VR Surgery in COVID
1. Should we be doing pneumatic retinopexy rather than more conventional vitrectomy or buckling surgery for retinal detachment?
Mario Romano, Milan Italy: Knowledge about ophthalmic surgery transmission is still in the making, it is necessary to get to know if procedures like cataract surgery and vitrectomy release aerosol. Even before this outbreak, 95% of our procedures were performed with LA: this is a great advantage as general anaesthesia carries the higher risk. Retinopexy has probably a very low risk of contagion as a procedure, because it is very fast, not invasive and doesn’t require high-speed devices. There may be a need for repeated surgery which of course makes the risk of contagion higher. We can assume that buckling is safer that vitrectomy because no high-speed devices are employed, but they are both longer than retinopexy and the surgical drape is not a barrier against patient’s breath. Of course, the success rates and the eventual need for a second procedure depends on surgeon’s expertise and on having the right indication of every technique used. So, we would advise to decide the surgical technique on a case by case basis, while taking care of minimizing the risk by having the patient wearing the surgical mask underneath the surgical drape and by using adequate PPE.
Roxane Hillier, Consultant Ophthalmologist & Vitreoretinal Surgeon, NHS, UK: Pneumatic retinopexy is non aerosol generating, independent of the need for nursing assistance or an operating theatre (a ‘clean room’ dedicated to intra-vitreal injections is sufficient) and is performed under local anaesthesia. The simple and inexpensive equipment necessary for pneumatic retinopexy is readily available in any ophthalmic theatre, and is therefore relatively resistant to fluctuations in the availability of specialist surgical equipment. Therefore, the technique has potential clear advantages in terms of safety and logistics, which extend beyond the COVID-19 crisis. Pneumatic retinopexy offers excellent functional outcomes, and is considered by some to be the treatment of choice in a significant proportion of patients. Patients are reviewed at 24-48 hours and two weeks, and may safely be discharged at 4 weeks post-procedure (as re-detachments after this interval are rare).
The following are further considerations:
1. A careful pre-operative examination of the retinal pathology and a holistic consideration of the patient’s suitability for the procedure will optimise the primary anatomical success rates.
2. A full surgical drape (to isolate the patient’s nasopharynx) is preferable. If this is not available, then the patient should wear a standard face mask.
3. A ‘1-step’ procedure (i.e. cryotherapy immediately prior to gas injection) is preferable to laser retinopexy at a second sitting (once the retina has reattached), so as to reduce face-to face exposure time.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We have not altered our choice of procedure. We select what we think results in the best visual outcome in our patients with the least amount of surgical procedures.
2. How often should we see patients who have undergone a vitrectomy?
Mario Romano, Milan Italy: We perform the FU visit the day after the surgery and then another check-up after 1 month. After this we advise to reduce the frequency of controls to chronic patients, so a FU can be performed for example at 4-6 months, but we decide on a case by case basis. Telemedicine and self-monitoring can be useful: the patient should immediately call the hospital and be booked for a remote consultation in case of symptoms worsening. Another mean of FU with reduced risk of virus spreading could be to perform an OCT at an alternate care location instead of the hub. The OCT can then be remotely evaluated by the doctor. It could work for the follow-up of epiretinal membranes after two regular check-up visits.
St Thomas’ Hospital Eye Department, UK: This can be graded, patients with gas or oil need their IOP checked. Consideration can be given to using non steroidal drops (eg ketorolac) more in the post op phase. In the UK we also have lots of Optometrists who are both skilled and often well equipped and can take part in follow up.
Noemi Lois, Clinical Professor of Ophthalmology at Queen’s University Belfast: I have reduced the number of post-op visits for my VR patients. I explain in detail to them how to check their central and peripheral vision at home. I explain what will happen with the bubble of gas (in those having one) and where this will give the visual field defect and how this should reduce in size over time. Then I organise calls to their homes (I speak with them, all going well I do not bring them to clinic). Buckles are great now as if you put a buckle and the retina is flat (which will be happening even on the same day) it is done and dusted and follow up is in my opinion not required unless the patient has problems, in which case I tell them to contact us and we will arrange appointment on demand. I think macular holes, epiretinal membranes etc, if uncomplicated, again will require a phone call and may be one single review (or none at all if patient is happy with how things are going – if phaco-vit done obviously they will need a refraction in their optometrist). Complex cases (e.g. diabetic TRDs) I also call but these I do still tend to bring them, albeit less often, to clinic for review now.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: Usually ophthalmologists outside the hospital take over the postoperative care and individualize monitoring intervals.
3. How should we examine patients who have undergone a vitrectomy?
St Thomas’ Hospital Eye Department, UK: The indirect ophthalmoscope is very useful in this regard, combined with a device such as an iCARE tonometer there is minimum close contact with a post op patient.
Mario Romano, Milan Italy: Indirect ophthalmoscope and OCT can be useful tools to skip the slit lamp examination, which carries a high risk for contagion.
Roxane Hillier, Consultant Ophthalmologist & Vitreoretinal Surgeon, NHS, UK: Agree – use of the slit-lamp is often unnecessary.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: indirect ophtalmoscopy works well.
4. Should we be doing more phako IOL vitrectomy and oil procedures to provide long term stability and quick rehabililtation?
St Thomas’ Hospital Eye Department, UK: This is a good option in elderly or COVID increased risk patients with a macula off retinal detachment. I would be very concerned about doing this in a healthy younger patient with a macula on RRD due to the risk of vision loss due to oil toxicity.
Mario Romano, Milan Italy: It can be a rational option to perform combined surgery in order to avoid the need for a second surgery in the near future, because these patients are very often elderly people with comorbidities, very prone to COVID-19 contagion. In normal circumstances, there are some benefits to postponing the second surgery, but the risk of COVID-19 transmission in these elderly patients and the need for a clever allocation of hospital resources make combined surgery a better option. In younger patient with attached vitreous and clear crystalline lens, in many cases, scleral buckling is a better option. On the other hand, we don’t agree on the use of oil when there is not a clear clinical indication. When using silicone oil as a tamponade is generally necessary to perform a second surgery to take it out and, as we previously stated, we are in the coexistence phase for the long run, so we don’t think using oil it is such a great advantage. Moreover, when using oil there is a risk of vision loss because of toxicity effects.
Roxane Hillier, Consultant Ophthalmologist & Vitreoretinal Surgeon, NHS, UK: I can see the rationale for silicone oil, in terms of retinal stability and quick visual rehabilitation. I too have concerns about silicone oil toxicity. However, my main concern here is the increased likelihood of acute (e.g. iris bombe after combined phaco-vitrectomy-oil) and chronic (e.g. simple silicone oil related secondary ocular hypertension) incidences of post-operative raised pressure. These problems are seen more frequently after combined surgery involving phacoemulsification and silicone tamponade, and often necessitate multiple additional clinic visits. Furthermore, the silicone oil will have to come out eventually. For this reason, I would advocate leaving the crystalline lens in situ if possible, and careful consideration of the risks and benefits of silicone oil in that individual patient.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: See above – We select what we think results in the best visual outcome in our patients with the least amount of surgical procedures.
5. Are phako and vitrectomy an aerosol generating procedure? Why does this matter?
Mario Romano, Milan Italy: We still don’t know whether Ophthalmic surgery creates aerosol, which is relevant because when transmission can happen via aerosol rather than via droplets the pathogen proves to be more contagious and higher-level PPE, such as FFP3, are necessary. It is reported that surgeries under general anaesthesia and procedures involving the lacrimal system can be counted as AGPs. Surgeries involving high-speed devices can be counted as AGPs too, but it is still unclear if cataract and vitreoretinal surgeries constitute AGPs. We are working on this topic with a project in partnership with thermal fluid dynamics engineers. Since surgical drapes are not an adequate barrier against the patients’ breath, the best option for safe surgical procedures should be using PPE adequate to AGPs: surgeons are strongly advised to wear an FFP3 respirator and a waterproof gown.
St Thomas’ Hospital Eye Department, UK: It is not possible to know but the risk to health care professionals from an eye surgery generated aerosol is probably low. General anaesthesia is a separate risk.
6. Is there really a risk of catching COVID from an eye surgery generated aerosol?
Mario Romano, Milan Italy: Knowledge about COVID-19 and in particular regarding its transmission during ophthalmic surgery is still in the making. There are some procedures in ophthalmic surgery that carry a contagion risk for sure and other we are not so sure yet, anyway it looks like a sensible option to stay on the safe side and use the PPE appropriate to AGPs when performing surgery.
Noemi Lois, Clinical Professor of Ophthalmology at Queen’s University Belfast: It has been said that vitrectomy is aerosol generating. I think this is an overkill… we are so far away from the eye and we have our own eyes in the oculars of the microscope. We are wearing a mask. So I do not worry at all about that. I operate without visor (I could certainly not do my surgeries well if I was wearing one!)
7. What PPE is required for intraocular surgery?
Mario Romano, Milan Italy: As previously stated, we currently think it’s appropriate to use the PPE appropriate for AGPs, that’s to say: eye protection, FFP3/N95 respirator, waterproof gown and disposable gloves.
8. What cases should continue to undergo VR surgery during the COVID pandemic?
Mario Romano, Milan Italy: It is safe to assume that the phase of coexistence with the virus will last 6-12 months, maybe even longer. It is not possible to only perform emergency/urgency cases. It becomes necessary to arrange a careful planning, taking into account how many VR surgeries the hospital can perform per week. Priority should be given to urgent cases. We plan to perform less surgeries per day so that time between procedures can be increased: after allocating the necessary slots to urgent cases, the remaining slots should be allocated to medium-risk cases and finally to low risk cases. We are currently performing urgent cases; we delayed performing elective cases because of the extremely severe COVID-19 impact here in Bergamo. We’ll start with elective cases also by the end of May.
Boris Stanzel, Bonn, Germany: At the Sulzbach Eye Clinic/ Germany this includes: IVIs, retinal detachments, endophthalmitis, penetrating ocular trauma, macular holes, exploratory PPV for vitreous hemorrhages, early vitrectomy for PDR or RVO
9. Is macular hole surgery an urgent procedure?
Mario Romano, Milan Italy: No, it is a medium risk condition, so even if it is a severe condition it could not be deemed an urgency. OCT should be performed regularly to see the stage and progression of the hole because priority should be given to urgent cases., but it is also very important not to wait too long before treating a macular hole.
Boris Stanzel, Bonn, Germany: Yes, At the Sulzbach Eye clinic it is classified as such, this includes persistent or reopened large macular holes.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: It is of relateive urgency – the larger the hole progresses, the less likely is a favourable outcome.
10. Which diabetics should undergo VR surgery, they are at risk of COVID?
Mario Romano, Milan Italy: Of course, diabetic patients have a higher risk of COVID-19 contagion because their immune response is not as strong. We take care of minimizing the risk of contagion for inpatients through careful screening of patients and health personnel. It is also important to have a COVID-19 segregated area and less surgery per days so appropriate environment sanitation can be performed. Unfortunately, when glycaemic control is bad, diabetic can be a vision-threatening condition, so in many cases surgery may not be an urgency, but should be performed even during this outbreak because the phase of coexistence with the virus will be very long. So, when the condition is deferrable, like for example an epiretinal membrane, it could be wise to postpone, but tractional retinal detachment or vitreous haemorrhage are definitely urgent cases.
11. How long does the macula have to be off before the surgery? Can wait with the epi retinal membranes?
Mario Romano, Milan Italy: We prefer to reframe the question about macula off RD. Of course, RDs are a severe condition and they should be treated as soon as possible, but of course the possibility to treat a macula off RD depends on the OR availability: urgent cases and macula on RD should be treated first. Epiretinal membrane surgery is an elective surgery, so it can wait, but every clinical case should be thoughtfully evaluated: it is important to get the timing of the surgery right if we want to preserve a good visual acuity. So, OCT should be performed regularly to see the stage and progression of the ERM, in order to understand the best time to schedule the surgery. OCT can be performed at an alternate care location, instead of the hub, and then remotely evaluated by the surgeon.
12. We are only doing 3 vitrectomies per 8 hour day because of PPE/Covid precautions Can we set up clean hospitals with lesser PPE requirements? How else could we speed up turn around?
Mario Romano, Milan Italy: We choose to do an attentive inpatients screening: two throat-nose swabs 48h prior to admission are mandatory, they should be 24 h apart if the first is negative. We advise all patient to self-isolate for a minimum of 7 days prior to the surgery. It this way we can divide our OR in a COVID-19 positive area and in a COVID-19 free one. This one can have more patients scheduled. Of course, this coexistence phase will require us to perform less surgeries per day, one possible solution could be to split the health personnel in two separate surgical teams, these could work on alternate days, allowing OR to function more days per week.
13. What are the particular considerations regarding laser retinopexy?
Roxane Hillier, Consultant Ophthalmologist & Vitreoretinal Surgeon, NHS, UK: Only perform if necessary (sight threatening indication e.g. acute horse-shoe tears). Aim to minimise face-to-face exposure time. In practical terms, this means that the person applying the laser should be experienced enough to complete the retinopexy in in a time-efficient manner and in one sitting (if, for example, technical difficulty is anticipated due to tear location or poor visualisation, a trainee or general ophthalmologist should liaise with the vitreoretinal team before attempting the procedure). Use of indirect laser has the advantage of reducing face-to-face proximity. However, each clinician should opt for the technique (slit lamp vs indirect laser) with which they are most competent and familiar, as this is likely to be more time-efficient in their hands.