Guidelines of the Polish Ophthalmological Society on how to deal with ophthalmic patients during the COVID-19 epidemic

GENERAL INFORMATION

SARS-CoV-2 is a coronavirus that causes COVID-19 disease (coronavirus disease 2019). The viral particle contains single-stranded RNA composed of approximately 30 thousand nucleotides, and has a diameter of 60-140 nm, which makes it one of the largest RNA viruses [1]. The virus spreads through droplets. The incubation period is 1-14 days (approx. 5-7 days from exposure to symptom appearance) [2]. Its presence may be detected in secretions from the nose, throat, blood, sputum, stool, and tears. The first reports mentioning infections with the virus came from Wuhan in China (November 2019) [3]. Symptoms of the infection include, first and foremost, cough and fever (Table I). The virus has a predilection for the respiratory epithelium, and causes severe pneumonia that may require mechanical ventilation. Laboratory tests confirm leucopoenia and lymphopenia [4]. Mortality and severity of the disease course increase with age. Zhou et al. reported a higher prevalence of concomitant diseases such as arterial hypertension (30%), diabetes (19%), coronary arterial disease (8%), and chronic obstructive pulmonary disease (COPD) (3%) in patients requiring hospitalization due to COVID-19 in Wuhan [5].
On 11 March 2020, the World Health Organization (WHO) announced a coronavirus pandemic [6]. As of today, over 271 thousand patient cases and over 11 thousand deaths have been confirmed due to COVID-19 (data as of 21 March 2020) [7]. COVID-19 should be suspected in an individual who has at least one of the following symptoms: fever > 38°C, cough or shortness of breath (SaO2 < 95%, number of breaths > 20/min), and who meets one of the following additional criteria:
– during the last 14 days has travelled or been to a country/geographical region in which it has been noted that the virus is spreading;
– during the last 14 days has had close contact with a person who has a possible or confirmed case of COVID-19 disease;
– a severe (requiring hospitalization) course of a lower respiratory tract infection is confirmed with lack of another aetiology that could explain the clinical presentation.
So far, neither effective causal treatment nor vaccines preventing the disease have been developed. Only symptomatic treatment is available, and therefore preventive actions are of the essence [8].

OPHTHALMIC SYMPTOMS

Ophthalmic symptoms that may appear during the course of SARS-CoV-2 infection result from the presence of the virus in the tear film and conjunctival sac secretions [10]. So far, only cases of conjunctivitis and chemosis caused by SARS-CoV-2 have been described.

PROPHYLAXIS

Employees of ophthalmic departments and units are especially exposed to transmission of the virus due to the specific nature of an ophthalmic examination (the distance between the patient’s face and the physician in the slit lamp is < 1.8 m, which is considered a high risk factor for transmission of the virus).
Available forms of personal protection include:
– disposable gowns,
– masks: surgical, FFP2, FFP3,
– face shields, goggles,
– gloves [11].
It should be remembered to regularly disinfect one’s hands, the slit lamp, and objects that have contact with patients. Recommended disinfectants include a 70% solution of ethyl alcohol, 0.1% sodium hypochlorite, 5% bleaching agent, and hospital antiseptic viricidal agents [12]. Every piece of ophthalmic equipment should be disinfected before and after contact with every single patient (slit lamp, Goldmann applanation tonometer, three-mirror lens).
Due to the pandemic, we recommend introducing a three-stage path of taking precautions while providing ophthalmic care for patients [13]:
1. Level one includes:
a) limiting routine appointments and elective procedures (excluding conditions that pose a risk of irreversible vision worsening); postponing planned ophthalmic procedures; introducing telemedical advice services, and electronic prescriptions;
b) introducing an epidemiological questionnaire (1. Contact with a person who has COVID-19 symptoms or who is infected with SARS-CoV-2; 2. Staying in areas with a high percentage of infections during the last 14 days; 3. Symptoms: body temperature > 38ºC, cough, shortness of breath) that is the basis of triage of patients who report to the ophthalmologist’s;
c) discontinuation of procedures that produce aerosol, e.g. non-contact tonometry (air puff), endoscopic tear duct drainage, general anaesthesia;
d) training for the medical personnel on how to minimize the risk of infection in the face of the pandemic.
2. Level two includes:
a) usage of slit-lamp barriers (breath shields) that separate patients from physicians. It decreases the risk of ophthalmic personnel aspiring the air exhaled by the patient that potentially contains SARS-CoV-2 particles;
b) frequent disinfections of hands and equipment in the ophthalmologist’s room;
c) daily measurements of body temperature; reporting the following symptoms to the employer: shortness of breath, cough, fever, emesis, and diarrhoea.
3. Level three includes:
a) all employees of ophthalmic facilities and patients are to wear masks;
b) strict hand hygiene;
c) usage of proper personal protective equipment (PPE) by the medical personnel;
d) patients should keep a minimum 1-metre distance from each other (in the waiting room).
Every patient reporting to the ophthalmic clinic/hospital should have their body temperature taken and be asked to complete a short questionnaire (1. Contact with a person who has COVID-19 symptoms or who is infected with SARS-CoV-2; 2. Staying in areas with a high percentage of infections during the last 14 days; 3. Symptoms: body temperature > 38ºC, cough, shortness of breath) that constitutes the basis for taking special preventive measures. Table II shows necessary preventive measures that should be taken by medical personnel of the ophthalmic clinic/hospital depending on the clinical and epidemiological situation [2].
In cases where it is necessary to transfer a patient to an infectious disease hospital, or an infectious disease hospital where only patients with coronavirus infections are treated, the nearest facilities can be found at the following website: https://www.gov.pl/web/koronawirus/lista-szpitali

DISCLOSURE

The authors declare no conflict of interest.

References

1. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020, 382: 727-733.
2. https://www.aao.org/headline/alert-important-coronavirus-context
3. https://www.scmp.com/news/china/society/article/3074991/coronavirus-chinas-first-confirmed-covid-19-case-traced-back (accessed: 21.03.2020, 17.23)
4. Hui DS, I Azhar E, Madani TA, et al. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health – the latest 2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis 2020; 91: 264-266.
5. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; pii: S0140-6736(20)30566-3. doi: 10.1016/S0140-6736(20)30566-3 [Epub ahead of print].
6. World Health Organization (WHO). BREAKING „We have therefore made the assessment that COVID19 can be characterized as a pandemic”, @WHO, 11 marca 2020 (accessed: 11.03.2020).
7. ECDC https://www.ecdc.europa.eu/en/all-topics-z/coronavirus/threats-and-outbreaks/covid-19/preparedness-and-response-covid-19 (accessed: 01.04.2020)
8. https://www.gov.pl/web/koronawirus
9. Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19). World Health Organization 2020.
10. Xia J, Tong J, Liu M, et al. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol 2020, jmv.25725, doi: 10.1002/jmv.25725 (accessed: 11.03.2020).
11. Rymer W, Wroczyńska A, Matkowska-Kocjan A. Jakie środki ochrony przed wirusem SARS-CoV-2 zastosować w gabinecie okulistycz­nym? mp.pl: https://www.mp.pl/covid19/ekspertcovid2019/229593,jakie-srodki-ochrony-przed-wirusem-sars-cov-2-zastosowac-w-gabinecie-okulistycznym
12. https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-infection-prevention-and-control-healthcare-settings-march-2020.pdf
13. Lai THT, Tang EWH, Chau SKY, et al. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. Graefes Arch Clin Exp Ophthalmol 2020; doi: 10.1007/s00417-020-04641-8 [Epub ahead of print].

The guidelines were approved by the Management Board of the Polish Ophthalmological Society on 23 March 2020.