Tal Raviv, MD, FACS

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practice, patients are accustomed to having a smooth, high-touch experience from reception to checkout, with each step designed to convey our identity as a provider of superior care.

happened. It changed Manhattan overnight, and our practice had to change, to

We went from white glove and high touch to Vinyl gloves and no touch. Some luxury amenities are gone, but the same principles endure.

And our staff has found that despite the challenges faced by all of us, a few proverbial “silver lining” practice adaptations will endure long after this crisis is over.

Clinical changes: Less stress, more freedom


Lockdown orders and changes to daily life have laid bare some of the pain points in patient care, particularly compliance challenges for those with 

, or other chronic conditions, including uncorrected refractive error.

While patients missed appointments and found difficulty in getting eye drops, contact lenses or glasses, we took the opportunity to educate our patients about the new treatments available to increase their freedoms—from drops to contact lenses and reading glasses.

While the current pandemic robbed people of many every day freedoms, we have found many are eager to improve their quality of life by lightening the burden of ongoing care for these chronic ocular conditions.

Transitioning back to ophthalmic care during a pandemic


Toward that goal, our practice has increased the use of in-office procedures like intense pulsed light (Optima IPL, Lumenis) and thermal pulsation (Lipiflow, Johnson and Johnson Vision).

These in-office procedures result in a long-term, measureable impact on our patients’ symptoms without necessarily requiring monthly drops as well as the insurance and cost challenges they bring.

, selective laser trabeculoplasty (Selecta Duet, Lumenis) has proven benefits over the cost and burden of daily glaucoma drops for first-line therapy.

 or refractive lens exchange patients who take glaucoma drops are offered stent-based minimally invasive glaucoma surgery (MIGS) such as iStent Inject (Glaukos) or Hydrus (Ivantis)—both of which significantly reduce the burden of medication postoperatively.

 gives patients freedom from both medications and eyeglasses.

COVID-19 creates disruption, opportunity for ophthalmology

Practice changes: protocols, staffing , patient experience


The alterations our practice has made in response to the pandemic have taken a lot of planning. As many of these changes have had a positive impact for our patient experience, we will keep them in place after 

, we’d used voluntary, pre-visit, digital check-in for years. The pandemic pushed us to finally phase out in-office paper intake and consent forms.

We still give patients a choice, but all registration must be done in advance.

Patients check in via smartphone app or our website. If needed, they can download and print the forms or we will mail them.

In addition, our practice has instituted a wireless credit card terminal called Clover in the office, which allows many of our patients to opt to pay using contact-less credit card, Apple Pay, or Android Pay.



Emerging opportunities — and risks — with telehealth in a pandemic


Digital check-in and online payment saves hours of staff time. In the past, four or five staff members would work our front desk, Now only one team member is needed.

For a while, we experimented with directing all incoming phone calls to a stay-at-home staff member. We’ve since switched back to phone calls to the office, but are looking to permanently move them away from the reception area.

Surgical counseling has also moved to a combination of in-office counseling on the day of visit and some post-visit counseling by email or telehealth.

We’ve found that by allowing patients to choose a level of in-office experience, both they and our staff have felt more comfortable.

Capabilities of telemedicine for ophthalmologists during a pandemic: Part I


Although our luxury lounge is now a mostly empty room with spaced-out seating, patients sense a new kind of “luxury experience” of reduced wait time and greater privacy. 

With spaced appointments and digital check-in, many go straight from the front door to the work-up and exam rooms—no waiting. Patients have the full attention of the doctor and staff.

After their exam, if they haven’t prepaid online, there is just a fast, touchless payment, and they’re ready to go. It’s an Uber-like frictionless experience that, when applied to a doctor’s office, has the feel of VIP treatment.

Pearls to educate patients about ocular telemedicine options


Aside from the spaced scheduling, many of the changes we’ve made in response to 

were already under way before the pandemic. Now that the pandemic has accelerated these changes, we’ve begun to see their full benefits.

While it is certainly not the optimal way for our practice to evolve, nevertheless, it will improve how we serve patients in a future of smarter, more streamlined workflows with extra patient attention.

Furthermore, our continued focus on improving patients’ clinical freedoms will progress as new procedures and technologies help to ensure patients’ healthy vision without daily drops or external refractive appliances.



Dr. Raviv is founder and medical director, Eye Center of New York, Manhattan


1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT.

Articles

One ophthalmic practice's staff has found that, despite the challenges faced by all  healthcare professionals amid the coronavirus pandemic, a few proverbial “silver lining” practice adaptations will endure long after the crisis is over.

COVID-19 safety challenges accelerating welcome changes

	Take-home message: The advent of portable autorefractor technology may deliver autorefraction to populations that might not otherwise have any access to eye care.

-With a small, mobile platform, autorefractive technology (SVOne Pro, Smart Vision Labs) allows virtually anyone capable of operating a mobile device to conduct an autorefraction, potentially opening the door to providing refractive screening virtually anywhere in the world, or just outside office walls.

	The 1-pound, hand-held, smartphone-based autorefractor utilizes Hartman-Shack wavefront aberrometry. This update to the first version of the unit adds expanded measurement parameters and enhanced usability. The SVOne Pro allows the operator to see the patient’s eye when aligning the pupil, and once a good Shack-Hartmann grid is present, the software automatically records three autorefraction measurements. All of this is accomplished within 3 seconds per eye. The SVOne Pro has a spherical range of -14 to +14 D and cylindrical range of -7 to +7 D.

	The SVOne Enterprise includes all the features of the SVOne Pro, but is a patient-directed vision testing station. In other words, patients can autorefract themselves using onscreen and voice prompts.

	The device sits atop on a tripod/stand. First the device takes a photo of the patient and asks a series of patient history questions, then guides the patient through each eye’s measurement, and finally it displays the result-which can be printed or sent to a HIPAA-secured cloud account.

	Most millennial patients easily performed their own refractions without any assistance; basically, anyone who can take a “selfie” can operate the unit. Once they completed the exam, and saw their refraction, most patients had a “wow” response and described the experience as “cool.” A few older patients who were able to operate it did so with mixed reactions and results.

	Exam findings generated from the self-administered refraction tests were compared with the in-office legacy autorefractor and subjective exams. The results matched well for young healthy eyes, with occasional outliers. Accommodation must be controlled for with all autorefractors, and the device’s open-field design allows the patient to look in to the distance during the test. A recently published clinical study on the SVOne reported refractive measurements (in visually normal, young individuals) that were not significantly different from four other subjective and objective procedures.

	The potential of these low-cost, portable diagnostic instruments is large, and is just the tip of the iceberg of what is possible. There are already smartphone attachments in development for lensometry, subjective visual acuity, and indirect ophthalmoscopy/fundus photography.

	The platform may eventually measure higher-order aberrations, and perhaps even perform topography.

	Its portability increases access and can help bring refractive eye care to underserved populations around the globe and here in the United States. Domestically, future versions of this device may be of value for school vision screenings, mobile medical services, pediatric medical practices, or nursing homes to name a few.

	Future versions of the self-guided, vision-testing station could become integral to the burgeoning realm of telemedicine. Imagine a refractive vision-screening kiosk next to the blood pressure testing kiosk in pharmacy retail locations. Significant refractive errors can be evaluated by eye-care professionals from any location, and follow-up service can be provided or recommended as needed.

	Theoretically, the device will become small and inexpensive enough to ship to consumers who could perform their own refraction and send the device back (or purchase it).

	Subjective manifest refinement of autorefraction data is the standard of care in the United States, as is a comprehensive eye examination for pathology. This technology is not going to replace autorefractors that are currently in physician’s practices, or comprehensive exams that all patients should undergo. In the near term, this technology may bring autorefraction to populations who might not otherwise have access to eye care.

	Though in its infancy, this technology is promising in that it has real-world applications, and will only get better.

	1. Ciuffreda KJ, Rosenfield M. Evaluation of the SVOne: A handheld, smartphone-based autorefractor. 

	Dr. Raviv is founder and medical director, Eye Center of New York. He did not indicate a proprietary interest in the subject matter.

The advent of portable autorefractor technology may deliver autorefraction to populations that might not otherwise have any access to eye care.

Tal Raviv, MD, FACS

Articles

COVID-19 safety challenges accelerating welcome changes

Mobile refractive screening technology yields real-world applications