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Clinical Eye Care

What guidance is there on delay to elective surgery post recovery from SARS-CoV-2 infection?

Please click on this link for surgical advice from Victorian specialties.

What guidance is there on restoration of elective surgery in Australia?

Following the Australian Government’s announcement on 21 April, elective surgery has re-commenced as of 27 April. The Australian Commission on Safety and Quality in Health Care’s COVID-19: Elective Surgery and Infection Prevention and Control Precautions provides guidance for health service organisations with implementation of partial easing of restrictions on elective surgery, investigations and procedures, and standard and transmission-based infection prevention and control precautions. Elective surgery caps have been introduced in Victoria due to community transmission increases in July. Please refer to the RANZCO Triage Guidelines to assist in decision-making on prioritising surgery.

See RANZCO communique to members on 28 April and the Return to Elective Surgery in Australia Guidance.

The statement from the Australian Health Protection Principal Committee (AHPPC) covers principles around reintroduction of hospital activity, patient selection principles for first tranche of elective activity re-commencement, and suggested approach for elective surgery.

Please refer to Quick Links for advice from the Australian and New Zealand governments, and others.

The National COVID-19 Clinical Evidence Task Force supports Australia’s healthcare professionals with continually updated, evidence-based clinical guidelines that can be accessed here.

What guidance is there for Victoria-based Fellows?

Victoria has declared a State of Disaster as of 2 August. Please visit the Victorian government website for more information regarding restrictions.

Important elective surgeries  will resume across Victoria’s regional public and private hospitals as of 17 September and in metropolitan Melbourne from the end of September. Please see the Premier’s media release on safely reopening elective surgery for Victorians.

The Victorian Premier and Victorian Minister for Health have announced further changes to elective surgery in Victoria. Since Tuesday 28 July, the most urgent Category 1 and 2 surgeries are allowed in the current lockdown areas. As of midnight 5 August, the Victorian Government have paused all Category 3 and non-urgent Category 2 elective surgery in regional Victoria. Where possible, already booked Category 3 and non-urgent Category 2 surgery should still take place at the hospital’s discretion. No new non-urgent surgeries will be booked. The changes apply to the public and private sector. The new restrictions will remain in place “as long as is reasonably necessary.” To assist Fellows in decision making re prioritising of surgeries, please refer to the RANZCO Triage Guidelines.

Fellows are advised to adhere to the Interim advice on non-inpatient care of persons with suspected or confirmed Coronavirus disease (COVID-19), including use of personal protective equipment. RANZCO recommends that ophthalmologists, staff and patients wear masks for routine care and all procedures. Masks are the last line of protection. Gowns, hand hygiene and socially distancing behaviour (including not using shared desks, phones, etc.) are equally important. Ophthalmologists should wear eye protection for all procedures.

DHHS has advised that COVID testing prior to all inpatient hospital admissions will become a requirement for patients from Wednesday 15 July.

Key Resources:

Is it safe to commence lacrimal surgery?

On 15 May 2020, the Australian and New Zealand Society of Oculoplastics Surgeons (ANZSOPS) advised that in the context of extremely low prevalence of COVID-19 in Australia and New Zealand, lacrimal surgery may be cautiously resumed in patients who are low-risk for COVID-19 infection using standard universal precautions including gloves, gown, eye protection and mask. Pre-operative COVID-19 testing is not mandatory but may be indicated in some circumstances if consistent with local indications for testing.

Are special precautions required during cataract surgery?

Cataract surgery is thought to be an aerosol generating procedure. The following video (as yet non-peer reviewed and therefore not endorsed by RANZCO) from Bristol Eye Surgery suggests the following:

  1. Povidone iodine antiseptic be used during sterile preparation (this kills SARS-CoV-2 on the conjunctival surface).
  2. Perform irrigation and aspiration for six seconds before starting phacoemulsification (to clear the AC of any virus).
  3. Use a smaller wound size to minimise aerosolisation.
  4. Apply hydroxypropyl methylcellulose every minute over the corneal wound during phacoemulsification to minimise aerosolisation.

The adoption of these practices is at the discretion of the surgeon, depending on their assessment of the local level of COVID-19 risk.

What does the change in Alert Levels mean for patients and ophthalmologists in New Zealand?

The New Zealand government announced that the Auckland region will move to the standard Alert Level 2 as of 11:59pm Wednesday 23 September 2020. The rest of the country has moved to Alert Level 1 as of 11:59pm Monday 21 September 2020.

Find out more from the Unite Against COVID-19 website.

Resources

Lai, T, Tang, E, Chau, S, Fung, K, Li, K. (2020). Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. Graefe’s Archive for Clinical & Experimental Ophthalmology.

RANZCO NZ Branch Guidelines: Change to COVID-19 Level 3

The NZ Branch has co-developed (with NZAO and ODOB) the Guidelines for Optometry Essential Services During the Lockdown Period in New Zealand.

What are the new Australian COVID-19 temporary Telehealth arrangements?

To view a brief Powerpoint presentation detailing these arrangements, click here.

Additional relevant resources are:

Australian Cyber Security Centre – Web Conferencing Security

COVID-19 Temporary Telehealth Fact Sheets

What are the risks of COVID-19 transmission during automated perimetry?

At present, well patients and practice staff have a relatively low risk of having pre-symptomatic COVID-19 but the absolute risk will vary with population prevalence and social contact. In ophthalmology practices with meticulous anti-viral hygiene, no COVID-19 cases or suspects and universal precautions to reduce droplet spread of viruses, the episode-related additional COVID-19 risk to a patient is primarily from the known vectors of transmission associated with the healthcare visit (including travel and interactions before, during and after the visit). In this context, the marginal additional risk of performing standard automated perimetry should be weighed against the benefit of the visual field result on medical decision making for that patient. Automated perimetry has not been reported to be a vector for viral transmission. Such a risk would most likely come from an infected patient or staff member coughing or sneezing directly on the other during the test. There is an additional risk of an infected patient or staff member contaminating surfaces by touching, coughing or sneezing and a subsequent patient or staff member being infected by touching contaminated surfaces and then touching a mucous membrane. If it is possible for an infected patient to create an aerosol (as opposed to droplets) by coughing, sneezing or breathing, then it is conceivable that such an aerosol suspended in the perimeter bowl could be an airborne vector for infection of a subsequent patient.

What are the safety requirements for Visual Field testing (standard automated perimetry) during COVID-19?

RANZCO recommends the following during the COVID-19 pandemic:

  • If a patient has COVID-19 or is a suspect, they should not have standard automated perimetry for glaucoma.
  • If masks are available and COVID-19 prevalence warrants it, all patients and staff should wear masks during visual field testing that covers their noses and mouth. If required, the bridge of the nose should be taped to prevent exhaled breath fogging the trail lens.
  • Before the test, all surfaces touched by the patient and staff member should be disinfected.
  • The shortest possible test which provides the appropriate data should be used.
  • Immediately after the test, all surfaces touched by the patient and staff member should be disinfected.
  • If the bowl of the perimeter becomes contaminated, it should be cleaned in accordance with the manufacturer’s instructions.

The benefit of a visual field test is critically dependent on the training of the staff member setting up and monitoring the test, the testing conditions (especially with respect to lighting and noise) and the training and monitoring of the patient. The safety of visual field testing and all parts of the healthcare visit is critically dependent on a very thorough understanding of infectious diseases, public health, disinfection and sterility as well as virology. This is a product of medical school and surgical training and is well understood by all RANZCO Fellows.

RANZCO therefore recommends that established glaucoma patients should have their regular glaucoma testing with their treating ophthalmologists during COVID-19.

What guidance does the College have for GPs and other primary care providers?

Practical guidance for GPs can be found here.

RANZCO guidelines for primary care of patients with eye symptoms during the COVID-19 pandemic can be found here.

Where can I find guidance on use and sourcing of PPE?

Revised advice (mid-May 2020) on PPE use during the pandemic is available from the Australian Health Protection Principal Committee and the Communicable Diseases Network Australia.

For jurisdictional guidance, please refer to the following websites:

On 14 May, the Australian Chief Medical Officer advised RANZCO that the government is not yet in a position to be enabling access to the National Medical Stockpile (NMS) more broadly. As supply lines reopen, it is expected that private medical specialists access PPE through commercial means. Individual medical practitioners or practices who are unable to secure stocks through commercial means are able to request small amounts of PPE from the NMS by emailing stockpile.ops@health.gov.au. Requests will be prioritised based on clinical need.

On 19 May, Dr Nigel Lyons, NSW Deputy Secretary, Health System Strategy and Planning advised RANZCO that the use of surgical masks for asymptomatic patients should be based on local epidemiology and localised areas with elevated risk of community transmission as defined by public health authorities. Noting that ophthalmology patients are seen in a range of inpatient and outpatient clinical settings, it is recommended that PPE guidance for ophthalmology follows the advice in the CEC guidance document COVID-19 Infection Prevention and Control – Advice for Health Workers available on the CEC’s website (see link above). NSW Health has a state-wide strategy to ensure all staff continue to have access to the PPE needed to protect them at work and participates in the Whole of Government strategy through the Whole of Government Procurement Group. For access to supplied in private practice (where the usual supplier is unable to supply), there are options for commercial availability of surgical masks. A portal has been created for the private sector to access a register of suppliers who have indicated their ability to provide critical supplies during the COVID-19 crisis.

How do I manage confirmed, probable or suspected COVID-19 patients?

Ophthalmologists seeing a patient with an emergent or urgent eye problem who is at risk or has symptoms suggestive of COVID-19 will need to refer to the statement from Australian Health Protection Principal Committee (AHPPC) about the restoration of elective surgery. Surgery should only be performed in patients with suspected or confirmed COVID-19 in an emergency. For patients with suspected or confirmed COVID-19, non-urgent surgery should be postponed until the patient has been cleared as non-infectious. In these circumstances, contact and droplet precautions as outlined for elective surgery guidelines are appropriate (including the use of a surgical mask by the patient). Refer to Australian Commission on Safety and Quality in Healthcare (ACSQH) COVID-19: elective surgery and infection prevention and control precautions.

If the eye condition cannot wait, the current advice from the Australian Government Department of Health should be followed: Interim recommendations for the use of personal protective equipment (PPE) during hospital care of COVID-19 patients.

Airborne precautions and use pf P2/N95 respirator are only indicated in the context of an aerosol-generating procedure. These respirators must be carefully fit-checked with each procedure. Until more evidence is forthcoming, the following may be considered potentially aerosol-generating: phacoemulsification, vitrectomy, laser refractive surgery and oculoplastic surgery where cautery or high speed instruments are used (e.g. dacryocystorhinostomy).

What do I do when a COVID positive patient visits my clinic?

  • Document patient location and likely contacts in the clinic, duration and time
  • Report to the relevant state health authority
  • Implement clinic closure until appropriate cleaning has been undertaken and clearance has been given by the relevant state health authority
  • Communicate to staff and potentially affected patients of the need to be isolated/be tested, as per the relevant state health authority

How do I know whether I am at risk?

Given the practice context, ophthalmologists are at increased risk of being infected by SARS-CoV-2 compared to the general population based on:

  • COVID-19 is known to cause conjunctival congestion.1
  • SARS-CoV-2 has been isolated in tear and conjunctival secretions.2 However, the risk of infection from tears is thought to be low.3
  • The virus has shown viability in aerosols for hours and surfaces for days.4
  • Infected patients can be asymptomatic.5-7 The entire population of Vo, Italy were tested. Almost 3% of residents tested positive and most were asymptomatic.8 In Yokohama, Japan, within a cruise ship holding 3,711 passengers, 634 passengers tested positive (estimated 17.6% were asymptomatic).9
  • Ophthalmologists come into close contact with our patients, closer than the 1.5m social distancing that is being recommended by the Australian government. This occurs at the slit lamp and for longer periods whilst operating.
  • Ophthalmologists have died from COVID-19, and at least 3 from the Central Hospital of Wuhan including one after contact with an asymptomatic patient.10-13
References
  1. Guan W, Ni Z, Liang W, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;28:28 2020.
  2. Xia J, Tong J, Liu M, Shen Y, D G. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol 2020;26:26.
  3. Yu Jun IS, Anderson DE, Zheng Kang AE, et al. Assessing Viral Shedding and Infectivity of Tears in Coronavirus Disease 2019 (COVID-19) Patients. . Ophthalmology 2020.
  4. van Doremalen N, Bushmaker T, Morris DH. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020 2020;28.
  5. Lee K, J. Coronavirus kills Chinese whistleblower ophthalmologist. American Academy of Ophthalmology 2020.
  6. Lauer SA GK, Bi Q, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med 2020;10.
  7. Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. . Jama;21.
  8. Crisante A, Crisone A. Coronavirus outbreak: In one Italian town, we showed mass testing could eradicate the coronavirus. Guardian 2020 8/03/2020.
  9. Mizumoto K, Kagaya K, Zarebski A, G. C. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2019. Euro Surveill 2020;25.
  10. Parrish RK n, Stewart MW, Duncan Powers SL. Ophthalmologists Are More Than Eye Doctors-In Memoriam Li Wenliang. Am J Ophthalmol 2020;;09.
  11. Green AL. Obituary Wenliang. Lancet 2020;295.
  12. Cai J. Wuhan doctor who worked with whistle-blower Li Wenliang dies after contracting coronavirus on front line. South China Morning Post 2020 03/03/2020.
  13. Global Times 2020 09/03/2020.

Which countries and regions pose the highest risk?

Although recent travel through China, Iran, Italy or Korea is thought to pose the highest risk, travel through any overseas country within the last 14 days is now deemed to be a risk.

How do I protect myself and others from infection?

  • Implement basic infection control measures including hand hygiene, respiratory hygiene/cough etiquette (regular hand washing, covering mouth and nose with elbow when coughing and sneezing) and avoidance of touching of eyes, mouth and nose.
  • Keep a distance of 1.5 metre away from the patient unless closer proximity is required for examination. In New Zealand, 2m is recommended by the government.
  • Avoid wearing unnecessary accessories such as watches, ties or lanyards.
  • We recommend regular (minimum daily) environmental disinfection of office spaces, ophthalmic equipment and computers with appropriate disinfectants – 70% alcohol, 0.5% hydrogen peroxide and 0.1% sodium hypochlorite are suitable.1
  • Minimise staff-patient contact times in the clinic. Try to establish as much of the history and investigation results before calling the patient into the consultation room.
  • When testing visual acuity, start at the lowest achievable line to speed things up.
  • Use rebound (e.g. iCare) tonometry while standing beside the patient. When using Goldmann applanation tonometry, disposable tips are preferred. If this is not available, 70% of alcohol solutions should be effective at disinfecting tonometer tips from SARS-CoV-2. Clinicians should be aware that puff tonometry is an aerosol generating procedure.2
  • Avoid re-examination of patients who have already been assessed.
  • Avoid lengthy procedures at the slit lamp. Avoid talking at the slit lamp or talking directly face-to-face in close proximity. Where appropriate, use indirect ophthalmoscopy in preference to slit lamp examination.
  • Avoid direct contact with conjunctival mucosa or tears by wearing gloves or lifting the eyelid with a disposable cotton tip/bud.
  • Consider whether special close-contact examination and tests (gonioscopy, OCT’s, anterior segment and fundus imaging, visual fields, ultrasounds) are absolutely necessary and minimise these if possible.
  • Install protective slit lamp breath shields of large enough size to limit droplet spread.Breath shields are also advised for other ophthalmic equipment (e.g. OCT machines) when practicable.
  • Wash or disinfect your hands immediately before and after examining every patient.
  • Clean the slit-lamp and chair immediately after each patient use.
  • Refer to Australian Government Department of Health: Interim recommendations for the use of personal protective equipment (PPE) during hospital care of COVID-19 patients and Australian Commission on Safety and Quality in Healthcare (ACSQH) Screening checklist for patients for theatre not known to be COVID-19 positive.

For guidance related to each jurisdiction within Australia and New Zealand, refer to the following websites:

References

  1. Kampf G, Todt D, Pfaender S, E. S. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020;104:246-51.
  2. Britt JM, Clifton BC, Barnebey HS et al. Microaerosol Formation in Noncontact “air-puff” tonometry. Arch Ophthalmol 1991;109(2):225-228)
  3. Lai THT, Tang EWH, Chau SKY, Fung KSC, KKW. L. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong Graefes Arch Clin Exp Ophthalmol 2020;3:3.

How do I protect my work environment/clinic?

  • Consider a telephone consultation or rescheduling non-urgent appointments in elderly patients (over 70 years), those who are immunosuppressed, have multiple serious co-morbidities or are pregnant, as this demographic has the worse prognosis if they develop COVID-19.
  • Have SMS and telephone systems in place to screen patients for epidemiological risk factors and symptoms of COVID-19 and ask these patients to defer their appointment 14 days, if possible. Most conjunctivitis does not need to attend an ophthalmology clinic and may be managed via telehealth. If a patient needs to be seen face-to-face, attempts should be made to test the patient for COVID-19 first. If this cannot be done, then consider wearing PPE as per the advice from the Australian Government Department of Health: Interim recommendations for the use of personal protective equipment (PPE) during hospital care of COVID-19 patients.
  • Display proper signage on arrival to deter suspect COVID-19 patients entering the premises (unless the patient has an emergent or urgent eye problem).
  • Ophthalmologists seeing a patient with an emergent or urgent eye problem who is at risk or has symptoms suggestive of COVID-19 are advised to refer to the Australian Health Protection Principal Committee (AHPPC) statement on restoration of elective surgery.
  • Consider screening the temperature of all staff and patients on arrival. Non-contact thermometers are preferred. Defer appointments for 14 days in patients with a fever and non-urgent eye condition even if they do not meet the Australian criteria for a suspect COVID-19 case. Tell the patient to self-isolate and wear a mask. They should seek medical care if they develop respiratory symptoms.
  • Encourage regular use of hand disinfectant by staff and patients upon arrival to the clinic.
  • Decompress the workplace by distancing patients sitting in waiting rooms. Use mobile phone calls to notify patients when to return to the clinic.
  • Minimise magazines, toys and waiting room items that may be handled by multiple patients.
  • Minimise the number of accompanying people with the patient. Discourage carers and family members of patients from waiting inside the clinic waiting room.
  • Minimise visitors (e.g. representatives) to the clinic.
  • Consider treatment changes that might reduce the frequency of required attendance for the next few months e.g. changes in intravitreal treatment regime or a longer acting drug.
  • Consider rostering of staff to specific teams, work times or locations to minimise cross-infection. Consider dedicating a staff team for managing COVID-19 positive or suspect patients.
  • Discharge all inpatients who are fit to leave.
  • Encourage infection control training by all staff.
  • When undertaking surgery, discuss with the anaesthetist to try to restrict general anaesthesia to cases where there is no other option due to the higher risk of droplet and aerosol contamination.
  • Due to the high risk of COVID-19 infection from the nasopharynx, avoid all nasal syringing, lacrimal surgery and nasal endoscopy. If it is still necessary to operate, one should wear PPE as recommended by ASOHNS guidelines.
  • Treat thyroid eye disease medically first. If orbital decompression is still required, avoid medial wall/floor decompression which creates an entry into the paranasal sinuses.
  • After attending a suspected or confirmed case, perform cleaning of the room as follows:
    • Specialised equipment: Slit lamps, tonometer, contact lenses pinhole occluders or any other equipment that has come into close contact with the patient or mucosal surfaces should be cleaned with alcohol wipes or chlorine dioxide disinfectant immediately after seeing a suspect or confirmed case.
    • Disinfect all surfaces patients may have come in contact with, including door handles and frames, equipment, chin rests, chair, etc. as per other virulent diseases (such as viral conjunctivitis).
    • Examination room and communal areas in clinic cleaning: If there has been a suspect or confirmed case seen in the clinic, cleaners should observe contact and droplet precautions and don PPE. Clean frequently touched surfaces such as doorknobs, bedrails, tabletops, light switches in clinic and communal areas.
    • A combined cleaning and disinfection procedure should be used. Either two-step (i.e. detergent clean, followed by disinfectant) or 2-in-1 step – using a product that has both cleaning and disinfectant properties. Hospital-grade, TGA-listed disinfectant that is commonly against norovirus is suitable, if used according to manufacturer’s instructions.
  • Consider practical measures that may include the addition of breath shields to devices such as slit lamps (for example, slit lamp shield owned by an Australian Fellow). Further information can be found on the AAO COVID-19 Information Page or can be sourced from multiple suppliers in Australia. Some quick, low-cost, do-it-yourself options for device face shields can be found here. There are many places – Bunnings is a good start – where you can find clear Perspex.

Here’s a video link to some DIY protect slit lamp shields.

DISCLAIMER: Please note that RANZCO has no interest in and does not endorse any particular device or product.

When should I use PPE?

The New Zealand Ministry of Health has published principles on supply of PPE, where you can find the most up-to-date information.

The use of PPE by ophthalmologists seeing asymptomatic patients remains contentious. Thus far the Australian Government Department of Health has only recommended use of PPE for healthcare workers caring for suspect or confirmed COVID-19 cases. There is strong evidence from other respiratory viral epidemics that wearing PPE (including mask and eye protection) minimizes the risk of infection.1-3 It is likely ophthalmologists are at higher risk of being infected by SARS-CoV-2 compared to the general population.

This is based on the following:

  • COVID-19 is known to cause conjunctival congestion. In a large Chinese cohort of 1,099 patients with laboratory confirmed COVID-19, this was reported in 0.8% of patients.4 In a smaller cohort from Hubei, China, 12 out of 38 (31.6%) of COVID-19 patients had ocular manifestations consistent with conjunctivitis.5
  • SARS-CoV-2 has been isolated in tear and conjunctival secretions (although this is infrequent and one study failed to detect it in tears of 17 patients with COVID-19).6
  • The virus has shown viability in aerosols for hours and surfaces for days.2
  • Infected patients can be asymptomatic.3,7,8 In a testing of the entire population of Vo, Italy, almost 3% of residents tested COVID-19 positive and most were asymptomatic.9 In Yokohama, Japan, within a cruise ship holding 3,711 passengers, 634 passengers tested positive for COVID-19. It was estimated that 17.6% of these were asymptomatic.10 One paper has suggested an undocumented infection rate of up to 86%.11
  • Ophthalmologists come into close contact with our patients, closer than the 1.5m or 2m social distancing that is being recommended by the Australian and New Zealand governments respectively. This occurs at the slit lamp and for longer periods whilst operating.
  • Ophthalmologists have died from COVID-19, and at least 3 from the Central Hospital of Wuhan, including one after contact with an asymptomatic patient.11-14

Given the fact that ophthalmologists may themselves be asymptomatic carriers and see multiple patients, mask-wearing may prevent infection of patients. This is particularly relevant for our patients who tend to be older and co-morbid (the most vulnerable to COVID-19).

A retrospective review of 493 medical staff at Zhongnan Hospital of Wuhan University found none of 278 staff became infected by SARS-CoV-2 when wearing N95 respirators versus 10 of 213 staff who were infected when they did not wear a mask. This is despite the fact that the non-mask wearers worked in departments that were considered to be of lower risk than the group that wore N95 masks (who worked in the Departments of Respiratory Medicine, ICU and Infectious Disease).15

A review of health care workers from Mass General Brigham, the largest healthcare system within Massachusetts with more than 75,000 employees demonstrated a linear reduction in SARS-CoV-2 positivity rates from 14.65% to 11.46% after the implementation of universal masking for health care workers and patients, despite state wide increase during the same period.16

A systematic review of 172 observational studies and meta-analysis of 44 comparative studies of betacoronaviruses including SARS-CoV-2 suggested lower rates of transmission with the following interventions: physical distancing of 1m or more, use of face masks (with stronger protection conveyed by N95 versus disposable surgical masks) and eye protection.17

Surgical masks are currently recommended for ophthalmologists seeing asymptomatic routine patients in the following countries: USA, UK, China, Italy, South Korea and Singapore.18 They are recommended in some, but not all Local Health Districts in Australia for health care workers caring for patients in a vicinity closer than 1.5m.

In Australia, when face-to-face consultations are required, both ophthalmologists and asymptomatic patients are advised to wear a surgical mask. Ophthalmologists should avoid touching patients directly, and if they need to, should wear disposable gloves or practice hand washing after each contact. Eye protection is preferable. These general recommendations need to be determined on a case-by-case basis, taking into account the local prevalence of disease, local policies and importance of preserving supplies of PPE. If supplies are limited in a public health setting, ophthalmologists should be permitted to wear their own PPE, if they feel this is clinically justified.

References

  1. Yu Jun IS, Anderson DE, Zheng Kang AE, et al. Assessing Viral Shedding and Infectivity of Tears in Coronavirus Disease 2019 (COVID-19) Patients. . Ophthalmology 2020.
  2. van Doremalen N, Bushmaker T, Morris DH. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020 2020;28.
  3. Lauer SA GK, Bi Q, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med 2020;10.
  4. Guan W, Ni Z, Liang W, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;28:28 2020.
  5. Wu P, Duan F, Luo C, et al. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmology 2020.
  6. Xia J, Tong J, Liu M, Shen Y, D G. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol 2020;26:26.
  7. Lee K, J. Coronavirus kills Chinese whistleblower ophthalmologist. American Academy of Ophthalmology 2020.
  8. Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. . Jama;21.
  9. Crisante A, Crisone A. Coronavirus outbreak: In one Italian town, we showed mass testing could eradicate the coronavirus. Guardian 2020 8/03/2020.
  10. Mizumoto K, Kagaya K, Zarebski A, G. C. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2019. Euro Surveill 2020;25.
  11. Cai J. Wuhan doctor who worked with whistle-blower Li Wenliang dies after contracting coronavirus on front line. South China Morning Post 2020 03/03/2020.
  12. Parrish RK n, Stewart MW, Duncan Powers SL. Ophthalmologists Are More Than Eye Doctors-In Memoriam Li Wenliang. Am J Ophthalmol 2020;;09.
  13. Green AL. Obituary Wenliang. Lancet 2020;295.
  14. Global Times 2020 09/03/2020.
  15. Healthcare Infection Society. Association between 2019-nCoV transmission and N95 respirator use. Journal of Hospital Infection. Letters to the Editor 2020:2020. https://doi.org/10.1016/j.jhin.2020.02.021
  16. Wang X, Ferro EG, Zhou G, Hashimoto D, Bhaat DL. Association Between Universal Masking in a Health Care System and SARS-CoV-2 Positivity Among Health Care Workers. Jama 2020.
  17. Chu DK, Duda S, Solo K, Yaacoub S, Schunemann HJ. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet 2020;395:1973-87.
  18. Li J, Shantha J, Wong Y, et al. Preparedness of Ophthalmologists during and beyond COVID-19 pandemic. Ophthalmology 2020.

What do I do if my staff get sick?

For further advice on managing staff with COVID-19 refer to the Employment New Zealand webpage or Australian Fair Work Ombudsman webpage.

How do I protect myself and others when I am at greater risk of exposure?

Do not attend work and self-isolate at home (except to seek medical care) if you have:

  • returned or arrived from overseas/interstate (until 14 days have lapsed)
  • come into close contact with a confirmed COVID-19 patient (until 14 days have lapsed)
  • symptoms of an acute respiratory illness

If fever or respiratory illness (even if mild) occur, seek medical attention as soon as possible. Call the Australian Healthdirect helpline 1800 022 222 or the New Zealand Healthline (for free) on 0800 358 5453 (or +64 9 358 5453 for international SIMs) for advice. Alternatively, call ahead before seeing your GP or go directly to the local Emergency Department.

If you know you are at high risk of severe COVID-19 disease (including those with organ transplantation being immunosuppressed and those with cancer undergoing chemotherapy) should consider minimising patient contact and working remotely.

How do I safely see children during the COVID-19 pandemic?

Due to the social distancing rule, it’s no longer possible to have several people in the waiting room, no matter what their age.

Perform pre-screening to allow rescheduling of patients sick or self-isolating and re-screen all patients on arrival to preclude entry of any high risk patients. Mandatory hand sanitiser on entry.

Specific strategies for children include:

  • Limit bookings for children to one/30 minutes.
  • Only parents are allowed to attend appointment. No siblings or other relatives.
  • Limit numbers in waiting room to only one family at a time.
  • Children who are dilating are asked to leave the practice and wait outside the clinic if safe to do so.
  • Remove all toys and books from the waiting room and no lollies be given out for ‘bravery’.
  • Ophthalmologist to wear gloves and N95 masks as children usually cough or sneeze on you.
  • 70% alcohol or antiviral disinfectant to all surfaces upon departure as children touch everything.
  • Ask next patient and parents to wait outside the clinic until previous child and family has departed.
  • Consider Telehealth where appropriate. It is recognised that Telehealth may not be suitable for many paediatric cases due to difficulty in testing vision in children. Medicare item numbers currently require bulk billing for all those under age 16 but there may be changes to these item numbers so Fellows should keep themselves regularly updated.

Last updated: September 22, 2020

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