In February 2020, the death of ophthalmologist Dr Wenliang Li from COVID-19 in Wuhan, China, gained worldwide publicity as he was among the first whistleblowers to notify Chinese authorities of the virus. Dr Li probably contracted SARS-CoV-2 from an asymptomatic glaucoma patient, highlighting the risk of COVID-19 infection during eye examinations.1 General practitioners (GPs) frequently see patients with eye and vision complaints. Therefore, they need to be aware of how to mitigate risk during examination and triage patients to receive eye care during the current COVID-19 pandemic.
The reasons for increased risk during eye examination remain uncertain but may relate to the close face-to-face proximity of slit-lamp biomicroscopic examination and presence of SARS-CoV-2 viral RNA in tears of patients with COVID-19 conjunctivitis.2 GPs can take several practical steps to mitigate the risk of infection. The Australian Government Department of Health recommends personal protective equipment (PPE) including gown, gloves, eye protection (goggles or face shield) and mask (surgical or N95 if the patient has severe symptoms suggestive of pneumonia) when caring for patients with suspected or confirmed COVID-19.3 The role of PPE in asymptomatic routine patients is more contentious, as there is insufficient evidence to recommend its use despite the theoretical risk of infection. The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) position statement ‘COVID-19: Practical guidance for general practitioners performing eye examinations’ suggests taking histories and performing examinations as much as possible at a distance of at least 1.5 m.4 Many ophthalmic examinations (eg gross inspection, visual acuity, confrontation visual fields, pupillary light reaction, red reflex, extraocular movements) can be performed at this distance. Direct contact with conjunctival mucosa or tears can be avoided by wearing gloves and lifting the eyelid with a disposable cotton tip/bud. It would be beneficial to minimise direct ophthalmoscopy unless it changes management, such as in diagnosing papilloedema. Slit lamp biomicroscopes should have a large breath shield.
Recently, RANZCO published COVID-19 Triage Guidelines regarding the urgency of ophthalmic care in Australia.5 The aims are to minimise face-to-face consultations (with their associated risk of COVID-19 infection for both doctors and patients) and preserve healthcare resources including PPE. Timely provision of eye care for those requiring it is still critical and must not be neglected despite the current COVID-19 crisis. Three triage categories have been delineated: ‘High Urgency’ ophthalmic emergencies and conditions requiring review within one month, ‘Medium Urgency’ conditions requiring review within three months, and ‘Low Urgency’ conditions that are not normally time-sensitive and can usually safely be delayed by 4–12 months.
Highlights of the RANZCO COVID-19 Triage Guidelines include the following:
- Elective cataract surgery has been categorised as ‘Low Urgency’ and will cease, consistent with the Australian Federal Government directive to only perform Category 1 and ‘urgent’ Category 2 operations from 2 April 2020. Exemptions include cataract surgery performed for intractable high intra-ocular pressure and patients who are legally blind.
- Most conjunctivitis is ‘Low Urgency’ and, in many cases, can be managed via telehealth between the patient and healthcare provider using digital photographs. This is important, as approximately 0.8% of patients with COVID-19 present with conjunctival congestion.6
- Intravitreal injections, which are often performed for retinal conditions such as neovascular age-related macular degeneration, have been categorised as ‘High Urgency’ and should continue to be performed as they are exquisitely time-sensitive and cannot be delayed without associated irreversible vision loss.
GPs are encouraged to communicate directly with their ophthalmologists (ie registrars at public hospitals, private consultants). Telehealth and sharing of eye photos and videos can minimise delay and unnecessary presentations. The ability of GPs to triage ophthalmic conditions appropriately is critical in our fight against COVID-19 to ensure that only patients with time-sensitive conditions are referred until the current situation has improved.
First published online 17 April 2020.