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The American Academy of Ophthalmology (AAO) has updated COVID-19 guidance for ophthalmologists and other eyecare providers to help further reduce the spread of the novel coronavirus SARS-CoV-2 within communities.

The Academy’s Board of Trustees met on March 18, and at that meeting voted unanimously to strongly urge all ophthalmologists and other eye care providers against operating on individuals for routine or elective cases and from evaluating patients that are considered to have routine care.   

The decision came after the US Centers of Disease Control and Prevention recommended that eyecare providers and dentists stop all routine care, commented Anne L. Coleman, MD, PhD, University of California, Los Angeles (UCLA), who is president of the AAO, speaking at a press conference held March 20.

AAO considered the new guidance to be necessary and important because of the close contact between patients, clinicians, and members of staff in the eye care provider’s office. Typically, there is less than 3-feet between the patient and provider during an eye examination, for example, she explained.

Coleman noted that patients needing routine eye care are currently considered to be those who can wait approximately 2 months for an evaluation because they are not deemed at imminent risk of vision loss without either an eye examination or treatment intervention during this time.

By contrast, patients needing urgent care are those who could not wait 2 months for an eye examination or treatment intervention without the risk of vision loss, she added. Eye care providers can see these patients but should follow specific protocols implemented by their own offices and local health systems.

AAO also reported that the Centers for Medicare & Medicaid Services and the US Department of Health & Human Services have also expanded telehealth benefits during the COVID-19 outbreak for patients with or without symptoms associated with the disease. This allows eye care providers to offer services to patients via telephone, internet-based consultation, or telehealth exam, to help reduce the number of office visits.

Coleman noted that at her institution (UCLA) patients are being prescreened by telephone before a visit to identify those with symptoms associated with COVID-19. Any patients who report having fever, cough, or respiratory illness are advised to visit their primary care physician’s office or the emergency room instead of visiting their eye care provider.

Individuals who are prescreened by telephone and considered fit for examination can visit their eye care provider where they will be screened again by members of staff wearing personal protective equipment (PPE) to ensure they are healthy enough to be examined.

Eye care providers can also take various other precautions to reduce the risk of transmitting SARS-CoV-2. These include using protective breath shields on slit lamps, said Coleman. If a patient has respiratory symptoms, the patient, provider, and staff should wear masks, she added.

Providers should also thoroughly disinfect their office environment, she said.

Because the virus is very susceptible to alcohol, disinfectants that are 62% or more alcohol-based are recommended for cleaning, as is dilute bleach solution. Coleman recommends cleaning both before and after a patient visit. Staff should pay particular attention to all surfaces that patients touch or contact, especially in the consulting and waiting rooms, as well as surfaces on which respiratory droplets may have fallen. The seating arrangement in the waiting room should also be organized to create sufficient space in between patients, she said.

Stressing that asymptomatic patients represent a particular problem in SARS-CoV-2 transmission, Coleman also recommended that eye care providers, patients, and staff avoid talking during examinations to reduce the risk of potential virus exposure.

Referring to previous reports suggesting a link between SARS-CoV-2 infection and conjunctivitis, and because of concerns that the infection may have been transmitted via aerosol contact, Coleman recommended that all providers and staff who interact with infected or potentially infected patients should wear PPE, including a facemask, protective goggles, and gloves.

AAO suggests that providers should use single-use, disposable tonometer tips if they are available. Although cleaning tips with 70% alcohol solutions should be protective against SARS-CoV-2, this will not protect against adenoviruses. However, cleaning tonometer tips with diluted bleach remains a safe and acceptable practice.

Emphasizing the Risk of Transmission

How should providers deal with individuals who remain reluctant to take SARS-CoV-2 precautions seriously?

Speaking to Medscape Medical News, Coleman noted that patients may fall into this category for different reasons. Some patients become focused on their own condition and needs, she said, while others may lack comprehension of medical issues related to disease and the infectious nature of things they cannot see.

She suggested that providers and their staff members should take the time to speak with patients about this issue, either on the telephone or during prescreening visits.

Providers need to highlight the risk of virus transmission, especially by individuals who are infected with the virus but are asymptomatic. It is important to explain the need to slow down the spread of the virus to avoid overwhelming the healthcare system, Coleman added.

“But there are patients that almost demand to be seen,” she noted, adding that, in these situations, the provider needs to talk to them. “Sometimes a staff member will give the same information I give, but the patient doesn’t believe it until I say it.”

Coleman stressed that providers also need to take COVID-19 seriously. Some still believe the situation is overblown, she said, especially if they don’t really understand public health and epidemics.

“We really haven’t gone through this in our lifetime, except for maybe with swine flu, but it was nowhere near this level.” Many people don’t really comprehend it, and unfortunately that includes medical personnel, concluded Coleman.”

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