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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19

 11th May 2020

OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT

OF COVID 19

All India Ophthalmological Society

PRELUDE

IN the current COVID 19 situation, Central and State Governments have issued a series of
Guidelines primarily focusing on protection of interests of all the concerned and prevention of
the spread of Infection. AIOS, in the backdrop of above, has collected and collated expert inputs
from various sub-specialities both from India and abroad to generate these Guidelines. This is
done with a singular mind to inform and guide Ophthalmic Practitioners in the best interests of
doctors, patients, healthcare staff and community in general. Owing to the present context and
also the complex nature of the medical profession in terms of unpredictable outcomes, these
Guidelines are required to be construed as bona fide opinions of experts. Be that as it may, it is
necessary to understand and appreciate that these Guidelines do not substitute or override
applicable statutory and ethical mandates.

Similarly, in a given patient care scenario, it is ultimately the clinical judgment or decision of the
Physician prevails, which is being taken considering overall circumstances and the patient’s
underlying condition. These Guidelines present recommendations considering the available
information as on date. Needless to mention that as the situation evolves and unfolds, these
Guidelines also would warrant appropriate changes.

AIOS appeals to all the Ophthalmic Practitioners to adopt safeguards in the best interest of
everyone concerned in the community.

===============

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 All India Ophthalmological Society
Governing Council
President Prof. (Dr.) Mahipal S. Sachdev
President Elect Dr. Barun Kumar Nayak
Vice President Dr. Lalit Verma
Hon. General Secretary Prof. Namrata Sharma
Hon. Treasurer Prof. Rajesh Sinha
Chairman Scientific Committee Dr. Partha Biswas
Chairman ARC Dr. Chitra Ramamurthy
Editor IJO Dr. Santosh G. Honavar
Editor Proceedings Dr. Arup Chakrabarti
Immediate Past President Prof. S. Natarajan
Acknowledgements:
Intraocular Implant and Refractive Society of India (IIRSI)

Indian Society of Cornea & Keratorefractive Surgeons (ISCKRS)

Eye Bank Association of India, (EBAI)

Cornea Society of IndiaV(CSI)

Glaucoma Society of India (GSI)

Uveitis Society of India (USI)

Vitreo Retina Society of India (VRSI

Oculoplastics Association Of India (OPAI)

Strabismus and Pediatric Ophthalmological Society of India

(SPOSI)

Indian Neuro-Ophthalmological Society (INOS)

Ocular Trauma Society of India (OTSI)

Vision 2020

NPCB

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Index
S.N. Particulars Page No

1. Abbreviations 05

2. Declaration/Screening Form for Covid-19 Infection 07

3. Covid-19 Pandemic Ophthalmic Treatment Consent Form 09

4. Guidelines For Functioning Of Eye Care Facilities Under NPCB & Vi B 11

Ministry Of Health And Family Welfare, 8th May 2020
5. Guidelines For Functioning of Ophthalmology Facilities 12

6. Guidelines For Operation Theatres 27

7. Guidelines For Cataract Surgery 30

8. Guidelines For Refractive Surgery 40

9. Guidelines For Cornea and Eye Banking 46

10. Guidelines For Glaucoma Practice 53

11. Guidelines For Uveitis Practice 59

12. Guidelines For Vitreous – Retina Practice 63

13. Guidelines For Oculoplasty & Oncology Practice 72

14. Guidelines for Paediatric ophthalmology, Squint and Neuro 78

Ophthalmology Practice
15. Guidelines for Ocular Trauma Practice 87

16. Guidelines For Community Eye-Health and Vision Centres 92

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Abbreviations

ACAL Assurance Clinical Administrative Legislative

AIOS All India Ophthalmological Society

ARN Acute retinal necrosis

BMW BioMedical Waste

C/S Culture Sensitivity

CSI Cornea Society of India

CT Computerized tomography

EBAI Eye Bank Association of India

EDC Eye Donation Counselor

FFA Fundus fluorescein angiography

GI Gastrointestinal

GOI Government of India

GSI Glaucoma Society of India

HCQ Hydroxychloroquine

HCRP Hospital Cornea Recovery Program

HICC Hospital Infection Control Committee

ICG Indocyanine angiography

ICMR Indian Council of Medical Research

IIRSI Intraocular Implant & Refractive Society of India

IPD In-Patient Department

ISCKRS Indian Society for Cornea and Refractive Surgeons

LRI Lower Respiratory Tract Infection

MoHFW Ministry of Health and Family Welfare

NOTTO National Organ & Tissue Transplant Organisation

OCT Optical coherence tomography

OPAI Oculo Plastic Association of India

OPD Out-Patient Department

OT Operation Theatre

OTSI Ocular Trauma Society of India

PPE Personal Protective Equipment

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
PRP Panretinal Photocoagulation

RT-PCR Reverse Transcription Polymerase Chain Reaction

SARS Severe Acute Respiratory Syndrome

SOTTO State Organ & Tissue Transplant Organisation

SS Stainless Steel

THOTA Transplantation of Human Organ and Tissue Act

TOCC Travel/Occupational/Contact/Clustering

U/S Ultrasound

URI Upper Respiratory Tract Infection

USI Uveitis Society of India

UV Ultraviolet

VRSI Vireo Retina Society of India

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 DECLARATION/SCREENING FORM FOR COVID-19 INFECTION

To ensure your safety and the safety of the doctors and hospital staff who are trying to help you
with your eye condition and for the safety of the other patients visiting the hospital, as per the
guidelines issued by the Ministry of Health and Family Welfare, Government of India and WHO,
We need the following particulars before we take you up for consultation/surgery/procedure.
Please note that in case of any event in the future, if any of the below-given details are found to
be false and not correct, strict action may be initiated against you and your family members as
per guidelines and regulations laid down by MH&FW, Government of India.

Name of Patient: __________________________________ Age / Sex: __________________

Address: ____________________________________________________________

Mobile No: _______________________________________. (Verified Y / N)

MRD No: _____________________________________________

Alt Mobile No: (Verified Y / N) ____________________________

Email __________________________ Aadhar Card Number ______________________

S.No. COVID- 19 QUESTIONAIRE Yes No

1. Do you or your accompanying relative or a family member staying with you

have symptoms of Fever, Cough, Sneezing, Sore throat, Extreme
tiredness/body ache, difficulty in breathing, Loss of smell and taste

2. Have you or a family member staying with you travelled outside city to any
other city/town/place/containment zone/country in past 21 day? If Yes,
mention
details.
Details of place visited: _________________________________

3 Are you or a family member staying with you a health care worker? If yes,
do you work in a hospital where COVID infected patients are treated?

4 Did you or a family member staying with you have any exposure to a
confirmed COVID-19 patient or to a suspicious patient in last 21 days?

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 5 If yes, have you downloaded Arogya Setu application on your phone and
kept it “ON”?

6 If no, Has your close family member downloaded it?

7 Have you or a family member staying with you visited a health care facility
in the past 21 days?
If Yes, mention purpose ____________________________________

8 Did you or a family member staying with you have a red eye in last 21 days

Body Temperature recorded:…………………………………………………………………………………………..

Name and Signature of the patient: .....................................................................................

Name and Signature of Accompanying Relative: ................................................

Verified by Staff Sign......................................................

Time....................................................................Date.........................................................

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 COVID-19 PANDEMIC OPHTHALMIC TREATMENT CONSENT FORM

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel
coronavirus has unknown and long incubation period during which carriers of the virus may not show
symptoms and still be contagious. Even though lockdown is lifted, in the wake of the current
Coronavirus threat pandemic (present all over the world), I have come to ______________________
(Name of the Hospital) by my own free will for my Eye Treatment. If I am an asymptomatic carrier
(with no discomfort or symptoms present, but the virus still present hidden in my body) or an
undiagnosed patient with COVID 19, I suspect it may endanger doctors and hospital staff. It is my
responsibility to take appropriate precautions and to follow the protocols prescribed by the hospital
staff.

I am aware that I may get an infection from the hospital or from a doctor, or other patients in the
hospital even after the hospital has taken precautions, which have been explained to me, as per
guidelines prescribed by the Ministry of Health and Family Welfare, Government of India and WHO.
This disease spreads by aerosol and is very contagious even though every precaution is taken it will
reduce the risk of transmission and will not completely eliminate the risk.

I understand that ophthalmology (eye) procedures(OPD & OT) might create droplets which is one
way that the novel coronavirus can spread. The droplets can linger in the air for minutes to
sometimes hours, which can transmit the novel coronavirus.

I confirm that I am not in a high-risk category, including: diabetes, cardiovascular disease,

hypertension, lung diseases including moderate to severe asthma, being immunocompromised, or
over age 60. OR I fall into the following high-risk category (_________________) and my doctor and I
have discussed the risks, and I agree to proceed with treatment.

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

I verify that I have not been identified as a contact of someone who has tested positive for novel
corona virus or been asked to self-isolate by the government.

I also understand that during my treatment and recovery, I can contact this infection outside the
hospital premise. I will take every precaution to reduce the risk of transmission from happening, but I
will not at all hold doctors and hospital staff accountable if such infection occurs to me or my
accompanying persons. In case I or my attendant gets the COVID-19 infection after the visit to the

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
hospital, I will inform the hospital authorities at the earliest, so that appropriate tracking of the
patients/attendants and hospital staff present on the day of my visit can be done.

I verify the information I have provided on this form and in the questionnaire overleaf is truthful and
accurate. I knowingly and willingly consent to necessary investigations and treatment completed
during the COVID-19 pandemic. I am also aware, if any details provided by me or by my
accompanying relative are found to be false and not correct or if I or accompanying relative has
hidden facts and other relevant details, appropriate legal action may be initiated against me and my
family members as per applicable government rules.
_______________________________________
SIGNATURE/THUMB IMPRESSION OF PATIENT

Name____________________________________ Date_______________________

Mobile No.:___________________________________________________________

Address: _____________________________________________________________

Name of the Attendant: ___________________Date: __________ Mobile No._______________

Signature of the Attendant

Name of the Doctor/Hospital Personnel ______________________ Date: ___________________

_____________________________________
SIGNATURE OF THE DOCTOR/ HOSPITAL PERSONNEL

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Guidelines for Functioning of Eye Care Facilities under NPCB & VI
By Ministry of Health and Family Welfare
8th May 2020

1. All eye care facilities to carry out routine clinical activities including OPD, IPD and Surgical
Procedures, in all areas except the containment areas in red zones
2. But all due precautions for preventing the spread of infection to be taken like Social distancing,
wearing of face masks, face shield, Goggles etc. and frequent Hand Wash/Hand rub ( as per
MOHFW additional guidelines for non-COVID hospitals.
3. Ensure minimum patients at any given time in the premises and maintain social distancing norms
of six feet* between the patients.
4. SOPs regarding the above points may be made and strictly enforced.
5. Ensure minimum touch of OPD Cards, Trial Frames, Trail lenses and other paraphernalia being
used in the Eye OPD and their frequent disinfection.
6. Ensure patient wears a face covering and uses a hand rub before entering the OPD and does not
have symptoms resembling Covid infection.
7. A special consent form should be got filled by the patient before any invasive procedure is
undertaken, disclaiming responsibility from the development of future Corona infection in the
patient. This fact should be well explained to the patient.
8. No outreach camps to be undertaken. No mobile vans to be sent in the field.
9. Tele - ophthalmology and Teleconsultation practices to be explored and encouraged specially in
difficult areas.
10. IEC messages through digital means only
11. No eyeball retrieval from homes, however, HCRP can be continued in Non-Covid dead patients,
for the need of corneas for therapeutic purposes only.
12. During surgical procedures, the surgeons and the OT team should follow the guidance and
precautions as for other surgeons (as per MOHFW additional guidelines).
13. Pre-surgical Covid test on patients is not mandatory

* Corrigendum: Ensure minimum patients at any given time in the premises and maintain social
distancing norms of 1 to 2 metres between the patients.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Functioning of Ophthalmology Facilities
Version: 1
w.e.f. May 11, 2020

Prepared by: Mandeep Jot Singh, Mahipal S Sachdev, Namrata Sharma, Rajesh Sinha
and AIOS Governing Council

 All Ophthalmology facilities to carry out routine clinical activities including OPD,
IPD and diagnostic procedures, irrespective of being located in green, orange or
red zones except for those eye care facilities that are located in designated
containment areas..
 All due precautions for preventing spread of infection to be taken as detailed later
in this document.
 Ensure minimum patients at any given time in the premises and maintain physical
distancing norms of 1 to 2 meters between the patients. To achieve this, the
working timings/days of the Centres should be increased to space out the
appointments as per the workload.
 Teleconsultation practices to be utilized as may be required.
 Patient education messages to be disseminated preferably through digital means-
displays in waiting areas and through Social media accounts.
 All public marketing activities, and camps/ outreach activities shall remain
suspended till local govt allows resumption.
 Eye Banking: Hospital Cornea Recovery Program may be continued in Non- COVID
deceased donors, for the need of corneas for corneal transplantation. No eyeball
retrieval from homes.

Advise to Staff:

While Going to Work

 Carry minimum number of personal belongings, like laptops, bags, lunchboxes,

water bottles, etc. Carry only the bare essentials.
 Since frequent hand washing would be required, it is advisable to remove watch
and jewellery worn on hands.
 Wear personal clothing to work. Bring uniform in a washable bag. Those who do
not have the uniform, bring a set of personal clothing or extra shirt.
 Wear shoes that can be easily cleaned.
 Wear mask upon leaving your house.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 During Work

1. Upon reaching the hospital:

a. wash your hands and/or use hand sanitizer,
b. get yourself screened at the screening desk for fever,
c. change into the set of clothes brought along,
d. sanitize phone, ID cards, spectacles, vehicle keys, etc,
e. keep the doors of your rooms open to avoid touching the doorknobs and
handles,
f. wash your hands again before starting work, and
g. Wear PPE as may be applicable.
2. Practice physical distancing.
3. Greet your colleagues and patients with Namaste. Avoid handshake.
4. Avoid touching your face and politely remind others too.
5. Observe hand hygiene protocols.

PPE to be Used: (Ref: Additional guidelines on rational use of Personal Protective Equipment
setting approach for Health functionaries working in non-COVID areas by Ministry of Health and
Family Welfare dated 1st May 2020)

S. No Category of staff PPE to be used

OPD Department
He Shoe
Glov Face Shield/
Mask ad Gown Cove
es Goggles
Cap r

1. Patient Screening 3 layer medical Nitrile / Linen

Yes No Yes
Desk## mask Latex Gown

Yes if in
2. 3 layer medical Nitrile /
Pharmacist No No No open
mask Latex
counter

3. 3 layer medical Nitrile /

Opticals No No No Yes
mask Latex

4. Front office and 3 layer medical Nitrile /

No No No Yes
Billing mask Latex

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Centre Managers,
Managers and 3 layer medical Nitrile /
5. No No No Yes
Operations mask Latex
Executive **

6. Patient Care 3 layer medical Nitrile /

No No No Yes
Coordinators mask Latex

7. OPD attendants 3 layer medical Nitrile /

No No No Yes
mask Latex

8. 3 layer medical Nitrile /

Counselors No No No Yes
mask Latex

9. Optometrist ## 3 layer medical Nitrile /

Yes No No Yes
mask/ N95 Latex

10. Doctors ## Nitrile /

N95 Yes No No Yes
Latex

11. Imaging Technician 3 layer medical Nitrile /

Yes No No Yes
## mask/ N95 Latex

12. 3 layer medical Nitrile /

Security Guards No No No Yes
mask Latex

Heavy
13. 3 layer medical
Housekeeping Yes Duty No No Yes
mask
Gloves
Visitors / Patient
14. Face Cover No No No No No
Attendants @@

IPD Department
Shoe
Head Glove Face
Mask Gown Cove Goggles
Cap s Shield
r

3 layer medical Follow To be used if indicated

1. mask/ Nitrile / depending on the procedure
Doctors & Anaesthetist ## Yes regular OT
Latex No being performed
N95 protocol

Follow To be used if indicated

2. 3 layer medical Nitrile / depending on the procedure
Optometrist ## Yes regular OT No
mask Latex being performed
protocol

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Follow To be used if indicated
3. 3 layer medical Nitrile / depending on the procedure
Nurse ## Yes regular OT No
mask Latex being performed
protocol

Follow To be used if indicated

4. 3 layer medical Nitrile / depending on the procedure
OT Technician ## Yes regular OT No
mask Latex being performed
protocol

5. 3 layer medical Nitrile /

Counselor** No No No Yes
mask Latex

Heavy
6. 3 layer medical
Housekeeping** Yes Duty No No Yes
mask
Gloves

7. 3 layer medical Nitrile /

Manager** No No No No
mask Latex

8. 3 layer medical
Patient Attendants No No No No No
mask

Other Department

Head Shoe Face

Mask Gloves Gown Goggles
Cap Cover Shield

1. Office staff (IT, HR, Finance, No No

Face Cover No No No
Accounts, Marketing, etc.)

Nitrile /
Latex/
2. Maintenance** Face Cover No Heavy No No No
Duty
Gloves

3 layer
3. Yes when present in
Quality ** medical No No No No
patient care areas
mask

3 layer
4. Nitrile / Yes when present in
medical No No No
Biomedical Engineer** Latex patient care areas
mask

5. Other Support Service No No

Face Cover No No No
Staff **

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
NOTE:

● The staff marked with (**) to don PPE’s as per area they visit for work.
● The staff marked with (##)

1. N95 mask is recommended for use in OT when patient being operated is a resident of
a containment zone.
2. Anesthetist and assistant to wear PPE, as recommended in guidelines issued by
MoHFW on May 1, 2020, for GA cases as intubation/ extubation can generate
aerosols. During intubation/ extubation surgeon and other staff to move out of OT.
3. Either one of these two PPEs is to be used – Goggles/ Glasses & Face Shield as per the
Procedure
a. Use of Face Shield is recommended when a splash of Body Fluid is expected.
b. Use of Goggles is recommended when performing Aerosol generating
procedure.
● For @@ - Attendant / Visitor are allowed only with Elderly / Paediatric Patients. The
attendant/visitor are required to wear mask.

Policy for Disinfecting and Reusing Personal Protective Equipment (PPE)

S. No PPE – Type Reuse Disinfection

1. N 95Mask ONLY 4 times. **** Refer to the
Disinfection Protocol
below.
2. 3 ply Mask NO -
3. Gloves NO -
4. Head Cap NO -
5. Shoe Cover NO -
6. Face Shields YES **** Refer to the
Disinfection Protocol
below.
7. Goggles YES **** Refer to the
Disinfection Protocol
below.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 1. N95 MASKS – ONE MASK TO BE REUSED 4 TIMES ONLY.

● N-95 masks to be issued to all doctors for use in OPD.

● The number of masks to be issued will depend on the duty roster.
● N95 mask can be reused with 72 hours of air drying between uses.
● The reuse can be up to a maximum of 4 times.
▪ All the N95 Masks to be labelled with user Name & Numbered 1, 2, 3, etc.
▪ On the first working day, the use Mask No 1.
▪ After the day end, the mask should be carefully removed, packed in a
breathable bag (paper bag can be used) for Re-use purpose.
▪ The mask should be left in the breathable bag. (72 hours of air dry is required
between uses. It is Mandatory).
▪ The location for air drying will depend on the convenience of the user and it can
be done at your home. Please ensure that it is kept at a location where no one
else will be touching it.
▪ On the Second working day you should wear Mask No 2 and repeat the steps
given above and so on.
● After wearing and removing the masks, sterilize your gloved hands with sterilium.
● After using each mask for 5 working days (one fresh use + 4 re use), bring all masks in
a bag and throw them in the YELLOW BIN.
● New set of N-95 masks to be issued and the above-mentioned steps to be followed.

2. FACE SHIELDS AND GOGGLES

● Eyeshields and goggles can be cleaned with 70% alcohol solution/ Alcohol Swab.
● This should be done prior to beginning the work and should be repeated at the end of
workday prior to leaving the hospital.
● Please keep these in your possession and avoid mixing it with other staff. Preferable
to write your name in one corner for identification.

3. DISPOSAL AS PER Bio Medical Waste (BMW) RULES: DISPOSE EVERY DAY AFTER
FINISHING THE WORK

● 3 PLY Masks, Head Caps, PPE Suits, Disposable Gowns in Yellow bin
● Gloves in the red bin

DOS AND DON’TS:

● Please never use OPD PPE for OT WORK. They must be USED for OPD work ONLY.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 ● PPE should be discarded in an appropriate waste container after use, and hand
hygiene should be performed before putting on and after taking off PPE.
● DON’T touch the outer surface of your PPE while working or doffing of the PPE.

After Work

1. Remove PPE. Disinfect (protective glasses and face shields) or dispose as may be
applicable according to the BMW Management Rules. Masks and caps in YELLOW
and gloves in RED.
2. Change back into the home clothes and place the work clothes in the washable bag
brought along.
3. Sanitize phone, ID cards, spectacles, etc.
4. Leave what you can at the workplace. Whatever items are needed daily at the
workplace and not needed at home should be left at the workplace.
5. Wash your hands.
6. Ring-up phone when you are about to reach home. Someone at home should keep
the front door open so that you do not have to touch any objects like call bell,
doorknobs.
7. Again sanitize phone, ID cards, spectacles, shoes, etc on reaching home.
8. Take bath (including head bath) immediately after arriving home.
9. Wash your work clothes along with the bag and change into clean clothes.
10. Practice wellness activity every day.

Other Measures to be observed during Work:

1. All persons to wash hands and/or use hand sanitizers at the entry point to the hospital.
2. Strict enforcement of screening protocols, self-declaration form, and one attendant only
policy at the entry point.
3. The Self Declaration/ Consent Form is to be filled and every visit and body temperature
to be noted
a. All OPD patients.
b. All IPD admissions- this form to be included in the MRD file of the patient.
c. All staff- daily
4. Arogya Setu app to be downloaded by all staff and patients as mandated by Govt
guidelines with location enabled in his/her mobile.
5. A checklist for patients to be pasted near the screening counter for information and
education about the measures.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 6. All persons inside the hospital to wear masks at all times (refer to the table of
recommended PPE). Patients and their attendants to be advised to come wearing masks.
In case anyone does not have a mask, the same is to be provided at the screening
counter near the entrance.
7. Identify opportunities to modify process flow in OPD to minimize people’s movement
inside premises and also to reduce time spent during the hospital visit.
8. Physical distancing to be observed at all times and in all areas.
a. Cords/ribbons/Tapes to be tied to alternate chairs in the waiting area to ensure
that people are seated at least one chair apart.
b. Tapes on the floor and physical barriers like queue managers, etc to be used to
help people maintain physical distancing.
9. Reducing instances of hand to hand transfer (handing over of bills/ prescriptions)
10. Avoid cash transaction.
11. Preferably no folder to be used or plastic folders may be used for movement of Patient
stationery (prescriptions, files, coordination slips, etc.) during OPD and IPD visits so that
the same can be easily disinfected with 1% hypochlorite or 70% alcohol solution.
12. Hand hygiene and disinfection protocols to be strictly complied.
13. Equipment maintenance protocols to be continued.

Protocol for Screening and Triaging

The patient screening desk shall be located near the entrance to the hospital and would be the
first contact point before the patient reaches the front desk/registration counter.

1. The patient screening desk shall be manned by a nurse and/or paramedical person who
shall screen all the patients and attendants. Other staff may assist depending on the
requirement.
2. The screening desk shall have the body temperature measuring device, the self-declaration
form, hand sanitizer, Yellow BMW bin, spare masks, a register to note down the details of
the patients and their attendant.
3. Body temperature of the patient, attendants and staff to be checked. Persons with fever to
be advised to seek appropriate medical help and not enter the building.
4. All patients and their attendants to show IDs (Aadhar, Driving License, Voter Card,
Passport, etc). The name and address details of the patients and attendants to be noted for
future contact tracing if needed.
5. The patient (or attendant on behalf of the patient) shall fill up the self-declaration form.
6. The triaging to be done as follows:

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 a. Patients with no fever and negative history of travel, no Flu-like illness and negative
history of contact with a known case of COVID-19: to proceed further to the
registration counter.
b. Patients with fever and/or positive history of travel and/or Flu-like illness and/or
contact with a positive case of COVID-19: to be directed to seek treatment at Govt
designated facilities for handling such cases.
7. All persons to observe hand sanitization before proceeding further to the registration
counter.

PROTOCOL FOR OPD

1. The general instructions are already outlined above.

2. Wear PPE as indicated: surgical mask, goggles/ face shield and gloves.
3. Observe hand hygiene.
4. Slit-lamp should have the barriers/ breath shields.
5. Equipment disinfection protocols to be followed. Ensure proper disinfection
frequently, where patient is coming in contact.
6. Speak as less as possible.
7. Ensure safe use of consumables.
8. Ensure proper management of Biomedical Waste as per the BMW Management
Rules.
9. Prophylaxis: Staff should refer to ICMR guidelines for indications and dosage.

PROTOCOL FOR DILATATION

1. Avoid touching patient while instilling dilating drops.

2. Instruct patients to pull lower eye lid down by themselves while drop is being
instilled.
3. If you have to touch patient, use a bud to pull lower lid down or use disposable
gloves.

PROTOCOL FOR REFRACTION

1. Follow general guidelines as already detailed above.

2. Wear recommended PPE.
3. During vision screening and refraction maintain 2-3 feet distance from the patient.
4. If patient has 6/6 and N6 vision unaided or with current spectacles, retinoscopy may
be avoided.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 5. Follow disinfection protocol.
a. Keep a bowl with disinfectant solution and cotton next to the trial set. Used
lenses to be disinfected before being returned back to the set. Avoid mixing of
unused lenses with used lenses before they are properly disinfected.
b. Trial frames, lenses, furniture, etc used by patient to be disinfected immediately.
c. Unused instruments, tabletops, computers, etc to be disinfected every 2 hours.
6. Contact Lens:
a. Contact lens trial to be avoided unless there is an urgent clinical indication.
b. Use fresh contact lens for every patient to check the fits.
c. Use regular contact lens disinfecting solution.
d. For soft lens, trial use disposable lenses.
e. In the case of specialty Contact lenses, the lenses have to be disinfected using
3% H2O2 and neutralize with normal saline for 2 hours. Space the specialty
appointments in such a way that the same lens would be used after a week or
whatever period you feel would be safer.

PROTOCOL FOR OPTICAL SHOP

1. Follow general guidelines as already detailed above.

2. Wear recommended PPE.
3. Maintain a physical distance of 1-2 metre during checking the prescription, ordering
of spectacles, money transaction, and delivery of spectacles.
4. Avoid handling the prescription.
a. From OPD, a digital copy of the prescription may be sent to the optical shop
counter.
b. From the patient, prescription may be sent over by email and WhatsApp...
c. If hard copy is available with the patient, it may be visualized from a distance.

5. For measuring pupillary distance (PD)

a. Ensure that you are wearing the face shield and gloves.
b. Ensure that appropriate physical distance is maintained.
c. Follow hand hygiene and disinfection protocols.
6. Patient should perform hand hygiene before touching the frames.
7. Request them to shortlist and try on as few frames/sunglasses as possible. Explain
that all products worn need to undergo an elaborate disinfection process.
8. Sample frames touched and tried by the patient should be placed in a separate
plastic tray, and returned to the display only after disinfection.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 9. Sample frames, mirrors, furniture, etc touched by the patient must be disinfected
immediately before use by the next patient.
a. Spectacle frames: 0.5% Hydrogen peroxide or liquid dish soap and rinse with
water.
b. Sunglasses: Liquid dish soap and rinsing with water.
c. Spectacle lenses: Use Isopropyl Alcohol.
d. PD meter/lens meter: Rundown gently with 70% Isopropyl Alcohol. Don’t spray.
10. Use tissue paper to clean the frames and dispose it immediately. Cloth cleaning may
be avoided to discourage multiple use.
11. Explore the possibility of home delivery of spectacles to avoid frequent visits to the
Optical shop.
12. Encourage cashless transactions.

PROTOCOL FOR PRE ADMISSION COVID-19 TESTING

Pre-surgical COVID test on patients is not mandatory as per the guidelines issued by the Indian
Council of Medical Research for Rapid Antibody Test in Hotspot Areas on 17th April 2020.

Protocol for Surgery /IPD Procedures

Scheduling of surgery/ IPD procedures can be done while maintaining the OT air-conditioning,
disinfection and culture protocols.

● All persons going to OT to wear PPE as recommended.

● Reduce the number of staff going to OT to have less crowding and also economical
use of PPE. The suggested bare minimum OT team is one surgeon, one assistant to
the surgeon (only if necessary), one anaesthetist, one circulation staff (nurse or OT
tech as may be required) and one housekeeping staff.
● Choose the quickest possible surgical procedure. Quick and safe surgery is warranted.
● A gap of at least 20 minutes is to be maintained between two procedures in the same
OT for GA cases.
● Surface disinfection of OT table, equipment, trolleys, etc to be carried out between
two procedures.
● Ensure safe use of consumables.
● Ensure proper management of Biomedical Waste as per the BMW Management
Rules.
● Aerosol generating procedures such as intubation and extubation should be done by
anesthetist with recommended PPE use and the surgeon should be outside the OT

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 during these procedures. Bare minimum staff should be present when the patients
are intubated and extubated in the OT.
● Prophylaxis: Staff should refer to ICMR guidelines for indications and dosage.

PROTOCOL FOR DISINFECTION

EQUIPMENT SURFACES THAT TOUCH THE PATIENT

● Clean the patient contact areas on medical equipment with alcohol wipe.
● These include Forehead rest and Chinrest of the following equipment
o Slit lamps
o Keratometers
o Autorefractometers
o Retina Laser
o YAG Laser
o OCT
● These also include the trial lens and frames.
● Change Chin‐rest Papers on Slit Lamps in‐between every patient.
● Slit-lamp barrier screens to be disinfected in between patients with 70% isopropyl
alcohol.

EQUIPMENT AND EQUIPMENT PART THAT COME IN CONTACT WITH THE EYE

● These should be cleaned with alcohol swabs and dried before using for another
patient.
● These include
o Applanation Tonometer
o Pachymeter probe
o A scan probe
o B scan probe
● Lenses that come in contact with the cornea, like Gonioscopes, YAG lenses, etc.
o Gel is placed on the corneal contact part of the lens, so this must be rinsed off
after every use.
o The lens should be dried with a soft cloth after use.
o The lens should be disinfected with alcohol before and after use.

Specific Guidelines for Equipment Disinfection

Coordinate with the Biomedical Engineering Team and Quality team to keep update on any
particular guidelines that may be provided by the Equipment Manufacturer.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Housekeeping Protocol

The hospital areas shall be classified as follows:

High-risk areas: OT, Registration, OPD, Counselling room, Consultation room, Patient waiting
areas, Lifts, Washrooms

Moderate risk areas: Meeting halls, Lounges, Cabins

Low-risk areas: NONE

 Floor of all the high-risk areas MUST be cleaned with 1% Sodium Hypochlorite every 2
to 3 hourly and Moderate risk areas 3 times a day.
 Deep Cleaning to be done any time when there is any contamination.
 Door handles, side rails on stairs, bedside rail, high touch surface like- reception
counter, help desk, gate with 1 % Sodium Hypochlorite ( 2 to 3 hourly)
 Chair in the waiting area (head end, armrest etc), Electronic /IT equipment like
monitor, Keyboard, Mouse etc must be done with alcohol swab frequently.
 All wheelchair and stretcher trolley must be cleaned with 1% Sodium Hypochlorite
solution
 The fogging frequency to be increased for ALL hospital areas. This is to be done at the
end of every working day.

Protocol for reporting for Flu-like Symptoms or Confirmed case of COVID-19

Action to be taken on detection of COVID -19 case

When a person is identified or suspected as positive COVID-19 patient:

 Inform the local health authorities about the case

 Assess the clinical status of the patient prior to referral to a designated COVID
facility
 Disinfection procedures at the entire facility to be done
 All contacts of this patient (other patients being managed in the same area / OPD
consultation room/ward, healthcare workers who have attended to him/her,
support staff who may have come in close contact, caretaker/visitors etc.) should be
quarantined and followed up for 14 days. Their details of the same to be shared with
the local health authorities.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
  All close contacts (other HCWs and supportive staff) of the confirmed case should be
put on Hydroxychloroquine chemoprophylaxis for a period of 7 weeks, keeping in
mind the contraindications of HCQ.

1. When a suspect/confirmed COVID-19 employee is identified

 Any employee developing respiratory symptoms (e.g. fever, cough, shortness of

breath) should be considered a suspected case of COVID-19.
 He/she should immediately inform his supervisor/designated authority /HICC.
He/she should be isolated and arrangement must be made to immediately to refer
such employee to COVID-19 designated hospital for isolation and further
management.
 He/she should be immediately taken off from the duty roster.
 Rapidly identify other employees and other patients that might have been exposed
to the suspect employee and put them under quarantine and follow up for 14 days
(or earlier if the test result of a suspect case turns out negative). Their details to be
shared with the local health authorities.
 All close contacts (other HCW and supportive staff) of the confirmed case should be
put on Hydroxychloroquine chemoprophylaxis for a period of 7 weeks, keeping in
mind the contraindications of the HCQ.
 Organization should follow a contingency plan to maintain continuity of operations.
Staff rosters may done by dividing into two teams which alternate between
reporting to hospital and work from home.
 Ensure that the disinfection procedures are strictly followed.

Once a suspect/confirmed case is detected in a healthcare facility, the standard

procedure of rapid isolation, contact listing and tracking disinfection will follow with no
need to shut down the whole facility.

2. Follow up actions
When Organization reports a COVID-19 case, the HICC will ensure the following in order to
minimize the possibility of an undetected contact/case amongst other patients/HCWs:

 Ensure that active screening of all staff at the hospitals is done daily (by means of
thermal screening especially at the start of shift)
 All healthcare and supportive staff is encouraged to monitor their own health at all the
time for the appearance of COVID-19 symptoms and report them at the earliest.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
  Standard precautions which has already been shared by Govt. of India and Quality team
to be followed diligently by all
 Follow all guidelines regarding the triaging of patients

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Guidelines for Operation Theatre
Version 1.0
w.e.f. May 11, 2020

Prepared by: Kumaran Murugesan, Rajashekar Y L, Lalit Verma, Namrata Sharma, Mahipal S
Sachdev, M.S. Ravindra, T. Nirmal Fredrick, Samina Zamindar Satanshu Mathur, Deepak
Mishra, Rajesh Sinha, Mandeep Jot Singh, Rohit Saxena, Partha Biswas, Jagadeesh Reddy,
Gagan Dudeja, Renu Sinha, Suneeta Dubey, Arup Chakraborti, Nikhil Gokhale

Overview: The main intent of this article is to highlight the important changes to be adopted by
ophthalmic surgeons when they recommission their OT after/during the ongoing SARS CoV-2
pandemic. The routine operation theatre aseptic process and protocols are to be followed as
usual.

Re-commissioning

 Overhaul cleaning of all OT zones as per protocol followed by the hospital

 Air sampling (open/split plate) for culture sensitivity (C/S)
 Swabs and C/S as per the protocol of the Health care organization/ Small health care
organization/Eyecare organization

Staff
Consent of staff as applicable to all
Thermo scanning and History to be done for staff

Recovery Room/Pre-Anesthetic room staff attire/Housekeeping staff attire/Physical

parameters

 Cap
 3-ply mask
 Nitrile gloves
 Protective Goggles/face shield
 Linen OT attire
 Separate zoning for staff

CSSD area attire and Physical parameters

 Cap

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
  3-ply mask
 Nitrile gloves
 Protective face shield
 Linen OT attire

OT staff and surgeon attire

 Cap
 N 95 mask/ 3-ply surgical masks
 Sterile gloves
 Protective Goggles/face shield depending on microscopic / non-microscope surgery
 Normal OT footwear
 Linen OT attire with surgical gown

Patient flow in OT recovery rooms

 Physical distancing to be followed.

 Floor/Instruments/Furniture to be disinfected by surface mopping
 Linen changed as and when required.

Operation Theatre (Topical/Regional Anesthesia)

 Minimal staff (Surgeon/OT nurse/Anesthetist/Running nurse)
 Segregate Bio Medical Waste at the source with proper colour-coded covers and
handled as per guidelines.
 Ensure safe use of consumables
 Surface cleaning of equipment, OT table and floor in between cases and allow
appropriate time for the disinfectant to act. (time taken for the disinfectant to act
and dry up)
For those who are having HVAC systems Ventilation in OT:

 Air handling units (AHU) can be functional in-between cases

 Temperature and humidity to be appropriate.
 Maximize air changes and fresh air intake as per your HVAC.

For those having Split air conditioners:

 Non - COVID OT can have stand-alone room air-conditioners

 Re‑circulate air within a single occupied zone in the OT complex.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
  Temperature and humidity to be appropriate
 Clean air filters (indoor AC unit) frequently.

Operation Theatre for GA cases

 Surgical team to enter the OT after intubation and induction of anesthesia
 Anesthetist team to wear PPE which includes a 3 ply or N95 mask, Cap, Sterile
gloves, Goggles or Face shield.
 After surgery, the surgical team to wait outside the OT and de-gown only after the
patient is shifted to the recovery room safety

Bio-Medical Waste (BMW) disposal:

BMW segregating at source

 Use appropriate color-coded covers

 Follow the current guidelines on the color coding for the biomedical waste disposal.
 BMW should leave the hospital within 48 hrs.
 Soiled Linen should be separated and disinfected as soon as possible.

Instrument cleaning
Instruments should be handled safely by the staff for cleaning. The cleaned instruments are then
packed to be autoclaved appropriately.

Patient’s attire

Patient attire is as per the protocol followed by the hospital. All patients to wear the fresh 3 ply
masks after hand sanitization.

Patient draping during surgery

 Draping of the patient eye should be done with a linen and with an adhesive eye drape.
 The drape should be firmly stuck around the patient eye and the drape should extend all
around.
 Care should be taken to ensure that the drained water during surgery is not spilled while
removing the drape from the patient.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Guidelines for Cataract Surgery
Version 1.0
w.e.f. May 11, 2020

Prepared by: Jagadeesh Reddy, Namrata Sharma, Rajashekar Y L, Mahipal S. Sachdev, Rajesh
Sinha and AIOS Working Committee

Prepared in association with: Intraocular Implant and Refractive Society of India (IIRSI)

AIOS Working Committee:

Amar Agarwal, Amit Porwal, Arup Chakrabarti, Barun Kumar Nayak, Bhudhendra Kumar Jain,
Chandrasekhar D., Chitra Ramamurthy, Cyres Keiki Mehta, Debasish Bhattacharya, Gaurav
Luthra, Haripriya Aravind, Harsha Bhattacharjee, Himanshu Rasiklal Mehta, J. S. Titiyal, Jagat
Ram, Jatinder Singh Bhalla, Keerthi Kumar Dasari, Keiki R. Mehta, Krishna Prasad Kudlu, Krishna
Prasad R., Kumaran Murugesan, Mandeep Jot Singh, Mohan Rajan, Murthy Somasheila I., Om
Parkash Rohit, Padmanabhan Prema, Parikshit Gogate, Partha Biswas, Pravin Krishna V., Ragini
Hasmukuray Parekh, Rohit Khanna, Santosh G. Honavar, Sonu Goel, Sri Ganesh, Vinod Kumar
Arora

Preferred practices pattern for evaluating and managing adults with cataract during the
recovery from COVID-19 pandemic

These guidelines outline the infection prevention and control advice for ophthalmologists and
health care workers involved in the treatment of patients for ophthalmic care.

They are based on the available literature from India and abroad at this point of time and should
be used in conjunction with the guidance received from the Ministry of Health and Family
Welfare (MoHFW), Government of India (GoI and Indian Council of Medical Research
(ICMR).Please follow regulations from State governments / local appropriate regulatory
authorities

With the evolving situation on COVID19, further updates will be made to this guidance as and
when required.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Planning the functioning of ophthalmic setup

It is important to minimize the amount of time the patient spends in the clinic and also decrease
the number of visits that patient has to make to the clinic.

1. Identify the minimum number of staff needed to function

2. Identify and delineate areas based on the flow of the patients

The following measures may help in decreasing the waiting time and the number of visits to the
clinic:

 Implement physical distancing at all-time points (reception, waiting areas,

consultation chamber, pharmacy, optical shop etc.)
 Fix prior appointments, if possible and function with a fixed number of patients per
hour to minimize the number of patients and one attendant in the waiting halls.
 One attendant to be allowed per patient. If possible, the attendant may wait outside.
 To take history of any symptoms of active COVID that is TOCC (history of travel,
fever, cough, difficulty in breathing, loss of taste, loss of smell) and also of any
primary /secondary contacts.
 Emphasize the patient and the attendant are mandated to download the Aarogya
Setu COVID-19 tracking App by the Government of India (with location enabled )and
register with their mobile number for possible future digital tracking.
 Every patient & attendant should pass through the triage area with norms of physical
distancing /appropriate partition and assessed on the risk of being COVID-19
positive. If the patient has any symptoms or signs of COVID-19 they should be
referred to the designated COVID hospitals in your area.
 There may be need for multiple stations based on number of patients seen.
 Temperature by non-contact method to be measured for each patient and
attendant.
 All elevators to have demarcation lines and ensure patients are standing facing walls.
 Online payment methods to be encouraged to minimize the contact with currency.

Safety precautions to be taken in the clinic

All norms of physical distancing should be maintained.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Patient related

 All patients and attendants should have a mask or equivalent.

 All should use sanitizer at the entry
 Minimize baggage to the clinic
 To be seated in designated seats only
 Avoid talking to other patients/ attendants

Employee related

 All staff should have the mask and the hand gloves on at all time points.
 Keep the doors open to allow free flow of air and minimize the contact with
doorknobs.
 Reduce workforce-patient contact time.
 Keep more than one meter away from patients except where clinical
examination/investigation/ surgery is performed.
 Avoid/Minimal speaking at the slit lamp.
 Keep the examination brief and pertinent to the decision making required.
 Avoid/ minimize re-examination of patients who have already been assessed.
 Clean all surfaces (chair units, stool, slit lamp, desk, keyboard, computer monitor,
trial frame etc.) with appropriate cleaning solution before starting clinics. Same
should be repeated after each patient examination. Sodium hypochlorite solution
may be used to clean chair, stools as well as desks and alcohol swab for slit lamp,
computers and keyboard etc).
 Hand sanitizing protocol to be followed during the examination and also in between
patient examinations

Examination protocols

The following safety protocols may aid in decreasing the possibility of developing cross infection.

• History:
Maintain distance while talking to the patient and keep the mask on while talking.
Minimize the need to touch the documents from the patient.

• Visual Acuity:
Distance: When testing visual acuity, one may start from the lowest achievable line to
speed things up. Avoid using occluder and request patients to close the non-testing eye

32
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 with their palm after using sanitizer. At least one-meter distance from the patient should
be maintained while assessing visual acuity.

Near: Hold the near vision chart with gloved hands at appropriate distance instead of the
patient holding the chart. One may assess the near vision while standing so that the
examiner is at a higher level compared to that of the patient.

• Manifest Refraction: Avoid touching the forehead of the patient to measure working
distance. The Trial frame, pinhole occluder and all lenses used should be wiped with
alcohol swab or appropriately sanitized before bringing the next patient and provide
sufficient time to make the surface of these instruments dry.

• Intraocular Pressure (IOP): IOP may be performed using Schiotz tonometry or Goldman
applanation tonometry (GAT) or such devices to minimize the risk of cross infection. The
GAT prism to be wiped with alcohol between every case and with 1:10 sodium
hypochlorite at the beginning and end of the day. Refer to the guideline by the Glaucoma
Society of India.
• Non-contact tonometry may be avoided as it is may generate aerosols.
• Slit lamp examination: The breath shields should be used to minimize the risk of aerosol
contamination by acting as a barrier between the patient and the ophthalmic health care
professional. All the surfaces should be cleaned before examining the next patient.
• Lacrimal sac evaluation: Take universal precautions while examining the lacrimal sac. In
suspicious case of chronic nasolacrimal duct obstruction or chronic dacryocystitis, it is
advisable to postpone cataract surgery. Refer to the guideline by the Oculoplasty Society
of India
• Fundus examination: Do not use direct ophthalmoscope. Use indirect ophthalmoscope.
Indentation to be avoided. Refer to the guideline by the Vireo Retina Society of India
• Nd: YAG Capsulotomy: It can be considered wherever necessary. The breath shield
should be installed as a barrier between the patient and the ophthalmologist.

Dilatation Protocol

• Avoid touching patient while instilling dilating drops

• Instruct patient to pull lower eyelid down by themselves while drop is being instilled
• If you have to touch patient, use a bud to pull lower lid down or use disposable gloves

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Diagnostics in cataract surgery

General Guidelines:

• Patient to be allowed into the room which has diagnostic instruments after wearing mask
covering the nose and mouth of the patient.
• Hand sanitizer to be made available in the diagnostic room.
• The patient and technician should sanitize hands before proceeding for the scan.
• All instruments head rest to be attached with a breath shield.
• All instruments in diagnostic area to be cleaned once in the morning before the start of
OPD and once in evening after the completion of OPD.
• Minimal touching of surfaces by the patient and attendant in the diagnostic premises.

Ultrasound (U/S) Biometry:

The tip of the probe should be cleaned with alcohol swab after every case and sufficient time
to dry should be given. In case of use of immersion scan it may be advisable to use clean fluid
and also clean the Prager shell along with the probe.

Keratometry:

To measure the keratometry any keratometer can be used. The breath shield can be
customized and placed as a barrier. The joystick, locking screw for the instrument base, head
rest, chin rest, handlebar should be cleaned using alcohol swab after examining each patient.

Optical Biometry:

Clean the main instrument panel using a soft, lint-free cloth dampened with alcohol at
maximum 70%. All necessary cleaning protocols as per the manufacturer should be followed.
Breath shields should be incorporated between the technician and the patient to prevent
direct contact with the aerosols generated. Following parts to be cleaned with alcohol swab
after every patient: joystick, locking screw for the instrument base, head rest, chin rest,
handlebar which the patient holds, keyboard and touch display

Counselling:

Once a patient has been diagnosed with a cataract and scheduled for surgery it would be
preferable to complete the discussion and minimise the patient mingling with other people.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 One can fix the date, provide pricing details and also give clear instructions for surgery-day
protocols.
Confirmatory tests for COVID-19 and chest x-ray may be requested at the discretion of the
operating surgeon. The patient may be counselled for surgery and special COVID consents
should be taken before the surgery.

Preparedness for opening the operating theatre (OT): Fulfilment of Administrative Clinical and
Legislative (ACAL) criteria

Assurance

• Health care facilities may provide awareness to the public of the use of infectious control
measures and the safety involved in the elective consultation and surgery.

Clinical

• Personal Protection Equipment: Check for availability and also follow the evolving
policies for the health care workers and specific procedures.
• Analyse the patient backlog: Assess the number of patients who have been examined
earlier and are due for cataract surgery. Scheduling can be done based on priority and
available resources.
• Cleaning protocols: Cleaning in all areas should be addressed based on recommended
protocols (e.g., preoperative, anaesthesia room, patient waiting room, OTs, changing
rooms etc.).

Administrative

• The risk profiling zones would keep changing and hence monitoring the same would help
in changing the hospital protocols.
• Utilization/efficiency: Apart from ensuring the safety of patients and the health care
workers the utilization of the OT space and the efficiency of the staff should be
monitored to maintain economic stability.
• OT schedules: The schedules may be staggered over a period of time and the team
/facility should be ready to accommodate the influx of ophthalmic cases, if any. The
scheduling efficiency can be improved by opening up extended hours and weekend
working schedules, if required.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Logistics

• Accessibility to patient: Health care facility may engage the patients by being accessible
through other technologies such as teleconsultation etc.
• Availability of staff: The entire multidisciplinary cadres (surgeon, anaesthesia, nursing,
biomedical, housekeeping) of OT staff should be made aware of the most updated
protocols. Mock drills may be done to assess their acquaintance with new protocols
before commencing the OT.
• Current inventory: It is important to assess the current inventory and to ensure that all
the necessary consumables required for cataract surgery are available and also make
sure that a constant supply of these are available.
• Equipment: Most of the equipment (surgical microscopes, phacoemulsification
platforms, Femtosecond lasers, etc.) would have been idle for several days and is
important to ensure that all these are functioning, as per standards proposed by the
manufacturer.
• Operating room: In the absence of any definite evidence for the need to change the
operating environment for cataract surgeries, the current OT facility may be continued
till definitive guidelines are issued by the GoI. Refer to the guideline by the OT
committee.

Flow of patients in the operating room/waiting room

• Patient may be contacted before surgery to understand if the patient or any family
members have symptoms of COVID-19 or any history of recent travel to
hotspots/containment zone.
• Entry through triage area for temperature check
• Only one attendant is allowed.
• Patients should change into OT clothes before entering the OT.
• Both patient (triple layer mask) and attendant to wear mask/equivalent all through and
sanitize hands
• Ensure safe distancing at all time points
• Space out surgeries

Cataract Surgery

Cataract surgery including phacoemulsification has not been proven to be an infective

aerosol generating procedure till date. (Email communication with James Chodosh).

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Operating Room:

PPE to be worn by the surgeon/ assistant/ scrubbing nurse

• N 95 mask/ triple layered mask to be used at all times

• Surgical scrubs, cap, footwear cover
• Sterile gloves to be used while operating
• Protective goggles and/or glasses to be used during surgery
• Sterile linen gown/disposable gown should be used during the surgery.

Anesthesia

Use Topical anesthesia or block anesthesia, as appropriate.

Local anesthesia

• Use gloves and PPE recommended in the OT

• Mark the eye
• Instill topical anesthetic drops , 5% povidone iodine eye drops (2 minutes contact time) in
the eye to be operated.
• Apply povidone iodine to the operating eye and the adnexa
• Care to prevent spillage of body fluid on surgeon / anaesthetists / staff or floor
• Peribulbar anesthesia/retrobulbar anesthesia can be given
• If the number of patients is limited, the peribulbar anesthesia/retrobulbar anesthesia
may be administered directly on the operating table.

During Surgery:

• Scrub and put on sterile linen gown /disposable gowns and gloves.
• Instill povidone iodine 5% in the operating eye (2 minutes of contact time) before
applying sterile drapes as it inactivates any virus in the tear film.
• Drape the eye appropriately; taking care that the draining pouches is open and not
leaking.
• Viscoelastic may be used frequently over the cornea as this may avoid need for frequent
instillation of balanced salt solution/ ringer lactate over the cornea.
• Handle equipment carefully so as to avoid injury with sharps to self and others.
• Avoid spillage of body fluid or blood particularly when squirting ringer/viscoelastic from
syringes

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 • Assisting team must handle patient with gloved hands wearing the mask and a linen
gown.
• Sterilized phacoemulsification tip and sleeve should be used for each case
• Avoid delivering of ultrasound energy when the phaco probe is not in the anterior
chamber
• Ensure that all the fluid is collected in the pouch and not spilled on the floor
• All sheets on the operation table should be changed in between patients and the tables
should be sanitized using appropriate disinfectants.
• At the conclusion of the surgery discard used disposable instruments following
biomedical waste policy.

Postoperative care and follow up

The postoperative care can the customized case to case basis at the surgeon’s discretion

References:

1. Ashour HM, Elkhatib WF, Rahman MM, Elshabrawy HA. Insights into the recent 2019
Novel Coronavirus (SARS-CoV-in light of past human coronavirus outbreaks. Pathog.
2020 (Basel,Switzerland);9(3):1–15. doi:10.3390/pathogens9030186.
2. https://static.mygov.in/rest/s3fs-public/mygov_15883406691.pdf
3. Smith R. Social measures may control pandemic flu better than drugs and vaccines.
BMJ 2007; 334 : 1341.
4. Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al. SARS-CoV-2 viral load in
upper respiratory specimens of infected patients. N Engl J Med 2020; 382 : 1177-9.
5. World Health Organization. Coronavirus disease (COVID-19) advice for the public.
WHO; 2020. Available from: https://www.who.int/emergencies/diseases/novel-
coronavirus-2019/advice-for-public, accessed on March 17, 2020.
6. Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. [The
epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases
(COVID-19) in China]. Zhonghua Liu Xing Bing Xue Za Zhi 2020; 41 : 145-51.
7. Van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of
SARS-CoV-2 as compared with SARSCoV-1. N Engl J Med. 2020. Mar 17 [Online ahead
of print].
8. Zhou Y, Zeng Y, Tong Y, Chen C (2020) Ophthalmologic evidence against the
interpersonal transmission of 2019 novel coronavirus through conjunctiva.
medRxiv:2020.2002.2011.20021956. https:// doi.org/10.1101/2020.02.11.20021956

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 9. Parrish 2nd RK, Stewart MW, Duncan Powers SL. Ophthalmologists are more than
eye doctors: in memoriam Li Wenliang. Am J Ophthalmol. 2020. Mar 9 [Online ahead
of print]. https://doi.org/10.1016/j.ajo.2020.02.014.
10. Xia J, Tong J, Liu M, et al. Evaluation of coronavirus in tears and conjunctival
secretions of patients with SARS-CoV-2 infection. J Med Virol. 2020. Feb 26 [Online
ahead of print]. https://doi.org/10.1002/jmv.25725.
11. Seittzman GD, Doan T. No time for tears. Ophthalmology. 2020;127(7). [In Press]
https://doi.org/10.1016/j.ophtha.2020. 03.030.
12. Thomas R., Thomas S., Braganza A. Evaluation of the role of syringing prior to
cataract surgery. Indian J Ophthalmol. 1997; 45:211–214.
13. https://www.haag-streit.com/haag-streit-diagnostics/campaigns/haag-streit-
supports-you/
14. https://www.zeiss.com/meditec/int/product-portfolio/optical-biometers/iolmaster-
700.html
15. Malhotra N, Joshi M, Datta R, Bajwa SJS, Mehdiratta L. Indian Society of
Anaesthesiologists (ISA National) Advisory and Position Statement regarding COVID-
19. Indian J Anaesth. 2020;64(4):259‐263. doi:10.4103/ija.IJA_288_20

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Guidelines for Refractive Surgery in COVID Era
Version 1.0
w.e.f. May 11th, 2020

Prepared by: Pooja Khamar, Namrata Sharma, Rohit Shetty, Rajesh Sinha, Mahipal S.
Sachedev, and AIOS Working Committee

Prepared in association with: IIRSI and ISCKRS

AIOS Working Committee: Anagha Heroor, Arun Kumar Jain, Ashvin Agarwal, Chitra
Ramamurthy, Cyres Keiki Mehta, Diva M., D. Ramamurthy , Darak Ambarish Balkrishna,
Gaurav Luthra, Himanshu Mehta , J. S. Titiyal, J.S. Dhami Krishna Prasad Kudlu, Kumar J.
Doctor, Manpreet Kaur, Partha Biswas, Pravin Krishna V., Rupal Shah, Samaresh Srivastava,
Somasheila I. Murthy, Sonu Goel, Sri Ganesh, Sudhank Bharti, Vardhaman Kankaria

Preferred practice patterns for operating room and managing operating instruments
during Covid -19 global pandemic

Covid -19 outbreak has posed as an extraordinary threat affecting global health. To address
this issue in order to avoid unwanted exposure certain guidelines are curated in conjunction
with the protocol received from Ministry of Health and Family Welfare (MoHFW),
Government of India (GOI) and Indian Council of Medical Research (ICMR) and after
discussing with fellow ophthalmologists all over India. These instructions need to be
followed in stepwise pattern throughout to ensure complete safety

Measures followed while entering the hospital

 Before scheduling the patient for any surgery, patient and his/her family members
should be thoroughly questioned about the presence of any COVID-19 symptoms and
history of recent travel to hotspots/ containment zone
 Pre-op COVID testing should be done as per rule by government and the cost can be
owned by the patient/doctor which is to be discussed
 One attendant per patient should be allowed. This prevents unnecessary
overcrowding in the waiting room.
 Temperature by non-contact method should be used both for the patient and the
attendant
 All patients and attendants should have a mask covering nose and mouth of the
patient and should sanitize hands on entering OPD & OT

40
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
  The patient and the attendant are explained the current scenario and mandated to
download the Arogya Setu Covid – 19 tracking App with their mobile number for
future digital tracking and enable the access of their location in the mobile.
 During the movement in all areas like reception, waiting area, pharmacy shop social
distancing should be strictly followed
 Online payment methods to be encouraged to minimize the contact with currency

1. Refractive surgeries

Refractive surgeries are elective procedures and are included in the non-urgent category
of the recent COVID 19 related ophthalmic guidelines published by the Indian journal of
Ophthalmology.1 Studies have reported that the prevalence of SARS-CoV-2 in tears is
low.2 Also, the excimer laser ablation of the cornea in a human immunodeficiency virus
(HlV)-infected or herpesvirus-infected patient posing a health hazard to the operating
surgeon is extremely unlikely.3 Refractive surgeries being a day care procedure, if
performed with proper protocols and safety precautions can be considered to be safe.
Excimer laser procedures might generate aerosols and hence due precautions should be
taken to maintain safety. Therefore, it is at the surgeon’s discretion to start the refractive
procedures.

Pre-operative Workup

While performing refraction, avoid touching the forehead of the patient to measure
working distance. The Trial frame, pinhole occluder and all lenses used should be wiped
with alcohol swab appropriately sanitized before bringing the next patient and provide
sufficient time to make surface of these instruments dry.
Intraocular Pressure (IOP): Non-contact tonometry -should be avoided as it may
generate aerosols.

IOP may be performed using Schiotz tonometry or Goldmann applanation tonometry

(GAT) or such devices to minimize the risk of cross infection. The GAT prism to be wiped
with 70% isopropyl alcohol between every case and with 1:10 sodium hypochlorite at
the beginning and end of the day. Refer Glaucoma guidelines.

The breath shields should be on the slit lamp to minimize the risk of aerosol
contamination by acting as a barrier between the patient and the ophthalmic health care
professional. The chinrest, the head band, the hand rest and both the surfaces of breath
shield should be cleaned before examining the next patient.

41
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Corneal topography is the most important investigation in the pre-operative work-up of
a refractive surgery. It is a quick, non-aerosol generating and non-contact procedure
entailing a negligible risk of transmitting the virus to the patient. Additionally,
applications of breath shields and cleaning of the device by alcohol in-between two
patients should be followed to be extra-precautious. Also, wearing of mask during
topography by the patient to be deemed mandatory. The examiner must give clear,
concise instructions to minimize touching the patient for positioning.

Ultrasonic Pachymetry can be done - As per A Scan guidelines listed in cataract surgery
guidelines.

OT etiquettes to be followed

 Ensuring your safety – use of personal protective equipment according to the

general OT guidelines
 N 95 mask/ triple layered mask, surgical scrubs, cap, sterile gloves, protective
goggles and sterile linen gown/disposable gown should be used while operating.
 Staff members equipped with the necessary protective items
 Avoiding over-crowding and practice social distancing in waiting area as well as
inside the OT
 One patient (wearing appropriate protective gear) at a time in the waiting area
 Changing into OT dress and keeping your clothes in a plastic bag to avoid contact
with any surface.
 Regarding an additional consent form for surgery- to follow general ophthalmic
surgery guidelines

Intra-operative precautions

 Under aseptic conditions: well draped patient with adequate exposure of the
surgical area
 Drying ocular surface properly using sterile dry swab before starting the surgical
procedure to avoid pooling of secretions and tears.
 Drying of the surface is essential to prevent the aerosols from collecting in the fluid.
 Swabs collected in a dry sterile pouch
 Immediate disposal of cone and tubing after sanitizing it
 Ensure drying cul-de-sac throughout the procedure to avoid coming in contact with
aerosols from splashing of secretions
 Use povidone iodine eye drops diluted in lubricating eye drops.
 Minimal ocular surface wash from a distance

42
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
  The refractive suite be covered with screens that can be easily sterilized without
damaging the surface of the machine.
 At the conclusion of the surgery discard used disposable instruments following
biomedical waste policy.
 Use proper technique for removal and disposal of the gloves and the gown .
 Preparing for the next patient- Cleaning patient interface in between.

Postoperative care

The routine post-operative instructions and medications to be followed. One can

consider an early tapering of steroids. Avoid NCT, in case wherein it is imperative to
check the IOP, consider using the GAT after following sterilization guidelines as
mentioned above. One may also consider keeping the post-operative follow-up visits
beyond day one to minimal.

2. Corneal Collagen Crosslinking (KXL)

The decision regarding performing KXL will depend on the clinical stage of the
keratoconus, and the clinical judgement of the treating surgeon.

Pre-operative and operative precautions to be taken are similar to the ones outlined for
the refractive surgery.

Intra-operative precautions and OT etiquettes to be followed

Only one patient per OT rule to be followed. Prefer a bandage contact lens over the use
of pad and bandage. Remove the bandage contact lens and dispose it taking proper
precautions. The KXL equipment for administering the UVA light should be cleaned with
solution as per manufacturer’s recommendation.

Cleaning of instruments and machines

It should be followed according to the manufacturer’s guidelines of each machine in order

to avoid inadvertent damage by the cleaning solutions.

3. Implantable collamer lens

Implantable collamer lens implantation has not been proven to be an infective aerosol
generating procedure till date. Refer Cataract surgery guidelines.

Pre-operative Precautions

To be followed as in refractive surgery section mentioned above

43
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
OT etiquettes to be followed

 PPE to be worn by the surgeon/ assistant/ scrubbing nurse

 N 95 mask/ triple layered mask to be used at all times
 Surgical scrubs, cap.
 Sterile gloves to be used while operating
 Protective glasses with a side protective patch to be used during surgery
 Sterile linen gown/disposable gown should be used during the surgery.

Anesthesia
 Use Topical anesthesia or block anesthesia, as appropriate.

Intra-operative precautions

 Use gloves and PPE recommended in the OR

 Mark the eye.
 Instill topical anesthetic eye drops, 5% povidone iodine eye drops (2 minutes contact
time) in the eye to be operated.

 Povidone iodine paint applied to the operating eye and the adnexa
 Care to prevent spillage of body fluid on surgeon / anaesthetists / staff or floor
 Peribulbar anesthesia/retrobulbar anesthesia can be given using proper precautions
.See OT guidelines
 Sub tenon or intracameral anesthesia can be given during the procedure
 If the number of patients is limited, the peribulbar anesthesia/retrobulbar anesthesia
may be administered directly on the operating table.

During Surgery:

 Scrub and put on sterile linen gown /disposable gowns and gloves.
 Instill povidone iodine 5% in the operating eye (2 minutes of contact time) before
applying sterile drapes as it inactivates any virus in the tear film.
 Drape the eye appropriately, taking care that the drainage pouch is open and not
leaking.
 Viscoelastic may be used frequently over the cornea as this may avoid need for
frequent instillation of balanced salt solution/ ringer lactate over the cornea.
 Handle equipment carefully so as to avoid injury with sharps to self and others.
 Avoid spillage of body fluid or blood particularly when squirting ringer/viscoelastic
from

44
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
  syringes
 Assisting team must handle patient with gloved hands wearing the mask and a linen
gown.
 Ensure that all the fluid is collected in the pouch and not spilled on the floor
 All sheets on the operation table should be changed in between patients and the
tables should be sanitized using appropriate disinfectants.

References:

1. Sengupta S, Honavar SG, Sachdev MS, Sharma N, Kumar A, Ram J, et al. Indian Journal
of Ophthalmology Expert Group for COVID-19 Practice Guidelines; Composition of
the All India Ophthalmological Society - Indian Journal of Ophthalmology Expert
Group for COVID-19 Practice Guidelines includes the Writing Committee (as listed)
and the following members (in alphabetical order by the first name):. All India
Ophthalmological Society - Indian Journal of Ophthalmology consensus statement on
preferred practices during the COVID-19 pandemic. Indian J Ophthalmol. 2020
May;68(5):711-724.

2. Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, Wu K. Characteristics of Ocular Findings of

Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA
Ophthalmol. 2020 Mar 31. doi:10.1001/jamaophthalmol.2020.1291. [Epub ahead of
print]
3. Hagen KB, Kettering JD, Aprecio RM, Beltran F, Maloney RK. Lack of virus
transmission by the excimer laser plume. Am J Ophthalmol. 1997 Aug;124(2):206-11.
4. Shajari M, Steinwender G, Herrmann K, Kubiak KB, Pavlovic I, Plawetzki E, Schmack I,
Kohnen T. Evaluation of keratoconus progression. Br J Ophthalmol. 2019
Apr;103(4):551-557. doi: 10.1136/bjophthalmol-2017-311651. Epub 2018 Jun
1.PubMed PMID: 29858179.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Guidelines for Cornea and Eye Banking during COVID Era
Version .1
w.e.f. May 11. 2020

Prepared by: Namrata Sharma, Rakhi Nathawat, Sharon D’souza, Rajesh Sinha, Nikhil S.
Gokhale , Rajesh Fogla, J.S.Titiyal, Quresh B. Maskati, Gobinda Mukherjee, Mahipal Sachdev,
and AIOS Working Committee

Prepared in Association with: Eye Bank Association of India, Cornea Society of India, India
Society of Cornea and Keratorefractive Surgeon

AIOS Writing Committee: Arun Kumar Jain, Geetha Iyer, Hemant Kumar, Himanshu Matalia,
Hitendra Ahooja, J.K.S.Parihar, Jnanankar Medhi, Mandeep Jot Singh, Manisha Acharya,
Mukherjee Rajib, Nilesh Mohan, Paras Mehta, Praveen K. Vadavalli, Promila Gupta, Radhika
Tandon, Rajiv Garg, Rakesh Shah, Rekha Gyanchand, Rishi Mohan Ritika Sachdev, Ritu Arora,
Samar Basak, Shakeen Singh, Srinivas K. Rao, Sujata Das,Sunita Chaurasia,Swati Tomar, Vikas
Mittal, Atul Kapoor, Prafulla Maharana

Disclaimer: The current outbreak is unpredictable. If widespread community-transmission

occurs, healthcare infrastructure and capacity issues may have a further impact on donation and
transplantation. These recommendations will be regularly updated to account for the changing
epidemiology and new information regarding treatment and testing. All transplant units and eye
banks must be aware of national and local government guidance. These guidelines to be used in
conjunction with guidelines from appropriate State Authorities.

No suit or legal proceedings shall lie against any person for anything done or intended to be
done in good faith under this suggestions/advisory unless proved otherwise.

Introduction:

As per the Ministry of Health and Family Welfare (MoHFW) – all medical activities as deemed
required by the hospital can be carried out by all hospitals except in containment zones. COVID
testing for pre-operative patients is not mandatory but can be done as per the hospital policy
and anaesthetist /doctor discretion even if the patient is asymptomatic. Prioritize surgeries as
per medical emergency – For corneal transplants: Tectonic and therapeutic corneal transplants
to be done on priority over optical and lamellar corneal transplants. Special consents can be

46
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
added to the preoperative protocol for COVID time

Advisory for resuming the Eye Banking Activities

• The Eye Banking activities to be resumed through hospital cornea retrieval programme
(HCRP) and to be from a hospital which is declared as non-COVID
• No eye banking activities to be started in the containment areas of Red zones.
Containment zones shall be demarcated within Red (Hotspots) and Orange Zones by
State/UTs and District Administration based on the guidelines of MoHFW
• Voluntary / Community donation is more hazardous for the recovery team and to be put
on hold for 2 weeks or until the fresh guidelines are circulated whichever is earlier
• The Recovery Technician/ doctor to use PPE ( including N95 mask, cap, face shield/visor,
gloves, gown) while recovering the donor tissue for 2 weeks or until the fresh guidelines
are circulated whichever is earlier
• The technicians and relevant staff must be given training about the PPE use and other
precautions during retrieval to reduce the risk of acquiring infection
• Eye Bank Association of India recommends that the collection of a nasal swab of the
deceased donor for RT-PCR COVID19 testing can be done and sent to the laboratory
immediately.
• All collected tissues should be quarantined for 48 hours prior to the release of the tissue
for usage for transplantation. Avoid immediate usage

The Eye Bank Association of India recommends that eye banks exclude the following potential
donors for ocular tissue collection:

• Tested positive for or diagnosed with COVID -19.

• Acute respiratory illness or fever 100.4°F (38°C) or at least one severe or common
symptom known to be associated with COVID -19 - (e.g. unexplained fever, cough,
shortness of breath, diarrhoea) with no other etiology that fully explains the clinical
presentation
• Individuals who have been exposed to a confirmed or suspected COVID-19 patient within
the last 14 days, who have returned from nations with more than 10 infected patients
and those whose cause of death was unexplained respiratory failure should not be
accepted as deceased donors.
• As India, itself is a country where COVID pandemic is spreading rapidly, any patient who
lives or has visited the red zone as defined by the Ministry of Health and Family Welfare
vide D.O.No. Z.28015/19/2020-EMR dated 30.04.2020, will be considered as a risk and
must be assessed for the clinical symptoms and avoided for eye donation

47
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 • Evidence of conjunctivitis
• ARDS, Pneumonia or pulmonary computed tomography (CT) scanning showing “ground-
glass opacities” (regardless of whether another organism is present)

Algorithm to follow for Deceased Tissue Donation (Ref: SPANISH RECOMMENDATIONS TO

MANAGE ORGAN DONATION AND TRANSPLANTATION REGARDING THE INFECTION
ASSOCIATED WITH THE NEW CORONAVIRUS (SARS-CoV-2) PRODUCER OF COVID-19 dated
27th March 2020)

COVID19 Symptoms:
COVID19 Symptoms

Severe Common Less Common

Difficulty in breathing Fever Myalgia, Fatigue

Chest Pain Dry Cough Headache, Hemoptysis
Confusion Shortness of breath Diarrhoea, Sore Throat
Bluish lips or face Rhinorrhea
Unresponsiveness Wet Cough
Loss of smell and test

*Close contact is defined as a) being within approximately 6 feet (2 meters) of a COVID-19 case

48
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
for a prolonged period of time; close contact can occur while caring for, living with, visiting, or
sharing a health care waiting for area or room with a COVID-19 case; or b) having direct contact
with infectious secretions of a COVID-19 case (e.g., being coughed on)

General Functioning Guidelines

• Eye banks should document the risk assessment of the deceased by taking a relevant
history from attender or family members and ensure that all staff are aware of the above
• It is recommended that only corneal scleral rim excision be performed and avoid the
whole eyeball enucleation.
• Use Intermediate preservative media for the preservation of corneas
• Donor corneas in intermediate preservation media if not utilised should be shifted to
glycerol on the last day of preservation and kept in a deep freezer for future use for
tectonic purposes.
• Recovery procedures mandatorily require double contact of povidone-iodine to ocular
tissue before retrieval
• The entire disposable PPE kit to be removed immediately after tissue retrieval, properly
packaged to avoid cross infection and disposed off after reaching the hospital as per the
guidelines
• As precaution use double-layered bags (using 2 bags) for collection of waste (blood
sample /Cornea ) to ensure adequate strength and no leaks
• Non-disposable parts of the PPE like goggles/visor to be cleaned with spirit or sodium
hypochlorite immediately after returning to the hospital
• Clean all external surfaces of MK Medium/Cornisol bottles, Flask, ice Gel packs,
Instrument tray, SS Bin with Surgical spirit, alcohol wipes or freshly prepared sodium
hypochlorite after recovery and repeat it at Eye Bank.
• All the donor forms and documents are to be exposed to UV light in the Laminar flow
hood for 30 minutes immediately after the team arrives at the eye bank. (Expose both
sides of forms -30min + 30min)
• The technicians who handled the tissues and materials, to wash hands thoroughly with
soap and water for about 30 sec up to elbow before handling any other work in the eve
bank. (Staff should occupy only their dedicated chair and should not sit in somebody's
chair)
• Each eye bank should monitor and consult local THOTA/NOTTO/SOTTO/ROTTO/State
health authority/NPCB for daily or weekly reports
• EDC/Eye Recovery Technicians may be asked to be on call with limited movement in the
Hospital
• Eye bank-related officials must disclose the history of a hospital visit in the past 14 days
(Verify papers for the cause of visit)

49
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 • The Eye Banks must follow the instructions of local State Government for starting of
services

Cleaning of the Eye Bank

• The floor of the eye bank and laboratory areas MUST be cleaned with 1% Sodium
Hypochlorite every 2 hourly
• Deep Cleaning to be done anytime there is any contamination
• Door handles, side rails on stairs, high touch surface like- reception counter, help desk,
gate with 1 % Sodium Hypochlorite ( 4 Times /Day)
• Chair in the waiting area (head end, armrest etc), Electronic /IT equipment like monitor,
Keyboard, Mouse etc must be done with alcohol swab every two hourly

Human Resource:

• Eye banks should consider reorganisation of the activities, introducing work shifts and
batches and the personnel from one shift to not get in touch with the other shift to
minimise the possibility of infection. If a team gets quarantined due to any reason than
the other one can still continue to work eye banking functions.
• PPE at the workplace should include mask (N95)/other approved masks, gloves and Visor
(face shield) and regular apron. Usage , sterilisation/ disposal of masks as per protocol for
each mask.
• All Eye Bank Staff should be provided with sufficient number of mask, gloves, single-use
plastic aprons with hand sanitizers
• Frequent hand washing and use of hand sanitizer are recommended and sanitizer should
be readily available with all team members during their duty timings.
• Mask mandatory in the presence of other persons
• Separation of office workstations
• Maintain 1.5 m physical distance at all times
• If staff suspected of contact but asymptomatic, quarantine for a minimum of 14 days and
test as per protocols and symptomatology

Sequence for safely putting on PPE

Gown Mask Goggles/Face Shield Gloves

Sequence for safely Removing of PPE

50
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Gloves Goggles/Face Shield Gowns Mask
Wash Hands or use an alcohol-based hand sanitizer immediately after removing all PPE.

All the staff members are advised to follow below steps while going back home from eye
bank/Hospital as per the guidelines of Ministry of Health and Family Welfare dated 7th April
2020 :

• Ring up home when you start form office

• Someone at home should keep the front door open (so that you don’t have to touch the
calling bell or door handle) and a bucket of water with washing soap powder or bleaching
powder added to it in the front door
• Keep things (vehicle keys, pen, sanitizer bottle, phone) in box outside the door
• Wash your hands in the bucket and stand in the water for a few minutes. Meanwhile use
tissue and sanitizer and wipe the items you have placed in the box
• Wash your hands with soap water again
• Now enter the house without touching anything
• The bathroom door is kept open by someone and a bucket of detergent soap water is
ready.
• Take off all the clothes and soak inside the bucket
• Take head bath with a shampoo and body with soap
• Wash your clothes and dry clothes in direct sunlight

Staff training: A training program is to be organized for all the staff of the eye bank, covering all
the above guidelines and proper usage of doffing and donning of PPE and collection of nasal
swab prior to resuming eye donation program by the Medical Directors/eye bank manager.

Urgency Wise List of Corneal Procedures:

Emergency procedure Semi-emergency procedures Elective procedure

Corneal Tear repair/ *Keratoplasty for bilaterally *All keratoplasties
Open Globe injury: Repair ± A/C blind/paediatric
reconstruction ± Cataract Sx ± Ant Vit,
etc. Lid Repair
Wound Dehiscence Repair- Post Closed Globe injury:
PK/Post ThPK/DALK Pracentesis/Hyphema drainage,
Traumatic intumescent cataract
ALC tear

51
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 *Therapeutic / Tectonic keratoplasty Shield Ulcer debridement All Ocular Surface
Supratarsal steroid surgeries

Emergency tarsorrhaphy
Emergency Perforation C3r
repair - Tenons patch /
AMG / Glue+BCL

Pseudo membrane peeling for Pseudo membrane

Ulcers - Corneal EKC (Be sure its not COVID EKC) peeling for EKC
scrapings /AC tap /wash
/ Intracameral Inj
/Tarsorrhaphy

Broken/Loose suture: Removal Acute hydrops: C3F8 injection ±

Epilation Compression sutures
SubTenon/Peribulbar injection of
Kenacort in Graft Rejection
Or IVMP injection in Rejection
Mx of Acute SJS/ Burns as per protocol Mx of SJS/Chemical Burn as per
protocol
Foreign Body Removal: Surface or
Intracameral
Sx for OSSN

References:
• https://www.mohfw.gov.in/pdf/63948609501585568987wastesguidelines.pdf
• http://www.gaeba.org/2020/alert-coronavirus-2019-ncov-and-ocular-tissue-donation/
• https://restoresight.org/covid-19-updates/
• https://www.iapb.org/news/corneal-donation-in-times-of-the-covid-19-pandemic/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177097/pdf/main.pdf
• https://www.mohfw.gov.in/pdf/Guidelinestobefollowedondetectionofsuspectorconfirm
edCOVID19case.pdf
• https://restoresight.org/covid-19-updated/
• https://www.gaeba.org/
• https://www.eatb.org/images/COVID-19_Summary_of_Spanish.pdf

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Guidelines for Glaucoma Management during COVID times
Version 1.0
w.e. f. May 11th, 2020
Prepared by: Sushma Tejwani, Dewang Angmo, Barun Kumar Nayak, Namrata Sharma,
Mahipal S Sachdev, Rajesh Sinha and AIOS working committee

Prepared in Association with: Glaucoma Society of India

AIOS working Committee: Sood Devindra, Arup Chakrabarti, Chandrima Paul, Chitra
Ramamurthy, Harsh Kumar, Jatinder Singh Bhalla, Krishna Das R, Manav Deep Singh, Murali
Ariga, R. Venkatesh, Shahinur Tayab, Sirisha Senthil, Suresh Kumar, Surinder Singh Pandav, Tanuj
Dada, Amit Porwal, Ankur Sinha

We are all going through a complex and unique situation, where it is difficult to take decisions
and manage the patients the way we used to do earlier. Now as we are learning to live with the
pandemic we need to device guidelines that allow us to take optimum care of the patients along
with minimizing the threat of COVID spread. It is important to prevent blindness from glaucoma
and equally important is the responsibility to safeguard public health and mitigate the spread of
this virus. These guidelines are based on the available information about COVID. However, these
would keep evolving pretty fast as we keep getting wiser about handling the situation.

To resume elective procedure and medically necessary procedures, following prerequisites to

be kept in mind as per WHO guidelines1 and are common for all ophthalmology patients

1. Authorization for resumption of elective procedures by state govt. guidelines

3. Hospital’s preparedness for resuming facilities and updating infection control protocols and
staff training in general and for COVID in specific.
4. Arrangements for COVID screening prior to surgery, social distancing, regular disinfection.
5. Patients coming for an appointment should be asked prior to entering the waiting room
about respiratory illness/Fever and whether they or a family member reside or have
travelled to the containment zone area in the past 14 days. If they answer yes to either
question, they should be sent to Covid care centre or dedicated Covid hospitals.2
6. Patients & attendant need to wear a three ply / cotton mask throughout their stay in the eye
care facility
7. All the instruments are well functioning and systems in place for sanitizing them in between
the patients

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
8. Doctors, optometrist, and para medical staff have adequate PPE: like N95 or equivalent
masks, Face/ Eye shields and gloves etc.
9. Availability of slit lamp breath shields and explaining patient about minimum talking during
examination
10. To plan much lower patient load than pre-COVID times to avoid crowding of waiting rooms.
Preferable to give appointments with staggered timings to patients to avoid crowding and
prevent long queues and inconvenience to patients. Allow only one attendant per patient
inside the premises.

However, these can be adapted according to the requirement of the clinic/hospital/ institution
and state authority guidelines

Prioritizing the care for outpatients is important to reduce the load on the clinics

1. Clinical prioritization into high risk, medium risk and low risk using tele-triage, medical
records, performa etc. and then give appointments accordingly
2. Tele consult, virtual/video consultation, network of local ophthalmologist, opticians or
optometrists services can be used for low risk patients to avoid crowding in the
hospital/clinics.
3. Based on treating hospitals ability to deal with the number of patients and treating
physician’s discretion, the priorities for medical treatment and frequency of follow up can be
decided.

Prioritization plan for surgery is based on the discretion of the treating Ophthalmologist

As we are slowly resuming our normal practice we should prioritize scheduling surgeries
that require immediate attention, and then shift to urgent, semi urgent and routine
surgeries based on health care facility situation and also state government guidelines.3, 4
However, the surgeries to be avoided in containment zones.

Guidelines for glaucoma management are in many ways similar to the general guidelines for
Ophthalmology patients. The guidelines as regards specifics to glaucoma are mentioned below

A. Clinical examination: When and how, this includes

General guidelines:

• Keep patient in the clinic as minimal time as possible. Let the attendant into the
examination or diagnostic area only if there is a need.
• Only one test to be performed in the diagnostic lab at a time.
• Receive the patient records with gloved hands and give them back after reviewing, do
not place them on your tables.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 • If you are using electronic medical records, ensure hand sanitization or sanitising the
gloves before touching the keyboard or mouse.
• All cleaning of surfaces and equipment to be done with gloved hand.
• Avoid BCL Insertion or removal, suture removal If possible. If need to be used avoid
placing forceps on table, take necessary precautions

1. IOP measurement

• Goldmann applanation tonometer: Use of single-use, disposable tonometer tips if

available to prevent cross contamination.5

For disinfection the GAT prism, the prism is kept in 0.5% bleach /Sodium hypochlorite (1
Part of 5% Sodium hypochloride : 9 Parts distilled water) or 3% Hydrogen peroxide for 5
min, then washed with distilled water, dried and then mounted at the beginning and at
the end of the clinic on daily basis. However Bleach is available in various concentration
ranging from 2-10%, hence dilution can be done accordingly to make it 0.5% solution.
The wipes dipped in 70% Isopropyl alcohol (IPA) solution or alcohol wipe commercially
available with 70% IPA) can be used to clean the tips in between the patients. Since
alcohol will not effectively sterilize the tip against adenoviruses and HSV, additional use
of Sodium hypochlorite at the start and end of the day will help effective disinfection
against adenovirus, HSV, Coronavirus and other viruses commonly associated with
nosocomial outbreaks in eye care.6
• Noncontact tonometers (NCT) should be avoided as they create micro aerosols which
can disperse the virus and hence increase chances of spread of the virus. 3,7
• Icare: For screening with disposable probe, and use a fresh probe for each patient.
• Tonopen: With disposable sleeves. Fresh sleeve to be used for each patient
• Perkins: To be used in pediatric patients, if tonopen and I care not available and should
be used with adequate precautions and tip cleaned similar to the GAT
• The Schiotz tonometer should be dipped in a 1:1000 merthiolate solution and rinsed in
saline/distilled water prior to use8. Heating the base of the instrument with the flame of
a spirit lamp for 10 seconds and allowing sufficient time for cooling before use8. Either of
these procedures are followed at the beginning and the end of the clinic on a daily basis.
Cleaning the foot plate and test cornea with alcohol swab (70% IPA) (allowing sufficient
time for drying of chemicals) between the patients.

2. Gonioscopy:

• To be done as per discretion of Ophthalmologist with appropriate precautions

Gonioscopes can be cleaned (Volk guidelines) in running water with soap solution, dried

55
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 and wiped with wipes or cotton or gauze soaked in 70% IPA, and dried after every use
before placing them in the boxes.9
• 0.5% (5000 ppm) household bleach. Soak the lenses for minimum of 10min (1 Part of 5%
Sodium hypochloride : 9 Parts distilled water in ambient/ room Temp 62º– 72ºF (16.67º –
22.22ºC). (Volk guidelines) 9

3. Fundus evaluation

• Using 90D or 78D with slit lamp biomicroscopy, and fundus photographs
• Indirect ophthalmoscopy using 20D in Covid positive cases
• Avoid using direct ophthalmoscopes as it requires very close proximity to patients face
and mouth.
• Disinfection of lenses 90D/78D/20D/ Laser lenses – 0.5% (5000ppm) household bleach.
Soak the lenses for a minimum of 10min (1 Part 5 % Sodium hypochloride : 9 Parts
distilled water in ambient/ room Temp 62º– 72ºF (16.67º – 22.22ºC). (Volk guidelines)
• 2% Aqueous Solution of Glutaraldehyde. To avoid surface damage to contact lenses,
never clean the contact elements with alcohol, peroxide or acetone

Koeppe and goniotomy lenses can be sterilized with ethylene oxide, prior to use in surgery.

A WORD OF CAUTION:

Use of higher concentration of more than 0.1% of house hold bleach is detrimental for the
surfaces. Hence, regular use of this disinfectants should be avoided for sensitive
instruments.

B. Investigations:

1. Visual Fields: Keeping in mind the lesser possibility of disinfecting the perimetry bowl, visual
field test should be performed

• Only if necessary for diagnosis, planning or changing management

• Tab based perimetry or VR perimetry can be used if possible

Disinfection of perimeter (Recommendation from Carl Zeiss)10

• 70% IPA to wipe all patient and technician interface surfaces e.g. eyepatch, chinrest,
headrest, trial lens holder, trial lens, patient response button
• To clean the bowl of perimeter please follow manufacturer’s guidelines as they vary with
different companies (Quick-start guide from Zeiss and Octopus)

56
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 • Chin rest and forehead rests can also have paper cover, which can be discarded after
each patient

However, the manufacturer’s guidelines should be followed for each perimeter. Also 3
layered masks to be worn by the patient and can be sealed by micropore/ tape above the
nose to prevent spread of aerosols from the patient's breath into the perimeter bowl.

2. Imaging and fundus photography: Imaging preferable over visual fields for suspects and
glaucoma patients, as it would have lesser chances of cross contamination, sanitization is
easier, and the test is faster. The patient should be wearing a 3 layered mask with tape while
performing the test.

Disinfection of OCT, fundus photography machine and others imaging machines

 70% IPA to wipe all patient and technician interface surfaces e.g. eyepatch, chinrest,
headrest. The lens to be wiped with soft cloth, non fibre using ethanol (according to
manufacturer’s advice in manuals) between patients to avoid contamination.

3. Ultrasound biomicroscopy (UBM): To be used only if mandatory and required to decide the
management of a condition that is vision threatening. Always use gloves while performing
the UBM. Best to use disposable tips where possible, can also use a cut glove to cover the
tip of the probe and dispose after every use. Otherwise the UBM cups can be sterilized by
ETO and should be changed after every patient. The probe can be cleaned with 70% IPA, or
covered with a disposable glove that can be discarded after each use.

C. Lasers: Indications to be decided by Ophthalmologists discretion

Use of gloves, masks with tape, Slit lamp breath shield, appropriate disinfection of Abraham
lens and laser need to be kept in mind.

D. Surgical Procedures

Level of urgency as per discretion of the treating surgeon/ hospital/ state authorities
guidelines. Preferable to operate under LA with day care and procedures that require less
postoperative follow up can be chosen based on the treating physician’s discretion

General guidelines for Operating room are similar to any ophthalmology OT

To conclude, the barrier and disinfection systems to be kept in mind at each step.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
References:

1. WHO CDC guidelines, latest updates 1st May

2. Guidance document on appropriate management of suspect/confirmed cases of COVID-19
Ministry of Health & Family Welfare, Directorate General of Health Services, EMR Division
3. Ophthalmology, the journal of the Academy. Preparedness among Ophthalmologists:
During and beyond COVID -19 Pandemic. Ophthalmology’s COVID articles collection
4. AAO guidelines and updates on COVID management
5. Salvi SM, Sivakumar S, Sidiki SS. Use of disposable prism tonometry in routine clinical
practice. Eye (Lond). 2005;19(7):743‐746. doi:10.1038/sj.eye.6701633
6. Junk AK, Chen PP, Lin SC, Nouri-Mahdavi K, Radhakrishnan S, Singh K, Chen TC. Disinfection
of Tonometers: A Report by the American Academy of Ophthalmology. Ophthalmology.
2017 Dec;124(12):1867-1875. doi: 10.1016/j.ophtha.2017.05.033. Epub 2017 Jul 11.
7. Britt JM, Clifton BC, Barnebey HS, Mills RP. Microaerosol formation in noncontact 'air-puff'
tonometry. Arch Ophthalmol 1991;109:225-8.
8. Sood D, Honavar SG. Sterilisation of tonometers and gonioscopes. Indian J Ophthalmol
1998;46:113-6.
9. https://volk.com/pdf/CCG-001-Cleaning-and-Care-Guide.pdf
10. Recommendations from Carl zeiss and Octopus

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Guidelines for managing uveitis patients during COVID 19 Era
Version 1.0
W.e.f May 11th, 2020

Prepared By: Manisha Agarwal, Vishali Gupta, Namrata Sharma, Mahipal S Sachdev, Rajesh
Sinha and AIOS Working Committee

Prepared in Association with: Uveitis Society of India

AIOS Working Committee : Amit Khosla, Amod Kumar Gupta, Balamurugan V., Jyotirmay
Biswas, Kalpana Babu Murthy, Murthy Somasheila I.,Padmamalini Mahendra Das, Parthapratim
Dutta Majumder, Pradeep Venkatesh, R. Rathinam Sivakumar, Salil Mehta, Soumyava Basu,
Sudharshan S.

Modification of the OPD Protocols

1. Triaging the patients in OPD and if anyone has a history of contact or travel or with
symptoms such as cough/fever/myalgia/loss of taste or smell/headache/vomiting, then
to be referred to a COVID clinic for further evaluation
2. Any new patient of uveitis has to be examined in the clinic for making a diagnosis, with
due precautions in place
3. Prefer tele consultation for patients on follow up and have been stable on last two
follow ups or for monitoring of the blood reports in order to avoid frequent visits to the
clinic
4. Fewer patients seen per hour with only one accompanying attendant
5. Punctuality of the appointments to be honored both by patients and doctors to optimize
throughput time from the clinic
6. To maintain social distancing in waiting area
7. Universal precautions to be followed in OPD- face mask/gloves/head cover/face shield
8. To avoid contact instruments such as applanation tonometer or clean after each use
9. Sterilization of the head rest and chin rest of the slit lamp after each patient and
cleaning of 20 dioptre lens with soap and water after each use
10. Minimal talking to the patient in OPD
11. Cleaning of the clinics as frequently as possible

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Guidelines for diagnostic procedure:

Non-invasive

 Optical coherence tomography (OCT)- may be performed with cleaning of the chin rest
and head rest with alcohol swab after each patient who is wearing a face mask while
sitting on the machine with no talking and not touching any part with hands. The lens of
the machine may be protected from droplet contamination by putting a cling film over it
which is changed after every patient or the lens is cleaned as per the recommendation
of the manufacturer.
 Fundus photo or Autofluorescence-maybe performed if essential, with cleaning of the
chin rest and head rest with alcohol swab after each patient who is wearing a face mask
while sitting on the machine with no talking and not touching any part with hands. Lens
is cleaned as per the recommendation of the manufacturer.

Invasive

 Fundus fluorescein angiography(FFA) and indocyanine angiography(ICG)- best avoided

 Anterior chamber tap- to be performed with an informed consent and under strict
aseptic precautions, betadiene 1 % eye drops to be instilled in the cul de sac. 1
 Diagnostic Vitreous biopsy- for vision-threatening conditions to be performed with
informed consent and under strict aseptic precautions. All universal precautions to be
followed in the operation theatre as per the recommendation.2

Management of uveitis

A. Anterior uveitis: Topical steroids may be started or continued at the discretion of the
treating doctor

B. Intermediate uveitis/posterior uveitis/panuveitis

Guidelines for a new patient of uveitis:

● To prefer local therapy in the form of posterior sub-tenon triamcinolone or
intravitreal dexamethasone implant over systemic corticosteroids.
● Intravenous methyl prednisolone is best avoided and one should prefer local therapy
(periocular or intravitreal steroids) alone or in combination with lower doses of
systemic steroids.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 ● Avoid starting high dose oral corticosteroids or immunosuppresants in high risk
patients defined as the following: age ≥70 years, severe chronic lung disease (e.g.
asthma, bronchiectasis, cystic fibrosis, COPD, etc.), severe heart disease, CD4 count
<200, history of diabetes/hypertension/smoking/cardiovascular event.
● Any one eyed patient or with a vision-threatening condition requiring the initiation of
corticosteroids or immunosuppressants may be started on the treatment at the
discretion of the treating doctor and after evaluation by a physician.
● Strict vigilance has to be kept on the blood counts of the patient with a special
precaution to maintain white blood count is kept above >4000 per microliter.

The COVID pandemic is not a contraindication for the initiation of immunosuppressants.

Patients need to be explained regarding the additional risk of secondary infections at the time of
start of the therapy including the following precautions:
● Hand and personal hygiene.
● Avoiding crowds and working from home.
● To have the face mask on at all times.
● If they are sick with fever, malaise then should contact the infection control specialist
and if advised then to consider stopping the therapy.

Guidelines for uveitis patients on maintenance therapy

On Corticosteroids

● Patient is stable then one may consider a gradual taper and stopping of the drug or
maintain at a low dose <10mg/day. However if there is a high risk of recurrence at it
might be vision threatening then one may continue at the same dosage (as per the
discretion of the treating doctor).
● Strict monitoring of blood sugar and blood pressure is recommended.
● In case of any illness or symptoms suspicious of COVID then to be referred to an
infection control clinic.
● In a case of recurrence then to prefer local therapy (sub-tenon or intravitreal) over
systemic corticosteroids.

On Immunosuppresants

● If the patient has been stable for the last two visits and one was considering the
stoppage of the drugs then it may be done at the discretion of the treating doctor
however they do not need to be discontinued due to COVID pandemic.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 ● Patients on immunosuppressants are already primed to monitor their blood counts
regularly, however we may need to reiterate the importance of the same again.
● Strict vigilance has to be kept on the blood counts of the patient with a special
precaution to maintain white blood count is kept above >4000 per microliter and tele
consultation may be useful for the same.
● A patient on immunosuppressant if develops symptoms suspicious of COVID infection
, then needs to be referred to an infection control specialist and if they feel necessary
to stop the ongoing medication, it may be done at their discretion.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 COVID 19 Retina Practice Guidelines
Version 1.0

w.e .f. May 11th, 2020

Authors:,Vishali Gupta1,, Anand Rajendran2, Raja Narayanan3, Shobhit Chawla4, Atul Kumar5 ,
Mahesh Shanmugam Palanivelu6, NS Muralidhar7, Chaitra Jayadev8, Rajeev Pappuru3, Manoj
Khatri9, Manisha Agarwal10, Ajay Aurora11, Pramod Bhende12,Muna Bhende12 , Prashant
Bawankule13, Pukhraj Rishi12, Anand Vinekar8, Hemant Singh Trehan14, Jyotirmay Biswas12,
Rupesh Agarwal15, S. Natarajan16, Lalit Verma17, Kim Ramasamy18, A. Giridhar19, Ekta Rishi12,
Dinesh Talwar17, Avinash Pathangey20, Rajvardhan Azad21, Santosh Honavar22

1. Advanced Eye Centre, Post Graduate Institute of Medical Education and Research,
Chandigarh
2. Aravind Eye Hospital Chennai
3. LV Prasad Eye Institute, Hyderabad
4. Prakash Netra Kendr, Lucknow India
5. Dr. RP.Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New
Delhi.
6. Sankara Eye Hospital, Bengaluru
7. Retina Institute of Karnataka, Bengaluru
8. Narayana Nethralaya Eye Institute, Bengaluru
9. Eydox Hospital, Chennai
10. Shroff Charity Eye Hospital, New Delhi
11. Vision Plus Eye Centre, NOIDA
12. Sankara Nethralaya, Chennai
13. Sarakshi Nethralaya, Nagpur
14. Army Hospital R&R, Dhaula Kuan, New Delhi
15. National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
16. Aditya Jyot Eye Hospital, Mumbai
17. Centre for Sight, New Delhi
18. Aravind Eye Hospital, Madurai
19. Giridhar Eye Hospital, Kochi
20. LV Prasad Eye Institute, Visakhapatnam
21. Regional Institute of Ophthalmology Indira Gandhi Institute of Medical Institute of
Medical Sciences, Patna.
22. Centre for Sight, Hyderabad

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 23. Dr. R P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New
Delhi.
24. Centre for Sight. New Delhi
25. Dr. R P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New
Delhi.

Prepared in Association with: Vitreo Retina Society of India

The position on COVID-2019 is dynamic and constantly changing. We will keep updating the
advisory as required. In light of the potential peril, extra caution is being exercised. The stringent
measures may be relaxed later or revised as more knowledge comes to light.

The Corona virus disease 2019 (COVID-19) pandemic has thrown up several challenges that
healthcare systems and the world, in large, and are struggling to deal with. The All India
Ophthalmological Society (AIOS) – Indian Journal of Ophthalmology (IJO) recently published a
consensus statement on preferred practices during the COVID-19 pandemic and has offered
directions that may prove useful in the post-lockdown period too.1 These guidelines are being
suggested to help restart and conduct Retina services in this new environment. Needless to say,
these would be keep evolving and one needs to follow their respective state’s prevalent ruling at
any given point in time. At the moment of writing, the Ministry of Health and Family Welfare
(MOHFW) has declared that all medical activities, as deemed essential, by a hospital can be
carried out by all hospitals except those in containment zones.

Advisory for resuming Retina Practice

The use of teleconsultation is encouraged to maintain communication, prioritize patients and

affix appointments to avoid crowding in the clinic. Patient details, prior to patient’s arrivals, can
thus be used for new patients. On arrival, patients should be asked, prior to entry, about

 if they have tested COVID positive

 fever, respiratory illness or any of the COVID related symptoms,,
 if they or their family members have been in quarantine

If they answer affirmatively to these questions, they need to be referred to a COVID designated
hospital. The urgency of the need for an examination may be the discretion of the retinal
specialist.1,2

Once the Patient is assessed and considered safe for an ophthalmic examination, the patient

64
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
may be allowed to proceed to the OPD area, ensuring adherence to all the stringent norms for
OPD patient flow listed in the AIOS-IJO Consensus statement. 1

Ensure that patients wear masks covering their face and nose, at all times, while in the hospital.
In order to avoid crowding, it is prudent to give appointments with staggered timings. Only one
attendant per patient needs to be permitted within the premises. All the norms of social
distancing need to be strictly followed.

Preferred protocols for Retinal examination

All precautions regarding the breath shield, disinfection of slit lamp and lenses to be followed as
per AIOS-IJO recommendations.1 Home dilation, where possible for review patients may be
advised. Non touch techniques, Retinal examination during this period may be essentially the
same different except for a few precautions:

1. Contact lens examination of the fundus to be avoided if possible.

2. A face shield mounted on the indirect ophthalmoscope or on the examiner’s head is
recommended in addition to the personal protective equipment (PPE). The indirect
ophthalmoscope mounted shield with a cut out for the eye piece, offers better
visualization of the fundus. Patient should wear a mask during the examination, with the
upper border taped to reduce the risk of patient’s breath contaminating the examiner’s
hands.
3. Alcohol sanitization of the hands prior to wearing the indirect ophthalmoscope and also
prior to removing it is recommended.
4. Scleral depression is best avoided unless essential in a given case. A cotton-tipped
applicator maybe an alternative.
5. Talking during fundus examination is to be avoided.

General Functioning Guidelines for Imaging and Procedures

A. Retinal Imaging

1. The following guidelines may be considered1-3 Clinicians should exercise prudence

while deciding about investigations. Essential and critical investigations may
preferably be only resorted to.
2. Noninvasive Investigative modalities that are less time-consuming or have no
patient contact are preferred. Optical coherence tomography (OCT) and optical

65
OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 coherence tomography angiography (OCTA) can be used as an alternative to dye-
based angiography.
3. Indocyanine Green Angiogram ICG, a long procedure, may be avoided if possible.

B. Retinal Lasers

A prioritised list of indications for Retinal lasers have been detailed in Table 11,2

Laser Delivery Modes, Protocols

1. Non- contact laser delivery systems to be preferred over slit lamp for non –macular
lasers.
2. If both are available, then multispot laser is preferred over single spot laser to make
the process faster and with lesser number of sittings.
3. A drop of povidone iodine may be instilled in the conjunctival cul de sac after
removal of the contact lens.
4. The laser contact lenses or 20 dioptre lens to be washed with soap and water after
every use or may be dipped in sodium hypochlorite (0.5%) solution

C. Intravitreal Injections (IVI)

The Indications are stratified in Table 1. In addition to the standard practices being
followed in the COVID era, all processes need to be in sync with the consensus statement
by AIOS.1,3

1. The injections should be given with patient wearing a mask, draped and the person
injecting should wear gown, N95, face shield (PPE) or as per their institute’s protocol.
2. Between the injections 10-15 minutes time can be given during which scrubbing can
happen.
3. Only the injection for that patient must be loaded on the table and not all the
injections for the day.

Follow-up after Intravitreal Injections

Patient can be asked to give a call the day after injection. In case the patient is comfortable, they
may be called after 4-8 weeks depending on the clinical situation. Patient should be able to
contact the facility at any time if they have issues.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
D. Cleaning and maintenance of Equipment and lenses:

Contact Lenses for Laser and Examination: While they are preferably avoided, if they are
essential, the contact surface of the lens should be washed with detergent and running water
for 20 seconds prior to applying it on the cornea, repeating the washing after the examination.
The lens can be disinfected by immersing the contact surface in 0.5% sodium hypochlorite for 10
minutes after washing. Laser lenses may be covered with cling film that can be removed at the
end of procedure.

Lens for Indirect Ophthalmoscopy & slit lamp biomicroscopy : The condensing lens may be
washed with soap and water or wiped with 95-99.9% isopropyl alcohol between patients. Some
manufacturers have prohibited the use of alcohol to clean their lenses. Shanmugam et al, to
reduce the risk of damaging the lens, have modified it by mounting it on to a custom designed
holder with a clear plastic barrier at the end facing the patient.
(https://www.youtube.com/watch?time_continue=1&v=BC8DCTDkcog&feature=emb_title).
This plastic barrier and the lens mount may be wiped with alcohol in between examinations.

Slit Lamps, Lasers, OCT and OCTA : Wrapping a cling film over the lens can protect the lens of
these equipment from droplet contamination. The surface of the film can be cleaned with an
alcohol based disinfectant or is changed after every patient. The lens of the machine may be
cleaned by the technique recommended by the manufacturer.
Fundus Cameras: Cling film causes compromise in image quality and thus fundus cameras can be
left uncovered. The rest of the device is covered with cling wrap to permit frequent cleaning.

Cleaning of the forehead band, chin rest, lens, the handles and the table which comes in contact
with the patient needs to be done regularly between cases.
Touch Screen Devices: All touch screen devices function fairly well with a cling wrap
B scan probe – Needs cleaning with alcohol wipes between scans. Patients should wear caps.
Electrophysiology - Use of disposable electrodes of the non-contact lens type; cleaning of
equipment between patients,

Vitreo-Retinal Surgery in COVID era

It is emphasized that best practice protocols in VR surgery will be influenced by the practice
situation of each facility and surgeon. The Indications for different vitreoretinal surgeries are
indicated in Table 2. A few concerns around restructuring retinal surgical practice in this era are
detailed below.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
1. Preoperative COVID Testing :

Preoperative COVID testing is not mandated . If a patient is proven COVID positive case, or has a
very strong suspicion of being so, based on history or symptoms, the patient should be referred
to a COVID designated centre. As regards asymptomatic and regular cases, it would be safe to
assume that every surgical patient is a potential COVID spreader and all necessary precautions
be taken.

2. Operation Theatre Specifications :

a. OT designation and flow: It would be useful to have a specifically designated surgical

OT with a donning and doffing area near the OT. The donning could be done in the
regular washing area but will need adequate space. For surgeries under GA, the
surgeon should not enter the OT until the patient is fully stabilized on the anesthesia
circuit and the surgical team is adequately protected.17

b. OT Air conditioning: Switching off air conditioning or more practically keeping the air
conditioning operational with increased rate of air changes and increased ratio of fresh
air mixing in the AHUs should suffice. Negative Pressure OTs are not deemed
mandatory. Positive pressure OTs may continue to be used if it is difficult to convert to
a negative pressure facility. Negative pressure OTs can be created by use of dampers,
altering fan speeds and other engineering modifications.4 If an exhaust system is
added, the exhausted air should be expelled after passing through a HEPA filter. 5,6

2. Patient related Protocols:

Patients for surgery under local anesthesia should wear a surgical mask. If they are
uncomfortable, any device that keeps the drapes away from the nose can be used. Under
General anesthesia, the anesthesia circuit isolates the respiratory tract.

- 5% Povidone iodine should be instilled in the conjunctival sac 5-10 minutes before the
surgery and also used for prepping as it is virucidal , disinfecting the ocular surface and
conjunctival cul-de-sac in 15 seconds.21

3. Personal Protective equipment (PPE):

i. The donning sequence is different from the usual PPE wear in wards and clinics by
the need to wear the N95 mask, boot covers and goggles before handwashing so as
to maintain sterility.
ii. Coveralls are quite difficult to wear in a sterile manner, hence gowns need to be
worn along with N95 masks, goggles, a hood and boot covers. Face shield may
make visualization through a microscope difficult during surgery; therefore, goggles
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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 are preferred and must be worn before the hood. If the hood is worn first, it would
ride over the eyes - the goggles do not push it back. As an alternative, a coverall can
be used, and a sterile gown worn over it.
iii. The doffing sequence is similar to standard protocols, though goggles can be reused
after decontamination. N95 masks if reused on the same day must not be touched
or worn again between cases. If an N95 with a respiratory valve is used, it should be
covered with a surgical mask to decrease the surface contamination.

4. Sterilisation Protocols and Re-use Practices :

Conventional preset institutional protocols, complying with the manufacturer’s

recommendations, regarding sterilization of the instruments should be followed.

 It is preferable not to re-sterilise or reuse residual silicone oil and perfluorocarbon

liquids
 It is advisable to use a fresh bottle of Ringer Lactate or BSS/BSS Plus for each case
 It needs to be ensured that all surgical consumables – (the cutter, tubing, cassettes
etc) should be absolutely sterile and all steps to prevent cross-infection between
successive cases need to be strictly adhered to.

5. Surgical technique modifications:

a. Draping: The draping needs to be done appropriately ensuring watertight sealing

to minimize chances of aerosol dispersion from nasal and oral cavities.
b. Valved Vs Non-valved cannulas: Valved cannulas are preferred, as much of the
fluid spills and bubbling during fluid air exchange may be avoided. Spillage of fluid
or air over the surgeon and assistant(s) especially with IOP controlled machines or
a high bottle height can be caused by non-valved cannulas.

● If only valved cannulas are available, reduce the bottle height or intraocular
pressure during instrument exchange to reduce leakage from sclerotomies.

a. Diathermy : Diathermy is known to cause aerosolization, and a suction tubing

may be used to evacuate the smoke from the surgical field.8

b. Scleral Buckle Vs Vitrectomy: Scleral buckling involves more tissue contact and
diathermy and hence more likely to cause exposure than vitrectomy.

Prevention of fluid spill, high pressure bubbling at the ports or the flute
needle during Fluid air exchange are to be cautioned watched out for during

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 vitrectomy. Passive rather than active aspiration would be safer in this regard.
Reduced instrument exchanges is also preferable.

c. In this period experienced surgeons should perform the surgeries. As the

crisis abates, trainee surgeons may also operate.

6. Resource management:

a. It is preferred to have only one case operated in an OT at a time.

b. As supplies may be limited in this period, it would be prudent to manage

one’s inventories carefully.

c. Extra items should be stored safely in the OT itself to reduce movement of

the circulating nurses to and fro from the stores. Extra items may be kept in a
common Ziploc bag or a transparent box so that the external surface of the
box may be cleaned after the procedure. Each item does not then need to be
separately cleaned if the box remains closed during the surgery.

The guidelines for management of Retinopathy of prematurity (ROP) and Oncology have
been suggested in their respective publications and society updates. 9-12

References

1. Sengupta S, Honavar SG, Sachdev MS, Sharma N, Kumar A, Ram J, et al. All India
Ophthalmological Society – Indian Journal of Ophthalmology consensus statement on
preferred practices during the COVID-19 pandemic. Indian J Ophthalmol 2020;
68:711-24.
2. Chodosh J, Holland GN, Yeh S. Important coronavirus updates for ophthalmologists.
Available from: https://www.aao.org/headline/alert-important-coronavirus-context.
[Last accessed on 2020 Apr 04].
3. Honavar SG, Sharma N, Sachdev MS for the Governing Council of the All India
Ophthalmological Society. AIOS-Operational-Guidelines-COVID19. Available from:
https://aios.org/pdf/AIOSOperational-Guidelines-COVID19.pdf. [Last accessed on
2020 May 05].
4. Brucher BLDM, Nigri G, Tinelli A, Lapena Jr JFF, Espin-Basany E, Macri P et al. COVID-
19: Pandemic surgery guidance.[published online 2020 April 10] 4open; 3 (1). doi:
10.1051/fopen/2020002
5. Park J, Yoo SY, Ko J, Lee SM, Chung YJ, Lee JH et al. Infection Prevention Measures for
Surgical Procedures during a Middle East Respiratory Syndrome Outbreak in a
Tertiary Care Hospital in South Korea. Sci Rep 2020; 10:325.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 6. Chow TT, Kwan A, Lin Z, Bai W. Conversion of operating theatre from positive to
negative pressure environment. J Hosp Infect. 2006; 64:371-378
7. Eggers M, Eickmann M, Zorn J. Rapid and Effective Virucidal Activity of Povidone-
Iodine Products Against Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
and Modified Vaccinia Virus Ankara (MVA). Infect Dis Ther. 2015; 4:491-501.
8. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I et al. Surgery
in COVID-19 patients: operational directives. World J Emerg Surg. 2020 15:25.
doi.org/10.1186/s13017-020-00307-2
9. Vinekar A, Azad RV, Dogra MR, Jalali S, Bhende P, Narendran V, et al. for the Indian
Retinopathy of Prematurity Society. Retinopathy of Prematurity screening and
treatment guidelines during the COVID-19 lockdown 2020. Available from:
https://sites.google.com/view/iropsociety/newsroom?authuser=0. [Last Accessed on
2020 May 5].
10. Project operational guidelines. Prevention of Blindness from Retinopathy of
Prematurity in Neonatal Care Units. Available from: https://phfi.org/wp-
content/uploads/2019/05/2018-ROP-operational-guidelines.pdf. [Last accessed on
2019 May 21].
11. Skalet AH, Allen RC, Shields CL, Wilson MW, Mruthyunjaya P, Gombos DS.
Considerations for the Management and Triage of Ocular Oncology Cases during the
COVID-19 Pandemic. Ocul Oncol Pathol 2020;6:219–222
12. American Association of Ophthalmic Oncologists and Pathologist. Available from:
http://www.aaoop.org/corona-virus/. [Last Accessed on 2020 May 04].

Acknowledgements: Namrata Sharma , Mahipal S Sachdev , Rajesh Sinha and AIOS Governing
Council

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 Guidelines for Oculoplastic Surgery during the COVID-19 Pandemic
Version 1.0
w.e.f May 11th, 2020

Prepared by: Usha Kim, Mohammad Javed Ali, Raghuraj Hegde, Akshay Gopinathan Nair and
AIOS working Committee

Prepared in Association with: The Oculoplastics Association of India

AIOS Working Committee : Anita Sethi, Ashok K Grover, Fairooz P M, Gangadhara Sundar,
Lakshmi Mahesh, Mahipal Sachdev, Mandeep Singh Bajaj, Maya Hada, Mukesh Sharma,
Namrata Sharma, Parveen Mongre, Rajesh Sinha, Roshmi Gupta, Santosh Honavar

I. Introduction

Oculoplastic surgeries include emergency surgeries for traumatic conditions and infectious
disorders as well as elective aesthetic procedures. Globally the COVID-19 pandemic has
brought elective procedures to a standstill. Currently guidelines globally recommend only
performing emergency procedures during the pandemic, especially during the lockdowns
imposed in many countries. We need to incorporate evidence-based screening and
protective measures into our practices while offering this emergent medical care to patients.
The purpose of this document is to compile evidence-based guidelines for surgical
procedures for oculoplastic surgeons which can be put into practice during the COVID-19
pandemic. These sets of recommendations will form the foundation upon which further
suggestions may be based on, in the future, so oculoplastic surgeons can begin performing
elective surgeries at a later point in time. The recommendations in this document should be
adopted for the next few months till the pandemic completely subsides. This document must
be viewed in light of local policy – which may vary in every city/state and availability of the
resources must also be taken into consideration. New evidence about the virus and the
disease are continuously emerging, hence these guidelines are subject to changes as the
disease pattern changes and our knowledge about COVID-19 and its impact on
ophthalmology and oculoplastic surgery, in particular, increases.

II. Clinical Examination:

The basic rules of social distancing shall be followed at all times. The details of cleansing,
sanitising the OPD and the waiting area have been described in detail by Sengupta et al

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 (Indian J Ophthalmol 2020;68:711-24). For the physician and the assistant in the patient
examination area in the clinic there has to be an emphasis on the use of surgical gloves, a
respirator/mask and face shield. In addition, the patients should also wear a mask at all
times. Prior to entering the doctor’s examination room, the patient must be instructed to
wash his/her hands. The clinical examinations should be done in well ventilated rooms with
good air circulation. A detailed clinical history should be elicited including history of fever,
cough & cold, or contact with COVID-19 positive patients or if the patient resided in a
containment zone. A COVID-19 questionnaire may be used for this purpose. (Table 1) In the
clinic, ensure that no accompanying person is allowed entry into the waiting room or the
examination room except for vulnerable patients; such as children, elderly above 65 years of
age and non-ambulatory patients among others. One attendant for female patient is
allowed. Patient should be asked to give all the history and symptoms prior to examination
and should be requested not to talk while examination. Based on the hospital infrastructure,
the number of patients seen in a day should be limited and the appointments should be
spaced out to allow for social distancing.

If the patient has symptoms suggestive of COVID-19, the ophthalmologist may request for
pre-operative COVID-19 testing, keeping in mind local municipal and state guidelines for
testing; or carry out any further treatment at a higher centre that is equipped to handle
cases of COVID-19. It is also recommended that any surgical procedure on a previously
diagnosed case of COVID-19 be done in a hospital that has dedicated COVID-19 care facilities
including inpatient care, operating room and intensive care facilities for COVID-19 patients. If
testing facilities are not available and the patient requires emergency surgery, surgery may
be performed with personal protection equipment (PPE) assuming that the patient has
COVID-19.

During examination, lacrimal syringing should be avoided as it is an aerosol generating

procedure. Where possible, fluorescein dye disappearance test may be performed which can
be interpreted accordingly for further management. Routine nasal endoscopies prior to any
lacrimal surgery is best avoided while the pandemic lasts.

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 Table 1: COVID-19 Questionnaire:

COVID-19 QUESTIONNAIRE

HISTORY QUESTION YES NO

Occupation Was the patient working at a grocery shop/ bank/

hospital/ etc. which potentially involves exposure to
large group of people in the last 28 days

Travel National travel (Inter-district or Inter-state) particularly

to hotspot areas or international travel in past 28 days

Family Any travel by family members to hotspots (Inter-district

or Inter-state) or international travel in past 28 days

Any history of symptoms (URI/LRI/FEVER/DIARRHOEA) in

past 28 days

Any family member on COVID Duty

(Police/Army/Doctor/Drivers etc.) living in same house

Contact Any contact with suspected or diagnosed COVID Case in

the past 28 days

Symptoms Fever
(Current or in
LRTI symptoms - Cough/ Expectoration/ Breathlessness
last 28 days)
URTI Symptoms - Sore throat/Nasal
block/Rhinorrhoea/Cough

GI Symptoms - Diarrhoea

III. Surgical Procedures:

Surgeries have been classified based on their urgency. This classification offers a broad time
line but is not absolutely binding and may be modified based on individual or institutional
discretion.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 Level A – Emergency / Urgency – The need to operate within 4-72 hours.
Level B – May be deferred for up to 4 weeks with or without conservative management.
Level C – May be deferred beyond 6 weeks without adversely affecting the outcomes.

Procedures commonly performed in oculoplastic operating rooms have been classified using this
risk stratification and tabulated as follows:

a. Risk stratification for Orbital Surgeries

Level A Level B Level C

1. Canthotomy and cantholysis for 1. Optic nerve sheath 1. Orbital

sight-threatening orbital fenestration for decompression
haemorrhage. progressive visual loss. for aesthetic
2. Drainage of an orbital or 2. Orbitotomy for rehabilitation.
periorbital abscess. malignancy or sight 2. Socket
3. Exenteration for life-threatening threatening tumour/ Reconstruction.
infection. other lesions.
4. Orbital biopsy (incisional or 3. Thyroid Eye Disease:
excisional) for life or sight- Orbital decompression in
threatening conditions. case of optic neuropathy
5. Repair of orbital and other facial or uncontrolled orbital
fractures fracture in presence of congestion.
oculo-cardiac reflex. 4. Orbital fracture repair
6. Evisceration/Enucleation for with symptomatic
severe, untreatable infection, residual entrapment.
malignancy. 5. Plaque brachytherapy.

b. Risk stratification for Eyelid and oculofacial plastic surgery

Level A Level B Level C

1. Periocular malignancy 1. Entropion in the 1. Other eyelid

(biopsy-proven or suspected) presence of progressive malposition’s like
including locally advanced sight-threatening corneal long standing
disease with features such as exposure/disease congenital or
orbital invasion 2. Botulinum toxin acquired ptosis,

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 2. Severe unilateral ptosis in an injections for severe ectropion and
infant blepharospasm and dermatochalasis
3. Eyelid lacerations including other facial dystonia 2. Benign periocular
canalicular lacerations 3. Lid reconstruction tumours like
4. Tarsorrhaphy in cases of chalazion,
impending corneal papilloma
compromise 3. Upper & lower
blepharoplasty
4. Aesthetic
procedures and
surgeries like
browlifts, facelifts,
thread-lift,
aesthetic fillers
and botulinum
toxin injections for
aesthetic
indications

c. Risk stratification for Lacrimal procedures

Level A Level B Level C

1. Congenital Dacryocystocele 1. Inflammatory 1. Primary Acquired

with airway compromise secondarily acquired Nasolacrimal Duct
2. Lacrimal Abscess nasolacrimal duct Obstruction
3. Pediatric Acute Dacryocystitis obstruction (SALDO) with (PANDO)
4. Acute lacrimal drainage trauma exacerbations (ex -
(canalicular lacerations, NLD autoimmune disorders) 2. CNLDO
injury in complex facial trauma) 2. Infectious canaliculitis (exceptions in
5. Lacrimal Sac Malignancy 3. Post-traumatic SALDO levels A and B).
(biopsy proven or suspected) without complex facial
including locally advanced trauma
disease with features of orbital 4. Biopsy proven benign
or intranasal extension. lacrimal sac mass
5. Stent extubation.
6. Idiopathic canalicular

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 inflammatory disease
(ICID)
7. Lacrimal sac diverticulitis

IV. General guidelines for oculoplastic surgery:

1. Avoid general anaesthesia (intubation, extubation) whenever possible.

2. PPE for all medical and non-medical personnel involved in the surgery.
3. Only the essential anaesthetic, surgical and allied health staff should be present
inside the operating room.
4. Surgeon and surgical assistants should be outside the operating room during
a. intubation and extubation
5. Use of aerosol protection devices is advisable during intubation and extubation to
limit spread of aerosols away from the patient.
6. Avoid monopolar cautery for cutting/coagulation. Instead, Use a cutting blade for
skin and mucosal incisions whenever possible.
7. Use bipolar cautery for haemostasis in the lowest power setting.
8. Practise minimal handling of tissues especially mucosal surfaces.
9. Avoid repeated irrigation and suctioning of tissues.
10. Avoid / minimize drills, oscillating osteotomes and other powered instruments.
11. Consider closed reduction if fracture is stable for zygomatico-maxillary complex
(ZMC) fractures. Avoid intra-oral incision, if possible.
12. Self-drilling screws are preferred over self-tapping ones that require pre-drilling.
13. To plan orbital decompression surgery avoiding endo-nasal endoscopic approach
and only utilising an orbital approach so that there is minimal to no breach of sinus
mucosa. Consider a temporising procedure of shorter duration initially – a later
procedure can be planned.

These guidelines will help oculoplastic surgeons offer emergent care to their patients who need
it. As mentioned earlier, as our understanding of this virus and the disease transmission process
increases with time, it is expected that these guidelines may change. It is evident that some
areas in India are more affected by the outbreak as compared to others and expectedly, there is
variation in the recommendations by the local health authorities. All clinicians must tailor the
guidelines mentioned in this document, especially when it comes to COVID-19 testing, based on
the prevailing rules and regulations put in place by local/state/municipal authorities.

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 Guidelines for examination of patients in Paediatric Ophthalmology
And
Neuro ophthalmology sub-specialty during COVID Pandemic
Version 1.0
w.e.f May 11th, 2020

Document Commissioned by: Prof. Mahipal Sachdev, Prof. Namrata Sharma, Prof. Rajesh
Sinha
(on behalf of AIOS)

Document prepared by: Prof Rohit Saxena

Document edited by: Dr Digvijay Singh

Prepared in Association with: Strabismus and Pediatric Ophthalmological Society of India

(SPOSI) And Indian Neuro-Ophthalmological Society

Inputs from:

Abadan Khan Amitava, Ambika Selvakumar, Ankur Sinha, Arun Samprathi, Digvijay Singh,
Elizabeth Joseph, Gopal Krushna Das, Hemalini Samant, Jaspreet Sukhija, Jitendra, Nenumal
Jethani, Jyoti Matalia, Kalpana Narendran, Kalpit Shah, Krishna Prasad R, Lav Kochgaway,
Mahesh Kumar, Meenakshi Swaminathan, Pradeep Sharma, Rajamani Muralidhar, Ramesh
Kekunnaya, Rashmin Gandhi, Renu Sinha, Rohit Saxena, Sandra Chandramouli, Santhan Gopal,
Satish Thomas, Shashikant Shetty, Shkiha Bassi, Shubhangi Bhave, Siddharth Agrawal, Sudarshan
Kumar Khokhar, subash Dadeya, Sujata Guha, Suma Ganesh, Urmil Chawla, Vimla Menon,
Virender Sachdeva, Yogesh Shukla

About the Document:

The document is meant to be a guide for ophthalmologists dealing with pediatric cases and
neuro-ophthalmology cases during the COVID-19 Pandemic. The content of this document is
merely to help establish best practices for safety of patients, staff and treating ophthalmologists.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
The document has been divided into six sections; section 1 refers to emergency cases pertaining
to paediatric ophthalmology and neuro-ophthalmology where treatment should not ideally be
delayed. Section 2 encompasses general guidelines which hold true for all ophthalmology
patients. Section 3 covers specific guidelines for examining and managing eye disease in
children. Section 4 covers specific guidelines for managing neuro-ophthalmology conditions.
Section 5 lists conditions which are amenable to teleconsultation by following established
regulations. Section 6 consists of basic operating theatre practices which should be followed
keeping in view the need for general anesthesia in paediatric eye surgery.

The content of this document has been generated based on inputs from experts in the field of
paediatric ophthalmology, strabismus and neuro-ophthalmology and may be modified over time
based on new evidences.

Section 1

List of emergency/ urgent conditions in paediatric ophthalmology and Neuro ophthalmology

requiring examination/ management (medical/surgical):

This list is not comprehensive and treating ophthalmologists may decide on a case to case
basis.

1. Pediatric cataract / congenital cataract in amblyopic age group/ Traumatic cataract

2. Buphthalmos /Paediatric glaucoma
3. Strabismus surgery for torn or lost extra-ocular muscle/ post injury
4. Optic nerve sheath decompression or fenestration for progressive vision loss due to
persistent disc edema
5. Complaint of recent / sudden loss of vision/ fields in one or both eyes
6. Complaint of recent onset diplopia or acute onset of squint / nystagmus/ ptosis/ head
posture
7. Traumatic head & eye injuries
8. Probing of the naso lacrimal duct obstruction in case of dacryocystocele
9. ROP screening / treatment
10. Retinoblastoma and other ocular tumors
11. Retinal detachment
12. Breakage/Loss of glasses of child with high/pathological refractive error
13. Acute Red eye/purulent discharge
14. Acute dacrocystitis , preseptal cellulitis/ Orbital cellulitis

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 15. Unexplained headache / Acute headache referred to rule out papilledema

Section 2

General examination guidelines for ophthalmology patients

1. Pre-registration patients/ attendants should be screened for symptoms/ signs of infection

along with history of contact
2. Examine single patient at any time in the room with staggered timing to avoid crowding in
the waiting area.
3. Wear gloves, N95 masks, aprons and protective eyewear for examination. Disinfect gloves
after each examination.
4. Rooms and instruments should be thoroughly disinfected after each patient encounter.
5. Wear disposable gloves when cleaning and disinfecting surfaces, and discard the gloves
after use. Slit lamps, including controls and accompanying breath shields, should be
disinfected after each patient, particularly wherever patients put their hands and face.
6. Cleaning at regular intervals and at the end of the day.

All other guidelines for running ophthalmology OPD and standard operating procedure as
described in AIOS Operative Guidelines for COVID-19 to be followed.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Section 3

3.1 Special aspects for examining children:

 Children may get scared of doctors in masks, so an attractive mask may be useful
 Children wear masks which are ill fitting and ineffective or may not wear masks at all, so
self-precaution is imperative esp less than 2 years children
 Children always need 1 maybe 2 attendants with them, hence a higher chance of
exposure is likely; allow mother or father only if possible
 Children may not follow social distance protocols and OPD etiquette, so parents to be
cautioned
 Children are more likely to be asymptomatic virus shedders, especially as prolonged
shedding in nasal secretions and stool has been shown in children who have no
symptoms, hence COVID symptomatic screening may be falsely negative
 There is also a report of the possibility of asymptomatic disease and potential
transmission via infants, hence doctor must take adequate self-precautions even with
infants and neonates
 A crying child may be aerosolizing the virus particles which may stay in the air longer and
travel greater distances, so treat this exam as a potential aerosol generating procedure.
Extra care needed for ROP screening.
 To avoid crowding the waiting room with dilating patients (for retinal exam or for
refraction), ask the parents to instill drops at home and return (can plan the next visit
same day or next). If cannot return, ask them to instill in the car and come back in 1 hour.

3.2 Additional aspects:

 Infected children are usually asymptomatic. Be sensitive for complaints of: fever, dry
cough and fatigue; occasional gastrointestinal symptoms, including abdominal
discomfort, nausea, vomiting, abdominal pain and diarrhea. Defer examinations if
suspect.
 Require the parent, and if possible the child, to wear a mask (is mandatory >2 years).
 Basic history taking can be done on phone so that time in examination room can be
minimized. Similarly after the examination is over, only 1 attendant should remain in the
room to understand the advice/ management. It is at this time that the child often runs
around handling things in the clinic which can be minimized by sending the child out
under supervision

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
  Ask patients and attendants to sanitize their hands before and after leaving exam
rooms.
 Close play areas for children in clinics; Remove all soft toys and toys that cannot be
wiped clean. play area and baby care room- disinfection protocols to be followed.
 Hand out of sweets or candies to be stopped
 Examination under sedation may be preferred to examination under anaesthesia (where
possible)

3.3 Guidelines for pediatric ophthalmology patients:

New patients:

1. Parents should be advised not to bring special kids and low vision kids because they are
high risk especially as evaluation takes a long time.
2. Ask the parent or the caregiver to compare the vision of a preverbal child in either eye
applying a patch/cover the eye with the hand on the other eye and compare at home.
3. For an older child visual acuity on the chart may be noted / app based vision screeners
are available. Parent may be asked to close one eye of the child.
4. In case of strabismus, old/current pics of the child can be shared the pedantic
ophthalmologist on phone or email (avoid exchanging mobiles and other gadgets)
5. Previous documents / records can be sent by whatsapp / e mail so that there is no need
for carrying actual documents for the appointment
6. Retinoscopy to be avoided for preverbal child. Use hand held automatic refractometer
and for an older child automatic refractometer used to perform refraction under
cycloplegia.
7. Over-refraction with glasses on is preferred to look for change in power and only if
significant discrepancy should a full refraction and acceptance be done.
8. Photoscreeners can be used
9. Based upon the AR readings the glasses can be prescribed and acceptance may be
avoided
10. Try and obtain a good photograph of the child, preferably the photograph can be sent to
the doctor by a social media platform rather than exchanging the mobile phones and
devices.
11. Fundus examination with an indirect ophthalmoscope / 90 D examination or a fundus
photograph may be preferable to a direct ophthalmoscope examination
12. In case of suspected posterior segment disorders, OCT may be used for screening (where
possible)

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 13. In case of recently diagnosed and amblyopia, part-time occlusion may be started and
followed up on a monthly basis. Full-time occlusion should be avoided. Periodic self-
checking of the eye undergoing occlusion should be advised to prevent occlusion
amblyopia.
14. Avoid starting penalisation in young kids.

Old/ follow-up patients:

1. Encourage teleconsultation
2. For older children maintaining the visual acuity as per the previous visit and pre verbal
children the old glasses maybe continued for next 3 to 4 months
3. Cycloplegic refraction for new glasses prescription may be avoided unless complaint of
significant drop in vision from previous records
4. For preverbal children with strabismus - the information regarding the fixation
preference from the parents and caregivers to be obtained, photographs with flash
maybe requested from parents and caregivers so as to know the fixation preference. If
the child is having similar fixation preference as before then the old glasses/amblyopia
therapy should continue
5. For operated strabismus patients a digital photograph with flash maybe sought for and
alignment be assessed, if all is well then the consultation visits to be avoided (can use 9
gaze app)
6. For follow-up patients of amblyopia, maintaining similar visual equity the prescribed
pattern of patching maybe continued
7. IOP in children: Avoid unless essential. Avoid NCT as causes aerosol generation; consider
using rebound tonometer and clean after each use.
8. Avoid checking stereopsis and colour vision as charts cannot be disinfected and have to
be handled by the patients.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Section 4

Guidelines for Neuro-ophthalmology cases:

1. Visual acuity may be noted on the chart / app based vision screeners are available
2. Pupil reflex / RAPD assessed using distance direct ophthalmoscopy
3. Fundus photographs, OCT and indirect ophthalmoscope may be utilized to assess
pathology rather than direct ophthalmoscope
4. While observing patients with cranial nerve palsies, patient must be taught to keep the
head straight and look at a fixed distance so that increasing double vision can be
perceived and a neuro imaging can be advised in suitable time
5. Acquired strabismus can be evaluated using clinical photographs taken by the attendant
using phone and flash which can be sent electronically.
6. Investigations for systemic disorders (FBS, BP monitoring, Lipid profile) can be advised
and evaluated remotely for screening for etiology.
7. Traumatic neuropathy needs IV steroids but first rule out high risk features for COVID19
(physician consult before giving steroids)
8. Visual fields: Fields do only if essential; Most cases can be evaluated by confrontation
fields. All patients must wear masks during perimetry; clean chin and forehead rest with
alcohol swabs; have a gap between patients. Can use light soap water to clean the
dome.
9. For tele-consultation, visual fields may be done with the help of certain App’s available
with help of another attendant at home.

Additional aspects:

1. Ophthalmologists must be cautioned about the report of optic neuritis/ cerebral

vasculitis in covid patients.
2. Frequent cross-consults from other departments such as neurology, medicine and
neurosurgery are received by neuro-ophthalmologists and there is a need to take
adequate protection when visiting or examining these patients as they may be carriers
of Novel SARS-COV2 or have manifestations secondary to infection.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Section 5

Telemedicine

Advice on telemedicine / phone should be considered for following conditions:

1. Refraction / Amblyopia follow up

2. Conjunctivitis management
3. Post op squint
4. Paediatric oculoplastic/adnexal cases
5. Non-specific headache, mild to moderate
6. Orbicularis myokymia
7. Asthenopia
8. Vernal keratoconjunctivitis
9. Post op cataract in older children
10. Resolving cranial nerve palsies
11. Review of all the reports
12. Follow up of old optic neuritis or optic atrophy cases
13. Follow up cases of pituitary adenoma with no new complaints

Any other cases which the ophthalmologist deems appropriate for tele-consultation may be
added to this list on a case to case basis.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Section 6

OT issues:

a. Follow guidelines formulated by the OT guidelines committee

b. PPE essential for GA (anaesthetist / surgeon)
c. For GA cases lasting more than 30 minutes, it is advisable to have a pretesting for
COVID-19.
d. Sterilise the circuits used in the GA machine
e. Do not use spontaneous ventilation and preferably use closed circuits
f. Can use LMA or ET tube
g. Presurgery: CxR and Covid are not mandatory investigations as of today
h. Have a dedicated Doffing and Donning area, if possible
i. During intubation only anesthetists and technician and patient should be inside
the OR, after intubation Scrub nurse can go in and drape and prepare, finally
followed by the surgeon. Any trainees should watch from outside or viewing box
j. Avoid cautery (risk of aerosol) and separate cassette to be used for all cases

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Guidelines for the management of Ocular Trauma during the COVID-19 Pandemic
Version1.0
w.e.f May 11th, 2020

Prepared by : Akshay Nair, Raghuraj Hegde, G Mukherji, Purendra Bhasin, Gangadhara

Sundar, Namrata Sharma, S Natarajan, Mahipal Sachdev, Rajesh Sinha, and AIOS Writing
Group

Prepared in Association with: Ocular Trauma Society of India

AIOS Writing Group : Alok Sen, Ashok Kumar Grover, Bhaskar Srinivasan, Gangadhara Sundar, J.
S. Titiyal, Jayanta Kumar Das, Kasturi Bhattacharjee, Kim Ramasamy, J K S Parihar, Mehul Shah, O
P Agrawal, Prashant Bawankule, Rajiv Raman, Ruchir Mehta, Rupesh Agrawal, Sanjiv Mohan,
Shakeen Singh, Thirumalesh M.B., Usha Kim, Vinod Kumar Baranwal

Coronavirus 2019 disease (COVID-19) is caused by severe acute respiratory syndrome

coronavirus 2 (SARS-CoV-2). The guidelines presented in this document focus only on surgical
procedures and subsequent follow-up visits and are based on the available literature on COVID-
19, guidelines issued by other societies and other branches of medicine. The necessary
precautions to be followed as a routine in the outpatient department as per AIOS guidelines
released along with.

1. Preoperative assessment:

A. History:

When evaluating a case of ocular trauma, all precautions must be taken, assuming that the
patient is a case of COVID-19. This would involve having basic protective gear including but not
limited to the facemask, face shield and gloves. In addition to ophthalmic history and
assessment, a general medical history would also have to be elicited using the COVID-19
questionnaire (see below). If the patient has symptoms suggestive of COVID-19, the
ophthalmologist may request for pre-operative COVID-19 testing, keeping in mind local
municipal and state guidelines for testing; or carry out any further treatment at a higher centre
that is equipped to handle cases of COVID-19.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
It is also recommended that any surgical procedure on a previously diagnosed case of COVID-19
be done in a hospital that has dedicated COVID-19 care facilities including inpatient care,
operating room and intensive care facilities for COVID-19 patients.

COVID-19 QUESTIONNAIRE
HISTORY QUESTION YES NO
Occupation Was the patient working at a grocery shop/ bank/ hospital/
etc. which potentially involves exposure to a large group of
people in the last 28 days
Travel National travel (Inter-district or Inter-state) particularly to
hotspot areas or international travel in the past 28 days
Family Any travel by family members to hotspots (Inter-district or
Inter-state) or international travel in the past 28 days
Any history of symptoms (URI/LRI/FEVER/DIARRHOEA) in
the past 28 days
Any family member on COVID Duty
(Police/Army/Doctor/Drivers etc.) living in the same house
Contact Any contact with suspected or diagnosed COVID Case in the
past 28 days
Symptoms Fever
(Current or LRTI symptoms - Cough/ Expectoration/ Breathlessness
in last 28 URTI symptoms - Sore throat/Nasal
days) block/Rhinorrhoea/Cough
GI Symptoms - Diarrhoea

B. Testing for COVID-19

It may not be possible to have all patients undergo RT-PCR for COVID-19 pre-operatively. At
present, the testing facilities for COVID-19 are not available freely across the country and
therefore requests for COVID-19 test may have to be made judiciously. The guidelines for testing
for COVID-19 are not uniform across the country and vary as per state and local municipal
guidelines. It is advised that testing be performed pre-operatively in cases of ocular trauma, as
per the local guidelines.
In a patient suspected to have COVID-19, the surgery can be deferred till the results of COVID-19
tests are obtained, if delaying surgery does not affect the outcome. Or else, in such cases, one
may choose to operate with full precautions, assuming the case to be positive for COVID-19.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
C. Basic Guidelines for Ocular Trauma Surgery during the COVID-19 pandemic:

a. Avoid general anaesthesia (intubation, extubation) whenever possible

b. PPE for all medical and non-medical personnel as per the Government of India
guidelines dated 1st May 2020
c. Only the essential anaesthetic, surgical and allied health staff should be present inside
the operating room.
d. Surgeon and surgical assistants should be outside the operating room during intubation
and extubation
e. Use of aerosol protection devices is advisable during intubation and extubation to limit
the spread of aerosols away from the patient.
f. Avoid monopolar cautery for cutting/coagulation.
g. Use a cutting blade for skin and mucosal incisions whenever possible.
h. Use bipolar cautery for haemostasis only in the lowest power setting.
i. Practise minimal handling of tissues especially mucosal surfaces such as conjunctiva
j. Avoid repeated irrigation and suctioning of tissues while dealing with orbital trauma
k. In the case of orbital fractures, avoid/minimize drills, oscillating osteotomes and other
powered instruments which are aerosol-generating.

l. Consider closed reduction if the fracture is stable for zygomatico-maxillary complex

(ZMC) fractures. Avoid intra-oral incision, if two-point fixation (rim and ZF) is sufficient
for stabilization.
m. Pole to pole surgeries (multi-speciality surgery) should be done in the same setting – to
avoid repeated exposure to anesthesia.
n. If a planned second surgery is to be done, it should be at least 14 days after the primary
procedure and treat the case as a new patient in terms of the pre-operative work up

D. Risk stratification for ocular trauma surgery

This classification offers a rough guide but is not exhaustive and may be modified based on
individual/institutional discretion on a case-to-case basis.
Level A – Emergency / Urgency – The need to operate within 4-72 hours.
Level B - May be deferred for up to 4 weeks with or without conservative management.
Level C – May be deferred beyond 6 weeks without adversely affecting the outcomes.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Using this classification, common surgeries that have to be performed for ocular trauma cases
have been classified as follows:

Level A Level B Level C

Open globe injury (penetrating, Tectonic corneal and Enucleation /
perforating and globe ruptures). scleral grafts Evisceration for
phthisis bulbi
Deeply embedded corneal foreign bodies Traumatic cataracts in Aesthetic/functional
adults without keratoplasty
endothelial touch,
secondary glaucoma,
etc
Intraocular foreign bodies
Retinal detachment / tear
Vitrectomy for trauma-related
complications*
Paracentesis for vision-threatening
hyphaema
Chemical and Electrical Injuries
Repair of orbital and other facial fractures
fracture in presence of oculocardiac
reflex.
Orbital haemorrhage requiring
canthotomy /aspiration
Intravitreal injections for traumatic
endophthalmitis

*Intraocular infection, vitreous hemorrhage, retinal tear, IOFB, misdirected aqueous/ciliary block
glaucoma, malignant glaucoma, vitreous prolapse, tube shunt blocking filtration
(Modified from: Hegde R. Sundar G. Guidelines for the Oculoplastic and Ophthalmic Trauma
Surgeon during the COVID-19 era – An APOTS & APSOPRS Document)

E. Follow-up:

Routine follow-up on post-operative day 1 can be conducted by the operating surgeon as

before. Subsequent follow-ups at day 3 and day 7 post-operatively need to be scheduled at the
discretion of the operating surgeon. It is advisable that as few post-op visits as possible,
without compromising on the outcome of the treatment. The operating surgeon may

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 defer/reschedule the post-op follow-up visits taking into consideration the type of surgery, the
type of intraocular foreign body (organic vs. inorganic) and the presence of complaints.
Tele-consultation and engaging the referring surgeon (if any) for interim visits may be useful in
minimising visits to the hospital.

Ocular emergencies cannot be deferred indefinitely and need to be tackled immediately in

most cases. These guidelines will serve as a good resource such that ophthalmologists can
resume offering healthcare services to patients in need of emergent care without
compromising on safety; their own and the patients’.

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 Guidelines for Community Eye-Health
And
Vision Center Guidelines during Covid-19 Pandemic in India
Version 1.0
w.e.f. May 11th, 2020

Prepared by: Praveen Vashist, Suraj Singh Senjam, Souvik Manna, Noopur Gupta, Vivek Gupta,
Surabhi Agarwal, Namrata Sharma, Rajesh Sinha ,Rohit Saxena, Mahipal S, Sachdev

Prepared in Association with: Vision 2020, NPCB & VI, Community Ophthalmology experts from
RP Centre and major NGO representatives

AIOS Writing Committee: Bhupendra Kumar Jain, Elesh Jain, Harsha Bhattacharjee, Lubna
Zameer, Madan Deshpande, Parikshit Gogate, Promila Gupta, R.D. Ravindran, Sara Varughese,
Rohit Saxena, , Sudhir Rachapalle, Uday Ranchhoddas Gajiwala, Mandeep Jot Singh, Elizabeth
Kurian , Phanindra

Introduction

The COVID-19 pandemic has taken tragic proportions and has disrupted lives globally. In the
wake of governmental lockdowns, primary eye care workers need practical and actionable
guidelines based on advisories from national health authorities on how to deliver services during
nationwide lockdowns and after these are lifted. The GoI has mandated a country-wide total
lockdown of all non-essential services from March 25 to May 3, 2020, following which the
government has partially relaxed the restrictions to slowly and systematically bring ease in
routine life. In this document, All India Ophthalmological Society attempts to develop a guideline
for community eye-health programs based on consensus discussion between Vision 2020,
NPCB&VI, Community Ophthalmology experts from RPCentre and major NGO representatives.

Zoning of areas during the lockdown

GREEN ZONES:
They can be defined as those districts having zero confirmed cases of coronavirus in the last 21
days.
RED ZONES/Hotspot district:
Districts with several active cases, high doubling rates of confirmed cases will be classified under
Red Zones.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
ORANGE ZONES:

Those zones which are neither red or green will be called Orange Zones

Containment zones will be demarcated with red zones and orange zones by district
administrations by taking into account the factors such as: mapping of cases and contacts,
geographical dispersion of cases, and contacts. The boundary of the containment zone could be
a residential colony, mohalla, municipal wards, municipal zones, gram panchayat, a cluster of
villages, blocks, etc.

According to Home Ministry,GoI guidelines, OPDs, medical clinics shall be permitted to operate
in red, orange, and green zones with social distancing norms during the lockdown.

Zone wise recommendation of services/activities

Activities Green Zone Orange Zone Red Zone Containme

nt Zone
Vision Centres1 Advisable. Advisable. Advisable. No Vision
(Primary Eye Centre
Care)
Transport facility Advisable. Not advisable Not advisable Not
for camp patients advisable
Mobile Van Advisable. Not advisable Not advisable Not
2
Clinics (Mobile advisable
Vision Centres)
Comprehensive
Eye Camps Advisable to postpone for 2 months in all Zones

Refraction Advisable. Advisable. Advisable. Not

Facilities Optometry and Optometry and Optometry and advisable
Opticals guidelines Opticals guidelines Opticals guidelines
to be followed. to be followed to be followed
Tele- Advisable, as per Advisable, as per Advisable, as per Advisable,
Ophthalmology MoHFW MoHFW MoHFW as per
guidelines. guidelines. guidelines. MoHFW
guidelines.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Tele-education/ Advisable Advisable Advisable Advisable
Tele-counselling

Reach-in Cataract As per AIOS As per AIOS As per AIOS Not

3
Surgeries guidelines for guidelines guidelines advisable
Cataract Surgery

2
Many hospitals provide mobile eye care services or refraction clinics from secondary level
hospitals. These are important for increasing the coverage of primary eye care services including
refraction to populations in remote areas and underprivileged communities but these are not
vision centers as they are not a permanent static facility existing within the community.

3
Cataract Surgery Guidelines
1. Free cataract surgery patients may be admitted from vision centres and also walk-in
patients at base hospital as previous NPCB guidelines.
2. Guidelines for social distancing and PPE to be followed
3. Pre-surgery COVID testing at discretion of operating surgeon/hospital policy.No
separate guidelines for high volume/cost-effective surgeries, general COVID
guidelines to be followed.

Vision Centres

In view of Government directives to reopen non-essential services in a graduated manner, it is

deemed appropriate to re-open Vision Centres at this stage in the community. Primary eye-care
services are also expected to cater to primary needs of the community, for preventing over-
burdening the secondary and tertiary level hospitals that are already reeling under a crunch of
human resources and finances, owing to the global pandemic.

Services to be provided by Vision Centres during the Pandemic

Essential Desirable
Early detection of eye problems Surveillance and VC based screening
Treatment of common eye problems Edging and spectacle fitting
First line management and timely referral of eye Follow up; Motivation and counseling
emergencies
Vision testing and refraction Assist in community based rehabilitation
Dispensing spectacles Rehabilitation of visually impaired

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 Refer and triage individuals needing surgery or
specialist attention to the higher center in a
graded manner
Post-operative follow up (preferably through
Teleconsultation/ASHA)

Services which should be postponed at Vision Centre owing to the pandemic

Essential
Training of school teachers and preliminary screening by teachers
School eye screening
Community gathering for IEC activities (Health education)
Screening camps for cataract, Diabetic retinopathy and other ocular morbidities

Social Distancing in Vision Centres

There should be adequate space for patient consultation, refraction, and dispensing spectacles
and distance of 1 metre should be ensured at all times. The first room should provide for the
patient reception and waiting area and the spectacle dispensing unit (preferably 10' x 8'). A
separate area should be available for patient examination and refraction. (preferably 10' x 8'). A
private space should be provided for the office and spectacles workshop (preferably 6'x 6').
The vision center should ensure social distancing at each step: patient reception, optical counter,
patient waiting area, client examination station etc. Unidirectional flow of patients should be
ensured, i.e., entry and exit must be different if there are two doors.
One such lay out is proposed below

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Point of entry screening and check-in

 Every vision center to set up an entry control and screening facility at the point of
entry.
 PPE in the form of surgical caps, surgical scrub suits, three-ply surgical masks/N95
masks and gloves must be provided to the HCW at the point of entry.
 There should be a security barrier at the entry point so that only the patient and
one attendant, if required, can enter the hospital.
 If there are >3 patients at a time, they should be asked to wait in a designated
open area.
 At all times, a distance of one meter must be maintained between each patent
and between the patient and the VC staff (except for the HCW who performs
point of entry screening).
 Symptom screening: History of fever, cough, breathlessness, loss of smell or
acute conjunctivitis in patients or attendants or family members in the last 2
weeks
 Fever screening: Body temperature screening with an infrared non-contact
thermometer. Anyone with temperature of 98.6 F (37 C) must be immediately
escorted to an isolated waiting area and seen by an optometrist in complete PPE
in a pre-designated examination room. In the absence of an ophthalmic
emergency, the patient should be referred to a Physician or a COVID-19
Treatment Centre as appropriate.
 Once entry screening is passed, the patients and their attendants should be
provided with three-ply surgical masks and hand sanitizers (at least 70% alcohol-
based) to disinfect their hands before they enter the waiting room. Surgical masks
should be worn by everyone who enters the hospital. There should be mandatory
hand sanitization at the point of entry

 OPD Card Handling

1. All OPD cards will have to be with optometrists. It will be handed over after the
final prescription, so avoid handing over OPD card to patients in between.
2. Try to minimize people touch / handle / hold the OPD card, trial frames, lens,
etc.
3. Restrict registration to 50 to 60 most needy patients

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  A daily list of all HCW, patients, their attendants and other hospital visitors with their
verified mobile number and verified ID proof should be maintained (for contact tracing if
necessary, in the future).
 The patient and the attendant are mandated to download the Aarogya Setu COVID-19
tracking App by the Government of India and register with their mobile number for
possible future digital tracking of warranted.

Waiting hall guidelines

 Maintain a one meter distance at points where a queue is likely to form.

 Seating to be arranged in a manner that patients should remain at least 1m from each
other.
 All optometrists and FAs/MSWs/HCWs must be instructed to clean and disinfect (using
the standard procedure as recommended by the manufacturer) their equipment such as
lenses, indirect and direct ophthalmoscopes, pen, and torches, and other such items.

Precautions during performing refractions

 Protections for head, mouth, nose, and eye (with a surgical cap, three-ply surgical mask,
goggles/face shield) for the examiner and a three-ply surgical mask for the patient.
 Masks should be changed every 6 hours or immediately when contaminated/wet.
 Speak as little as possible. The patient should also be informed not to speak during the
examination. Refraction can be performed using autorefractor or a streak retinoscope
where mandated.
 Trial frame and the metal rim of the lenses used should be cleaned with alcohol-based
sanitizer after examining each patient. Isopropyl 70% or ethyl alcohol 70% can be used
to wipe down metallic surfaces.
 Avoid contact lens trial unless therapeutic-NOT TO BE DONE IN VC.
 Optical dispensing and Pharmacy services should be available, but with 1-meter
distancing protocol using distance separators and PPE for the staff (hand sanitizers,
three-layer surgical masks and gloves).
 Avoid retinal examination, e.g. using fundus photography.
 In case of urgent ophthalmic problems in a patient who is at high risk for COVID-19, eye
care is best provided in the multispecialty hospital setting.
 In case of urgent ophthalmic problem in a patient with documented COVID-19 or a
person under investigation, the patient should remain in the multispecialty hospital
setting, ICMR-GoI guidelines should be followed, along with transmission precautions
for treating optometrists, including full-body protection (PPE or an HIV kit).

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  Patients with conjunctivitis should be seen in a designated OPD room with an isolated
waiting room. Since conjunctivitis is reported as part of the disease spectrum of COVID-
19, all patients with conjunctivitis should be COVID-19 suspects and should be examined
in isolation, using N95 mask and disposable gloves, face shield & gown.
 All HCWs should be encouraged to take a soap bath at once they reach home. They
should be encouraged to bring minimum possible personal items to the VC to minimize
seeding at home and vice versa. If needed, items such as food carriers can be carried in
a larger outer case that can be easily disinfected . Minimum number of HCWs shall be
posted in VC
 Prophylaxis: ICMR has advised oral Hydroxychloroquine (HCQ) 400 mg BD on day 1,
followed by 400 mg OD weekly for 7 weeks. This must be taken only after direct
consultation with an internal medicine expert.
 Digital prescriptions for glasses and medicines, digital medical report and electronic
medical records if feasible.
 Hand hygiene: Optometrists should perform hand hygiene using alcohol-based hand rub
(minimum 20 seconds) or by washing with soap and water (minimum 20 seconds).
 Mask and PPE etiquette

i. Place the mask carefully to cover mouth and nose and tie securely to minimize any gaps
between the face and the mask.
ii. While in use, avoid touching the mask
iii. Remove the mask by using the appropriate technique (i.e., do not touch the front but
remove the lace from behind)
iv. Remove PPE in the reverse order that it was worn and discard the material in
appropriately colored disposal bags for infective plastic items (red)
v. Do not reuse or use three-ply surgical mask for more than 8 hours. If using the same
mask while examining multiple patients, transmission to the patient must be avoided
by not touching the front of the mask. Additionally, do not allow the mask to hang
down on shirt/clothing when not examining patients.

 Environmental hygiene: Environmental cleaning is part of standard precautions, which

should be applied to all patients in all healthcare facilities. Ensure that cleaning and
disinfection procedures are followed consistently and correctly.

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
Role of Tele-Ophthalmology during Covid-19

Tele-Health is defined as health care delivery over distance or time using electronic
communication technology. It serves to enhance health-care access, quality and patient
satisfaction. Telemedicine is provision of traditional clinical service using electronic
communication technology, often in live format. Tele-ophthalmology which till now was
confined to ROP and DR have now the application in community ophthalmology practice as
well owing to the global pandemic situation.

An ophthalmologist from the secondary level should hold tele-ophthalmology services to the
vision centre once every week. The 'tele-consultation' should be organized at the same time
and same day of the week every time and should adhere to the tele-medicine guidelines
issued by the Government from time to time.(2,3) The tele-consultation should target problem
cases, postoperative cases and complicated refractions. A vision center coordinator should be
located at the service center and should supervise each vision center every fortnight
(preferably every week) over telephone. The coordinator should help in augmenting
managerial and clinical skills of vision center staff and in training other categories of health
personnel.

The ophthalmologists should follow the MOH&FW telemedicine guidelines and make sure they
are aware of all the procedures to be followed when dealing with patients using telemedicine
such as informed consent, prescription, sharing of photographs, and other aspects. The

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OPHTHALMIC PRACTICE GUIDELINES IN THE CURRENT CONTEXT OF COVID 19
 doctors can make sure of facilities such as videoconferencing with other referring doctors and
general practitioners. Telemedicine practice should be widely advertised on social media and
other platforms so that it reaches to peers and patients.

Health Talks at Vision Centres

It is mandatory that all VCs discourage and stop health talks as it may lead to crowding and
social gathering. Any health talk, if needed can be performed using online portals such as
web meetings, Skype, Zoom, and other mobile apps. Health talks and health material may be
run/displayed on TV monitors at VC.

Cost-effectiveness of PEC activities

In wake of the requirement for expensive PPE equipment, cost-effectiveness should be
ensured by exploring new revenue options and avoiding redundant costs as much as
possible.

Some Do’s and Don’ts for Vision Centre Staff and Patients

Dos DON’Ts
Only one attendant allowed for patients: Don’t overcrowd the room.
1. age > 60 years,
2. blind / disabled patients
3. children less than 16 years
Wear mask. Cough or Sneeze with open face. Cover
face with elbow.
Sanitise/Wash hands at entrance. Avoid touching tabletops, door handles,
lift buttons etc.
Maintain social distancing. Don’t visit the centre if you are suffering
Stand and Sit only in designated areas. from cold, cough, fever or feeling unwell.
Maintain fresh air circulation by keeping Don’t touch your eyes, nose and mouth.
doors and windows open.
Keep open as many doors as possible to Do not spit in public.
avoid touching of doorknobs.
Try to follow an open-door and no-AC policy
if possible

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 All India Ophthalmological Society

AIOS Headquarters
8A, Karkardooma Institutional Area, Near DSSB Building, Manglam Road
Karkardooma, Delhi-110092
Tel: 011- 22373701 – 05
Website: www.aios.org, Email: [email protected]

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