Paul Rosen FRCS FRCOphth is a Consultant Ophthalmic Surgeon at the Oxford Eye Hospital and Chairman of the Trustees of ESCRS and a former President of ESCRS. Speaking to EuroTimes, Dr Rosen stressed the need for adaptability and new working practices and said residents had the opportunity for a new and very different form of training in these challenging times.
How is this situation affecting ophthalmology in the UK?
The UK Government has adopted a policy aimed at slowing the spread of the virus to protect the NHS and allow them to cope with those who are severely affected by the infection.
All routine clinical activity, outpatient clinics and surgery, has stopped. Certain things will continue for the moment, for example, emergency vitreoretinal surgery, and intravitreal injections for macular degeneration, but I suspect the latter may come to halt if the health service is overwhelmed.
It is extremely important to try and see the opportunities in this otherwise terrible situation. This includes people showing their leadership skills, working at the limits of their comfort zone and stretching their personal and clinical skills.
We have to look at our clinical practices and care pathways and challenge what has become established and adapt them for the current situation. For example do we need to see patients as frequently as we do, do we need to see them face to face or even at all? We have had to start telephone consultations, which you may think is not possible in ophthalmology, because of the lack of examination of the eye, but you can gain a lot of information from talking to the patient – we are going back to the basics of taking a history from the patient.
In these very difficult circumstances, everyone is having to make significant compromises and at the moment we can’t deliver the perfect, ideal care that we have all previously aspired to.
The effects of COVID – 19 will last many months, and we are initially planning for the next three months; the NHS has taken over a number of Private Hospitals initially for three months with an option to extend; the suspension of routine activity has no end date proposed.
People are now working from home as much as possible to avoid coming into the hospital and risk transmitting or catching COVID-19. But we’re in an a period of calm before the storm. When the storm hits, possibly this weekend in the UK, ophthalmologists will in addition to their own work , have to support those on the frontlines, in Intensive Care Units (ICU) , respiratory wards and accident and emergency departments. We’ve been asked what medical skills we have, which, if you’re a senior ophthalmologist, general medicine was a long time ago. The trainees who have done general medicine more recently, may be drafted into supporting the physicians and ICU and we will be running the eye department on a skeleton staff.
PPE, (Personal Protection Equipment) is a hot topic in the UK because of availability. Ophthalmologists are at increased risk because of the close proximity to patients during clinical examination and we are now demanding PPF3 masks etc. We are triaging people coming into the hospital, for the well-known features of fever, cough etc, but now ENT surgeons in the UK have identified anosmia as a potential initial feature.
What sort of measures have you been taking in terms social distancing and keeping a distance from staff?
It is quite difficult to maintain social distancing in the workplace, with staff and patients, in part due to the confines of the physical space in eye departments. We’re all wearing face masks in the clinics, with the level of protection dependent on the type of activity/intervention eg intravitreal injections, lasers, surgery.
Success in dealing with COVID-19 will depend on great teamwork – every member, from the most senior surgeon to the newest administrator has a vitally important role to play. Without the support of the ‘troops’ on the ground we will not achieve success.
What is the situation with research and training?
We have been told that we can’t submit new research proposals to the ethics committees or recruit or follow-up research patients. This is in part to reduce patient footfall in the hospital.
Routine training is no longer possible and all the Royal Colleges have cancelled the National Exams at least until September. It is important to emphasise that out of this disaster one can create opportunities and experiences which will be of lifelong value. Having to work in different circumstances, scenarios, and situations at the edge of your “comfort zone” makes you evaluate your clinical practice and attitudes, and makes you take decisions that will challenge you. Therefore formal training is on hold, but there is still learning and training to be had in abundance.
What are your concerns about the impact on patients who might not be able to get in for appointments?
In the Oxford Eye Hospital, we have triaged our clinics with all routine appointments deferred for four to six months. Urgent conditions are being seen, bearing in mind the risk to the patient, other patients, the general public and our staff. We have modified our post-op regime to reduce follow-up visits after surgery. The biggest problems are firstly the great unknown – we don’t know how long this is going to go on, and secondly if you’re cancelling thousands of appointments, there is the risk of losing patients completely, known as “lost to follow up”, resulting in permanent visual loss.
How do you see the future of ophthalmology in the UK after this?
Very busy. Once everything has settled down, which may be a long time, there’s going to be a huge backlog, which will need to be managed. Patients are going to have to make significant compromises, for example needing cataract surgery. The way services are delivered may be very different with more use of Artificial Intelligence (AI) for consultations, as a part of imaging for virtual clinics and remote consultations. This period of great uncertainty will, I hope, lead to the opportunity and stimulus for innovation.
Out of this adversity and tragedy we have to create opportunity, opportunity for people to excel, to show leadership, to innovate and to demonstrate what we can do for our fellow mankind.
Finally, a key to success in dealing with this terrible situation is communication; between individuals, within specialties, within Eye Hospitals, within Nations and between colleagues across the world. I would like to congratulate the ESCRS team for their major contribution to this key element.