REPORT: Université de Paris, Ophthalmology Department, AP-HP, Hôpital Lariboisière, Paris, France

 

Department of Ophthalmology, Lariboisière Hospital, Université de Paris, France – Ramin Tadayoni, Aude Couturier and the Lariboisière Ophthalmology Department Team*

Measures Taken for Eye Care related to Covid-19 Outbreak in the Department of Ophthalmology in Lariboisière Hospital, Université de Paris, AP-HP, Paris, France

 

The COVID-19 pandemic has required the complete reorganization of our department of Ophthalmology of Lariboisière Hospital, APHP, Paris France, from March 9th. All the staff, caregivers and administrative staff, are working to protect the patients, by postponing non-urgent appointments or by teleconsulting.

All the actions of reorganization are aimed at 3 objectives:

1-Limit the exposure risk for our patients who are old and vulnerable, achieved by:

-postponement of all visits, surgeries and intravitreal injections considered as non-urgent
– tele-consultation and home monitoring development
– reinforced hygiene measures in the department.

 

2- Avoid any risk of loss of vision in our patients:

– all surgeries, intravitreal injections and visits for retinal conditions at high risk of vision loss need to be maintained
– reorganization of the department in order to facilitate the visits for emergencies

 

3- Be ready to participate in the fight against Covid-19 if necessary and to help other departments.

 

Reinforced hygiene procedures and protective measures for patients

Protective measures should be observed to avoid any Covid-19 contamination in the ophthalmology department:

– patients are asked for Covid-19 symptoms and if any: mask and send for a test.

– Only one person max. can accompany the patient in the department if really needed.

– No wait policy: as the number of patients has decreased, the organization should permit a nearly-zero waiting time for all patients: as soon as they arrive, they are seen to and as soon as they have finished they leave the department.

– Reorganization of the waiting room as well as the IVI preparation area for seat spacing: at least 1 meter between each seat

– Room ventilation procedure in all the department with regular opening of windows (at least twice a day if not permanently open)

-Protective shield on slit-lamp based on T. Lay et al. Graefes Arch Clin Exp Ophthalmol 2020 (cf. photograph from our department for a homemade version)

– Regular disinfection of all equipment including door handles

– All staff to wear masks, as well as all at-risk patients, in particular diabetic patients

– Provide masks to all patients coming for IVI, given that the majority are elderly and diabetic patients, and as during the injection the distance from the nurse and doctor is short.

-Ophthalmologist should wear gloves for examining and disinfect hands between each patient (disposable gloves available in each room)

– If a Covid+ patient needs an eye exam, a slit lamp is identified to be moved to covid + departments and remain there, FFP2 mask, surblouse etc as required by hospital recommendations should be used and all rules followed.

– Any nurse, secretary or doctor having any doubt about being infected must immediately consult with Medical work department for a test

– Covid + caregivers are, as required by regulation, to be isolated at home and submitted to the remote monitoring of Paris University hospitals and be treated as recommended.

Containment and telecommuting

All unnecessary staff on site have to stay home for telecommuting: working on patients’ files, research projects etc

No personal patients: each doctor at a specific duty sees all patients to reduce number of doctors present and also waiting time for patients

All volunteers can ask to be redeployed to Covid + departments or the specific sites to help

Everyone can be required to help for the Covid+ fight at any moment and should be reached by phone all the time (local White plan activated)

Organization for retinal diseases visits

All doctors need to check their appointments for visits planned until the end of April (estimated end of peak by regional health authorities) and decide for each patient either:

-maintained visit: in case of high risk of vision loss

-postponed visit: a letter for visit cancellation and new appointment will be sent to the patient

-tele-ophthalmology visit for home monitoring: all tele-ophthalmology visits must be registered in the medical chart and specified “TELECONSULTATION in the context of COVID-19 pandemic”.

Additionally, all changes in appointments and tele-ophthalmology visits have to be recorded in a specific excel spreadsheet to be tracked if needed.

Patients requiring surgery

Requirement ordered by health authorities: only emergency surgery.

Any emergency surgery has to be done ASAP, as usual.

One doctor and his resident are at OR each day and perform all surgeries of the day. If the doctor needs help from another surgeon, the resident will stay home and the 2 surgeons instead perform all surgeries.

All doctors need to check their appointments for surgery planned until the end of April (estimated end of peak by regional health authorities) and decide for each patient either:

-maintain surgery in case of high risk of vision loss if the surgery is in the coming days and relatively urgent

-postpone non-urgent surgeries to May at least (estimated end of peak) or even later as we will have a backlog of many patients to operate on at that time: a letter for cancellation and new appointment will be sent to the patient.

-tele-ophthalmology visit for home monitoring: if needed to explain and discuss with patients

Additionally, all changes in appointments and tele-ophthalmology visits have to be recorded in a specific excel spreadsheet to be tracked if needed.

Organization for patients requiring intravitreal injections (IVI)

The new organization to include:

-The continuation of intravitreal injections when needed, on a case-by-case basis.

-The medical charts of patients followed in the department for retinal disease requiring IVI (AMD, DME…) with planned visits and IVI are checked by a retina specialist every day, one week in advance (i.e. each day all visits planned for the same day the following week ) in order to decide whether or not the patient require IVI for the next 3 months.

– Most of patients are converted to fix regimen and then to reduction of exposure time in the clinic: no mandatory ophthalmologic examination (slit-lamp examination and fundus) and no OCT imaging before the IVI if the patient doesn’t report any new symptom.

In practice, each day a doctor is assigned to IVI the must:

1/ Perform IVI for patients with maintained visit, starting early at the patient’s arrival time in order to have fewer patients in the waiting room and in the preparation area.

2/ Check all the charts from the list for the corresponding day of the following week and complete the medical chart with the mention “postponed injection due to the COVID-19 pandemic”. The doctor should decide either postpone or maintain IVI for each patient but also plan the next IVI with a fix regimen for at least the next 3 months. The nurses then call the patients to inform them and give the new appointment for IVI.

3/ Review all the charts of patients who did not show up for IVI the previous afternoon despite maintained appointments:

-Systematically send a letter for patients who did not come for their planned IVI

-Evaluate the level of emergency and, if needed, call the patients to inform them of the risk of visual loss.

Decision for postponed or maintained IVI

A committee was formed to discuss the ethical aspect of this complex issue: risk of infection versus loss of vision. The conclusion was that there should be no strict rule applicable to all patients and an analysis of the charts and a decision on a case by case basis is necessary, taking into account in particular the risk factors of mortality in the event of COVID-19 contamination (high age, immunosuppression, diabetes, obesity, heart or kidney failure), the risk of vision loss and, if in any doubt, a discussion with the patient through a teleconsultation should be done to take into account their wishes .

If a patient still wants to have IVI despite our recommendation of postponed appointment, the doctor must inform him of the benefits and risks but should practice the IVI after the patient confirmation.

  • For AMD: mostly maintained IVI because of the risk of vision loss from delay of IVIs or extension of intervals.

– In case of a Treat and Extend regimen: planned IVI with the last interval which allowed an absence of intra-/sub-retinal fluid on B-scan OCT.

– In case of PRN regimen: if the patient has received at least one injection in the last 6 months: bimonthly injections are recommended. If the patient has not been injected in the last 6 months: postpone the visit to mid-June (< 10 weeks) but call the patient for self-home monitoring and ask them to come for an emergency visit if they experience vision loss or metamorphopsia.

  • For DME:

– Promote the postponement of IVI but not systematic cancellation.

– Maintain IVT in case of:

o Florid retinopathy (i.e young type 1 patient with rapid progression of ischemia and DME)

o One eye patients

o Rubeosis and neovascular glaucoma

o Sensitive to anti-VEGF DME with significant fluctuation in VA in the absence of IVI if this constitutes a handicap for the patient.

  • For macular edema secondary to CRVO:

– Promote the postponement of injections but not systematic cancellation.

– Postpone IVI for patients who have been treated by PRP

– Do not leave an interval without follow-up of more than 10 weeks if the patient did not have PRP.

– If ischemic IVI maintained or if PRP needed perform ASAP.

  • For macular edema secondary to BRVO:

– Except in special cases – postponed IVI: cf DME

  • For patients who have received a Dexamethasone implant in the previous 2 months:

– No more systematic visit for IOP check is necessary if the patient has already had at least Dexamethasone implant injection with no high IOP

– If the last IVI was the first Dexamethasone implant injection:

o No systematic IOP control is required if the IOP before the injection was < 19 mmHg with a normal optic nerve head

o Systematic IOP control is required if IOP before the injection was ≥ 19 mmHg, if the patient is treated with one or more IOP-lowering drop, if the patient is one eye.

Examples of templates for chart review and decision report:

Case 1: Postponed visit – patient to call to postpone their appointment – deadline date to be fixed to make their visit or IVI after mid-June

Please write in the chart:

“Tele-ophthalmology visit in the context of the COVID-19 pandemic

Postponed +

Postponement deadlines: …X… months

Next appointment: IVI and/or visit …

IVI to be planned: (if next appointment = IVI) RE / LE – product – and foresee IVI until the end of June with fixed interval regimen

Next visit: (if next appointment = IVT) to be planned after mid-June

Information provided to the patient regarding the need for emergency visit in case of sudden vision loss and / or metamorphopsia.”

Case 2: Maintained visit – the patient will come on the date scheduled for either IVI or visit –

Please write in the chart:

“Tele-ophthalmology visit in the context of the COVID-19 pandemic:

Postponed –

Maintained appointment

Next appointment: IVI / visit

IVI to be provided: (If next appointment = IVI) RE / LE – product – and foresee IVI until the end of June with fixed interval regimen

Next visit appointment: to be expected after mid-June

Appointment for laser treatment

Postponed laser appointment for 3 months, except for diabetic patient with florid retinopathy (i.e. young type 1 patient with rapid progression of ischemia), rubeosis and neovascular glaucoma.

Answers to patients calling for an ophthalmologic appointment during the COVID-19 pandemic

For patients who are not followed for a retinal disease in the department and want to have a first appointment:

-for preoperative cataract visit, they need to call back after May 1st (estimated end of peak and movement limitation)

-for retinal disease: patients should have a teleconsultation to evaluate emergency or fell or has been told that it is an emergency can come in the ophthalmology department: the doctor will confirm the visit in case of emergency and risk of vision loss

For patients who are already followed in the department for a retinal disease:

– If no emergency, no vision loss: they need to call back after May 1st (estimated end of peak and movement limitation)

-In case of emergency (vision loss or pain): they should come for an ophthalmologic examination in the department

-Undetermined cases: email to the doctor possible

Any questions: each day a doctor is assigned to solve unexpected issues and answer any questions by staff or patients.

Lariboisière medical team having directly contributed to the conception of this organization:

Pr Ramin Tadayoni

Dr Aude Couturier

Dr Ali Erginay

Dr Elise Philippakis

Dr Valérie Krivosic

Dr Bénédicte Dupas

Dr Sophie Bonnin

Dr Mardoche Chetrit

Dr Ismael Chehaibou

Dr Azzeddine Mokrane

Dr Guillaume Le Guern

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