The future of laser vision correction

When the COVID-19 lockdown restrictions were initially eased and Germany began to reopen in the middle of May, the country had one of the lowest death rates from the novel coronavirus in the world. By the time June was ending, Michael C Knorz, MD, Professor of Ophthalmology, FreeVis LASIK Center at the University Eye Clinic, Mannheim, Germany, said that he had essentially taken care of the backlog of cases of laser vision correction (LVC) that had been deferred during the shutdown. In addition, new inquiries from patients interested in a refractive procedure seemed to have dropped minimally relative to pre-pandemic days. When asked about his thoughts regarding how COVID-19 will impact the future of LVC, however, Dr Knorz offered a dichotomous perspective. He told EuroTimes: “I am an optimistic person, and I do not believe that COVID-19 by itself will have a significant impact on laser refractive surgery. We could live with it, just like we live with the flu.” Yet, Dr Knorz qualified his comment by noting it represents a rational view. His response based on an emotional reaction is more pessimistic. “From what I see, the whole world is in a panic mode today and seems to be grossly overreacting to the scientific facts. This extreme overreaction will cause an economic downturn that will affect laser refractive surgery in the same negative way it will affect other aspects of our lives, and it may lead to a global depression,” Dr Knorz said. “I truly hope that politicians will come to their senses, but we will have to wait and see the course ahead. A reliable prediction of the future of laser refractive surgery is not possible today. In the coming months we will see what happens.” Practice update Dr Knorz reopened his practice to elective surgery April 20. Patients were contacted to reschedule the LVC procedures that were cancelled because of the lockdown, and only a few decided they would not go forward. “By the end of June, over 90% of the patients whose LVC procedure was deferred had undergone their surgery,” Dr Knorz said. Interest in LVC remains. Relative to the months preceding the pandemic, Dr Knorz said he has seen a drop of only 5-to-10% in the number of inquiries for consultation visits. Dr Knorz believes that unemployment with its accompanying loss of income will be the primary factor determining uptake of LVC going forward. “In Germany, we are quite lucky because unemployment is not a big issue yet. Job loss, however, was the main reason given by the approximately 10% of our patients who decided not to go ahead with their planned surgery when we called them back to reschedule it,” he said. Dr Knorz said that so far, he has not seen any age-related difference in patient willingness to proceed with the elective procedure. “Both our lens patients in the 50-to-70-year age range who are candidates for refractive lens exchange and our LVC patients are mostly willing to come for surgery,” he observed. COVID-19 has necessitated new processes to ensure a safe environment, and making patients aware of the strategies being implemented is critical to their willingness to attend office visits and proceed with surgery. At the FreeVis LASIK Center, all patients are given a surgical mask and sanitising gel to disinfect their hands at entry, and no more than six patients are allowed in the 20m-squared waiting room. Disinfection of all contacted surfaces and instruments is being done in view of patients, and all documents are now being handled electronically with Adobe Sign used for informed consent and invoices. “The feedback we have received from patients is that they feel very safe,” said Dr Knorz. Aggressive response Thanks to a swift, aggressive government response to early cases of COVID-19, Greece was one of the first countries to see restrictions eased. Despite the absence of a mandate, A John Kanellopoulos MD, Director, Laservision Eye Institute, Athens, Greece, chose from March 1 to voluntarily stop performing all elective surgeries at his centre and enforce spacing between patient exams along with wearing of facial masks and gloves for all. By mid-May, just a few weeks after the beginning of staged lifting of COVID-19 restrictions, he was already seeing patients for laser vision correction (LVC) consultation visits and performing his first operations. Considering the level of patient interest and the value of laser refractive surgery, Dr Kanellopoulos is hopeful about its future. “If we do not let our guard down and remain dedicated to delivering safe and ethical care, I believe the volume of LVC will return to the pre-pandemic state,” he told EuroTimes. Dr Kanellopoulos recalled that during the lockdown period in Greece, he was contacted by several patients who were interested in Laser Vision Correction surgery because they felt the “down time” they had from work and other usual activities offered an opportune time to undergo the surgery. He also postulated that the stay-at-home situation itself, may have fuelled interest in LVC. “With more unoccupied time, some individuals may have focused more on difficulties they were having with contact lenses and/or self-reflected on making lifestyle changes,” Dr Kanellopoulos explained. “With safety in mind, we kindly deferred and postponed requests to perform surgery during the lockdown, parallel to this we counselled patients to try to refrain from wearing contact lenses considering that they may become a mode of transmission for the coronavirus.” Although in general, people in Greece are still somehow limiting some of their elective and leisure activities, including choosing to undergo various elective surgeries, Dr Kanellopoulos said that he is seeing an increased interest in LVC relative to the past. “Although my surgical volume has not returned to what it was a year ago at this same time, the proportion of my surgical population that is interested in LVC has grown,” he said. “Previously, laser refractive surgery accounted for approximately one-third of my surgical practice. Now almost half of the patients I see are interested in updating their contact lens prescription and very interested in LVC. Dr Kanellopoulos suggested the “surge” may have been enhanced by his having incorporated ray-tracing customisation and excellent early results since November 2019 using an artificial intelligence platform that combines wavefront, Scheimpflug tomography and interferometry measurements from a single device. Implementation of measures to minimise risk for virus transmission is critical so that patients are comfortable coming in for a consultation visit and proceeding with surgery. The changes include wearing of surgical face masks at all times-by all staff, breath shields on all slit-lamps, and reconfiguration of the waiting area to maintain social distancing among others. Prior to their visit, patients are carefully screened for infection or recent exposure to COVID-19. At entry into the building, they are given disposable masks and gloves to wear and must clean their shoes with a disinfectant solution. In addition, adult patients must be unaccompanied unless they require assistance for ambulation or another issue. “We recognise, however, that in making the decision to undergo surgery and for support postoperatively, many patients rely on an informed family member or friend. Therefore, we have employed extraordinary measures using videoconferencing and live, private online broadcasting of each surgery to fulfil this need,” Dr Kanellopoulos said. “Our team’s high standards and my personal quest in offering excellence in patient care has been the driving force in rebooting refractive surgery in our practice post COVID-19. I personally have found the great majority of patients to have ‘returned’ to normalcy with a more heartfelt physician-patient relationship, and I am thrilled!” Screening Is Important When Ireland started to ease its lockdown measures, ophthalmologists faced the challenge of getting their practices back up and running to deal with patient demand. The Wellington Eye Clinic in Dublin, one of the country’s best-known cataract and refractive surgery practices, introduced a range of measures to reassure patients and minimise disruption in the wake of the COVID-19 pandemic. “We have resumed the majority of appointment types except for contact lens trial appointments. We had virtual consultations and the odd in-person consultation for emergencies during lockdown,” said Arthur B. Cummings MD, FRCS, Medical Director Liz Brennan, Head of Research and Clinical Support at the clinic says they have removed many of the chairs in the waiting area, added screens to separate patients where chairs are closer, asked all patients to wear masks and put phones in zip lock bags and sanitised station set up at the entrance with a motion sensor “welcome doorbell” that notifies the team that someone has arrived at the sanitising station. “The team wash hands between every patient (as per usual) and the clinical team are wearing gloves for clinical exams. All patients attend the assessment station in the hospital assessment area prior to their appointment in our clinic and all staff have their temperature checked twice daily. This is logged on a tracker that also allows us to monitor staff contacts in the event of a requirement to contact trace,” she said. They have also added a large splash screen at the front desk and smaller screens and breath shields at devices and slit lamps. Floor stickers also give a visual guide to patients and patients are instructed to conduct conversations in the consultation room once the medical staff is at the sticker (i.e. 2m away) Screening is also important, said Dr Cummings. All patients visit an assessment station in the concourse where they are asked a series of questions to check potential exposure/ symptoms and they have their temperature checked. They are given a clearance certificate which they present to us on arrival at reception and this is scanned into their EMR file. They also complete and submit an online COVID-19 form that we send them prior to their appointment where they state the same and digitally sign before submitting. All diagnostic equipment and rooms are deep cleaned each morning as standard pre-COVID and alcohol wipes used between patients. Since reopening, staff at the clinic have increased the frequency of this deep clean throughout the day, ensuring to include phones, keyboards, light switches, door handles and chair armrests as well as the device and equipment tables. Dr Cummings says that the lessons learned from dealing with the COVID 9 pandemic will have long term benefits. “It has been a period of adjustment for us as a team. All of our processes have been challenged with COVID but our team came together via Zoom staff meetings to offer their feedback and ideas of how our new process and patient journey would work. Collectively, we designed a new process that aimed to have maximum safety and convenience for the patient while keeping our team safe too. We have introduced online medical history forms and payment links and we are currently reviewing options to allow patients to book their appointments via an automated SMS system. While we are not at the stage yet, I think in time that we will look back on this time as a major challenge for the clinic but one that forced growth that may not have occurred without COVID and which will leave us with a more efficient clinic as a result,” he said.