The COVID 19 pandemic and the subsequent lockdown has resulted in an unprecedented scenario, especially as ophthalmologists. These are testing times, but as is natural to humankind, we are rising and growing from this. We are all trying to the best of our abilities to adapt to the new normal and eventually reboot. In these uncertain times, the main focus has been to keep our patients, families, and ourselves safe.The team at eOphtha asked a few important questions on reverting to a functional glaucoma practice from threeluminaries in glaucoma.
Dr. G Chandrasekhar (GC) MD, FRCS has been associated with L V Prasad Eye Institute (LVPEI) since its inception in 1987 and is currently the Vice-Chair, LVPEI. Dr Chandrasekhar is an esteemed clinician and a passionate teacher. Dr GC is a mentor to many national and international fellows. He has published over 100 papers in national and international peer-reviewed journals and has been a reviewer for numerous ophthalmology journals. He is the Clinical Professor at the University of Rochester and has been a visiting professor at University of California, San Diego, USA. Dr GC has served as the President of the Glaucoma Society of India and is a member of the elite Glaucoma Research Society. He has served on the Clinical Guidelines Committee of the International Council of Ophthalmology (ICO) and the Membership Committee of Glaucoma Research Society. He is currently on the board of the World Glaucoma Association.
Dr. Lingam Vijaya (LV) MS, FRCS is a distinguished Senior Consultant at Medical Research Foundation, Sankara Nethralaya. She was Adjunct Associate Professor, Senior Clinician, Singapore National Eye Center. She is a revered clinician, researcher and has shaped and mentored many ophthalmologists and glaucoma specialists. She has many noteworthy contributions in indexed journals and has authored many chapters in glaucoma textbooks. Her contributions to the field of ophthalmology and glaucoma have been honored with multiple awards. She has been an invited faculty at multiple national and international glaucoma meets. Dr. Vijaya has held distinguished posts at various national and international societies including president Glaucoma society of India(GSI), consultant to the World health organization (WHO) for strategies to prevent blindness from glaucoma, member Glaucoma Research Society (GRS), member of board Asia Pacific Glaucoma society, member of World Glaucoma Association (WGA), chair for WGA global outreach committee.
Dr. Ramanjit Sihota (RS) MD, FRCS, FRCOphth is the Head of the Glaucoma research and clinical services at Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi (AIIMS). She completed her MD Ophthalmology in 1982, and her FRCS, Edinburgh in 1984. Her research with angle-closure diseases and glaucoma surgeries is noteworthy. She’s the recipient of the prestigious ‘Research recognition award’ 2011 by the World Glaucoma Association and many other awards at national and international platforms. As a distinguished glaucoma specialist, she has held revered posts as a member of the international Glaucoma Research Society, the National Taskforce in Glaucoma, the Glaucoma advisory group and Project evaluation committee of the Indian Council of Medical Research, the Postgraduate Committee of the Medical Council of India, the executive committee of Glaucoma Research Society, Asia Pacific Glaucoma Society and committees of the World Glaucoma Association, president of the Glaucoma Society of India. She has also been an invited faculty at multiple national and international glaucoma society forums.
eOphtha Given the fact that the first doctor to succumb to COVID-19 was a glaucoma specialist, what would be the best approach to start Glaucoma practice with measures to safeguard against contracting the infection?
Dr. G Chandrasekhar: Following universal precautions is needed. Like Wearing a N95 or equivalent, protective goggles or face shield, gloves and cap. Avoid touching the patient or their reports with non-gloved hand. Immediately after check-up needs to sanitize the gloved hands before writing or typing the case details. Maintaining adequate distancing is important while talking to the patient.
Dr. Lingam Vijaya: Interesting question, yes first doctor to succumb to COVID 19 was a glaucoma specialist from Wuhan. But we are not sure whether he got infected from the clinic or somewhere else. We do not have evidence to say one can get infected while examining a glaucoma patient and cause and effect relationship is almost nil.
Dr. Ramanjit Sihota: Self-protection with an N95 mask, a face shield, gloves, and disposable OT gown. A large X-ray sheet between observer and patient on the slit lamp. Sanitizer and cleaning of all surfaces between pts
eOphtha What would be the most effective sterilization procedure of the indispensable contact instruments such as applanation tonometer head andgonioscope?
Dr. G Chandrasekhar: Washing with Soap and water is most effective but might not be practical. 70% Isopropyl alcohol wipes can be used between every case for disinfecting the biprism head. The use of 1:10 dilution of Sodium hypochlorite is effective against the Adenovirus and Coronavirus. The tonometer tip can be dipped or placed in the sodium hypochlorite solution for 3-5 minutes at the beginning and end of the day to completely disinfect the biprism. For gonioscope, can wash with soap and water and later clean with 70% Isopropyl alcohol.
Dr. Lingam Vijaya: Sterilization of applanation tonometer prism and the gonioprism is mandatory for any safe clinical practices at any time. If somebody is not doing it routinely for all patients, I would say it is wrong and one should immediately change their methods of clinical practice. These measures should be followed even after COVD 19 pandemic. The applanation prism can be sterilized by keeping the tip of the prism in 0.5% bleach /Sodium hypochlorite (1 Part of 5% Sodium hypochlorite and 9 parts of distilled water) or 3% hydrogen peroxide for 5 min, then the prism should be washed with distilled water, dried and mounted at the beginning and at the end of the clinic on every day. Wipes of 70% Isopropyl alcohol (IPA) or equivalent effective solution can be used to clean the prism tips for each use. Similar wiping should be done for the gonio prism after washing it with the tap water.
Dr. Ramanjit Sihota: Wipe applanation tonometer tip with70% isopropyl alcohol and allow to dry. NCT surfaces should be wiped with any sanitizer and disposable tissues. Gonioscope – Wash with soap and clean the depressed surface with 70% alcohol wipes.
eOphtha Should fluorescein strips still be advocated, or ophthalmologists need to shift to fluoresceinsolution or let go fluoresceinaltogether as it comes to direct contact with tearfilm?
Dr. G Chandrasekhar: Disposable sterile strips are better than fluorescein solution. Solution has been reported to carry pseudomonas bacteriae. IOP assessment without the dye can be fallacious.
Dr. Lingam Vijaya: I always believe in doing things right. I do not see the need for skipping the fluorescence strip or drop. I would prefer a strip, I use anesthetic drop to wet the tip of the strip and gently place the strip end on the bulbar conjunctiva while patient is looking upwards. The anesthetic on the strip anesthetizes the corneal surface that is enough to measure IOP. There is no need to apply a drop of anesthetic. Instruct the patient to look straight, open the eyes widely, and not to blink. Under these conditions, one can measure IOP without touching the patient
Dr. Ramanjit Sihota: Fluorescein strips can be used and disposed of carefully, if applanation essential
eOphtha What additional precautions should be exercised for laser procedures as the patient’s eyelids need to be touched, instructions need to be given time to time and proximity to the patient is prolonged?
Dr. G Chandrasekhar: Any procedure should be done with proper PPE and gloved hand. Patient should definitely wear a mask as well. Give instruction prior to the procedure and avoid talking while examining. Slit-lamp guard/ transparent shields should be used. Washing of hands and disinfecting the used instruments is a mandatory
Dr. Lingam Vijaya: Recommended PPE should be used.mportant guidelines are – give routine instructions maintaining at least one-meter distance, make sure patient is wearing the mask properly, ask patient not to talk at all. One can use the disposable glove to avoid contact with ocular surface and properly dispose the glove after use. At the end of the procedure, all the surfaces should be cleaned with antiseptic spray.
Dr. Ramanjit Sihota: Use of gloves and cleaning of lenses as for gonioscopes
eOphtha In your expert opinion, what extra precautions need to be taken for planned glaucoma surgeries?
Dr. G Chandrasekhar: In case of diagnosed or at presumed carrier of COVID, elective surgery should be avoided. Universal precautions for all cases are needed.
Dr. Lingam Vijaya: None of the glaucoma surgeries are aerosol generating procedures. Whatever routine is followed for sterility and safety are enough for protection.
Dr. Ramanjit Sihota: Check for history of COVID symptoms, N95 masks
eOphtha Last but not the least, kindly share tips and self-help measures for the clinician to tackle the anxiety and depression in this trying time.
Dr. G Chandrasekhar: Following all precautions while taking care of patients, and the reassurance that the mortality is low, and recovery is very common at least in otherwise healthy patients would help.
Dr. Lingam Vijaya: Difficult question to answer. It all depends upon various things such as what stage of the professional carrier, financial conditions, age of the individuals etc. Whatever may be the situation we all are affected in various degrees. What is important to remember is that it is a transient period and ultimately, we are going to come out of it. The most important and only goal for anyone should be to remain healthy with good immunity for months to come. Keep in touch with friends and relatives, follow healthy schedules and remain positive to achieve the goal of remaining healthy
Dr. Ramanjit Sihota: Understand that it will spread, and Indians are largely recovering well. Build up your immunity, as best as possible, enjoy the blue skies, walk.