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Recommendations for oculoplastic surgeons during the COVID-19 pandemic

Updated: 5th April 2020

Dear ESOPRS Members,

The current COVID-19 pandemic – caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) – has caused an unprecedented international public health challenge.

Having first spread in parts of China, it has subsequently spread to more than 100 other countries, with Italy, Spain, and Germany currently bearing the brunt of the disease and its complications in Europe.

Although the great majority of individuals affected by COVID-19 will have mild to moderate symptoms, the virus is highly contagious – and more so than SARS – and elderly patients and those with underlying medical conditions are particularly at risk.

Ophthalmologists, ENT surgeons, and anaesthetists are known to be at increased risk of exposure to higher (and more frequent) viral loads, due to the frequency and proximity in their interactions with patients. Although viral transmission occurs chiefly via respiratory droplets within a range of about 2 metres, indirect contact from contaminated surfaces can also occur. Viral particles can remain viable on plastic and steel for several days (but are less viable on cardboard), and, importantly, are inactivated by soap. Relevant to us as ophthalmologists is that viral transmission can also occur to and from the conjunctiva and tears.

It therefore follows that all practicing Oculoplastic Surgeons should adopt all necessary procedures and policies to limit the transmission of COVID-19 within our respective communities, whilst continuing to provide urgent patient care.

* added 5/4/2020  start *

Oculoplastic Surgery Priorities

Urgent procedures – not to be delayed

  • Eyelid
    • Upper lid entropion or retraction in the presence of progressive sight-threatening corneal exposure/disease
  • Orbit
    • Canthotomy and cantholysis for sight-threatening orbital haemorrhage
    • Drainage of an orbital or periorbital abscess
    • Exenteration in life-threatening infection or tumour
    • Orbital incisional or excisional biopsy for life or sight-threatening condition
    • Repair of orbital fracture in presence of oculocardiac reflex

 Urgent procedures, according to surgeon’s judgement

  • Eyelid
    • Excision of rapidly progressive adnexal malignancy
    • Repair of eyelid lacerations
    • Repair of severe amblyogenic ptosis with uni or bilateral brow suspension
    • Botulinum toxin injections in case of severe blepharospasm
  • Ocular/socket
    • Enucleation for intraocular neoplasia
    • Evisceration for severe, untreatable infection
    • Optic nerve sheath fenestration for progressive visual loss
  • Lacrimal
    • Decompression of dacryocoele in a neonate
    • Drainage of an infected mucopyocoele
    • Suspected lacrimal outflow malignancies
  • Orbit
    • Orbital decompression in case of optic neuropathy or corneal perforation if other treatments have failed or are contraindicated
    • Temporal artery biopsy in suspected giant cell arteritis
    • Orbital exploration in case of no sight-threatening conditions
    • Repair of upper or lower lid entropion determining severe corneal compromise, unresponsive to non-surgical measures

* added 5/4/2020 – end *

ESOPRS supports the following recommendations:

  1. All elective clinical services should be suspended. Oculoplastic surgeons should remain available to treat urgent cases, such as severe infections, trauma, tumours, acute optic neuropathy, etc.
  2. A triage system should be set up to identify patients with fever, respiratory symptoms, acute conjunctivitis or recent travel to outbreak areas (FTOCC, Fever – Travel – Occupation – Cluster –  Contact). These individuals should be encouraged to postpone their appointments for at least 14 days and should not be seen unless the unit is equipped with extra protective measures
  3. A plastic breath shield should be added on the slit lamp, protective masks should be worn constantly and changed every four hours. Personal protective equipment, such as gloves, protective glasses and gowns are highly recommended – note, the ‘N99’ (filtering 99% of particles) or ‘PPF3’facial masks are advocated, as is protective eye-wear (particularly for operating). Full disinfection is needed in between consultations. Decontamination of surfaces, protection of the mucous membranes and good hygiene are vital to reduce the transmission risk.
  4. Micro-aerosol generating procedures, such as operations under general anaesthesia should be avoided unless considered urgent by the surgeon. Surgical patients requiring GA and high-speed procedures (bone drilling/sawing) should be tested for SARS-CoV-2 wherever possible. Rapid flow oxygen delivery (‘Optiflow’, also known as ‘THRIVE’ – Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) is also not to be used for the foreseeable future.
  5. Finally, wherever possible, all nasal procedures such as nasopharyngeal swabbing and endoscopy should be avoided or undertaking with heightened protection.

Our knowledge grows with the epidemic, and we shall provide episodic updates which we hope will be helpful to us all in ESOPRS and beyond. Please be advised by your own recognised health authorities and the WHO, and not by social media, which can contain misleading and poorly informed information.

The European Centre for Disease Prevention and Control (ECDC) has issued guidance documents on infection control and personal protective equipment (PPE) needs in healthcare settings where patients suspected/confirmed of COVID-19 infection are being treated, as well as regular updates on the spread of the disease (www.ecdc.eu).

For more information:

  • Lai THT, Tang EWH, Chau SKY, Fung KSC, Li KKW. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. Graefes Arch Clin Exp Ophthalmol. 2020 Mar 3. doi: 10.1007/s00417-020-04641-8. [Epub ahead of print]
  • Li JO, Lam DSC, Chen Y, Ting DSW. Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear. Br J Ophthalmol. 2020 Mar;104(3):297-298. doi: 10.1136/bjophthalmol-2020-315994
  • https://www.who.int/emergencies/diseases/novel-coronavirus-2019
  • Johns Hopkins Coronavirus Resource Center –  https://coronavirus.jhu.edu/
  • Accreditation Council for Continuing Medical Education – COVID-19 Clinician Resources

Please be safe, look after your own health, and that of your families and your patients. Please remember that soap inactivates the virus, and that social distancing reduces transmission. We must all remain in good physical, mental and spiritual health if we are to play our role in supporting our families and communities in this unfolding emergency.

With our very best wishes to you All.

Francesco Quaranta Leoni, President
Dion Paridaens, Secretary
David Verity, Treasurer

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