Eye Care and COVID-19: How to prevent the cross-contamination
The American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery and the Outpatient Ophthalmic Surgery Society recently developed a checklist to assist with reopening ophthalmic surgery centers, sharing important ophthalmology-specific information related to COVID-19. Until there is reliable point-of-care testing, an approved and highly effective therapy and/or an approved and effective vaccine, 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.
Recommended protocols when scheduling patients are reported below:
• 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 and told to speak to their primary care physician about testing.
• Keep the waiting room as empty as possible, advise seated patients to remain at least 6 feet (1,8 meters) from one another. As much as prudent, reduce the 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.
• 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 refrains from talking.
• When examining patients, a surgical mask for the patient, and a surgical mask and eye protection for the ophthalmologist are recommended. The recommendation that ophthalmologists wear eye protection is based on the theoretical risk of infection of the ocular surface if exposed. The ocular mucosa, in fact, may be not only a site of virus entry but also a source of contagion as already reported in the previous article. .
• For any in-office procedures that require physical proximity to the patient (e.g., intravitreal injection, lateral tarsorrhaphy), it recommends the patient wears a surgical mask, and that the surgeon wears a surgical mask and eye protection. For example, the Macular Society reported that the University Hospital Southampton have launched a new drive-through service for vulnerable patients who need sight-saving injections. The ophthalmology team at University Hospital Southampton has redesigned its services to reduce the risk in all patients who need anti-VEGF treatment to ensure those patients who need their routine services maintained receive the care they need.
• 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, the ophthalmologist should wear an N95 mask, rather than a surgical mask, in addition to gown, gloves and eye protection.
• 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.
• Regarding tonomer 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.
• 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.
In the end, there is another important element to consider related to Covid-19: the use of multi-dose vials in the operating room or during office-based procedures has resulted in infection outbreaks and errors. Cross contamination is always a possibility when using multi-dose vials (with or without preservatives). Also, in some cases, when medications are supplied in quantities that exceed the amount typically given, practitioners may misinterpret the amount in the vial as a single dose, leading to overdoses.
The Association of periOperative Registered Nurses released a set of recommended practices that include a recommendation to collaborate with pharmacists to procure and store only single-dose vials in the operating room and post-anesthesia unit. Multi-dose vials should be avoided.
• American Academy of Ophthalmology, Important coronavirus updates for ophthalmologists, CDC, WHO Comprehensive Ophthalmology, May 11, 2020
• Matthew Grissinger; Shared Eye Drop Bottles: The Danger in Making Every Drop Count; 762 P&T® December 2003, Vol. 28 No. 12
• Macular Society, Hospital trust launches drive-through injection service for vulnerable patients; Thursday, 30 April, 2020