COVID-19 continues to have huge impacts on patient care and our health care system. In an interview with Dr Dennis Lowe, respected neurologist and ophthalmologist, we explored the pandemic’s impact on patients’ vision and health care.
Q. Did the pandemic cause patients to delay treatment and did this result in preventable vision loss?
COVID-19 has had a profound impact on patient care. During the pandemic, the need to travel on either public or private transport to access our service in the Sydney CBD created exposure concerns – patients were concerned about potential Coronavirus transmission on public transport, as well as within the clinic. This greatly affected new patient numbers, as well as the number of patients returning for ongoing care.
We observed that patients who normally came in at regular intervals were delaying their visit
In my practice, I noticed patients who suffered the most, in terms of vision loss, were those who needed laser therapy or regular intravitreal injections to manage diabetic retinopathy or macular degeneration. Both of these conditions have the highest requirement for regular assessments to maintain vision and reduce the risk for sight threatening loss.
Additionally, I noticed patients with glaucoma suffered more loss of vision compared to other ocular conditions, again due to missed visits and delayed treatment interventions.
We observed that patients who normally came in at regular intervals were delaying their visit. Sometimes they waited until their vision profoundly deteriorated, despite noticing early signs and symptoms. This of course, was devastating. In these cases, vision loss cannot be reversed, so by the time they came in, we’d missed the window of opportunity to manage the condition and preserve sight.
Q. What consequences are you seeing now?
It feels like the community is getting ‘back to normal’, but in reality people are still fearful about going out to seek medical and eye care assistance in case they contract COVID. In early March 2022, at the time of this discussion, we were seeing about 65% of our normal patient load and our operation lists were at about 65% capacity.
The consequences for patients’ vision has been dependent on the stage of their disease when we saw them for the first time, the frequency of visits by those with an established condition, and the frequency of previous injections or laser therapy. In some cases, the return of some lost vision has been possible, however for others, vision loss was irrevocable.
Q. How do you think the pandemic has impacted healthcare services for patients in eye care?
The issues faced within eye care are similar to the broader issues surrounding patient health care management in hospital emergency departments (ED).
We are seeing patients wait until their condition is critical, life threatening, or beyond a safe window of opportunity for treatment, rather than act on early warning signs. For example, we’re seeing patients experiencing early symptoms of chest pain or pins and needles down their arm during COVID-19, ignoring these symptoms for a lot longer – then finally going to the ED once they’ve escalated to a heart attack or cardiac arrest.
We are seeing the same behaviours in eye care. Patients are waiting for profound vision loss before they act to seek advice and treatment. Those who could have had their vision saved by the delivery of health services are not being seen in a timely manner.
This has broader ramifications on both the individual and society. Patients who, for example, no longer have adequate vision, become unable to maintain their employment. The negative impacts of this are far reaching – they lose their ability to work, their capacity to earn and live independently, and they have to take up a disability pension, due to their blindness, for the rest of their life.
Quality of life is also impacted when a patient shifts from having functional vision to impaired vision – relationships are stressed, they must depend heavily on others for their care and may even require a carer.
Q. What do you think we have learned about the importance of regular eye care?
The most important thing we’ve learned is that unless patients with these ocular conditions make ongoing, regular visits to an eye care practitioner, we can’t maintain a standard of care that ensures their vision and eye health needs are met.
Unfortunately, ‘erratic’ eye care schedules don’t work. The spontaneous ‘snap’ lockdowns caused by the pandemic meant we were unable to provide patients with regular follow-up, which greatly compromised optimal care and led to many suffering vision loss.
Q. During the pandemic, some politicians suggested the public defer eye tests unless experiencing pain. What was your view on this?
As ophthalmologists, we see a lot of pain syndromes. However, ocular pain isn’t the only symptom that points to blinding conditions – in fact, it is one of the rarer symptoms. Painful ocular conditions that can lead to blindness include transient ischaemic attacks, uveitis, temporal arteritis and acute angle closure glaucoma. With this in mind, waiting for pain symptoms alone will not allow timely detection of all, or even most, sight threatening conditions.
Q. Within this context, what message should practitioners communicate to their patients?
Any change of vision should be investigated; don’t assume that pain is the only symptom indicating the potential for vision loss.
For simplicity and clarity, an effective message would be: “If you experience any change in your vision, go to see your eye care practitioner. Because any vision change could signify a loss of vision.”
Q. Where do you see advances coming in the treatment of macular degeneration?
Wet macular degeneration is a response to retinal endothelial leakage, and this is largely a degenerative ocular response. Laser therapy inherently can’t be regenerative.
That means any advances in macular degeneration need to focus on regenerative treatments. I see longer acting anti- VEGF injections for age-related macular degeneration (AMD) being the next treatment to be helpful to patient care, as well as the production of oral agents, such as antioxidants and anti-degenerative oral medications, or tablets in the form of treatment of AMD itself.
Potentially, stem cell therapy advances that address the regenerative process will also be helpful to patients with macular degeneration.
THE CASE OF BLANCHE*
Blanche is a 91-year-old female patient with a three year history of wet age-related macular degeneration (nAMD) in the left eye, which was being well controlled with intravitreal Aflibercept (Eylea) every eight weeks prior to the pandemic.
Blanche visited her eye care practitioner for review on 8 May 2021.
Vision was R 6/12 and L 6/15.
Optical coherence tomography (OCT) was dry (Figure 1).
An injection was conducted and follow-up was scheduled for eight weeks.
Blanche delayed follow-up due to COVID-19 concerns and lockdown, returning six months later on 18 November 2021.
By that time, her vision had significantly decreased in the treated eye with a review showing:
R 6/12 and L 6/120.
OCT showed increase oedema (Figure 2 and 3).
Blanche has subsequently had four weekly intravitreal injections, with decreased oedema noted on OCT (Figure 4). Unfortunately, vision in her left eye remains at 6/120.
Because Blanche delayed time critical and essential health care due to fears of contracting Coronavirus, she has experienced a significant, irreversible deterioration in her health.
As eye care practitioners, we must remind patients of why it is essential to return for review and treatment in a timely manner. Only continuity of care will ensure their vision and eye health needs are met.
*Patient name changed for anonymity.
Dr Margaret Lam is the National President of the Cornea and Contact Lens Society of Australia, Deputy President of Optometry Australia and a Director of Optometry NSW/ACT. She teaches at the School of Optometry at UNSW as an Adjunct Senior Lecturer and works as the Head of Optometry Services for George and Matilda Eyecare.
Dr Dennis Lowe is a neurologist and ophthalmologist. The only practitioner in Australia to hold these dual specialties, he has particular interest in ophthalmic surgery (cataract and laser), medical retina, neurologically related eye disease as well as general ophthalmology.
Dr Lowe completed his specialist training through Sydney Eye Hospital with further study at Moorfields Eye Hospital in the United Kingdom. He currently holds VMO positions at Royal Prince Alfred Hospital, St Vincent’s Hospital and Sydney Eye Hospital (Sight Foundation). He is a court examiner for the Royal Australian and New Zealand College of Ophthalmologists (RANZCO). Dr Lowe enjoys participating in charitable/ pro-bono surgical training and teaching in Australia and overseas, contributing his time and expertise to the Vietnam Vision Project, Sight for All Foundation, Australian Health Humanitarian Aid, and the Australian Council for the Promotion of Peaceful Reunification of China.