Pearls for managing COVID-19 pandemic north of the border

This article was reviewed by Sherif R. El-Defrawy, MD, PhD, FRCSC

In the wake of the COVID-19 pandemic and Canada-wide lockdown, Canadian ophthalmologists have moved to screening patients by phone, triaging the need for in-person visits and attempting to treat emergent and urgent cases in general ophthalmology, as well as retinal and glaucoma care.

On May 15, 2020, the University of Toronto’s Department of Ophthalmology and Vision Sciences held a roundtable webinar discussion to update ophthalmologists across Canada about best practices they should implement during the COVID-19 pandemic.

As health care comes under provincial jurisdiction, it will be up to individual provinces to decide on plans to reschedule elective surgeries.

Related: COVID-19: Should ophthalmologists prepare for a second surge?

In Ontario, Canada’s largest province, nearly 53,000 surgeries were cancelled or unscheduled, and there is currently no specific timeline for when the procedures are expected to resume.

“We do not anticipate elective surgery to open until late June,” said Sherif R. El-Defrawy, MD, PhD, FRCSC, Nanji Family Chair in Ophthalmology and Vision Sciences, professor and chair of the Department of Ophthalmology and Vision Sciences at the University of Toronto, and the ophthalmologist-in-chief at Kensington Eye Institute in Toronto. “I anticipate we will be seeing a large backlog in cases.”

El-Defrawy suggested plans such as operating on Saturdays and having 12-hour operating days, with 2 surgeons working in 6-hour shifts, to help address the backlog when elective surgery resumes.

When community ophthalmology practices do resume operating, it is vital that ophthalmologists wear personal protective equipment and minimize their verbal interaction with patients, according to Abdu Sharkawy, MD, FRCPC, internal medicine and infectious diseases consultant and assistant professor of medicine, University of Toronto.

“Even through speaking, if you are within 6 feet of someone who has tested positive for COVID-19, there is a risk of transmission through the droplets,” Sharkawy said. “You want to minimize the amount of talking you are doing and tell the patient to do likewise during your examination.”

Related: COVID-19 mutations: A more efficient virus

Moreover, Sharkawy discussed how ophthalmologists can mitigate risk, noting that there is clear evidence that COVID-19 can be detected in tears and conjunctival secretions.

“This is problematic because the type of follicular conjunctivitis that presents as part of COVID-19 may be completely indistinguishable from that caused by a lot of other benign, viral etiologies,” Sharkawy said. “It really behooves the ophthalmologist to have a very high index of suspicion when they are seeing someone who has conjunctivitis [to be aware] that they may be dealing with a patient who has COVID-19.”

Because it is an aerosol type of transmission that can occur, an ophthalmologist should ideally be wearing an N95 mask and a face shield when examining a patient with a conjunctival issue, according to Sharkawy.

A routine surgical mask, however, is adequate for basic assessments such as tonometry and slit-lamp examinations if the patient does not have a conjunctival issue, he added.

Related: The dropless future: SLT as a first-line treatment for glaucoma

Managing glaucoma
Yvonne Buys, MD, FRCSC, a professor in theDepartment of Ophthalmology and Vision Sciences, University of Toronto, and codirector of the Glaucoma Unit at the University Health Network, noted that the Canadian Ophthalmological Society put out a statement in late March outlining how glaucoma cases can be triaged, such that only urgent and emergent cases are seen.

“You can do assessments on issues with drops by phone,” said Buys, noting prescription refills can be faxed to pharmacies to avoid a patient visit. “In the glaucoma area, drug shortages and discontinuation (of medications) is really a problem.”

Pharmacies are sometimes writing back to Canadian ophthalmologists treating patients with glaucoma, letting them know about the lack of medical therapies.

“There are no topical β-blockers (available in Canada),” Buys noted. “This is a made-in-Canada problem. It is not a problem south of the border (in the United States).”

Related: Glaucoma treatment alternatives: Thinking outside the box

Buys speculated that the lack of availability of topical β-blockers is related to drug benefit plans and pricing and companies may not be choosing to stock pharmacy shelves.

To respond to the dearth of topical β-blockers in Canada, Buys suggested ophthalmologists consider looking to other sources for obtaining these medications.

“Don’t forget about compounding companies,” she told fellow ophthalmologists. “We should probably be using those more than we are.”

Related: COVID-19: Smart thermometer shows real-time changes in fever levels

Patients should definitely be seen if intraocular pressure is very elevated (more than 38 mm Hg), if there are symptoms of acute angle closure, bleb-related endophthalmitis, bleb leaks, and hypotony with a high risk of vision loss.

“If a patient has uncontrolled glaucoma and has had surgery in the past few months, and the threshold should be lower for a monocular patient (then a patient should be seen in person),” Buys added.

Tonometry should continue to be performed with alternatives such as the Tono-Pen (Reichert Technologies) or Icare tonometers (Icare USA) with disposable tips that allow for greater spacing between the patient and the examiner.

Related: Glaucoma 360: Decision-making in surgical glaucoma

Retinal care
Similar to glaucoma management, medical retina management can be triaged, to ensure more urgent care is seen.

Visits to see patients with diabetic macular edema and retinal vein occlusion can be delayed, whereas premature babies who require screening and treatment for retinopathy of prematurity should be seen, according to Radha Kohly, MD, PhD, FRCSC, of Sunnybrook Health Sciences Centre in Toronto and an assistant professor in the Department of Ophthalmology and Vision Sciences at the University of Toronto.

Patients who undergo regular intravitreal injections may choose to continue to come to clinic, to ensure that they can continue to drive and get their groceries, explained Kohly.

“These are patients who are undergoing a lot of stress and feel that they have to choose between their vision and their life,” Kohly added. “We need them to know that we understand the predicament that they are in, and we are here for them.”

Read more by Louise Gagnon

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Sherif R. El-Defrawy, MD, PHD
p: 416/978-7931
e:seldefrawy@kensingtonhealth.org
Dr. El-Defrawy has no financial disclosures related to this content.