28/03/2020
Interim guidance for triage of ophthalmology patients
Clinical Situation
Patient Management / Precautions
1. Routine ophthalmic issues and previously scheduled appointments
Routine problems should be deferred and previously scheduled appointments should be canceled.
Appointments should be rescheduled only upon clearance from public health authorities.
Refill all necessary medications.
2.Urgent ophthalmology appointment for a patient with 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 and gloves are not routinely required for patient or clinician.
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 with the door closed and asked to wear a surgical mask. The treating ophthalmologist and health care personnel require surgical masks.
Gowns, gloves and eye protection are recommended.ā An N-95 mask should be worn if a procedure is planned that will result in aerosolized virus.
The examining room must be cleaned after examination.
4. Urgent ophthalmic problem in a patient who is at high risk for COVID-19
The patient is best 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 is best provided in the hospital setting. Transmission precautionsā” for treating ophthalmologists include wearing a surgical mask, gown, gloves and eye protection (face shield or goggles).
5. Urgent ophthalmic problem in a patient with documented COVID-19 (or person under investigation [PUI])
The patient should remain in the hospital setting if possible.
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 is best 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 precautionsā for treating ophthalmologists include wearing an N-95 mask, gown, gloves and eye protection (face shield or goggles).
[Read the American College of Surgeonās guidelines for operating on COVID-19 patients]
* 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.
ā 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 PPE should be considered on an institutional and case-by-case basis; universal usage for all patient encounters is not appropriate.
ā” 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
Ophthalmology offices should provide only urgent care, make efforts 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 and guidelines from the CDC regarding canceling elective surgeries. Specifically, the CDC recommends that health care providers:
Delay all elective ambulatory provider visits
Reschedule elective and nonurgent admissions
Delay inpatient and outpatient elective surgical and procedural cases
Postpone routine dental and eye care visits
Circumstances vary for hospitals, hospital-based outpatient surgery departments, freestanding ASCs and office-based procedures. However, all ophthalmologists should now adjust their surgical volumes. Even outpatient ASC-based procedures may expose other patients and health care workers to virus shed from asymptomatic patients or even asymptomatic physicians. Elective surgical procedures also deplete scarce personal protective equipment, including but not limited to masks, gowns, gloves, and face shields.
Barring special extenuating circumstances for the patient or physician, the Academy recommends postponing all elective visits and surgery indefinitely, to be reinstated only upon recommendation of public health authorities This recommendation is consistent with those of the American College of Surgeons, the CDC, the U.S. Surgeon General and many other organizations. As noted above, the primary purposes are to reduce the risks of disease transmission and to help conserve scarce resources. The definition of āelectiveā is up to the ophthalmologist but in general should be defined as anything that can be postponed for 2 months without substantive risk to the patientās vision, material functioning or general health.
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.
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.
Updated Resources
WHO
Coronavirus portal
Situation dashboard
CDC
Coronavirus disease 2019 (COVID-19)
General information for health care professionals
Evaluating and reporting persons under investigation
Resources for hospitals and health care professionals preparing for patients with suspected or confirmed COVID-19
For ophthalmologists asked to fill other roles during COVID-19
American College of Physicians: An ACP Physician's Guide + Resources
American College of Emergency Physicians: COVID-19 resource center
Society of Critical Care Medicine: Critical Care for Non-ICU Clinicians
