Managing ophthalmic practices in a referral emergency COVID-19 hospital in north-east Italy.

Editor,

The novel coronavirus disease (COVID‐19) is highly contagious in humans. It is mainly transmitted through direct or indirect contact with respiratory droplets produced by infected people, also with evidence of the virus in tears and ocular secretions (Lai et al. 2020). Different levels of COVID‐19 activity were found in different countries, depending on the features of the virus and the public health response. The Italian COVID‐19 spreading is one of the largest worldwide with related public severe health emergency (Armocida et al. 2020). To diminish the risk of contamination, some healthcare facilities, included our hospital, were assigned as referral regional care centre for COVID‐19 patients.

Due to the effect of COVID‐19 last weeks, we adopted a complete reorganization of our department to ensure continuous ophthalmic medical care. According to our recent experience, we share a series of measures to prevent the nosocomial transmission of the disease and to reduce the risk of contamination for patients, caregivers and administrative staff.

The accesses to the healthcare facility are reduced only to essential gateways with a separate checkpoint for the patients and the personnel. The admission of carers should be avoided, if possible. In waiting areas, a social distancing is guaranteed with at least 1.5 m apart from one another, properly wearing a surgical mask. The triaging system screens patients through temperature measurements, and a questionnaire about upper respiratory symptoms, fever, myalgia and anosmia, domicile or travelling in hot areas, and contact history with confirmed or suspected COVID‐19 patients within the past 14 days. Patients who meet one of these criteria are addressed to a separate controlled circuit to test for COVID‐19 positivity. If a patient under investigation needs a non‐deferred ophthalmology examination, the visit is conducted in a dedicated room and, until further notice, the patient treated as a positive patient.

For outpatient care, a risk stratification process with a review of the patient's medical record is used to identify in which patient the visit cannot be delayed. All patients receive a screening by telephone with the same questionnaire performed upon the arrival in the hospital. Patients with any positive findings are postponed. In this setting, patient education is crucial. In waiting areas, videos about personal hand hygiene, proper surgical mask‐wearing and practising social distancing should be considered useful approaches. The visits were rearranged, tending to no waiting policy, and the seats were spaced at least 2 m. Adequate environmental ventilation and sanitation should not be overlooked. Washing or alcohol‐rubbing the hands is an essential procedure also required after taking off gloves. Ophthalmologists are a high‐risk category, and appropriate personal protective equipment is required (Romano et al. 2020). Protective shields were installed on the slit lamps to prevent droplets transmission. The micro‐aerosol formation procedures should be avoided, including ‘air‐puff’ tonometry (Wan et al. 2020). The intraocular pressure is measured using a disposable tonometer tip. Direct ophthalmoscope examination is avoided and replaced with fundus photography or slit light examination. Laser treatment is reserved for retinal tears, high‐risk developing neovascular glaucoma or proliferative diabetic retinopathy. To avoid the threat of irreversible vision loss, intravitreal injections should be continued for scheduled patients.

As regards ophthalmic surgery, all elective procedures were deferred. In our practice, patients with an urgent surgical condition (such as retinal detachment, endophthalmitis, open globe trauma and sight‐threatening uncontrolled ocular pressure) are first screened for COVID‐19. For positive patients, a dedicated operating theatre with negative pressure laminar flow is provided.

In conclusion, the COVID‐19 puts under severe stress the healthcare system in different countries. To limit the outbreak of the disease and to ensure the safety of the caregivers, appropriate countermeasures are mandatory. Specific specialty protocols might help to look after our patients more efficiently in the future.