A Year of Living Dangerously: Challenges and Recommendations for Safely Performing Ophthalmic Surgery During the COVID-19 Pandemic, from Start to Finish

Figures & data

Figure 1 Suggested flow-chart to deliver ophthalmologic assistance during COVID-19 pandemic.

Table 1 General Recommendations for Institutions and Health Workforce

Concerning Area	Recommendations
Institution	It is wise to have two different clear circuits. One for patients who have tested negative for COVID-19 and one for patients with symptoms or suspected epidemiological background positive to COVID-19. Use a signalling system to indicate circulation, where people should stand, where they should sit, to remind them to keep social distancing.^Citation58,Citation59 Make sure to install desks and countertop barriers for employee protection. As a way to reduce the use of PPE and avoid viral transmission, physical barriers, such as acrylic or glass windows, could be installed.^Citation60 Ensure adequate ventilation and air exchange in all areas. High-efficiency particulate air (HEPA) filters in air conditioning systems will reduce the possible dissemination of the virus. Reduce unnecessary objects on surfaces to facilitate the cleaning and disinfection process. Implement the digital signature in as many processes as possible (eg at the registration desk, in informed consents, prescriptions, and medical records).
Staff	The staff could be divided into two or more teams, avoiding contact between them, to reduce chances of interpersonal dissemination of the virus. Protect all the staff that may be at higher risk for COVID-19. (Assign roles that are out of exposure: telemedicine, counselling, writing, research, etc.). Contemplate the introduction of infection control by checking temperature and symptoms to staff daily. Assign inspection roles. Check and recheck processes and implementation of protective measures.

Table 2 Facts to Consider in the Decision-Making Process Regarding the Necessity of the Elective Eye Surgery During COVID-19 Pandemic

Concerning Area	Facts to Consider
Institution	Resource limitations (PPE, health workforce, OR necessity for other urgent procedures) COVID-19 transmission risk Ophthalmic Institution Only/General Hospital OR facility and installation
Patients	Individual patient risks General anaesthesia necessity Case prone to complications Ocular disease
Time	Duration of surgery Disadvantages of postponing operation in the surgical outcome or disease process.
Surgery	Postoperative complications and readmissions Assess the effectiveness of nonoperative treatment options. Costs

Table 3 Comparative Chart: Different Possible Scenarios According to the Percentage of Intensive Care Unit Occupancy

Percentage of ICU Occupied by COVID-19 Patients	< 5%	6 to 25%	26 to 50%	51 to 75%	> 76%
Resources	Not compromised	Not compromised	Generally compromised	Compromised	Very Compromised
Surgical Activity	Complete, with caution	Reduced	Limited to urgencies	Limited to urgencies	Emergencies
Main indications	Pathologies that compromise the quality of life	Limited to sight-threatening pathologies	Limited to sight-threatening pathologies	Limited to sight-threatening pathologies	Limited to life-threatening pathologies

Table 4 Facts to Inquire in the Triage Process During COVID-19 Pandemic

Triage	Scenario 1	Scenario 2	Scenario 3	Scenario 4	Scenario 5
	Assessed Variables
Clinical	Presence of fever (>37,5ºC) Presence of respiratory symptoms: cough, shortness of breath Sudden onset of anosmia, ageusia or dysgeusia Conjunctivitis Diarrhoea Fatigue Muscle or body aches Headache Sore throat Congestion or runny nose Nausea or vomiting
Epidemiological	Close contact with a person known or suspected to have coronavirus. The patient has been in an area where ongoing COVID-19 transmission has been confirmed. The patient has ever been diagnosed with COVID-19 infection Date of diagnosis Time since recovery

Figure 2 Chronological estimate of diagnostic test probability to detect SARS-CoV-2 in the COVID-19 natural history. Estimated time intervals should be considered approximations. Publications are not consistent with this information since many factors have a significant influence on the shift of the curves. 1-PCR indicates real-time polymerase chain reaction. 2-IgM, Immunoglobulin M. 3-IgG, Immunoglobulin G.

Table 5 Staff Assignments in the Operating Room for an Ophthalmic Surgery During COVID-19 Pandemic

Member of the Surgical Team	Assignments in the Operating Room
Circulating Nurse	Have a preoperational checklist In charge of bringing materials and instruments into the OR as the surgery develops.
Surgical Assistant	Properly plan the material that will enter the OR. Any unnecessary material will be assumed as contaminated and should be discarded.
Surgeon	The operation should be led by an experienced surgeon to minimize complications, risks, and time of exposure inside the OR. Avoid risky manoeuvres during surgery. Aim to perform safe surgeries. Contemplate those surgical approaches that have the lowest probability of postoperative complications.
Anesthesiologist	Since this is one of the most exposed specialities, generally anaesthetists have very clear protocols to follow to reduce aerosolization and extreme air contamination during urgent and elective surgeries.^Citation59 Try to avoid general anaesthesia unless mandatory. Topical anaesthesia should be preferred to local anaesthesia whenever possible. The OR staff must not access the OR until the patient is intubated. N95 or OR PAPR (powered air-purifying respirator) must be used for all aerosol-generating procedures. If intubation is required for the surgery, recommend intubation in a negative pressure room prior to OR, as well as extubation. Consider using an aerosol box to reduce aerosolization in the OR.^Citation104,Citation105 Use an extra heat and moisture exchanger (HME) filter and viral filter on the expiratory limb of the anaesthesia machine circuit.^Citation105 Clamp endotracheal tube before any disconnection is planned.

Figure 3 Formula to dilute sodium hypochlorite at desired concentration.

Public Health England. COVID-19: guidance on social distancing and for vulnerable people. GOV.UK. Available from: https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people. Accessed March 16, 2020.

 Google Scholar

World Health Organization. Coronavirus Disease (COVID-19) Situation Reports; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/. Accessed December 22, 2020.

 Google Scholar

Weinstock MB, Echenique A, Russell JW, et al., Chest X-Ray Findings in 636 ambulatory patients with COVID-19 presenting to an urgent care center: a normal chest X-Ray is no guarantee. J Urgent Care Med. 2020;May:13–18.

 Google Scholar

Malik JS, Jenner C, Ward PA. Maximising application of the aerosol box in protecting healthcare workers during the COVID-19 pandemic. Anaesthesia. 2020;75(7):974–975. doi:10.1111/anae.15109

 PubMed Web of Science ®Google Scholar

Tseng JY, Lai HY. Protecting against COVID-19 aerosol infection during intubation. J Chin Med Assoc. 2020;83(6):582. doi:10.1097/JCMA.0000000000000324

 Web of Science ®Google Scholar