In a world that is changing by the day as a result of the coronavirus (COVID-19) pandemic, and acknowledging that some of the following recommendations are not possible in communities in which eyecare offices are closed, Contact Lens Spectrum reached out to a number of prominent eyecare professionals who own specialty contact lens practices to obtain their input on how they are managing contact lens patients during this challenging time. The individuals who responded are acknowledged at the conclusion of this article.
Each of the strategies detailed below represents what a responding practitioner is doing in his or her own practice. You will note that there are some repeating patterns in the strategies, which serve as a testament to their success as best practices.
But before jumping into these strategies, it is important to remind everyone that contact lens wear continues to be safe; however, practitioners and their patients must remain vigilant in the fight against COVID-19. Most critical is proper handwashing (for at least 20 seconds and drying with unused paper towels); for contact lens wearers, handwashing should be performed before both contact lens application and lens removal. It is also crucial that patients dispose of their lenses on the proper schedule and that they follow all contact lens and case care instructions. As the COVID-19 virus can maintain viability for two to three days on hard surfaces, remind patients to disinfect spectacles (with soap and water). Lastly, as always, patients should discontinue contact lens wear when sick and follow the guidance of their eyecare provider in this regard. Guidelines for safe, evidence-based contact lens wear and care from global contact lens experts are available in a Special Edition of Contact Lenses Today at https://www.clspectrum.com/newsletters/contact-lenses-today/march-12,-2020. Please also see the "Additional Resources" box for more information on safe contact lens wear and protecting yourself and your patients from contracting COVID-19.
HOW DO YOU HANDLE PATIENTS IN NEED OF REPLACEMENT LENSES?
Strategy 1 Send a blast email to all patients stating that if they are worried about losing their benefits or running out of contact lenses, the practice will waive shipping charges and will extend, if reasonable, recently expired contact lens prescriptions and will dispense a six-month or a 12-month supply of lenses. This is not only an ethical, humane solution for patients, it can prove to be a great boost in revenue as well.
Strategy 2 For any patients who are scheduled for their annual exam and who will run out of lenses, ship them a three-month supply. In the case of monthly lens wearers, send them a minimum supply (six months’ worth of lenses). For patients who haven’t picked up lenses that were delivered to the office, call and ask them whether they would like to have their contact lenses mailed to them.
For patients who choose to come to the office to pick up their lenses, post a sign on the door instructing them to call or text when they arrive and that their lenses will be brought out to them. It helps in this case for practices to have software that allows patients to text the office number; it is usually viewed immediately and, therefore, can be responded to in real time.
Strategy 3 Pull a report of all patients who are or soon will be due to order contact lenses, then call each of these patients and offer free shipping on a replacement lens order. This provides much needed revenue and also prevents overwear of lenses. Patients are usually very appreciative and thankful for this service.
For specialty lenses, ship them to patients when possible, but don’t place any new orders in an effort to preserve warranty periods. Fortunately, many laboratories have already communicated their intent to extend some warranties.
Strategy 4 Provide some staff members with remote access to the practice’s electronic medical record (EMR) and practice management systems. These staff members can respond to requests from patients and also can proactively reach out to patients who would be due to come in for an appointment and to order replacement contact lenses. Offer these patients the option to have lenses ordered and shipped directly to them.
For custom and/or medically necessary contact lenses, it is important to request that laboratories extend warranty periods should lens modifications be necessary when patients are once again able to come to the office for non-urgent care.
Strategy 5 It is important to maintain excellent communication with patients during this trying time. Make clear on your practice websites how you would like patients to contact you, and send email blasts with this information. Be available by phone during all normal business hours and anytime via email.
Shipping lenses directly to patients is ideal to maintain social distancing. Liberally extend the prescription period, and politely make it clear that this is only because of the extraordinary circumstances to avoid changes in future expectations.
Strategy 6 If you have debt structure that needs to be serviced, liquidate your office inventory and offer the lenses to applicable patients for purchase. Rather than entering the office to pick up the lenses, patients can have them delivered to their car (for drive-up offices) or to just outside of the office if they don’t want them shipped directly. When patients arrive to get their lenses, make sure that the staff member who delivers the lenses wears gloves to comfort the patients who are receiving the products. Also recommend that patients open their direct-ship boxes outside of their house and bring only the contact lenses into their home, as some are recommending with Amazon shipments.
If your practice has no debt and/or larger cash reserves, consider ordering and direct shipping any requests for replacement lenses and retaining your in-office contact lens inventory in the event of any possible future supply line shortages.
Strategy 7 Established scleral lens wearers who are waiting on replacements/remakes/updated prescriptions of existing lenses can have their lenses mailed to them. If that is not convenient, the lenses can be delivered “curbside” without patients entering the office. Instruct patients to remain in their car.
Strategy 8 Encourage most patients to have lenses and products shipped directly to their homes, but for those who wish to come to the office to pick them up, have a staff member deliver the products to them at the front
HOW DO YOU HANDLE URGENT CARE OF CONTACT LENS WEARERS?
Strategy 1 Patients who experience an eye emergency (acute pain, swelling, flashes and floaters, foreign bodies, blunt trauma, etc.) should be seen in the office. Only the affected patients should enter the office…no family members. Wear laboratory coats and surgical gloves, and wipe down everything after each visit.
Strategy 2 Careful triage. Video chat provides practitioners with an opportunity to not only visualize the eye but also to see a patient’s body language; some patients may downplay symptoms on the phone, but seeing their face can show the level of discomfort or pain that they are actually experiencing. Also, this allows practitioners to direct patients in performing a gross initial ocular examination. Listen for triggers indicating that a patient must be seen in person, such as pain or photophobia.
Currently, telemedicine can be used to evaluate patients and to treat them appropriately. If a case is too complex, the patient can be recommended for in-office examination or referred to the appropriate provider for emergency evaluation. Be careful about seeing patients who have conjunctivitis, as this has been documented in association with COVID-19. For those displaying viral conjunctivitis signs and symptoms, it is appropriate to triage for other COVID-19 symptoms and factors.
Strategy 3 As you always would, have a practitioner on call who will respond to emergency cases of any type. That practitioner will determine whether a live visit is required and will then see the patient at the office. Otherwise, they can perform a virtual telehealth visit. Many applications are available to allow for such video connections with patients. The key is that regulations have been changed to allow billing using either telehealth-specific codes or, if video based, Evaluation and Management codes, with the appropriate modifier (GQ) and location of service code (use location code #2). This is applicable to both Medicare and commercial insurance.
Strategy 4 Remember that video telemedicine patient examinations pay better compared to telephone telemedicine examinations. With proper documentation, you can now bill the video exams at 99XXX code levels.
Strategy 5 Patients who have an emergency should initially have a phone consultation with the practitioner on call for that office. The next step is a virtual consultation using a video communications app so that the clinician can see the eye. If the practitioner feels that the patient’s condition requires an in-person visit, the patient should be evaluated in the office.
Strategy 6 In this pandemic situation, an office visit is similar to a surgical procedure; practitioners must weigh the risk/benefit ratio for not only the patient but the practitioner and staff as well. Medically necessary contact lens-wearing patients who require care should have, at minimum, a dispensing appointment in the office, as this fits the criterion of complex or urgent care.
Strategy 7 For patients needing medically necessary contact lens fittings, it is important—if possible—to still see them. Some of them are delivery drivers and grocery store employees who are working hard to serve the country in this dire time. Limit visits to only one patient in the office at a time, and take extra precautions when sanitizing the equipment and diagnostic lenses.
Strategy 8 It is important to continue to handle urgent/emergency care in person at the office. In addition, it is important to remember that for many patients who wear specialty lenses, they can be functionally impaired to degrees that vary from mildly inconvenienced to completely debilitated. Although the eye may not be in jeopardy of being lost to infection, these people may not be able to function safely without their contact lenses because of either the visual handicap or unrelenting pain without their lenses in cases of patients who get relief from pathological dryness only by wearing a scleral lens; this elevates their needs well above those of standard soft lens wearers, who can still function normally with a pair of spectacles. That said, when evaluating specialty lens patients during this pandemic, it is essential to sanitize all surfaces and to use a slit lamp face shield.
WHAT ELSE WOULD YOU DEEM IMPORTANT IN CONTACT LENS PRACTICE TODAY?
Strategy 1 During this difficult time, eyecare practitioners should try their best to provide the best possible patient care; but, they should not do this at the expense of their own well-being. As the virus becomes more widespread across the United States, practitioners should keep their contact lens practice and emergency care to a minimum until it becomes safe again.
Strategy 2 Practitioners have the potential to be significantly disrupted by this pandemic. If you don’t have a way to address patients’ needs, companies who do not have the best interests of patients or eyecare practitioners in mind will be advertising that they can provide for patients during this time of crisis. Our patients will accept this as the new norm, which poses a post-pandemic threat to eye care. Be in communication with, and available to, your patients. Many are scared in this uncertain time, and to know that you are available and able to answer their questions and concerns is important.
Strategy 3 Use this time to make changes within the office including:
• Work on getting your contact lens software ordering platforms up and running. Many of these software programs with contact lens distributors and companies require you to build a library of contact lens parameters, which is too time consuming during normal operations. If your office can do it now, you are poised for more efficiency when the doors open back up.
• During downtime at the office, clean all of the GP fitting sets using the new disinfecting guidelines (available at: https://www.gpli.info/wp-content/uploads/2020/03/2020-01-15-in-office-disinfecting-of-diagnostic-lenses.pdf).
• Revisit all of your new and existing contact lens patient instruction materials and in-office patient pamphlets. As in most busy practices, they probably need to be updated—in graphics if not in words.
A crisis such as COVID-19 does, in fact, force some positive change. Patient and practice hygiene has become paramount, and this will continue. Just as distance learning has to be embraced by our universities at this time, contact lens practitioners are relying on many forms of distance communication—including telecommunication—to ensure that their patients are well informed and do not lack contact lenses and contact lens care during this time. In addition, as our experts have emphasized, a crisis such as this one reinforces the value of fitting specialty lenses. These patients are closely associated with the office, and they will return once the doors have reopened for routine contact lens care.
The COVID-19 virus has forced every contact lens practitioner to use every conceivable form of communication to show their patients how much they care. Because of that, we will all get through this…together. CLS
Acknowledgements: Tom Arnold, OD; Mile Brujic, OD; Brian Chou, OD; S. Barry Eiden, OD; Rob Ensley, OD; Melanie Frogozo, OD; John Gelles, OD; Elise Kramer, OD; Ken Maller, OD; Robert Maynard, OD; Clarke Newman, OD; Roxanna Potter, OD; David Seibel, OD; Jeff Sonsino, OD; Laurie Sorrenson, OD; and Stephanie Woo, OD.
Dr. Bennett is professor emeritus at the University of Missouri-St. Louis College of Optometry and is executive director of the GP Lens Institute. He is also clinical features editor for Contact Lens Spectrum. You can reach him at firstname.lastname@example.org.
This article is a companion to another feature in Contact Lens Spectrum titled "Helping Specialty Lens Wearers Succeed During the Pandemic."