Sustainability of ophthalmology practice during COVID-19 | OPTH


Affected patients and healthcare workers (HCWs) with various infectious diseases may frequently present at the eye clinics. Since they have direct contact with clinical equipment, it increases the risk of spreading COVID-19. Globally, the number of COVID-19 cases are still dramatically increasing. The HCWs are at high risk of being exposed to COVID-19. According to the Pan American Health Organization (PAHO), in September 2020, the COVID-19 has infected 570,000 HCWs and killed 2500 in the USA.1 In a recently published paper, Bandyopadhyay et al2 estimated the healthcare worker’s (HCW’s) COVID-19 infections and deaths. The analysis showed the case fatality rate for the HCWs ages between 18–29, 30–39, 40–49, 50–59, 60–69 and above 70-year old were 1.1%, 0.8%, 1.1%, 2.6%, 7.1%, and 37.2%, respectively. Nguyen et al3 conducted a study (in the USA and the UK) and found that the HCWs are at increased threat for reporting positive COVID-19 test results compared to the general community. The study has shown that the prevalence of COVID-19 for the HCWs was 2747 cases per 100,000 people and for the general community was 242 cases per 100,000 people.

During the COVID-19 pandemic, the HCWs are working for long hours in high-pressure circumstances. Additionally, they are at increased risk of infection; thus, they are also at a risk of infecting their families. Consequently, these causes are likely to increase the risk of mental health disorders. Greenberg4 has suggested six key elements to protect the mental health of the HCWs and are as follows:

  • proper acknowledgment of the hard work to foster resilience,
  • contacting the staff who does not turn up to work, in case his/her absence is due to impacted mental health,
  • the HCWs should receive the “return to normal work” interviews by expert mental health supervisors once COVID-19 begins to recede,
  • paying attention to HCWs in high-risk groups and/or being overwhelmed,
  • monitoring anyone who is at higher risk of developing mental health problems, and
  • managers should assist anyone who has been exposed to morally distressing circumstances.
  • As the number of COVID-19 positive cases increases, the transmission is also expected to increase. Unfortunately, there is a lack of well-established protocols dedicated to attenuate healthcare workers’ risk.5 Thus, strict protocols are required for more protection at the clinic, taking into account the clinic’s sustainability.


    Inclusion and Exclusion Criteria

    The analysis inclusion criteria concerned all the ophthalmology practice and training protocols during and after COVID-19 for inpatients and outpatients. It is worthwhile to mention that the exclusion criteria was any ophthalmology practice and training protocols not dedicated to COVID-19.

    Research Criteria

    For this review, the reference articles were collected from January 2020 to January 2021 using standard web search engines, such as Google Scholar, PubMed, Web of Science. The keywords to search the literature were ophthalmology protocols during COVID-19, ophthalmology training during COVID-19, ocular surgeries during COVID-19, ophthalmology inpatients, and ophthalmology outpatient during COVID-19. Through the electronic databases, 483 citations were selected. Then, the unrelated titles were removed. A screening of abstracts was conducted for 69 citations. Full-text screening was performed for 13 manuscripts. Finally, six papers, comprising four original articles and two review papers fulfilled the inclusion criteria.

    Study Selection

    For this review, original articles and review papers regarding the ophthalmology practices and training protocols during COVID-19 were chosen.

    Ethical Consideration

    No ethical considerations were required for this review.


    Globally, the ophthalmology clinics have responded to COVID-19 in various ways to manage the risks to the staff and patients in the absence of respiratory symptoms. In this regard, different protocols have established (see Figures 1–6). Safadi et al6 have established a protocol, as shown in Figure 1, which covers the safety and effectiveness of hospital settings. Three subdivided categories for infection measures were considered in their practice protocol and are given below:

  • The use of personal protection (PPE), including wearing masks and eye protection. The patients are requested only to speak when asked during the slit-lamp examination.
  • Environmental control for slit-lamp testing is undertaken by installing large protective plastic shields between the patient and the practitioner. Disinfection has to be performed, after each patient, on all clinical equipment and the air ventilation in the waiting areas.
  • Administrative control by first identifying the patients exposed to COVID-19 to follow the procedures indicated in Figure 1.
  • Figure 1 Flow chart of patients in ophthalmology clinics. Note: Reproduced from Ophthalmology practice during the COVID-19 pandemic, Safadi K, Kruger JM, Chowers I, et al., 5, e000487, copyright 2020] with permission from BMJ Publishing Group Ltd.6

    Figure 2 Registration workflow for outpatients and inpatient. Blue letter referral: inpatient interdisciplinary referrals to outpatients to be seen after 9:30 AM. Note: Reprinted by permission from Springer Nature Customer Service Centre GmbH: Springer Nature, Graefe’s Archive for Clinical and Experimental Ophthalmology, Sustainable practice of ophthalmology during COVID-19: challenges and solutions, Lim LW, Yip LW, Tay HW, Ang XL, Lee LK.  Copyright 2020.7

    Figure 3 Flowchart of the patient triage protocol. Note: Copied from COVID-19: limiting the risks for eye care professionals, Sadhu S, Agrawal R, Pyare R, et al., Ocular Immunology and Inflammation, 2020 Taylor & Francis, reprinted by permission of the publisher (Taylor &Francis Ltd,

    Figure 4 Decision tree in the eye clinic during the COVID-19 pandemic. Note: Reproduced from Gharebaghi R, Desuatels J, Moshirfar M, Parvizi M, Daryabari SH, Heidary F. COVID-19 preliminary clinical guidelines for ophthalmology practices. Med Hypothesis Discov Innov Ophthalmol. 2020;8(2):149.9

    Figure 5 Decision tree in the ophthalmic outpatients’ clinic during the COVID-19 pandemic. Note: Data from Romano MR, Montericcio A, Montalbano C, et al. Facing COVID-19 in ophthalmology department. Curr Eye Res. 2020;45(6):653–658. doi:10.1080/02713683.2020.1752737.10

    Figure 6 Patient triage in ophthalmology outpatient clinic.

    Abbreviations: A&E, Accident and Emergency Department; TOCC, travel, occupation, contact, and clustering. Note: Reprinted by permission from Springer Nature Customer Service Centre GmbH: Springer Nature, Graefe’s Archive for Clinical and Experimental Ophthalmology, Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong, Lai TH, Tang EW, Chau SK, Fung KS, Li KK. Copyright 2020.11

    Other specific measures have contemplated, such as encouraging the use of telemedicine, dividing the workers into teams, separating the imaging areas, admitting only urgent cases for surgery, and check-ups for staff members. Optometry services were closed, except for biometry tests for urgent surgeries. The contact lenses fitting can raise concerns regarding coronavirus transmission, thus, increasing the risk of exposure to the virus.

    Lim et al7 have stated the challenges affecting the ophthalmic practice in the ophthalmology department at Tan Tock Seng Hospital, the leading centre for managing COVID-19 patients in Singapore. The protocol is more comprehensive by covering both inpatient and outpatient care for the patients and their accompanying persons, as shown in Figure 2. Enhancing the detection of COVID-19 cases and minimising the transmission risks are some of the challenges healthcare workers face. Thus, guidelines for the ophthalmic practice were addressed, which included:

  • general infection control by the use of appropriate…

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