The unpredictable virus stokes misinformation about prevention, patient care. To help clear the muddied waters, the American Academy of Ophthalmology (AAO) conducted a webinar to outline the best measures for patient care, and help physicians decide how and when to fully reopen their practices.
The coronavirus spreads with remarkable ease and efficiency, often despite the maximum use of available precautions, and it seems to behave differently in different age groups and world communities, leading to confusion about prevention and predictions about resolution.
In addition, the information disseminated to the public from numerous sources seems to change on a daily basis.
To help clear the muddied waters, the American Academy of Ophthalmology (AAO) conducted a webinar to bring its audience up-to-date on the most recent understanding of the virus’s behavior, address current controversies, outline the best measures for patient care, and help physicians decide how and when to fully reopen their practices.
Advocacy and practice management
David W. Parke II, MD, kicked off the webinar by describing the AAO’s leadership regarding COVID-19. He directed physicians to the AAO website, www.aao.org/coronavirus, for detailed information on every aspect of the pandemic ranging from the science and transmission of the virus, treatment/vaccine status, issues specific to ophthalmology regarding personal protective equipment (PPE) for ophthalmic use, questions to ask patients, scheduling, and triage; guidance for clinics, surgery, elective care, and disinfection among others.
Dr. Parke is chief executive officer of the American Academy of Ophthalmology, San Francisco.
The AAO’s advocacy initiatives include “business and economics to assist ophthalmologists in transitioning back to patient care in a sustainable model of practice, immediate short-term financial relief and fundamental longer-term changes, and a mix of legislative and regulatory aspects,” according to Dr. Parke.
Among other measures to streamline the health system, he also reported that the Centers for Medicare and Medicaid Services Financial Relief Programs has expanded its payment programs to assist practices through the Part B Accelerated and Advance Payment Program and the CARES Act Provider Relief Funds, the latter of which includes the Paycheck Protection Program and Economic Injury Disaster Loans/Advances that are components of the Small Business Association loans/grants.
SARS-COV2 and COVID-19
The horseshoe bat is the most likely natural reservoir for severe acute respiratory syndrome (SARS)-CoV-2, a “beta” coronavirus with about 70% sequence identity with SARS-CoV, which causes a severe acute respiratory tract infection, said James Chodosh, MD, the Cogan Professor of Ophthalmology, Harvard Medical School, Howe Laboratory – Viral Pathogenesis Unit, Massachusetts Eye and Ear, Massachusetts General Hospital, Shriners Hospitals for Children, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Boston.
COVID-19 symptoms now include cough and shortness of breath/difficulty breathing or at least two of the following: fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell. The ocular manifestation is conjunctivitis, which is transient.
The virus infects the nasopharynx, lung, gastrointestinal tract, kidney, and heart, Dr. Chodosh reported.
The virus is fickle ,with some scenarios including elderly patients who are quite ill with no signs or symptoms. They may have a brief cold-like illness, but exhibit only lethargy and confusion. Healthy-appearing individuals of any age can have signs of stroke and have COVID-19; or very healthy persons can experience slow loss of oxygenation and suddenly become very ill.
The strokes result from the binding of the spiked protein to angiotensin-converting enzyme 2 receptors on target cells that is followed by a cell-signaling cascade that leads to virus internalization.
This can cause coagulopathy leading to thrombotic stroke resulting from formation of large clots.
Testing can cause confusion
Reverse-transcriptase polymerase chain reaction (RT-PCR) identifies the nucleic acid of the virus but does not indicate that the nucleic acid is an intact and infectious virus.
“This has resulted in a great deal of overinterpretation of published studies, because very few have actually tested for infectious virus when environmental studies are done,” Dr. Chodosh said.
Testing can cause confusion.
RT-PCR measures viral RNA; serology measures the antibody immune response to infection. An RT-PCR-positive test suggests either that the virus is present or replicating and recent; a positive IgM by serology shows very recent infection, which usually becomes positive within 1 to 2 weeks of infection; a positive IgG indicates a past infection that could still indicate present infection.
“Having a positive IgG does not mean that patients are no longer infectious,” Dr. Chodosh noted. “They can remain RT-PCR-positive for 5 weeks after disease onset or be RT-PCR-positive again after apparent recovery and after a negative RT-PCR test. During most of the time they can be IgG-antibody-positive.”
Dr. Chodosh added that surgical patients cannot be screened by serology alone--if they are IgG-positive, they might still be RT-PCR positive and infectious.
PPE and risk mitigation in the clinic
The key features of PPEs are exposure, durability, appropriateness, and fit.
Regarding COVID-19, the virus is transmitted through contact, surfaces, respiratory droplets, and aerosol-generating procedures.
For medical personnel treating COVID-19 patients, the following PPEs are used: a face shield/goggles; an N95 face mask or higher respirators preferably, but face masks are acceptable; one pair of clean, nonsterile gloves, and an isolation gown, according to Steven Yeh, MD, who holds the M. Louise Simpson Professorship in Ophthalmology Emory Eye Center, Emory University School of Medicine, Atlanta.
In the clinic, the AAO interim guidance regarding PPEs depends on patient status, risk level, and the need to protect the health care providers.
With a high risk for COVID-19, the patient is sent to the emergency room or hospital for COVID-19 management.
COVID-19 testing and management take precedence over eye disease. The patient must wear a mask and the provider, an N95 mask, gloves, gown, and eye protection. Following an acute illness, the CDC allows return to work 14 days after the acute illness, during which they were asymptomatic for 7 days and afebrile for at least 72 hours.
The practical guidelines regarding equipment and environment in clinic and for an inpatient or in the intensive care unit, Dr. Yeh noted, include mindfulness of the space and equipment landing locations; equipment/consumables in a patient area for a patient under investigation (PUI) or a COVID-19 patient are considered contaminated; the equipment should be discarded or meticulously disinfected; presence of dirty and clean carts/tables outside inpatient rooms are useful; the nursing staff and critical care team should be alerted about dilation and examination time if consulted; and additional help outside the room is helpful for disinfection.
In the clinic, he pointed out, patients should be assessed for respiratory symptoms before presenting to the clinic. At the clinic patients are screened for symptoms and temperature; and the waiting room space should be increased. Patients can remain in their cars until the time of their appointments.
Staff members can conduct virtual meetings and should remain home if they develop fever/respiratory symptoms.
They should use PPEs judiciously. Environmental precautions include droplet and fomite precautions for surfaces, and a disinfection protocol for slit-lamps and equipment; use of large breath shields; and for imaging devices, and visual field analyzers manufacturer guidelines can be followed.
Operating room considerations include preoperative patient screening for fever, symptoms, and COVID-19 contacts and COVID-19 testing for non-emergent surgery in a region with SARS-CoV-2 presence; recognition of the higher perioperative morbidity/mortality (arrhythmias, pneumonias) of COVID-19; and consideration of the surgical urgency. Operative considerations include adjudication/sign-off for PUI/COVID-19-positivity; intubation precautions and low-flow oxygen by nasal cannula; a limited number of persons in the room; and determination of PPE based on the risk and procedure.
Current controversies and need for evidence
Gary Holland, MD, provided a practical framework for assessing the current COVID-19 situation and planning for future changes. According to Dr. Holland, the most pressing current concern surrounds the stay-at-home orders.
Dr. Holland is the Jack H. Skirball Professor of Ocular Inflammatory Diseases, and Chief of the Cornea-External Ocular Disease & Uveitis Division, Department of Ophthalmology, David Geffen School of Medicine at UCLA, UCLA Stein Eye Institute, Los Angeles.
“Within the medical community, different approaches to the pandemic are less about opposing viewpoints in the community and more about uncertainty and confusion about how best to interpret the limited information that we have had to date,” he said. “Resumption of surgery and what to expect in the future going forward are the two big issues in terms of the operating room and the clinic.”
As the industry considers resuming surgical procedures, it is worth noting that the initial shut-down allowed facilities to establish procedures for infection control, preserve limited supplies, and determine what resources to divert to care for COVID-19 patients.
However, patient care cannot be delayed indefinitely and there are economic and employment considerations.
“Now is the time to start opening up to some extent,” Dr. Holland said.
Dr. Holland also underscored the importance of continuing strict infection control measures, which preclude high surgical volumes for now.
New requirements will slow turnover. One example is a 20-minute shut-down of operating rooms after an aerosol-generating procedure. To minimize the risk to surgeons and staff, all patients should be considered as having the SARS-CoV-2-infection, he emphasized
“We do not yet know whether there are unique risks associated with some procedures, such as phacoemulsification or retinal surgeries,” he added.
Many regions of the United States have moved beyond the peak numbers of cases from the disease, and as of May 1, the United States has moved beyond the peak numbers of deaths per day, Dr. Holland reported.
In the future, new infections and more deaths will continue to occur. Smaller outbreaks will develop.
Medically speaking, surgeons can begin to perform surgeries but there will be new exposures and small increases in virus cases, which will require a more rigorous return to using masks and avoiding crowds, until the numbers again begin to drop.
This scenario may have to be repeated again and again over months at least to avoid a second big disease surge, he said.
In the future, an effective widely available vaccine and herd immunity are necessary to stop COVID-19. Antibody testing is needed, as is the need for evidence regarding modes of transmission, potential for aerosolization of virus by various procedures, spectrum of disease manifestations, immunity, and sensitivity and specificity of various antibody tests and their implications, Dr. Holland concluded.