Musings from the Wise in the Covid Era

Dr. Soumya Podury
Dr. Tandava Krishanan
 Parthopratim Dutta Majumder
Published Online: April 2nd, 2021 | Read Time: 38 minutes, 1 second

We all are in the midst of an unprecedented global crisis due to the COVID-19 pandemic. This global pandemic has changed the ophthalmology practice pattern and there is an atmosphere of growing uncertainty among the ophthalmologists. We three spoke to some of the finest and sharpest minds in Indian ophthalmology and teachers of the teachers.

Dr. Amod Guptais a world-renowned ophthalmologist and teacher of teachers. Dr. Gupta retired from the Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. Dr. Amod Gupta has been a teacher and mentor to many for over four decades.

Dr. GullapalliNageswaraRao founded the L V Prasad Eye institute in 1987. Dr. G N Rao has shaped many minds in his illustrious career in the field of ophthalmology. He has notable contributions to the advancement of ophthalmology in the nation. He currently holds the honorable position as the Chair of the Academia Ophthalmological Internationalis.

Dr. Lingam Gopal is a pioneer in the field of ophthalmology. He has been a mentor and has shaped the minds of many in the field of Vitreoretinal surgery. He holds distinguished senior consultant posts at prestigious institutes like Sankara Nethralaya, Chennai, National University Hospital Systems (NUHS), Singapore, National University of Singapore.

Dr. Perumalsamy Namperumalsamy is a visionary ophthalmologist from India and one of the founding members of the Aravind Eyecare System. He is a pioneer in the field of ophthalmology and has made remarkable contributions to the field. He is currently the Chairman Emeritus and Professor of Ophthalmology at Aravind Eye Care System.

eOphtha: What are your greatest concerns with the pandemic?

Dr. Amod Gupta: If the reports and images of the large congregations to celebrate birthdays, weddings, political meetings or religious functions that we see every day are true, some people seem to be living in their make-believe world that they are safe and it is the others who will get it. This means our message is not reaching where it should. Instead of harping on the complicated graphs, the emphasis should have been on the consequences of such gatherings. If this behavior continues we are in this pandemic for a long haul.

The pandemic has exposed the ugly reality of our grossly underprepared health care manpower and the infrastructure. These pandemics in one or the other form are likely to visit us now and then and unless we draw lessons from the current pandemic, we shall be back to square one.

Patients of chronic diseases, like DM, hypertension, CAD, lung diseases and others who need to visit their doctors are not doing it, discouraged as they are of police threat if they dare step out of their house. It may in the long-term result in increased morbidity and mortality. Patients of ARMD and DR who need their monthly shots in the eye are perhaps not getting these.

People living on the margins of society, daily wage earners, migrant labour force, and urban slum dwellers are taking a heavy toll during this pandemic. How long their patience would last is anybody’s guess. In addition to the public health specialists and epidemiologists, social scientists should have been playing a greater role in this pandemic. We don’t seem to be doing it.

Dr. GullapalliNageswaraRao: Ophthalmology is certainly hit hard as most services come under the elective category

Dr. Perumalsamy Namperumalsamy: The primary concern is the severe health emergency that the global community is now experiencing. With over more than 3 million affected and about 200 000 fatalities, this is a pandemic of epic proportion our generation has not seen with no definitive treatment, prophylaxis, or vaccine feasible in the near future. More than anything, the easy way it spreads in the populations due to droplet or contaminated surfaces, is something unprecedented.

The second major concern is with the global economy. Most experts in this field are of the opinion that the impact of the COVID pandemic on the livelihood of common people and national economies throughout the world is anticipated to be far out of proportion to the effects of the virus pandemic on the peoples’ health. It is widely surmised that hunger and joblessness across the economies are bound to have far more impact on the lives of the people than the infection itself. The economic downturn, which will become more prominent and noticeable as the infection subsides in the next few months, is expected to last several years to revert to that of the pre-COVID times. We will require far-sighted global leadership to navigate humanity from such an unprecedented crisis.

Last, though not the least, is my concern regarding healthcare delivery models in general, and eye care in particular. Most eye care organizations meeting the eye care needs of the economically underprivileged, in particular in the developing economies depend on the Non-Governmental, Non-Profit Sector. These organizations need not only to cater to the community needs at large, but also require protecting and safeguard thousands of their eye-health workforce and their families by providing a secure livelihood. Sustainability of many such eye care programs are likely to pose huge challenges to healthcare leadership. Leaders of eye-care organizations will have to re-invent their strategies to continue to remain relevant and sustainable in the face of Post COVID economic crises.

The lockdown season has resulted in making lives of all of us taking a different turn. Saving ourselves and the community from the spread of the infection is the need of the hour. It does not mean that we need to be panic. Our governments both at the centre and state levels have charted clear cut guidelines to contain the spread of the virus. There are several basic hygiene measures like frequent handwashing, avoid touching mouth, eyes or nose, and social distancing which we have been asked to follow strictly. Our duty at this point of time is just to abide by these instructions. Together, we will overcome this crisis.

eOphtha: How has your ophthalmology practice been affected due to the current pandemic?

Dr. Lingam Gopal: I am practicing in Singapore in a government general hospital and hence the conditions as well as patient profile would be totally different from India. Hence my comments may be irrelevant from the Indian ophthalmologist perspective. There are obviously lots of differences that have to be kept in mind when you interpret my comments.

Direct affects:

a)This is perhaps common to all professions where contact with public is required and hence there is always a lingering fear that one of the public whom we are dealing with is carrying the virus. The duration of contact is perhaps longer for a medical professional compared to other professions such as a banker/ cashier at the super market etc. Even among medical professionals there could be significant difference in the time duration of contact. In addition to the measures to reduce risk of drop let transmission that we are all currently practicing, we are also conscious of the duration the patient spends in the consultation room. Hence we avoid unnecessary wastage of time while the patient is in front of us. This is achieved by several simple measures. a) Go through the patient’s records before patient is brought into the clinic including the previous OCTs, HVFs etc. b) No answering phone calls during the interaction with patient.

b)At an institutional level several measures had to be taken to follow social distancing norms. This resulted in a drastic cut in the number of patients one could see in a day. Hence a system had to be evolved to screen all patients scheduled for the subsequent week, call each one of them and post pone their appointment where possible. This is indeed a huge exercise.

c) This ended up in each one of us spending a lot of time in the clinic but seeing very few patients. In normal circumstances one would have bundled up these few patients within 2- 3 hours and completed the job. But to avoid crowding at the counters/ waiting room etc, one had to space them at long intervals. Hence our efficiency really drops.

d) There is also the difficulty in deciding which cases to post pone the appointment and by how many months.

e) One also had to get into one’s system the new working order: the cleaning of the surfaces of potential contact etc between each case. etc.— so that it becomes a reflex and not missed.

f) All non-emergency surgical cases have been postponed.

Indirect affects:

a) The constant worry as to what will happen once the restrictions are removed- the deluge of patients that one has to face and how to handle it

b) The mounting back log of surgical cases and how to handle the load. One is faced with some difficult decisions. A case considered not an emergency now can turn into semi emergency as time elapses.

c) Although the work load is less during this period, I find that out time management is not the best. A lot of time gets wasted and we are unproductive for a major part of the day. Of course if one is diligent, one can use this time to catch up on the reading of publications or writing papers etc.

eOphtha: Recently a study on COVID-19's effect on outpatient visits found ophthalmology to be the hardest hit specialty. What’s your take on this? What do you think is the role of an ophthalmologist in the current scenario?

Dr. Amod Gupta: I think the Ophthalmologists’ mistaken belief that they are safe since they don’t directly deal with the COVID patients has led to an initial surge in the numbers. We must remember that nobody is safe from the COV-2 infection. I recall the early days of HIV infection in the 1980’s when we did not know how HIV spread, how much panic it created, how extraordinary precautions were taken, HIV positive patients were isolated, nobody allowed them near them or shook hands or shared meals. Ophthalmologists were no exceptions, they wore gloves, had shields on the slit-lamps and sanitized tables, doorknobs, slit lamps and other equipment, and in short, they took all possible precautions to prevent the spread of infection. We stopped taking these preventive measures once we knew that it is sexually transmitted. We are used to taking these precautions during the 'Eye-Flu' that visits us practically every year to avoid getting infected and prevent the spread of the infection to other patients in the clinic. We are better placed with COV-2 infection, by and large, we know how the infected COV-2 droplets contaminate all surfaces. Whether the COV-2 hangs in the air for long hours is still not clear although, preliminary evidence from China shows that the air in the changing rooms and hallways is contaminated with COV-2. We also know that asymptomatic (infected) patients may also spread infection. Thus we need to take universal precautions, believe all people who walk into the clinic are potentially infected, all places that are frequented by people are contaminated and we should obsess about taking universal precautions that should include compulsorily wearing of masks by all people who walk in the clinic or market places, wearing of gloves by the clinicians, sanitizing all the surfaces after every patient and of course, frequent hand washing. Ophthalmologists need to keep themselves safe and above all ensure the safety of their patients.

Dr. GullapalliNageswaraRao:

a. Continue to provide ophthalmic care for emergencies and those whose condition is sight threatening.
b. Provide patients more awareness about COVID and educate them

c. Same way for the public

d. Prepare for the post - COVID practice

Dr. Lingam Gopal: I think we fit into the overall system where we are working- the specifics would be vary depending on where one is working. In a system like ours ( a general hospital), ophthalmologists have been called to assist the core COVID group in ways that they can assist. In view of this redeployment, the eye department has been working with less staff.

Dr. Perumalsamy Namperumalsamy: Ophthalmology is one speciality which requires close proximity with patients for various diagnostic procedures, from the simple ones to the most advanced. That being the case, ophthalmologists are a high-risk category. Most of the ophthalmic clinics have high patient volume, the waiting areas are overcrowded, creating high chances for the spread of virus, thus risking the lives of health care workers and other patients alike. A great majority of patients in an eye clinic are the vulnerable elderly people who may have other underlying health issues.

Ophthalmology depends largely on the cataract surgeries performed for its sustainability as a practice. With most outpatient services and elective surgeries being asked to be suspended, it has become a herculean task for not only individual eye care practitioners but also for large institutions to be financially sustainable. The role of ophthalmologist and eye care institutions in the current critical juncture is to ensure the safety of its facilities so that patients who visit for their routine or emergency eye care and their front line staff including eye doctors, paramedical and support staff are adequately protected from spread of corona infections. It is essential not only to provide for the Personal Protective Equipment (PPE) required to protect the staff, but also actively facilitate the staff use them unfailingly without putting themselves and their colleagues to any undue risks. They may have to constantly train and motivate their staff in this hour of crisis to continually provide the safest and best care of their patients. Ophthalmologists also need to ensure their facilities, and equipment are stringently disinfected according to the norms and monitor their staff adequately meet the regulatory requirements for safety of the premises and the personnel. In the same vein, ophthalmologists need to ensure timely and appropriate care is provided to patients who seek such care without any prejudice and irrespective of their capacity to pay. They need to continuously innovate and adapt , and start exploiting technology that is available for remote consultations, remote monitoring as much as possible, while ensuring the critical care of those requiring physical evaluation is also adequately met.

Aravind Eye Hospitals have already been practising remote consultations in its primary eye care centres. Patients visiting these centres, mostly set up in rural or suburban areas, can consult the ophthalmologist in one of the base hospitals via telemedicine and get necessary treatment. In this challenging times, Aravind has opened e-consultation facility in all its hospitals. As far as eye care is concerned, 80% of the problems can wait to get treatment. Most of the surgeries are done electively and so, there is no sense of urgency. There are only very few cases that need immediate attention – severe pain or infection in eye, injuries and sudden vision loss. Patients with conjunctivitis need not visit the clinic, instead can avail the e-consultation. Follow up of patients who have had intravitreal injections for conditions such as diabetic macular edema, retinal vein occlusions, age-related macular degeneration can wait until the situation gets better or reduce the frequency of visits during this critical time.

eOphtha: What are your thoughts on e-learning especially webinars? Do you think it might become the preferred mode of learning now, replacing the conventional conference, meetings?

Dr. Amod Gupta: Presently there is a surge of webinars of all shapes and hues. Everyone is trying to plug in their webinar. It is a good platform to share didactic information and generate discussion. As for Ophthalmology is concerned I think AIOS should take lead in regulating calendar of events viz. the time, date, subject and content of webinar to avoid duplication and ensure even spread of the events. The e-learning should have become popular much earlier, though it is never too late. I have seen for the last some years live webcast of the select AAO sessions. I did not miss being physically present in the US. In my opinion, there is no need for physical gatherings for academic pursuits for all times to come. But, we need to ensure the conference platforms we use are safe. Currently, most of these events are being sponsored by pharma companies, how long they will do it is a major concern. I believe MCI should give credit hours if the attendees can pass the post-test which should be integrated into the webinar. Moreover, MCI may be persuaded to provide a safe platform for organizing these events. For clinical skills development and hands-on learning, we will need to organize events on a much smaller scale.

Dr. GullapalliNageswaraRao: e-learning has become increasingly more common even before COVID. It has now become a necessity. If done well, can be very effective.

It still cannot match traditional education 100 percent at the present time particularly in medicine. The current crisis may necessitate accelerated innovations that may bring distance education closer to on campus education.

Conventional meetings , in my view, will be much less in number in the near future and may be completely extinct in future unless the social instinct of our race continue to demand personal interactions.

Dr. Lingam Gopal: I guess everything has its place. But I honestly do not think it will replace physical meetings. They have a lot to offer that webinars cannot: a) Permits meeting of people that are not the faculty. Sometimes these people ( a part of the audience) may have more to offer than the core faculty. b) For the same reason it helps networking. c) The chances of a person sitting in a auditorium and listening to the talks is more when he/she has paid for the course and travelled long distances than when it comes free on line as a webinar. I am not talking of the core enthusiasts here.

Dr. Perumalsamy Namperumalsamy: Most academic organizations are increasingly adopting webinars or online seminars to get through their message, interact and educate their target audience. This is increasingly true of all dissemination of medical knowledge as well. Though nowhere close to replacing a session in physical space, these online initiatives are serving its purpose of educating and engaging the audience. A major advantage of these online sessions is that they completely do away with physical boundaries and are able to reach a wider audience across the globe. Given the success, such webinars are here to stay even after normality is restored in the post lockdown phase, especially in a cash strapped environment. We have learnt that these sessions cost a fraction of what they would otherwise have. Yet another advantage is that technology makes it feasible for people to attend these sessions virtually at a later time as well, and probably is much more effective as a source of learning. It is often the industry that supports and sponsors such physical meetings of medical professionals and switching to such online sessions will also result in huge cost savings which can now be diverted to meaningful research or other corporate social responsibility initiatives to benefit the community. Reduction in physical attendance will mean lesser cost, lesser travel and is likely to benefit the environment and climate change favorably.

Having said all these, some limited physical meetings will of course, need to continue since learning in Medicine should also involve some amount of personal interactions and sharing of skills.Given the nature of the subject, budding doctors has a lot to learn from direct interactions and sharing of knowledge. They need to get exposed to the latest trends, skills and technology in practice, which is less likely to achieve through an online session.

The possibility of setting up a virtual academy is worth considering these days, given the tremendous advancements in the field of technology. At Aravind, we have been doing this for over a decade. Aravind centers are spread across various parts of Tamil Nadu, Pondicherry and Andhra Pradesh. Our post graduate students are also dispersed across these centers. To make the best use of our expert doctors’ time and expertise as well to facilitate knowledge sharing, we regularly organize Grand Rounds virtually. These sessions also have eminent faculty from prestigious universities across the world and are found to be of great benefits especially for the ophthalmology students.

eOphtha: How are you coping with social isolation? What are the new things you are doing now a days?

Dr. Amod Gupta: As a retired person, it did not make much difference to our lifestyle, although I miss my daily walks. However, living without any assistance for the first time in my life, allowed me to realize how critical is it to be able to independently manage your household chores. This last month I have become adept at all these. This keeps me occupied for nearly 8 hours a day. It has been a blessing in disguise as I feel lighter and healthier like of which I never felt in the last so many decades.

Dr. GullapalliNageswaraRao:

- Work on other hidden talents - art, music, writing , cooking etc.

- clear backlogs

- catch up with books you always wished to read but couldn’t

- more independence at home

- more time with family

- or binge on movies or TV

Dr. Lingam Gopal: Frankly this has not been the most important problem for me since I still go to the hospital every day even if I work less. Obviously there is more spare time on my hands to spend- I use it in several ways such as crossword puzzles, catching up with some reading, listening to music and of course face time with my loved ones.

Dr. Perumalsamy Namperumalsamy: Social isolation has given me a designated time to consolidate and shape up ideas that have been in my mind for a long time. It is my dream project to develop Aravind Eye Hospital, Theni, one of our secondary care centres, as a model for universal eye care in the country, especially in the management of diabetic retinopathy, glaucoma and retinopathy of prematurity. Several new concepts are being evolved like family screening for glaucoma, prevention of blindness due to RoP to make this a reality. I envisage this to be achieved through public-private partnership working along with the government primary health centres. An experimental approach towards improving uncorrected refractive errors among the illiterates in rural areas is being developed. This isolation period has given me time to think about the steps ahead towards materializing these and develop a concrete plan.

Attending virtual meetings with the hospital management team to take stock of the current situation as well as sharing inputs while developing policies in the context of the pandemic has become my routine these days. I continue to engage in research activities, help develop research proposals and writing for grants. Discussions are underway with Department of Biotechnology, Govt. of India to work on an Indo-Australian collaborative project. Of late, I am seriously involved in various developmental activities in my village where I was born and brought up. Some of these initiatives include provision of safe drinking water, installation of solar streetlights/solar power plants, arranging yoga and training sessions for the villagers, renovation of water tanks, temples, community halls, etc. Developing the infrastructure facilities of my school - furniture, library, lab - is one of my prime concerns. I also enjoy farming in the village making use of the modern technologies like drip irrigation and other horticulture activities. On a more personal note, I utilize the time to keep myself fit and healthy – doing Yoga, listening to Vethathiri Maharishi’s teachings, performing Art of Living sessions, walking, mild exercises, reading books and watching television.

eOphtha: To conclude on an optimistic note, what gives you most hope moving ahead?

Dr. Amod Gupta: Humankind has survived the ice age, flu and plague pandemics, famines and world wars, it will surely survive this pandemic as well. I am sure we shall emerge much stronger and much better prepared the next time over. I think it is for the first time in history that health and hygiene have drawn overwhelming attention. I am hoping for a major enhancement in the budgetary provisions for health and healthcare facilities all across the globe. Hopefully, in future too, healthcare workers will continue to receive the much-deserved respect what they are getting now and were on the verge of losing it. This pandemic has taught us so much and so quickly about resecting the personal space, patiently wait in lines and not peeping over the shoulder of the next guy, and not spitting and coughing into someone’s face. Compulsory face masks would hopefully reduce TB burden, reduce smoking, reduce oral and lung cancer, and reduce drug addictions and alcohol dependence. For all these to change in society it would have been a herculean task and yet take several generations to achieve it.

Dr. GullapalliNageswaraRao:

The human spirit will find ways to deal with the challenge

- some lessons learned may change certain things

- personal hygiene at personal level

- more respect and resources for health care and science from the policy makers

- opportunity for medical profession to redeem itself as a noble profession and that “ service “ is our motto.

Dr. Lingam Gopal: I am a born optimist. Everything in the history tells us these issues have to end at some time or other. Instead of getting depressed about the present, it is best we concentrate on what we are going to do once the restrictions are lifted. That will keep our minds busy on the planning etc. Meanwhile it is important to keep our minds busy and body fit. I am happy to share with you that I could increase the distance I can now run continuously from 0.5 km one month back to almost 3 kms now. The message - stay safe, but stay fit and stay alert.

Dr. Perumalsamy Namperumalsamy: Homo Sapiens as a species has not only dominated the planet, but has survived for over 70 000 years, enduring challenge of every kind, including Wars, Pandemics, emerging diseases, famines and floods. Humanity has withstood every calamity with courage and forbearance. I firmly believe this too shall pass. The entire global community has stood as one, sharing knowledge, experiences and other resources to combat the emerging pandemic. I have to make a special mention of medical scientists involved in pioneering research with the objective of understanding the pathogenesis of the COVID infection, unraveling the viral genome and finding possible therapeutic interventions including vaccines. Somehow, these front-line warriors are not as celebrated as the medical and healthcare professionals or others in combat. The humanity owes significantly to these researchers who will, in co-ordination with clinician-scientists will ultimately help us conquer the virus as we have done in the past. The most important consideration at this crucial moment is we, as human beings should continue to practice compassion to the lesser unfortunate amongst us to overcome this battle, be it in conquering the disease or overcoming the adverse economic impact of the pandemic. It is the human endurance, tolerance, empathy, concern and care that will ultimately win the war against the virus. Humanity, in its quest for prosperity has also plundered the Nature and its rich resources with Climate change and its adverse consequences on the very survival of humanity. All this has to change, and we need to leave the world for our subsequent generations as it was when we had come into being.

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