July 29, 2020
Vision Problems have become part of COVID-19’s collateral damage. Delayed care due to the pandemic threatens to leave ophthalmology patients in the dark.
By Katja Ridderbusch
The coronavirus tidal wave has made Dr. Ruth Williams rethink what she considers essential and elective care in her field of ophthalmology – which cases constitute an emergency, and which count as routine.
When her office opened up after shutting down earlier this year, she was "amazed to see how many people had developed serious eye problems," says Williams, a glaucoma specialist at the Wheaton Eye Clinic in the Chicago suburbs and a clinical spokesperson for the American Academy of Ophthalmology.
Across most medical specialties, doctors have noted a sharp drop in care during the pandemic, as nonessential visits and procedures were curbed and people feared a medical appointment could lead to coronavirus infection. Data and anecdotal reports from earlier in the pandemic pointed to plummeting hospital admissions for serious issues such as heart attack and stroke.
But it wasn't just the more dramatic specialties where medical professionals witnessed the collateral damage from COVID, and ophthalmology has been hit particularly hard. In early April, eye doctors had experienced a drop in patient visits of nearly 80%, according to data published by The Commonwealth Fund – the largest loss among all specialties shown.
A separate analysis across more than 200 hospitals in 40 states by Strata Decision, a cloud-based analytics platform, showed that patient encounters for cataracts were down 97% during a two-week period in March and April compared with the same period last year. Encounters for glaucoma, which can cause blindness, were down 88%.
"In ophthalmology, the decision to skip or delay treatment rarely results in a life-or-death type of scenario," says Dr. Kenneth Neufeld, an ophthalmologist and oculoplastic surgeon at the Thomas Eye Group in the Atlanta area. "But it can certainly lead to permanent vision damage or even blindness."
Eye doctors in most states saw patients for emergencies or urgent treatments during the shutdown and closed their offices to routine care. But for many patients, the line wasn't clearly marked. Williams, for example, was particularly concerned about patients with newly diagnosed, severe or unstable glaucoma.
Glaucoma is often referred to as "the silent killer of vision" because patients have few symptoms as the disease progresses. The most common sign of glaucoma is high eye pressure that over time damages the optic nerve and leads to a loss of peripheral vision.
It's a journey that Myra, who lives in Monterey, California, is sadly familiar with. The 56-year-old, who does not want her full name published for privacy reasons, has glaucoma in both eyes. A few years ago, her doctor placed silicone shunts in each of them to help drain fluid and relieve pressure, and she uses eye drops twice a day. Myra is also dealing with stage 4 breast cancer – for the past eight years, she's received chemotherapy every four weeks.
When COVID hit, Myra decided to skip the appointments with her eye doctor, whose office is in San Francisco, about two hours away. "My immune system is weak, and I was terrified to contract COVID," she says. She also couldn't find anyone to drive her, she adds, and didn't want to take public transportation.
Then in May, Myra's right eye started to feel "somewhat gummy," and she noticed her night vision was almost gone. Once she went back to see her specialist in mid-July, he confirmed what she'd suspected: Her vision had decreased. She now takes additional medication and may have to undergo laser surgery. It's unclear if her eyesight will ever be back to where it was before the pandemic.
"I feel guilty," Myra concedes, "and I think over and over, 'Should I have pushed myself harder to fight my fears?'"
Williams says that unfortunately, "glaucoma is often considered non-emergent." One of the painful reminders of the COVID shutdown was that "this is a chronic disease, and a chronic disease needs constant management and care."
Other examples of chronic eye conditions are retinal diseases, such as diabetic eye disease and macular degeneration – two leading causes of blindness in the U.S. For certain forms of these conditions, patients receive injections into the eye, typically every four to six weeks.
"We know that delays to get patients in for treatment did impact their vision in a measurable way," says Dr. Timothy Murray, a retina specialist and ocular oncologist in Miami and president of the American Society of Retina Specialists. He adds that eye scans, called OCTs, clearly show that the longer treatment is delayed, the more a patient's vision declines.
One of Murray's patients is a 73-year-old woman who lives in a nursing home. She previously lost one eye and suffers from wet macular degeneration – a particularly severe from of the disease – in the other. Her family decided not to bring her in for treatment during the shutdown. When she finally visited her doctor after a break of more than three months, she was legally blind.
Today, her vision has recovered some, "but it's uncertain whether she will have permanent damage because of the delay," Murray says.
In addition to chronic eye conditions, there are also eye emergencies for which patients should seek immediate medical care – even as the coronavirus pandemic peaks, says Dr. Alan Kozarsky, an ophthalmologist and eye surgeon at Eye Consultants of Atlanta.
"Any new or substantial change in vision should be a warning sign," he says, such as blurry vision, eye pain or a sudden decrease in sight. These symptoms can be the result of problems like retinal tears and retinal detachments; eye strokes, which occur when a blood clot blocks an artery in the retina; or eye infections – all of which can lead to scarring, permanent damage or complete vision loss.
Kozarsky has a patient who suffers from an inflammatory neurological disorder that requires strong medications. During the shutdown, the patient developed an infection of an oil-producing gland in the eyelid. It's a condition that can normally be treated with warm compresses and over-the-counter ointments. But Kozarsky's patient developed an abscess in his eyelid, and the physician had to bring the man in to drain the abscess.
Had the patient not contacted the office, "the infection could have moved to other parts of the eye and into the eye socket," Kozarsky says. "And from there, it could have become a systemic infection" with a potentially deadly outcome.
Other eye emergencies include trauma and cancer. Neufeld, the reconstructive eye surgeon in the Atlanta area, says he treated several patients with eye socket fractures during the shutdown. One needed surgery after a bad fall, but because the clinic's outpatient surgery center was closed, Neufeld had to take the patient to a local hospital that let him operate.
"Some orbital fractures must be dealt with urgently," he says. "Otherwise, there could be irreversible damage to the muscles around the eye," resulting in double vision, misalignment of the eyes or vision loss.
Neufeld also performed some reconstructive procedures during the pandemic for patients who had previous skin cancer surgery around the eyes. "These surgeries have to be done in a timely manner," he explains, as the initial cancer removal often "leaves the patient susceptible to infection, scarring and disfigurement."
Neufeld says it's difficult to know exactly how delaying treatment impacts longer-term outcomes in eye care: "But in the case of cancers in or around the eyes, it is pretty clear that the longer you wait, the larger the growth and the more advanced the disease becomes" – and the more involved the treatment is going to be.
Since states started reopening – a start-and-stop process in many places – doctors' offices have adopted new protocols to keep patients and staff safe. They include removing furniture in the waiting room to support social distancing, installing plexiglass barriers, performing temperature checks and mandating face masks.
Many eye doctors – just like dental providers and ear, nose and throat specialists – are wearing N95 respirators, goggles or face shields. After all, Kozarsky says, "when we perform an eye exam with a slit lamp or an ophthalmoscope, we're only inches away from the patient's face."
Also, pink eye has been reported as a symptom in some COVID-19 patients, which makes implementing rigorous safety protocols an even higher priority for eye care providers.
Kozarsky insists the new practice environment is even better for patients and staff now than it was before the pandemic. "We've learned the dance," he adds. "We've upped our game." He, as have most of his colleagues across the country, has resumed operating.
And even with the new surge in coronavirus cases rippling through the South and West, most eye doctors do not plan to shutter their offices again, glaucoma specialist Williams says.
"We've figured out how to safely practice medicine in the era of COVID."
© U.S. News & World Report / Katja Ridderbusch