In a very short space of time we have plunged into the unknown. Overnight our daily vocabulary has transformed to include Covid-19, PPE, ‘flattening the curve’, infection spikes, contamination, lockdown, quarantine… and more. Ophthalmology and optometry are classified as essential services, but what does that mean for clinicians and patients?
Safe practice guidelines
Guidelines emerged quickly about how to approach this unfamiliar territory, with all the eye health representative bodies issuing safe practice protocols for us to adhere to. The underlying message was and still is we are available to help others in acute need but must maintain safe practice.
On Friday 27 March, the Royal Australia and New Zealand College of Ophthalmology (RANZCO) released a set of subspecialty specific guidelines splitting patients into three categories: 1) those with acute conditions that require care within two weeks; 2) those with moderate conditions that can be managed with telemedicine and reviewed in three months; and 3) everyone else with non-urgent conditions who can be seen after four months. Acute cases falling into category one included patients requiring regular anti-VEGF treatments or post-operative care, or those with sudden loss of vision, eye infections, uveitis and trauma. So, with the number of do-it-yourself projects exploding exponentially during lockdown, those patients on the receiving end of a misfired nail gun were still being cared for!
The effect on private and public eye care services?
In the lead up to the Level 4 lockdown, each practice had to make a decision about whether they would open their doors to patients. Dr Richard Hart of City Eye Specialists, Auckland said, “We are seeing a severe reduction in the number of patients and a corresponding reduction in revenue during the lockdown period because private ophthalmology practices predominantly provide elective consultations and services.”
In the public sector, effects were similar, with all elective clinics and surgeries cancelled.
Running a clinic during lockdown
A study published on 10 March in the Annals of Internal Medicine found that the mean incubation period for SARS-CoV-2 is five to seven days, while emerging research indicates SARS-CoV-2 can survive 24 hours on cardboard and two to three days on plastic and stainless steel (see story p8).
At City Eye Specialists, patients were triaged on the phone by medical staff and then asked to wait in their car upon arrival. When social distancing wasn’t an option, City Eye installed slit lamp guards to limit contamination.
Personal protective equipment (PPE) was advised when seeing patients who are at risk of Covid-19 exposure and should be seen in hospital.
Since plunging into Level 4 restrictions, we have embraced the lockdown and consequently business is quiet. We have scrambled to obtain adequate masks, gloves, scrubs, gowns, alcohol wipes and slit lamp shields as we eagerly awaited positive news the country has ‘flattened the curve’. But what does the new business model look like as we clamber out of Level 4 and into Level 3 and beyond?
Level 3 still requires people to work from home where possible. Telemedicine should be the first point of contact and https://doxy.me appears to be the platform of choice for health sector clinics for secure, free online consultations. We all still need to adhere to social distancing, which will mean longer appointment times to maintain an empty waiting room, and a contact tracing log must be kept in all practices.
“RANZCO and Ophthalmology New Zealand (ONZ) have put together guidelines in agreement with the DHBs that safe resumption of elective services is both appropriate and desirable,” said Dr Hart. “Given the risks associated with Covid-19 are reducing and the ever-increasing numbers of patients with eye disease are awaiting treatment for their conditions, it is becoming essential that safe practice resumes.”
At the time of going to press, ONZ and RANZCO had also just issued a joint statement to the Ministry of Health requesting ophthalmologists be permitted to increase clinical activities from Tuesday 28 April to include routine patients, not just acute, whilst conducting safe physical distancing, as well as resume elective surgery. Immunocompromised patients, however, and those over 70 will still need to self-isolate at home, and anyone who’s unwell should not attend appointments.
When we look at other countries tracking ahead of us in the war against Covid-19, New Zealand still has a long way to go. Our new normal will be social distancing with protection and increased disinfection protocols. Surgery will continue to be limited, likely resulting in a huge backlog in the public sector. Health workers will always be in demand but there remains no guarantees when normality will be restored.
In this uncertain time, we are unsure of the long-term repercussions of the lockdown. Our public hospitals already practice at capacity and have significant waiting lists for elective eye surgeries. We may see ophthalmology patients from the public hospital system being triaged into the private sector to cope with the backlog.
We fill a valuable role in helping our patients in whatever way we can. Staying safe and protected is of primary importance for both patients and clinicians.
Louise Wood is a therapeutically qualified optometrist working at City Eye Specialists in Auckland, New Zealand.
This article is an updated version of an earlier article distributed online in early April