|Year : 2021 | Volume
| 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
|Date of Submission||03-Aug-2021|
|Date of Decision||05-Aug-2021|
|Date of Acceptance||06-Aug-2021|
|Date of Web Publication||01-Nov-2021|
Dr. Sudhakar Potti
Consultant, Cornea and Refractive Services, Sankara Eye Hospitals, Pedakakani, Guntur-Vijayawada Expressway, Guntur, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
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
|How to cite this article:|
Potti S, Sakare E. Ophthalmic practice in current COVID crisis. J Ophthalmol Clin Res 2021;1:32-7
| Introduction|| |
Coronavirus disease-2019 (COVID-19) has been declared as a public health emergency of international concern. It is highly transmissible and has a significant fatality rate, especially in the elderly and those with comorbidities such as immunosuppression, respiratory disease, and diabetes mellitus and obesity. It was concluded that severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), which causes COVID-19, spreads primarily through droplets of saliva or discharge from the nose when an infected person talks, coughs, or sneezes. Currently, reverse transcriptase-polymerase chain reaction (RT-PCR) detection of the viral genome in the upper respiratory tract swabs is the most reliable diagnostic test. Every profession has been affected by COVID-19 either directly or indirectly, ophthalmic practice is not an exclusion. Following certain guidelines at various levels will help reducing transmission of COVID-19 and getting adopted to “NEW-NORMAL.”
| Methods of Literature Search|| |
A literature search was conducted in PubMed and Google Scholar databases. Several search terms were used including coronavirus, SARS-CoV-2, COVID-19, ophthalmology, ophthalmologist, telemedicine in ophthalmology, and their combinations. Recommendations of the American Academy of Ophthalmology (AAO), WHO, the Centres for Disease Control and Prevention (CDC), All India ophthalmology society guidelines, and Ministry of Health and Family Welfare for safe practice during the COVID-19 pandemic were also reviewed.
Ophthalmic manifestations of COVID-19
Presentation of covid-19 virus disease occurs in wide varied ways. Every ophthalmologist must have knowledge about the ophthalmic manifestations, so that extra care and multidisciplinary approach can be taken to treat the condition. The various ophthalmic manifestations of covid 19 are listed in [Table 1] and [Figure 1].
|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)|
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[Figure 3] shows 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 1st week of infection (acute, day 0–day 7), between the 2nd and 3rd 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 20 days).
|Figure 3: Marking on the seating arrangements, so that physical distancing can be maintained.|
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| General Considerations|| |
Personal protective equipment
AAO has published a report advising ophthalmologists to wear masks and eye protection when caring for patients potentially infected with COVID-19. Anecdotal reports suggested that, when no eye protection was worn, COVID-19 could be transmitted by aerosol contact with the conjunctiva. Personal protective equipment (PPE) are protective gears designed to safeguard the health of workers by minimizing exposure to a biological agent. Components of PPE are goggles, face shield, mask, gloves, coverall/gowns (with or without aprons), head cover, and shoe cover. PPE at various departments of the hospital as given by the Ministry of Health and Family Welfare is mentioned in [Table 2].
|Table 2: Personal protective equipment for hospital staff at the various department|
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| Environmental Measures|| |
The objective of environmental control was to prevent the spread and reduce the concentration of infectious droplets in ambient air. Air ventilation at the waiting areas can be enhanced through the opening of the fresh air dampers in the air handling equipment. Mobile high-efficiency particulate air (HEPA)units addition augments the total air change rates in waiting areas where necessary. During the ophthalmic examination, the face-to-face proximity of the slit-lamp biomicroscopic examination may place the ophthalmologist at a higher risk of aerosolized particles from respiratory droplets and contact. Installing large protective plastic shields on slit lamp minimizes the risk of droplet contamination between the patient and the ophthalmologist [Figure 2].
|Figure 2: Slit lamp microscope with protective shield to reduce the risk of droplet contamination in between ophthalmologist and patient while examination|
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The communicable diseases control recommendations for disinfectants specific to COVID-19 include:
- Sodium hypochlorite 0.5%–1%– preferable freshly prepared every day
- Alcohol solutions with at least 70% isopropyl alcohol.
Disinfection of instruments including slit lamps, controls, accompanying breath shields and tonometer tip, keyboards, desks, door handles, and chairs after examination of each patient must be performed.
| Administrative Measures|| |
Physical distancing and triage systems are the most important key factors in administrative measures. A proper protocol or policy implementation at the administration level will reduce the transmission of COVID-19.
Physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.
- 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].
A triage station setup is a must at the entrance of the eye clinic. All patients and their accompanying persons must be screened using infra-red thermometers. Fever patients can be provided with health advice pamphlets and should be advised to seek medical attention and reschedule their eye clinic appointments if their eye conditions are nonurgent. Those with urgent eye conditions and fever are seen by the on-call ophthalmologist either at the Accident and Emergency Department, or separate areas earmarked for the purpose.
Usage and daily correspondence of health declaration form by employee or health-care worker and its surveillance help in identifying the recent activities of employee which may aid in the transmission of COVID-19. The health declaration form should include
- Experience of any flu-like symptoms (fever, cough, breathlessness, and breathing difficulty) since yesterday
- Experience of flu-like symptoms by a family member or roommate since yesterday
- Whether employee attending any get-together or present in a crowded place or not, since yesterday
- Whether employee/family member/roommate returned from any intercity travel since yesterday
- Whether employee/roommate/family member came in contact with any COVID-19 positive people since yesterday.
| Guidelines for Cataract Surgery During Covid Times|| |
Preoperative cataract surgery assessment
- 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.
- Patient vaccination status can be noted.
- 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.
- Rapid test/RT-PCR can be used to screen elective surgery patients, but it has to be within 24–48 h before surgery.
- Better to do intraocular pressure measurement by iCare tonometry or applanation tonometry
- 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
- Pulse oximetry is recommended for all patients and spo2 more than or equal to 96% is ideal for surgery
- 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
- While doing laboratory investigations, proper PPE should be maintained.
At counseling station
- 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.
At admission desk
- 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.
At daycare ward
- 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.
At anesthesia (block) room
- 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.
At operation theater
- 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.
At day care room/discharge
- 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|| |
COVID-19 vaccines have proven to be safe, effective, and lifesaving. Similarly, all vaccines, they do not fully protect everyone who is vaccinated, and we do not yet know how well they can prevent people from transmitting the virus to others. Hence, as well as getting vaccinated, we must also continue with other measures to fight the pandemic.
We should encourage patients to get vaccinated as early as possible. All the hospital health workers should get vaccinated on a priority basis such as exposure, transmission risks are more.
A gap of 2 weeks between ophthalmic surgical procedure and vaccination is considered ideal for benefit of the patient.
| Telemedicine|| |
Telemedicine is defined as the use of information technologies to support health care between participants who are separated from each other. It represents a combination of expertise and technology that delivers medical services and information over distance. During the current COVID-19 crisis, telemedicine has a huge impact on treating patients who are suffering from illness and do not need an in-person consultation for treatment. Certain guidelines are issued by the Ministry of Health and Family Welfare, Government of INDIA for teleconsultation.
| 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|| |
- 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
- Telemedicine consultation should not be anonymous: Both patient and the RMP need to know each other's identity
- MODE OF TELEMEDICINE: Multiple technologies can be used to deliver telemedicine consultations.
- VIDEO: Telemedicine facility, Apps, Video on chat platforms, and Facetime
- AUDIO: Phone, VOIP, and Apps
- TEXT BASED: Specialized Chat-based Telemedicine Smartphone Apps, SMS, Websites, messaging systems, for example, WhatsApp, Google Hangouts, and FB Messenger
- 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.
- Patient consent is necessary for any telemedicine consultation, it can be implied or explicit
- 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
- An RMP may impart health promotion and disease prevention messages and provide counseling related to the specific clinical condition
- 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
- 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.
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.Patient records, reports, documents, images, diagnostics, data etc. (digital or nondigital) utilized in the telemedicine consultation should be retained by the RMP.
| Conclusion|| |
COVID-19 has impacted everyone's life professionally, personally, and financially. Adopting the proper guidelines given by certain bodies as mentioned above will help to get to “NEW-NORMAL,” preventing and protecting from this dangerous virus. Telemedicine can be applied by every practitioner to reduce the frequency of patient visits to the hospital as well as to hamper the COVID-19 transmission.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]