Experience at one ophthalmic practice in Bulgaria demonstrates that new operating procedures, technologies and good management can enable clinics to remain open and operate safely during the COVID-19 pandemic. Ophthalmic training and education should continue to be a priority.
Although SARS-CoV-2 has been detected in tears, it is important to note that there is currently no proof that it affects the ocular surface. However, clinics and ophthalmic practices have implemented new operating procedures to ensure they can remain open and operate safely during the COVID-19 pandemic, and it is more important than ever for surgeons to protect themselves and their patients.
Ophthalmologists and patients need to follow the rules and regulations mandated by the state or country where their practice or hospital is located. Unfortunately, the rules can differ between countries and sometimes between states in the same country. A large part of navigating this virus has been determining ways in which we can individually implement safe practices.
Battling emotional strain
The COVID-19 pandemic has placed an emotional strain on our patients. They are extremely afraid of contracting the virus, which has kept many from entering hospitals where there are potentially other sick people and where the virus is concentrated.
In ophthalmology, less than 5% of our cases are urgent, wherein a patient has endured trauma to the eye. Most of our patients need to be seen on a regular basis, so are now presented with a dilemma: is it more important to preserve their general eye health, increasing their chances of coming into contact with COVID-19, or better to defer their checkups and lessen their chances of contracting the virus?
Unfortunately, many patients have chosen to postpone their visits. Some have been doing so for months and even up to a year at this point, depending on when the COVID-19 outbreak occurred in their place of residence.
Additionally, our staff—not only physicians but also technicians, nurses, support staff and administrators—are at high risk of being exposed to the virus due to the number of people they come into contact with daily. Although staff may not express their worry outright, they know they are in a difficult position as their chosen profession does not allow them the privilege of working safely from home.
From a manager’s point of view, the COVID-19 pandemic has created a constant need to navigate the doubts of all parties involved as well as find a way to prevent sickness and preserve the health and safety of everyone while continuing to function. In this unfortunate situation, we learned that spending more time with each member of staff and sharing common assignments between staff members calms the atmosphere and provides a feeling of collective safety and security.
The approach to patients, however, is different. Their greatest need is to receive information in advance and to manoeuvre quickly and securely through the diagnostic pathways. In the past, several members of staff undertook specific procedures for many patients: today, we try to reduce each patient’s contact to no more than one staff member and care is dictated more by the patient than the procedure.
Distancing in the operating room
When the pandemic first started, the first thing we did as a practice was to make special shields to prevent very close contact with patients during an examination. Even though we and the patients wear protective gear, the patient is not fully covered, especially if they are claustrophobic, and we need to make adjustments.
In the operating room, the patient lies flat on his or her back, and we use a microscope that hovers over them, meaning that we are in line with their breath at all times. Equally, when we are over the operating field, what comes out of our airways goes down to the patient’s exposed eyes. It is technically impossible to wear a shield when operating a traditional microscope during surgery.
To combat this concern, we use a digital microscope, which offers greater opportunities to protect both patients and surgeons from infection during operations than a traditional kind. The three-dimensional heads-up microscope allows more distance from the patient. Moreover, because oculars are not used for 3D surgery, the protection shield above the 3D glasses is very easy to adjust.
This technology also benefits nurses, who need to have close contact with patients in all steps related to preparation, the surgery itself and immediate postoperative care. The microscope allows the nurse to be on the other side of the room and still view the procedure in real time using 3D glasses, which provides additional safety and allows for social distancing from the patient. Although the surgeon, nurse and assistant need to be in the operating room, we can distribute ourselves evenly, maintaining safer separation.
Treating COVID-19-positive patients
It seems that it would be easy for a surgeon to choose not to operate on patients who test positive for COVID-19. However, in Bulgaria at least, whether patients should be requested to take a COVID 19 test has been a controversial topic for ethical and legal reasons and hospitals have varying policies in this country.
Although my hospital does not ask patients to be tested for COVID-19 prior to surgery, we do screen them for fever and ‘flu symptoms as well as taking their temperature. If a patient is displaying symptoms, we ask them to see their general practitioner who decides whether a COVID-19 test is appropriate.
I experienced the delicacy of treating patients with suspected COVID-19 in a case that presented to me at the beginning of the pandemic. In Bulgaria, we initially had a very small number of cases. As most people experienced, we were not allowed to leave the city or even go outside for walks.
During this time, I received a call from my associate at the hospital to say that there was a 12-year-old girl traveling from Pleven, the hottest region for COVID-19 in Bulgaria, with a perforated eye. The reason for the perforation was unknown and the child was also experiencing a fever and a cough. At that time, I was most worried that the child was coughing, since in cases of perforation the tissues might prolapse.
The anesthesiologist was not able to give the child general anaesthesia because of her temperature and other factors. I agreed to see the child, and when I arrived at the hospital almost everyone was staying almost 3 meters away from the family. The family was frightened because they did not understand what was happening.
It turned out that the child was a contact-lens wearer; because of the lockdown she had been unable to buy contact lenses. As a result, she was wearing old lenses that were 2 weeks overdue. The child had anisometropia with plano refraction on one eye and −7.0 D on the other eye.
From the documentation, I discovered that she had developed bacterial keratitis very quickly and her eye was almost perforated. In normal times she would undergo lots of tests but instead of moving her around the hospital for evaluations, I decided to examine her in the operating room and be prepared to take material for microbiological evaluation.
I explained to the patient that she needed to be very cooperative because I could not give her general anaesthesia due to her coughing. Fortunately, she calmly agreed, especially when I explained that it would be painless.
Using the digital microscope and optical coherence tomography (OCT) imaging, I managed to evaluate her entire cornea while protecting myself from what I thought was a potential COVID-19-positive patient. I found that she, in fact, did not have any perforation. Instead, she had a zone of thinning surrounded by cornea with massive infiltration.
Thus, I performed a noninvasive procedure that is painless to the patient, called PAX crosslinking, which uses ultraviolet light to kill microorganisms and also makes the cornea stronger. I combined the procedure with transplantation of amniotic membrane as a cover. The 3D technology and the OCT control, which often is called ‘the third hand’, allowed me to be very precise as I performed these steps. As a result, the child now sees 20/50 with correction, which is a big accomplishment considering that she was about to lose her eyesight.
To complicate the case further, the child and her parents tested negative for COVID-19. In fact, she had ordinary ‘flu. However, if I had decided to wait for 48 hours for COVID-19 test results before operating, she would definitely have lost her vision, which would have been devastating for a girl of such a young age.
Thus, in the age of COVID-19 we must be flexible and consider the circumstances of each case individually. In medicine, we still need to take some risks, but it should be well understood and well planned. I was able to go confidently into the operating room with this patient because I felt assured that I would be able to protect her and the staff and provide an option that was less traumatic for her.
Even though we are in the midst of a pandemic, we should not forget the importance of education in medicine. Unfortunately, the first thing that happens during a lockdown in a hospital is that, while the permanent staff stays, all people who are on educational duties are sent home for distance learning. In the long term, we need to think that if we postpone education for 6 months and then postpone it for another 6 months, a year will go by very quickly, which will create gaps in the system for qualified eye specialists.
3D microscopy offers a great educational tool because students can stay 10 meters away from patients, wear 3D glasses and be able to look at a big screen and view the surgery as if they are participating. They see so much more detail than if they were looking over the patient with a conventional microscope. I do believe that we need to continue with practical education, perhaps on a smaller scale, but it is necessary for education and training to continue in whatever way is possible.
We do not really know how to react to the stress of a global pandemic, and we have surely made—and will make—a lot of mistakes that will be revealed in time. However, we need to focus first on being good doctors, good managers and good teachers. Regardless of the situation, we should continue to treat and work in teams.
Safety is the priority, of course, and new technology is facilitating novel and sometimes very complicated procedures for disinfection and social distancing. Integration and shared information when using equipment is of great help when reducing patient movement is necessary in the clinical setting. The circumstances are not easy, but we will survive this and learn more and, I hope, will end up with better solutions for the future that are beneficial for ophthalmic care not only during a pandemic but also when we return to normal life.
Prof. Christina N Grupcheva, MD, PhD, DSc, FEBO, FICO(Hon), FBCLA, FIACLE
Prof. Grupcheva is head of the Department of Ophthalmology and Visual Science and vice rector at the Medical University of Varna. She represents Bulgaria and is also currently president elect of the European Board of Ophthalmology. She has no financial disclosuresrelated to the content of this article to report.