UK ophthalmologists are pulling together - EuroTimes

UK ophthalmologists are pulling together

Philip Bloom

Philip Bloom is President of the UK & Ireland Society of Cataract & Refractive Surgeons (UKISCRS), Chair of the International Glaucoma Association (IGA) and trustee and board member of the Royal Society of Medicine (RSM) and has been involved in the planning to deal with the impact and fallout of the COVID-19 crisis. He told EuroTimes about the present situation as he sees it, and what may follow in the longer term.

Could you tell me a bit about your experience of working with the impact of the coronavirus?
I work in two hospitals, one of which is a district General Hospital, and one of which is a teaching hospital, and they’ve been affected to varying degrees. The planning has been going on for a long time and involved the pretty rapid shutdown of all elective activity, for a variety of different reasons, to reduce the footfall into the hospital, so that there was a reduced risk of transmission generally, but also because people with glaucoma and other eye conditions tend to be elderly and we’re putting them at more risk bringing them in. So as of about two weeks ago, all routine cataract surgery stopped.

But I also deal with glaucoma and that’s an issue, so very rapidly we got together – I’m the chairman of the International Glaucoma Association, and we have an organisation called UKEGS, the UK and Eire Glaucoma Society. and we have a quite an active group and we very rapidly adopted a set of guidelines whereby we could stratify patients according to their risk of sight loss based on various criteria. Thankfully the two hospitals I work at, we already risk-stratify in terms of ensuring that patients’ follow-ups are not postponed. They’re stratified broadly into three categories – red, which is high risk, amber, which is medium risk and green, which is low risk. With almost immediate effect, low-risk patients have been pushed by anywhere between three and six months. We made the proviso that as long as their appointment hasn’t already been moved or cancelled and therefore that they’re being followed up with the appropriate urgency. The medium-risk patients, we’re inspecting on a case-by-case basis, and the high-risk patients we are still bringing in if we think they need to be.

The clinics are still being manned by doctors, but we’re trying to phone all patients and have a telephone consultation. So, we’re asking them about visual symptoms. The problem with glaucoma of course, is that it is asymptomatic. So, you can’t really assess people’s progression according to any visual symptoms they may have. There is lots that you can do on the phone actually, and even in video consultations. The hospital has very rapidly employed platforms like Zoom, Microsoft Teams and Adobe meeting software. So, we have the option of either chatting to patient by phone or by video. Again, for non-glaucoma conditions, external eye conditions, there are some things that you can see on video. obviously, they’re not proper slit lamps, but there are things you can pick up so we endeavour to speak to all patients. And we all know that glaucoma is a slowly progressive condition and so a lot of what people need is reassurance, we can reassure you that your sight is at no risk if you delay your appointment by three months. And patients do need to hear that. Thankfully, the hospitals I work at, the vast majority of notes are electronic. So that’s a very fortunate position to be in because we can just call them up on the system and just sit at a terminal, either at home because, we’ve very rapidly expanded our remote working base or by going into hospital working from the terminal there, which again is not ideal because we want to reduce the footfall.

I work at a big hospital that’s got an A&E department and that A&E department is open for emergencies and urgent cases. And both of the hospitals that I’m working in are still able to do emergency surgery. The definition is – the hospitals initially would allow operations for life or limb, but we very rapidly got them to agree that any permanent sensory disability, would also be treated in the same way as loss of limb. So, any, condition that would lead to a permanent loss of vision. So cataract, we know causes temporary loss of vision but once you take it out the vision’s just as good as it would have been. Glaucoma surgery, if it’s deemed to be high risk, is still going ahead, as is retinal detachment surgery, as is treatment for macular degeneration, etc. But we do have to examine things on a case-by-case basis. We have stratified all the surgical patients that we have on our waiting list, and we ordered them according to the risk of delay and over the last few weeks we’ve been doing large numbers of glaucoma lists in order to clear the backlog because we know that although their risk of vision loss may not be bad this week, in a month or two, they may have some issues, especially if the pressures are very high. For example, I did two trabeculectomies yesterday on patients with pressures in the high 40s, which is very, very high. We are now doing much more complex surgery, but all together and then I think there’s a reason to do that, because there’s a good chance, when the real tsunami hits us, that staff will be sick. facilities will be less able to be kept open properly.

So what we’re doing is clearing the backlog of all the urgent stuff now, so that we can still keep the doors open as time goes on, by which I mean we hope to continue to be able to offer service to a patient with a retinal detachment, who, we know if they don’t have that operation within a day or two, and that is both for patients who do not have coronavirus and of course, the nightmare scenario is if someone has an urgent medical condition and they have an infection, the coronavirus infection. We have eventualities in place to meet those scenarios

There’s a lot of concern about PPE, personal protective equipment, but equally we have to differentiate between the evidence base and the need to reassure patients that we are treating them in a clean manner. And staff do want to be reassured that they’re not being put in the way of harm. There are reports in the papers that some junior doctors have suggested that they’ve been treated as cannon fodder. Personally, I don’t believe that’s true, but I think it’s very unfortunate if anyone feels that they’re in a situation which is outside their comfort zone. And I personally think that if you want to wear a mask when you’re examining a patient, I think you should be given a mask and be able to wear it. The problem is of course, if everyone wears a mask for every examination, we will very quickly run out. So, I think it’s not an entirely straightforward argument. But at the moment, it appears that the government is acting to clear the backlog of equipment so that people can feel protected as well as be protected.

You mentioned junior doctors. What is the situation with residents and trainees for you?
Our residents this week have been off their general duties because they’re being trained online, being given training for what they might expect when they go to the general ward. Again, that’s all part of the plan. Because the junior doctors have done general medicine much more recently than the more senior doctors. So that makes sense to get them along first. And so, what’s being done is they’re being given some online training to refresh their skills and knowledge and both about general conditions but also about COVID. So, at the moment, the services on the front line are being provided by consultants, and in some cases by the senior fellows. But I think that’s entirely appropriate. And I’m sure that in line with what’s been happening in other parts of Europe, we, as eye surgeons, will, in some locations and in some instances, be called to do some medical duties ourselves, but I think most of us are prepared to do so, as long as you don’t have underlying health issue that put us at risk – of course age is one of those, but thankfully, there aren’t many people over 70 who are still working regularly. And I know that people between 60 and 70 are at a slightly increased risk.

But I think what I think will be interesting to speculate is the extent of asymptomatic infection. There’s a chance that many more of us have been infected and recovered without much in the way of symptoms than we imagined. At the moment, we have no junior doctors and I don’t think we can get them back anytime soon. The ones that we do have are still manning emergency services on the front line, but I think those will be going soon and we’ll be looking after our very busy, normally very busy casualty departments as consultants pretty soon.

How do you see the future of ophthalmology? You’ve had to postpone a lot of things, what do you see happening down the line?
When this eventually lifts, there’s going to be a huge backlog of patients and those will be all the elective conditions, so there’ll be a big backlog of cataracts to be done. But equally, in my other specialty of glaucoma, there’ll be a big backlog of glaucoma follow-up. And the fact that the follow-up has been postponed by a certain period of time makes them a bit more urgent to see. So that will be the phase two if you like of the conundrum, how do you manage the inevitable tidal wave of catch-up that’s going to have to be played? And I think we can only guess at how that’s going to play out, really. I suspect the health service will take years to recover fully and will require significant extra funding to allow it to do so. But I think that’s been pretty much accepted. I think the government is being pretty smart about the need to invest and hopefully that will continue. it remains to be seen, but I hope so.

I think that once we’ve got reliable antibody tests that allow us to know if someone’s genuinely at risk of infection, that will make staffing so much easier because of course, people who are self-isolating, a lot of them are doing so for entirely understandable and very important reasons, but may be doing so unnecessarily, because they may think that they have been exposed but haven’t been. So I think once we have a reliable antibody test, and once testing is much more widespread then it’s a no brainer to understand that the planning of health services is going to be a lot easier. Now, there’s a possibility if anyone has to self-quarantine once or even twice? And then has the infection, people might be off work for six weeks, as opposed to knowing that you definitely have it. We might be able to get the window of inactivity of our staff down to two weeks, which will make it much easier to plan the delivery of services if that was the case.

Do you have any kind of message for your colleagues both in the UK and abroad?
It’s difficult to come up with inspirational messages that haven’t already been made. I would just say, clearly, we’ll get through this, we need to support each other, we need to work in teams and not have a short-term view. I think we all have to take a long-term view. I think what’s interesting is that some of the some of the messages that have gone out to our patients have included statements like for example, ‘we’re sure that you understand that there’s a possibility that some patients may lose some vision as a result of this’. Now, if we had said that three months ago, in reaction to any other occurrence, you know, a funding crisis, a governmental issue, people would have been up in arms, but it’s extraordinary to me how people are pragmatic and clearly have a sense of proportion about it. I think the great public understand that there is a threat to their life, and there is a threat, for some of them, to their sight. But I think people are willing to put up with those risks in an extraordinarily generous way now that the whole country is very much pulling together in a way that we might have thought was unlikely in the past. I think that it’s encouraging how people are working together, pulling together and long may that continue.

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