Dr Sonal Tuli on How Ophthalmologists Are Optimizing Eye Care Amid the COVID-19 Pandemic

We're sending patients eye charts via email, doing zoom visits or telehealth visits by video or audio– it's been interesting to see that ophthalmologists can adapt to to this. I think that's going to be something that will stay on in some way, shape, or form after this pandemic subsides, said Sonal Tuli, MD, Clinical Spokesperson for the American Academy of Ophthalmology (AAO).

We're sending patients eye charts via email, doing zoom visits or telehealth visits by video or audio— it's been interesting to see that ophthalmologists can adapt to to this. I think that's going to be something that will stay on in some way, shape, or form after this pandemic subsides, said Sonal Tuli, MD, Clinical Spokesperson for the American Academy of Ophthalmology (AAO).


AJMC®: Hello, I’m Matthew Gavidia, here today on behalf of The American Journal of Managed Care. I’m welcoming Dr. Sonal Tuli, Clinical Spokesperson for the American Academy of Ophthalmology (AAO).

Dr Tuli: Hi, nice to meet you!

AJMC®: While COVID-19 is typically associated with cough or fever, evidence has shown that it can cause conjunctivitis and can be transmitted by aerosol contact with conjunctiva. Can you discuss what current recommendations AAO have provided ophthalmologists during the pandemic?

Dr Tuli: So what's interesting is that these are things that the American Academy of Ophthalmology says anyway—that it's a bad idea to touch your eyes, bad idea to touch things such as surfaces and then touch your eyes or rub your eyes. Those apply even in this time of COVID-19, and so even though we do talk about conjunctivitis with COVID-19, it's pretty rare. They have shown that the virus has been secreted in the tear film occasionally, but again, it's extremely rare and it's much more rare to get an infection through the conjunctiva too, but certainly can happen. So it's a good idea to make sure you wash your hands frequently, to not rub your eyes, not touch surfaces and then touch your eyes or touch your eyes and then touch surfaces because you can transmit any disease, not just COVID-19.

AJMC®: In patients with eye issues known to be caused by the virus, how can these symptoms be optimally treated in the home or through virtual care?

Dr Tuli: So actually, conjunctivitis is a perfect condition to be treated by telehealth because the treatment is usually supportive. So, in fact, I'm speaking to somebody this afternoon via telehealth who's got pinkeye, and we can send them an eye chart to examine their vision at home to make sure that's not affected. You can look at the patients and make sure that they don't have possio purulent discharge from the eye, but to advise the normal precautions, to maintain eye hygiene, to not touch their eyes, to not share towels. Essentially, it's supportive treatment. So, you would use artificial tears, cold compresses, things like that. So those are perfect examples of things you can treat via telehealth.

AJMC®: As the pandemic continues to surge nationwide, surgeries and treatments deemed non-essential have been either postponed or cancelled. Can you discuss what implications this may have for patients who require regular eye injections or surgery?

Dr Tuli: So, 1 of the things we're doing and what's become important as we see less patients is triaging patients appropriately. So figuring out which patients still need to be seen because they have problems that cannot be handled via telehealth or postponed for a later date. So, somebody who's got a bad eye infection, obviously you have to see those patients; but also determine which patients can then be postponed for 3 months or however long this takes, or handled via telehealth or some hybrid visits where they could come in.

We're doing a lot of hybrid visits where now patients coming in, they'll get testing done and leave. Then we can discuss their findings over telehealth or over the phone. So, figuring out how to best and optimally care for the patients is important. Certainly, it causes a lot of, I guess inconvenience to patients because somebody who's had surgery on 1 eye now needs the surgery on the other eye and is lopsided because they can't have it. Again, looking at those individually, patient by patient, to see which ones could be dangerous to leave for later and those you obviously have to do even if there's a worry about COVID-19. And then some that can be postponed and it's an inconvenience, but they are safe to be postponed for later. Figuring that out is the important part right now.

AJMC®: Have ophthalmologists voiced concerns about the lack of personal protective equipment (PPE)? And if so, how are these physicians adapting?

Dr Tuli: Initially there was quite a bit of concern because people were saving up the PPE as we were worried about supply chains and things like that. We were trying to keep the personal protective equipment for high risk cases only. Fortunately, now the supply chains have been established in a lot of cases, we've had donations from people, people have come up with innovative things; but initially everybody had put breath shields on their slit-lamp, so they had some sort of protection. We were telling all our patients not to speak when we were examining them, to wait until we were 3 feet or 6 feet away before we had a conversation. So, when we were examining, not to speak, obviously washing our hands before and after touching patients.

We also made these cool face shields that we could use to speak to the patients. Obviously you can't use those when you’re at the slit-lamp, but at least for the speaking part of it, we had protection for aerosols. And now we have started rolling out more of the personal protective equipment. So, people are wearing masks as they examine patients, which is some goggles and masks.

AJMC®: Malaria drugs chloroquine and hydroxychloroquine have both become available for use to treat COVID-19, however, they lack substantial evidence related to its efficacy. What should eye patients understand about these drugs?

Dr Tuli: Ophthalmologists are very familiar with these drugs, but especially with hydroxychloroquine, because we see patients who have been on these long term because they can cause complications with the eyes if they've been used long term. Fortunately, short-term use probably wouldn't cause any eye problems. So, patients who are taking these medications should obviously continue to take the medications.

At this point, evidence is still lacking as to whether or not these are beneficial, and whether the risks and the benefits, which 1 outweighs the other. There is some evidence that they do protect in early stages of the disease to prevent them from progressing. So, there are some studies that have shown that. There are other studies that have shown that they can cause some cardiac problems if taken in high doses or frequently. So, I think we're still waiting to hear the final determination. At this point. Patients who are on those for other reasons should continue to take those and hopefully, they'll have those available to take.

AJMC®: What innovations in eye care delivery have generated from the pandemic?

Dr Tuli: So I think of course telemedicine has been the biggest innovation. Traditionally, ophthalmologists thought, “oh my gosh, there's no way we can do telemedicine,” because we need to have the patient right here in front of us. Need, I guess, has been the mother of invention and so people have come up with all sorts of different ways that they can do telehealth visits even in ophthalmology. So, we're sending patients eye charts via email and then doing zoom visits or telehealth visits by video or audio.

There are various little devices that people have for self checking their vision—you can check color vision, you can have patients’ family members help to check how their eye moves or cover their eyes and test things. So, people have come up with some pretty innovative ways to have patients self-test and also to be able to see them via telephone encounters or via video encounters. So, it's been kind of interesting to see that ophthalmologists can adapt to this. So I think that's going to be something that probably will stay on in some way, shape, or form even after this, probably not to the extent that we're doing now, but that will be very interesting to see.

AJMC®: Do you have any other thoughts on how ophthalmologists can provide optimal care for patients?

Dr Tuli: So I think ophthalmologists need to for 1 thing, make sure their patients are safe, they themselves are safe, and obviously their staff are safe too, but also need to make sure that the patient's eye needs are taken care of. So that goes back to what I talked about, triaging patients correctly to figure out which patients can be postponed, sort of indefinitely without having them come to harm; but giving them the option of—I can still check in with you, we can do a telehealth visit, so patients don't feel abandoned during this time because they're worried too–I've got this eye problem, am I going to go blind because nobody's seeing me? And so letting patients know that we will always be there to see you for urgent problems; but also there are other things we can do to check in on you to make sure everything is okay.

Then seeing patients who do need to be seen but then taking precautions—telling patients not to talk while I'm examining you, make sure you keep the distance as long as possible, keeping the doors open so that the articles settle down properly, cleaning the rooms between patients, and things like that. Not doing unnecessary things, washing hands, making sure patients don't touch things after rubbing their eyes. So, taking the precautions, but I think with that we will all get through this, individualizing the care to patients because not everything is going to fit each patient; but I think as long as we have the right idea, and the patients understand where we're coming from, I think this will come to pass.

AJMC®: Thanks, Dr. Tuli.

Dr Tuli: Thank you.

AJMC®: To read updates on AAO guidelines for ophthalmologists, visit aao.org.

I’m Matthew Gavidia. Thanks for joining us!