key: cord-0775009-m09222sk authors: Gelnick, Samuel; Akanda, Marib; Lieberman, Ronni title: Retina in the Age of COVID-19 date: 2021-04-27 journal: Adv Ophthalmol Optom DOI: 10.1016/j.yaoo.2021.04.013 sha: bf9d9a8ab45581915164042740cf7a081dceee08 doc_id: 775009 cord_uid: m09222sk This chapter describes the experience of ophthalmology practices, with an emphasis on retina-specific concerns and procedures, during the COVID-19 pandemic. We describe the protocols implemented to help safely provide care amidst the risk of contagious illness, including increased hygienic cleaning of offices and equipment, personal protective equipment, disposable ophthalmology equipment, office social distancing, appointment triaging and entry screening, and triaging and implementing protective strategies for procedures and surgeries. The lessons gained from this pandemic will allow us to more efficiently transition into these strategies to provide excellent, vision saving care when the next eventual crisis presents itself. social distancing, appointment triaging and entry screening, and triaging and implementing protective strategies for procedures and surgeries. The lessons gained from this pandemic will allow us to more efficiently transition into these strategies to provide excellent, vision saving care when the next eventual crisis presents itself.  In the post-COVID-19 era, patient and health-care worker safety is of utmost importance while maintaining appropriate clinical care  In addition to regular handwashing and use of PPE, all equipment and patient rooms should be wiped down and cleaned between patient exposures  Providing up-to-date information on guidelines for patients to schedule appointments and triaging visits to urgent, semi-urgent, and delayed appointments can help manage patient flow through the office  In-office visits, when appropriate, should be done with proper screening, and care taken in the office to minimize patient exposure  Reducing frequency of visits using methods of treatment, whether medical or surgical, that can extend follow up time should be considered  As society relieves restrictions, it is important to maintain safe practices and screening to minimize exposure  When permitted elective surgeries should be conducted with appropriate screening and safety precautions  Emergent procedures can be conducted with COVID positive patients by following safe procedural protocol. The novel coronovarius SARS-CoV-2 (COVID-19) pandemic presented numerous challenges for ophthalmology practices with regards to safely operating and providing care to patients, especially those at risk of vision loss. These obstacles were significant especially for retina practices in which patients may be due for intravitreal injections or need urgent work-up for vision loss. Similarly, many glaucoma patients have treatment plans with time constraints preventing extended delays in care. Numerous adaptations were implemented, including the use of personal protective equipment (PPE), rescheduling strategies, and precautionary measures to allow for safely performing procedures both in the office and operating room. Patients with sight threatening disease faced both the risk of vision loss because of their disease, which was then compounded by the risks posed by exposure to COVID-19 when seeking care. To curb the spread of illness, local, regional, and federal governments placed restrictions that also limited the ability of clinics to provide care for these patients. In order to adapt and safely protect patients from the risks of the virus while adhering to rapidly changing regulations, providers adopted many new practices. These included employing improved infection control principles, triaging and screening patients to better settings, adjusting clinic patient flow to decrease exposure, and additional precautions with more efficient protocols for operating room cases. Although the recommended precautions and practices described below changed the typical office flow and protocol for staff and physicians, they allowed crucial medical care to continue during an unprecedented crisis. General cleaning and hygiene All staff should be educated on COVID-19 precautions including appropriate use of PPE. Masks should be worn at all times by both staff and patients. Staff should clean hands often, including immediately after removing gloves and after contact with a patient by washing hands with soap and water for 20 seconds. If soap and water are not available and hands are not visibly dirty, an alcohol-based hand sanitizer may be used. A new pair of gloves should be worn for each patient encounter. Cleaning and disinfecting should be done prior to each patient being seen in an exam room and prior to the use of any imaging or testing 1 . The CDC recommends using bleach containing 5.25%-8.25% sodium hypochlorite 1 . Alcohol solutions with at least 70% alcohol also may be used 1 . All slit lamps, imaging or testing equipment, and other patient contact surfaces including exam chairs should be cleaned and disinfected prior to each use. When cleaning any lenses, including those of imaging equipment, indirect lenses, or laser lenses, the manufacturer's manual should be consulted prior to cleaning to avoid damage to the lens surface or coating 2 . Alternatively, clear cling wrap can be used to surround the lenses, and then wiped down between patients and changed when soiled 3 . All slit lamps and imaging modalities should be equipped with commercial barriers or breath shields in order to maximize protection for the patient and physician 4, 5 . . Appropriate measures must be taken to prevent the mask from becoming contaminated, such as wearing a surgical mask over the N-95 respirator, and proper donning and doffing performed 9 . A face shield is also recommended to be used during close encounters with patients, which can even be used during indirect ophthalmoscopy examination 3 . Commercially manufactured breath shields also are recommended for slit lamp examinations 5 . While both the patient and physician should be wearing masks, during the exam the patients' mask may slip, and because of the close proximity, a breath shield can protect from unexpected sneezing or coughing. Under the guidance of local, state, and federal authorities, the COVID-19 required varying levels of restriction in order to safely protect the public and control disease outbreaks and hospital burden. When restrictions required lockdown of all non-essential businesses, stay-at-home orders, and other significant restrictions, disease activity was typically high or at risk of increasing, and these situations are described here as an "active pandemic." As spread and incidence rates decrease, restrictions may slowly loosen and allow businesses to open in stages and social activities to resume gradually. As the course of the pandemic changes fluidly, so too do the restrictions on outpatient care providers fluctuate. Thus, rules and regulation for office visits of patients will differ between these disease activity levels, and the precautions under the most significant restrictions are described first. Care in an active pandemic Office visits should be limited to only urgent matters when under lockdown or regional stay-athome orders. All non-urgent office appointments should be cancelled or rescheduled into telehealth visits. Although there is a significant amount of pressure to use telehealth measures both during a pandemic and in the future, ophthalmology is poorly suited at present to use telehealth to any reasonable extent. Patients should be notified of the cancellations in a timely manner to avoid any unnecessary travel and exposure. All patients should be called on an individual basis to confirm knowledge of the closure and need to reschedule when it is safe, and the office is reopened. At this time, an over-the-phone symptom screening and chart review should be conducted by a physician to ensure that red flag symptoms are not overlooked. In addition, patients should be given appropriate instructions regarding signs and symptoms they need to be aware of that would necessitate a more urgent appointment or intervention. Finally, the appropriate information on how to contact the office in the event of any changes, questions, or concerns that the patients may have regarding their condition, appointments, or office functioning status should be communicated clearly. Note that although we are limiting the discussion to retina practices, these guidelines can be extrapolated to other ophthalmic specialties, using their published guidelines. Patients that are considered urgent or emergent and need to be seen during an active pandemic will need to be treated appropriately in order to ensure safety for the patient as well as the staff. Scheduling patients will need to be based on an appropriate risk assessment scale that takes into consideration patient characteristics, procedure factors, and disease factors. Patient characteristics consider the ability of a patient to attend the appointment, and have appropriate follow up. Procedural factors in a retina practice can be split up into procedures that can be performed in the office and those that require an operating room. Operating room procedures include pars plana vitrectomy, scleral buckle, membrane peeling, enucleation, and brachytherapy for example. Office procedures include laser therapy, J o u r n a l P r e -p r o o f intravitreal injection, pneumatic retinopexy, and cryotherapy 10 . Disease factors play a major role in the stratification process for patients in a retina practice. Patients can be divided into urgent, semi-urgent and delayed appointments 3, 11 . Note that other factors (social, age, co-morbidities, monocular status) must be taken into account, with each patient being considered individually. Appointments scheduled during a pandemic require strict adherence to appropriate guidelines to ensure the safety of patients and staff. Staff and MDs alike must be cognizant of the fear that patients have coming into an office or hospital setting, and must be able to reassure them as to the steps taken to assure their safety. Prior to the day of the visit, a travel history and symptom screen should be taken 6, [12] [13] [14] . If the screening questions are negative the patient may enter for the appointment according to the strict guidelines on distancing. Companions will be strongly discouraged in order to prevent spread of the virus. If a companion is necessary, only one companion may be allowed, undergoing the same testing and screening as the patient. The patient should be encouraged to wait in another location (home, car, outside, hospital, or medical center lobby) until there is room in the office to maintain social distancing. At that time the patient may be called in to the office for the appointment. At the door there should be another symptom screen and temperature test. All patients and companions would be required to wear a mask, and masks should be provided if the patient arrives without one. The patient should sit in a clearly marked, socially-distanced location. When the office is ready for the patient to come in, they should be escorted to the appropriate room. If imaging is required, they should be brought to the appropriate imaging modalities at this time. It is important to maintain appropriate distancing, and no other patients should be in the halls or around the imaging locations. Some practices are using directionality (every hallway is one way), in order to decrease contact. After this is complete, they should be escorted to the room where they will be examined by the physician. Patients should not leave the exam room from this point until they are finished. While in some practices, patients were shuffled from room to room for different aspects of the exam, such as vision testing, dilation and exam, now, in order to limit the exposure of each patient and ease adherence to disinfecting protocols, the entire exam should take place in one room. During the various parts of the exam, it is important that the nurse, technician, provider, and patient all wear the appropriate PPE for the given situation, and surfaces disinfected as described above. Use of the slit lamp only when medically necessary may be appropriate due to the close nature of the exam. If examination at the slit lamp would not change the management of the retinal disease, a 20D J o u r n a l P r e -p r o o f examination of the patient may be substituted. If required, a 78D or 60D lens examinations may be preferred to increase the working distance necessary for an exam at the slit lamp, decreasing exposure and helping prevent fogging of the lens from the patient's redirected exhalation from the mask. While talking should be held to a minimum, appropriate discussion regarding patient care should be had at a comfortable distance where all the information can be understood clearly and safely. Masks should be worn through the entirety of the exam. When it is determined that a procedure is medically necessary the appropriate safety protocols need to be followed to ensure safety of staff and patients. While the majority of the procedure will be the same as any other procedure, there are certain aspects of the procedure that should be considered in light of COVID-19 and the necessary changes to practice. Due to their role in vision-threatening retinal disease and dosing interval, intravitreal injections have been one of the more common procedures done during an active pandemic. Appropriate anesthetic should be applied according to regular practice. Topical betadine should be applied in the usual manner. It is important to properly visualize the area of injection. If a practitioner finds that due to the face shield, he or she is unable to maintain proper visualization, the face shield should be removed prior to preparation for the injection. Alternatively, or if the practitioner needs glasses during the injection, it may be useful to tape the superior portion of the mask to the side of the face preventing exhaled breath from exiting the superior aspect of the mask and fogging the view. Similarly, the patient should have the superior portion of the mask taped as well. While there has been much debate about the need for practitioners to wear masks during injections, during the COVID-19 era this a foregone necessity. As patients must wear masks as well, there is a theoretical increased risk in infection due to their own redirected airflow superiorly from the mask. Given the concern, it, therefore, is recommended to tape the superior portion of the mask to the side of the face during the procedure to limit this exposure. Although masks will be worn, no talking during the injection is advised to avoid any possible increased risk of Several international studies prioritized patients for intravitreal injections and split patients into three priorities 3, 11, 15 . Below is a summarization of these lists: High Priority -0-7 days from their original appointment or from referral When the patient who screens or tests positive must be seen or undergo a procedure, the decision has to be made whether or not the patient can be cared for safely in the office setting, rather than a nearby hospital or medical facility that can accommodate a patient with positive illness 6 . In order to safely treat a patient with possible COVID-19, ideally a negative pressure room will prevent further exposure to other staff or patients 6 . If a practice has the ability to do this, an exam or procedure can be done safely in such a room. If possible, any equipment necessary, including laser equipment, should temporarily be moved into this room for the procedure. If not possible, there needs to be appropriate referral or arrangement with a local facility that has the capability of managing patients with COVID-19. When the patient is in the appropriate setting, the physician can begin the encounter. As much that can be taken care of over the phone without entering the room should be done to minimize time of exposure. This includes any additional pieces of information regarding the condition, explaining the risks, benefits, and alternatives of the procedure, and obtaining consent for the procedure. When this is complete and the physician is ready for the exam, he or she should enter the room in full PPE. In addition to transmission from aerosolized or contacted respiratory droplets, 24% of patients with moderate to severe disease have been shown to test positive for the virus in samples of their tears, presenting another concerning vector for the treating ophthalmologist 19 . These risk factors necessitate the use of full Care after immediate pandemic restrictions are lifted During this time, it is important to recognize that while the office will be opened, adhering to strict protocol is important to ensure appropriate patient care without risking increasing spread of the disease. Scheduling appointments will not result in the same volume as pre-COVID-19 numbers, but routine visits will be welcome at this point in addition to the urgent emergent cases that will continue from during the time when the pandemic is active. Every patient will be given a COVID-19 symptom questionnaire either by telephone or email two days prior to the office visit. Anyone with a positive screen should be offered to reschedule for a later time period when the symptoms resolve. If this is an urgent or emergent situation as described above, the same protocols should be followed as described above, and COVID-19 testing should be done prior to entering the office. If the screen is negative, there is less risk, and the COVID-19 test may be omitted. The patient should arrive at the office, and, if necessary, with a maximum of one companion. Patients and companions should be screened regarding symptoms 20 . As per the CDC symptoms such as fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea may represent infection 20 . Although transmission through ocular surface and tears has been shown to be low, especially in patients that are asymptomatic, owing to the nature of the eye exam, including symptoms of conjunctivitis would be recommended to be included in the screening questionnaire 19, 21 . If the screening test is negative, it should be documented as such in the medical record. If the screening test is positive the decision needs to be made whether this is an urgent or non-urgent visit as described above. In either case the primary care provider of the patient should be contacted in order for the patient to obtain the appropriate testing. In the event that this is a non-urgent matter, the appointment should be rescheduled for a later date. Regular reminders are encouraged with non-urgent patients in order to prevent being lost to follow up when the symptoms have resolved. If the decision is made that the patient has an urgent matter that needs to be dealt with, an appropriate protocol needs to be in place to facilitate appropriate care of these patient as documented above. Due to the prevalence of false negative tests, patients with documented negative testing are not excluded from screening 22 . Patients that have negative screening and temperature tests should be given the option to wait outside the office until there is a room ready, and should not be allowed in the waiting room until the waiting room can fit the patients properly socially distanced. When they are ready to be seen, similar Performing elective surgery Preoperative testing may be performed for patients with no history of the disease. When there is regional presence of the disease, every patient needs to undergo screening and testing for the disease 23 . If negative, a patient can undergo the procedure as normal with appropriate precautions in place. If a patient tests positive the procedure should be postponed as below. Elective surgeries requiring anesthesia for patients with symptoms or positive test. All positive patients with non-urgent elective procedures should be rescheduled for when they are out of the isolation and COVID-19 precaution phase 24 . CDC recommends a symptoms-based approach when discontinuing isolation precautions 25 . Patients with mild-moderate disease should fulfill all three criteria: at least ten days since symptoms first appeared, at least 24 hours since last fever without the use of fever-reducing medications, and any symptoms (e.g., cough, shortness of breath) have improved. Patients with severe disease or who are immunocompromised, may follow these guidelines as well, with the exception that up to 20 days should be considered since symptom onset to make sure the virus has cleared. Repeat testing can be considered in the setting of suspicion for persistent infection with the knowledge that the patient can test positive for a prolonged period of time after the virus has cleared. Patients who were asymptomatic with a positive COVID-19 test need be symptom free for ten days from their positive test. Recommended wait times from disease until surgical procedures are as follows: 24  Four weeks for an asymptomatic patient or recovery from only mild, non-respiratory symptoms.  Six weeks for a symptomatic patient (e.g., cough, dyspnea) who did not require hospitalization.  Eight to ten weeks for a symptomatic patient who is diabetic, immunocompromised, or hospitalized. J o u r n a l P r e -p r o o f  Twelve weeks for a patient who was admitted to an intensive care unit due to COVID-19 infection. This is based on various studies showing the effect of Covid-19 and other respiratory illness on the postoperative recovery period [26] [27] [28] [29] [30] . There is no role for repeat testing in these patients at this time, unless new symptoms arise and/or 90 days have passed since the last test. If there is a need for general anesthesia, only staff that are required to be present in the room for the intubation and extubation should be present and wearing N-95 respirators, faceshield, and gown to prevent spread of infection through aerosolization. For monitored anesthesia care with conscious sedation, if supplies permit, it is still recommended for the surgeon to wear an N-95 respirator and patient to wear a surgical mask, due to the prolonged exposure and close proximity of the surgeon to the respiratory system of the patient 2 . Air conditioning can still be used during operating room cases. While negative pressure systems are recommended, if this is not possible a positive pressure system can still be used. If an exhaust system is used, air should be expelled only by a High Efficiency Particulate Air (HEPA) filter. 5% povidone iodine should be used in preparation before the case as it is viricidal and disinfects in 15 seconds. In order to maintain sterility, mask, faceshields, and shoe covers should all be donned prior to gowning in the operating room. Goggles may be preferred when using a microscope and they can be decontaminated and reused. N-95 respirators can be reused the same day as long as they are not soiled during a case, or touched in between cases. Other surgical instruments should not be reused from one case to the next without sterilization to prevent infection spread. Proper draping with water tight seal is important especially around lower eyelid to prevent upward redirected airflow into the sterile field. COVID-19 required numerous changes as above in order to safely provide care to patients. This particular pandemic represented a steep learning curve that resulted in many "lessons learned" that should continue to be employed. By minimizing risk of transmission through good infection control principles, patients and providers are able to safely continue operations. Frequent hand hygiene, Prevention CfDCa. Cleaning and Disinfection for Households Important coronavirus updates for ophthalmologists Evolving consensus on managing vitreo-retina and uvea practice in post-COVID-19 pandemic era Important coronavirus updates for ophthalmologists Efficacy of Slit Lamp Breath Shields Perceptions of Occupational Risk and Changes in Clinical Practice of United States Vitreoretinal Surgery Fellows during the COVID-19 Pandemic Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings Respirator tolerance in health care workers Considerations for Recommending Extended Use and Limited Reuse of Filtering Facepiece Respirators in Healthcare Settings List of urgent and emergent ophthalmic procedures Proposed algorithm during COVID-19 pandemic for patient management in medical retina clinic Practice Patterns and Responsiveness to Simulated Common Ocular Complaints Among US Ophthalmology Centers During the COVID-19 Pandemic Impact of the COVID-19 Pandemic on Essential Vitreoretinal Care with Three Epicenters in the United States Intravitreal injections during COVID-19 outbreak: Real-world experience from an Italian tertiary referral center Efficacy and Treatment Burden of Intravitreal Aflibercept Versus Intravitreal Ranibizumab Treat-and-Extend Regimens at 2 Years: Network Meta-Analysis Incorporating Individual Patient Data Meta-Regression and Matching-Adjusted Indirect Comparison Efficacy of a remote based computerised visual acuity measurement Preparedness among Ophthalmologists: During and Beyond the COVID-19 Pandemic Evaluation of SARS-CoV-2 in Tears of Patients with Moderate to Severe COVID-19 Prevention CfDCa. Symptoms of Coronavirus Assessing Viral Shedding and Infectivity of Tears in Coronavirus Disease 2019 (COVID-19) Patients Detection of SARS-CoV-2 in Different Types of Clinical Specimens apsf-joint-statement-on-elective-surgery-and-anesthesia-forpatients-after-covid-19-infection Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease Recovery of pulmonary functions, exercise capacity, and quality of life after pulmonary rehabilitation in survivors of ARDS due to severe influenza A (H1N1) pneumonitis. Influenza and Other Respiratory Viruses Delaying surgery for patients with a previous SARS-CoV-2 infection Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis