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      Precautionary measures needed for ophthalmologists during pandemic of the coronavirus disease 2019 (COVID‐19)

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          Abstract

          The novel coronavirus disease 2019 (COVID‐19) caused by severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) emerged in December 2019 in Wuhan, China, has spread to over 113 countries with 118 326 infected and 4292 died as of 11 March 2020 and the World Health Organization (WHO) has just announced COVID‐19 a global pandemic. A person under investigation (PUI) for COVID‐19 is less likely to present initially to the ophthalmologists compared to emergency care or internal medicine physicians. However, in late February 2020, 2 patients presented simultaneously to our eye casualty with sudden onset of unilateral painful red eye associated with a decline in visual acuity; their intraocular pressure was over 40 mmHg, and slit‐lamp examination findings were suggestive of acute primary angle closure (APAC). The episodes aborted with topical treatment and laser iridotomy. A more elaborate history taking revealed they have been taking over‐the‐counter (OTC) cold/flu medication for respiratory symptoms and fever. Further enquiry about their history of travel identified a recent return from Mainland China. Given these patients fulfilling both the clinical feature and the epidemiological criteria for PUI proposed by the Centers for Disease Control and Prevention (CDC), they were admitted to the isolation ward and had nasopharyngeal aspirate and throat swab samples tested for SARS‐CoV‐2 and respiratory viruses. Both patients were negative for SARS‐CoV‐2 but were positive for respiratory syncytial virus and para‐influenza type 2 virus, respectively; they were discharged to the general medical ward subsequently. Over‐the‐counter (OTC) cold/flu medication can precipitate APAC in predisposed eyes such as those with an anatomically narrow angle. Although COVID‐19 and APAC are apparently unrelated, these two cases illustrate that ophthalmologists could be the first healthcare provider to evaluate suspected cases that present to us in inconspicuous ways. Our specialty strongly relies on physical examination to make the diagnosis, which is performed at a short distance from the patient. The CDC defined close contact of being approximately 2 m from a patient for a prolonged duration, where any contact longer than 1–2 min of exposure is considered prolonged until more is known about transmission risks. The time it takes an ophthalmologist to complete a comprehensive ophthalmic examination is well beyond this duration. Despite we do not perform any aerosol‐generating procedures, the close proximity and prolonged duration of patient contact could increase our risk of exposure. A self‐made transparent polycarbonate protector mounted to the slit‐lamp offers a physical barrier between the patient and ophthalmologist while not interfering with its normal usage and patient interaction. Alternatives to direct ophthalmoscopy such as binocular indirect ophthalmoscope should be performed in view of the shorter working distance in the former. The presence of SARS‐CoV‐2 in the tear film has been detected using real‐time reverse‐transcription–polymerase‐chain‐reaction (RT‐PCR) assays in the infected individuals (Xia et al. 2020). A medical expert who visited Wuhan developed conjunctivitis prior to the onset of respiratory symptoms; he was later tested positive to SARS‐CoV‐2, suggesting conjunctivitis could be one of the signs of COVID‐19 (Lu et al. 2020). We should, therefore, remain vigilant in attending a patient with conjunctivitis. In patients presenting with acute conjunctivitis but without any catarrhal symptoms or recent travel to affected geographic areas, conjunctival swab for RT‐PCR could be considered to address whether SARS‐CoV‐2 is found on the ocular surface and could also possibly aid in the earlier diagnosis in these subclinical cases if the facility is available and not too costly. Tear film disturbances have also been associated with non‐contact air‐puff tonometry, suggesting that this could be a micro‐aerosol formation procedure (Li et al. 2020). The intraocular pressure should be measured using alternative instruments as far as possible. Substantial involvement of nosocomial transmission in both the SARS‐CoV outbreak in 2003 and the Middle East respiratory syndrome CoV outbreak in 2012 was evident. Given the similarity in genomic sequence between SAR‐CoV‐2 and these coronaviruses, the propensity for nosocomial spread for the current COVID‐19 should not be taken lightly, and measures should be taken to limit such transmission. Urgent consultations (penetrating ocular injury, acute glaucoma and alkali chemical injury, etc.) should be attended with adequate appropriate personal protection equipment (PPE), whereas non‐urgent cross‐specialty consultations for in‐patients should be referred to outpatient setting after discharge. For stable patients without changes in medications or drug‐related issues, prescription refill could reduce their trip to the clinic. Patients scheduled for elective surgery and laser treatment should be deferred in the midst of an outbreak. We should also ensure rapid triage and isolate suspected patients upon their arrival to the healthcare facility. As much is still to be learned about COVID‐19, comparison with SARS‐CoV is often made and strategies adopted during the previous coronavirus pandemic could also be applied during the current outbreak (Chan et al. 2006). During the SARS‐CoV outbreaks, we carried out studies in Hong Kong to evaluate ophthalmic manifestation of SARS‐CoV by performing ocular screening, tear swabs and conjunctival scrapping in confirmed cases (Chan et al. 2006). No ophthalmologist involved in the care of these patients was infected; therefore, our standard of PPE used by the ophthalmologist during the SARS‐CoV pandemic could serve as a reference for PPE in the current coronavirus pandemic. Basically, the three‐pronged strategies are (1) protecting staff with appropriate PPE; (2) preventing spread of the virus from our patients; and (3) reengineering of workflow to minimize exposure time and/or risk of cross infections. We recommend following standard precaution and masks/respirators should be worn by everybody inside the ophthalmic practice. N95 respirators provide more protection but in case of shortage, surgical masks are good alternative for our day‐to‐day practice. However, full PPE including caps, gowns, N95 respirators and eye goggles for the protection of mouth, nose and eye should be worn in handling cases confirmed or PUI cases. Ensuring the safety of medical personnel is imperative to avoid spread of the virus but safeguard continuous patient care. Recent evidence suggests that the SARS‐CoV‐2 could be transmitted via asymptomatic infected individuals. An asymptomatic index patient from Shanghai attended a meeting in Germany had no symptoms until her flight back to China. Two of this index patient's colleague who had close contact with her and another two colleagues who attended the meeting without close contact were later found to be infected with COVID‐19 (Rothe et al. 2020). Of the 114 asymptomatic predominantly German evacuated from Wuhan, who were labelled negative in a multistep process of signs and symptoms screening of infection, two were later tested positive for SARS‐CoV‐2 by RT‐PCR (Hoehl et al. 2020). Given the suboptimal effectiveness of symptom‐based screening process in detecting COVID‐19 in serologically positive cases and that transmission can occur during the incubation period in asymptomatic individuals, this highlight the importance of our proposed precautionary measures as the transmission dynamics, infective potency and epidemiology are changing on a daily basis during the ongoing COVID‐19 pandemic. Clinics and hospitals are places that people do not want to go during a pandemic. It can be envisaged that interaction between doctors and patients through the Internet with the aid of artificial intelligence will become more and more important (Balyen & Peto 2019; Tan et al. 2019).

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          Most cited references 4

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          2019-nCoV transmission through the ocular surface must not be ignored

          Chaolin Huang and colleagues 1 reported the epidemiology, symptoms, and treatment of patients infected by the 2019 novel coronavirus (2019-nCoV) in Wuhan, China. As ophthalmologists, we believe that transmission of 2019-nCoV through the eyes was ignored. On Jan 22, Guangfa Wang, a member of the national expert panel on pneumonia, reported that he was infected by 2019-nCoV during the inspection in Wuhan. 2 He wore an N95 mask but did not wear anything to protect his eyes. Several days before the onset of pneumonia, Wang complained of redness of the eyes. Unprotected exposure of the eyes to 2019-nCoV in the Wuhan Fever Clinic might have allowed the virus to infect the body. 2 Infectious droplets and body fluids can easily contaminate the human conjunctival epithelium. 3 Respiratory viruses are capable of inducing ocular complications in infected patients, which then leads to respiratory infection. 4 Severe acute respiratory syndrome coronavirus (SARS-CoV) is predominantly transmitted through direct or indirect contact with mucous membranes in the eyes, mouth, or nose. 5 The fact that exposed mucous membranes and unprotected eyes increased the risk of SARS-CoV transmission 4 suggests that exposure of unprotected eyes to 2019-nCoV could cause acute respiratory infection. Thus, Huang and colleagues 1 should have analysed conjunctival scrapings from both confirmed and suspected 2019-nCoV cases during the onset of symptoms. The respiratory tract is probably not the only transmission route for 2019-nCoV, and all ophthalmologists examining suspected cases should wear protective eyewear.
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            Promising Artificial Intelligence-Machine Learning-Deep Learning Algorithms in Ophthalmology.

            The lifestyle of modern society has changed significantly with the emergence of artificial intelligence (AI), machine learning (ML), and deep learning (DL) technologies in recent years. Artificial intelligence is a multidimensional technology with various components such as advanced algorithms, ML and DL. Together, AI, ML, and DL are expected to provide automated devices to ophthalmologists for early diagnosis and timely treatment of ocular disorders in the near future. In fact, AI, ML, and DL have been used in ophthalmic setting to validate the diagnosis of diseases, read images, perform corneal topographic mapping and intraocular lens calculations. Diabetic retinopathy (DR), age-related macular degeneration (AMD), and glaucoma are the 3 most common causes of irreversible blindness on a global scale. Ophthalmic imaging provides a way to diagnose and objectively detect the progression of a number of pathologies including DR, AMD, glaucoma, and other ophthalmic disorders. There are 2 methods of imaging used as diagnostic methods in ophthalmic practice: fundus digital photography and optical coherence tomography (OCT). Of note, OCT has become the most widely used imaging modality in ophthalmology settings in the developed world. Changes in population demographics and lifestyle, extension of average lifespan, and the changing pattern of chronic diseases such as obesity, diabetes, DR, AMD, and glaucoma create a rising demand for such images. Furthermore, the limitation of availability of retina specialists and trained human graders is a major problem in many countries. Consequently, given the current population growth trends, it is inevitable that analyzing such images is time-consuming, costly, and prone to human error. Therefore, the detection and treatment of DR, AMD, glaucoma, and other ophthalmic disorders through unmanned automated applications system in the near future will be inevitable. We provide an overview of the potential impact of the current AI, ML, and DL methods and their applications on the early detection and treatment of DR, AMD, glaucoma, and other ophthalmic diseases.
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              Precautions in ophthalmic practice in a hospital with a major acute SARS outbreak: an experience from Hong Kong

              Many new infectious diseases in humans have been derived from animal sources in the past 20 years. Some are highly contagious and fatal. Vaccination may not be available and antiviral drugs are not effective enough. Infectious control is important in clinical medicine and in Ophthalmology. Severe acute respiratory syndrome (SARS), as an example, is a highly contagious respiratory disease that has recently been reported in Asia, North America, and Europe. Within a matter of weeks, the outbreak has evolved to become a global health threat and more than 30 countries have been afflicted with a novel Coronavirus strain (SARS-CoV) that is the aetiologic agent of SARS. The primary route of transmission of SARS appears involving close person-to-person contact through droplets. Ophthalmologists may be particularly susceptible to the infection as routine ophthalmic examinations like direct ophthalmoscopy and slit-lamp examination are usually performed in a setting that has close doctor–patient contact. Being the Ophthalmology Department of the only hospital in the world that has just gone through the largest outbreak of SARS, we would like to share our strategy, measures, and experiences of preventing contracting or spreading of SARS infection as an infection control model. SARS is one of the many viruses against which personnel will need protecting in an ophthalmic setting. The experiences attained and the measures established might also apply to other infectious conditions spreading by droplets such as the avian influenza with H5N1.
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                Author and article information

                Contributors
                dennislam@hkcmer.com
                Journal
                Acta Ophthalmol
                Acta Ophthalmol
                10.1111/(ISSN)1755-3768
                AOS
                Acta Ophthalmologica
                John Wiley and Sons Inc. (Hoboken )
                1755-375X
                1755-3768
                27 April 2020
                May 2020
                : 98
                : 3 ( doiID: 10.1111/aos.v98.3 )
                : 221-222
                Affiliations
                [ 1 ] Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong Hong Kong
                [ 2 ] Department of Ophthalmology Tuen Mun Hospital Hong Kong
                [ 3 ] Retina Center of Ohio Cleveland Ohio USA
                [ 4 ] Bascom Palmer Eye Institute University of Miami Miami Florida USA
                [ 5 ] Department of Ophthalmology and Visual Sciences Prince of Wales Hospital Hong Kong
                [ 6 ] C‐MER Dennis Lam & Partners Eye Center C‐MER International Eye Care Group Hong Kong
                [ 7 ] Hong Kong International Eye Research Institute of the Chinese University of Hong Kong (Shenzhen) Shenzhen China
                Article
                AOS14438
                10.1111/aos.14438
                7540674
                32223068
                © 2020 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 0, Tables: 0, Pages: 2, Words: 2674
                Product
                Categories
                Editorial
                Editorial
                Custom metadata
                2.0
                May 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.9.2 mode:remove_FC converted:07.10.2020

                Ophthalmology & Optometry

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