On March 11, 2020 the World Health Organization declared the novel coronavirus disease 2019 (COVID-19) outbreak a pandemic. On March 18, 2020 the American Academy of Ophthalmology recommended that ophthalmologists limit patient visits to urgent and emergent cases in order to decrease virus transmission and conserve medical supplies. Proper hygiene and disinfection protocols became a focal point of interest for safely seeing high risk patients during the early outbreak and for safely increasing patient volume as restrictions began to relax. The authors of this review focus on hygiene and disinfection recommendations for outpatient glaucoma care, although many of the basic principles may be applied broadly across general ophthalmic care as well as for other specialties that require close patient interaction.
A general goal in all care is to decrease or prevent person-to-person viral transmission. Ophthalmologists represent a particularly high at risk physician group for contracting COVID-19.1 Recommendations include screening patients for COVID-19 symptoms, social distancing when possible by limiting patient numbers in waiting areas, minimizing speaking while in close proximity, and barrier methods such as breath shields. The AAO has updated recommendations since this review was published to include suggesting face coverings for patients and providers as well as eye protection for providers. The use of face masks may decrease transmission of COVID-19 in public settings, but their utility in closer encounters is not yet known.2 The use of face masks and large breath shields in conjunction appears to be particularly effective at reducing particle transmission.3
Exam rooms, waiting areas, and any other place patients congregate should be disinfected between patients. The Environmental Protection Agency maintains a frequently updated list of products that can be used to disinfect surfaces.4 Offices should have multiple disinfection products available as there is high risk of intermittent shortages of individual products.5 Any device used during a patient exam should be thoroughly disinfected after use. Slit lamps, lenses, and ocular coherence tomography machines are relatively easy to clean because potentially contaminated surfaces are easily accessible. Visual field analyzers present a challenge because respiratory droplets may accumulate within the perimetry bowl, but the bowl may be degraded by frequent application of disinfection products. Both Zeiss and Haag-Streit have suggested their respective perimetry bowls may be disinfected with atomized isopropanol or ethanol, but the long-term impact of these products is unknown. Contact tonometer tips should be disinfected with particular caution due to the risk of virus transmission between patients. Non-contact tonometry should not be performed due to the risk of tear aerosolization. However, it should be noted that the rate of viral shedding in tears remains controversial and may be lower than initially thought.6
Recommendations regarding the COVID-19 response are frequently changing as more is learned about transmission and infection by the virus. Many of the principles learned during the current pandemic will play a role in the response to future pandemics. There are many opportunities to update and improve glaucoma care as a response to this crisis. Tele-ophthalmology will likely be increasingly explored as a way to minimize patient exposure and transmission risks.7 Many products such as home tonometry and home perimetry will likely take an increasingly central role in the future of glaucoma care as we adapt to this shifting clinical environment.