Managing eye health during the COVID-19 pandemic

While the importance of good hygiene, particularly proper handwashing, and mask wearing has been continuously stressed, the role of eye care in COVID-19 prevention has not received much attention.

The evidence on ocular transmission of SARS-CoV-2 remains controversial. In a small study of 38 patients with COVID-19 in China, 31.6 percent had “ocular manifestations consistent with conjunctivitis” including conjunctival hyperaemia, chemosis, and epiphora. [JAMA Ophthalmol 2020;doi:10.1001/jamaophthalmol.2020.1291]

A small study from Singapore suggested that the risk of SARS-CoV-2 transmission via tears is low, though more research is needed to definitively prove this. [Ophthalmology 2020;doi:10.1016/j.ophtha.2020.03.026] According to the American Academy of Ophthalmology (AAO), while virus particles are most commonly spread through respiratory droplets, they can also be transmitted through the eyes. The infection can also be spread by hand-to-eye contact (eg, touching a contaminated object and then touching the eyes). [AAO, https://www.aao.org/eye-health/tips-prevention/coronavirus-covid19-eye-infection-pinkeye, accessed 30 April 2020]

“We know that … there are viral particles in tears … but the rate of conjunctivitis is very low,” said Dr Gareth Lema, a retinal surgeon at the Mount Sinai Hospital in New York, US. [https://www.youtube.com/watch?v=VnU9pRdd1uI, accessed 30 April 2020]

The virus doesn’t commonly cause eye infections, but can drain down the tear ducts, enter the nose and mouth, and cause infection, he said.

According to a review published by Sadhu et al, ophthalmology professionals have an increased risk of SARS-CoV-2 infection due to their close proximity to patients. [Ocul Immunol Inflamm 2020;doi:10.1080/09273948.2020.1755442] The AAO made several recommendations to reduce the risk of COVID-19 transmission without jeopardizing eye health.

 

AAO recommendation: Delay routine eye checks

Delaying routine or non-urgent visits could help minimize doctor-patient contact and conserve disposable medical supplies. Telemedicine strategies could be deployed if necessary.

Enabling patients to stock up on a certain amount of eye medications – about a 3-month supply – may be helpful, particularly for patients with chronic eye issues such as glaucoma or uveitis, said Lema. This will reduce a patient’s exposure to COVID-19 by avoiding unnecessary trips to the pharmacy as well as reduce the likelihood of running out of medication.

 

AAO recommendation: Treat eye emergencies and provide critical care

While routine care can be delayed, emergencies should not. Patients with diabetic retinopathy or macular degeneration who require regular injections should contact their ophthalmologists. In this scenario, Lema encourages patients to get in touch with their ophthalmologists to discuss if increasing the interval between injections is an option.

The emergence of symptoms such as floaters or flashes, eye pain, headache, red eye, nausea, and vomiting require urgent care. Changes in vision (eg, blurry, blank spots, vision loss) and any eye injury should be dealt with immediately.

Prior to entering the waiting room, a patients’ history of fever or respiratory symptoms and personal or family member contact with a person who tested positive for COVID-19 should be ascertained. [AAO, https://www.aao.org/headline/alert-important-coronavirus-context, accessed 30 April 2020]

According to Sadhu and co-authors, pre-visit information can also be garnered through a telephone call. Those with suspected COVID-19 should be examined in an isolated area and sent for further investigation. In the case of an eye emergency, the ophthalmologist should wear personal protective equipment (PPE) while treating the patient in an isolation room.

For aerosol-generating procedures, Sadhu et al recommend installing a slit-lamp barrier breath shield. Standard disinfection, sterilization, hygiene, and PPE- and mask-use measures apply, and use of disposable items is recommended. “[W]e hypothesize that eye drapes have the highest risk for contamination, given the proximity to the mouth and the nose, and the fact that these cover the whole face during the surgical procedure. These drapes need to be handled carefully and appropriately discarded at the end of the procedure.”

“Contact time with the patients should also be kept minimal. If longer durations or investigations mandating longer time [are] required, the urgency of the indication must be kept in mind and be done as a part of strict medical need,” they said. “Sight-threatening conditions that are urgent and emergency surgical procedures should be carried out.”

The AAO has compiled a list of urgent and emergency ophthalmic procedures which is available here: https://www.aao.org/headline/list-of-urgent-emergent-ophthalmic-procedures. A summary of the triage of ophthalmology patients is available here: https://www.aao.org/headline/alert-important-coronavirus-context. Clinical guidance recommendations by The Royal College of Ophthalmologists is available here: https://www.rcophth.ac.uk/2020/04/covid-19-update-and-resources-for-ophthalmologists/.

 

AAO recommendation: Use spectacles instead of contact lenses

According to AAO spokesperson Dr Sonal Tuli, temporarily switching from contact lenses to spectacles may be helpful in preventing COVID-19 spread.

“Consider wearing glasses more often, especially if you tend to touch your eyes a lot when your contacts are in. Substituting glasses for lenses can decrease irritation and force you to pause before touching your eye,” she said.

However, spectacles do not offer 100 percent protection against droplets as the virus can still get around the exposed sides, tops, and bottoms of the spectacles. Caregivers of ill or potentially COVID-19 exposed individuals may opt for safety goggles.

For those who need to use contact lenses, special care should be taken. [AAO, https://www.aao.org/eye-health/diseases/prevent-infection-with-proper-contact-lens-care, accessed 30 April 2020] This includes:

·       Rinsing or storing contact lenses in fresh solution (not water).

·       Using a proper disinfecting solution to disinfect lenses (not saline or rewetting drops).

·       Not reusing solution or topping off solution in contact lens cases.

·       Replacing contact lens cases often (at least once every 3 months).

·       Following eye care professionals’ advice on using and replacing lenses.

 

Tips on reducing eye strain

During this stay-at-home period, many of us are spending more time than usual on our various devices. Lema advises to try limiting screen time to 1–2-hour blocks, taking breaks every 20 minutes to look into the distance for about 20 seconds, and using artificial tears regularly.

 

Ophthalmology in the post-COVID-19 era

According to AAO CEO Dr David W. Parke II, “re-entering a more normal practice of ophthalmology” post-COVID-19 represents another challenge. “Physicians and patients will now bring different expectations to the clinical encounter … we likely will thrive as professionals only if we recognize those elements that will evolve,” he said. [JAMA Ophthalmol 2020;doi:10.1001/jamaophthalmol.2020.2004]

Ophthalmologists will need to manage these new expectations, he continued. Patients and staff may expect, among other measures, less crowding in the clinic, and use of masks and face and slitlamp breath shields. Continuous testing for SARS-CoV-2 infection and antibodies may also be required, at least until herd immunity is met.