key: cord-0727327-49btck9l
authors: Smith, Justine R.; Lai, Timothy YY.
title: Managing Uveitis During the COVID-19 Pandemic
date: 2020-05-19
journal: Ophthalmology
DOI: 10.1016/j.ophtha.2020.05.037
sha: e1a727369a4d7c16de6ce407743c17fc93618089
doc_id: 727327
cord_uid: 49btck9l

nan

The COVID-19 pandemic has resulted in professional changes in uveitis care, some of which may have long-term impact.

With office-based and surgical treatment prioritized for urgent or emergent care alone, many uveitis consultations are held by telemedical video-conferencing or simple telephone calls. Procedures to ensure access to immunomodulatory medications without an office visit have been instituted.

Discussions on professional listservs indicate that uveitis specialists are favoring in-person visits with ophthalmic examination for new presentations of uveitis, or when patients with a history of uveitis experience symptoms of recurrent inflammation. Examinations also may be needed to monitor effects of adjusting treatments. Visits are conducted with attention to local recommendations for patient care, including use of personal protective equipment (PPE). 1 Given that uveitis is often chronic, a patient-ophthalmologist partnership approach is common. If the uveitis is predictable, and the patient is familiar with their treatment plan, even an acute flare of posterior segment inflammation may be managed remotely. For patients whose uveitis is controlled on a stable drug schedule, history by conference plus standard blood tests may provide adequate review. However, intraocular pressure measurements in patients with a history of secondary ocular hypertension or glaucoma, or who have received depot corticosteroid, are essential to avoid glaucomatous damage.

Long-term impact: Ophthalmologists and patients are realizing opportunities to use telemedicine in managing chronic and stable uveitis. This practice could persist, particularly for delivering care to remote communities. After the COVID-19 pandemic, a randomized clinical trial comparing clinical outcomes for telemedical versus office-based consultations may be appropriate.

Making a specific diagnosis in a patient with uveitis often involves ophthalmic imaging and/or vision function testing, plus investigations that may include blood testing, radiology, and interventional ocular or systemic procedures.

Severe acute respiratory virus coronavirus 2 (SARS-CoV-2) persists on surfaces. 2 Although ophthalmic equipment is decontaminated between patients, only key imaging and/or function tests that inform a specific diagnosis are appropriate.

Uveitis specialists have long recommended a tailored selection of investigations based on the uveitis phenotype and a detailed history, rather than a standard battery of tests for every patient. 3 Only tests for syphilis, and depending on local prevalence, tuberculosis, are performed on all individuals who present with uveitis. Aerosol-generating procedures that pose high risk of SARS-CoV-2 infection are scrutinized carefully. 4 For example, bronchoscopy is likely unnecessary if the presentation is otherwise consistent with ocular sarcoidosis. Even lower risk procedures, such as neuroimaging and lumbar puncture when multiple sclerosis is suspected, are planned in collaboration with internist colleagues. Vitrectomy is deferred if possible, but may be essential for diagnosing certain conditions, such as vitreoretinal lymphoma or infectious retinitis. The operation can be performed under local anesthesia or monitored anesthesia care, rather than general anesthesia. If available for use in asymptomatic individuals, SARS-CoV-2 testing helps decisions around timing.

Long-term impact: Rational selection of ophthalmic tests and systemic investigations is necessary economically as well as medically. The present situation is highlighting the value of "old-fashioned" clinical skills in history taking and examination when diagnosing uveitis. Moving forward, this is a consideration for ophthalmic education programs targeted at all levels from resident through qualified ophthalmologist.

Treatment of infectious uveitis continues to involve systemic anti-microbial and antiinflammatory drugs, sometimes supplemented with intravitreally injected preparations. The World Health Organization issued a warning that individuals with tuberculosis and COVID-19 may have worse outcomes, particularly if the anti-tubercular therapy is interrupted. 5 SARS-CoV-2 has been detected in the blood during acute infection, 6 and intraocular tissues express angiotensin converting enzyme (ACE)2, which is a receptor for the virus, 7 raising the possibility of intraocular infection. However, to date there have been no published reports of COVID-19-associated uveitis, although subtle retinal microvascular pathology, and small lesions in the ganglion cell and inner plexiform layers are described. 8 There has been considerable discussion around the possibility that COVID-19 might be more common and/or more severe in persons who are pharmacologically immunosuppressed, including patients who are taking immunomodulatory drugs for non-infectious uveitis. Based on experience across multiple fields including rheumatology, dermatology and gastroenterology, immunomodulatory treatment does not appear to be a major risk factor for severe COVID-19, and the general recommendation is that such treatment should not be ceased in the absence of SARS-Cov-2 exposure or suspected or confirmed infection. [9] [10] [11] While immunomodulatory drugs are continued in patients with non-infectious uveitis, standard measures to limit the spread of COVID-19 -hand hygiene, distancing and selfisolation-and influenza vaccination are recommended. Patients have blood monitored for drug toxicity. Inflammatory cystoid macular edema and choroidal neovascularization are reviewed regularly, although a decision for retreatment may be based on clinical findings alone.

One special situation is the patient with non-infectious uveitis who is infected with SARS-CoV-2, whether asymptomatic or suffering from COVID-19. The uveitis specialist works closely with the other treating physicians, and immunomodulatory treatment is held or tapered temporarily. In-person assessments are undertaken with PPE. Locally delivered corticosteroid is an option to avoid systemic drug activity: corticosteroid eye drops are highly effective for anterior uveitis, and periocular and intraocular corticosteroids as well as corticosteroid implants are considered for patients with posterior segment uveitis. An electronically actioned effort led by Singapore NHG Institute, Chandigarh PGIMER and Moorfields Eye Hospital has already produced an expert opinion statement to guide immunomodulatory therapy in patients with non-infectious uveitis (manuscript under review). To inform on the issue of immunomodulatory treatment in patients with inflammatory diseases as a group, new registries have been launched (e.g., COVID-19 Global Rheumatology Alliance). 12 Long-term impact: Experience gained during the COVID-19 pandemic on the use of immunomodulatory drugs in non-infectious uveitis will inform future treatment approaches. Patients taking these drugs have become more aware of the principles of infection control and the importance of vaccination, which will reduce their risk of infection overall.

Uveitis specialists often co-manage non-infectious or infectious uveitis with internists. The ophthalmologist monitors drug effectiveness, while the internist monitors drug safety. During the COVID-19 pandemic, 3-way video-conference-and smart telephone-based consultations maintain communications between ophthalmologist, internist and patient.

Long-term impact: Historically, coordination of co-management has often been quite challenging, since medical practices are rarely co-located. Most consultations will move back to the office setting in the long-term. Nonetheless, multidisciplinary telemedicine is likely to strengthen collegial relationships and provide a process to facilitate co-management in the future.

In the wake of the COVID-19 pandemic, several global organizations -International Ocular Inflammation Society, International Uveitis Study Group and Foster Ocular Inflammation Society-produced a public document providing "evolving consensus experience with uveitis in the time of COVID-19" with input from their memberships, and review by Executive Committee members. 13 The American Uveitis Society has temporarily opened its listserv to non-members, to ensure that information regarding the management of uveitis during the pandemic is readily available. Uveitis specialists have contributed ophthalmology questions to COVID-19 Global Rheumatology Alliance registry.

Long-term impact: Clinical alliances forged during the COVID-19 pandemic are likely to persist, which will strengthen the uveitis community.

COVID-19: Limiting the risks for eye care professionals

Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1

Approach to the diagnosis of the uveitides

Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review

Detection of SARS-CoV-2 in different types of clinical specimens

Angiotensin II and its receptor subtypes in the human retina

Retinal findings in patients with COVID-19. The Lancet. 2020

What should gastroenterologists and patients know about COVID-19?

The COVID-19 Global Rheumatology Alliance: collecting data in a pandemic

The authors wish to thank Ms. Janet Matthews for administrative support in preparing this article