Caroline Richards, editor, Ophthalmology Times Europe®

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The respiratory symptoms caused by the severe acute respiratory coronavirus disease (COVID-19) that has been sweeping the world since late 2019 are well documented, given the regularity and consistency with which they occur. However, the role of the eyes and tears both as entry routes for the causative virus, SARS-CoV-2, and as sources of contagion are still the subject of debate, and relatively less is known about the ophthalmic implications of the disease.

It would appear from some recent studies that patients who experience the more severe forms of COVID-19 and present with pneumonia commonly display ocular symptoms. However, the authors of a recent Chinese study of 38 patients concluded that although a third of patients with the disease had ocular abnormalities, there was a low prevalence of the virus in tears1,2.

Nevertheless, it is possible that contact with infected eyes could be a route of transmission of SARS-CoV-2, especially given the knowledge that it can be spread via direct or indirect contact with other mucous membranes (the mouth and nose), so ophthalmologists should err on the side of caution and ensure rigorous prevention protocols are put in place.

In a literature review recently published in 

, Prof. Jorge Alió and Dr Alejandra Amesty reported that when it occurred, conjunctivitis was the most common ophthalmologic sign related to coronavirus infection1. And there are clues from previous coronavirus outbreaks as to why this should be the case: inflammation of the conjunctiva was first associated with a human coronavirus back in 2004 when children started to fall prey to the symptoms during the severe acute respiratory syndrome (SARS) crisis.

Genetically speaking, SARS-CoV-2, the virus that caused SARS, is around 70% similar to SARS-CoV and uses the same receptor (ACE2) to insert itself into human cells. This is potentially quite significant when one considers that ACE2 receptors have been found in the aqueous humour3.

But could the fact that conjunctivitis is mainly being seen in the most poorly patients mean that the presence of the virus on the surface of the eye and subsequent ocular events are down to decreased immune function? The researchers do not think so: “Both viral diseases and immune problems can lead to ocular manifestations, such as conjunctivitis, uveitis, retinitis, among others. It is difficult to determine the pathology of the ophthalmic involvement. However, since the virus has been cultured from conjunctival secretions, COVID-19 ophthalmopathy is more likely to be related to the actual virus infestation rather than the secondary immune reaction that the infection may cause.”

Any sign of conjunctivitis in the clinical setting should be considered to be a “possible coronavirus conjunctivitis, especially when accompanied by other respiratory tract problems or fever”, the authors pointed out.

Thankfully, viral conjunctivitis usually amounts to no more than an uncomfortable nuisance, so treatment strategies are typically supportive in nature. That said, it is important to try to lessen the potential viral load on the ocular surface and some of the general ophthalmic recommendations for viral conjunctivitis could also apply to COVID-19 patients.

“These include hygienic measures (frequent hand washing, especially when eye drops need to be applied or contact lenses worn; avoiding touching or rubbing the eyes; changing pillowcases, sheets) … we should be meticulous when examining patients who have tested positive for COVID-19.”

The close face-to-face proximity of ophthalmologists to their patients and frequent exposure to tears and ocular discharge, as well as regular handling of equipment such as slit lamps, tanometers and lasers, means they are perhaps at a higher risk of contracting COVID-19 than other types of healthcare professionals, the researchers said, referring to recent guidelines that have been published in an attempt to minimise the chances of infection spreading in ophthalmology clinics and hospital departments.4,5

In the guidance, ophthalmologists are advised to impose limits on the number of attending patients and to adhere to strict appointment timetables to prevent people from gathering in clinic waiting rooms. Online platforms, such as hospitals’ official websites, should be readily used, whilst simply making more telephone calls could reduce the need for patients to visit hospitals, for example, by helping them to distinguish between urgent and nonurgent ocular problems.

The guidelines go on to recommend triage systems to help to flag up patients with symptoms consistent with COVID-19 infection such as fever, and online ordering and delivery of prescribed medication, especially for chronic eye diseases such as glaucoma.

Recommendations for handling a patient’s visit include:

Reducing the number of accessible entry points to the hospital/clinic;

Screening patients for COVID-19 symptoms and contact history with confirmed or suspected within the past 14 days;

Seeing patients with eye infections in separate clinics with their own waiting areas;

Testing patients more than twice for evidence of SARS-CoV-2 RNA in the conjunctival sac and tears;

Limiting numbers of people in examination rooms;

Ensuring rooms are well ventilated and instruments used disinfected immediately after a patient’s visit; and

In addition, slit lamps should be protected by shields and direct ophthalmoscope examination could be replaced by slit light lenses, optical coherence tomography or fundus photography.

For inpatients, the suggested adaptations include preoperative infection screening and use of local rather than general anaesthesia to avoid contamination. Negative-pressure operating rooms should be used for emergency operations on any COVID-19-positive patients.

Human coronavirus is believed to be able to remain infectious on inanimate surfaces for as many as 9 days6, so disinfecting surfaces with water, detergent and commonly used disinfectants is extremely important, Prof. Alió and Dr Amesty explained. In addition, they suggested that some ocular spray disinfectants that contain hypochlorous acid (usually applied to treat blepharitis in order to reduce bacterial and viral load on the skin and eyelashes) could be used as “a measurement of prevention for the facial area where many other chemical agents cannot be applied”.

However, more studies are needed to establish a specific antiviral product that could be used to reduce the viral load on infected patients’ conjunctiva and lower the transmission rate via the eyes/tears. The authors conceded that this is no easy task when “so many doubts still remain regarding the ophthalmic implications” of the infection.

Summarising, the authors have called for “well-designed trials” to be conducted “to rule out other ocular manifestations [besides conjunctivitis] that may result from COVID-19 infection and to better elucidate the mechanisms of transmission through the eyes.”

Until more light can be shed on the ophthalmic implications of COVID-19, ophthalmologists can only remain as up-to-date as possible on emerging disease findings, whilst maintaining a cautious approach when dealing with patients before, during and after appointments.

1. Amesty MA, Alió del Barrio JL, Alió JL. COVID-19 disease and ophthalmology: An update.

https://doi.org/10.1007/s40123-020-00260-y

Wu P, Duan F, Luo C, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province. China 

https://doi.org/10.1001/jamaophthalmol.2020.1291

Holappa M, Vapaatalo H, Vaajanen A. Many faces of renin-angiotensin system—focus on eye. 

Lai THT, Tang EWH, Chau SKY, et al. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. 

Yong Y, Ruixue T, Xu S, et al. A comprehensive Chinese experience against SARS-CoV-2 in ophthalmology. 

Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents

Prof. Alió is professor and chairman of ophthalmology at the Miguel Hernandez University of Elche and scientific director at Vissum in Alicante, Spain. He has no financial interests in the subject matter.

Articles

Emerging data on conjunctivitis cases in COVID-19 patients necessitate high levels of caution and a meticulous approach during the pandemic.

The ophthalmic implications of COVID-19: What we know so far 

I spoke to Dr Anthony Khawaja of University College London and Moorfields Hospital, London, UK, about the exciting realm of precision medicine in glaucoma.

How do you define ‘precision management’?

In looking after our patients, most of us review the evidence in the literature. For example, when considering glaucoma patients, I might look at the UK glaucoma treatment study (UKGTS),

 a randomised controlled trial that showed that patients treated with a prostaglandin analogue do better on average than those who are not treated.

Evidence-based medicine tells us how best to treat people on average, but everyone is different. Not everybody in the UKGTS who received latanoprost necessarily benefited from it; in fact, 15% of such patients progressed over 2 years, so they were under-treated. Yet three-quarters of the placebo group did not progress, so some may have been over-treated.

Precision management is about going beyond simply what is best for the average group of patients and instead being able to predict, the first time you see a patient, their risk of worsening, and then titrating their treatment accordingly — maybe starting off more intensively in some high-risk patients so that you do not have to observe further vision loss before stepping up treatment. And it is it about choosing no treatment at all for other patients.

This means resources and treatments can be directed only to the people who will benefit, thus sparing the costs and side effects of treatments that will not work. The key here is understanding that one size does not fit all.

Could you expand on what this would look like for glaucoma?

One example of where precision glaucoma management could be useful is trying, the first time you see the patient, to make an assessment about whether they need treatment or not. Take the patient who has high ocular pressure but not glaucoma as of yet. We know from the Ocular Hypertension Treatment Study (OHTS)

 that if you treat such patients, they will do better on average than people who do not receive treatment: fewer of them will convert to glaucoma. But we also know that most of the group that is not treated do not develop glaucoma, so some are being treated unnecessarily.

An OHTS calculator that predicts the risk of conversion to glaucoma already exists,

 which takes into account the age of the patient, baseline pressure, corneal thickness, visual field mean deviation and cup-disc ratio. Unfortunately, this calculator, while helpful, does not really go far enough.

And so what we are looking to do is bring in other new technologies using genetic information or perhaps artificial intelligence (AI) assessments of images to help decide whether a patient will very likely benefit from treatment or, actually, are at such low risk that we can save the costs and the hassle of treatment. This will in turn also free up health service resources so that we can focus on the patients at highest risk.

You can apply this to other aspects of glaucoma care. For somebody with established glaucoma, do you treat or not, and how aggressively do you treat?

Another area which in my opinion can really benefit from the precision management approach in glaucoma is choosing the right treatment. There are so many different types of treatments available, including four major classes of drug, selective laser trabeculoplasty for open angle disease, and a whole spectrum of surgery from the minimally invasive glaucoma surgeries to the traditional incisional surgeries such as trabeculectomy and tube implants.

And if we are honest with ourselves, we do not know who is going to do well with each treatment. As mentioned, some people respond very well to latanoprost, but others do not respond at all and some experience side effects.

In recent years, we have really started to understand what causes glaucoma. In fact, glaucoma is one of the most hereditary of the common diseases in humans; it is about 70% heritable.

This means, in part, that some glaucoma is inherited through generations in an autosomal dominant fashion due to just a single mutation, most commonly in the myocilin gene. But this comprises only about 4% of primary open angle glaucoma (POAG).

The majority of cases are more complex because they are due to a lot of genetic effects, each one small and insufficient in causing glaucoma on its own but when put together cumulatively reach a threshold that causes disease. For years we were unable to identify these small effects, but recently, with large studies, we have been able to identify many more.

For example, 2 years ago, by looking at the pressure in the eyes of around 140,000 people, we identified over 100 points in the genetic code that underlie some people developing high pressure and then glaucoma.

 And what is exciting is that, when you combine the genetic information at all of these points, you can start to predict who is going to get glaucoma, even from the point of birth because our genetic code does not change after that.

Given that it has got such a genetic basis, what we can start to do next is pick out different types of glaucoma, for example, which are currently indistinguishable. So, POAG to us looks pretty uniform. However, genetically speaking there is a subgroup that seems to have a problem particularly located in Schlemm’s canal and collector channels; for another group the problem seems to particularly affect the trabecular meshwork.

If we could work out which of these patients had primarily a trabecular meshwork problem then we would know that treatment targeted to the trabecular meshwork, such as selective laser trabeculoplasty, or the iStent Inject (Glaukos) and trabecular bypass procedures with microstents (Hydrus), is more likely to work.

Conversely, if the issue is predominantly due to a problem with a patient’s collector channels and Schlemm’s canal, then maybe you are better off not targeting the trabecular meshwork. In that way, we can start to use genetic risk scores to be able not only to tell us about the risk of disease progression but also to predict response to treatment.

How exactly would artificial intelligence assist?

Well, in terms of personalising care, there is an awful lot of information that we collect as glaucoma specialists: images that provide detailed information and potential patterns that we recognise. We learned through our training that we can sometimes look at an optic nerve and see when there is a lot of damage and when a person is at high risk, meaning we need to treat them aggressively.

But there are other times where we just get it wrong and do not predict at baseline that somebody is at high risk of getting worse, and they worsen despite our best efforts. Conversely, we might treat other people that are at low risk and we can never know whether they needed that treatment.

The real power of AI in medicine so far is the ability to classify images, which it can do better than any single human grader. AI has the potential to see patterns in an image that no human being, no matter how expert they are, can see: an interesting study that supports this concept is one from the Google Brain group.

They trained an AI algorithm to look at photos of the retina of healthy participants in a couple of studies, including the UK Biobank study, and to predict sex. The algorithm is 97% accurate in identifying whether a fundus photo is from a man or a woman. Is there is one glaucoma specialist or retinal specialist or human in the world who can do that?

The enticing thought is that if AI can see patterns beyond what humans can appreciate currently, it can predict the future. I can definitely see AI working together with genomics in the future, providing much more individualised care.

I have set my research group an ambitious target: by 4 years’ time we will have developed proven algorithms that can predict the risk of glaucoma progression and response to two different treatments. Once we have got this tool, we need to make it easily accessible and understandable to general glaucoma doctors and physicians, and even patients.

We will need to test it prospectively to see whether it does improve decision making. Glaucoma trials can take quite a long time—at least 2 years—and so I think we are looking at an estimated 5 years to get the proof of principle and a pilot tool that will then need to be proven over a few years before something can be rolled out.

In parallel to this, we need genetic data to be available. Currently, most of our patients do not come with genetic data, although increasing numbers of people are obtaining it from direct-to-consumer genetic tests. There are already platforms where healthcare services can interact with genetic databases to pull out the information they need, with the patient’s consent. So, this is one possibility.

This type of testing can cost less than £50 and when done on scale might be nearer to £20 per person, which is excellent value. And if that one £20 test can tell you whether you should be screened for glaucoma, which treatment you should have and whether you need treatment at all, it could provide a similar picture for other diseases.

For example, it could also tell you, say, whether you should take statins if you have got high lipid levels. Should you be screened for breast cancer or should it be delayed? And for prostate cancer? This is just scratching the surface.

The £20 test can inform a whole gamut of health-related decisions. It will really become a question of 

 you test and obtaining genetic information for all people who interact with healthcare services will become routine.

The people in the aforementioned study were all of European descent and we can predict with a certain degree of accuracy someone’s risk of glaucoma if they are European. This prediction works quite well for Asian people too, but not so well for people of African descent.

If we are to develop a new, better way of managing glaucoma, which means that people get the best treatment for them from the get go and that we spare people who do not need treatment, can we really offer it if it only works in people of certain ethnicities? And I think we all know the answer to that is no.

So, one of the challenges is the need to make sure that we are getting enough data and information on people of all ethnicities. And this is why, having started the Moorfields Glaucoma BioResource, I am pleased to be able to recruit patients from all backgrounds due to London’s very diverse population.

The other challenge is to come up with a better way of managing glaucoma so that expertise is widely distributed and not clustered in certain centres of excellence where there are genetics experts. Such care needs to be delivered by any doctor and to an extent that even patients can understand.

It needs to be accessible and rolled out everywhere, equitably, to people of all ethnicities and backgrounds. And that is the key: we need to make this an equitable innovation.

Anthony Khawaja, MA (Cantab), PhD, FRCOphth

Dr Khawaja is associate professor at UCL Institute of Ophthalmology and honorary consultant ophthalmic surgeon at Moorfields Eye Hospital NHS Foundation Trust, London, UK. He reports acting as consultant to Aerie, Allergan, Google Health, Novartis, Reichert and Santen and has received lecturing fees from Grafton Optical and travel support from Thea.

Garway-Heath DF, Crabb DP, Bunce C, et al. Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial. 

Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. 

Gordon MO, Torri V, Miglior S, et al. Validated prediction model for the development of primary open-angle glaucoma in individuals with ocular hypertension.

Khawaja AP, Cooke Bailey JN, Wareham NJ, et al. Genome-wide analyses identify 68 new loci associated with intraocular pressure and improve risk prediction for primary open-angle glaucoma. 

Poplin R, Varadarajan A V., Blumer K, et al. Prediction of cardiovascular risk factors from retinal fundus photographs via deep learning. 

Artificial intelligence and genetic testing are expected to facilitate choosing the best treatment for each unique glaucoma patient within the next decade. This will not only lead to the best outcomes for individuals but will also spare them the costs and side effects of suboptimal treatments.

Precision management to revolutionise glaucoma diagnosis and treatment

I spoke with Prof. Christophe Baudouin, president of the European Dry Eye Society to find out more about the complex nature of dry eye disease.

Could you tell me more about the pathogenesis of dry eye disease?

Dry eye is a very complex disease. It is not just a question of lack of water and so it is impossible to treat patients just by lubricating the eye with water. It is a disease that involves a series of self-stimulating biological events, and the lack of tears, insufficient tear quality or their instability results in direct mechanical and/or osmotic stress, which causes further damage.

In addition, goblet cell loss results in further tear film instability or imbalance and thus, dryness. The drier the eyes become, the more inflammatory they become and the greater the inflammation, the more the eyes continue to dry out, i.e., a vicious cycle occurs (see Figure 1).

To give more context on the vicious cycle theory, the dryness of the eye stimulates the nerves, the inflammatory reaction and inflammatory cells, and those act as stimulation for further damage, and so tears and their quality are reduced further, resulting in the disease becoming chronic.

Overall, the disease is very complex, with many risk factors, causes and aetiologies having been defined. As a result, it is difficult to resolve.

How are primary and secondary inflammatory processes involved in the disease?

There is a constant state of inflammation with the most severe dry eye cases, and this can be primary; for example, as seen with Sjogren syndrome, where inflammatory cells infiltrate and block the lacrimal glands, as well as the conjunctiva and cornea, and thus invade the whole ocular surface. Secondary processes are also involved: the various types of stress including mechanical and osmotic factors also stimulates inflammatory cells and results in a chronic inflammatory state.

What do you think future treatment strategies need to focus on?

The increasing interest in the idea of the vicious cycle allows us to discriminate between different levels of events: the mechanical stress, the osmotic stress and the inflammatory stress, for example. This new way of understanding the disease may allow the physician firstly to try to prevent the patient from entering the cycle, which is important and can be made possible by controlling the environment, improving the eyelid and decreasing inflammation. Secondly, each part of the loop can be targeted with a specific approach such as lubrication, eyelid hygiene, anti-inflammatory strategies and maybe even Omega-3.

And so there are different complementary approaches that can improve the patient’s symptoms. That said, sometimes it is very difficult to help the patient and they can suffer a lot.

To discuss a further complication of dry eye, we are increasingly starting to understand the concept of neuropathic pain in dry eye disease. Sometimes, the overstimulation of the nerve causes chronic pain and so even when the cornea and tears have been improved, patients can continue to suffer.

And once neuropathic pain has been stimulated, it can be very difficult to control it. Therefore, a good future treatment approach would be to find the best ways of relieving pain symptoms either locally or systemically.

Another consideration is in how we treat and control inflammation. In Europe, there is only one ciclosporin formulation indicated for severe dry eye disease with corneal damage, Ikervis (Santen), whilst the United States market has the prescription eyedrop Restasis (Allergan).

Another medication for the treatment of signs and symptoms of dry eye, which is available in some countries, is lifitegast (Xiidra, Takeda Pharmaceutical), which blocks the activation of lymphocytes. Unfortunately, this drug is not available in Europe and so other anti-inflammatory strategies are needed here.

In addition, the eyelids are likely to be the location of a lot of inflammation and so represent potential targets. In fact, various strategies to treat the eyelids have been developed, based on pulse light or warming and massaging devices, and are certainly a good way of relieving the patient’s symptoms.

Has the incidence of dry eye disease increased during the COVID-19 pandemic as screen time has increased?

We do not yet have epidemiological data to assess, however, it is clear that long hours working at, or reading on, a computer do affect dry eye and there is a clear association between the two. So, most likely, patients who have dry eye are suffering more during this time.

Furthermore, it has also been found that wearing a mask seems to interfere with eyelids and lead to meibomian gland dysfunction, perhaps by blocking the lymphatics at the level of the eyelids or by focusing an air flow on the eyes, so some people are finding that their dry eyes have been worsening due to their mask use.


Prof. Baudouin is professor and chair of ophthalmology at Quinze-Vingts National Eye Hospital & Vision Institute, University Paris Saclay, Paris, France. He has no financial interest in the subject matter.

The vicious cycle theory is a new way of understanding dry eye disease and may help improve prevention and treatment strategies. 

How dry eye disease can become a complex vicious cycle

The coronavirus pandemic has triggered a seismic shift in the way ophthalmologists interact with their patients, forcing them to think on their feet and find ways to quickly adapt their workflows. 

However, as the crisis continues, it is becoming apparent that some of the changes they have had to make, such as increasingly opting for virtual consultations, could become more permanent, as evidence of their benefits to doctors and patients alike starts to mount. 

Arguably, the pandemic has paved the way for greater opportunities for positive change within ophthalmology and indeed, in healthcare in general.

I asked Prof. Mariya Moosajee, consultant ophthalmic surgeon and clinical academic ophthalmologist at Moorfields Eye Hospital, London, how her working life has changed and how those who specialise in providing services for genetic eye disorders can continue to provide the best care for their patients both during the pandemic and beyond.

Prof. Moosajee’s speciality is genetic eye disease, so the majority of her patients have been deemed non-urgent during the pandemic. 

A lot of such patients across the UK have seen their appointments cancelled, but Prof. Moosajee decided to consult all her patients virtually from the start of the crisis.

How have you had to adapt your workplace during the pandemic?

I have been able to work from home and consulted patients either by telephone or using ‘NHS attend anywhere,’ a secure web-based platform for patients with pre-arranged video consultation appointments, that was nationally funded by National Health Service (NHS) England and NHS Improvement to support NHS trusts and foundation trusts in their response to the COVID-19 outbreak.

I hold my clinics at the same time as they would have been held pre-COVID-19 and allocate patients to my team. I then meet with my colleagues at the end of every clinic on Microsoft Teams so that they can present each case.

We discuss the patients’ future management as a multidisciplinary team; we have a family support officer; a developmental paediatrician; a genetic counsellor; an extended role orthoptist; a low vision optometrist and a paediatric ophthalmology fellow. If we feel our patients need a low vision assessment or specific paediatric input (as a vast number of genetic eye disease patients have systemic features), then the relevant personnel will follow up the patient with a further phone call. It has worked really well; we have consulted 220 patients in total: 150 children and 70 adults with genetic eye disease.

We are restarting face-to-face clinics in the next month. At that stage we will have prioritised patients that will need to come in for clinical assessment and to give blood samples for genetic testing.

Adults who have had recent ophthalmology assessments locally or in other services at Moorfields can be sent blood packs which enables them to take their own blood without having to travel into London and send the sample back to us so we can process it for genetic testing. In fact, the whole process can be undertaken remotely.

What are your views on virtual consultations?

I have been pushing for virtual consultations in genetics for a long time. Prior to COVID-19 (last April–June 2019), we undertook a patient-reported survey with just over 100 paediatric or adult participants, who were either new or follow-up patients, to ascertain their views on virtual consultations and their acceptability.

We found that over 65% percent of participants prefer to have their investigations carried out locally, followed by a virtual consultation with specialists at Moorfields Eye Hospital for the review of these results. Adult participants favour video calls, with contact via the telephone being the least popular response.

The opposite is true for parents and guardians of children, who prefer contact via telephone over video call. There was no difference between the views of new or follow-up patients. Interestingly, despite most patients preferring virtual contact, the majority do not want to be seen virtually for every appointment until a treatment or trial becomes available.

What innovations do you think might be needed in the future?

I do not think we can go back to the way we were working. We can greatly increase our efficiency and patient experience by a combination of virtual and face-to-face consultations.

Patients do not want to wait for hours to have imaging and see a consultant, but they definitely want to see specialists who know about their rare genetic eye condition and who can assess the results of investigations undertaken locally, as well as inform them of the latest research and trials.

The long, detailed records we take in genetics on the onset and progression of symptoms, and prenatal, birth and family history can all be undertaken virtually. Genetic counselling is also a lengthy process that involves an unrushed conversation to ensure patient understanding of the complex topic of inheritance and genetic mutations, informed consent and family planning.

Studies in cardiac and oncogenetics in the Netherlands showed high levels of patient satisfaction for those receiving virtual genetic counselling. I would strongly recommend Telegenetics moving forwards.

In the UK, genomic medicine services are being introduced across all medical specialities, funding for genetic testing is becoming centralised and whole genome sequencing will soon be available to most patients on the NHS. We are trying to encourage more ophthalmologists around the country to order genetic tests for patients.

Moorfields Eye Hospital is also hoping to provide a virtual genomic service to ophthalmologists, to offer guidance and advice on how to manage genetic eye disease patients locally without the need to send them to tertiary referral centres unless necessary. I think this will be a huge step forward for patients who have previously not been able to access genetic services due to local funding restrictions.

I have also created an open access web-resource called Gene.Vision, which is an A-Z of genetic eye disease with two interfaces; one for healthcare professionals and the other for patients. The version for patients includes in-depth sections on how to cope with sight loss and associated aspects of daily life that can be affected, such as driving, education and employment.

The aim of the resource is to feature the signs; symptoms; genetic causes; patient management; referral needs; current information on research and trials for a disease/gene; and any support groups that would be beneficial for the patient, for each genetic eye disease. It has been tested by patients with sight loss with input from digital accessibility consultants, one of who is deaf-blind with Usher syndrome. It will be launched next month (www.gene.vision).

How can you best serve your patients during the pandemic?

Most genetic eye disease patients had their appointments cancelled during the lockdown. When you are forced into isolation, it can cause some individuals to focus more strongly on their own health and well-being.

Calls to sight loss charity helplines increased but they had no expertise to answer the medical queries. So, I offered to undertake a voluntary weekly ‘Ask the expert session’ for Retina UK, Microphthalmia, Anophthalmia and Coloboma Support (MACS) charity and Aniridia Network.

I spoke to at least six patients per session and every caller had a valid reason to get in touch; issues raised included not getting access to expert services, deterioration in vision and interestingly, I received a number of calls from patients who were experiencing increased visual hallucinations as part of Charles Bonnet syndrome (CBS). Based on this anecdotal evidence, we undertook a survey of 45 elderly patients with sight loss due to CBS, with over 40% of them having macular-related disease.

Over 55% of patients reported increased frequency of visual hallucinations;

Approximately 50% had alterations in the nature of their hallucinations and emotional response in terms of more sinister hallucinations, with more associated fear and anxiety; and

Nearly 70% felt greater feelings of loneliness but 60% had not accessed support services.

It is clear from this that we must learn to stay connected with our patients, ensuring they do not feel isolated. Sending a letter of cancellation or discharge is not appropriate during these difficult times. A phone call by an eye clinic liaison officer or genetic counsellor can be very gratefully received by patients. Sight loss charities may be able help in this regard but, like many, they have been suffering from reduced income and furloughed staff. 

Prof. Mariya Moosajee, MBBS, BSc, PhD, FRCOphth

E:  m.moosajee@ucl.ac.uk
Professor Moosajee has no financial disclosures.

Author | Caroline Richards, editor, Ophthalmology Times Europe®

Articles

Precision management to revolutionise glaucoma diagnosis and treatment

How dry eye disease can become a complex vicious cycle

COVID-19: How one ophthalmologist is dealing with non-urgent cases

The ophthalmic implications of COVID-19: What we know so far