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Glaucoma Practice in the COVID-19 Era

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■ A timely article by Jeffrey M. Liebmann, MD, of the Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, was recently published in the Journal of Glaucoma. In his editorial, Dr. Liebmann asserts that changes to the way glaucoma care will be delivered in the postpandemic era will be all encompassing. Telemedicine applications will have an immediate major role, “but the applications of teleophthalmology, while potentially impactful for data and image transfer, is not well suited at the present time for a detailed examination of intraocular structures and surgery,” he writes. “Since we will still need to physically (not virtually) examine patients in our offices or clinic settings, creativity is required as we rethink our care models, beginning from the first point of patient contact to the moment the patient leaves our offices.”

Dr. Liebmann says a number of changes are already being implemented, but more are still to come, including meticulous cleaning of slit lamps after each patient, improved barriers between the patient and the practitioner, mandatory masking for patient and practitioner, and increased use of gloves.

Use of reusable Goldmann tonometers must be studied, he advises, and more attention will be focused on disposable tonometers that have been thoroughly tested for accuracy and correlation with Goldmann tonometry.

“Some institutions may require the use of single-use gonioscopy, laser and hand-held indirect lenses. Pneumotonometers and air-puff tonometry, both of which can presumably aerosolize the tear film and viral particles, may need to be avoided. New techniques for the sterilization of non-disposable equipment require elucidation and our most basic interventions and handling of instrumentation reinvented.”

Dr. Liebmann posits that practice costs will rise, particularly in the areas of personal protective equipment and disposable equipment. Patient flow will be affected to maintain physical distancing of staff and patients.

“Certain staff will be redeployed to new tasks, such as pre-screening patients for COVID-19 symptoms before they even enter our offices. Efforts at curtailing waiting times and lines will become paramount and enforced hand sanitizing at check-in and check-out will become routine. Waiting rooms should be rearranged and reduced in capacity. Accompanying persons may be discouraged or be limited to one.”

Some patients may be required to wait in their cars and be sent a text message when they can enter the office. Trabeculectomy may be replaced in many cases by less invasive procedures with less intensive postoperative care, such as minimally invasive surgery and tube shunts. The use of diagnostic equipment for glaucoma care is of particular concern to Dr. Liebmann.

“Imaging devices will necessitate careful cleaning between patients and protocols updated to protect staff, patients, and equipment. Automated perimetry needs to be completely revisited, since the perimetry bowl is not only a potential source of viral spread, but also notoriously difficult to clean without damage.”

He urges clinicians and researchers to develop novel methods of diagnosing and monitoring glaucoma patients in the event that automated perimetry remains unsafe or is available for only a select few patients.

Office hours will also need to change. With a backlog of delayed patient visits on the horizon, “new safety protocols and physical distancing that will be required are incompatible with our present workflows. Our offices will remain open for far greater periods of time, by expanding or initiating evening and weekend hours and staggering physician and staff work schedules.

“Describing the issues raised here, and others yet to be identified, are but the first steps in dealing with our new eye care environment in a sensitive, thoughtful, and constructive way.”

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