Let's all keep each other safe

The coronavirus pandemic is creating unprecedented strains on health systems. At the same time, the eye care needs for people with pre-existing chronic diseases - including diabetic eye disease, glaucoma and macular disease - are unchanged.

Patients with chronic eye disease would do better with ongoing care, despite COVID-19. Three conditions cause 72% of irreversible, yet treatable, chronic blinding conditions: age-related macular degeneration (50%), glaucoma (12%) and diabetic retinopathy (10%). 

Patients with glaucoma and AMD are on average in their 70’s and 80’s, a known risk factor for an adverse outcome with COVID-19 ( ~ 15% mortality). Diabetes patients tend to be somewhat younger (typically in their 60s), but with diabetes a known significant risk factor, they fall into the high risk COVID-19 band also.

The benefits of actively managing chronic eye disease to avoid vision loss need to be balanced against the need to minimise the risks of attending for care in hospital outpatient settings and the need to prioritise dire emergency care against “routine” patients. 

We are in this for the long haul

Understandably, everyone is highly focused on the acute crisis. We see three phases of COVID-19 unfolding:
1. Acute phase – We are here! As you look around, you can see the crisis management with emergency shutdowns including cessation of elective activities, social distancing, limited ability to diagnose subclinical cases. Everyone is working very hard to modify and prepare to care for the acutely unwell. 

2. Subacute phase – as an antibody test becomes available and we can distinguish between people who have been infected and are now immune, we can progressively rebuild a partial workforce able to better care for the community.

3. Recovery phase – as we reach a critical mass for herd immunity and/or have better treatments and/or a vaccine, there will be an enormous phase of catch up - people who have stayed away from care or not been able to access it. I fear we will have a period of detecting unusually advanced disease (late stage cancer diagnoses, out of control diabetes, progressed renal failure, etc.), that will include vision loss that would have been better managed under normal circumstances. This may be a really messy time, considering how most public outpatients around the world were not adequately coping with demand before COVID-19.

Across each phase, telehealth can help. 

Acutely and sub-acutely, we can manage emergencies while keeping patients away from hospital settings and separate to health care workers to the greatest extent possible. 

In the recovery phase, we enable remote monitoring of patients by community-based private providers who can virtually report back to public services. Eye care appointments in the community require less travel - including public transport - for patients and are safer as patient flows can be managed to preserve social distancing. Most eye care professionals are appropriately equipped to conduct standard ophthalmic monitoring. They will likely have capacity. 

Teleophthalmology can increase safety in many ways - important as the world adjusts to life with COVID-19

The coming weeks will be very difficult - and important - for us all. First and foremost, let’s work together to look after ourselves, our carers, and our communities. 

Looking ahead, the implication of cancelling significant amounts of routine outpatient activity are going to be felt long after the crisis phase of COVID-19 has passed. There is an acute need to ensure that there are appropriate innovations in place, not just to relieve the burden of these appointments but to move them away from centralised sites where virally-infected patients are likely to be concentrated and instead to sites that are closer to and safer for patients. Doing so will ensure continuity of care, minimise risks for hospital staff and prevent unnecessary travel with associated risks for patients. It also prepares systems for the recovery phase,  post the peak of the epidemic, a time we are all looking forward to.