Glaucoma Dialogue IGR 20-4


Pradeep Ramulu

Comment by Pradeep Ramulu on:

82885 Review of hygiene and disinfection Recommendations for outpatient glaucoma care: A COVID era update, Shabto JM; De Moraes CG; Cioffi GA et al., Journal of Glaucoma, 2020; 29: 409-416

See also comment(s) by Ningli Wang & Chunyan QiaoLuciano QuarantaClement Tham & Poemen ChanBrandon J. WongTin Aung & Rahat HusainMichele C. LimAndrew CampClement Tham & Poemen Chan

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We thank Shabto, De Moraes, Cioffi, and Liebmann for offering a timely and informative review of formal disinfection recommendations for equipment used in the glaucoma exam, and for describing how they have changed their clinic in the COVID-19 era. No doubt, this is an issue all of our readers have been dealing with. Here, we highlight some of the authors' ideas that others may not have considered, expand upon areas of potential controversy, and discuss some suggestions the authors may well be implementing, but did not mention. We offer advice with the caveat that infection rates differ by region and time, and it remains important to adhere to regulations from the governments, medical bodies, and local institutions where you work. Another important caveat is many recommendations involve balancing cost and burden with an unquantifiable benefit in safety; until further knowledge is gained, we must 'first, do no harm' and err on the side of safety.

With regards to keeping the office safe, the authors highlight the need for frequent (hourly) cleaning of waiting areas, and also other areas including check-in kiosks, doorknobs, and bathrooms. As a way to decrease time spent in the clinic, they suggest collecting any payments on-line instead of in person. We are also reviewing medications and changes in vision/symptoms one to two days before the visit and scheduling all follow-ups by phone, lowering time spent with technicians and allowing quicker exits. The authors are limiting patients to one companion to lessen the number of patients in the waiting room; Johns Hopkins is limiting companions altogether except when necessary (poor mobility, limited cognition). In cases where difficult decisions must be made, patients can call their family/friend so they may join discussions by speaker phone.

We highly recommend readers review the official manufacturer recommendations for cleaning glaucoma-related equipment detailed in the manuscript tables. These thorough tables cover products by multiple manufacturers, describe the agents suitable for disinfection, the company-recommended frequency of disinfection, and provide links to the product manuals. Notably, products are covered which we may not often think about how best/often to clean, including non-Goldmann tonometers (iCare, Tono-Pen) and lenses (gonioscopy, ophthalmoscopy, laser). While these recommendations predate COVID-19, it is important that they are now followed with greater diligence.

Two pieces of glaucoma equipment deserve special mention based on their design and critical importance to decision-making. Regarding applanation tonometry, the authors make no firm recommendations. Prior systematic reviews and review articles on the topic are referenced, as is a recent paper demonstrating detectable COVID-19 RNA in the tears of 2/38 eyes, including 2/12 eyes with ocular findings, but none of the 26 eyes without ocular findings (chemosis, hyperemia, epiphora). A second study in 17 COVID-19- positive patients without ocular symptoms also found no detectable RNA in tears (PMID 32291098). These studies suggest no critical need for re-evaluating current applanation tonometer disinfection processes, at least in eyes without ocular findings.

Regarding perimetry, some manufacturers have issued new guidelines for disinfecting perimeter bowls with spray misting between patients ( However, multiple questions remain. Do aerosolized particles remain the bowl space after testing? For how long? Until better data are obtained on these issues, our service has limited visual field testing, encouraged the use of shorter (faster) testing algorithms, and rotated which machine is used to maximize time between tests. If remote perimetry/tonometry are ever going to become viable alternatives to in-clinic testing, now would be the time, and our group is exploring the potential of both.

We urge our readers to read this excellent piece to help formulate their thoughts on how best to keep their patients safe in this new era.

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