.

According to Royal Australian and New Zealand College of Ophthalmology (RANZCO) guidelines1 for triaging ophthalmology patients in consideration of COVID-19 (adapted from those of Moorfields Eye Hospital), glaucoma which is acute, unstable or high risk requires prompt clinical evaluation as always, and emergency glaucoma surgery must continue. Stable glaucoma monitoring (typically low risk cases) is to be deferred or adapted to telemedicine where possible.

A/Prof Skalicky says this is tricky to implement. “A case-by-case evaluation by the clinician is often required; telemedicine is unable to evaluate glaucoma progression for which retinal nerve fibre layer measurement, disc analysis, intraocular pressure and perimetry is required. Hence clinical glaucoma assessment will need to continue for some patients with more critical glaucoma. Perimetry needs to be considered very carefully; it may have a higher risk of COVID transmission than OCT analysis due to the prolonged time of head-to-machine contact, and difficulty sterilising the insides of machines,” he said.

ENCOURAGING CONTINUITY OF CARE

Despite uncertainty A/Prof Skalicky stressed the need to remain calm. “It is important for us clinicians to remember that many patients are anxious – anxious of contracting COVID, or of missing eye health checks. We must remain calm, caring and supportive of our patients.

“Many patients will self-elect not to attend routine appointments, which is often very reasonable but may have poor consequences to their eye health. In the best of times, adherence to routine glaucoma monitoring is not always great and will decline due to COVID.

“These changes will probably have a detrimental impact on patients’ eye health. It is our task as clinicians more than ever to advocate for our patients, look after their best interests and be creative in our approach to healthcare.

“My personal approach is to call each patient for whom the clinical visit has not occurred, to stay in touch, discuss their management and renew any scripts as required.

“Patient communication is essential, and letting patients know if the practice is remaining open or not, and providing guidelines as to for what reasons they should or should not attend is important. When in doubt, patients should feel free to call and discuss,” he said.

A/Prof Skalicky added, “A key message for us all to promote is that eye healthcare is important, and should not be neglected in the context of COVID – patients should discuss their concerns with their clinician, and decide if matters could be sorted by telehealth or whether an in person attendance is required. Provided practices strictly adhere to all safety policies the risk of transmission of COVID at the clinic should be low.”

Reference

1. ranzco.edu/home/covid-19-information 

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