Before the COVID-19 pandemic resulted in stay-at-home orders in the United States, a retina specialist in Hong Kong and colleagues reported on steps they’d taken to improve infection control measures in their ophthalmology clinic during the coronavirus outbreak there. The article, published online in Graefe’s Archive for Clinical and Experimental Ophthalmology,1 was widely circulated in the United States. For almost two months, it led MDLinx’s list of top-read articles in ophthalmology.
Senior author Kenneth K.W.Li, MCBhB, FRCS, agreed to answer questions from Retina Specialist about his team’s experience during the pandemic and lessons for U.S. colleagues. Dr. Li is chief of ophthalmology at United Christian Hospital/Tseung Kwan O Hospital in the Kowloon East Cluster Hospital Authority.
As a retina specialist, how have you fared communicating with patients who need regular intravitreal injections? Have they kept their appointments?
We are extremely fortunate that infection and deaths from COVID-19 in Hong Kong have been kept low and we are not in a complete lockdown. As a result, we are still continuing our regular intravitreal injections. As most of our patients understand any delay of intravitreal injections can have a detrimental effect on their vision, we are not seeing a substantial reduction in attendance.
However, recent surveys by the American Society of Retinal Specialists2 showed a lack of consensus among its members on the management of patients requiring intravitreal treatment in the current pandemic. The Vision Academy recently published a paper to provide guidance on intravitreal injections to the vitreoretinal community.3 It suggested a three-tier approach:
- prioritize patients with the greatest needs;
- adjust injection intervals for existing cases; and
- protection for both patients and health-care workers.
These general principles are more relevant than established college guidelines, as there is much variation among different countries in the state of the COVID outbreak, local regulations and service capacities. Nevertheless, patients should be provided with clear instructions on the situation and arrangements.
What insights have you gained since publication of your paper that would aid other physicians?
Over the past few months, the global ophthalmic communities have been focusing on stepping up infection-control measures. However, it’s important not to overlook the psychological and mental wellness of our colleagues, especially because the current pandemic may last longer than we expected.
Health-care workers have been facing immense stress from increased workloads, infection risks, physical stress, psychological stress or even burnout. Independent practitioners may worry about the possibility of financial turmoil due to suspension of clinical practices. With prolonged lockdown situations in many countries, many health-care workers are also juggling work and family commitments. Management should hold regular staff meetings to understand and address their concerns.
In our department, we hold weekly situation update meetings with our staff. Since March, we implemented flexible leave arrangements for our colleagues. We allow staff to cancel their annual leave as their original travel plans can no longer be realized, due to either travel restrictions or their worry about infection risks associated with traveling. On the other hand, staff with small children may want to take time off to look after family, and we allow them to take annual leave, even with a short notice of one week. Of course, they understand the bottom line: that there must be adequate staffing for our clinical service.
This initiative is well received by our staff. It’s important to let our staff know that we’re all in the same boat and eager to help each other.
Are you back to using non-contact tonometry yet?
We haven't resumed the use of NCT. Because of the concern of NCT generating microaerosol, we are still cautious about its use. I understand investigators worldwide are already studying this area and more evidence should be available soon.
We have preemptively adopted three measures to reduce the transmission risk. First, to limit intraocular pressure measurement only to indicated cases, including recent postoperative cases, those on anti-glaucoma and steroid eye drops, and first-visit cases. Second, to cease all NCT use in our triage stations and replace it with iCare tonometry. And third, to perform all Goldmann tonometry with disposable applanation tips.4
How have you fared with retina surgery that requires general anesthesia?
Both the British and Eire Association of Vitreoretinal Surgery and ASRS recently issued recommendations on the use of eye protection and FFP3/N95 respirators for pars plana vitrectomy.5 This is likely due to the high-speed nature of PPV and its potential aerosol generation. This has sparked intense discussion in the vitreoretinal community. An even greater concern is phacoemulsification with its much higher frequency than PPV. More study is warranted in the aerosol-generating nature of both PPV and phacoemulsificaiton.
We recently published a risk-stratification protocol for emergency surgery that our hospital has had in place since February.6 All patients are screened by the questionnaire on fever, travel, occupation, contact and clustering, and only high-risk cases undergo the COVID-19 rapid test.1 COVID status will determine the level of precautions and the need of negative-pressure operating facilities. Our preliminary experience has shown reduction in both the consumption of personal protective equipment and utilization of negative-pressure operating facilities. RS
1. Lai TH, Tang EW, Chau SK, Fung KS, KK Li. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. Graefes Arch Clin Exp Ophthalmol. Published online March 3, 2020.
2. Third COVID-19 member survey. American Society of Retina Specialist. https://www.asrs.org/clinical/clinical-updates/3997/results-are-in-3rd-covid-19-member-survey. Updated April 29, 2020. Accessed May 4, 2020.
3. Korobelnik JF, Loewenstein A, Eldem B, et al. Guidance for anti-VEGF intravitreal injections during the COVID-19 pandemic. Graefes Arch Clin Exp Ophthalmol. Published online April 23, 2020.
4. Ng VW, Tang GH, Lai TH, Tang EW, Li KK. Intraocular pressure measurement during COVID pandemic. Indian J Ophthalmol. 2020;68:950-951.
5. Recommendations for conducting vitreoretinal surgery during the COVID-19 pandemic. ASRS. https://files.constantcontact.com/98b7aceb001/c27fdd27-223d-45bc-90f3-031cd4f4cec0.pdf Accessed May 4, 2020.
6. Wong DH, Tang EW, Njo A, Chu CK, Chau SK, Lim HS, Fung KS, Li KK. Risk stratification protocol to reduce consumption of person protective equipment for emergency surgeries during COVID-19 pandemic. Hong Kong Med J. In Press.