The American Academy of Ophthalmology (AAO) continues to update its guidance for ophthalmologists dealing with the COVID-19 pandemic. Most recently, AAO updated its guidance on vaccine and treatment options, including on the use of chloroquine and hydroxychloroquine. The updates come about a week after AAO decided to make the major recommendation urging its members to immediately stop routine surgical and in-office visits.
To learn more about the guidance, including what types of procedures ophthalmologists should be performing, Bryn Mawr Communications’ Executive Editor, News, Stephen Daily, spoke with Anne Coleman, MD, PhD, president of the American Academy of Ophthalmology on this week’s EyewireTV. Dr. Coleman is a professor of ophthalmology at the UCLA Stein Eye Institute, as well as a professor of epidemiology at the UCLA Fielding School of Public Health.
Here is the Q&A from the episode:
Stephen Daily: Dr. Coleman, thanks for joining us today during such an important period. Last week, the Academy released an alert to its members to immediately stop routine surgical and in office visits, urging ophthalmologists to only provide ‘urgent or emergent care.’ As you know, that is a bold directive which could have a large economic and social impact on practices. Can you talk a little bit about the process by which the Academy makes such a decision and what factors are considered when determining whether to issue such guidance?
Anne Coleman, MD, PhD: Decisions like this are made very carefully and very deliberately by the chief executive of the Academy and the board of trustees. One thing we did is we took in to account a lot of the evidence-based medicine that was related to this issue, in addition to expert opinions. Number one from the CDC. The CDC did issue a guidance, and guideline that ophthalmologist should do no more routine eye care because of the virus. In addition, we talked to public health officials and also ophthalmic experts in this area. We then took it to the American Academy of Ophthalmology board of trustees, and this is 23 members. Three of these members are public trustees and two of them are international trustees at large. Unanimously the group voted. So this was done with a lot of deliberation and a lot of thought because we are aware that it has impact—not just in academic centers and in hospital settings—but also in many of our members private practices.
Mr. Daily: There are a lot of ophthalmologists we’re talking to who have some really difficult decisions coming up. They’re trying to decide whether to completely close their practice, or perhaps to only perform certain types of procedures. In the correspondence that AAO released, you used the term “urgent or emergent care.” I was just wondering if you can clarify what types of services AAO would consider routine and what would be considered urgent or emergent?
Dr. Coleman: Routine care is something that you can delay for 2 to 3 months or more. So that’s what we consider routine. So a perfect example, ‘I’m a glaucoma specialist. (For) my patients that are glaucoma suspects, they would be able to be deferred until we have a better handle on this crisis. In addition, people with mild open-angle glaucoma could be deferred because that would be more routine and the assumption is that they’re under control.’ You do have cases of patients with glaucoma that are having progression of their disease, or we don’t have their eye pressures under control, or the patient feels like they’re getting worse. That would then be an urgent case, just like someone that’s having flashing lights and new onset of floaters. We worry about a retinal detachment, that would be urgent or emergent. Also, children that are born and the pediatricians are worried about congenital glaucoma, the eye is enlarged or the cornea is cloudy, that would be urgent and emergent for those children to be evaluated.
We have quite a few urgent and emergent cases in ophthalmology. One that I didn’t mention right there was macular degeneration with the neovascular type—people that need anti-VEGF injections to help maintain their vision. That would be urgent or emergent. So a good way to look at it is that any eye problem that can be delayed 2 to 3 months or more without risk of losing vision, that would be routine. All the others we’re going to have to see or someone will, because we don’t want patients going blind during this crisis. So that’s why we’re still seeing patients.
Mr. Daily: The Academy has been doing a really great job providing daily updates, and updating its guidance continuously over the past couple of weeks since the outbreak really started to expand. As of this filming, which is on Monday, March 23, what is the most up to date regulations that ophthalmologists and eye care professionals should be aware of?
Dr. Coleman: They should be going to aao.org to be looking at the guidelines and the updates. But they had two new updates today. One was on vaccines—that there currently is no vaccine available that’s safe and effective. There is a MRNA vaccine that’s being tested now at Kaiser Permanente Health Research Center in Seattle. So that’s started but that’s just started enrolling patients. For treatment, which is the other new update, the Academy did place an opinion that the Academy has no opinion about the current recommendations of using malarial medications such as chloroquine or hydroxychloroquine for treatment. One thing that is in the Academy’s update is the knowledge that a baseline retina exam is not needed if someone is put on this treatment by their primary care doctor or people treating them. The reason for that is it’s expected that the Plaquinel or the hydroxychloroquine or the chloroquine treatments will be short term, so they don’t need a baseline retina exam. But we don’t have an opinion about whether or not they should be used. That’s because there really are no randomized controlled trials right now proving that they’re safe and effective, and so it’s hard to recommend it.