Implications of COVID-19 for Ophthalmologists

Abstract

Purpose To describe and explain the implications of COVID-19(SARS-CoV-2) for ophthalmologists in light of the rapid developments in our understanding of the virology, transmission and ocular involvement. Design Evidence-based perspective Methods Review and synthesis of pertinent literature Results Retrospective studies highlight that less than 1% of patients display COVID-19 related-conjunctivitis. However, prospective studies suggest the rate is higher, approximately 6%. Viral RNA has been identified in tears and conjunctival secretions in patients with active conjunctivitis as well as asymptomatic cases. Overall, conjunctival swabs are positive in 2.5%. Samples taken earlier in the disease course are more likely to demonstrate positive virus. Viral transmission through ocular tissues has not been substantiated. Ophthalmologists are in the high-risk category for COVID-19 infection for several reasons: high volume clinics, close proximity with patients, equipment intense clinics and direct contact with patients’ conjunctival mucosal surfaces. COVID-19 is predominantly contracted through direct or airborne transmission by inhalation of respiratory droplets. Evidence that aerosol transmission occurs is increasing in particularly prolonged exposure to high concentrations in a relatively closed environment. Based on the current evidence ophthalmologists should consider measures that include social distancing, wearing masks, sterilisation techniques and managing clinic volumes. Conclusions A major challenge to containing COVID-19 is that many infected people are asymptomatic. Droplet spread, contaminated environmental surfaces and shared medical devices are particular areas that require management by ophthalmologists. More studies are required to explore the role of the conjunctiva and ocular tissues in the transmission of disease.

Aerosol and droplet generation from orbital repair: Surgical risk in the pandemic era

“…The existing literature largely focuses on endonasal procedures [ 15 , 17 ]. However, there has been little to no objective measurement of droplet and aerosol production after orbital surgery, despite evidence that the ocular surface can harbor SARS-CoV2 virions [ 7 ] and the risk of direct contact with the mucous membranes of the eye [ 8 , 18 , 19 ]. In order to close this gap, this study presents a quantification of droplet and aerosol production during surgical repair of the inferior orbit rim.…”

“…This led the Centers for Disease Control and Prevention and other worldwide health organizations to recommend temporarily halting elective procedures during the start of the pandemic to limit spread of the virus [ 6 ]. Among those at increased risk for occupational exposure to the virus may be physicians who perform orbital procedures, as the SARS-CoV-2 virus has been isolated from the ocular surface of infected patients [ 7 ] and due to exposure to nasal and oral secretions [ 8 ].…”

“…This is especially pertinent in the field of orbital trauma, due to the potential for asymptomatic carriers [ 9 ] and because often surgical repair cannot be deferred until resolution of an active infection without detriment to the patient [ [10] , [11] , [12] , [13] ]. Additionally, these procedures which commonly employ electrocautery and high speed drills in close proximity to the mucous membranes of the eye [ 8 ] are suspected to be droplet and aerosol generating, placing providers at increased risk [ 14 ].…”

Microdroplet and spatter contamination during phacoemulsification cataract surgery in the era of COVID‐19

“…By the nature of clinical and surgical practice, ophthalmologists may be at risk of exposure to SARS‐CoV‐2 5,19,24,28 . However, while both microdroplets and exhaled aerosol have been identified as potential routes for SARS‐CoV‐2 transmission, the risk of viable viral contamination via ocular fluid, through the generation of microdroplets and aerosol during phacoemulsification surgery, appears to be low but is still under investigation 4,23,25,26,29 …”

SARS‐CoV‐2 and COVID‐19 for the ophthalmologist

“…Because of the significant occupational risk associated with close exposure to potentially contaminated liquid droplets and particles, recommendations have been proposed and publicized so as to warrant professional and patient safety during ophthalmic examinations 86,120‐124 . These recommendations are continuously evolving, and should be adjusted according to the local context.…”