Coronavirus (COVID-19): How It Relates to Eye Care

[How we handle viral conjunctivitis in daily practice]

In ophthalmology, we have always feared outbreaks of epidemic keratoconjunctivitis (EKC) (if EKC develops, staff must stay off work for 2 weeks), so ophthalmologists and clinical staff disinfect thoroughly (alcohol disinfection of test instruments and chin rests, hand washing by medical staff, and alcohol hand disinfection).
The doctor touches an alcohol swab between every patient’s exam to guard against infection.

Epidemic keratoconjunctivitis (EKC): conjunctivitis caused by adenovirus. It is extremely contagious, and infection of others can occur even from tables, chairs, handrails, and so on that have virus on them.

Epidemic keratoconjunctivitis (pink eye) / what to keep in mind after it clears　

Since the day we opened, we have had a system in which patients with marked redness are guided at reception straight to a separate room, where the exam and payment are completed.

After the exam, medical staff wash their hands thoroughly and disinfect them with alcohol, and disinfect with alcohol everything the patient touched.

With this system, people suspected of infection never use the waiting room.

Banknotes and coins used for payment are also disinfected with alcohol, dried, and exchanged for new ones.

For these reasons, I think it is fair to say that eye clinics are used to dealing with viral conjunctivitis.

In response to the novel coronavirus,

in addition to continuing to follow the “same procedures as for epidemic keratoconjunctivitis (EKC),”

we are strictly applying “standard precautions” and “using personal protective equipment.”

Since we opened, we have also combined time-slot appointments for both first and follow-up visits so that the waiting room does not get crowded (spreading out arrival times).

About waiting times / the clinic’s IT system configuration

I believe the high ceilings (3.65 m in the waiting room, 3 m in the exam and test rooms) help with ventilation.

When there is a long wait, such as during pupil dilation tests, you can also wait in the parking lot or the shopping street until your exam time.

While taking appropriate measures to prevent viral infection, I believe an ophthalmologist’s mission is to make sure patients do not suffer permanent loss of vision or visual field.

Coronavirus (COVID-19): how it relates to eye care

Policy of the American Academy of Ophthalmology (AAO)I had been watching this closely while thinking about how to describe our clinic’s stance, but

the other day, theJapanese Ophthalmological Society,Japan Ophthalmologists Association,and Japanese Society for Ocular Infectionspublished their views.

We are now responding based on these views.

Below I write this out, including quotations.

If anything is unclear, please contact us at any time.

Thank you.

For patients and everyone:

To the public (Japanese Ophthalmological Society)
http://www.nichigan.or.jp/news/068.pdf

The novel coronavirus infects through the mucous membranes of the upper airway, such as the mouth and nose, but it may also infect through the “conjunctiva,” the mucous tissue of the eye.

Eye clinics across Japan have always taken great care against viral conjunctivitis. For that reason, for the novel coronavirus as well, doctors and staff are fully carrying out safety measures such as wearing masks, thorough hand disinfection, and ventilating exam rooms.

Rather, let us not become so afraid that we avoid seeing a doctor too much, delay getting examined, or run out of our usual eye drops and make a disease worse.

• Please do not touch or rub your eyes, and please wash your hands.

• We recommend refraining from wearing contact lenses.

　Or wash your hands well with soap for 20 seconds before and after using them.

• Please wash your hands thoroughly before and after putting in eye drops.

• When going out for a clinic visit, please follow basic precautions such as taking your temperature beforehand, wearing a mask, and washing your hands.

• If you have a sore throat or cold symptoms, be sure to tell the clinic’s reception.

For ophthalmic medical personnel (Japanese Society for Ocular Infections)

https://www.jaoi.jp/coronavirus2/

The key questions are probably the following.

Through eye care:
① Can the novel coronavirus be passed from patient to healthcare worker?
② Can the novel coronavirus be passed from patient to patient?
First,
to summarize the information available so far:
① The conjunctiva may be an entry site for the novel coronavirus.
② The novel coronavirus may be present in the conjunctiva.
③ The novel coronavirus may cause conjunctivitis.
④ It is unknown whether the novel coronavirus is present in the conjunctiva of latent (asymptomatic) carriers.
⑤ It is unknown whether the novel coronavirus can be transmitted from conjunctiva to conjunctiva.
At present, setting frequency aside, the answer is that “infection through the conjunctiva is considered possible.”

However, it is also very important to take care that excessive caution about the novel coronavirus does not greatly affect ordinary eye care.

Q1. What is the rate of conjunctivitis in novel coronavirus infection?

A1. A paper reported a conjunctivitis rate of 0.8% in Wuhan, but not all infected people had eye examinations, so the data are not sufficient. Even so, it is certain that, although uncommon, conjunctivitis can accompany novel coronavirus infection.

Q2. How does the novel coronavirus usually spread? Can it also spread through the conjunctiva?

A2.
a. Droplet transmission (infection by droplets of 5 μm or more that fall to the floor within about 1 m, from coughs, sneezes, saliva during conversation, and so on: influenza, rubella, and so on)
b. Contact transmission (infection through contact with hands or skin or through contaminated objects: adenoviral conjunctivitis, MRSA, and so on)
In addition to these two routes,
c. Infection via aerosols（(minute liquid or solid particles floating in the air; in clinical settings this includes water vapor in exhaled breath, and viruses remain in the air for a long time)
has also been pointed out.

Infection of the novel coronavirus through the conjunctiva (from patient to doctor, or between patients through clinical care) is thought to be less likely than droplet transmission by coughs and sneezes.

However,when examining patients who may havedevelopednovel coronavirus infection, we recommend protecting the eyes in addition to the mouth and nose.

Q3 What should we do in ordinary eye care?

A3. The risk of infection with the novel coronavirus through the conjunctiva is thought to be low. However, with the rise in the number of infected people, it is quite possible that infected people are visiting hospitals and clinics. Therefore, for all visitors, in addition to thoroughly applying standard precautions (hand hygiene, disinfection of contact instruments, and so on), for the time being please take a careful history andask people with strong symptoms such as fever, cough, shortness of breath, or fatigue (malaise)to tell reception. For patients who need an eye visit but have only slight fever, cough, or cold-like symptoms, apply the same thorough infection-spread prevention measures as for patients with adenoviral conjunctivitis.

Q4 So what exactly are infection-spread prevention measures?

A4.
a. Thorough standard precautions
b. Use of personal protective equipment (PPE) is important.
Specifically, wear a mask and wash hands (thoroughly with soap, or use alcohol disinfection), and also take care to disinfect ophthalmic equipment and the environment with alcohol or sodium hypochlorite. In particular, when using gloves to examine patients with conjunctivitis, change them after each exam and be careful about infection through the glove surface.

Standard precautions:
Treat the moist biological materials of all patients (blood, saliva, nasal discharge, sputum, urine, stool, tears, body fluids, mucus, secretions from damaged skin, and so on) as potentially infectious. Hand hygiene is the foundation. Use gloves when handling moist biological materials, and use masks, goggles, and plastic aprons when secretions may splash, applying precautions suited to each procedure. Cough etiquette is also part of standard precautions. It includes covering the nose and mouth with a mask or similar when coughing or sneezing, and performing hand hygiene if contaminated by secretions.

Personal protective equipment (PPE):
This includes gowns, gloves, masks, caps, aprons, shoe covers, face shields, and goggles. They are worn according to the situation. Care is also taken with changing them for each patient and with how they are put on and taken off.