On the front lines in the

Retina in the pandemic

Schepens Lecture describes a subspecialty overcoming multiple challenges. Howard Larkin reports

For Julia A Haller MD, the relentless march of COVID-19 down the eastern seaboard of the United States in the early days of the pandemic brought to mind Winston Churchill and the London blitz as described by Erik Larson in “The Splendid and the Vile.”

“It felt as if there were uncanny parallels between the unrelenting bombardment of London in the 1940s and the onslaught of coronavirus. Shops were shuttered, traffic was absent and we were facing a foe as menacing as any squadron of approaching Nazi Messerschmitts. The COVID blitz was upon us,” said Dr Haller in the Charles L Schepens lecture at AAO 2020 Virtual Retina Subspecialty Day. In addition to his transformational contributions to vitreoretinal surgery, Dr Schepens was himself a resistance fighter who helped dozens of refugees escape during the second world war, she noted.

“We found ourselves in a different but very real war, the COVID-19 pandemic, in which our field of retina has stood on the front lines of battle fighting blindness,” said Dr Haller, who is ophthalmologistin-chief at Wills Eye Hospital and chair and professor of ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University, both in Philadelphia, USA. As to her own role in her subspecialty’s response to the pandemic, Dr Haller quoted Churchill, who in 1954 said: “It was the nation that had the lion’s heart. I had the luck to be called upon to give the roar.”

Dr Haller detailed Wills’ response to the pandemic as an example of the order of battle.

“We closed our ambulatory surgery network, funnelled all entrants into one access point at Wills, created new signage, posted encouraging safety messages and informational videos online, and conducted a warp-speed makeover, with hand sanitising and screening at the entrance, masking for one and all, distanced standing and seating, even an elevator attendant who wiped down the buttons with disinfectant and warmly welcomed our patients to their allotted spots.”

Overall, ophthalmology was the medical specialty most affected by limiting care to urgent and emergency only, Dr Haller noted. Surgery volumes plummeted 81% with the nadir in April and mid-May, followed by an upturn in June and July, returning to normal

It felt as if there were uncanny parallels between the unrelenting bombardment of London in the 1940s and the onslaught of coronavirus

Julia A Haller MD

volumes in October. Retinal surgeries also declined but accounted for more than their normal proportion during the downturn.

Wills’ scholarship also continued, with the pandemic itself a major new research focus, Dr Haller said. Among the topics were a study of how academic and private practices across the USA responded to requests for appointments for refraction, cataract evaluation and posterior vitreous detachment during the first viral wave as of 30 April 2020.

“They found resounding compliance with AAO guidelines both for types of care and COVID safety screening.” (Starr MR et al. JAMA Ophthalmol. 2020;138:981-988.)

Remote patient care technology also flourished. “We used the pandemic to permanently expand our portfolio of telemedical solutions. As our oncology service, led by Dr Carol Shields, put it, ‘Cancer never stops and neither do we,’” Dr Haller said.

Using a hybrid model, the Wills oncology service opened testing sites with telemedical review and consultation. In the Emergency Department, analysis of a remote phone-triage system for evaluating eye problems found that it significantly improved the accuracy of diagnosis for sight- and life-threatening emergencies (Deaner JD et al. Ophthalmology. 2020 Jul 27. Epub ahead of print).

Yet another Wills study found that patients seen for emergency problems during the stay-at-home orders were more likely to lack insurance, travel farther to seek care and have a delay in presentation, Dr Haller reported.

“Truly, our patients faced a host of new challenges in this pandemic.” (Wu C et al. Curr Opin Ophthalmol. 2020 Sep;31(5):423-426.)

Analysis of more than 2 million retina patient records found that the changes Wills experienced were widespread across the USA, Dr Haller said. Retinal outpatient visits, new patient visits, intravitreal antiVEGF injections and imaging declined in

A patient receiving intravitreal injections with a surgical mask taped to his face

the early stages of the pandemic, though injections declined less than office visits (Xu D et al. Curr Opin Ophthalmol. 2020 Sep;31(5):427-434).

Through October, new patient visits nationally were affected more severely than existing patient visits. Moreover, mean visual acuity was reduced for new patients in the COVID era compared with before. Similarly, due to treatment delays, detached retinas treated at Wills were more likely to present macula-off and with primary PVR during the pandemic than in the year before (Patel LG et al. Ophthalmology 2020 Oct 13. Epub ahead of print).

Training and continuing education went online as well, resulting in an actual increase in attendance at many retina conferences, Dr Haller said. Clinical trials also have rebounded following a drop off in the early pandemic.

“Retina has risen to the challenges to every aspect of our mission with leadership and courage … Good job, Retina, in this pandemic. Keep on roaring!” Dr Haller concluded.