We Salute Our Heroes
In early March, GUILLERMO AMESCUA, M.D., saved the vision of an elderly woman with a rare autoimmune disease that can scar the surface of the eye. “She had already lost one eye to OCP (ocular cicatricial pemphigoid), but we were able to surgically repair the conjunctiva in her other eye,” said Amescua, associate professor of clinical ophthalmology and medical director of Bascom Palmer’s ocular surface program.
Two weeks later, Amescua’s patient developed an inflammation that needed medical treatment. But in the meantime, Bascom Palmer had implemented new protocols to protect patients, physicians, nurses, researchers, and other staff members from the dangerous COVID-19 virus.
Rather than have her return to the clinic, Amescua arranged a series of video telehealth visits with the help of the patient’s daughter. “I prescribed medication for her eye, and the inflammation responded well to treatment,” he said. “Now, she can walk by herself and manage her daily activities again. It’s a great example of how we adapt to changing circumstances and continue to deliver the best possible care for our patients.”
Through emergency surgery, timely clinic visits, video conferences, and old-fashioned phone calls, Bascom Palmer’s physicians have continued providing the best possible patient care despite the many challenges of COVID-19.
An expert in ocular infectious diseases, Bascom Palmer’s director, EDUARDO C. ALFONSO, M.D., paid close attention to COVID-19 when the first reports surfaced in China and conferred with experts at the Centers for Disease Control and Prevention (CDC), the University of Miami, and other national and international organizations. Those discussions facilitated the dramatic changes in Bascom Palmer’s operations in mid-March. “Since then, I have met regularly with our faculty, administration, physicians, and scientists to determine what’s best for our patients,” said Alfonso, the Kathleen and Stanley J. Glaser Chair in Ophthalmology. “The COVID-19 pandemic has given us an opportunity to critically examine our processes and develop new ideas, instruments, and protocols that will serve patients, education, and research now and into the future.”
“The real heroes during the pandemic have been our residents and fellows,” said STEVEN J. GEDDE, M.D., professor of ophthalmology; the John G. Clarkson Chair in Ophthalmology; vice chair of education; and residency program director. “They have been our frontline providers in our emergency department and our affiliated hospitals, and have done a beautiful job of shouldering the burden of patient care during this unusual time.”
The global COVID-19 public health threat has touched every aspect of the Institute’s clinical operations. “We have been focused on balancing risks and benefits for our patients, while protecting our employees,” said ELIZABETH A. HODAPP, M.D., associate professor of clinical ophthalmology, and medical director of clinic operations and quality. “Every step of our clinical operations has been given careful consideration along with multiple reviews by our leadership.”
Along with the physicians, fellows, and residents, Bascom Palmer’s support teams have played a pivotal role in the Institute’s ability to continue to serve the community. “Bascom Palmer is number one in the country because of our staff, as well as our physicians,” said ANTHONY GARAND, executive director for the Naples and Palm Beach Gardens satellite facilities. “Today, the most important people in the buildings are the housekeepers who clean the equipment, the waiting areas, the elevators, and the bathrooms. They are the unsung heroes who work behind the scenes to help provide a safe and comfortable experience for all our patients.”
The Institute’s vision research work has also been dramatically affected by COVID-19. Most clinical studies have been put on hold, although some basic science projects have continued in the laboratories. Several researchers have launched projects related to COVID-19 and the eye, while others have used their extra time to prepare grant proposals or write up findings from completed studies for professional publications.
Another adjustment has been a shift in medical education from in-person to remote learning. In some cases, that has proven to be an unexpected benefit, as lectures, grand rounds and journal club sessions can now be accessed by vision professionals around the world.
“Medical education entered a new phase this year,” said MARIA SERRANO-BROSCO, executive director of Bascom Palmer’s Global Center for Ophthalmic Education. “As the demand for digital content increases, there are many time- and cost-saving advantages to online education. CHRIS R. ALABIAD, M.D., associate professor of clinical ophthalmology, led the grand rounds during this time, and more than 400 attendees from around the world regularly logged in each week to participate,” she added.
The pandemic also put Bascom Palmer’s community outreach programs on hold, according to ZUBAIR ANSARI, M.D., assistant professor of clinical ophthalmology, associate director for international physician education, and medical outreach director. “In the coming months, our outreach initiatives will become very important, because so many South Florida residents have delayed their vision care,” Ansari said. “Serving resource-poor communities is a crucial aspect of our mission.”
Bascom Palmer’s global network of vision professionals has stayed closely connected throughout the pandemic. Two retinal fellows from 15 years ago, who are now professors in Shanghai, sent a donation of 4,000 N95 masks, and a grateful patient donated a large box of N95 masks from her company’s warehouse in Wynwood back in March, when protective equipment was in short supply.
Here is a closer look at how Bascom Palmer’s team responded to the COVID-19 pandemic after a March 16, 2020 directive changed the delivery of patient care, research and education throughout the University of Miami Miller School of Medicine and UHealth – the University of Miami Health System.
Providing Emergency Care
When COVID-19 became top-of-mind concern in March, many South Florida eye care centers closed their doors, and Bascom Palmer’s emergency department in Miami became one of the only places where patients could safely receive expert medical eye care.
“Keeping the emergency department open to serve the community was a huge challenge at first, because there were so many unknowns about COVID-19,” said KARA M. CAVUOTO, M.D., associate professor of clinical ophthalmology and director of emergency services. “We had to bring all the moving parts of the care team into alignment, including the faculty, fellows, residents, nurses, patient guides, and support staff. We had to ensure that our patients were safe, as well as ourselves.”
While the changeover was an “abrupt turn,” STEVEN I. GAYER, M.D., professor of clinical anesthesiology and medical director of surgical services, said, “We continued to run our operating rooms as safely and efficiently as possible. Emergency care is something that needs to happen in less than 24 hours. Some problems are obvious, such as a traumatic injury to the eye or a retinal detachment.”
Gayer said his first emergency patient had a retinal detachment and came to Bascom Palmer as other centers were shut down. “In mid-March, we had only the rudiments of protective gear and no quick means of testing for COVID-19,” he said. “We took the patient’s medical history and knew we were taking a risk to help him. His vision depended on us.”
Since then, emergency procedures have evolved, as more personal protective equipment, commonly referred to as “PPE,” became available for everyone involved in the operating rooms. “While the physician is the ‘quarterback’ in the operating room, it takes an entire team to succeed,” Gayer said. “That includes surgery assistants, scrub technicians and nurses who are all on the front lines of care.”
While eye injuries due to construction, automobile accidents, sports, or other mishaps declined this spring due to stay-at-home guidelines, the emergency department continued to see 50-plus patients a day in March and April, with a steadily increasing volume since then.
“I remember one patient who was using an exercise resistance band at home when it snapped, hitting him in the eye,” Cavuoto said. “We also treated patients for corneal ulcers, conjunctivitis and serious eye infections and irritations.”
Determining which patient conditions required emergency or urgent care was another early challenge. “We had to prioritize our patients who needed surgery,” said SONIA H. YOO, M.D., professor of ophthalmology, and the Greentree Pruett Hickman Chair in Ophthalmology. Working remotely, she provided guidance to the emergency team in the hospital. “Fortunately, we were able to launch our videoconferencing applications quickly, making it easier for those doctors working from home to stay in close touch with the teams at the hospital.”
Protecting Against COVID-19
To identify and provide care for COVID-19 positive patients, Cavuoto and KIMAR M. ESTES, M.S.N., the nurse manager of the emergency department, guided the implementation of a negative air pressure room in the lobby area of the Miami facility. Commonly used in medical settings, a negative pressure system prevents airborne diseases from escaping and infecting other people by pulling outside air into the room and filtering it before it moves out of the room. “This allowed us first to identify, and then to provide emergency care for COVID-19 patients, while maintaining a sterile environment throughout the facility,” said Estes.
Another innovative approach to protecting patients and staff came from the 1990s Nickelodeon show, “Legends of the Hidden Temple.” Residents were divided into three separate teams who did not interact either at work or socially, Cavuoto said. The three teams – wearing custom T-shirts to represent their unity – were the Green Monkeys, the Orange Iguanas, and the Purple Parrots. “We wanted to lighten the mood for our patients and help our team to maintain their smiles behind their masks,” said Estes.
In the emergency department, chief residents NICOLAS A. YANNUZZI, M.D., and NIMESH A. PATEL, M.D., coordinated medical care, while working different schedules. “Our residents deserve full credit for seeing patients, even before we had the PPE and COVID-19 screening criteria,” said Yannuzzi. “Going into medicine, you know you are here to serve the patients and their families. For us, the delivery of emergency services was a natural transition of care.”
Like Yannuzzi, Patel saw many patients with eye injuries, including a man who had been drilling on a construction project in February. A CT scan found a tiny foreign body in his eye and the surgeon was able to remove it successfully.
“One of our biggest challenges as chief residents is keeping up with the changing guidelines from the CDC,” said Patel. “Because those guidelines affect scheduling, our 21 residents were calling patients to assess the severity of their condition and determine how soon they may need treatment. We were also doing telehealth visits, checking in with patients who are at higher risk or who have difficulty traveling. Our patients appreciated our ability to see them ‘virtually’ while they stayed at home.”
Vitreoretinal surgeon, LUIS J. HADDOCK, M.D., assistant professor of ophthalmology, also saw patients who needed immediate care for problems like retinal detachments. “I treated one patient who woke up, saw a gray shadow in her right eye that grew larger during the day,” he said. We examined her, quickly rushed her into the surgical center, and were able to save her vision.”
On May 4, UHealth announced that it had reactivated key clinical services, allowing the gradual increase of regular health care. “Our focus was to move forward safely, not only for our patients, but also for our staff members,” said Estes. “We continually asked, What is our new normal? How many patients can we safely treat every day? How can we continue to practice social distancing as we increase the number of patients?”
Despite the challenges from the pandemic, the camaraderie throughout Bascom Palmer has been a source of inspiration for many. “I am so happy to come to work every day and continue to take care of our patients,” Cavuoto said. “It has been a source of energy and excitement knowing that I am still able to do what I love.”
Affiliated Hospital Care
Along with staffing Bascom Palmer’s emergency department, Bascom Palmer’s physicians assisted with eye emergencies at UHealth Tower, Jackson Memorial Hospital, and the Miami Veterans Administration (VA) Hospital.
NINEL GREGORI, M.D., professor of clinical ophthalmology, and chief of the Eye Care Section, Miami/Broward/Homestead VA Medical Centers, treated a steady stream of VA patients for retinal detachments and other problems. “When patients recognized a visual disability, we examined them, and if necessary, performed urgent surgery at the VA.”
In April, Gregori treated a patient in his 60s with a detachment in both eyes that without treatment would have led to blindness. “We were able to treat both eyes on the same day, using a laser on the second, less affected eye,” she said. “I was wearing my N95 mask as well as a surgical mask with the laser headset. For me, the biggest challenge was not the surgery, but because COVID-19 testing was limited at the time, it was not being able to touch our patients without fear.”
Making a rapid shift to telehealth services has allowed Bascom Palmer’s physicians to continue delivering clinical care to patients who do not need emergency or urgent surgery. “We didn’t want to put patients, physicians or staff members at undue risk,” said RANYA G. HABASH, M.D., medical director of technology innovation, and assistant professor of clinical ophthalmology. “Within two weeks of the stay-at-home order in place, we had Bascom Palmer’s virtual visit program up and running.”
While it was challenging to make a rapid adjustment, the Institute’s professionals have been at the forefront of remote technology for many years, developing equipment and applications for evaluating, diagnosing and treating many types of vision conditions, along with artificial intelligence (AI), and virtual and augmented reality tools. “Telehealth has tremendous potential for delivering eye care – not only to our patients, but also to those needing eye care around the world,” said Habash.
Once the decision was made to implement telehealth services – supported by a reimbursement authorization from the U.S. Centers for Medicare & Medicaid Services (CMS) – Habash began developing new workflows for patient care, from scheduling, patient access and the patient experience, to staff training and coding for reimbursement. “The landscape has shifted for patients, as well as physicians,” she noted. “Everyone at the Institute was receptive to doing video evaluations and consultations. We have continued to refine our workflows based on the changing COVID-19 situation.”
JAYANTH SRIDHAR, M.D., associate professor of clinical ophthalmology, worked closely with Habash in developing Bascom Palmer’s telehealth services. “We developed guidelines for different scenarios, including patients with and without COVID-19 symptoms, so we could deliver the appropriate care while protecting patients and staff members.”
For THOMAS E. JOHNSON, M.D., professor of clinical ophthalmology, telehealth offers an efficient way to see oculoplastic patients, including a recent consultation with an individual in Australia. “Using the video camera, I can look at suspicious eyelid lesions, droopy eyelids and other conditions,” he said. “It’s not as good as seeing the patient in person, but it allows me to set up an action plan if surgery is needed. Telehealth is also helpful for post-operative follow-up visits, which can be done at home rather than in our clinic.”
However, some types of vision conditions like glaucoma or retinal conditions aren’t suited to telehealth evaluations. Assessing patients for neuro-ophthalmic disorders is particularly challenging because they typically have general visual disturbance symptoms.
“It can be hard to get a sense of the seriousness without an in-person evaluation,” said BYRON L. LAM, M.D., professor of ophthalmology and the Robert Z. & Nancy J. Greene Chair in Ophthalmology. “We can use telehealth to look at how the eye is moving, but we can’t do prism measurements or assess the optic nerve.”
Those concerns led to a two-part visit, known as a “hybrid visit,” where the first part of the visit is testing that takes place in the office with ophthalmic technicians. The second part of the visit takes place with the patient safely at home on the telephone or video chat with the doctor. These visits have reduced the length of time that patients are spending at Bascom Palmer’s eye care centers.
That is a crucial concern for patients worried about the risk of COVID-19 infection. In April, Sridhar arranged a hybrid appointment for a patient in his 70s with macular degeneration. “He said he hadn’t been outside his house for 41 days,” Sridhar said. “Many others have told me their only recent travel has been to Bascom Palmer for imperative treatment.”
Hybrid appointments are also helpful in treating patients with glaucoma, the “silent thief of sight.” To find diagnostic signs, such as an increase in intraocular pressure (IOP) or decrease in the field of vision, requires an office visit, said RICHARD K. PARRISH, II, M.D., glaucoma specialist and holder of the Edward W. D. Norton Chair in Ophthalmology. “With our new scheduling procedures, a patient can come in at 8:00 a.m., for instance, get the examination at 8:15 and leave at 8:45,” said Parrish. “Then the ophthalmologist will contact the patient at home with the results.”
For glaucoma patients, regularly measuring IOP is very important as increased pressure damages the optic nerve and can cause loss of vision. Before patients were able to come into Bascom Palmer for testing, the Institute offered “drive-up” IOP testing at the Miami and Plantation locations. Patients made an appointment, drove to the front entrance and remained in their cars when having pressure checked.
As a specialist in retinal diseases like age-related macular degeneration (AMD), PHILIP J. ROSENFELD, M.D., PH.D., professor of ophthalmology, delivers regular medication injections to patients in danger of losing their vision.
“It’s hard to provide telemedicine care for retinal diseases, because we can’t look into the back of the eye with specialized imaging equipment like optical coherence tomography (OCT). I am a big proponent of getting these monitoring systems in the homes of patients. That would allow us to see what is happening with the retina in real time.”
Rosenfeld is working with optical instrument companies to develop a wearable device that a patient could put over the eyes to obtain an OCT image that could be interpreted by means of an artificial intelligence algorithm or by uploading the image to the cloud, where a physician could log in and see the images. “This technology is not available yet, but COVID-19 has accelerated the development effort. I think we’ll be able to do this within the next year.”
Meanwhile, Bascom Palmer’s retinal specialists have modified their patient care processes. First, a patient with the aggressive “wet” form of AMD comes into the Institute for an OCT examination with a technician. New patients also get a visual acuity test, but that examination is waived for most returning patients. “This process allows the patient to spend less time in the clinic, while dealing with the most essential questions: does the patient need an injection for wet AMD, and how soon does the patient need to come back for further monitoring?” said Rosenfeld. “Some are in a predictable pattern and need injections every six to eight weeks, while others have variable injection schedules.
Rosenfeld has continued to see AMD patients in Miami and Palm Beach Gardens as regular injections are necessary to preserve their vision. “I am hopeful that research into sustained release treatments will accelerate, as that would mean patients could come in less frequently for their treatments,” he said.
Another change in clinical processes involves testing eye tissues for COVID-19. As an experienced corneal surgeon, Amescua often transplants donor tissues to improve a patient’s vision. But today there are questions about whether corneal tissues could possibly transmit the COVID-19 virus to recipients. “The coronavirus can be incubating in individuals without symptoms,” he said. “Therefore, we follow CDC guidelines and test corneal tissues before proceeding with a transplant.”
DARLENE MILLER, D.H.SC., M.P.H., research professor of ophthalmology, notes that the current tests for COVID-19 use nasal and sputum swabs to check for respiratory infections. “While the risk of transmission from ocular samples is small, the virus has been documented in tears and conjunctiva swabs,” she said.
In the laboratory, Miller and her team are also taking clinical samples from patients and performing polymerase chain reaction (PCR) tests to detect COVID-19. “We are documenting our findings, while following the latest research from around the world,” she said.
Making Other Adjustments
For families throughout Florida, Bascom Palmer provided invaluable vision care to patients of all ages at the height of the pandemic. Take the case of an 11-year-old girl from North Florida with retinoblastoma, a rapidly progressive cancer that often involves both eyes.
“Her father had the same disease, and her mother passed away, so the girl’s grandmother drove all night to arrive here at 6:00 a.m. for testing and treatment,” said J. WILLIAM HARBOUR, M.D., professor of ophthalmology, the Mark J. Daily Chair in Ophthalmology, and director of ocular oncology.
“We were able to start her on chemotherapy medication,” Harbour added. “Despite having multiple tumors in both eyes, she has normal vision. If she continues to respond to treatment, she should wind up with excellent vision.”
Harbour also treats adults with melanoma who often travel long distances for urgent care. “Normally, we treat them with brachytherapy, a form of radiotherapy that involves inserting a device in the eye for three days while the patients stay in the hospital,” he said. “Rather than bring them in individually, we schedule a group of patients for the same day and find them nearby accommodations. They also need someone to drive them, so the logistics of these patient visits can become quite involved.”
Children with vision problems created other challenges during the pandemic. “Because children are still developing vision, we need to see them more frequently,” said HILDA CAPO, M.D., professor of clinical ophthalmology and the John T. Flynn Chair in Ophthalmology. “If they have amblyopia (“lazy eye”), for instance, we want to be sure their glasses have the right corrective lenses. It’s hard to assess visual acuity in a child in a home telehealth visit.”
Prior to COVID-19, children and adults with amblyopia or strabismus were seated together in a large waiting room to evaluate their need for prisms, patches or corrective surgery. Now, the young patients are brought to a special area with their parents when no other patients are around.
“If children need surgery, we call the parents the night before with assurances of care,” said LINA UTRERA, M.S.N., R.N., P.A.N., executive director of nursing. “It’s always hard to have a child in the hospital, but it’s even more difficult now. When the parents go home with their son or daughter, they tell us that we alleviated their concerns and their experience was much easier than they anticipated.”
Health and Safety
At Bascom Palmer, health and safety is the highest priority. All patients are screened for COVID symptoms and given masks when they arrive at any location. Reflecting those concerns, waiting areas throughout the Institute have been reconfigured so patients are socially distant from each other. “We now have fewer people in these areas at the same time,” said Capo. “For patients whose pupils need to be dilated, we do the eye drops right away, rather than after the initial exam. That shortens the time a patient is in the clinic.”
Sridhar notes that the traditional dress code for physicians, such as a suit and tie, had to be discarded with the arrival of the coronavirus. “Now, we are all wearing scrubs at work,” he said. “It’s much easier to put them on and take them off, and they can easily be disinfected in the wash. It doesn’t match the patient’s traditional idea of a doctor, but this may be the new standard.”
Nursing care has also been deeply affected by the pandemic. “With nursing there is a lot of touching and comforting, and with the virus we have to keep our distance,” said Utrera. “That’s a big change.”
“One of the lasting lessons from the pandemic is the importance of basic hygiene,” said Utrera. “Washing your hands is the foundation for preventing viral or bacterial transmission,” she said. “Perhaps even more importantly, COVID-19 has taught us to enjoy each day and appreciate our families, friends and colleagues.”
Serving Our Patients
In each Bascom Palmer location, clinical teams made major adjustments, concerning hours, services and schedules to serve their communities.
“We have all been trying to make the best of the situation,” said KENDALL E. DONALDSON, M.D., M.S., professor of clinical ophthalmology, and medical director of Bascom Palmer Eye Institute at Plantation. “Most everyone knows a family member, friend or neighbor with COVID-19.”
Like the Institute’s other locations, the Plantation staff was divided into teams, so in the event one staff person tested positive, the other team could continue seeing patients. “We have a different doctor in the office every day seeing urgent cases and post-operative checkups,” said Donaldson. “The patients are also screened on the phone. When they arrive at our facility, they are screened and given a mask before they walk through the door. We all have our masks and eye protection.”
Along with her colleagues, Donaldson has quickly become used to telehealth care. “I was treating a woman for conjunctivitis, and her kids helped set up the videoconference session,” she said. “Her husband and son also had symptoms, so I was able to prescribe medications for the whole family in that session. When we met in person a week later, she told me how much she enjoyed the experience.”
Looking ahead, Donaldson feels certain that telehealth will be a long-lasting positive change for vision professionals. “It won’t replace in-person visits, but it does have great potential for the future,” she said. “For instance, a technician could attach a video camera to a diagnostic microscope so the doctor could conduct the examination remotely allowing us to minimize risk to our patients.”
Bascom Palmer at Palm Beach Gardens has provided vision surgery and treatment for conditions that require urgent care, according to JORGE FORTUN, M.D., assistant professor of ophthalmology and medical director. “We have made some significant changes to the way we deliver care, including hybrid visits for diagnostic imaging with follow-up physician consultations by video chat,” he said.
On the technology side, Fortun says an advanced “heads up” visualization system deployed at Palm Beach Gardens last year can reduce exposure risk for physicians doing vitreoretinal surgery. “We traditionally do ophthalmologic surgery through a microscope looking down at the patient,” he said. “This 3D technology magnifies the stereoscopic image, so we look up at a big screen instead.”
Another improvement in patient care is the opening of the Lois Pope Center for Retinal & Macular Degeneration Research. “We have been observing social distancing guidelines that limit how many patients can be in a confined space,” Fortun said. “With the opening of the Lois Pope Center, we are able to open additional space throughout the Maltz Center, while continuing with our clinical trials.”
Bascom Palmer at Naples remained open five days a week to serve patients who needed urgent care. “One of our priorities was retina patients who needed regular injections, including several in their 90s or 100s,” said STEPHEN G. SCHWARTZ, M.D., M.B.A., professor of clinical ophthalmology and medical director. “We also took care of other acute conditions, like retinal detachments, to address a potential loss of vision.”
As in the other locations, the Naples physicians and staff members were divided into two teams, and patient volumes were limited to reduce risks of exposure. “Along with masks and gloves for all patient encounters, I have been wiping down the equipment in front of the patient before starting an exam,” Schwartz said. “I plan to keep doing that, as our patients appreciate the visible precautions.”
Along with treating her regular retinal patients, JACLYN L. KOVACH, M.D., associate professor of clinical ophthalmology, has continued to see participants in a clinical trial for advanced dry macular degeneration. “Fortunately, these patients can continue to get this investigational treatment, and we hope that the results will lead to approval by the U.S. Food and Drug Administration (FDA).”
Like other Bascom Palmer physicians, Kovach has received thanks from many grateful patients. “They are very appreciative that we have been here to help preserve their vision in this health crisis,” she said.
Behind the Front Lines
Much of the credit for Bascom Palmer’s ability to adjust quickly to changing health and safety requirements goes to the Institute’s support teams who work behind the front lines of care. That included major changes to scheduling patient visits led by MICHAEL GITTELMAN, chief executive officer, and JOANNE MARTIN, chief operations officer.
“Normally, we build scheduling templates for patients and providers through our electronic medical records (EMR) system,” said RYAN WHIDBY, M.B.A., executive director of clinical logistics and operations, who manages a lean, four-person team. “That involves a lot of coordination each day, depending on which physicians are available.”
Hundreds of patient appointments were cancelled when the stay-at-home order was issued. Working with staffers from other support teams, Whidby drew up a master spreadsheet of providers, and created a color-coding system for patients who needed urgent care, telehealth services, or in-person visits in the future. “Our goal is to keep everyone safe, continue improving our patient services, and ensure that all patients will be given new appointments to see their doctors,” he said.
Bascom Palmer also has more than 150 staff members dedicated to managing the patient experience, from check-in to discharge and follow-up care. “Our team has multiple interactions with patients,” said MARIO ALMEIDA, executive director of patient access.
The switch to virtual visits has greatly impacted patient scheduling and workflows, such as helping patients prepare for video chats with a physician. Other steps include streamlining the check-in process and explaining infection prevention procedures.
“Last December we had a video session with our entire team,” said Almeida. “I told them that 2020 was going to be a special year for us. Little did I know in what way it would be different. I am pleased we have managed those changes and we are continuing to move in the right direction.”
BELINDA QUINTA, director of sponsored research programs at Bascom Palmer’s Evelyn F. and William L. McKnight Research Center, leads a team that assists faculty with grant applications, prepares budgets, and makes sure that research projects comply with funding requirements.
As much of the laboratory research came to a stop, faculty members began preparing applications for new grants. “We submit more than 100 applications a year and that has increased because of COVID-19 proposal requests,” said Quinta. “However, teleworking has allowed us to be more productive because we’re not commuting in traffic every day.”
Bascom Palmer’s vision research programs have also been dramatically affected by the pandemic. Most clinical trials and laboratory studies had to be put on hold for safety reasons.
After CDC guidelines were posted in March, one of the first steps was determining which laboratory experiments needed to continue, said VITTORIO PORCIATTI, D.SC., professor of ophthalmology, the James L. Knight Professorship in Ophthalmology and Bascom Palmer’s director and vice chair of research. For those studies, a limited number of research staffers returned to the laboratories each day, for example, to care for experimental models critical for ongoing long-term research.
“It’s been a major adjustment for all of us,” said Porciatti. “Fortunately, many of our scientists and clinicians have been able to use this time for writing scientific papers on completed studies or preparing applications for new grants.”
Like other Bascom Palmer scientists, Porciatti is also staying in close touch with post-doctoral trainees and staffers through video meetings. “We are reaching out to other institutions, organizing research meetings with colleagues across the country and internationally. We can share screens with each other and work collaboratively on the same document – a real advantage for many studies.”
Bascom Palmer’s innovative clinical trials for gene therapy for inherited retinal disorders were put on pause this spring. “Our patients understand the need for safety and are disappointed they cannot participate at this time,” said LAM. “We are monitoring their conditions with telehealth calls and hope they can return soon to our clinics.”
Patient safety protocols have also halted many other clinical trials. “Some may be able to resume, while others might have to be restarted,” said Yoo. Researchers might also have to analyze the data from pre- and post-COVID participants differently. She added that the FDA is looking at that issue and may provide guidelines in the future.
The Institute’s researchers are also updating internal protocols, such as conducting the consent process online or over the phone, rather than in person. Other studies might take advantage of the Institute’s virtual visits. “These changes will make our clinical research more efficient,” said ALFONSO SABATER, M.D., PH.D., assistant professor of clinical ophthalmology. “The enrollment process will be able to flow much faster.”
Meanwhile, researchers are making good use of the slowdown in other ways. For instance, SANJOY K. BHATTACHARYA, PH.D., professor of ophthalmology, has built a team of 12 high school, undergraduate, medical and graduate students who are poring through literature from 1757 to 2020 on neuronal regeneration.
“The idea is to turn old scanned literature into readable materials to build actionable knowledge through natural language processing, an area of artificial intelligence,” he said, adding that the study includes UM experts in related fields. “This two- to three-year study is designed to build a big database on the optic nerve and regeneration.”
A second project involves metabolomics as a predictor of severity of exfoliation glaucoma. Bhattacharya is working with RICHARD LEE, M.D., PH.D., associate professor of ophthalmology and the Walter G. Ross Distinguished Chair in Ophthalmic Research, ANNA JUNK, M.D., professor of clinical ophthalmology, and other machine learning experts to identify patients who may need to be followed aggressively.
Moving to Online Education
For Bascom Palmer’s medical education programs, moving to an online platform has created new opportunities to connect with vision professionals here in South Florida and around the world. “We converted all of our lectures, grand rounds and journal clubs to an online video platform,” said Gedde. “Then, we opened that technology up to other residents, fellows, and ophthalmologists worldwide.”
For the Global Center for Ophthalmic Education, the conversion process was a “huge undertaking” that has received extremely postive feedback from participants, according to Serrano-Brosco.
Currently, Bascom Palmer is offering 12 to 15 programs a week, such as a recent lecture on dry eye syndrome by ANAT GALOR, M.D., associate professor of ophthalmology. Attendance continues to grow with professionals now logging in from more than 125 countries. “Eye doctors are home trying to continue their education, and we are able to provide it virtually,” Serrano-Brosco said. “We recently launched www.BascomPalmerLearn.org, a new online learning portal for doctors that will provide an ever-increasing collection of our educational programs that can be viewed from anywhere at any time.
Online education also supports the Institute’s residents. “Along with lectures provided by our current residents, we are hosting sessions with former residents and fellows about applying for fellowships and positions,” said Patel. “These sessions help strengthen ties with our alumni from all over the world.”
Utrera added that many of the Institute’s nurses are also signing up for sessions to further their education on topics such as glaucoma and retinal disease. “It’s a great opportunity for nurses, who may not be currently working as many hours, to gain credits and prepare for new certifications,” she said.
The move to online learning has also increased awareness of Bascom Palmer’s leadership in technology. In a modern version of the “train the trainer” model, Habash has been advising other institutions about launching online educational programs. “Eye hospitals and professionals throughout the field of ophthalmology are coming together to share best practices and to learn from each other,” she said. “It’s very inspirational.”
Across the nation, the Institute’s ophthalmologists are arranging other types of collaborative educational programs. For example, Johnson set up an online session with a faculty member at University of California San Diego. Johnson presented a paper on anatomic socket reconstruction, and one fellow from each institution presented cases, which was followed by a general discussion. The online format received a positive reception and faculty from Stanford University, and residents from New York began attending as well. Now, the sessions are held weekly, giving participants an opportunity to compare practices in different parts of the country.
For Sridhar, the move to online platforms has included delivering podcasts, webinars, and other educational programs to a regional, national, and international audience of vision specialists. “Students, residents, and fellows are hungry for medical information,” he said. “Because they are constantly on the go, podcasts and video-on-demand programs meet an important need. We also have a library of lectures for eyecare professionals who want to improve their knowledge and skills.”
What Lies Ahead?
Looking to the future, it seems certain that many of the COVID-19 adjustments will have long-term implications for clinical care, vision research, and education. “Times of crisis create opportunities for innovation,” said Gedde. “We have all become more comfortable with virtual consultations, meetings, and lectures, and there are many advantages to hybrid visits that minimize a patient’s time in the clinic.”
“Meanwhile, physicians, nurses, and patients need to remain vigilant about personal safety,” said Schwartz. “The pandemic will not end abruptly, and we must continue to be careful to treat our environment as if the virus were present.”
While everyone hopes for an effective treatment or vaccination for COVID-19, Gregori cautions that there could be other viral outbreaks in the future. “I have learned that we need to be prepared as physicians, individuals, and communities,” she said. “That means keeping masks, sanitizers, and other emergency supplies at home, because no one knows when an infectious disease will come again.”
But the courage, creativity, and flexibility demonstrated by the entire Bascom Palmer team this spring shows the Institute is prepared to meet the challenges of the future. As Gedde said, “I am proud to be one of the many Bascom Palmer physicians fulfilling our oath to serve patients, even when it involves personal risk. Medicine is truly a noble profession, and our Institute will continue to stand on the front line of vision care.”