[Evidence summary:] What are the considerations regarding ophthalmic procedures with suspected or confirmed COVID-19 patients? [v2.0]

Ocular symptoms may occur in severe COVID-19 pneumonia and the virus can be isolated from the conjunctival sac. Conjunctivitis is not a common manifestation of the disease, but contact with infected eyes can be a route of transmission. Ophthalmic practice carries some unique risks and clinicians must have effective prevention strategies in place14, 32. For outpatient care, Lim et al31 recommend that a stringent screening and triaging process is carried out to identify high-risk patients, with proper isolation implemented for such patients. For surgical and laser procedures, 5% topical povidone-iodine applied pre-operatively inactivates virus on the ocular surface. It is not suitable for intra-ocular application. There is no evidence that the virus is present in aqueous or vitreous humour. Aerosol generation during cataract, glaucoma, and vitreo-retinal procedures is of low risk to the surgeon. External cautery should be minimised to reduce the risk of aerosolising blood and if used should be combined with irrigation in order to dilute any aerosol produced10, 20. For asymptomatic patients with no risk factors, the American Academy of Ophthalmology and the Royal College of Ophthalmologists recommend generic measures to protect ophthalmologists from infection; these include scrupulous disinfection practices, protective plastic slit-lamp breath shields, reducing or eliminating conversations with the patient during slit-lamp examination, limiting the time spent with the patient at the slit lamp, and considering whether ophthalmic investigations such as ocular imaging are critical to the decision-making process. Both organizations recommend cancelling non-urgent treatment11. The role of telemedicine in mitigating risk of transmission of SARS-CoV-2 in eye care is an emerging theme in the literature. Digital communication technology is particularly relevant for two reasons: 1. prolonged exposure in close proximity on the slit lamp may increase the risk of transmission and viral load; and 2. the ability to make clinical decisions based on structured examination metrics such as palpebral aperture, intraocular pressure, cup-disc ratios, and images6. Virtual video visits may be used to manage a range of ophthalmic complaints; remote within-clinic visual acuity testing and consultations can be undertaken with minimal specialist equipment and appears to provide useful information while being acceptable to patients.