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  • Important coronavirus updates for ophthalmologists

    CDC, WHO
    Comprehensive Ophthalmology
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    Updated May 14, 2021.

    Special Considerations for Ophthalmic Surgery
    Updated guidance for surgical decision-making and indications for preoperative testing and PPE.

    For complete coverage of the COVID-19 pandemic, visit the Academy's resource page Coronavirus and Eye Care.

    The Academy is sharing important ophthalmology-specific information related to the novel coronavirus, referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The highly contagious virus can cause a severe respiratory disease known as COVID-19.

    This page is principally authored by James Chodosh, MD, MPH, with assistance from Gary N. Holland, MD, and Steven Yeh, MD.

    Questions you should ask to identify patients with possible exposure to SARS-CoV-2

    • Does your patient have sore throat, fever, fatigue, loss of smell or respiratory symptoms? 
    • Has your patient been in the presence of someone with known COVID-19 in the last 2 to 14 days? 

    Given the significant prevalence of COVID-19 across the United States affecting every community, it is safest to assume that any patient could be infected with SARS-CoV-2. The CDC is urging health care providers who encounter patients meeting the criteria above to immediately notify both infection control personnel at your health care facility and your local or state health department. However, those patients who do not admit to the above can still be infected and pose risk to eyecare providers and their staff.

    Outpatient clinics and elective surgery

    On March 18, the Academy issued a statement urging all ophthalmologists to immediately cease providing any treatment other than urgent or emergent care. That statement was made based on recommendations from the American College of Surgeons and the CDC. Elective surgeries then fully resumed by July 2020, and protocols established during the first wave of COVID-19 have enabled the safe delivery of ophthalmic care during the second wave of infections. However, it remains to be seen whether current increases in use of PPE in hospitals caring for COVID-19 patients will force regional reductions in elective eye surgeries.

    Decisions on keeping eye clinics open for routine care and elective eye surgery should be made in consideration of numerous factors, as outlined by the American College of Surgeons and other leading medical organizations. These include but are not limited to evolving city and state restrictions to nonessential services, local/regional new case rates, availability of PPE and access to COVID-19 testing.

    Guidelines on providing elective ophthalmic care

    Practices and clinics should continue to mandate social distancing in waiting rooms, frequent and meticulous disinfection of patient waiting and care areas, and the wearing of face coverings by both patients and caregivers. This means that clinic schedule volumes may need to remain below pre-COVID-19 levels for the foreseeable future. Additional precautions required in operating rooms may lead to longer turnover times between cases, thus impacting the number of surgical cases that can be performed per session. Presuming compliance with state and local regulations, the Academy recommends clinical activities be performed with continued caution. The American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery and the Outpatient Ophthalmic Surgery Society developed a checklist to assist with reopening ophthalmic surgery centers that is still relevant as we negotiate the second wave of infections.

    Elective cataract surgery may again become restricted by state and/or local mandates.. However, this should not preclude anyone from leaving home to obtain essential services. Cataract surgery is considered semi-urgent, not elective, when the affected person cannot drive, work or see to take their medications properly, or has an increased risk of falling, phacomorphic glaucoma or intolerable anisometropia. Such cases warrant surgery within days to weeks.

    The Academy recognizes the potential role of testing for ophthalmologists, other health care providers and patients, when considering continuation of elective visits and surgeries. RT-PCR, typically performed on a nasopharyngeal swab, can identify the presence of SARS-CoV-2 nucleic acid and can remain positive for as long as 35 days from onset of symptoms, although it is very unlikely that a person would remain infectious for this long. Serology can be used to determine whether someone has recently been infected with SARS-CoV-2, but studies have not yet proven that the presence of neutralizing antibodies after a natural infection confers sufficient protection against reinfection. Notably, a SARS-CoV-2 antibody test from Roche was awarded FDA Emergency Use Authorization, with a reported 99.8% specificity and no cross-reactivity to other coronaviruses associated with the common cold. When used 14 days post-PCR confirmation of COVID-19, the sensitivity was 100%. However, because humoral antibody responses to SARS-CoV-2 typically appear within 1 to 2 weeks of infection, while infected individuals have been shown to shed virus for as long as 5 weeks from the onset of infection, a person with positive serology could still be shedding virus and therefore remain infectious.

    On December 15, 2020, the FDA authorized the first over-the-counter fully-at-home diagnostic test for COVID-19 antigen, reporting that in persons without symptoms, the test correctly identifies 91% of positive samples and 96% of negative samples. However, for now, the Academy recommends caution in the use of a negative at-home antigen test as a substitute for RT-PCR testing. 

    Recommended protocols when scheduling or seeing patients

    • If the office setup permits, patients who come to an appointment should be asked prior to entering the waiting room about fever and respiratory illness and whether they or a family member have had contact with another person with confirmed COVID-19 in the past 2 to 14 days. If they answer yes to either question, they should be sent home or to a testing center.
    • Keep the waiting room as empty as possible, advise seated patients to remain at least 6 feet from one another. As much as prudent, limit the length of visits of the most vulnerable patients.
    • The use of commercially available slit-lamp barriers or breath shields is encouraged, as they may provide a measure of added protection against the virus. These barriers do not, however, prevent contamination of equipment and surfaces on the patient's side of the barrier, which may then be touched by staff and other patients and lead to transmission. Homemade barriers may be more difficult to sterilize and could be a source of contamination.
    • To further decrease the risk of viral spread, ophthalmologists should inform their patients that they will speak as little as possible during the slit-lamp examination, and request that the patient also refrain from talking.
    • When examining patients, a surgical mask or cloth face covering for the patient, and a surgical mask and eye protection for the ophthalmologist are recommended. If the patient cannot wear a mask for medical reasons or when examining young children, the ophthalmologist is better protected by wearing an N95 mask instead of a surgical mask. When examining young children or if the patient cannot wear a mask for medical reasons, the ophthalmologist is better protected by wearing an N95 mask instead of a surgical mask.The recommendation that ophthalmologists wear eye protection is based on the theoretical risk of infection of the ocular surface if exposed. The Academy recognizes that in some situations, wearing goggles may be impractical, and we will reappraise the issue as new data emerges.
    • For any in-office procedures that require physical proximity to the patient (e.g., intravitreal injection, lateral tarsorrhaphy), regardless of the prevalence of COVID-19 in your area, the Academy recommends the patient wear a surgical mask or a cloth face covering if surgical masks are in short supply, and that the surgeon wear a surgical mask and eye protection. An N95 mask for the surgeon can be considered if not in short supply. The CDC’s recommendations on N95 extended use and/or reuse should be followed. 
    • Because U.S. testing for SARS-CoV-2 infection remains incomplete, the true regional prevalences of SARS-CoV-2 within the United States remain mostly unknown. Therefore, for surgical procedures that may generate aerosolized virus, preoperative testing (RT-PCR) for asymptomatic patients, orthe use of N95 masks (and eye protection) by operating room personnel is recommended. In the absence of preoperative testing, for cases that require general anesthesia, personnel not in N95 masks should remain out of the OR during intubation/extubation. For non-aerosolizing procedures performed under monitored anesthesia/conscious sedation, the patient should be placed in a surgical mask. Because of prolonged proximity of the eye surgeon to the patient, the surgeon can consider wearing an N95 mask if supplies permit.
    • Increasingly, ophthalmologists will be asked to examine and perform office-based procedures on patients who have recovered or are recovering from COVID-19. Because viral shedding can be prolonged (up to 37 days in one study), repeat testing (RT-PCR performed on a nasopharyngeal swab) is recommended for patients prior to treatment if less than 6 weeks from COVID-19 diagnosis, except in emergent circumstances. If the repeat SARS-CoV-2 test is positive, delayed or not available, the patient should wear a surgical mask and the treating ophthalmologist should wear an N95 mask, rather than a surgical mask, in addition to gown, gloves and eye protection. 
    • The CMS and HHS have allowed for the expanded use of telehealth services during the COVID-19 public health crisis. For more information on telephone services, internet-based consultation or telemedicine exam, visit the Academy’s Coding for Phone Calls, Internet and Telehealth Consultations.
    • The FDA issued emergency use authorization (EUA) for the COVID-19 vaccine from Pfizer/BioNTech, BNT162b2 (Tozinameran), on December 11, 2020. The vaccine made by Moderna, mRNA-1273, received its EUA on December 18, 2020. An EUA for the Johnson & Johnson adenovirus-based vaccine, JNJ-78436735, was approved on February 27, 2021. All 3 vaccines were shown in phase 3 clinical trials to dramatically reduce the risk of moderate to severe COVID-19 disease in individuals infected with SARS-CoV-2. However, while a vaccinated person who subsequently becomes exposed to SARS-CoV-2 may not develop clinical disease, there may still be a window of time in which they are infectious to others. Therefore, current RT-PCR testing and PPE protocols for surgical patients should remain in place. Similarly, ophthalmologists who have been vaccinated should continue to wear a mask during all patient encounters. Any patient with a positive RT-PCR test for SARS-CoV-2 should be considered potentially infectious whether they have been vaccinated or not. And because these are mRNA vaccines, a history of being vaccinated should not alter the interpretation of subsequent RT-PCR testing.
    • For vaccinated healthcare providers, the CDC now considers it permissible to leave off masks (and eye protection) and be less than 6 feet away from other vaccinated providers, e.g., when in breakrooms and for work meetings. However, providers should continue to follow all previous CDC recommendations regarding PPE when seeing and interacting with patients, irrespective their vaccination status.

    Recommendations for reducing risk of SARS-CoV-2 transmission in the clinic

    Patient Population Ophthalmic problem Appropriate Precautions* Comment
    Patients who have no evidence of COVID-19 and no specific risk factors for SARS-CoV-2 infection. Routine eye care or urgent problems
    • Masks or face covering on patients at all times (inform patients that they are not to pull masks down onto their chins at any time while in the clinic).
    • Maintain physical distancing. Be in close proximity to patient only during the examination. Maintain distance while taking history (or obtain history over the telephone prior to visit).
    • Reduce duration of direct contact with patient (e.g. have the patient return to the waiting room while charting or reviewing imaging and records, if appropriate physical distancing can be maintained in that setting†).
    • Limit the number of individuals in the examination lane (only patients and 1 parent for pediatric patients or 1 caretaker for adults who require assistance.
    • Clinicians should wear surgical masks. N95 masks provide additional protection, but may not be available in all facilities.
    • Eye protection (face shields or goggles) should be worn to the extent practical; it may be necessary to remove such protection during some examination procedures. Care must be taken not to contaminate the eye protection devices during removal.
    • Thorough handwashing before and after each patient contact, and the clinician should not touch his or her face.
    • Instruct patients not to touch anything other than chairs and slit lamp biomicroscope handles or place personal objects on environmental surfaces in the room.
    • Surfaces and equipment should be cleaned with virucidal wipes between all patients.
    		 Assume that anyone may be infected, asymptomatic or pre-symptomatic, and shedding virus
    Patients with symptoms suggestive of COVID-19 Routine eye care Defer appointment until infection is ruled out and symptoms have resolved.  
    Urgent problems As for the patient population with confirmed SARS-CoV-2 infection (see below).
    Confirmed SARS-CoV-2 infection (recent PCR- or antigen-positive tests) or highly suspected of infection in the process of being evaluated. Routine eye care
    • Patient should quarantine at home as specified by CDC, state public health, or institutional guidance.
    • Defer appointment until after quarantine and after symptoms have resolved.
    • Not all jurisdictions require follow-up testing for the presence of virus after quarantine.
    		 Antibody tests alone do not necessarily indicate current infection; the presence of IgG antibodies may indicate prior infection.
    Urgent problems All of the precautions taken for routine care of uninfected patients, as described above, with the following additions or exceptions:
    • Patients should be escorted directly to the examination lane. There should be no contact between the patient and other patients or staff.
    • Only those individuals necessary for direct patient evaluation or care should be in the examination lane.
    • N95 masks should be worn by clinicians.
    • Gowns and gloves should be worn.
    • Eye protection should not be removed.
    • Care must be taken when doffing protective gear.
    • Examination rooms should be put out of service after the examination until the room can be thoroughly decontaminated per CDC, state public health, or institutional guidance.
    • If practical, it may be more appropriate for the patient to be seen in a hospital or other setting equipped to provide both eye and medical care to patients with COVID-19.

    * In all clinic situations, good ventilation will reduce the risk of transmitting aerosolized virus. Ventilation is quantified by “air changes per hour” (ACH). Maximizing ACH and use of appropriate filters (e.g., HEPA) in the heating, ventilation, and air conditioning (HVAC) system will reduce the concentration of any aerosolized virus in a room, but modifications to achieve desired results may not be possible in all areas of every building. Alternatives include portable air filtering units or ceiling-mounted ultraviolet C units for individual rooms with poor circulation. Reducing the time that patients spend in examination lanes will reduce the amount of virus that might be placed in the air.

    † Clinicians should also be mindful of other public spaces in which patients will be present, such as waiting rooms. Patients should be instructed to remain at least 6 feet away from others in public spaces and to wear a mask at all times while waiting. Waiting and registration areas may need to be reconfigured to facilitate such distancing. To avoid crowding in public spaces, patients may need to wait outside or in their vehicles, if possible, until they are called back into the facility by staff members, using cell phones or other devices. It may also be necessary to adjust clinic schedules to reduce the number of patients present at any given time. Patients should be asked not to arrive early for appointments, or if they do arrive early, to leave the building after check-in, and return at their scheduled appointment times.

    Environmental cleaning and disinfection recommendations

    Rooms and instruments should be thoroughly disinfected after each patient encounter. Wear disposable gloves when cleaning and disinfecting surfaces, and discard the gloves after use. Slit lamps, including controls and accompanying breath shields, should be disinfected, particularly wherever patients put their hands and face. The current CDC recommendations for disinfectants specific to COVID-19 include:

    • Diluted household bleach (5 tablespoons bleach per gallon of water)
    • Alcohol solutions with at least 70% alcohol.
    • Common EPA-registered household disinfectants currently recommended for use against SARS-CoV-2 include Clorox brand products (e.g., disinfecting wipes, multi-surface cleaner + bleach, clean up cleaner + bleach), Lysol brand products (e.g., professional disinfectant spray, clean and fresh multi-surface cleaner, disinfectant max cover mist), Purell professional surface disinfectant wipes and more. The EPA offers a full list of antimicrobial products expected to be effective against COVID-19 based on data for similar viruses.

    Visual field analyzer cleaning

    Manufacturers’ guidance should be followed when cleaning delicate diagnostic equipment such as visual field analyzers. Zeiss has updated its guidance on how to treat their Humphrey perimeter during visual field examinations, and a quick-start guide demonstrates how to clean the bowl. Other manufacturers may offer similar guidance from their websites or in instructional materials. Because there could be aerosolization during disinfection, we recommend that staff wear a surgical mask and eye protection while cleaning visual field analyzers.

    Tonometer tip cleaning

    The virus causing COVID-19 is an enveloped virus, unlike adenoviruses that are much more resistant to alcohol. If a tonometer tip is cleaned with alcohol and allowed to dry in room air, 70% alcohol solutions should be effective at disinfecting tonometer tips from SARS-CoV-2. However, alcohol will not effectively sterilize the tip against adenoviruses. Use single-use, disposable tonometer tips if available. Tips cleaned with diluted bleach remain a safe and acceptable practice.

    Multidose eye drops

    For diagnostic eye drops required for ophthalmic examinations, multidose eye drop containers should be kept in cabinets or other closed spaces away from anywhere that could become contaminated during a patient encounter. As should always be the case, care must be taken not to touch the eyelashes or ocular surface with the tip of the eye drop bottle, and the examiner’s hands should be disinfected immediately after touching the patient’s face.

    Resources

    WHO

    CDC

    For ophthalmologists filling critical care roles

    Ophthalmic subspecialty-specific recommendations

    Relevant articles

    EyeNet magazine

     Journal studies and scientific articles

    If you have practical, clinical experience to share about the COVID-19 outbreak, email onefeedback@aao.org. The site editors will review and post items that will benefit the community.  

    James Chodosh, MD, MPH, is the Edith Ives Cogan Professor of Ophthalmology at Harvard Medical School’s Department of Ophthalmology, a member of Harvard’s PhD program in virology and an expert in cornea and external disease working at the Massachusetts Eye and Ear.

    Gary N. Holland, MD, is the Jack H. Skirball Professor of Ocular Inflammatory Diseases, director of the Ocular Inflammatory Disease Center, and a member of the cornea/external disease and uveitis divisions at the Jules Stein Eye Institute, David Geffen School of Medicine at UCLA. 

    Steven Yeh, MD, is the M. Louise Simpson Associate Professor of Ophthalmology, a member of the uveitis and vitreoretinal surgery divisions at the Emory Eye Center, and a faculty fellow of the Emory Global Health Institute.

     

    Photo Credit: Content Providers(s): National Institute of Allergy and Infectious Diseases (NIAID) - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #18109.