Changes to Ophthalmic Clinical Care During COVID-19

Abstract and Introduction

Abstract

Purpose of Review: Given the impact that society as a whole, and medicine specifically, has experienced as a result of the COVID-19 pandemic, an examination of clinical care changes enacted in the field of ophthalmology is of interest to the specialty.

Recent Findings: In order to adapt to the reality of the COVID-19 pandemic, measures, such as broadening telehealth capabilities, adopting universal masking, careful sanitation procedures, applying virtual teaching in academic environments, and deferring elective surgeries were put in place. These were aimed at reducing person-to-person spread of SARS-CoV-2. Though best efforts were made at triaging ophthalmic emergencies during these times, unfortunate delays in care were observed in some circumstances. Finally, a prospective study interrogating the risk of spread at slit lamp distances for short periods of time was encouraging, suggesting low risk of transmissibility, though limited by a small case-positive sample size.

Summary: Significant changes have been made in the design and delivery of ophthalmic care during the COVID-19 pandemic. Some of these, such as telemedicine, may provide value in a postpandemic world.

Introduction

DEDICATION

When addressing ophthalmology-specific clinical changes brought about by the COVID-19 pandemic, we acknowledge that early recognition of the pandemic itself began in an ophthalmologic clinic environment. Dr Li Wenliang, our late ophthalmology colleague from Wuhan, China, has been credited with sounding the early alarm of a new disease before succumbing to its devastating effects. We both honor his commitment and allow his memory to remind us of the importance of ophthalmology as an important contributor to advances in medicine in general.

In early 2020, as more information became available regarding the transmissibility of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it became clear that ophthalmology as a profession carried potential for increased risk of virus exposure. Along with our colleagues who also work in close proximity to the oral and upper respiratory mucosa including otolaryngology, anesthesiology, and oral and maxillofacial surgeons,^[1] early reports from China and Italy indicated that not only were we at greater risk of exposure but exposure to a high viral load. This could predispose to significant morbidity and even mortality.^[2]

As ophthalmologists, we began critically evaluating our professional environments and determining means of minimizing viral transmission risks to both us and our patients. We rapidly learned that SARS-CoV-2 remained viable in aerosols for 3 h and on metal and plastic surfaces for up to 3 days.^[3] Many health agencies began to champion the six-foot distance as ideal for minimization of transmission. However, the vast majority of ophthalmology examinations and procedures cannot be performed from six feet; rather, we often find ourselves less than six inches away from our patients. Information regarding virus transmissibility began emerging at a furious pace. However, information regarding risk of SARS-CoV-2 transmission specifically at slit lamp distance was lacking. In the 1930s, it was thought that large respiratory droplets containing tuberculosis particles, another pathogen known to be spread through the air, were unlikely to travel greater than three feet when expelled.^[4] Analysis of spread of the original severe acute respiratory syndrome (SARS) on an aircraft indicated that SARS-CoV-1 viral transmission could still occur at three feet and did occur at up to six feet. In addition, behaviors, such as coughing and singing were shown to increase transmission likelihood at greater distances.^[5] It became clear that distancing and minimizing vocalization would produce the most ideal environmental conditions. The traditional ophthalmologist's work environment, full of plastic and metal surfaces with shared aerosolized space in close quarters, as well as a close working distance to numerous patients per day, was less than ideal. Although transmission risk during examination of a patient, often actively speaking at the slit lamp, had not been studied specifically, it became readily apparent that this required further examination. By deduction from what was known regarding aerosolization at short distances, there was concern that this specific 'slit lamp distance' would portend higher risk of viral transmission, and preventive measures at short distance were likely required.