Oculoplastic, Orbital, and Lacrimal Care in the Coronavirus Disease 2019 Pandemic: A Shared Experience From Melbourne.

To the Editor:

The Orbital, Plastic, and Lacrimal clinic at the Royal Victorian Eye and Ear Hospital, Melbourne, consists of 12 subspeciality ophthalmologic consultants, a clinical fellow, and a trainee registrar. We provide elective and emergency care for a population of 7 million people, spread over a large geographical area. We discuss our basis for delivery of care in the coronavirus disease 2019 (COVID-19) era to offer some guidance and reassurance to others in this time of uncertainty.

AN UNIMAGINABLE CRISIS

The World Health Organization officially declared COVID-19 (caused by severe acute respiratory syndrome coronavirus 2) a pandemic on March 11, 2020. Severity of symptoms is highly variable with asymptomatic carriage also reported.[1] This novel virus is highly infectious being transmitted primarily through respiratory droplets and contact with infected persons, in the presymptomatic and early symptomatic phase. Detection of the virus in tears and conjunctival secretions has been speculated, and conjunctivitis may be the presenting symptom.[2,3] As clinicians, we rely on experience and the published literature to guide us. We acknowledge the published consensus from international ophthalmologists discussing the preparedness of general ophthalmologists in the COVID-19 era.[4] An oculoplastic perspective from Hong Kong shows some similarities to our approaches taken.[5] Our adaptation to deliver care for our patients while minimizing risk to them, ourselves, and our colleagues is discussed here.

CHALLENGES IN THE DELIVERY OF PATIENT CARE

Numerous strategies have been adopted across the globe to contain the spread of the virus, including social distancing, self-quarantining if symptomatic, and cocooning of the elderly. The individual national efforts aim to spread the number of infected cases over a longer time period, and success appears dependent on the timing and extent of implementation of these measures. Our unit is guided by the Department of Health and Human Services guidelines issued by the Victoria State Government, Australia.[6] Guidelines change almost in real time with hospital management briefing staff daily by email. Current restrictions have huge implications for the delivery of care in our subspecialty in ophthalmology.

Assigning Priority.

We adopted the consensus guidelines from the Royal Australian and New Zealand College of Ophthalmologists, in turn broadly adopted from the Moorfields Eye Hospital guidelines, and the American Academy of Ophthalmology.[7,8] Priority is given to potentially sight- or life-threatening conditions. Due to the high risk of infection from the upper aerodigestive tract, nasal syringing, any sinonasal surgery including lacrimal outflow surgery, and nasal endoscopy are being avoided where possible. Stents post nasolacrimal duct bypass surgery are left in situ if the patient is comfortable. If removal is required, the stent is divided between the puncta and the patient is asked to blow their nose away from other people. Nunchaku (FCI Ophthalmics, Tokyo, Japan) bicanalicular stenting offers the advantage of removal via the conjunctival aspect. Similarly, if bony orbital decompression surgery is necessary, only the lateral wall is decompressed. The majority of our current workload involves high-risk periocular malignancies (melanoma, sebaceous carcinoma, squamous cell carcinoma, high-risk basal cell carcinoma, medial canthal, recurrent, high-risk subtype, locally advanced or orbital invasion. Orbital inflammatory disease, sight-threatening orbital lesions (e.g., vascular anomalies), or orbital disease suggestive of a systemic life-threatening condition (e.g., lymphoma or metastatic malignancy) continue to be investigated, including orbital biopsy if relevant. Similarly, dysthyroid optic neuropathy requires treatment to preserve vision. Emergency presentations such as traumas and infections are treated in the usual manner.

An audit of the Orbital, Plastic, and Lacrimal waiting list is currently being undertaken by the unit to defer nonurgent, changing face-to-face consultations to phone or telehealth consult and discharging patients whose condition has resolved. This also allows clinicians to work remotely from home via the hospital’s Information Technology arrangements.

Patient Consultations.

Priority is given to patients with the above conditions. Where possible, phone or telemedicine consultations are undertaken. Telemedicine consultations have been proposed to be suitable for almost all consultations, at least for triaging.[9] However, the technology can be difficult for elderly patients or those without internet connection, and there are gaps in the physical examination. Where face-to-face consultations are necessary, personal protective equipment and slit-lamp shields are used according to Australian guidelines and time spent in close proximity to the patient and carer is minimized.[10] Icare (Icare, Helsinki, Finland) tonometers with single-use probes are used to measure intra-ocular pressure.

Temperature checks, travel history, and respiratory symptoms are screened by a concierge nurse at the hospital entrance. Strict visitor controls allow only 1 chaperone if necessary. Patients who fail screening are isolated, and an Orbital, Plastic, and Lacrimal doctor is consulted who reviews the urgency of the consultation in the context of a possible COVID-19 diagnosis. The patient is referred to a nearby fever clinic for testing if appropriate. Social distancing is employed throughout the hospital.

Surgical Procedures.

General anesthetic procedures are avoided unless necessary due to the increased risk of aerosolized particles during intubation. If airway intervention or manipulation is required, only anesthetic staff are present in the operating theater for induction and extubating. We have discussed with our anesthetic colleagues efforts to avoid the sneezing reflex which can occur with periocular anesthetic injection, while the patient is sedated with the use of alfentanil or fentanyl.[11-13] Hudson masks deliver oxygen to patients requiring sedation to provide a seal around the airway. A clear plastic drape taped to the oxygen mask is tucked behind the patient’s shoulders for further protection. After draping the surgical area, sterile adhesive transparent film dressings (Tegaderm, 3M Medical, Neuss, Germany) and adhesive disposable drapes are used to seal any potential gaps.

To date, no surgical procedure has been undertaken in a known COVID-19-positive patient at our institution. Only those procedures considered as priority have been undertaken. Dissolvable skin sutures (6-0 plain gut) are preferred so postoperative care can be delivered by telemedicine.

Medical Management.

The management of orbital inflammatory conditions has posed a significant challenge. We have adopted the UK guidelines issued by the Department of Public Health regarding “shielding” for patients requiring immunosuppression.[14] These measures include self-isolation, strictly avoiding contact with anyone displaying symptoms of COVID-19, and advise to maintain social contacts using technology as necessary. A template letter, adapted from the British College of Rheumatology, is provided to patients.[15]

The use of intravenous methylprednisolone for dysthyroid optic neuropathy is considered necessary, and patients are advised to “shield” afterward. Pulsed intravenous steroids for moderately active thyroid eye disease has been deferred on a case-by-case basis, and orbital radiotherapy considered as an alternative. An increased risk of serious COVID-19 disease in patients taking nonsteroidal anti-inflammatory drugs has also been postulated.[16] Corticosteroids and nonsteroidal anti-inflammatory drugs may have a role in the management of COVID-19 infections; however, safe pharmacotherapy in COVID-19 is currently evolving.[17,18]

EDUCATION AND TRAINING

The fortnightly unit meeting has moved to a secure online platform. Conference leave has been cancelled with all local, national, and international meetings currently deferred or cancelled or moved to online Webinar format. Such meetings are crucial for sharing of ideas, self-development, and maintaining and building international collaborations. All Royal Australian and New Zealand College of Ophthalmologists trainees have had their training suspended for 6 months and have been diverted to work in eye casualty on separate teams without contact between different teams. As such, morale among trainees may be low with little or no surgical exposure and restricted interactions with colleagues. Online live teaching for registrars has been well attended.

PERSONAL IMPACT

Shortage of personal protective equipment for health care workers has been a constant concern.[19] While ophthalmologists are not at the “coalface” treating the sickest patients, we are key players in recognizing and limiting its spread. Orbital, Plastic, and Lacrimal procedures are considered high risk due to the airway proximity or involvement of nasal or sinus mucosa.

The financial impact has been discussed widely in the media with a global economic depression predicted, despite national measures to retain employees generally and to simulate the economy.[20] The current and future impact on private practice is of concern while uncertainty lingers on with further outbreaks and restrictions possible.

However, most have been able to spend more time with family and have an opportunity to balance life priorities and revisit incompleted projects. The importance of good collegial support and networks has never been more obvious, while people learn to adapt to current circumstances.

CHALLENGES LOOKING FORWARD

As Australia tentatively examines relaxing restrictions on the delivery of surgical procedures, we must consider how to continue to offer these services while protecting patients and staff. It is impossible to predict what the new “normal” will be. Will we ever shake the patient’s hand to establish rapport at the outset or end of a consultation again? The obvious benefits of telemedicine may encourage us to continue this where appropriate in the future.

Communication and education has been acknowledged as an area where clinicians need to lead in the effective response to this pandemic.[21] We hope our description of how the Orbital, Plastic, and Lacrimal unit in Melbourne has adapted to delivery of care will be helpful to those in similar situations and we welcome suggestions from other international units as to their own experience of adaptation.