COMMISSIONED ARTICLE

Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 32-37

Ophthalmic practice in current COVID crisis

Sudhakar Potti, Eswar Sakare
Department of Cornea and Refractive Services, Sankara Eye Hospital, Guntur, Andhra Pradesh, India

Correspondence Address:
Dr. Sudhakar Potti
Consultant, Cornea and Refractive Services, Sankara Eye Hospitals, Pedakakani, Guntur-Vijayawada Expressway, Guntur, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jocr.jocr_21_21

Corona virus (covid-19) pandemic has shaken the entire world, its wide spread transmission has restricted everybody's day to day life, ophthalmologists are no exception, but in greater danger, as most of ophthalmologic examinations include close contact between patient and doctor, increasing the risk of transmission of deadly covid-19 virus. Adopting certain measures in ophthalmic practice reduces the transmission risk. Various ophthalmic manifestations of covid 19 includes follicular conjunctivitis, viral keratoconjunctivitis, hemorrhagic and pseudomembranous conjunctivitis, Central retinal vein occlusion (CRVO), Central retinal artery occlusion (CRAO) Cerebrovascular accident (CVA) with vision loss, Mucormycosis etc. For this review, literature search was conducted in PubMed and Google Scholar databases by using terms coronavirus, SARS-CoV-2, COVID-19, ophthalmology, ophthalmologist, telemedicine in ophthalmology and their combinations to gather efficient information that can enhance the daily practice. Most important modifications include personal protective equipment, environmental measures (air ventilation, instrument handling), administrative measures (physical distancing, triage setup). Vaccination plays a crucial role in hampering the effect of covid crisis, it should be given significant importance and extensive awareness. Telemedicine can change the entire scenario in doctor-patient relationship and everyone should have thorough knowledge about its guidelines. All these measures need gigantic efforts in reducing the covid-19 effect, paving the path for the “NEW-NORMAL”.

Keywords: Covid-19, ophthalmic practice, preferred practice pattern

Introduction

Methods of Literature Search

Table 1: Various ophthalmic manifestations of Coronavirus disease 2019 Click here to view

Figure 1: A broad timeline of the different ophthalmic manifestations of COVID-19. They can be divided into those which present with ocular symptoms initially (before COVID-19), within the first week of infection (Acute, Day 0-day 7), between the second and third week since the onset of COVID-19 symptoms (Subacute, day 7-day 20) and those which present as late sequelae of the infection (Delayed, after 20days) Click here to view

Figure 3: Marking on the seating arrangements, so that physical distancing can be maintained. Click here to view

General Considerations

Table 2: Personal protective equipment for hospital staff at the various department Click here to view

Environmental Measures

Figure 2: Slit lamp microscope with protective shield to reduce the risk of droplet contamination in between ophthalmologist and patient while examination Click here to view

• Sodium hypochlorite 0.5%–1%– preferable freshly prepared every day
• Alcohol solutions with at least 70% isopropyl alcohol.

Administrative Measures

• Limiting visitors to the facility to those essential for the patient (care partner and parent)
• Scheduling appointments to limit the number of patients in waiting rooms or creating a process so that patients can wait outside or in their vehicle whereas waiting for their appointment
• Arranging to seat in waiting rooms so patients can sit at least 6 feet apart [Figure 3].

1. Experience of any flu-like symptoms (fever, cough, breathlessness, and breathing difficulty) since yesterday
2. Experience of flu-like symptoms by a family member or roommate since yesterday
3. Whether employee attending any get-together or present in a crowded place or not, since yesterday
4. Whether employee/family member/roommate returned from any intercity travel since yesterday
5. Whether employee/roommate/family member came in contact with any COVID-19 positive people since yesterday.

Guidelines for Cataract Surgery During Covid Times

1. Patient to be examined after screening for COVID-19 by checking temperature, eliciting a history of fever, cough, cold, and taking COVID-19 consent in outpatient department.
2. Patient vaccination status can be noted.
3. COVID-19 suspects to be referred to the nearest COVID-19 treatment center and surgery to be deferred until the patient recovers with a negative RT-PCR test.
4. Rapid test/RT-PCR can be used to screen elective surgery patients, but it has to be within 24–48 h before surgery.
5. Better to do intraocular pressure measurement by iCare tonometry or applanation tonometry
6. Regurgitation on pressure over the lacrimal sac area should be used to rule out dacryocystitis or patency can be evaluated by fluorescein dye disappearance test. If necessary in suspected cases of dacryocystitis, lacrimal syringing should be done with necessary PPE
7. Pulse oximetry is recommended for all patients and spo2 more than or equal to 96% is ideal for surgery
8. Biometry ideally to be recorded by an optical method. If manual/immersion biometry is done, decontamination of the probe must be done after every case as per the disinfection protocol
9. While doing laboratory investigations, proper PPE should be maintained.

• Other than regular consent forms, specific COVID-19 consent forms are to be signed by the patient attendant and doctor
• Reduce the chair time during counseling by showing videos of different surgical and intraocular lenses (IOL) options
• Inform that only one attendant to accompany the patient on the day of daycare surgery.
• Encourage cashless transactions
• Advice to avoid social gatherings till the day of surgery and also a minimum of 15 days after surgery.

• Hand hygiene (sanitizer) and thermal screening of patient and attendant before entry point into the hospital building
• Check COVID-19 test reports if advised as a screening. Defer by 2 weeks at least if positive.
• Make sure both patient and attendant are wearing 3-ply mask
• Recommended investigations on the day of surgery to be done before breakfast.

• Vital parameters to be checked and documented including pulse oximeter
• The patient is given a clean dress to wear
• The eye to be operated is marked with a sticker.

• Case sheet and consumables (IOL and CTR) to be handled only by OT staff
• The patients are instructed to wear a clean OT gown over the patient dress
• All eye medications are to be instilled preferably by no-touch technique
• Routine antiseptic protocol to be used whereas administering peribulbar anesthesia.

• Only one surgical patient is in an operating room at a time
• Allow 3 min contact time of povidone-iodine 5% for conjunctival surface and 10% for periocular cleaning
• Monitor SpO2 during surgery
• Avoid spillage of body fluids
• Phaco tubing to be cleaned after each surgery with alcohol-soaked pads
• Operating table and surrounding surfaces to be disinfected after each case
• OT room to be cleaned as per the guidelines given by the ministry of health
• Adequate time should be given for air exchange
• OT doors may be opened into the clean corridor to allow for dilution
• Staff should wear necessary PPE according to the Hospital and National Guidelines for Ophthalmic Surgery.

• On receiving the patient, monitor SpO2 again and document
• Patient counseled regarding postoperative regimen and safety measures to be followed, preferably using a video
• Appointment for postoperative follow-up fixed according to the hospital protocol, ensuring adequate time gap between patient appointments
• After 1 h of observation, the patient can be discharged.

Vaccination

Telemedicine

The Principles of Telemedicine Include

• The professional judgment of a registered medical practitioner (RMP) should be the guiding principle: An RMP is well positioned to decide whether a technology-based consultation is sufficient, or an in-person review is needed. The practitioner shall exercise proper discretion and not compromise on the quality of care
• The RMP can choose not to proceed with the consultation at any time. At any step, the RMP may refer or request an in-person consultation. If a case requires a video consultation for examination, RMP should explicitly ask for it
• At any stage, the patient has the right to choose to discontinue the teleconsultation.

The Following Are the Salient Features

1. The RMP should exercise their professional judgment to decide whether a telemedicine consultation is appropriate in a given situation or an in-person consultation is needed in the interest of the patient
2. Telemedicine consultation should not be anonymous: Both patient and the RMP need to know each other's identity
3. MODE OF TELEMEDICINE: Multiple technologies can be used to deliver telemedicine consultations.



1. VIDEO: Telemedicine facility, Apps, Video on chat platforms, and Facetime
2. AUDIO: Phone, VOIP, and Apps
3. TEXT BASED: Specialized Chat-based Telemedicine Smartphone Apps, SMS, Websites, messaging systems, for example, WhatsApp, Google Hangouts, and FB Messenger
4. ASYNCHRONOUS US: e-mail, Fax, recordings, etc


All these technology systems have their respective strengths, weaknesses, and contexts, in which they may be appropriate or inadequate to deliver proper care.


4. Patient consent is necessary for any telemedicine consultation, it can be implied or explicit
5. RMPs must make all efforts to gather sufficient medical information about the patient's condition before making any professional judgment by exchange of information for patient evaluation. RMP shall maintain all patient records including case history, investigation reports, and images as appropriate
6. An RMP may impart health promotion and disease prevention messages and provide counseling related to the specific clinical condition
7. Prescribing medications, through telemedicine consultation, are at the professional discretion of the RMP. It entails the same professional accountability as in the traditional in-person consult. Prescribing medicines without an appropriate diagnosis/provisional diagnosis will amount to professional misconduct, so RMP should prescribe medicines ONLY when RMP is satisfied that he/she has gathered adequate and relevant information about the patient's medical condition
8. If the RMP has prescribed medicines, he/she shall issue a prescription as per the Indian Medical Council (Professional Conduct, Etiquette, and Ethics) Regulations and shall not contravene the provisions of the Drugs and Cosmetics Act and Rules



• RMP shall provide the photo, scan, a digital copy of a signed prescription, or e-prescription to the patient through e-mail or any messaging platform
• In the case, the RMP is transmitting the prescription directly to a pharmacy, he/she must ensure explicit consent of the patient that entitles him/her to get the medicines dispensed from any pharmacy of his/her choice.



9. Principles of medical ethics including professional norms for protecting patient privacy and confidentiality as per the IMC Act, shall be binding, and must be upheld and practiced.
10. Patient records, reports, documents, images, diagnostics, data etc. (digital or nondigital) utilized in the telemedicine consultation should be retained by the RMP.

Conclusion

References

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