Cynthia Matossian, MD, FACS

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Ophthalmology Times®
	
	These are challenging times for all of us. As a physician with offices in New Jersey and Pennsylvania, we had to close our practice and surgery center early on.

Most of our staff has been furloughed. I am still seeing urgent and emergent situations (although those have been relatively few). However, we are now offering telemedicine consultations on a regular basis. 
	
	

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 patients whose appointments were either cancelled during the shutdown or are upcoming to offer a telemedicine option via Zoom videoconference.

In one day, I had 11 telemedicine consultations. The focus of the “visit” is a bit less about the physical exam (since our abilities there are limited) and more about symptoms and compliance with their treatment regimen.

Patients have been appreciative of our telehealth services.

Here are three key lessons from this experience so far:

In talking with patients one on one, I’m discovering that they are doing a lot of things wrong, such as taking their omega-3 fatty acid supplements erratically or forgetting to take them with a meal.
	
	They may be using their

 drops (Restasis, Allergan; Cequa, Sun Ophthalmics; or Xiidra, Novartis) once per day or on an “as needed” basis rather than twice daily as prescribed.

People only absorb a fraction of what we say during an in-person office exam, so I’m realizing that we need to give instructions in many different formats: in writing with pictures or images, and underscore key messages more often-perhaps, even after patients leave the office, as follow-up, touch-base reinforcements.
	
	

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Unfortunately, for many patients, binge-watching streaming TV and spending a lot of time on their devices at home is likely worsening their 

In these symptom-driven consultations, I’ve been able to educate patients about the importance of taking screen breaks and staying compliant with their prescribed treatments.
	
	When they are able to return to the office, I’ll be able to image their glands with meibography.
	 

2. Patients’ disease state comprehension is worse than I thought

One of the reasons that patients may be noncompliant is that they don’t understand the reasons behind what was prescribed. I am taking the opportunity, during these Zoom calls, to reset expectations for the future.

For example, I spoke to a patient recently who mistakenly thought that one thermal pulsation treatment (LipiFlow, Johnson & Johnson) would fix her problems forever because, “My glands have been ‘cleaned out’ now, right?”

We talked about how she sees her dental hygienist twice a year, and that, in a similar fashion, we have to continue to maintain lid and meibomian gland health over time. 

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We all tend to get caught up in the daily grind of our busy lives. But suddenly, being cut off from normal practice, has made me truly appreciate how much I love ophthalmology. 
	
	I miss the daily patient interaction, seeing colleagues at professional conferences, and the ability to perform procedures and use all the powerful diagnostic tools we have at our disposal.

I believe there will be some lasting effects of this crisis, both good and bad. We will make changes to office cleaning protocols and likely reconfigure reception and dilation areas to provide more space between patients, even after the risk of transmission of this particular virus has lessened.
	
	

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We hope to incorporate some aspects of telemedicine by phone-to shorten patients’ time filling forms-and review their past medical history or their current medications in the office.

I’m already thinking about promotions we can run-both to jump-start the practice once we reopen and to show patients we are empathetic and compassionate about their financial difficulties and want to help them despite those challenges.

How are you dealing with the coronavirus crisis, and what changes will you make to your practice moving forward?
	
	

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	Astigmatism is something we treat every day in our 

practices, yet it can be surprisingly hard to explain to patients.

In my experience, patients are generally confused by the analogy so many doctors use when they say, “Your eye is shaped like a football rather than a basketball.”

In today’s tech-savvy and visual world, that simple analogy doesn’t always resonate.
	
	

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And yet, we ask patients to spend money-out of pocket-for correction of astigmatism with limbal relaxing incisions, a toric IOL, or laser vision correction.

If they don’t understand what the condition is or how the proposed treatment can help, patients may be hesitant to make that additional expenditure, and then end up unhappy when they don’t have good uncorrected vision.

Fortunately, there are many ways to use technology to help patients understand complex concepts like astigmatism. 


	
	Here are four patient education tools I like to use:

Tecnis Vision Simulator (Johnson & Johnson Vision)


	This is available from the Apple app store (for iPad only) or online at www.tecnisvisionsimulator.com. 
	
	There is a slider at the bottom of the screen that you can move to simulate astigmatism and vision after surgery with a toric or standard monofocal IOL, during the day and at night 

(Figure  1a, seen above; Figure 1b, to the right)

Simulation of vision with presbyopia and astigmatism after implantation of a standard monofocal.

This makes it obvious to the patient that vision won’t be as clear without correcting the astigmatism.
	
	

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 I like to show patients the multicolor axial view of the corneal topography and ask if they see the “bowtie” shape (See 

The full color axial map on a topographer is a good way to help patients visualize that they have astigmatism

“That’s your astigmatism, and we can correct most of it,” I explain. 

I also like the simulator on this device, which displays a beach scene with a boat.  A lay person can see that when astigmatism is corrected, the image is crisp and clear.

When it is not corrected, there is more blur overall, which is especially noticeable on the edges and fine details of the boat.
	 

Color-LED topography measures corneas consistenly in analysis 


	This is an interactive patient engagement platform that uses auditory, visual, and touch elements to help patients understand their conditions. We have CheckedUp wallboards in most of our exam rooms. 
	
	 


	I also utilize the educational videos from Rendia, where astigmatism is explained through easy-to-understand animation software. It can be sent to patients after the visit or shown in the office.
	 

These are all 21st-century methods for showing patients what we mean by astigmatism, and most importantly, what it means for their lifestyle and visual function to correct astigmatism.
	
	

Astigmatism: A ‘clear-as-mud’ concept to patients 

Optometric practice is going through a lot of change, with online sales of contact lenses and prescription glasses eroding some of optometry’s traditional revenue streams.

At the same time, an aging population is leading to an increased demand for treatment of age-related eye diseases, such as cataract, glaucoma, macular degeneration, and 

. Given these trends, more optometrists are seeing the financial and clinical need to go beyond vision care to manage or co-manage medical conditions. 
	
	

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presents a perfect opportunity for ophthalmologists and optometrists to work together for the benefit of our patients. There are two common situations in my practice where this occurs. 

I work with many optometrists in the surrounding community who will diagnose patients with 

and offer a range of treatments to address their symptoms. They may prescribe immunomodulators like Restasis (Allegan), Xiidra (Novartis), or Cequa (Sun), microwavable moisture masks, oral omega-3 supplements, lid hygiene wipes, and artificial tears. 

If these measures aren’t enough or if they suspect the patient actually has impacted meibomian glands that require a procedure for evacuation, many will refer the patient to me for thermal pulsation therapy (LipiFlow, TearScience/Johnson & Johnson Vision). 
	
	

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I will treat the patient and send them back to their optometrist for ongoing management of their ocular surface disease, with the understanding that the patient may need a repeat LipiFlow treatment in a year or two.

To capture patient referrals like this, it is important that optometrists in your area learn about the advanced technologies you offer, both for diagnosis and for treatment. This is essential for 

, but also for procedures like cross-linking for keratoconus and refractive cataract surgery. 

We send an e-newsletter to primary-care providers and optometrists; send a practice liaison to visit practices in person; and offer educational seminars for COPE credit, as well as non-credit dinner programs that are a mix of social networking and educational reinforcement. I have found it powerful to demonstrate our technologies whenever possible at these seminars. 

At a recent gathering, for example, several optometrists discovered that they had significant gland dropout on Lipi­View meibography, despite being asymptomatic. That experience helped to underscore the value of the diagnostic tool better than anything I could have said.
	
	

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Scenario 2: The surgical referral who isn’t ready

We often see patients who have been referred for cataract surgery but who turn out to have an unstable tear film that I want to address before surgery.
	
	The patient may have a positive MMP-9 test, abnormal osmolarity, and moderate to severe meibomian gland dropout-but it may be the first time they have been told they have dry eye. This can be a tricky situation that calls for diplomacy. 

I tell the patient that we have specialized equipment that specifically checks for 

.
	
	“Not all practices have this technology, so that’s why Dr. Smith referred you to me,” I will tell them. “We’ll get that tear film stabilized and then we’ll be able to get more reliable measurements for surgery. When you go back to Dr. Smith after surgery, she will continue taking care of your 

This can let the patient know that their care is important. It creates a level of trust, and can help lead to a better outcome. 

I also take the time to communicate directly with the optometrist and educate him or her about my findings and the treatment protocol that is needed to ensure the patient gets the best outcome from

.
	
	As partners in the patient’s care, we both want to avoid time-consuming refractive surprises and instead have a satisfied patient with excellent visual outcomes.

Both of these scenarios are working well for our practice. What strategies have you used to promote good co-management relationships with optometrists in your region?
	
	

Dr. Matossian has no relevant financial interests to disclose. 

Author | Cynthia Matossian, MD, FACS

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