Our Eyes, Our First Defence

As Singapore emerges from the “circuit breaker”, a measured approach and long-term plan for eye care to better prepare for possible future outbreaks should be considered

SGSecure, a national campaign launched in Singapore four years ago for crisis preparedness has been a success in informing residents of the need to be vigilant against terrorist attacks and other civic emergencies. It has a catchy tagline of “Our eyes are our first defence”, with eyeball mascots keeping an eye out for signs of trouble. I cannot agree more, since our sense of sight comprises 80 per cent of our senses.

2020, the year for good vision, has quickly degenerated into the worst public health and financial crisis in a generation, no thanks to Covid-19. As the world hunkers down to avoid what seems to be a threat worse than terrorism, local essential services like healthcare, transport, food supply and infrastructure have soldiered on these two months, including my specialist eye clinic, albeit on a much smaller scale.

Eye diseases are rarely life-threatening, even though they can blind one and affect one’s independence and livelihood. Yet the trickle of patients with eye problems, significant enough to leave home to see a doctor for, has told a sobering story of how prevention is truly many times better than cure. Apart from symptoms like seeing floaters and flashes which may be due to unavoidable retina tears that can cause detachment, most other acute eye diseases are arguably avoidable, either by early detection and preventive treatment, or careful management of general health problems that may give rise to eye diseases as a complication.

Flattening the curve
Very few would have predicted that a viral pandemic could bring human activities to such an abrupt halt. Deriving Singapore’s coping strategies from our Sars-hardened political leaders, public health and infectious diseases experts, themselves on a steep learning curve, we do our best to flatten the Covid-19 curve by staying home as much as possible.

Meanwhile, life goes on, and the usual urgent and emergent health problems happen as they normally would, with some exceptions such as reduction in influenza and air pollution-related allergies. On the other hand, as a result of the stay-home campaigns, health-seeking behaviours, other than pandemic-related, are altered and delayed by the healthcare bottlenecks worldwide. As such, there are emerging signs of increased disease severity at presentation in affected specialties, with possibly higher morbidity and mortality.

Even though I fully agree with and have operated by the Ministry of Health’s guidelines on appointments and social distancing during the past crucial weeks, my heart aches when I see otherwise able-bodied patients lose their vision. Chronic diseases like cataracts can sometimes progress faster than what conservative treatment plans for. This has resulted in some patients going from doctor to doctor, seeking surgical relief for functional restoration.

Furthermore, delays in seeking medical attention can cause one’s vision to be permanently damaged from common eye diseases like glaucoma, macular degeneration and diabetic retinopathy, all of which are usually symptomless in the early to moderate stages, where commencement of treatment to preserve sight is effective and strongly advised. In the worst scenarios, patients are unaware until they reach advanced stages of these eye diseases. By then, extensive treatment is indicated, unfortunately often unsuccessful in fully restoring vision. The consequent vision loss can render one unable to adequately manage activities of daily living and to work. It is my sincere wish that the eye care profession can satisfactorily manage the backlog of cases in the coming weeks.

As Singapore emerges from the “circuit breaker” and gradually resumes life as we knew it, my personal opinion is that a measured approach and long-term plan for eye care to better prepare for possible future outbreaks be considered. Ongoing management of acute cases aside, and while safe distancing and all applicable infection control measures are followed for protection of patients and doctors, emphasis should be on eye treatment to restore function as soon as possible for affected patients, so that breadwinners and families can get on with their lives.

Further to that, monitoring of previously diagnosed chronic eye diseases, particularly unstable cases, and eye screening for patients with risk factors should not be long-delayed, so that treatment outcome can be optimised. Efficient use of downtime As food for thought, in Hong Kong and South Korea where pandemic measures are reportedly balanced and infection control generally good, ophthalmologists, particularly those in non-hospital or privately-run settings, had continued to provide “compartmentalised” services for eye care including cataract and refractive laser surgeries.

Such practices, to my knowledge, had reportedly not contributed to a spread of Covid-19, is openly accepted locally and deemed an efficient use of enforced downtime, particularly by patients seeking laser refractive correction, who are typically young adults and more resilient to the pandemic. In other countries, Covid-19 swab tests are carried out as a screening prior to surgeries. In Hong Kong, eye specialists in different sectors seem to close ranks, with counterparts in the private sector proactively contributing to the care of public sector patients.

While practices differ from place to place, I opine that a universal principle should be to improve clinic infection control and time-efficiency so that eye service quality is not compromised. While we wait for sustained stabilization of the pandemic, clinical research, particularly commercial and unrelated to the pandemic, should continue to be scaled back. Certainly, in my practice, tests and procedures that are potentially aerosol-generating such as the airpuff eye pressure test, and that are invasive or prolonged, are currently avoided in favour of those that can achieve similar aims without the downsides.

Similar to how the pandemic forces us to hasten trends at the workplace, in retail and information technology, I believe in time to come, it will shape and perpetuate practice trends in healthcare and ophthalmology too. These trends may be the adoption of telemedicine, increasing use of non-invasive and contact-less diagnostic devices and embracing newer surgical approaches to reduce risks and improve long-term post-operative results, like using laser cataract and refractive laser lenticule techniques.

One thing is for sure, Zoom and webinars have resulted in unprecedentedly large participation in both public education and professional meetings I attended in the past two months, a trend that hopefully will stay for good. As for our first defence against the pandemic in the coming weeks, in addition to face masks, may I please suggest the anti-terrorist mentality of including eye protection, particularly in crowded places, since catching the virus through our eyes is not impossible – be it a wraparound eye shield, face shield or large-framed, close-fitting spectacles, all to be washed regularly. After all, Covid-19 is the most lethal terrorist to date!

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