The last 24 months of our professional careers have seen more challenges than we could ever have imagined facing in our working lives. We have had to alter our business models, re-shuffle our staff members, and abide by strict regulations imposed on us by our college boards and governments; all while trying to provide a reliable clinical service for our patients.
Fortunately, ophthalmologists and optometrists have come together during the pandemic to support each other and to ensure that, despite the disruptions, patients have continued to receive gold standard eye care.
One thing is for certain: no one could have predicted the past 24 months, and even if they had, they couldn’t have prepared for it. However, despite the challenges we have faced, there has remained one constant – collaboration with our peers.1
Over the last year alone, I have been more ’in touch’ with my colleagues than ever before
Over the last year alone, I have been more ‘in touch’ with my colleagues than ever before. Whether via text message, email, an impromptu virtual meeting or Facetime, lockdowns and curfews have brought us closer together!
Impressively, a lot of the time, these interactions have not focused on our clinical work, but instead have provided an opportunity to lend a listening ear to each other’s viewpoints and share advice.
The New England Journal of Medicine describes this as the basis of positive collaboration within a professional community – a phenomenon which cannot be taught.2,3
The collaborative care network of which I am a part has ultimately led to our survival during the pandemic. With this experience behind us, I feel confident that should there ever be a similar scenario in the future, we will remain strong through it, thanks to our peers.
BACK YOURSELF – YOU’RE WORTH IT
I am constantly impressed by the astute diagnoses my optometric colleagues make. During a time of surgical restrictions, many post-surgical patients presented to their optometrist rather than to their ophthalmologist, and in some cases, the action taken was quite literally, sight saving.
As an example, one patient presented to their optometrist with a foreign body sensation, weeks after routine cataract surgery, which as many will know, is quite normal and often benign. While it can be tempting to deal with cases of this nature via a ‘telehealth’ consult, this dedicated optometrist chose to see the patient, only to discover a herpetic corneal ulcer requiring urgent treatment.
On commending my colleague, I asked, “What was it that made you see this patient?”, to which they replied, “I made myself a rule to see any patients who had surgery within the last three months”.
A very wise and sight-saving decision on the part of this optometrist, which reflects that an ‘ocular emergency’ really is as deemed by the clinician.
Don’t be afraid to ask a question of your colleague – it will only help strengthen your knowledge and theirs
Another surgical case that came to me, via a newly graduated optometrist, was a patient who belonged to a colleague of mine. During the pandemic, many of us covered for our colleagues, as we reduced the number of clinical consultations. On this particular day, the young optometrist called because they felt uncomfortable with the amount of post-operative inflammation present in the patient’s anterior chamber, given he was now four months post routine cataract surgery.
On examination, I found that the persistent inflammation was due to a retained lens fragment in the anterior chamber, almost the same colour as the patient’s iris, making it difficult to spot! A quick and straight-forward procedure ensued to remove the fragment. The patient had an excellent recovery.
This diligent optometrist’s enquiry about a clinical sign they had not previously encountered, is a powerful reminder to us all to ask for a second opinion when the case in front of us just doesn’t seem to make sense. While most of the time you’ll be on track with your thinking, you don’t want to regret not making a quick call.
You may find it surprising, yet reassuring, to hear that neither of the two scenarios mentioned here were the dangerous ‘vision loss’ scenarios of post-operative endophthalmitis or toxic anterior segment syndromes, of which we are constantly reminded to be vigilant in post-operative patients. As they say, the latter are less common and as you know – common things occur commonly.
RELY ON YOUR TEAM
These examples demonstrate the importance of building a tight rapport with our own clinical team, our referrers, and in general with each other. I encourage you to create a ‘clinical network’ in a manner that works for your practice and to embrace it. But how?
Perhaps you will find a formal way to do this – organise a regular group session on MS Teams or Zoom, weekly or monthly, where you can discuss the general running of your clinic as well as interesting case scenarios. You never know, it may even spark a conference presentation or a group publication.
Less formal ways to connect are equally valuable. Many of my close referrers have my personal number and/or email and get in touch promptly when they need advice or assistance. Some clinicians have formed a peer support group where they meet ‘virtually’ just to be a listening ear for each other in a safe space. These are our lifelines, given the pressure of our professional careers, and we need them now more than ever before.
I recall a mentor of mine once commenting, “Don’t be afraid to ask a question of your colleague – it will only help strengthen your knowledge and theirs”.
WORKING OUR WAY OUT OF COVID
COVID-19 Vaccinations and Related Eye Conditions
Many of you will agree that there has been far too much in the media recently about the adverse effects of COVID-19 vaccinations. Some would say this is perhaps premature, and almost everyone will agree it has caused undue distress. The media and politics aside, we must address the elephant in the room, and that is that there are indeed clinical scenarios that we, as eye care providers, may be faced with in our vaccinated patients.
So, what might we see in the coming months?
It is most likely that for many of us, this will be our first ever, and hopefully our last pandemic – we are all grateful for that
Through mostly anecdotal evidence and some recently published case reports, the adverse effects of these vaccinations seems to revolve around the theme of immune reaction. Clinically, this may occur as inflammation, reactivation of viremia, idiopathic vascular inflammation, and in some cases, thrombosis.4
Given that the primary goal of any vaccination is to boost our immune response, it is not unusual to expect that this may cause a heightened response of the immune system in general. Therefore, cases of idiopathic acute anterior uveitis (AAU), as well as recurrences of herpes simples virus (HSV) or varicella zoster virus (VZV) in predisposed individuals, has not been uncommon in my practice of late. Other colleagues describe scenarios of posterior segment inflammation, such as multiple evanescent white dot syndrome (MEWDS), which may initially present with visual disturbance but almost always self-resolves without sequalae. Some clinicians report central retinal vein occlusion, though to my knowledge, devastating cases of arterial thrombosis presenting as a central or branch artery occlusion have so far not been reported.5
In any case, the take home message appears to be: stay informed and alert but not alarmed.
Adopt A New Approach: Triage Your Clinics
It is most likely that for many of us, this will be our first ever, and hopefully our last pandemic – we are all grateful for that. However, it is likely that in the future, our businesses may need to undergo changes similar to those experienced throughout the pandemic. These may occur for various reasons – new staff joining, staff leaving, building renovations, to mention a few.
There may be times when we can’t run a ‘business as usual’ model, however, if there is one thing that this pandemic has taught me, it’s that we can prepare for these times in earnest. We need to think about potential future scenarios and what they may mean to running our practices – perhaps there are a few changes we can implement right now.
Drawing on those earlier examples, it’s clear that we should all adopt a protocol on ‘emergency consultations’. This could involve patients who have had surgery in the last three months, those patients with only one seeing eye, and those who have multiple ocular pathologies.
As an ophthalmologist with a large proportion of retinal patients, I tend to ensure that ‘only eye’ patients are seen no longer than two months apart. I also closely monitor their visual behaviour, sometimes via telehealth. If you see kids in your practice, this can almost all be done via telehealth. It often involves sending the parents a ‘vision pack’ with visual charts (picture or letter matching), so parents can be involved in helping to measure visual acuity, with your assistance, on telehealth.
Appointments for glaucoma reviews can often be postponed, however it would be useful to employ your administration staff to look through a patient list and call patients to ensure drug compliance, monitor adverse effects, and ensure they have recurrent scripts for their topical medications.
A system that works for you and your clinic will often be the best, but throwing some other ideas around early will help your planning.
Amidst it all, don’t forget about self-care. You and your team need to be at your best in order to offer optimal care to your patients. It is really important to take time out for group/team building sessions, regularly ‘check-in’ with each other, and ensure all your staff take timely leave.
Here’s to staying safe and well while going about our day-to-day business!
Dr Christolyn Rajakulenthiran FRANZCO, Int. FAAO, MMed & MPH, MBBS(Hons.) is a Melbourne trained and based ophthalmologist. Her special interest areas include cataract and laser-assisted cataract surgery and use of presbyopia correcting lenses including multifocal IOLs. Her extensive clinical experience and research in diabetic eye disease and other retinal vascular disease results in her overseeing the surgical care of many patients presenting with cataract and co-morbid disease. Dr Rajakulenthiran practises at Sunbury Eye Surgeons and Vision Eye Institute Camberwell and Coburg. She is an Honorary Senior Lecturer at The University of Melbourne, a RANZCO examiner and clinical tutor.
References
- Katon WJ, Lin EH, Von Korff M, et al: Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine 363:2611–2620, 2010.
- Fitzgerald L, Ferlie E, Hawkins C: Innovation in healthcare: how does credible evidence influence professionals? Health and Social Care in the Community 11:219–228, 2003.
- Kilbourne AM, Neumann MS, Pincus HA, et al: Implementing evidence-based interventions in health care: application of the replicating effective programs framework. Implementation Science 2:42, 2007.
- Jampol LM, Tauscher R, Schwarz HP. COVID-19, COVID-19 Vaccinations, and Subsequent Abnormalities in the Retina: Causation or Coincidence? JAMA Ophthalmol. 2021;139(10):1135–1136. doi:10.1001/ jamaophthalmol.2021.3483.
- Pichi F, Aljneibi S, Neri P, Hay S, Dackiw C, Ghazi NG. Association of ocular adverse events with inactivated COVID-19 vaccination in patients in Abu Dhabi. JAMA Ophthalmol. Published online September 2, 2021. doi:10.1001/jamaophthalmol.2021.3477.
