By mid-March 2020, ophthalmology faced the highest decline of any medical or surgical discipline in the wake of the coronavirus disease 2019 (COVID-19) pandemic.1 Elective surgeries — including cataract removals — were halted. Research slowed, or stopped entirely. Some practitioners joined the frontline workers in emergency departments. 

The American Academy of Ophthalmology issued a statement on March 18, 2020, encouraging all care providers to immediately stop any treatment beyond urgent or emergent care. These orders contributed to a 79% reduction in care in the United States. After this statement was released, the Association of American Medical Colleges recommended that medical schools pause all medical student clinical rotations and suggested that students not be involved in any direct patient care.1 

But now that higher education is slowly returning, educators in medical schools face a unique challenge. They are tasked with keeping students as safe as possible while continuing to serve the public to the highest standards. It was incumbent upon these educators to create a system that kept professionals in contact with trainees, which they were able to accomplish by approaching this historic moment with scientific curiosity while creatively employing all the technology at their disposal. 

This is a review of the research issued throughout the academic literature on coping with the changes to ophthalmology, the resulting technological innovations that will be a part of practice for decades to come, and the logistics of how a team of ophthalmic instructors at the University of Minnesota overcame the many obstacles the pandemic has introduced.   


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Keeping in Contact

“During the time when there were no students allowed to come to campus, education didn’t stop. Many things changed, but education really did not stop,” explains Hossein Nazari, MD, a Vitreoretinal Surgeon and faculty member at the University of Minnesota’s Department of Ophthalmology and Visual Neurosciences. 

Like so many fields, restrictions around in-person activities necessitated ophthalmology departments to quickly move operations — from administrative tasks, educational meetings, and research — to the virtual space. 

“The pandemic has forced a rapid, and perhaps long overdue, reassessment of our approach to education and catapulted the use of technology to the forefront of our activities,” according to Columbia University Irving Medical Center researchers, in a Journal of Glaucoma editorial.2 

The New York-based practitioners say that the lockdown prompted many discussions on innovation in education, especially since many of them had more time on their hands because they could only treat urgent or emergent cases. Among the ideas that came out of their “new-found freedom and flexibility,” as the Journal of Glaucoma editorial puts it, were the 15- to 30-minute “eye-talks” that were mostly patient-focused and linked the scientific underpinnings to decisions about patient care. 2

“These informal discussions between residents and senior faculty members were initiated by trainees on single topics of their choice. In this reverse-classroom model, slide decks and reading materials were shared beforehand, and the ‘lecture’ time became focused on discussion and clinical application,” the piece explains. 2

Since there were so few patients during the first few months of the pandemic, group learning from an individual case benefitted all trainees instead of just one. Both faculty and residents reported that they enjoyed the interactive nature of the talks and were overall more engaged in the process. 

Dr. Sandra Montezuma leads medical student education in the Department of Ophthalmology at the University of Minnesota and reports similar success with facilitating a different style of discussion, a departure from the traditional lecture where students simply listen and absorb. 

“Zoom has opened the door to many things,” says Dr. Montezuma. “We’re doing what we call flip-flop lectures. I provide the students with a clinical case and they have to review it, then we discuss. It becomes very interactive, it’s not just me giving a talk.” 

Online meeting platforms, such as Zoom, have created more access points to information. With so many using these platforms, Dr. Montezuma says it will be easier for people to tune in and learn from home, something that she thinks is going to stay post pandemic. 

Virtual Visits

However, implementing virtual lectures and discussions, while critical, is the easy part, compared to the pandemic-era challenge of continuing to provide physicians-in-training the essential in-clinic experience that puts them in front of patients.

According to Dr. Montezuma, technology has served as a bridge here as well. 

With support from Dr. Nazari, she provided medical students with plastic, “dummy” eyes to take home and practice injections and procedures on. Other tactics included pointing students to mock examinations from the American Academy of Ophthalmology’s online resources where students could learn how to measure visual acuity and how to practice with a “patient” at home. Also, trainees shadowed attendees during virtual appointments with actual patients to learn how to perform examinations, and how to do it virtually — a skill that may prove more valuable now than ever. 

“While learning may be impacted by the currently limited nature of the virtual ocular examination and the level of patient facility with digital platforms, this is a chance for trainees to gain experience with telemedicine, which will undoubtedly play an increasingly relevant role in all of our careers,” the British Journal of Ophthalmology reports in a recent article, “This also represents an opportunity to evaluate our current systems and pinpoint where inefficiencies in workflow and disparities in care delivery may exist.” 3

According to a report published by the American Journal of Ophthalmology, patients are now actively looking for digital care. Before the pandemic hit Americans, 74% of patients were unaware of a telemedicine option. Now, some leading telehealth platforms are reporting patient visits have increased by 257% and 700%.4

The study authors report, “This crisis will likely spur innovation that will transform care delivery. For ophthalmology that could mean scalable and more accurate home testing. There may be improved near focus on smartphone cameras or attachments for self-photography. Remotely controlled slit-lamp devices, nonmydriatic fundus cameras, and optical coherence tomography machines may become more available in public areas.” 4

In fact, a study presented at this year’s American Academy of Ophthalmology virtual conference saw an investigative team from the Bascom Palmer Eye Institute at the University of Miami utilize a novel, real-time, remotely controlled slit lamp robot that permitted clinicians to evaluate patients’ anterior segment features completely remotely. That research showed parity between the technology and on-site evaluations.5  

Further research shows incorporating virtual postoperative protocols can be not only successful, but also even preferable for patients. A recent research study shows a path forward for retinal detachment patients to receive virtual follow up in some cases. Patients rated the virtual visits a 4.3 out of 5, and more than half said they would consider replacing an in-person follow-up appointment with telemedicine even after COVID-19 restrictions are lifted.6

Making The Most

Additionally, some new implications for research have arisen during the pandemic. 

For instance, patients with conditions such as macular degeneration, which often requires treatment with intraocular injections, have likely missed appointments. 

“For people who miss injections, we want to see the impact. We’ve never had the data. Now, we have it,” explains Dr. Montezuma. “Medical students can look at medical records from the time of quarantine when the patient missed the appointments to when the patient was able to come back. There are research opportunities if we look for them.” 

In addressing the pandemic itself, Dr. Nazari led a team of investigators tasked with examining whether the coronavirus could be detected in tears, potentially offering an alternative to current diagnostic tests. That team, which launched its research in the summer, was supported by the university’s CO:VID (Collaborative Outcomes: Visionary Innovation & Discovery) grants program, which aims to catalyze and energize small-scale research projects designed to address and mitigate the COVID-19 virus and its associated risks.

Ophthalmologists at Columbia University in New York cite that many research projects were adversely affected by the pandemic, if not suspended indefinitely. However, it has also shaped a new environment that has been more collaborative than ever. 2

“These virtual interactions fostered mentorship and the development of collaborative research projects throughout the department. With the ease of recording on online platforms, lectures across the New York metropolitan region are being uploaded to a collective, web-based platform, to be shared across institutions. This level of academic cooperation has never been so simple or rapidly adopted,” they wrote in the Journal of Glaucoma. 2

The pandemic has pushed educational programs and practitioners to approach things differently, but not without cost. 

“For trainees, the pandemic may bear multiple sources of apprehension, as they consider implications for their education, changes in examination scheduling and milestones, financial and employment concerns, and deferment of personal and professional plans,” reported the British Journal of Ophthalmology. “This may be compounded by fears of exposure for themselves and loved ones, mixed with anxiety around preparation and the challenging experience of caring for affected patients if redeployed.” 3

Drs. Montezuma and Nazari discussed ways to mitigate stress, from encouraging their students to take a walk while listening to lectures to participating in a cooking class to help relax and build community. But they know the impacts of the pandemic will be lasting. 

“Students want to interact with real patients. They want real encounters. And then there’s the stress of losing a job or finding any job, applying for residency or how to apply for medical school. These things are not easily measured, and the impact isn’t immediate,” says Dr. Nazari. “We, as an academy, have to think about these things. We have to come up with a way to measure it, see what the impact is and figure out how to address it.”

References

1. Quillen D, Siatkowski M, Feldon S. COVID-19 and the ophthalmology match. Ophthalmol Retina. Published online July 9, 2020.  doi:10.1016/j.ophtha.2020.07.012

2. Nanda T, Chen R, Cioffi G, Liebmann J. Academia in quarantine. J Glaucoma. 2020;29(9):723-725. doi:10.1097/IJG.0000000000001633.

3. Bakshi S, Ho A, Chodosh J, Fung A, Chan R, Ting D. Training in the year of the eye: the impact of the COVID-19 pandemic on ophthalmic education. Br J Ophthalmol. 2020;104(8):1181-1183. doi:10.1136/bjophthalmol-2020-316991

4. Saleem S, Pasquale L, Sidoti P, Tsai J. Virtual ophthalmology: telemedicine in a COVID-19 era. Am J Ophthalmol. 2020;216(8):237-242. doi:10.1016/j.ajo.2020.04.029.

5. Cabot F, Cavuoto K, Alfonso E, Yoo S, Parel J. Assessment of anterior segment features using a novel, real-time, remotely operated slit lamp robot. Presented at: American Academy of Ophthalmology 2020 Annual Meeting; November 13-15, 2020. Abstract PO222.

6. Shahid S, Anguita R, daCruz L. Telemedicine as a platform for postoperative consultations following vitrectomy for retinal detachment repair during the Covid-19 crisis: a patient satisfaction survey. Can J Ophthalmol. Published online December 7, 2020. doi:10.1016/j.jcjo.2020.11.011