EYE CLINIC

Important coronavirus updates for ophthalmologists

*Source: American Academy of Ophthalmology

(https://www.aao.org/headline/alert-important-coronavirus-context)

 

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), which was previously known by the provisional name 2019-nCoV. 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.

What you need to know

• Several reports suggest the virus can cause conjunctivitis and possibly be transmitted by aerosol contact with conjunctiva.
• Patients who present to ophthalmologists for conjunctivitis who also have fever and respiratory symptoms including cough and shortness of breath, and who have recently traveled internationally, particularly to areas with known outbreaks (China, Iran, Italy, Japan, and South Korea), or with family members recently back from one of these countries, could represent cases of COVID-19.
• The Academy and federal officials recommend protection for the mouth, nose and eyes when caring for patients potentially infected with SARS-CoV-2.
• The virus that causes COVID-19 is very likely susceptible to the same alcohol- and bleach-based disinfectants that ophthalmologists commonly use to disinfect ophthalmic instruments and office furniture. To prevent SARS-CoV-2 transmission, the same disinfection practices already used to prevent office-based spread of other viral pathogens are recommended before and after every patient encounter.

Latest statistics

Global

167,511 cases (updated March 16, 2020; source: WHO)

• Total deaths: 6,606
• Countries reporting cases: 143

United States

3,467 confirmed and presumptive positive cases (updated March 16, 2020; source: CDC)

• Total deaths: 68
• States reporting cases: 53 (49 states, District of Columbia, Puerto Rico, Guam, and US Virgin Islands)

On March 11, the COVID-19 outbreak was officially declared a pandemic by the World Health Organization. Areas with documented ongoing widespread or sustained community transmission include China, Iran, South Korea and most of Europe. The 2 countries with the highest number of cases, China and South Korea, have shown consecutive multi-day declines in new cases.

Currently, U.S. COVID-19 cases include imported cases in travelers, cases among close contacts of a known case and community-acquired cases where the source of the infection is unknown. Three U.S. states are experiencing sustained community spread: New York (967), Washington (904) and California (557) [updated March 16, 2020, numbers based on the Johns Hopkins University COVID-19 interactive map]. On March 13, the President of the United States declared the COVID-19 outbreak a national emergency

Background

The SARS-CoV-2 is an enveloped, single-stranded RNA virus that causes COVID-19. Although the virus appears not quite as likely to cause fatalities as the SARS coronavirus or MERS coronavirus, a significant number of global fatalities have already occurred. There have been numerous worldwide reports of infections, including in the United States.

Patients typically present with respiratory illness, including fever, cough and shortness of breath; conjunctivitis has also been reported. Severe complications include pneumonia. Symptoms can appear as soon as 2 days or as long as 14 days after exposure. A March 10 study in the Annals of Internal Medicine found that the mean incubation period for SARS-CoV-2 was 5 to 7 days. More than 97% of those who developed symptoms did so within 11.5 days of exposure, findings that further support current 14-day quarantine recommendations.

At this time, there is no vaccine to prevent infection, and no medication known to be effective in treatment. On March 5, Kaiser Permanente began enrolling for mRNA coronavirus vaccine trials in the Washington State area.

Current understanding about how COVID-19 spreads is based largely on what is known about other similar coronaviruses. The virus is believed to spread primarily via person-to-person through respiratory droplets produced when an infected person coughs or sneezes. It also could be spread if people touch an object or surface with virus present from an infected person, and then touch their mouth, nose or eyes. Viral RNA has also been found in stool samples from infected patients, raising the possibility of transmission through the fecal/oral route.

Currently, federal officials are trying to determine if there is asymptomatic transmission. A Feb. 21 report in JAMA details a case of an asymptomatic carrier who possibly infected 5 family members despite having normal chest computed tomography (CT) findings. In addition, Li Wenliang, MD, the whistleblower ophthalmologist who sounded the initial alarms on the coronavirus, said he was infected by an asymptomatic glaucoma patient. These reports, however, are preliminary.

In a study posted March 10 on MedRxIV, scientists were able to detect viable SAR-CoV-2 in aerosols up to 3 hours post-aerosolization. However, this experiment was performed in a Goldberg drum that lacks ventilation, which might not necessarily reflect how the virus would behave in real-life conditions. In addition, the study found the virus could survive up to 24 hours on cardboard, up to 4 hours on copper and up to 2 to 3 days on plastic and stainless steel. This study has not yet been peer-reviewed; results may therefore change or additional information may be provided when the study is published. There are no changes in recommendations related to use of masks on the basis of this study, but it does emphasize the importance of handwashing and cleaning surfaces and materials possibly contaminated by respiratory secretions from infected patients.;

Ophthalmology ties

Two recent reports suggest the virus can cause conjunctivitis. Thus, it is possible that SARS-CoV-2 is transmitted by aerosol contact with the conjunctiva. 

• In a Journal of Medical Virology study of 30 patients hospitalized for COVID-19 in China, 1 had conjunctivitis. That patient—and not the other 29—had SARS-CoV-2 in their ocular secretions. This suggests that SARS-CoV-2 can infect the conjunctiva and cause conjunctivitis, and virus particles are present in ocular secretions. 
• In this larger study published in the New England Journal of Medicine, researchers documented "conjunctival congestion" in 9 of 1,099 patients (0.8%) with laboratory-confirmed COVID-19 from 30 hospitals across China.

While it appears conjunctivitis is an uncommon event as it relates to COVID-19, other forms of conjunctivitis are common. Affected patients frequently present to eye clinics or emergency departments. That increases the likelihood ophthalmologists may be the first providers to evaluate patients possibly infected with COVID-19.

Therefore, protecting your mouth, nose (e.g., an N-95 mask) and eyes (e.g., goggles or shield) is recommended when caring for patients potentially infected with COVID-19. In addition, slit-lamp breath shields (e.g., here) are helpful for protecting both health care workers and patients from respiratory illness.

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

• Does your patient have fever or respiratory symptoms?
• Has your patient or their family members traveled recently? Red flags include international travel to countries such as China, Iran, Italy, Japan and South Korea, and domestic travel to states with high numbers of infected patients (e.g., Washington, California, New York).

The CDC is urging health care providers who encounter patients meeting these criteria to immediately notify both infection control personnel at your health care facility and your local or state health department for further investigation of COVID-19.

Recommended protocols when scheduling or seeing patients

• In response to the state of emergency declared at the federal level and in multiple states as of March 14, 2020, as well as the US. Surgeon General's warning, clinicians should postpone those outpatient visits and procedures that can be safely delayed, particularly in elderly patients and those with comorbidities.
• When phoning about visit reminders, ask to reschedule appointments for patients with nonurgent ophthalmic problems.
• If the office setup permits, patients who come to an appointment should be asked prior to entering the waiting room about respiratory illness and whether they or a family member have traveled to a high-risk area in the past 14 days. If they answer yes to either question, they should be sent home and told to speak to their primary care physician.
• Keep the waiting room as empty as possible, and as much as prudent, reduce the visits of the most vulnerable patients.
• If a patient with known COVID-19 infection needs urgent ophthalmic care, they should be sent to a hospital or center equipped to deal with COVID-19 and urgent eye conditions, ideally in a hospital setting under hospital infection control conditions.
• 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. In general, barriers are not a substitute for careful cleaning of equipment between patients and asking those patients who cough, sneeze, or have flu-like symptoms to wear masks during examination.
• To further decrease the risk of any virus transmission, 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.

NEW Interim guidance for triage of ophthalmology patients

Clinical Situation	Patient Management / Precautions
1. Routine or urgent ophthalmology appointment, patient has no respiratory illness symptoms, no fever, and no COVID-19 risk factors	Standard precautions* only. Added precaution of not speaking during slit lamp biomicroscopic examinations is appropriate. Mask, gown, gloves are not routinely required for patient or clinician. Consideration should be made to postponing routine ophthalmic care.
2. Non-urgent ophthalmic problem in a patient with respiratory illness symptoms, but no fever or other risk factors for COVID-19	With telephone contact before appointment, request that patient not come to clinic and reschedule appointment. For patients who present to clinic, ask the patient to return home and reschedule appointment.
3. Urgent ophthalmic problem in a patient with respiratory illness symptoms, but no fever or other COVID-19 risk factor	The patient can be seen in the eye clinic. The patient should be placed in an examination lane immediately and asked to wear a surgical mask. The treating ophthalmologist and health care personnel require surgical masks. Gowns, gloves and eye protection are recommended.† An N95 mask should be worn if a procedure is planned that will result in aerosolized virus. The examining room must be cleaned after examination.
4. Any patient at high risk for COVID-19	The patient should be sent to the ER or other hospital-based facility equipped to evaluate for, and manage, COVID-19. If the patient has an urgent eye problem based on screening questions, the facility should be one that is equipped to provide eye care in the hospital setting. If SARS-CoV-2 infection is confirmed, CDC (or hospital) guidelines for care of suspected COVID-19 patients should be followed for health care facility preparation and infection control. Eye care should be provided in the hospital setting. Transmission precautions‡ for treating ophthalmologists include wearing a surgical mask, gown, and eye protection (face shield or goggles).
5. Patient with documented COVID-19 (or person under investigation [PUI]) who is referred for evaluation and management of an eye problem	The patient should remain in the hospital setting. Determine whether the eye problem is urgent based on screening questions, and if so, evaluation and management should be in the hospital setting. If the patient is not hospitalized at the time of referral, the patient should be referred to the ER or other hospital-based facility equipped to manage both COVID-19 and eye care. CDC or hospital guidelines should be followed for care of COVID-19 patients. Transmission precautions† for treating ophthalmologists include wearing an N95 mask, gown, and eye protection (face shield or goggles).

*  Standard (Universal) Precautions: Minimum infection prevention precautions that apply to all patient care, regardless of suspected or confirmed infection status of patient, in any health care setting (e.g., hand hygiene, cough etiquette, use of personal protective equipment, cleaning and disinfecting environmental surfaces). See CDC: Standard Precautions.

†  Currently, there are national and international shortages of personal protective equipment (PPE), which also warrant consideration. Excessive use of PPE may deplete the supply of critical equipment required in the future for patients with COVID-19 as the epidemic expands. Use of PEE should be considered on an institutional and case-by-case basis; universal usage for all patient encounters is not appropriate.

‡ Transmission Precautions: Second tier of basic infection control, used in addition to Standard Precautions when patients have diseases that can spread through contact, droplet or airborne routes, requiring specific precautions based on the circumstances of a case. Transmission precautions are required for cases of suspected COVID-19. See CDC: Transmission-Based Precautions.

Guidance for outpatient clinics and elective surgery

In response to the state of national emergency declared at the federal level, particularly as COVID-19 progresses in a given community, ophthalmologists should seriously consider both the intensity of clinic scheduling and the issue of elective surgeries, particularly in elderly patients and those with medical comorbidities.

The CDC has issued mitigation plans, including a recommendation for the cancellation or reduction of elective procedures in health care settings, for the following communities: Santa Clara, California; New Rochelle, New York; Florida; Massachusetts; and Seattle, Washington.  

Outpatient clinics

Office waiting areas often violate social distancing guidelines due to the number of patients and staff in confined spaces. Ophthalmology practices should reconfigure examination schedule templates to decompress their waiting areas and consider alternatives such as encouraging patients to wait in other locations (e.g., their cars or outdoor spaces). Mobile phone calls or other approaches can be used by office staff to notify patients when they should return to the office.

Elective surgical procedures

The American Academy of Ophthalmology supports the recommendation from American College of Surgeons regarding minimizing, postponing or canceling elective surgeries, while recognizing that the timing may vary by community and disease indication. In addition, circumstances vary for hospitals, hospital-based outpatient surgery departments, freestanding ASCs and office-based procedures. However, all ophthalmologists should be prepared to adjust their surgical volumes as local circumstances dictate. Even outpatient ASC-based procedures may expose other patients and health care workers to virus shed from asymptomatic patients. Elective surgical procedures also deplete scarce personal protective equipment, including but not limited to masks and face shields.

Environmental cleaning and disinfection recommendations

Rooms and instruments should be thoroughly disinfected after each patient encounter. Wear disposable gloves when cleaning and disinfecting surfaces. 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.

 

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.