Acta Ophthalmologica 2021

Review Article

Recommendations for ophthalmologic practice

during the easing of COVID-19 control measures
Jos
e A. Geg

undez-Fern
andez,1 Fernando Llovet-Osuna,2 Jos
e I. Fern
andez-Vigo,1
Javier Mendicute del Barrio,3 Luis Pablo-J
ulvez,4 Francisco J. Mu~ noz-Negrete,5
Javier Zarranz-Ventura,6 Juan Dur
an de la Colina,7 Victoria deRojas Silva,8 I~nigo Jim
enez-Alfaro,9
10 11 12
Margarita Calonge-Cano, Alicia Galindo-Ferreiro, Alfredo Castillo-G
omez,
Cristina Mantol
13 14

an-Sarmiento, Antonio Duch-Samper, Juan Alvarez de Toledo-Elizalde,15
Francesc Duch-Mestres,16 Daniel Elies-Amat,17 Julio Ortega-Usobiaga,18
Mar
ıa Antonia Saornil-Alvarez,19 Alberto Villarrubia Cuadrado,20 Gonzaga Garay Aramburu,21
Alejandro Fonollosa Carduch,22 Jos
e Miguel Cordero Coma,23 Salvador Garc
ıa Delpech,24
Juan Antonio C
arceles C
arceles,25 Jos
e Manuel Ben
ıtez del Castillo S
anchez,1
Pilar G
omez de Lia~
no S
anchez,26 Miguel Harto Casta~ no,24 Alfonso Arias Puente27 and
Alfredo Garc
ıa-Layana28 Spanish Ophthalmology Societies
1
Hospital Cl
ınico San Carlos, Madrid, Spain
2
Cl
ınica Baviera-AIER EYE Group, Madrid, Spain
3
Hospital Universitario de Donostia, San Sebasti
an, Spain
4
Hospital Universitario Miguel Servet, Zaragoza, Spain
5
Hospital Ram
on y Cajal, Madrid, Spain
6
Hospital Clinic, Barcelona, Spain
7
Instituto Cl
ınico-Quir
urgico de Oftalmolog
ıa, Bilbao, Spain
8
Complejo Hospitalario Universitario, A Coru~ na, Spain
9
Hospital Universitario Fundaci
on Jim
enez D
ıaz, Madrid, Spain
10
Instituto Universitario de Oftalmobiolog
ıa Aplicada IOBA, Valladolid, Spain
11
Hospital R
ıo Hortega, Valladolid, Spain
12
Hospital Universitario Quir
onsalud, Madrid, Spain
13
Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
14
Hospital Cl
ınico Universitario, Valencia, Spain
15
Centro de Oftalmolog
ıa Barraquer, Barcelona, Spain
16
Institut Catala de Retina, Barcelona, Spain
17
Instituto de Microcirug
ıa Ocular, Barcelona, Spain
18
Cl
ınica Baviera-AIER EYE Group, Bilbao, Spain
19
Hospital Cl
ınico Universitario, Valladolid, Spain
20
Hospital La Arruzafa, C
orboba, Spain
21
Hospital OSI Araba, Vitoria Gasteiz, Spain
22
Hospital Universitario de Cruces, Bilbao, Spain
23
Hospital Universitario, Le
on, Spain
24
Hospital Universitario y Polit
ecnico La Fe, Valencia, Spain
25
Cl
ınica Coatvisi

on, Murcia, Spain
26
Hospital Universitario Gregorio Mara~
n, Madrid, Spain
no
27
Hospital Universitario Fundaci
on Alcorc
on, Madrid, Spain
28
Cl
ınica Universitaria de Navarra, Pamplona, Spain

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Acta Ophthalmologica 2021

ABSTRACT.
In the context of the COVID-19 pandemic, this paper provides recommendations for medical eye care during the easing of
control measures after lockdown. The guidelines presented are based on a literature review and consensus among all
Spanish Ophthalmology Societies regarding protection measures recommended for the ophthalmologic care of patients
with or without confirmed COVID-19 in outpatient, inpatient, emergency and surgery settings. We recommend that all
measures be adapted to the circumstances and availability of personal protective equipment at each centre and also
highlight the need to periodically update recommendations as we may need to readopt more restrictive measures depending
on the local epidemiology of the virus. These guidelines are designed to avoid the transmission of SARS-CoV-2 among both
patients and healthcare staff as we gradually return to normal medical practice, to prevent postoperative complications and
try to reduce possible deficiencies in the diagnosis, treatment and follow-up of the ophthalmic diseases. With this update
(5th) the Spanish Society of Ophthalmology is placed as one of the major ophthalmology societies providing periodic and
systematized recommendations for ophthalmic care during the COVID-19 pandemic.

Key words: COVID-19 – eye care – eye health – lockdown easing – pandemic – personal protective equipment

Acta Ophthalmol. 2021: 99: e973–e983

ª 2021 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

doi: 10.1111/aos.14752

Introduction Current knowledge about how SARS-CoV-2 is transmitted in res-

COVID-19 spreads is largely based on piratory sprays or droplets to the
Coronavirus disease COVID-19 is our understanding of other coron- conjunctiva, as virus particles have
caused by the highly transmissible aviruses. The virus is believed to spread been detected in ocular secretions. Here
SARS-CoV-2. Its mortality rate is high, mainly from person to person through they can cause conjunctivitis and this
especially in elderly patients with comor- respiratory droplets produced when an may even be the first manifestation of
bidities such as immunosuppression, res- infected person exhales, coughs, or systemic infection (AAO 2020a; Guan
piratory disease, cardiovascular disease, sneezes (Parrish et al. 2020). It is also et al. 2020; Seah et al. 2020; Xia et al.
obesity or diabetes mellitus, and also thought to be transmitted when a person 2020). As ophthalmological examina-
among persons constantly exposed to the touches an object or surface with the tions are conducted at 30 cm in the
virus (Yang et al. 2020b). The COVID-19 virus present and then touches the case of the slit lamp or even closer for
outbreak has had a global impact and is mouth, nose or eyes (Ghinai et al. other procedures (e.g. intraocular pres-
causing a previously unknown number 2020). In addition, viral RNA has been sure measurement, direct ophthal-
of deaths among younger, seemingly found in stool samples from infected moscopy, tear duct examination or
healthy individuals. Such deaths have patients, suggesting the possibility of instilling eye drops), they should be
been attributed to cytokine release syn- transmission via the faecal-oral route considered high-risk procedures and
drome, also known as cytokine storm, (Wang et al. 2020). There is also evidence performed according to standard mea-
which ends up producing multi-organ that SARS-CoV-2 is transmitted both in sures (Aleci 2020; Cheena et al. 2020;
failure (Mehta et al. 2020). the asymptomatic and presymptomatic Hellewell et al. 2020; Lai et al. 2020; Li
The symptoms of COVID-19 usually period (Bai et al. 2020). et al. 2020; Sadhu et al. 2020; Zhang
appear 2–14 days after exposure to the Environmental contamination by et al. 2020).
virus. These symptoms may include SARS-CoV-2 is another cause for con- Povidone–iodine effectively inacti-
fever, chills, muscle pain, headache, sore cern. In one study (Van Doremalen vates viruses at concentrations nor-
throat, loss of sense of taste and/or et al. 2020), viable SARS-CoV-2 was mally used in clinical practice. This
smell, diarrhoea and follicular conjunc- detected in aerosols up to 3 hr after antiseptic is effective against coron-
tivitis (Chen et al. 2020). Complications aerosolization, although in an experi- aviruses (AAO 2020b) and should be
in severe cases include pneumonia, acute mental configuration that lacked ven- used for surgical preparation, although
respiratory distress syndrome (ARDS), tilation, so this does not necessarily not in the presence of a penetrating
kidney failure, cardiomyopathy, stroke, reflect how the virus behaves in real-life incision or during intraocular surgery.
encephalopathy and severe thromboem- conditions. This study also found that SARS-CoV-2 is susceptible to the same
bolism (Guan et al. 2020). One study infectious viruses could survive up to alcohol-based disinfectants and sodium
(Lauer et al. 2020) found that the 24 hr on cardboard, up to 4 hr on hypochlorite (bleach) solutions in
average incubation period for COVID- copper, and up to 2–3 days on plastic water that are commonly used to dis-
19 was 5–7 days, and patients were or stainless steel. In another study, the infect ophthalmic instruments and
generally infectious for several days authors found evidence of SARS-CoV- office furniture. (Junk et al. 2017;
before the onset of symptoms. Further, 2 RNA from personal items and envi- Balibrea et al. 2020).
more than 97% of those who developed ronmental surfaces in hospital rooms Recent reports have reviewed the
symptoms did so within 11.5 days of for COVID-19 patients, but the virus possibility of the generation of aerosols
exposure, also supporting recommen- could not be isolated from air samples that transmit the virus during pha-
dations of 14 days of quarantine. (Santarpia et al. 2020). coemulsification and pars plana

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Acta Ophthalmologica 2021

vitrectomy (Darcy et al. 2020; Harding Methodology used to reach consensus on factors, or motive for care. In general,
et al. 2020). However, until we have the recommendations scientific approaches to estimate the
more data available, current evidence risk of SARS-CoV-2 infection are still
All Spanish scientific Ophthalmology
suggests that it is unlikely that there will at an early stage, so the recommenda-
Societies of the different subspecialties,
be sufficient virus or aerosols generated tions proposed here are based on the
both national and regional, helped pre-
during a phacoemulsification or a pars latest developments in science. As oph-
pare this set of recommendations. These
plana vitrectomy to infect surgical per- thalmological examinations or treat-
societies are detailed in the authors’ list.
sonnel (Chandra et al. 2020). ments most often require close physical
The two main authors (JAGF and FLO)
There is much controversy over what proximity, these procedures must be
coordinated a working group composed
constitutes PPE and what should be deemed high risk for both patients and
of one or two representatives of each
used by ophthalmologists performing ophthalmologists and other health and
society, and these authors moderated
eye examinations, particularly regard- nonhealth professionals in the different
discussions of the different recommen-
ing the use of masks and goggles (CDC ophthalmology settings.
dations and proposals (detailed in
2020; Lei et al. 2020; Li et al. 2020).
Tables 1–3). In a first round of discus-
Data on environmental virus contami-
sion, there had to be at least 75% Protection and security measures
nation and increased awareness of
agreement for a recommendation to be
transmission by asymptomatic carriers Until accurate diagnostic tests, an
accepted. A second round was then held
or by patients in the presymptomatic effective treatment and/or an approved
with the general coordinators of the
stage of a new infection support the use vaccine are available, establishing and
different societies to discuss the final
of protection for the mouth, nose and complying with rigorous protective
inclusion of items for which agreement
eyes (Hu et al. 2020; Tindale et al. 2020). measures in outpatient and inpatient
was not 75%, but was greater than 66%
In this report, we provide guidelines clinics is key both for healthcare work-
(2/3). The confinement situation in
and recommendations for ophthalmol- ers and patients. (Borrelli et al. 2020)
Spain during the period (April–May,
ogy practice during the easing of con- These measures include social distanc-
2020) when this document was prepared
trol measures following lockdown. The ing in waiting rooms and minimizing
precluded any face-to-face meetings, so
measures proposed here are designed to visits to and time spent in health
these discussions were held via email or
reduce the chances of cross-transmis- centres; providing the necessary PPE
video conference. Finally, the definitive
sion between patients and healthcare to clinicians and face masks to patients;
version of the document was validated
personnel and to prevent postoperative following disinfection guidelines rec-
by the board members of the Spanish
complications in the management of ommended by preventive medicine ser-
Ophthalmology Society coordinated by
patients with an eye condition. vices; and periodic diagnostic tests on
the main author (JAGF).
healthcare professionals to optimize
the distribution of tasks within the
Basis for Implementation period and validity organization. We should stress that in
the following months, depending on the
Recommendations The recommendations detailed in this control and prevalence of COVID-19,
This document is the result of a review of paper need to be constantly updated these measures could be deferred.
the state of knowledge and consensus and adapted based on the quickly
between the different Spanish ophthal- evolving situation in our country
(Geg
undez-Fern
andez et al. 2020). Expected clinical–healthcare impact
mology societies. It includes recommen-
dations for eye care ensuring the highest Many of the measures proposed are Under the present circumstances, vol-
levels of safety during the gradual return dependent on restrictions imposed by umes of activity may be substantially
to normality in the context of the the government in each autonomous reduced or have to be redistributed
COVID-19 pandemic. All measures are community, region, province or health across longer time intervals than before
targeted at minimizing exposure to the area to services considered nonessen- the pandemic. Additional precautions
SARS-CoV-2 virus, reducing the tial, the particular characteristics of the required in operating rooms may also
chances of cross-transmission between centres, epidemiological indicators, lead to longer rotation times, which
patients and healthcare personnel, and availability of protective equipment may affect the number of surgeries that
avoiding the development of postoper- and access to COVID-19 tests. Once can be performed per session. In any
ative complications. These measures are the health authorities have completed case, it is recommended that the
based on several basic principles derived this phase of gradual stepping down of resumption of activities be carried out
from the evidence available in the scien- control measures, these recommenda- gradually, stratifying and prioritizing
tific literature (Wormald 2003; Wor- tions will have to be revised. the patients that will have to be exam-
mald & Dickersin 2013). To date, ten ined face-to-face (SOFCALE 2020) to
major international ophthalmology adapt healthcare activity to the circum-
Variability
societies (including the Spanish Society stances at each moment and stage of
of Ophthalmology) have provided rec- At the time of writing, several new the gradual return to normality.
ommendations regarding urgent patient outbreaks of COVID-19 are emerging
care, social distancing, telemedicine and in Spain. Accordingly, it is safer to
Role of telemedicine
PPE for members on their websites assume that any patient requiring eye
(American Academy of Ophthalmology care could be infected with SARS- In the current situation, telematic
2020a, 2020b; Nguyen et al. 2020). CoV-2, regardless of the diagnosis, risk means may be used for tele-assisted

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Acta Ophthalmologica 2021

Table 1. Checklist for use in outpatient clinics. Table 2. Triage checklist to identify possible
exposure to SARS-CoV-2.
Responsible
Area personnel Yes No Question Answer

Reception Managers Safety barriers with screens and marked Have you during the past 14 days Yes /
distances had any of the following No
One-way transit circuits symptoms?: fever, malaise,
All facilities equipped with hydroalcoholic tiredness, respiratory symptoms
gel dispensers (dry cough, dyspnoea), loss of taste
Nursing staff Patient on time for appointment (ageusia) or smell (anosmia),
Patient alone or accompanied by a single diarrhoea, headache, rash on trunk
person or limbs
Clinical–epidemiological triage done in Do you have symptoms of Yes /
reception area conjunctivitis such as red eye, No
Patients and companions instructed not to discharge, itching, burning or
touch surfaces or equipment photophobia?
Patients and companions instructed to be Have you been in contact with or Yes /
quiet lived with a family member or No
Patient and companion are wearing masks friend who has been diagnosed with
Patient and companion have washed their COVID-19 or quarantined because
hands with gel of COVID-19 in the last 14 days?
Patients with acute conjunctivitis assigned Have you recovered from COVID- Yes /
to separate circuits and rooms 19 disease? No
Waiting Rooms Managers Waiting rooms have the minimum If you have had COVID-19, when Days
separation distance set were you told you were disease- ago
Basic instructions regarding behaviour free?
and hygiene provided in waiting rooms Did you self isolate or were you Yes /
Cleaning staff Continuous cleaning of waiting rooms isolated for 14 days? No
Consultation and Managers Slit lamps fitted with methacrylate screens Did you have any test to show that Yes /
Examination Ophthalmologists Patients stratified by eye condition into you were not contagious? No
Rooms three risk categories
Patients needing face-to-face consultation COVID-19 = Coronavirus Disease 2019.
prioritized
Informed consent for tele-assisted medical
care obtained
Devices for self-examination provided in Recommendations in the
the first face-to-face consultation
Complementary examinations reduced to
Outpatient Clinics
those strictly necessary Figure 1 shows the main protection
Exams involving friction on the ocular measures recommended during con-
surface avoided
finement easing. Table 1 provides a
Devices used with disposable protectors
Nursing staff Extreme cleaning-disinfection measures checklist summarizing the recommen-
for instruments and equipment dations detailed below.
General All staff Daily self-health assessment before setting
out for work
PCR and serological tests
Patient recommendations
Correct wearing of surgical mask or FFP2 • Patients should attend their appoint-
Nitrile gloves worn ments unaccompanied or accompa-
Goggles or face shield worn
nied only by one person in the case
Uniform or pyjamas worn
Mobile phone use minimized of physical, psychological or social
Regularly ventilation of facilities dependency, or children up to the
Ophthalmologists Hands washed with gel after each patient age of 18 years.
or examination • Nursing and administrative staff who
Eye drops used to avoid contact with the are duly protected (mask, gloves,
eye surface or eyelids face shield or protective screens) will
Use of available single-dose eye drops be in charge of the tasks to be carried
Eye dressings applied and removed
out in the reception area prior to
carefully
Cleaning staff Hygiene and cleaning measures of all patient admission.
facilities have been extreme • Body temperature measurement with
a noncontact thermometer is contro-
FFP = filtering face piece; PCR = polymerase chain reaction. versial for patients attending the
clinic or centre. The absence of fever
consultations through voice calls or of an unfavourable disease course or does not necessarily exclude asymp-
videoconferences (Saleem et al. 2020) complications, a face-to-face appoint- tomatic carriers of COVID-19. Fur-
In patients deemed to have a low risk ment can be postponed. ther, the Spanish Agency for Data

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Acta Ophthalmologica 2021

Table 3. Checklist for use in the surgery area. seated until they are called to enter the
office. It is recommended that seats be
Responsible
removed or taped to maintain the
Area personnel Yes No
safety distance. The accumulation of
Preoperative Ophthalmologists Clinical and epidemiological triage done prior patients in waiting and testing rooms
to surgery should be avoided at all times.
Negative SARS-CoV-2 PCR documented 48 hr • Waiting rooms for children should
before surgery be separate.
Complementary informed consent for surgery • We recommend audio/video, posters
provided
or electronic panels with basic
Case assessed to avoid general anaesthesia as
much as possible instructions for patients.
Outpatient regimen planned to avoid • The number of patients scheduled
hospitalization for appointments should be carefully
Anaesthesiologists The preanaesthesia has been performed and the calculated to ensure that appoint-
preoperative tests requested ment times are accurate and avoid
Nursing staff Triage performed on the companion on the day overcrowding.
of surgery • It is also advisable that clinics design
Patient provided with surgical mask
patient flow circuits to minimize
Patient has washed hands with gel
All the staff PCR and serological tests crossing of paths. Whenever possi-
Operating Ophthalmologists Surgical drape placement confirmed to avoid ble, circulation should be unidirec-
Room aerosols tional, so that patients access the
Valved trocars used in vitreoretinal surgery clinic through one entrance and exit
OVD used on ocular surface to avoid through a different one. Safety dis-
aerosolization tances should be marked with lines.
Health personnel PPE including pyjamas, surgical cap, shoe • Patients will be instructed on the
covers, FFP2 mask, goggles or face shields,
need to avoid touching surfaces and
gown, gloves
Nonhealth staff Surgical mask, gloves and face shield or goggles devices mainly in the testing and
worn consultation areas. In the case of
All the staff Usual asepsis and antisepsis measures in children, warn parents about this
surgical area have been extreme point. Likewise, efforts will be made
In the operating room, minimum essential staff to speak as little as possible in the
stay on and movement is reduced waiting rooms and during eye exam-
Operating Ophthalmologists Only urgent interventions in COVID-19 inations or treatments. Door handles
Room patients
or knobs must be disinfected each
COVID-19 Surgery delayed for as long as possible or until
PCR negativity time they are used.
Patient informed so that life risk/eye benefit can • As a general rule, all new patients
be weighed with an ocular problem without
Maximum PPE used symptoms of coronavirus infection
will be seen. Patients with suspected
COVID = coronavirus disease 2019; FFP = filtering face piece; OVD = ophthalmic viscosurgical
or confirmed COVID-19 should be
device; PCR = polymerase chain reaction; PPE = personal protective equipment; SARS-CoV-
2 = severe acute respiratory syndrome coronavirus 2.
referred to the primary care services
according to the clinical criteria and
instructions of the different health
Protection (AEPD) has warned of masks. If COVID-19 is suspected services, or to the emergency services
about a possible violation of the for any reason, the patient will be of reference hospitals. For successive
rights of patients. Thus, if done, instructed to stay home and contact outpatient visits, the eye condition
temperature measurement should be their local health authority. can be stratified into three risk levels
carried out by healthcare personnel • Once the patient and companion (if (low, medium and high) so that the
and the data subject to data protec- appropriate) are admitted, they will follow-up of low- or medium-risk
tion regulation (AEPD 2020). Body be instructed to wash their hands problems could be spaced out or
temperature measurement will be with hydroalcoholic gel, and surgical replaced with telematic appoint-
therefore optional or follow guideli- masks will be provided if needed. ments. It may be useful to separate
nes established by the health author- The use of masks is also recom- visits for certain pathologies by day,
ities. mended in children. time interval or physical space,
• Triage checklist to identify possible • The use of elevators should be depending on the subspecialty and
exposure to SARS-CoV-2 is shown reserved for elderly, disabled or demand for eye care, as well as
in Table 2. pregnant persons and if possible only prioritizing those that will need to
• If possible, triage should be con- one or two persons should use an be attended in person. The latter
ducted via a phone call the day elevator at a time. should be assessed on a case-by-case
before the appointment. In this call, • In waiting rooms, patients and com- basis through the medical history.
patients can also be reminded of panions should keep a distance of 1– • Complementary examinations
hygiene measures regarding the use 2 m and will be instructed to remain should be limited to those necessary

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Acta Ophthalmologica 2021

Basic rules of activity

• Paent and professional safety
• Minimum paent stay me
• Priorizaon of pathologies for face-to-
face consultaons
Virtual consultation • Mixed or telemac consultaon in the
• Paent contact rest
Waiting room • Checklist
• Separaon – marking chairs distance • Priority
• Control venlaon and air condioning 1 Non-delayed face-to-face consultation
• Frequent cleaning of chairs-handles- 2 Semi-face-to-face consultation
3 Non-priority consultation- telemedicine
sinks
• Instrucons-informaon panels

Secretary
Consultation Area - face-to-face
• PPE

Staff
Patient reception • Disinfecon between each paent
Surgical mask. Face shield
• Auxiliary staff • Methacrylate screen in slit-lamps Do not share pen
Surgical mask or FFP2 if possible • Control venlaon and air Methacrylate screen
Face shield
Disposable gown Nursing / Optometry
Gloves • PPE
• Informaon check Surgical mask or FFP2 if possible
Fever cough anosmia ageusia contacts + Goggles or face shield
• Fever: IR thermometer Gloves
• Surgical mask Semi-face-to-face consultation Hand washing between paents
If patient does not bring it, it is provided • VA, OCT, VF test ...
• Hand hygiene: hydroalcoholic gel • Paent exit Ophthalmology
• 1 companion only • Ophthalmology review • PPE
Surgical mask or FFP2 if possible
Stay in the waiting room if possible • Telephone recommendaon prescripon Goggles or face shield
Gloves
Hand washing between paents

Fig. 1. Gradual reactivation model for outpatient clinics.

to make an accurate diagnosis and Recommendations regarding infrastructure • Each session, all items in the offices
prescribe the appropriate treatment. and equipment and examination rooms (furniture,
• Patients with acute symptoms of
• Extreme hygiene and cleaning mea- devices, knobs and door handles,
conjunctivitis should be isolated computer equipment, etc.) should
sures should be implemented for
through separate circuits and zones be cleaned with 70 alcohol, dilute
floors, walls, surfaces, furniture and
(in hospitals generally in the emer- sodium hypochlorite or 0.5% hydro-
medical or other equipment such as
gency department) as these patients gen peroxide (Kampf et al. 2020).
computers. At the end of a session,
are considered COVID-19 suspects. Between each use, chin rests and
all offices, waiting and examination
If this is not possible and there are support fronts of slit lamps and
rooms, halls, walkways, reception,
no guarantees of safety, they would other examination equipment, as
toilets, etc. must be disinfected using
have to be referred to the emergency well as joysticks and push buttons,
the usual methods.
department of a reference hospital.
These patients need to wear a surgi-
• Ventilate facilities. instruments and test frames and

cal mask and gloves after hand

• Reception, information and admin- lenses, should be cleaned and disin-
istrative areas should be protected fected (ECDC 2020).
washing with hydroalcoholic gel.
with screens and marked safety dis- • Scanning devices, such as slit lamps,
Likewise, the responsible clinician argon or YAG lasers, OCT and
tances maintained.
will use an FFP2 or FFP3 mask,
gloves and, if available, a waterproof
• Waiting rooms and other meeting indirect ophthalmoscopes should be
places need to be adapted to ensure fitted with methacrylate screens. As
gown. Both patient and clinician the virus persists on plastic surfaces,
the minimum distance of 1–2 m.
should have their hair tied up or between one patient and the next
Seats between patients that should
wear a surgical cap. All protections these screens must be cleaned on
not be used need to be clearly
should be discarded before seeing the both sides with a disinfectant (alco-
marked. We also need to consider
next patient. Patients with conjunc- hol, sodium hypochlorite).
areas where patients need to wait
tivitis of viral appearance should be
between tests or while undergoing • All manoeuvres or exams involving
considered and managed as COVID friction on the eye surface (e.g. con-
pupil dilation.
suspects and therefore diagnostic
tests requested for SARS-CoV-2
• There should be hydroalcoholic gel tact pachymetry, contact or immer-
dispensers in the waiting and exam- sion biometry, ultrasound, contact
(Cheena et al. 2020; Colavita et al. examination lenses, esthesiometry,
ination rooms.
2020).

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Acta Ophthalmologica 2021

Schirmer test, etc.) should be conditions permitting. FFP2 or • Extreme protective measures should
avoided as far as possible and FFP3 masks should be used on be taken in the presence of conjunc-
replaced with a noncontact proce- suspect COVID-19 cases or when tivitis.
dure. the exam planned carries a risk of • In the case of consultations by
• Pneumotonometry should not be generating aerosols, or requires close other specialists regarding hospital-
performed as the intense force of proximity and/or contact with the ized COVID-19 patients who pre-
the air can cause aerosolization of eye. sent with eye problems, once the
tear drops to the environment • Hand washing should be a priority suitability of the visit has been
(ChunchunLi et al. 2020). The use before and after any activity with the discussed with the responsible spe-
of devices with disposable protectors patient. This can be done in the same cialist, assistance will be carried
such as the Tonopen, Icare or the way with a hydroalcoholic gel when out in the patient’s room or in a
Goldmann tonometer is recom- wearing gloves (Goktas et al. 1992; special COVID examination area
mended. If these protectors are not Scheithauer et al. 2016). Posters with within the ‘contaminated’ circuit
available, recommended disinfection washing guidelines in offices and established at each centre. If exam-
methods will be used on each device. waiting rooms are helpful. inations are carried out in areas
The use of the Perkins handheld • Eye drops should be instilled with not equipped with conventional
tonometer is not recommended given gloves avoiding contact with the ophthalmic equipment, portable
the extreme closeness to patients ocular surface or adnexa. If avail- equipment may be used depending
required. If used, protective goggles able, the use of single-dose eye drops on their availability (slit lamps,
and FFP2 / FFP3 masks should be is recommended. tonometers and indirect ophthal-
worn. • Safety precautions should be extreme moscopes). Perkins-type tonometry
• Recommended disinfection measures when placing or removing eye should not be performed in these
for test glasses and frames, occlud- patches and dressings. patients because of the close prox-
ers, pinholes, prism bars or lenses, • When examining the tear ducts or imity to the face required. For this
etc., should be cleaned with 70 removing silicone tubes from the same reason, direct ophthalmo-
alcohol, sodium hypochlorite or nostrils, FFP2/FFP3 masks and gog- scopes should not be used to visu-
hydrogen peroxide after each use. gles or face shields should be worn. alize the fundus. After each use,
The use of phoropters is preferable • The use of mobile phones should be equipment will be cleaned and
to that of trial frames and inter- restricted as much as possible during disinfected by staff.
changeable lenses for refraction as a consultation to avoid contamina-
they are easier to clean. tion and virus transmission in this
• While protection of self-refractome- way (Olsen et al. 2020).
Recommendations for telemedicine
ters and portable slit lamps with
plastic bags is recommended, this • During the COVID-19 public health
Care of patients testing positive for SARS-
measure should also be adapted to crisis, telematic consultations via the
CoV-2
the particular circumstances of each telephone, internet or videoconfer-
case as it can greatly limit their use. • These patients should not be ence have been encouraged. The
attended by an ophthalmologist until possibility of carrying out certain
they have been examined at the successive reviews, both in outpa-
Recommendations for healthcare and
General Emergency Service accord- tient clinics and hospitals, and excep-
nonhealthcare personnel
ing to the protocol of each centre. tionally for first-time consultations,
• For the safety of everyone, it is
a Peripheral centres: These patients
should be considered according to
essential that any infection risk clinical criteria. The balance between
should contact by telephone the
among workers be detected early. risk/benefit, both systemic and oph-
health authorities of their autono-
This requires daily health self-assess- thalmological, should be carefully
mous community and follow their
ment before heading to the work- weighed for the patient in all cases
instructions.
place. Screening tests (PCR and (SERV 2020).
b Reference hospital centres: For
serological tests) should be scheduled • Non face-to-face consultations will
the care of these patients, an exam-
at intervals set by occupational be considered a ‘procedure for Tele-
ination is first conducted in an iso-
health experts. assisted Medical Council’. It is con-
lated area with complete individual
• Administrative staff in contact with
protection equipment (FFP2/FFP3
venient to obtain informed consent
patients must wear a surgical mask for tele-assisted medical care. The
masks, gloves, shoe covers, surgical
and gloves. In reception areas and consent form can be previously sent
cap, waterproof gown and goggles
counters, protective screens prefer- by email to the patient, family mem-
or face shields) according to the
ably or the use of face shields is ber or guardian, so that it can be
preventive medicine service of each
recommended. returned signed or, if not, accepted
centre.
• Healthcare personnel (ophthalmolo- by telephone via voice recording
gists, nursing staff and optician-op- • Multidose eye drops in COVID-19 systems. If consent cannot be
tometrists) should wear their normal positive patients should be single- granted in this way it may be
work clothes, a disposable gown, used and discarded. If possible obtained verbally.
gloves, mask and face shield or single-dose eye drops should be • Although telemedicine is limited in
protective goggles, the examination available. ophthalmology because of the

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Acta Ophthalmologica 2021

complex exams and devices required, of infection, so results must be procedures should be carried out on
telephone consultations may be espe- interpreted with caution. Table 4 an outpatient basis, thus avoiding
cially useful in children, given the shows the possible diagnostic impli- hospital admission.
anxiety that the current situation can cations of the results of a PCR and
generate in parents, and may help serological tests for SARS-CoV-2
avoid unnecessary visits to the emer- infection (SEI 2020). It should be
Recommendations regarding infrastructure
gency services. clarified that a positive IgM result
and equipment
• It should be remembered that the accompanied by a negative PCR and
follow-up of many chronic ocular IgG test does not only suggest early • The usual measures for other areas
diseases requires complementary stage disease and a false negative also apply to the surgery area in
tests (e.g. visual field tests, retinal PCR result, but could also mean a terms of maintaining conditions of
imaging, optic nerve or cornea tests) false positive IgM result and there- hygiene and the cleaning of floors,
and a direct eye exam. These consul- fore the absence of disease. If the walls, surfaces, furniture and other
tations are thus not really amenable urgency of the situation does not items.
to telemedicine unless combined with allow for testing, the patient should • Asepsis and antisepsis measures in
some face-to-face visits. For organi- be treated as infected. In any case, the operating room should be
zational purposes, it may be useful to the guidelines issued by the central extreme. In preparation for surgery,
differentiate between consultations and autonomous community health the use of povidone–iodine 5% on
for glaucoma (tele-glaucoma), retina advisers must be followed at all the ocular surface has been shown
(tele-retina) or the other ophthalmo- times. effective against SARS-CoV so is
logical subspecialties. • In accordance with the guidelines of assumed to also protect against
• To facilitate visual self-examination each centre or hospital in coordina- SARS-CoV-2 (Kariwa et al. 2006).
during teleconsultations, resources tion with the anaesthesiology ser- • To contain the aerosols that can be
can be provided in the first face-to- vices, preoperative analytical tests, generated during the use of instru-
face consultation, (e.g. cards with COVID risk profiles, electrocardio- ments such as phacoemulsifiers, vit-
optotypes, Amsler grid, websites of gram, chest X-ray or chest CT reotomes, lasers, burrs, cutting
computer applications, etc.). should be conducted at the discretion systems and electrical coagulation
of the anaesthesiologist. devices, or after certain procedures
Recommendations for • Complementary informed consent such as irrigation of the ocular sur-
for surgery during the COVID-19 face with saline solution, the use of
Eye Care in the Surgery pandemic is needed added to specific surgical fields specifically designed to
Area consent for the procedure scheduled. act as barrier systems could be use-
• Once admitted, the patient should be ful. If available, 3D visualization
Table 3 provides a checklist as a sum- instructed to wash their hands with systems can provide some distance
mary of the recommendations detailed hydroalcoholic gel and they will be between patient and surgeon (Lovino
below. provided with surgical masks until et al. 2020).
they are transferred to the surgery • For vitreoretinal surgery, valved tro-
Patient recommendations room. cars should be used and viscoelastic
• The patient should be warned of the applied to the valves to minimize the
• For all patients, a checklist will be need to avoid touching any surfaces spread of particles and aerosols dur-
completed prior to the intervention or devices, and to speak as little as ing air exchange.
to assess the possible presence of possible during the surgical proce- • The preferential use of ophthalmic
symptoms of COVID-19 or positive dure. viscosurgical devices (OVD) is rec-
epidemiological contacts. On the day • Surgeries requiring general anaesthe- ommended for all ocular procedures
of surgery, triage should also be sia should be limited to those strictly that may require hydration of the
carried out on the accompanying necessary. ocular surface, as we understand that
person. • As far as possible and in patients the likelihood of dispersing aqueous
• Before a major surgery procedure testing negative for COVID, surgical particles is reduced compared with
(24–72 hr) especially if it is per-
formed under general anaesthesia Table 4. Diagnosis of SARS-CoV-2 infection.
(Sainz 2011), and when there is a
high risk of generating body fluid PCR IgM IgG Diagnosis
aerosols, a polymerase chain reac- Negative
tion (PCR) test for SARS-CoV-2 + Initial stage
virus should be conducted. The pre- + + Early stage
operative determination of antibod- + + + Active stage
ies in itself does not serve to + + Advanced stage
distinguish between infected individ- + Early stage, false negative PCR?
uals or those who have already had + + Disease progression
+ Resolution stage
the infection. A positive IgM anti-
body result will not be obtained until IgG = immunoglobulin G; IgM = immunoglobulin M; PCR = polymerase chain reaction.
approximately 5 days after the start Reported by the Spanish Society of Immunology (SEI).

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Acta Ophthalmologica 2021

continuous profuse irrigation of the magnifying glasses, and these also provided in the algorithm shown in
ocular surface with saline. impair correct visualization of the Fig. 2.
• If the patient is COVID-19 positive surgical field. For oculoplastic sur-
a Any intervention should be post-
or infection is suspected, the operat- gery, it may be advisable to use the
poned ideally until the PCR result is
ing room set up for these patients surgical microscope with a wide-field
negative. The patient should always
should maintain negative atmo- visualization system or to operate
be assessed in terms of life risk/eye
spheric pressure to minimize the with protective screens without mag-
benefit.
spread of the virus outside. In addi- nifying glasses until specific screens
b If surgery cannot be delayed (e.g.
tion, a high frequency of air are designed for these.
eye perforation), the mortality risk
exchange (25 times per hour) will • FFP2 masks should be discarded and
must be evaluated, especially in
rapidly reduce the viral load within replaced in any of the following
hypertensive patients over 65 years
the surgery room (Wong et al. 2020). circumstances: if damaged, moist-
of age with obesity, chronic obstruc-
ened, dirty or contaminated (e.g.
tive pulmonary disease, cardiovascu-
with secretions or body fluids), or
Recommendations for healthcare and lar disease, ARDS,
when the facial seal is compromised,
nonhealthcare personnel immunosuppression, severe lym-
uncomfortable or breathing becomes
phopenia, or before very complex
• It is recommended that PCR and difficult. It is also important to fol-
surgeries. In these scenarios, various
serological tests be carried out at the low the manufacturer’s instructions
studies have revealed high ICU
frequency established by the national regarding time of use and expiry
(Intensive Care Units) admission
health system authorities. date.
rates and mortality (Lai et al. 2020;
• Nonhealthcare personnel in the sur- • In the operating room, there should
Wu et al. 2020; Yang et al. 2020a).
gery area must wear a surgical mask, only be the minimum personnel nec-
eye protection (face shield or gog- essary and their movement should be
gles) and gloves. minimized. Transplant regulations
• Surgeons and nurses should take
Ocular tissue transplants should be
appropriate protective measures,
Care of patients testing positive for SARS- considered in terms of patient and
especially when managing COVID-
CoV-2 clinician safety applying the protection
19 patients: surgical pyjamas, water-
measures mentioned in this document.
proof gown, disposable cap and shoe • These recommendations only apply
To accept donor tissue, the recommen-
covers, surgical gloves, face protect- to urgent surgical interventions. Any
dations issued by the National Trans-
ing goggles or shields, protective planned surgery will be postponed
plant Organization (ONT 2020),
mask (FFP2 or equivalent N95 or until the COVID-19 situation has
reference BV-ES-20200122-5, of March
FFP3). Valve masks must not be improved and the patient has com-
13, point 2 on ‘Tissue Donation’ need
used. pleted a 14-day period of home
to be followed:
• The use of goggles and face shields is isolation after returning a negative
in many cases incompatible with the PCR result. Guidelines for measures Regarding donation of tissues, at
use of surgical microscopes and to be taken in emergency surgery are the current time, any confirmed

Consider deferring
Delay a few days IC and paent decision
Consider non-surgical Tt.
COVID-19
Posive
Hospitalizaon
Non-postponable Life risk assesment**
Ophthalmic (Emergency) IC and paent decision
Emergency Consider non-surgical Tt.

** over 65 years
COVID-19 SI HBP
Obesity
Negave PPE Condions COPD
CV disease
ARDS
Immunosuppression
Severe Lymphopenia
Complex SI

* Adapted from Asociación Española de Cirujanos (Balibrea et al. 2020)

** Factors that increase rates of admission by 45% and mortality by 20% (Lei et al. 2020)
HBP = High Blood Pressure. COPD = Chronic Obstrucve Pulmonary Disease. CV = Cardiovascular. ARDS = Acute Respiratory Distress Syndrome. SI = Surgical Intervenon. COVID =
Coronavirus Disease 2019. PPE = Personal Protecon Equipment. IC = Informed Consent. Tt = Treatment

Fig. 2. Algorithm for urgent surgical interventions.

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Acta Ophthalmologica 2021

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Acta Ophthalmologica 2021

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