key: cord-338341-bywxb8e4
authors: Nanda, Tavish; Bond, John B.; Chen, Royce W.S.; Bearelly, Srilaxmi; Day, H. Russell; Cioffi, George A.; Handa, James T.; Arevalo, J. Fernando; Donahue, Sean P.; Breazzano, Mark P.
title: A Measured Approach to Inpatient Ophthalmologic Screening in the COVID-19 Era: A Multicenter Perspective
date: 2020-08-07
journal: Ophthalmology
DOI: 10.1016/j.ophtha.2020.08.003
sha: 
doc_id: 338341
cord_uid: bywxb8e4

nan

Control and Prevention [CDC] 2020). 1 It is likely that this virus will persist in urban centers and 33 spread across the United States in a consecutive fashion for months to come. With hospital 34 systems attempting to limit spread amongst their own workforce and the added effort of 35 minimizing non-urgent interventions, ophthalmology has found itself tasked with optimizing 36 care while performing a new risk-benefit analysis on virus transmissibility and patient/physician 37 exposure. As a by-product of these new challenges, departments nationwide have had to take a 38 closer look at resource allocation and perform data-driven risk stratification holistically, 39 from routine ophthalmologic exams to glaucoma surgery. Crises such as COVID-19 allow us to 40 reevaluate processes that were otherwise reflexive and unsupported by adequate study. 41

A screening examination for ocular findings is one of the most common ophthalmologic 42 inpatient consultations for any patient that develops a Candida bloodstream infection 43 (candidemia). 2 This occurrence has been particularly common in the recent COVID-19-related 44 intensive care population, many of whom are critically ill with both prolonged intubation and a 45 26-76% mortality rate. 3-5 The imperative for this examination is based on the Infectious Disease 46 an ophthalmologist, within one week of a blood culture positive for Candida, although the 48 society notes low-quality evidence for this recommendation. 6 A recent systematic review, 49 however, found an incidence rate of less than 1% across 38 studies and greater than 7,000 50 patients that included more than 1,000 who were prospectively examined. A change in 51 success. The mortality rate, regardless of intervention, was 26%. 7 53

These findings appear consistent with several institutional experiences, including New Outside of candidemia, it is important to analyze the physician's role in all screening 70 examinations, including cytomegalovirus (CMV) retinitis, pre-lung transplant clearance, and 71 ocular lymphoma. In the post-highly active antiretroviral therapy era, for example, the estimated 72 incidence of CMV end-organ disease is less than 6 per 100 person-years, without a direct 73 correlation with titer levels. 11 Like candidemia, many cases of retinitis are thought to remain 74

Retrospective data on 295 patients found zero ocular contraindications to lung transplantation in 76 routine pre-transplant examinations in this especially vulnerable, immunocompromised 77 population. 13 These findings have recently been replicated. 14 78

Experience with this pandemic is likely to spur future data-driven studies on the utility of 79 ophthalmologic screening for these conditions, or at the very least, a closer inspection of existing 80 data in a systematic fashion. As suggested previously by Oh et al. in pre-COVID 2019, 81 physicians must first determine nonessential vs. essential screening consultation, and consider 82 providing a list of nonessential items for consulting services to assist in appropriate triage and 83 resource allocation. 2 Telemedicine has inserted itself as a fixture in many current pandemic-84 response care models, but has yet to be realized in the inpatient setting, or more specifically, 85 inpatient screening (e.g. performing confrontation visual fields for neurosurgical procedures or 86 assessing disc photos for excluding papilledema). Ophthalmologists are at particularly high risk for contracting COVID-19, possibly because they 96 are in close proximity to patient respiratory secretions during the ophthalmologic examination. 18 currently limited, the study population was exclusively residents 18 who typically perform many 99 of these consultations. A focused and intelligent selection for ophthalmologic screening 100 examinations based on signs and symptoms in this context is a most reasonable approach moving 101 forward, given known previous mortalities from adenoviral infection even when screening has 102 been appropriate and necessary. 10 It will remain important to monitor the efficacy of this 103

proposal and adjust it if needed, both throughout and beyond this crisis. 104

Emergency Room Ophthalmology Consultations at a Tertiary Care Center

inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Clinical practice guideline for the 122 management of candidiasis: 2016 update by the Infectious Diseases Society of America

Utility of ophthalmologic screening for 125 patients with Candida bloodstream infections: a systematic review

Do all candidemic patients need an 128 ophthalmic examination?

Fungal eye disease at a 130 tertiary care center: the utility of routine inpatient consultation

Outbreak of adenovirus in a neonatal intensive 133 care unit: critical importance of equipment cleaning during inpatient ophthalmologic 134 tests in the screening for lung transplantation

Clinical utility of pre-transplant ophthalmic 144 consultation for lung transplant recipients: implications in the COVID-19 pandemic era

Klebsiella pneumoniae, and Enterococcus faecium in hospital-acquired 148 bloodstream infections

Candida auris: a rapidly emerging cause of hospital-151 acquired multidrug-resistant fungal infections globally

Candida auris and endogenous 153 panophthalmitis: clinical and histopathological features

New York City COVID-19 resident 156 physician exposure during exponential phase of pandemic