In December 2019, Dr Li Wenliang, a Chinese ophthalmologist, warned of the risk of a new and unusual type of pneumonia. On February 7, 2020, he died of COVID-19. This 33-year-old ophthalmologist, was the first doctor in the world to warn that an unusual form of respiratory infection was spreading.<\/p>\n
A few days after the outbreak began, Dr Li Wendliang was hospitalised with fever and cough and eventually died. He was declared a national hero in recognition of his sincere efforts to make the virus known to the world.<\/p>\n
On 31 December, China reported to the World Health Organization (WHO) an unusual outbreak of pneumonia in Wuhan, with an unknown cause. A seafood market appeared to be the main source of the disease, as most of the sick people came into contact with this market. On 7 January, a new coronavirus was identified by the China Center for Disease Control (CDC) and named, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which was later renamed COVID-19 by WHO. The origin of this virus is unclear, although it is structurally similar to Severe Acute Respiratory Syndrome (SARS-CoV) and Middle East Respiratory Syndrome Coronaviruses (MERS-CoV). Some studies reported bats as the main source of infection, while others reported pangolins.<\/p>\n<\/p>\n<\/p>\n
By the first week of April 2020, more than 1.3 million people worldwide had been infected and more than 75,000 had died from this contagious virus. In the United States, the battle with COVID-19 entered a critical period, as the number of infections exceeded 360,000, with nearly 10,000 deaths.<\/p>\n
It was estimated that based on the projections of the Federal Reserve Bank of St. Louis, the economic downturn due to the epidemic could result in huge job losses and lead to an unemployment rate of 32%. Many people have lost their jobs, people are deeply depressed and it is necessary to conduct multidisciplinary studies in various fields of medical and social sciences. Certainly, this was an unexpected challenge for the world and shows that people are still incapable of properly managing communicable diseases.<\/p>\n
The global impact of the COVID-19 epidemic is reminiscent of that of the Spanish flu (1918-1920), which infected about 500 million people worldwide and caused the deaths of 50 to 100 million people. The COVID-19 epidemic had a high mortality rate, in contrast to the influenza mortality rate, which was less than 1%, so there is an urgent need for effective treatment. To date, the number of deaths from COVID-19 is higher than the total recorded deaths from SARS-CoV and MERS-CoV. In addition, it is necessary to take preventive measures to avoid future health crises. These may include, monitoring of open markets and thorough testing of virology laboratories.<\/p>\n<\/p>\n<\/p>\n
COVID-19 is a virus with a cloned, positive RNA genome. The main route of transmission is via respiratory droplets. The virus enters the body via the ACE2 enzyme and blockade of this receptor has been proposed as a potential strategy for treatment. Immunological evidence suggests that patients with COVID-19 may have cytokine syndrome, suggesting the possibility of immunomodulatory agents against infection. To date, there is no definitive cure or vaccine for COVID-19, and most of the measures are based on preventing transmission of the virus. The incubation period of this viral infection is 2 to 14 days, with an average of about 5 days.<\/p>\n
Clinical symptoms of COVID-19 include fever, dry or productive cough, fatigue, shortness of breath, myalgia, dizziness, confusion, headache, headache, sore throat, anorexia, hemoptysis, rhinorrhoea, chest pain, diarrhoea, nausea, vomiting and anaemia. It is noteworthy that the mortality rate associated with COVID-19 is significantly higher compared to seasonal influenza and may be exacerbated in the elderly and in people with underlying medical conditions. Also, the mortality rate is higher in closed facilities without intensive care units. Compared to the characteristics of H1N1 patients, patients with COVID-19 are more likely to have an unproductive cough in combination with other symptoms such as fatigue, gastrointestinal symptoms. Also given that COVID-19 patients require mechanical ventilator support for longer periods of time, this will indirectly limit their availability and require an additional supply that is unexpectedly larger than what we have had to date.<\/p>\n
With the increasing number of cases and admissions to intensive care units that we are seeing today, frontline medical and paramedical staff are at greater risk of becoming infected.<\/p>\n<\/p>\n<\/p>\n
Close proximity between the patient and the ophthalmologist is a risk factor for COVID-19 transmission. The CDC recommends social distances, where people should be at least 2 meters apart to avoid transmission of the virus. Any contact longer than a few minutes of exposure is considered prolonged. However, during the eye exam, the distance between the patient and the ophthalmologist is as close as 20 cm in most cases, and the time required for a complete evaluation, including taking a history, checking visual acuity, measuring intraocular pressure, waiting for pupil dilation, etc., is more than half an hour. In the ophthalmic examination, contact with the patient is unavoidable.<\/p>\n
As stated in the introduction, the first report came from an ophthalmologist who reported a patient with COVID-19 and died of COVID-19 himself. Studies on other coronaviruses have shown that they are likely to be transmitted by tears. Although the risk may be quite small, studies have shown that tears are an infectious ocular secretion. In a recent study, researchers studied the tears and conjunctival secretions of 30 patients with pneumonia and found that three patients with conjunctivitis were COVID-19 positive. This suggests that the virus can infect the conjunctiva and cause conjunctivitis. In another study, researchers reported conjunctival infection in 9 of 1099 patients with COVID-19. In a study from Singapore, 64 tear samples were collected from 17 patients with COVID-19 between days 3 to 20 from the onset of the first symptom, but culture showed a negative result. The researchers therefore concluded that the risk of transmission through tears is low. Although this was the first report to evaluate the possibility of COVID-19 transmission through tears, it had some limitations, such as a small sample number. Although studies have shown a low probability of COVID-19 transmission, there remains a risk of transmission due to the long patient stay in the ophthalmology clinic, the short distance between the ophthalmologist and the patient, and possible transmission via respiratory droplets.<\/p>\n
In a study involving 38 patients with COVID-19, 12 patients had severe ocular symptoms, such as conjunctivitis, epiphora or chemosis, which occurred in patients with more severe systemic problems. The results showed a low rate of conjunctivitis as the first symptom, only one in twelve.<\/p>\n
Research in cats and mice has shown that coronaviruses can affect the eyes. Coronaviruses are generally known to cause many eye infections in animals. Clinical findings such as conjunctivitis, anterior uveitis and optic neuritis have been diagnosed in animal models. Studies show that COVID-19 is transmitted from asymptomatic individuals, making it difficult to control. However, it should be noted that inadequate diagnostic methods in many geographical areas may lead to underdiagnosis, especially in patients with less severe disease.<\/p>\n
In addition, a doctor who visited Uhan was wearing an N95 mask, but without protecting his eyes, reported that redness of the eyes can occur even before respiratory symptoms.<\/p>\n<\/p>\n<\/p>\n
Local and international Ophthalmological Societies have published recommendations on the International Council of Ophthalmology website, creating and implementing evidence-based clinical guidelines for the evaluation, research and management of high-risk patients in the Ophthalmology Clinic.<\/p>\n
There is an example of comprehensive recommendations from the American Academy of Ophthalmology (AAO) and a well-designed study from Hong Kong.<\/p>\n
Today, a new chapter in the history of infectious diseases is being written, and a multidisciplinary approach should focus on the different aspects of this difficult health crisis.<\/p>\n<\/p>\n<\/p>\n
1. HIGHER PROTOCOLS<\/p>\n
Preventive protective measures for patients and clinic staff should start outside the clinic. A patient screening protocol should be followed, which includes a concise but comprehensive questionnaire to investigate symptoms of COVID-19 including fever, dry or productive cough, fatigue, dyspnea, myalgia, dizziness, confusion, headache, sore throat, anorexia , haemoptysis, rhinorrhoea, chest pain, diarrhoea, nausea and vomiting, anosmia, presence of conjunctivitis, recent travel and contact with a previously diagnosed case, which should be completed by telephone prior to scheduling the patient's appointment. Patients should be asked about a recent positive, negative, or if they are awaiting test results for COVID-19, which they or persons in their immediate family environment performed. The main eye problem should also be reported so that its severity can be assessed before scheduling the appointment.<\/p>\n
The aforementioned protocol will hopefully reduce unnecessary face-to-face visits and allow for screening of patients into groups based on low or high risk of COVID-19 and low or high visual acuity. Patients with low visual acuity may be eligible for either referral to a later appointment date or tele-ophthalmology services. The proven effectiveness of tele-ophthalmology in rural areas suggests the possibility of extending this technique to other areas. However, evidence on the use of tele-ophthalmology in the elderly is scarce and may be further limited for visually impaired patients. If patients' contact details are accessible, they should be notified that their non-urgent surgery or visit will be postponed.<\/p>\n
2. NECESSITY OF INDIVIDUAL PROTECTION<\/p>\n
Personal protective equipment is important, but only partly protects staff and patients from possible infection. All clinical staff, including security staff, should wear personal protective equipment according to the instructions, availability and symptomatology of the patient being treated. At a minimum, all personnel should be equipped with an N95 mask and gloves. Personnel examining patients at close range, such as in the slit lamp , or intervening in the eye, should use eye protection, gloves and the examiner should touch patients' eyes using a disposable cotton swab. High-risk patients should also be equipped with similar personal protective equipment to reduce the chances of spreading the virus through droplets or contact.<\/p>\n
Personal protective equipment is essential to reduce the risk of exposure to the virus and includes gloves, goggles, face shields, water-resistant gowns and respiratory protective equipment. Medical staff in the eye clinic, ward and operating theatre must have full insurance cover.<\/p>\n
It is clear that reuse of masks should be avoided as they may put health workers at risk.<\/p>\n
Some guidelines, in high-risk cases, stress the use of double gloves. Protecting the health of health workers is a top priority. Just as in an airplane, where it is recommended to apply the oxygen mask yourself first before helping others. Therefore, healthcare workers must be healthy to be able to continue to provide their services, to their patients. Therefore, it is of utmost importance to maintain the health of medical personnel and provide them with protective equipment.<\/p>\n
3. WORKFLOW<\/p>\n
We need to ensure that after the initial check at the entrance of the surgery and before entering the waiting area and generally in all areas where there is a waiting room, everyone must wear a mask.<\/p>\n
Specific procedures should be developed to categorise patients according to their clinical requirements and risk of spreading COVID-19. All patients should maintain a two-meter clearance and should not be allowed to crowd into waiting rooms or other common areas. Reduce the number of seats in the waiting room, always keep a few empty examination rooms so that elderly and immunocompromised patients can be led directly from reception, bypassing the waiting room. The waiting room should be reserved for low-risk patients only. Leave a 6 m distance between diagnostic machines and computer monitors. Staff body temperature and screening for infection-related symptoms should be assessed daily.Within the capabilities of the clinic, patients should be transported directly to the examination rooms which should be properly disinfected between patients. High risk patients should be admitted to the operating room with negative pressure ventilation. Mono patients should be considered special cases.<\/p>\n
Patients with early cataracts and those who need refractive surgery could be scheduled later. However, in cases such as endophthalmitis, there should be immediate treatment.<\/p>\n
4. MEDICAL DEVICES AND CLINICAL ENVIRONMENT<\/p>\n
Medical equipment that requires use at close range, such as the slit lamp, must be appropriately adapted. It has been suggested that plastic breathing shields should be placed between the examiner and the patient. Although there are no standard recommendations, the use of a slit breathing shield is recommended to reduce droplet transmission. In view of this very difficult health situation, due to the COVID-19 pandemic, perhaps in the future remote examination via slit-lamp, where the examiner will be in a different room from the examinee, will be developed. This underlines the urgency of the development of robotics and telemedicine in ophthalmology.<\/p>\n
The surfaces of mobile phones, keyboards and face masks, which are frequently used, are among the dangerous sources of contamination.<\/p>\n
It is very important to wash your hands with soap and water before entering the examination room. It is recommended that patients be educated on the correct way to wash their hands. Proper ventilation should be available in the exam room. All equipment should be disinfected between patients by staff. Diagnostic equipment is also subject to 2 metre distance parameters.<\/p>\n
COVID-19 coronavirus can persist for up to 6 days on some surfaces based on some data. It is very important to clean the floor, appliances, and areas that the patient comes in contact with (such as the handles and the slit lamp's hypodermis). After each examination, the equipment used, especially the patient's point of contact, should be disinfected by staff. Each practice should have an accessible, effective and low-cost method of cleaning surfaces and equipment based on protocols. An individual must regularly monitor the implementation of these protocols, acting as the COVID-19 quality control officer.<\/p>\n
Gloves must be changed after each examination. Do not exchange cash in the office. The patient's record and receipt should not be given to the patient and the procedure should be done electronically.<\/p>\n
Examination rooms shall have adequate ventilation. There should be a restriction on conversations in the waiting room and during the examination.<\/p>\n
5. SURGICAL ASSESSMENTS<\/p>\n
It is generally recommended that you do not perform surgery in the doctor's office, especially for patients with underlying diseases, and instead refer them to specialist care clinics . In the current health crisis, it is recommended that regular examinations and regular surgery be postponed.<\/p>\n
Patients must complete a COVID-19 consent form prior to surgery. If the patient requires surgery, a negative test for COVID-19 is recommended prior to surgery. In the operating room, procedures should be performed remotely and expeditiously. However, accuracy should not be sacrificed. It is recommended not to use general anaesthesia. Both in the doctor's office and in the operating room, the health of the healthcare staff is very important and should be meticulously guarded. Their body temperature should be checked regularly and a symptom checklist should be completed at regular intervals.<\/p>\n
6. OTHER CONSIDERATIONS<\/p>\n
Many patients use contact lenses and cannot function without them. We believe that emphasis should be placed on strict hygiene of contact lenses, but their use should be optional unless someone has viral conjunctivitis or ocular manifestations of COVID-19, where their use is prohibited.<\/p>\n
Finally, mental health is just as important as fighting the virus. The anxiety epidemic is growing much more than the COVID-19 epidemic itself. It should be noted that people are naturally anxious about this situation.<\/p>","protected":false},"excerpt":{"rendered":"
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