Precautions in ophthalmic practice in a hospital with a major acute SARS outbreak: an experience from Hong Kong.

Sir,

Chan et al[1] report their experience in ophthalmic practice during an outbreak of SARS. First of all I would like to point out the authors’ wrong affirmation on two issues. Firstly, their hospital was not the only one in Hong Kong, not to say in the world, that had gone through the largest outbreak of SARS. Our hospital, which has an Ophthalmology Department, admitted more than 100 suspect and probable SARS cases during the outbreak in 2003. Secondly, they claimed that ophthalmologists in Hong Kong had abandoned direct ophthalmoscopy. I wonder if they have ever taken a survey to make such a comment. Many ophthalmologists in Hong Kong have been and are still using direct ophthalmoscope.

The authors seem to share their experience in ophthalmic patients’ management during the outbreak of SARS in Hong Kong. However, their suggestion on the management of clinical admission was in contrary to the public hospital management policy at the time of SARS outbreak. All clinical admissions were cancelled in the midst of SARS as part of the infection control measures and for the purpose of saving beds for the SARS cases. In their flow chart (Figure 1),[1] they admit emergency eye patients to an infection triage ward for physicians’ assessment but for clinical admission, patients are only screened by a resident with clinical history taking only. I do not see why there should be a difference and why emergency cases cannot be screened by residents before admission to the appropriate ward. For a suspected case in the out-patient clinic, the authors advocated attending the patient in the last time slot. It is very unusual to leave the suspected case in the crowded clinic for an unnecessary long period of time to increase the risk of cross-infection. The usual practice is to see the patient in a special room as early as possible and to discharge the patient to the appropriate destination.

The authors placed too much emphasis on the personal protective equipment (PPE). Although PPE plays an important role in the prevention of infection, the authors only mentioned lightly and failed to highlight the importance of the proper technique in donning and sequential removal of the PPE in areas designed for such purposes. There is a high risk of being infected during removal of the PPE especially when they have been contaminated with the SARS coronavirus. It is therefore extremely important for the hospital to provide, besides adequate stock of PPE, proper and adequate areas for putting on and removal of PPE, training courses and regular refresher courses for the technique, as well as audit on the practice of the proper technique.

It is interesting to know what PPE was used by the authors in their wound revision operation on the suspected SARS case. The use of enhanced PPE including positive air-powered respirator is advised when operating on a suspected SARS case.[2] Although not impossible, it is certainly painstaking to use the operating microscope and the indirect ophthalmoscope after wearing the respirator and its helmet.