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      Sustainability of Ophthalmology Practice and Training During and Post the Pandemic of Coronavirus (COVID-19): A Review

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          To review and analyse the globally established ophthalmic practice protocols during the coronavirus disease (COVID-19).


          A literature review using search strategy was conducted to identify appropriate publications relevant to COVID-19 and ophthalmology practice and training. The safety and feasibility of the protocols were illustrated and discussed.


          Challenges in different eye care settings at various international ophthalmology departments have identified and analysed to introduce solutions. Several clinical protocols were established and concerned for screening procedures, waiting area, clinical flow (ie, patients’ registration, personal (patients and healthcare workers) protection), and equipment safety in the clinics and operation rooms.


          In the review of this protocol, the strategic and operational missions of the Academic Medical Centers (AMCs) are demonstrated and discussed. This is in addition to the sustainability of the established protocols for cataract surgeries and glaucoma clinics and training during and after COVID-19.


          All the protocols have established for temporary circumstances, such as postponing elective appointments and surgeries as well as applying the technology for regular follow-ups (transmission of image, video, and face-to-face interactions via widely available applications). Only, one protocol was stronger for the sustainability. Accordingly, recommendations are suggested for clinical sustainability during and after COVID-19.

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          Most cited references 19

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          Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

          Summary Background Data for front-line health-care workers and risk of COVID-19 are limited. We sought to assess risk of COVID-19 among front-line health-care workers compared with the general community and the effect of personal protective equipment (PPE) on risk. Methods We did a prospective, observational cohort study in the UK and the USA of the general community, including front-line health-care workers, using self-reported data from the COVID Symptom Study smartphone application (app) from March 24 (UK) and March 29 (USA) to April 23, 2020. Participants were voluntary users of the app and at first use provided information on demographic factors (including age, sex, race or ethnic background, height and weight, and occupation) and medical history, and subsequently reported any COVID-19 symptoms. We used Cox proportional hazards modelling to estimate multivariate-adjusted hazard ratios (HRs) of our primary outcome, which was a positive COVID-19 test. The COVID Symptom Study app is registered with ClinicalTrials.gov, NCT04331509. Findings Among 2 035 395 community individuals and 99 795 front-line health-care workers, we recorded 5545 incident reports of a positive COVID-19 test over 34 435 272 person-days. Compared with the general community, front-line health-care workers were at increased risk for reporting a positive COVID-19 test (adjusted HR 11·61, 95% CI 10·93–12·33). To account for differences in testing frequency between front-line health-care workers and the general community and possible selection bias, an inverse probability-weighted model was used to adjust for the likelihood of receiving a COVID-19 test (adjusted HR 3·40, 95% CI 3·37–3·43). Secondary and post-hoc analyses suggested adequacy of PPE, clinical setting, and ethnic background were also important factors. Interpretation In the UK and the USA, risk of reporting a positive test for COVID-19 was increased among front-line health-care workers. Health-care systems should ensure adequate availability of PPE and develop additional strategies to protect health-care workers from COVID-19, particularly those from Black, Asian, and minority ethnic backgrounds. Additional follow-up of these observational findings is needed. Funding Zoe Global, Wellcome Trust, Engineering and Physical Sciences Research Council, National Institutes of Health Research, UK Research and Innovation, Alzheimer's Society, National Institutes of Health, National Institute for Occupational Safety and Health, and Massachusetts Consortium on Pathogen Readiness.
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            SARS-CoV-2 Isolation From Ocular Secretions of a Patient With COVID-19 in Italy With Prolonged Viral RNA Detection

            Background: Coronavirus disease 2019 (COVID-19), the disease caused by the novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) that originated in China in December 2019, was recently recognized as pandemic threat by the World Health Organization, with the potential of rapidly overloading health care systems and causing substantial mortality worldwide (www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020). Human-to-human transmission occurs mainly through respiratory droplets, but other routes are under investigation, because SARS-CoV-2 has been detected in several body fluids (1). So far, few data are available on ocular samples from patients with COVID-19, although conjunctivitis has been occasionally reported among COVID-19 symptoms, similar to infections caused by other human coronaviruses (2, 3). During the SARS epidemic, eye exposure to infectious fluids was associated with an increased risk for SARS-CoV transmission to health care workers (3, 4). Although SARS-CoV RNA was occasionally found in ocular specimens during the early phase of illness, its infectivity is unknown (2, 3). With regard to COVID-19, unprotected ocular exposure was thought to be responsible for infections that occurred in the Wuhan Fever Clinic in January 2020 (3, 4); in addition, SARS-CoV-2 RNA was detected in conjunctival secretions collected from the only patient with conjunctivitis out of 30 patients with COVID-19 from a hospital in China (5). However, further studies are needed to evaluate the infectious potential of the SARS-CoV-2 RNA detected in the ocular specimens and to determine whether transmission may occur through ocular secretions (3, 4). Objective: To present the early detection of infectious SARS-CoV-2 in ocular fluids from a patient with the first confirmed case of COVID-19 in Italy, who had been hospitalized at the National Institute for Infectious Diseases “L. Spallanzani” (INMI) in Rome. Methods and Findings: The patient, a 65-year-old woman, travelled from Wuhan, China, to Italy on 23 January 2020 and was admitted on 29 January 2020, 1 day after symptom onset. At admission to the high isolation unit at INMI, she presented with nonproductive cough, sore throat, coryza, and bilateral conjunctivitis. She had no fever until day 4, when fever (38 °C), nausea, and vomiting began. Infection with SARS-CoV-2 was confirmed by performing real-time reverse transcription polymerase chain reaction (RT-PCR) assay on sputum samples (cycle threshold value [Ct], 16.1) on the admission day, followed by viral M gene sequencing (GenBank accession number MT008022), and virus isolation on Vero E6 cell line (2019-nCoV/Italy-INMI1). The full genome sequence was obtained from either clinical sample and or culture isolate (GISAID accession numbers EPI_ISL_410545 and EPI_ISL_410546). At admission, no other respiratory infections were detected (QIAstat-Dx® Respiratory Panel; Qiagen). On day 3 after hospital admission, owing to the persistence of conjunctivitis, an ocular swab was collected and viral RNA was detected (Ct, 21.6). Subsequent ocular samples collected with almost daily frequency resulted positive up to day 21, with declining virus concentration (increased Ct values). Conjunctivitis greatly improved at day 15 and apparently resolved at day 20. Five days after it became undetectable, SARS-CoV-2 RNA was detected again (Ct, 36.25) in the ocular swab sample collected at day 27 (Table). SARS-CoV-2 RNA was detected in ocular swabs days after it was undetectable in nasal swabs (Table). In addition, the Ct values detected in the late ocular samples were lower than those observed in the nasal swabs (Table 1), suggesting sustained replication in conjunctiva. With the aim of demonstrating that viral genomes detected in ocular swabs represented infectious virus, the first RNA-positive ocular sample was inoculated in Vero E6 cells, and cytopathic effect was observed 5 days postinoculum. Viral replication was confirmed by real-time RT-PCR on RNA purified from spent cell growth medium. Table. Viral Load in Ocular and Nasal Swabs From the First SARS-CoV-2 Infection Detected in Italy* Discussion: We found that ocular fluids from SARS-CoV-2-infected patients may contain infectious virus, and hence may be a potential source of infection. These findings highlight the importance of control measures, such as avoiding touching the nose, mouth, and eyes and frequent hand washing. A related implication is the importance of appropriate use of personal protective equipment for ophthalmologists during clinical examination, because ocular mucosa may be not only a site of virus entry but also a source of contagion. Furthermore, we observed that ocular involvement of SARS-CoV-2 may occur early in the COVID-19 course, suggesting that measures to prevent transmission via this route must be implemented as early as possible. Future studies are needed to define the human ocular cell types capable of supporting viral replication and the mechanisms underlying ocular tropism of SARS-CoV-2.
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              Facing COVID-19 in Ophthalmology Department


                Author and article information

                Clin Ophthalmol
                Clin Ophthalmol
                Clinical Ophthalmology (Auckland, N.Z.)
                04 June 2021
                : 15
                : 2355-2365
                [1 ]Imaging Research Department, King Abdullah International Medical Research Center , Riyadh, Saudi Arabia
                [2 ]King Saud Bin Abdulaziz University for Health Sciences , Riyadh, Saudi Arabia
                Author notes
                Correspondence: Ahmed Almazroa King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard , P.O. Box 3660, Riyadh, 11481, Saudi ArabiaTel +966114294324 Email almazroaah@ngha.med.sa
                © 2021 Almazroa.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

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