Impact of the COVID-19 Pandemic on Quantity and Characteristics of Ophthalmology Consults

The location of consult changed significantly between the years with fewer consults in the ED in 2020 (72.1% in 2019, 54% in 2020; p < 0.001, by Fisher’s exact test) and more consults to both the ICU (8.6% in 2019 and 18.3% in 2020; p < 0.001) and to the Inpatient Floors (19.7% in 2019, 28.1% in 2020; p < 0.001). In 2019, 369 patients were admitted primarily for ophthalmologic reasons; in 2020, this decreased to 154 (p = 0.002). In 2019, 7.5% of patients required ventilator support; this proportion increased significantly in 2020 to 10.8% (p = 0.04).

Bedside procedures dropped significantly from 2019 to 2020 (4.9% of initial consults in 2019, 2.6% of initial consults in 2020; p = 0.04). Despite the decrease in volume of procedures, the most common type of procedure for both years was corneal foreign body removal (46.5% of procedures in 2019, 50% of procedures in 2020) followed by eyelid laceration repair (11.6% in 2019, and 1.7% in 2020).

Baseline characteristics of consults between the 2 years did not differ significantly, such as age (42.2 years in 2019, 40.3 years in 2020; p = 0.21, by t-test) and gender (52.1% female 2019, 50.4% female in 2020; p = 0.57). Patient ethnicities between the 2 years differed significantly (p = 0.002). The Patient Unavailable category (selected if the patient did not provide this information) increased from 8.1% in 2019 to 15.2% in 2020. The rest of the categories exhibited a slight decrease: Spanish/Hispanic/Latino (39.6% in 2019, 36.5% in 2020), Not Spanish/Hispanic/Latino (47.1% 2019, 44.2% 2020), and Patient Declined/Not Applicable/Unknown (5.2% in 2019, 4.2% in 2020).

Chronic medical conditions did not significantly differ between the years; these included BMI (mean 27.8 in 2019, mean 27.2 in 2020; p = 0.46), Diabetes (23.4% in 2019, 20.2% in 2020; p = 0.20), hypertension (28.4% in 2019, 28.8% in 2020; p = 0.90), CAD (4.7% in 2019, 5.2% in 2020; p = 0.70), and COPD (1.6% in 2019, 1.7% in 2020; p > 0.99).

The three most frequent reasons for consultation remained stable between years: eye pain or pressure (16.4%, 14.1%, p = 0.79, by proportion test), trauma (13.1%, 13.7%, p > 0.99), and blurry vision (12.9%, 11.2%, p = 0.85) (Table 1). Following evaluation by the ophthalmologist, trauma was the most common diagnosis both years (14.0%, 15.2%; p = 0.95). In 2019, the next two most common diagnoses in 2019 were glaucoma (10.9%) and “miscellaneous” (8.0%). In 2020, they were retinopathy of prematurity (ROP) (11.2%) and “miscellaneous” (9.9%). For both years, the majority (61%) of “miscellaneous” diagnoses were eye exams requested by primary teams to identify ocular manifestations of a wide variety of systemic illnesses (Wilson’s disease, tuberculosis, autoimmune diseases, and congenital syndromes).

Discussion

Ophthalmology consults at a major New York City hospital system changed significantly during the COVID-19 pandemic peak in Spring 2020. Consult quantities decreased in late February, corresponding to the first COVID-19 case reported in New York State on February 29. There was also a drop in March, which may relate to the stay-at-home order on March 22 that required all New Yorkers to stay at home, except for essential workers.⁷ Overall, the number of patients admitted primarily for ophthalmologic care significantly decreased from 2019 to 2020. Following this trend, the number of consults and bedside procedures dropped significantly between years.

The proportion of ophthalmology consult patients in the ICU and on ventilators rose significantly from 2019 to 2020, reflecting the increased number of high-acuity patients admitted with COVID-19. There was a significant difference in patient ethnicities between the 2 years, although this is difficult to interpret given the limited available categories. The Patient Unavailable ethnicity category may have increased in 2020 due to the higher number of patients with respiratory distress, thus resulting in their inability to participate in patient registration as compared with those in 2019. At its peak pandemic volume on April 12, 2020, this 1,491-bed hospital system was overwhelmed with 2,208 patients admitted for COVID-19.¹

To assess the risk of COVID-19 exposure to ophthalmologists during consultations, positive COVID-19 tests that resulted within 2 weeks of examination were included in this study. Although only 2.4% of consult patients tested COVID positive, this low number likely reflects the limited availability of tests in Spring 2020. At that time, patients were presumptively diagnosed with COVID-19 based on symptoms, imaging, and exposure, while tests were reserved for those with new or unusual respiratory symptoms or prolonged exposure, although guidelines changed frequently. Given the overwhelming number of patients admitted with COVID-19 symptoms, ophthalmologists likely had a much higher risk of COVID-19 exposure in the hospital than indicated by the number of patients with a positive test.

Despite the risk of COVID-19 exposure to providers and the advent of the newly available E-consult, the majority (98.2%) of consults in 2020 remained in-person evaluations. E-consults accounted for a small fraction (1.8%) of total consults in 2020. The E-consult was first available on March 3, 2020, although the first note was not dated until April 7, 2020. Despite the risks of face-to-face patient care, over a month passed before E-consult was used in ophthalmology. This delay in usage and low volume likely reflects lack of primary team awareness of the new E-consult modality, as well as the need for an in-person slit lamp and fundus exam to adequately assess the patient. Regardless of the reason, consulting ophthalmologists remained at risk of COVID-19 exposure during the peak of the COVID-19 pandemic.

Other institutions have successfully implemented virtual inpatient ophthalmology consultations, with high levels of patient satisfaction.^8,9 In the future, teleophthalmology will likely play a larger role in inpatient ophthalmology care, especially in nonemergent cases.^10–13 Adoption of these new technologies may fundamentally alter how ophthalmology is practiced, ushering in a new era in the delivery of ophthalmological care; especially in the outpatient practices.¹² The nature of E-consults may improve both patient and ophthalmologist safety, especially during a respiratory illness pandemic.⁹

The top diagnoses in 2019 were trauma and glaucoma. In 2020, the top diagnoses were trauma and ROP. Despite the stay-at-home order in 2020, trauma was still the most common ophthalmology diagnosis among admitted patients. The prevalence of trauma is reflected in the procedure data as well, with eyelid laceration repair as one of the most common procedures in both years. This is likely due to the high volume of trauma cases in this hospital system’s catchment area of The Bronx, the most impoverished borough in New York City.¹⁴ Both COVID-19 and trauma cases may have been exacerbated by crowded living conditions and the consequential difficulty in adhering to social distancing guidelines.

Fewer patients had a diagnosis of glaucoma after an ophthalmology evaluation in 2020. This decrease may represent patients with routine ophthalmological concerns presenting less to the hospital in 2020 due to fear of contracting COVID-19. In contrast, ROP represented a greater percentage of ophthalmology diagnoses in 2020 than in 2019. This increase may reflect the fact that infants with ROP required hospital services in 2020 despite the risk for COVID-19 infection, thereby significantly increasing the relative percentage of cases in 2020.

Potential study limitations include the retrospective, single-institution nature of the study. The ethnicity data are limited due to the poorly descriptive nature of categories available in the electronic medical record. Furthermore, the quantity of bedside procedures may not reflect the true number. Only procedures documented in an Initial Consult Note were included, as per study protocol to ensure patients were counted once. Although the number of procedures is likely higher than reported, as they could have been documented in a Follow-Up Consult Note, Brief Note, or Procedure Note. Additionally, if diagnoses changed between initial and follow-up notes, the change was not reflected in these results. In the future, larger, multicenter studies examining the role of electronic or telemedicine consults would be valuable to establish their role during a pandemic.

Conclusion

With changing variants of COVID-19 and the possibility of other viral outbreaks, it is important for health care providers to learn from the most recent pandemic to improve future management. The quantity and characteristics of ophthalmology consultations at a major New York City hospital system changed significantly during the Spring 2020 COVID-19 pandemic peak. Although COVID-19 is a virulent respiratory illness, a strong demand remained for ophthalmology services in the ED, inpatient floors, and ICUs in 2020.

Given the prolonged and face-to-face nature of complete eye exams, ophthalmologists have an increased risk of exposure to COVID-19, as well as other respiratory illnesses.^15,16 Reimbursement policies have become more supportive of telehealth due to the Coronavirus Preparedness and Response Supplemental Appropriations Act in March 2020, and ophthalmologists may be able to incorporate more telemedicine into triaging patients and into follow-up visits.^13,17 Improving telemedicine for ophthalmology is a key area for development to maintain quality patient care and provide better protection for both patients and ophthalmologists during this and future pandemics.

Authors’ Contributions

All authors had the opportunity to view and contribute to the article before submission.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, A.B., upon reasonable request.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.