REPORT: Israeli Ophthalmological Society

Anat Loewenstein

Protection against Coronavirus – A Position Paper by the Israeli Ophthalmological Society

 

Forward

The pandemic plaguing the world and Israel in the last few months due to the coronavirus (COVID-19), is intensifying.

Information flowing in from organizations, colleagues and medical personnel in various countries who are dealing with the pandemic indicates that we must deal with this disease in our clinical and surgical work, for what seems like the long-term.

Based on the accumulating data, the Israeli Ophthalmological Society has decided to assemble a position paper in order to help the doctors in various frameworks ensure their personal protection, and a correct form of work that does not endanger the patients and the care providers under the circumstances of the pandemic. We aim to toe the line and give uniform and collective recommendations.

Our work environment as ophthalmologists and our close proximity to patients’ respiratory tract put us at high risk of contracting the virus and passing it on. This fact requires us to act with caution and protect ourselves. Reports in the professional literature indicate ocular involvement of the conjunctiva and tears in this disease (1).

It should be stressed that the Israeli Ophthalmological Society adopts the American Academy’s (AAO) recommendations that have been published recently (2-4), and used the experience of ophthalmologists from Hong Kong (during the SARS epidemic) which was also recently published (5).

Patient Definition

Below are patient definitions according to their connection the coronavirus, recommendations to follow. A patient coming into an eye clinic can be:

  1. A healthy patient – with no suspected coronavirus disease or contact with a person sick with coronavirus.
  2. A suspect patient – Suspected to be infected with coronavirus or is in isolation due to contact with someone who is infected, or a patient who came back from abroad.
  3. A sick patient – A patient with a confirmed diagnosis of coronavirus.

 

Clinical Guidelines in Hospitals and in Community Clinics

Due to the high risk, performing elective eye exams must be avoided, as well as elective surgical procedures which are not urgent and delaying them will not risk ocular health and the health of the visual system (such as retinal detachment or oncological surgeries).

For each patient, one must act according to hospital and ministry of health instructions relating to protection of doctors and medical staff, and if needed, of the patient as well.

It should be stressed that the Israeli Ophthalmological Society recommends full protective gear, according to the American Academy. See below.

We stress that a patient that is considered suspect or sick with coronavirus will not be examined, but will be asked to wear a surgical mask, and will be transferred by the staff to isolation in the Emergency Medicine Department or in a pre-defined area which has been fitted to treat diagnosed patients.

Clinical work in community clinics, independent clinics and private clinics – we recommend decreasing face-to-face appointments, and leaving only urgent appointments or procedures.

Of course, classifying patients who enter a community clinic also requires basic questioning regarding fever, respiratory symptoms, contact with someone sick with coronavirus or isolation following suspected contact with a sick person or return from abroad. We recommend refusing entrance to the clinic to patients fitting one or more of these criteria, and referring them to the HMOs sorting centers or to the emergency room, after giving them a surgical mask.

We recommend decreasing numbers of escorts to the bare minimum.

We recommend ensuring separation and appropriate distance between the clinic’s reception desk and the public (for example with tape) and equipping the receptionists with gloves and surgical masks.

We recommend that the doctors wear designated working clothes, and not the clothes they will wear when returning home.

According to the general instructions, we recommend working in a ventilated room with open windows, and disinfecting surfaces, handles and medical tools often.

 

Protection Recommendation for Ophthalmologists

We stress that according to the recommendations of the American Academy (2) the ophthalmologist must be protected by a surgical mask (replacing it when it becomes damp) for treating a “healthy patient”, with no suspected coronavirus sickness, and by an N95 mask (while performing a sealing test) when treating a “suspect patient”.

We recommend working with disposable gloves, changing them between each patient (even those not suspect). When treating a “sick patient”, doctors must wear full protective gear, according to the instructions by the ministry of health.

Additionally, we recommend installing a shield (bigger than the one that originally arrives with the appliance) on the slit lamp in order to increase the separation between the patient and the examiner.

Details about shield sizes and types according to the different testing equipment can be found in reference no. 4.

Regarding disinfection of medical equipment, with an emphasis on tonometers and diagnostic lenses, the recommendation is to disinfect between patients using alcohol 70%.

The ophthalmologist’s work, when it comes to proximity to the patient, is similar to that of ENT doctors, and we refer you to the position paper by the Israeli Society of Otolaryngology, parts of which we used in order to write this position paper (6).

 

Summary

Below is a summary of the position paper:

  1. The Society recommends cancelling all elective procedures (in clinics and surgical) when there is no risk in cancelling them.
  2. The Society recommends personal protection according to the American Academy:
  3. Gloves and surgical masks for a “healthy patient”.
  4. Gloves and N95 masks for a “suspect patient” who is not sick with coronavirus.
  5. Full protection gear for a coronavirus sick patient.
  6. Additionally, the Society recommends protection with a big shield, as recommended by the Academy and by the ophthalmologists from Hong Kong.

 

References

  1. Report of tear and conjunctiva involvement in coronavirus https://eyewire.news/articles/aao-alert-coronavirus-updates-for-ophthalmologists/
  2. The Academy’s recommendations for protection https://www.aao.org/headline/alert-important-coronavirus-context
  3. The Academy’s recommendations for canceling elective procedures https://www.aao.org/headline/new-recommendations-urgent-nonurgent-patient-care
  4. The Academy’s recommendations for a shield https://chinrestpapersource.com/oem-products/slit-lamp-breath-shields
  5. Lai et al. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. Graefe’s Archive for Clinical and Experimental Ophthalmology https://doi.org/10.1007/s00417-020-04641-8, Feb 2020
  6. Position paper by the Israeli Society of Otolaryngology, published March 21, 2020

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