Restructuring emergency eye services during COVID-19 in a tertiary referral centre

The effectiveness of interventions for optometric referrals into the hospital eye service: A review

PURPOSE

Ophthalmic services are currently under considerable stress; in the UK, ophthalmology departments have the highest number of outpatient appointments of any department within the National Health Service. Recognising the need for intervention, several approaches have been trialled to tackle the high numbers of false-positive referrals initiated in primary care and seen face to face within the hospital eye service (HES). In this mixed-methods narrative synthesis, we explored interventions based on their clinical impact, cost and acceptability to determine whether they are clinically effective, safe and sustainable. A systematic literature search of PubMed, MEDLINE and CINAHL, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), was used to identify appropriate studies published between December 2001 and December 2022.

RECENT FINDINGS

A total of 55 studies were reviewed. Four main interventions were assessed, where two studies covered more than one type: training and guidelines (n = 8), referral filtering schemes (n = 32), asynchronous teleophthalmology (n = 13) and synchronous teleophthalmology (n = 5). All four approaches demonstrated effectiveness for reducing false-positive referrals to the HES. There was sufficient evidence for stakeholder acceptance and cost-effectiveness of referral filtering schemes; however, cost comparisons involved assumptions. Referral filtering and asynchronous teleophthalmology reported moderate levels of false-negative cases (2%-20%), defined as discharged patients requiring HES monitoring.

SUMMARY

The effectiveness of interventions varied depending on which outcome and stakeholder was considered. More studies are required to explore stakeholder opinions around all interventions. In order to maximise clinical safety, it may be appropriate to combine more than one approach, such as referral filtering schemes with virtual review of discharged patients to assess the rate of false-negative cases. The implementation of a successful intervention is more complex than a 'one-size-fits-all' approach and there is potential space for newer types of interventions, such as artificial intelligence clinical support systems within the referral pathway.

"Comparing outcomes of advanced nurse practitioners to ophthalmologists performing posterior YAG capsulotomy, a six-year study of 6308 eyes"

PURPOSE

To primarily report the baseline characteristics and visual acuity (VA) outcomes of advanced nurse practitioners (ANP) compared to ophthalmologists following YAG posterior capsulotomy (YAGPC). We secondarily looked to characterise the risk factors that lead to a repeated YAGPC.

METHOD

Retrospective consecutive case series of 6,308 eyes attending the Birmingham and Midlands Eye Centre.

RESULTS

ANPs performed 33.1% of YAGPC compared to 66.9% ophthalmologists. Compared to ophthalmologists, ANPs performed YAGPC in lower proportion of patients with ocular co-morbidities (p < 0.001) and had lower proportion of patients requiring further YAGPC compared to ophthalmologists (p < 0.001). Median pre, post-operative and LogMAR gain in VA of 0.48 (IQR 0.30-0.78), 0.18 (IQR 0.10-0.40) and 0.30 (0.08-0.48) LogMAR units, respectively. Multivariate regression showed that ANPs had a significantly lower rate of repeat YAGPC compared to ophthalmologists even when adjusting for age, ethnicity, training grade and ocular co-morbidities. No difference in visual outcomes was found between operator grade and ethnicity on multivariate analysis.

CONCLUSION

YAGPC leads to excellent visual outcomes. ANPs can deliver safe and effective YAGPC.

Changes to ophthalmic clinical care during the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

Given the impact that society as a whole, and medicine specifically, has experienced as a result of the COVID-19 pandemic, an examination of clinical care changes enacted in the field of ophthalmology is of interest to the specialty.

RECENT FINDINGS

In order to adapt to the reality of the COVID-19 pandemic, measures, such as broadening telehealth capabilities, adopting universal masking, careful sanitation procedures, applying virtual teaching in academic environments, and deferring elective surgeries were put in place. These were aimed at reducing person-to-person spread of SARS-CoV-2. Though best efforts were made at triaging ophthalmic emergencies during these times, unfortunate delays in care were observed in some circumstances. Finally, a prospective study interrogating the risk of spread at slit lamp distances for short periods of time was encouraging, suggesting low risk of transmissibility, though limited by a small case-positive sample size.

SUMMARY

Significant changes have been made in the design and delivery of ophthalmic care during the COVID-19 pandemic. Some of these, such as telemedicine, may provide value in a postpandemic world.

Public perceptions of eye symptoms and hospital services during the first UK lockdown of the COVID-19 pandemic: a web survey study

Objective

This study aimed to explore the British public’s healthcare-seeking beliefs concerning eye symptoms, and assess how the first COVID-19 lockdown influenced these.

Methods and analysis

An anonymous web-based survey was disseminated through mailing lists and social media between June and August 2020. The survey sought participants’ views on the severity and urgency of the need for medical review for four ophthalmic and two general medical scenarios on a five-point scale. Participants were asked to answer questions twice: once ignoring the COVID-19 pandemic, and once taking this into account, with additional questions asked to identify factors influencing the decision to seek medical attention and ward admission.

Results

A total of 402 participants completed the survey (mean age 61.6 years, 63.1% female and 87.7% of white ethnicity). Scores for symptom severity and urgency of medical review increased significantly with the severity of the clinical scenario (both p<0.001). However, participants gave significantly lower scores for the urgency of medical attention when accounting for the COVID-19 pandemic (compared with no pandemic) for all scenarios (all p<0.001). Younger age, greater deprivation and non-white ethnicity were correlated with a lower perception of seriousness and urgency of medical attention.

Conclusions

During the first UK lockdown of the COVID-19 pandemic, reduced urgency of medical review for ocular and systemic pathologies was reported in response to the pandemic, which represents a barrier to healthcare-seeking behaviour. This has the potential to critically delay medical review and timely management, negatively impacting patient outcomes.

The impact of the COVID-19 pandemic on microbial keratitis presentation patterns

BACKGROUND

Microbial keratitis (MK) is the most common non-surgical ophthalmic emergency, and can rapidly progress, causing irreversible sight-loss. This study explored whether the COVID-19 (C19) national lockdown impacted upon the clinical presentation and outcomes of MK at a UK tertiary-care centre.

METHODS

Medical records were retrospectively reviewed for all patients with presumed MK requiring corneal scrapes, presenting between 23rd March and 30th June in 2020 (Y2020), and the equivalent time windows in 2017, 2018 and 2019 (pre-C19).

RESULTS

In total, 181 and 49 patients presented during the pre-C19 and Y2020 periods, respectively. In Y2020, concurrent ocular trauma (16.3% vs. 5.5%, p = 0.030) and immunosuppression use (12.2% vs 1.7%, p = 0.004) were more prevalent. Despite proportionately fewer ward admissions during the pandemic (8.2% vs 32.6%, p<0.001), no differences were observed in baseline demographics; presenting visual acuity (VA; median 0.6 vs 0.6 LogMAR, p = 0.785); ulcer area (4.0 vs 3.0mm2, p = 0.520); or final VA (0.30 vs 0.30 LogMAR, p = 0.990). Whilst the overall rates of culture positivity were similar in Y2020 and pre-C19 (49.0% vs. 54.7%, p = 0.520), there were differences in the cultures isolated, with a lower rate of poly-microbial cultures in Y2020 (8.3% vs. 31.3%, p = 0.022).

CONCLUSIONS

Patient characteristics, MK severity and final visual outcomes did not appear to be affected in the first UK lockdown, despite fewer patients being admitted for care. Concurrent trauma and systemic immunosuppression use were greater than in previous years. The difference in spectra of isolated organisms may relate to behavioural changes, such as increased hand hygiene.

Digital Transformation in Ophthalmic Clinical Care During the COVID-19 Pandemic

ABSTRACT

COVID-19 has placed unprecedented pressure on health systems globally, whereas simultaneously stimulating unprecedented levels of transformation. Here, we review digital adoption that has taken place during the pandemic to drive improvements in ophthalmic clinical care, with a specific focus on out-of-hospital triage and services, clinical assessment, patient management, and use of electronic health records. We show that although there have been some successes, shortcomings in technology infrastructure prepandemic became only more apparent and consequential as COVID-19 progressed. Through our review, we emphasize the need for clinicians to better grasp and harness key technology trends such as telecommunications and artificial intelligence, so that they can effectively and safely shape clinical practice using these tools going forward.