The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),
originated in Wuhan, China, and spread across the globe. As of 5th June 2020, it has
infected nearly 6.5 million individuals and killed more than 400,000 individuals.[1]
The route of transmission includes mainly droplets, fomites, and also aerosol particles.[2]
There is evidence that SARS-Cov-2 can also cause intestinal infection and present
in faeces, however there are no reports on the faecal-oral transmission.[2] The most
common symptoms reported are fever and cough.[3
4] Ocular involvement in the form of conjunctivitis can sometimes be the first symptom.[3
5] Advisory measures include social distancing, working from home and safe hygiene
practice. Legal measures include travel restrictions, reduction or postponement of
elective procedures, lockdown, and curfews.[6]
Health care professionals are at an increased risk of infection, including ophthalmologists,
000 other allied health personnel, as most of the ophthalmic procedures bring them
in close contact with the patients.[3
5
7] There are also reports of SARS-CoV-2 identified in tears and conjunctival swabs,
thus putting clinical eye care professionals at risk of acquiring the infection.[5
8
9
10
11] Different guidelines have been developed for ophthalmologists by the American
Academy of Ophthalmology (AAO),[12] International Council of Ophthalmology (ICO)[13]
as well as national societies such as All India Ophthalmological Society (AIOS).[14
15] Similarly, the American Optometry Association has developed guidelines for optometry.[16]
However, there are limited guidelines available for primary eye care (PEC) facilities
in India. In India, the government sector offers PEC through its Vision Centres (VC)
located within the primary health centres (PHC). The non-governmental organizations
(NGO) offer care through a stand-alone Vision Centre (VC) model.[17
18] In this article, we describe the guidelines followed in our PEC network, i.e.,
VC network of L V Prasad Eye Institute (LVPEI), India.[19]
LVPEI response to COVID-19 at primary level can be divided into the following steps:
Safeguarding infrastructure and equipment
Primary eye care personnel protection
Patient triaging and Clinical protocols (including optical dispensing)
Administrative control and monitoring
The protocols can also be viewed at:
https://youtu.be/zVcSiHfFojk
1. Protection of infrastructure and equipment: A PEC facility is typically set up
in a space of approximately a 500 square feet area. The existing structure has been
modified and re-arranged to suit the current COVID-19 situation. This includes seating
arrangement to ensure that social distance (3 feet distance) is maintained. Cleaning
and disinfection protocols have been developed [Table 1]. Sanitizers are also placed
at the entrance of the examination room as well as the optical dispensing counter
and used after each examination. As described in other guidelines, breath barriers
have been installed on slit lamp biomicroscopes.[12
13
14
15] Additional breath barriers have been created for retinoscopes, autorefractors,
and for fundus imaging equipment. The cleaning and disinfection protocols of the PEC
facility are shown in Table 1.
Table 1
Cleaning and disinfecting protocol for the primary eye care facility
Type of surface*
Disinfectant to be use
Frequency of cleaning
Metallic surfaces Door handles, Desk handles Locks, keys Partition surfaces, if
any
1% sodium hypochlorite solution
Twice a day (Morning when the centre is opened and after lunch time).
Electronic/Information technology equipment Monitor, Keyboard, Mouse Mobile, Tablet
70% Isopropyl Alcohol wipes
Three times a day
Floor All open areas in the examination room, waiting and seating areas
1% sodium hypochlorite solution
Three times a day
Wooden surfaces Desks/Benches/Chairs
0.5% Hydrogen Peroxide solution in a spray bottle or 1% sodium hypochlorite solution
Twice a day (Morning when the centre is opened and after lunch time)
Medical equipment Slit-lamp including barrier Trial frame and lenses Retinoscope
along with the Barrier sheet Autorefractor and its barrier sheet
70% Isopropyl Alcohol wipes Lenses to be cleaned with 0.5% Hydrogen Peroxide in
a spray bottle
Every time before starting an eye examination
Optical Dispensing area Spectacles frames Display mirror Display unit desk
0.5% Hydrogen Peroxide in a spray bottle or 70% Isopropyl Alcohol wipes
After every patient
Vehicle (if available)
1% sodium hypochlorite solution
Twice a day* (Once in the morning and once in the evening)
*High touch surfaces to be cleaned more frequently
2. Primary eye care personnel protection: Personal protective equipment has been provided
as described in other guidelines [Table 2].[13
14
15
16
20] The procedure for donning PPE (putting on) and doffing PPE (taking off) is detailed
in [Fig. 1]. Along with PPE, the importance of social distancing and hand hygiene
practice has been reinforced. They are also advised to avoid social gatherings and
visitors, as well as family holidays. All pregnant women and high risk persons are
given leave.[21] For education, the use of online platform is encouraged and being
used.
Table 2
Personal protective equipment for primary eye care personnel
Personal Protective Equipment
Frequency of changing
Disinfection methods
Comment
Face Protection (mask) Ideal: Masks N95 or FFP2 (Filtering Face Piece) Minimum: Triple
Layer Surgical mask
To be changed after 4-5 days of usage (cumulative) unless soiled Daily
UV Chamber or Light (254 nm) for 30 minutes Can be disinfected and used for 8-10 cycles
Disposable
Used masks are stored in individual on ziplock covers
Hair cover Ideal: Disposable Surgical cap or impermeable fabric Minimum: Cloth cap
Daily Daily
Disposable Wash it after single-use
Discard after a single use in a separate dustbin
Gloves Ideal: Latex or Nitrile (unsterile)
Daily
Disposable
Discard after a single use in a separate dustbin
Protective goggles Ideal: Safety goggles Minimum: Post cataract surgery protection
goggles
Reusable Reusable
Cleaned with the 1% hydrogen peroxide solution
To be cleaned daily
Face Shield Ideal: Visors covering up to the ears Minimum: Open Source Visor
Reusable Monthly
Cleaned with the hydrogen peroxide solution or 70% isopropyl alcohol wipes
To be cleaned daily
Cloth gowns Ideal: Disposable or cloth gowns Minimum: Full sleeve dresses/Apron
Daily/Reusable
Disposable/Wash it after a single-use
Foot protection Ideal: Disposable/impermeable fabric shoe cover Minimum: Shoes/footwear
that covers the entire ankle
Daily
Disposable
Discard after a single use in a separate dustbin
Figure 1
Donning and doffing of personal protective equipment by primary eye care personnel
3. Patient triaging and clinical protocols (including optical dispensing): The PEC
facilities are stand-alone units managed by a single person (in most cases). The core
functions include refraction and dispensing of spectacles, diagnosis of common eye
conditions, and appropriate referrals for further intervention. Hence, the clinical
protocols are developed with a focus on these functions as well as other guidelines.[13
14
15
16] Fig. 2 shows the clinical workflow at a PEC facility in our network. All patients
are instructed to wear a mask or cover their nose and mouth with cloth/scarf. The
patient is greeted (non-contact method). For patient triaging, a COVID-19 questionnaire
is administered and temperature is recorded. Anyone with high temperature is referred
to the nearest government facility. Before examination, the patient is asked to sign
a COVID-19 consent form.
Figure 2
Clinical workflow in a primary eye care clinic
Recording personal history and demographic information: The standard protocol with
social distancing is followed to obtain personal and demographic information. Aadhar
card (personal identification card issued by government) and mobile numbers (of patient
and next of kin) are mandatory as these details would be required at a later date,
if any positive cases are reported among the patients examined in the centre. Attendants
are discouraged unless the patient is a child or physically disabled.
Visual acuity assessment: Visual acuity for the distance is assessed using standard
illuminated Snellen's visual acuity chart. However L-Occluder is not used. Instead,
the patient is instructed to close the non-testing eye with his/her hand (not fingers).
The near vision chart is held by the examiner at a distance of 35-40 cm, and at least
one-meter distance from the patient is maintained while assessing visual acuity.
Objective and Subjective Refraction: Objective and subjective refraction is performed
on all patients. The trial frame is cleaned with an alcohol wipe before placing it
on the patient for refraction. Touching the forehead of the patient to measure working
distance is avoided. All the lenses used for neutralization are placed on the desk.
After completing a subjective examination, each lens and occluder is cleaned with
alcohol wipes before replacing in the trial box. The trial frame is also cleaned each
time. Retinoscopy barrier is used while doing retinoscopy, similar to the slit lamp
barrier as shown in Fig. 3. Wherever possible, spherical equivalent lenses are prescribed
and dispensed, so that movement of lenses and frames can be minimized.
Figure 3
A barrier for performing retinoscopy
Slit-lamp examination and applanation tonometry: Slit-lamp examination is performed
on all patients and the same protocols described in other guidelines are followed.[13
14
15
16] This includes avoiding all non-essential examination as well as 'no talking' policy
during the examination. Patients with conjunctivitis are not examined on slit-lamp,
and referred directly to higher centres. Aerosol generating procedures like non-contact
tonometry are avoided.[22] Wherever possible intraocular pressure (IOP) measurement
is avoided. This includes patients who are less than 30 years of age, those with redness
in the last 2 weeks, those likely to be referred to higher centres, and those with
Best Corrected Visual Acuity (BCVA) 6/6 and N6 for near. Procedures like direct ophthalmoscopy
is also avoided.
Lensometry: If the patient is using spectacles, preferably hand neutralization technique
is used to assess lens power and the spectacles are cleaned with hydrogen peroxide
before returning to the patient.
Fundus camera: A breath barrier is installed with the help of the manufacturer and
imaging is restricted to those who require the service. These include patients with
a history of diabetes; intraocular pressure more than 20 mm of mercury; and those
with shallow anterior chamber. It is also indicated if the vision is not improving
with refraction beyond 6/12; and if there is a relative afferent pupillary defect
(RAPD).
Spectacle dispensing: Patients are advised to clean hands with sterillium at the entrance
of the optical outlet. During frame selection, social distancing is maintained. All
frames tried by the patient is kept in a separate tray (Ex: Red colour tray). After
trial, the frames are cleaned using 0.5% hydrogen peroxide spray, especially the nose
pad and nose bridge before replacing them.
4. Administrative control and monitoring: The PEC centres are a part of a larger eye
care network, and are monitored by a higher level center through frequent phone calls
and physical checks where possible. A monitoring checklist is developed and implemented.
The checklist includes indicators to assess the adherence to protocols such as one
attendant policy, awareness of health messages, compliance with PPE and cleaning protocols.
One-to-one meetings are also held with the PEC personnel. The aim is to reduce anxieties,
obtain feedback, provide guidance for implementation, monitoring, and compliance.
The PEC personnel is also instructed to submit Incident Reports on any serious event.
To summarize, these guidelines are based on the best possible evidence and also align
with other recent guidelines in India.[14
15] While these guidelines are developed based on our experience at our higher centres,
these can be easily adopted by the PEC facilities in the developing countries of our
region. The guidelines are subject to change based on the generation of new evidence
as well as changes in national policies.
In conclusion, a good triaging system at multiple levels and following the best-preferred
practices would significantly mitigate the risk of COVID-19 at the PEC facility.
Disclaimer
The guidelines are based on the best available evidence as of today as well as experience
in our network of more than 100 centres. Despite adherence, they may not mitigate
the risk to 100%, however, they would aid in reducing the risk at multiple points.
These guidelines will be updated as and when new evidence is generated. Anyone interested
in following the updates and the protocols, we would recommend that they get in touch
with our Hospital Infection Control Committee.