Optometric Physician

A weekly e-journal by Art Epstein, OD, FAAO


Volume 20, Number 15

Monday, April 6, 2020


Inside this issue: (click heading to view article)
######### Off the Cuff: Chinese Roulette
######### Study on the Public Psychological States and Related Factors During the Outbreak of Coronavirus Disease 2019 (COVID-19) in Some Regions of China
######### Eye Diseases in Travelers
######### Advanced Keratoconus in a Child With Juvenile Scleroderma
######### News & Notes

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Off the Cuff: Chinese Roulette

As much as I planned to let the news media, government agencies and infectious disease experts handle the coronavirus outbreak and focus on more OD-centric issues, I quickly realized that COVID-19 is very much an OD-centric issue. By now, I am sure you realize it too. In this editorial I am going to share important clinical information and perspective.

COVID-19 is deadly. In the US, data shows about a 2% mortality rate among infected patients with higher incidence in older individuals especially those with preexisting conditions. Of those who have severe infections, between 70 and 80% who end up on ventilators do not survive. COVID-19 has been rendered even more dangerous by mishandling and very likely mis- and disinformation from China. Risk has been further compounded by bureaucratic bungling and incompetence in various federal agencies. Understand that the infection is not just killing older people or people in Italy or NYC, or some other unlucky place where you thankfully don’t live, it is potentially just as deadly for you, your family, your staff and your patients. It is up to you to protect yourself and those whom you care about and are responsible for. I am writing this so you understand how.

In addition to being dangerous, COVID-19 is extremely infectious. So infectious, that among a group of about 70 University of Texas at Austin college students who chartered a plane for a spring break trip to Cabo San Lucas, 44 of them—and perhaps even more since this was reported, tested positive for the virus two weeks later. This wasn’t the only example of high rates of infection among people in close contact.

You don’t need to be an infectious disease expert to realize that this virus is easily transmissible. With exponential increases in infection, it is becoming increasingly likely that it’s more than just sick people coughing and sneezing or contact with contaminated surfaces and unwashed hands that are causing disease. What makes this virus especially dangerous is that it appears easily spread by asymptomatic patients merely breathing nearby. The virus is carried in the air, and it is becoming more and more evident that people who are both infected and infectious but have no symptoms are spreading the virus.

Considering the dangers, both personal and by spreading infection, should we still be seeing patients? First, anyone performing routine examinations of any kind that can be delayed should stop if they haven’t already. While there may be slightly less risk in areas where infection is less widespread, the risk is still significant. Anyone forcing employed ODs or staff to perform routine exams should consider the potential liability if not the ethics of endangering employees and patients.

Those of us who provide medical eye care services should continue to care for patients with urgent problems and emergencies when possible. In many communities ODs are essential providers of medical eye care and also reduce the burden on emergency rooms and urgent care facilities that are currently being inundated with COVID-19 cases. In our office, we continue to see urgent and emergency patients both during and after office hours. In addition to the enhanced disinfection protocols and social distancing that I detailed previously, all of our staff uses Personal Protective Equipment (PPE) when seeing patients. Eye care requires close personal contact, so if you are seeing patients, you and your staff should be using PPE. Despite CDC policies that I believe were disingenuous and a cover for planning ineptitude and incompetence, expect new guidelines regarding the benefits of mask wear for the public to change shortly. Health care providers are not the public. Our exposure and resulting patient exposure to us is far greater. At the least, surgical masks should be worn, and NIOSH-certified N95 masks for close contact personnel would be preferred if available.

The uncertainty of this situation is maddening, and I know everyone is seeking answers and direction. Let me assure you that this will end at some point, and things will return to some semblance of normal. There is also some positive news being reported. Positive results have been reported for some drugs and drug combinations like hydroxychloroquine and azithromycin when used early in the infection. There is also evidence that the warmer weather coming will help reduce infection.This appears to have been the case in China.

This website provides useful current forecasting of mortality and morbidity for COVID-19 in the US and in each state. While the data is sobering and profoundly upsetting, it does provide insight into when the worst is likely to be over in your area. For our practice in Phoenix, AZ we anticipate a warm reboot starting mid-May and being back to a more normal schedule by the end of May. We expect to be incredibly busy catching up with patients who have waited for weeks to get in to see us. You should expect similar.

I have a lot more to say, but not enough space to say it. I will be covering the financial consequences and recovery strategies for our practices in detail in the coming weeks, but for now I wanted to point you to an incredible resource provided by our AOA. The AOA organization, staff, the AOA Board and President Barb Horn have been absolutely amazing during this very challenging time. I will cover the larger story in more detail soon. The AOA has assembled amazing resources for members. I especially want to recommend the brilliant webinar presented by Dr. Jeff Michaels last week. Understand that this is a member resource but because of the extreme circumstances is being made available to all ODs. The AOA has been one of the bright spots during this very dark time.

Note that I am considering increasing the frequency of OP during the crisis. Please let me know if you would like to see OP more frequently for the next few weeks. For now, be safe and stay healthy.
Arthur B. Epstein, OD, FAAO
Chief Medical Editor


Want to share your perspective? Write to Dr. Epstein at artepstein@optometricphysician.com.

The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of the editorial board, Jobson Medical Information LLC (JMI), or any other entities or individuals.


Study on the Public Psychological States and Related Factors During the Outbreak of Coronavirus Disease 2019 (COVID-19) in Some Regions of China

As COVID-19 occurs suddenly and is highly contagious, this will inevitably cause people anxiety, depression, etc. The study on the public psychological states and its related factors during the COVID-19 outbreak is of practical significance. A total of 600 valid questionnaires were received. The Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) were used.

Females' anxiety risk was 3.01 times compared with males (95% CI, 1.39 to 6.52). Compared with people below 40 years old, the anxiety risk of people above 40 years old was 0.40 times (95% CI, 0.16 to 0.99). SDS results indicated that the difference between education level and occupation was statistically significant (p=0.024, 0.005). Compared to people with a master's degree or above, those with a bachelor's degree group had a depression risk of 0.39 times (95% CI, 0.17 to 0.87). Compared with professionals, industrial service workers and other staff had a depression risk of 0.31 times (95% CI, 0.15 to 0.65) and 0.38 times (95% CI, 0.15-0.93).

Six hundred questionnaire participants were psychologically stable. Non-anxiety and non-depression rates were 93.67% and 82.83%, respectively. Anxiety was found in 6.33% and depression in 17.17%. Therefore, attention should be paid to the psychological states of the public.

SOURCE: Wang Y, Di Y, Ye J, et al. Study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (COVID-19) in some regions of China. Psychol Health Med. 2020. Mar 30. [Epub ahead of print].


Eye Diseases in Travelers

Traveling has been growing in popularity over the last several decades. Eye diseases, e.g., decreased visual acuity, inflammatory or degenerative lesions, chronic diseases or eye trauma, affect all groups of travelers. The main risk factors contributing to the manifestation or exacerbation of common ocular diseases include exposure to dry air (inside the airplane cabin or in air-conditioned hotel rooms), exposure to chlorinated or salty water (swimming/bathing in swimming pools or in the sea) and sudden changes in the weather conditions.

In addition, travelers to tropical destinations are at risk of ocular diseases that are rarely seen in temperate climate, e.g., onchocerciasis, loiasis, gnatostomosis, African trypanosomosis or trachoma. The most common condition of the eye seen in travelers is conjunctivitis; it may be either of cosmopolitan (bacterial or viral infections, allergic inflammation) or tropical etiology, e.g., arboviral infections (zika, chikungunya).

Given the fact that a large proportion of the general population has decreased visual acuity and many individuals wear contact lenses rather than glasses, keratitis has become a common health problem among travelers as well; the major risk factors in such cases include sleeping in contact lenses, prolonged exposure to air-conditioning, working with a computer or swimming/bathing in microbiologically contaminated water (e.g., Acanthoamoeba protozoa). Conditions affecting the cornea, conjunctiva or lens may also occur due to excessive exposure to solar radiation, especially if travelers wear glasses without a UV protection.

SOURCE: Korzeniewski K. Eye diseases in travelers. Int Marit Health. 2020;71(1):78-84.



Advanced Keratoconus in a Child With Juvenile Scleroderma

An 18-year-old male presented with complaints of gradually decreasing vision in both eyes for six years. He was diagnosed with juvenile scleroderma at the age of 11 years by a pediatric rheumatologist.

Clinical slit-lamp examination showed features of ectasia, thinning, Vogt's striae and apical scarring in both eyes. Bulbar and tarsal conjunctiva was quiet and normal. Corneal tomography revealed mean keratometry 65.8 and 65.4 diopters, and thinnest pachymetry of 351 and 224 microns in the right and left eye, respectively. There was no history of itching and eye rubbing in the past. Patients of juvenile scleroderma may have associated keratoconus.

The management of advanced keratoconus presents challenges related to handling and insertion of contact lenses in this condition. Keratoplasty is an option in those patients when contact lenses are not acceptable.

SOURCE: Biala A, Kazi M, Chaurasia S. Advanced keratoconus in a child with juvenile scleroderma. Indian J Ophthalmol. 2020;68(4):658-659.

News & Notes
SECO Names Dr. Raynor as President
SECO International announced R. Max Raynor, OD, will be the next president of SECO International. His term began on March 7, and will last through Feb. 28, 2021. Dr. Raynor officially accepted the honor during the House of Delegates meeting on March 7 at SECO 20/20. Dr. Raynor holds a bachelor’s in economics from East Carolina University and a bachelor’s in biology and doctor of optometry degree from Southern College of Optometry. Dr. Raynor has been practicing in North Carolina for 34 years, successfully operating a large multi-office practice in Eastern North Carolina. Dr. Raynor served as president of North Carolina Optometric Society from 2006 and was appointed to serve as the North Carolina Trustee to SECO in 2010.

Eyevance Launches Zerviate in the United States
Eyevance Pharmaceuticals announced the U.S. launch of Zerviate (cetirizine ophthalmic solution) 0.24% for the treatment of ocular itching associated with allergic conjunctivitis. Zerviate is formulated with Hydrella, the vehicle that contains glycerin and hydroxypropyl methylcellulose, two common ingredients in tear lubricants, and is designed to deliver the cetirizine molecule to the eye with ocular comfort. The active ingredient is cetirizine, an antihistamine that is highly selective in blocking the H1 receptor. Read more.

Allergan Announces ECP Program Enhacements, Donations to COVID-19 Efforts
Allergan announced program enhancements designed to assist eye care professionals and patients during the COVID-19 pandemic. These include:
• Lowering copay savings card offerings for Restasis, Restasis Multidose, Lumigan, Combigan and Alphagan P.
• Instituting a program in which eligible commercially insured patients will pay as little as $0 using the My Tears, My Rewards, or At Your Service programs, through May 31; patients can enroll at restasis.com or savewithays.com. (Note: This limited-time offer is not valid for patients enrolled in Medicare, Medicaid, a Medicare drug benefit plan, TRICARE, or other federal or state health programs such as medical assistance programs; other limitations may apply.)
• Increasing the coupon value on all Refresh products from $4 to $10. Patients can visit RefreshRewards.com for their coupon.
• Extending additional payment terns for product purchased directly from Allergan, specifically Ozurdex and Xen, on or before March 23.
Additionally, the Refresh brand donated $250,000 to DirectRelief to support ongoing COVID-19 emergency relief efforts, as part of the Refresh America program. In addition, The Allergan Foundation's 2020 donations include a total of $2 million dedicated to more than 70 organizations responding to the local impact of the COVID-19 pandemic. Read about the donations.

Walman Introduces Complimentary HelpLine
Walman and its family of optical companies launched Ask Walman, an information and resource helpline intended to help independent eye care practices during this uncertain time. Ask Walman will be available for everyone as a complimentary and confidential service. With experts ready to help with questions, customers can be expected to gain information about topics such as: where to start with staffing resources and payroll issues; extended payment terms and programs with Walman businesses; templates and resources for rental; landlord communications; how to focus on patients; what to know about government assistance & where your practice can start. Learn more.


Optometric Physician™ Editorial Board

Chief Medical Editor
Arthur B. Epstein, OD, FAAO

Journal Reviews
Shannon Steinhäuser, OD, FAAO

Contributing Editors
• Katherine M. Mastrota, MS, OD, FAAO
• Barry A. Weissman, OD, PhD, FAAO (Dip CL)

Editorial Board
• William Jones, OD, FAAO
• Alan G. Kabat, OD, FAAO
• Bruce Onofrey, RPh, OD, FAAO
• John Schachet, OD, FIOS
• Joseph Shovlin, OD, FAAO



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