Ophthalmologists are on the edge

Ophthalmologists are on the edge

The COVID-19 pandemic has led to an unprecedented health care crisis and crippled normal life, as we know it. India, with a population of 1.3 billion, leads the list of countries where movement of people had been restricted, as a precautionary measure. COVID-19, which stands for coronavirus disease 2019, was suggested by World Health Organization (WHO).…..
By Dr. Mahipal Singh Sachdev

Amongst other symptoms, ocular symptoms have been noted in the form of ocular congestion, foreign body sensation, conjunctivitis and keratoconjunctivitis, even though the frequency was less. Ophthalmologists are on the edge due to close face to face interaction with patients during slit lamp biomicroscopic and direct ophthalmoscopic examinations. Hence, a strict measure for opthalmologists, healthcare workers and patients was extremely necessary.
The ministry of Health & Family welfare laid out Guidelines on Safe Ophthalmology Practices in Covid-19 Scenario.1These guidelines are aimed to minimize the spread of Covid-19 infection among Ophthalmologist, Ophthalmic assistants/technicians, nurses, support staff, patients and their attendants.The basic preventive measures include simple public health measures that are to be followed to reduce the risk of COVID-19. These measures need to be observed by all (patients, staff and visitors) in these places at all times.

Physical distancing of at least 6 feet to be followed as far as feasible.
Use of face covers/masks to be made mandatory.
Practice frequent hand washing with soap (for at least 40-60 seconds) even when hands are not visibly dirty. Use of alcohol-based hand sanitizers (for at least 20 seconds) can be made wherever feasible.
Respiratory etiquettes to be strictly followed. This involves strict practice of covering one’s mouth and nose while coughing/sneezing with a tissue/handkerchief/flexed elbow and disposing off used tissues properly.
Self-monitoring of health by all and reporting any illness at the earliest to state and district helpline.

The All India Ophthalmological Society (AIOS) also laid out a set of guidelines towards the same effect, detailing all necessary steps.2

They include the following:

COVID-19 Declaration/Screening form for all patients and attendants, mandatory at the entry of the hospital.
The AIOS guidelines also encompass all directives laid out by MOHFW.
All Ophthalmology facilities to carry out routine clinical activities including OPD, IPD and diagnostic procedures, irrespective of being located in green, orange or red zones except for those eye care facilities that are located in designated containment areas.
All due precautions for preventing spread of infection to be taken as detailed later in this document. 

Ensure minimum patients at any given time in the premises and maintain physical distancing norms of 1 to 2 meters between the patients. To achieve this, the working timings/days of the Centres should be increased to space out the appointments as per the workload.
Teleconsultation practices to be utilized as may be required.
Patient education messages to be disseminated preferably through digital means- displays in waiting areas and through Social media accounts.
All public marketing activities, and camps/ outreach activities shall remain 
suspended till local govt allows resumption.
Eye Banking: Hospital Cornea Recovery Program may be continued in Non- COVID 
deceased donors, for the need of corneas for corneal transplantation. No eyeball retrieval from homes.

During Work

Upon reaching the hospital:
wash your hands and/or use hand sanitizer,
get yourself screened at the screening desk for fever,
change into the set of clothes brought along,
sanitize phone, ID cards, spectacles, vehicle keys, etc,
keep the doors of your rooms open to avoid touching the doorknobs and handles,
wash your hands again before starting work, and
Wear PPE as may be applicable.
Practice physical distancing.
Greet your colleagues and patients with Namaste. Avoid handshake.
Avoid touching your face and politely remind others too.
Observe hand hygiene protocols.

PPE to be used: The PPE to be used by hospital staff has been enlisted in detail, including details on their reuse and disposal.

After Work

Remove PPE. Disinfect (protective glasses and face shields) or dispose as may be applicable according to the BMW Management Rules. Masks and caps in YELLOW and gloves in RED.
Change back into the home clothes and place the work clothes in the washable bag brought along.
Sanitize phone, ID cards, spectacles, etc.
Leave what you can at the workplace. Whatever items are needed daily at the 
workplace and not needed at home should be left at the workplace.
Wash your hands.
Ring-up phone when you are about to reach home. Someone at home should keep 
the front door open so that you do not have to touch any objects like call bell, doorknobs.
Again sanitize phone, ID cards, spectacles, shoes, etc on reaching home.
Take bath (including head bath) immediately after arriving home.
Wash your work clothes along with the bag and change into clean clothes.
Practice wellness activity every day.

PROTOCOL FOR OUTPATIENT SERVICES

Wear PPE as indicated: surgical mask, goggles/ face shield and gloves.
Observe hand hygiene. 

Slit-lamp should have the barriers/ breath shields. 

Equipment disinfection protocols to be followed. Ensure proper disinfection 
frequently, where patient is coming in contact.
Speak as less as possible.
Ensure safe use of consumables.
Ensure proper management of Biomedical Waste as per the BMW Management 
Rules.

Protocol for Surgery /IPD Procedures

Scheduling of surgery/ IPD procedures can be done while maintaining the OT air-conditioning, disinfection and culture protocols.
All persons going to OT to wear PPE as recommended.
Reduce the number of staff going to OT to have less crowding and also economical use of PPE. The suggested bare minimum OT team is one surgeon, one assistant to the surgeon (only if necessary), one anaesthetist, one circulation staff (nurse or OT tech as may be required) and one housekeeping staff.
Choose the quickest possible surgical procedure. Quick and safe surgery is warranted.
A gap of at least 20 minutes is to be maintained between two procedures in the same OT for GA cases.
Surface disinfection of OT table, equipment, trolleys, etc to be carried out between 
two procedures.
Ensure safe use of consumables.
Ensure proper management of Biomedical Waste as per the BMW Management Rules.
Aerosol generating procedures such as intubation and extubation should be done by 
anaesthetist with recommended PPE use and the surgeon should be outside the OT .

TELEMEDICINE& HOMECARE IN OPHTHALMOLOGY

The pandemic brings with it, a silver lining, in the form of tele-ophthalmology, making eye-care services available to a larger part of the population.Encouraging Tele-counselling and teleconsultation, not only lessens the patient load in hospitals, but also makes eye-care services available to patients not being able to visit an ophthalmologist. Detailed guidelines have been set by the AIOS, on the healthy practice of tele-ophthalmology.
With good imaging techniques, a majority of eye conditions can be managed with tele-ophthalmology, deferring a hospital visit. Advancements in technology now allows most eye examination techniques to be carried out at home, with the help of portable machines. Basic eye examination including (but not limited to) vision testing, refraction, colour vision, dry eye tests, detailed eye examination with portable slit lamp, glaucoma tests and fundus examination can now be carried out at home by ophthalmologists and optometrists. These advancements help segregate cases that require hospital visits from cases that may be managed from home.

(The author is Padamshri Awardee, President, All India Ophthalmological Society, Chairman & Medical Director, Centre For Sight, New Delhi)