Covid 19 has left no country or surgical practice untouched but there has been a very wide variation in national severity. The UK and Belgium have had high death rates, Germany far fewer and Sweden has had no formal lockdown. As we get back to work we pose a question which six months ago would have seemed odd to all of us but now we have a patient in a high risk group by way of his age and living in an environment with a high risk of symptomatic or asymptomatic infection (at least in the UK ). We asked Drs Guy Sallet, Florian Kretz, Jorge Alio, Filomena Ribeiro and Mayak Nanavaty to give their expert opinions on this case involving a 76 year old man referred for routine cataract surgery
‘A 76 year man is referred to you for routine cataract surgery. He lives in a care home. As far as you know you are both fit and well and have not Covid related symptoms.
What is your PPE protocol (if any) for yourself and the patient?
* the initial examination
* the routine phaco operation
* post operative follow-up
GUY SALLET, BELGIUM
Hereby is my protocol for this clinical case:
High-risk paint considering age and living in a care home.
Pre-admission would do a questionnaire to look for possible COVID-related issues.
Pre-admission to clinic: would do a PCR swab-test for exploration of possible COVID-19 positivity.
If this is uncertain, would follow pathway through clinic as for COVID-patients (evt CT-SCAN thorax).
If negative, examinations/surgery can be planned.
-Initial examination: as close as possible to surgery date within one week or less (no need for second PCR-test)
Initial examination and test providing hygiene standard measures including:
Masks for patient and staff
Hand hygiene and alcohol gel
Disinfecting chin rests and instruments as well as examination chairs in between patients
Shorten visit-time to clinic as much as possible
Mask for patient and staff
No goggles for doctor as we are working through microscope
Patient mouth covered by drape
Disinfection of OR-bed and supplies in between patient (eg monitoring devices)
Routine sterilisation procedure and hygiene measures
Reduce work-load (fewer patients per hour – every 30’)
Injectable dilation solution (eg Mydrane) instead of eyedrops
Quick discharge from clinic postoperative
All drops in clinic in unidose per patient
Social distancing in waiting area
Consider simultaneous bilateral cataract surgery to reduce clinic visits
Postpone day one follow-up: tele-consultation
One-month follow-up as usual
FLORIAN KRETZ, GERMANY
When we schedule the patient and he comes for pre-examination we council him for maximum time slots of 15 min for diagnostics and counselling. He has to come on his own and measure fever in the morning on the day of his appointment. Also patients already get written information regarding diagnostics and IOL possibilities including questionnaires.
At the examination there is a time slot of 30min. All patients have to wear masks and disinfect their hands, on top of which we measure for fever.
Our phase protocol was changed. The patients have a time slot of 25min from entering the building to leaving after the surgery. That is tough, but it is possible and needed a lot of workflow changes. But those are very individual, depending on your floorplan and the team.
Post-op, we only do two routine visits. Day one and after one week.
The initial visual examination: the regular one for any cataract surgery including biometry (IOLMaster), cataract description, analysis of anterior segment, any particular study as necessary depending on the clinical evidence (such as endothelial cell count), corneal topography (tangential map), fundoscopy and in case of doubt about macular function, macular function test. This study is performed with the examining ophthalmologist with full protection (mask and protection goggles), gloves and a protecting screen at the slit lamp.
Routine phaco operation: the routine involves all the steps that are necessary in normal cataract surgery. Betadine 1% is used for five minutes. At the moment of the surgery, one more minute is used with betadine solution 1% around the eye. When phaco is started, we wait 30 seconds in order to avoid the initial fluid becoming aerosol and potentially contaminating.
Follow-up: with similar protection as with the previous preoperative exam performed by the ophthalmologist and all those in contact with the patient, there is a distance of 2 metres between patients and following each of the exams, and once the examination room is empty, everything that is touched by the patient cleaned and disinfected with hydroalcoholic fluid, as well as the instruments.
FILOMENA RIBEIRO, PORTUGAL
In Portugal, we are currently in the process of returning to regular activity on an increasing basis. Care homes have already been identified as foci of infection and have been monitored very actively so the most likely is that this patient is on epidemiological surveillance.
At this moment we have consultations every 30 minutes and with offices at different times, so we reduce the risk of contagion in the waiting room. All, health professionals and patients, we use protection with the episodes advised by the hospital’s infection committee. In consultation and in the OR.
We have implemented strict measures at our hospital to try to limit exposure to COVID-19. We carry out an epidemiological questionnaire with patients before they are allowed to enter the hospital and also perform a temperature check.
We have provided all staff with surgical masks, glasses, gloves and waterproof gowns. We use acrylic protectors for the slit lamp. We have stopped performing air puff tonometry and applanation tonometry, except where absolutely necessary and use disposable tips. All the rooms, materials and surfaces are disinfected after each patient.
All the departments at the hospital, including the OR, have separate circuits for positive and negative COVID-19 patients.
We have stratified the risk by pathologies and we have developed guidelines for video consultation which we have started implementing.
In the OR we schedule at one-hour intervals, and we treat all cases as potential COVID positive. In the event of anticipation of the need for general anaesthesia, the patient is asked to perform the COVID test in their car without direct contact with the hospital.
In the operating room, we all use FFP2 masks and have a microscope protector on a bell to prevent aerosol spread. The rooms after each surgery are cleaned and put to rest. To guarantee all the necessary care we are currently working on an exclusive OR for ophthalmology.
The patient would be summoned for an appointment to assess the visual impairment and the diagnosis of cataracts with surgical indication and what is the associated pathology. On the same day, the patient would perform all the necessary preoperative exams to avoid further contact with the hospital and to decrease the number of patients in the waiting room, he would later be called to a video consultation where the results of the exams, the operative indication and the logistics required for the surgical day and postoperative evaluation. The follow-up implies a phone call in the next 24 hours and a brief consultation in the three days postoperatively. The patient has direct contact with the hospital and the doctor in case of alarm symptoms (as previously explained to the patient).
Mayank A. Nanavaty
In the United Kingdom, we have not yet restarted routine surgeries as of mid-May 2020. We are only allowed to see and operate on time-critical and emergency patients until further advice from the Government. On the private sector, the same rules apply. The majority of the big private hospital chains have been contracted by the Government until the end of June 2020 and are kept on the standby to deal with capacity-related issues in the Government hospitals. However, plans are being made to slowly re-open routine surgeries in near future.
In this case study, I give a hypothetical perspective of what might happen to a 76-year old man when we re-open for routine surgeries.
This 76-year old man will be contacted by telephone in the first instance to ask if he is happy to have cataract surgery as soon as we re-open for routine surgeries. If he shows the willingness to proceed then he will be asked further questions based on the UKISCRS/RCOphth guidelines to see if he qualifies for priority over other patients on the waiting list. He will only be given priority if he qualifies for the surgery as per the guidelines. Assuming that he qualifies for cataract surgery as a priority during the post-COVID 19 era he will be given a pre-assessment appointment. This patient will be encouraged to have a COVID-19 test done at his care home if possible (even if he is asymptomatic) and will be screened on the phone with a detailed questionnaire to assess whether he or anyone in his care home had any symptoms suggesting of COVID-19 in resent past. He will also be explained the risk of contracting COVID-19 through hospital visits and whether he still agrees to proceed understanding this risk.
The pre-assessment appointment will be arranged three-to-four days prior to his surgery date. All patients entering the hospital are given surgical fluid-repellent masks on the door and have their temperatures checked and he will have the same. He will be seen by a nurse for history and biometry. A nasopharyngeal COVID-19 test will be performed at this time (This might be done irrespective of the patients recent/previous nasopharyngeal COVID-19 test at the home). The surgeon will see him following this to take a consent for his cataract surgery, discuss the intraocular lens options and to make sure he understands the risk of COVID-19 transmission too. The patient will also be briefed about the postoperative drop regime at this appointment by the nurse or the doctor. It will be encouraged to have a policy whereby the operating surgeon sees the patient at the pre-assessment so that he/she can meet the patient directly in the theatre on the day of the surgery. The patient will also be given the dilating drops to take home and the care home nurse will be instructed to instil the drops one hour before the hospital arrival time for surgery. All the medical personnel involved at his pre-assessment visit will see him with FFP3 mask, gloves and plastic aprons (these will be changes between patients). The patient will be contacted prior to the surgery date about their COVID-19 antigen test results. They will only be invited for surgery if the test is negative.
On the day of the surgery, this patient will be called 30 minutes prior to the surgery on the ward. His temperature will be checked at the hospital entrance and he will be given a surgical fluid-repellent mask to wear. A single nurse in FFP3 mask, gloves and plastic apron will deal with one patient at a time. The nurse will mark the eye for surgery, check the patient’s identity and the consent form in the notes. This nurse will instil topical anaesthetic drops such as G. Proxymethacaine 1% and G. Povidone Iodine 5% in the inferior conjunctival fornix. This nurse will escort the patient to the theatre where she will hand over the patient to the theatre nurse and wait to collect the patient following surgery. The theatres are likely to treat all patients as COVID-19 positive until robust testing or vaccine is available. In the theatre, there are likely to be three people per case in full PPE e.g a scrub nurse, the surgeon and the runner. They will be in full PPE with FFP3 mask, double gloves and a visor (all patients will be treated as COVID-19 positive when they enter the theatres as the sensitivity of the antigen test is low and there is some uncertainty of phacoemulsification being an aerosol-generating procedure). The surgeons will be encouraged to use visors (although they may not be very comfortable with the operating microscopes).
The runner in full PPE will receive the patient from the ward nurse and the patients notes, intraocular lens power and consent is re-checked by the scrubbed team. The runner will instil an additional drop of G. Proxymethacaine 1% or G. Tetracaine 1% (based on the surgeon’s preference) and the surgeon paints the side of the face with povidone iodine. The patient will be draped in the normal fashion with fluid-repellent drapes in such a way that the drape covers the entire upper torso of the patient. As there are some uncertainties about phacoemulsification being an aerosol-generating procedure, additional plastic drapes may be used over this drape around the microscope and surgeon’s arms. Adequate oxygen supply will be maintained under the drape with oxygen tube inside the drape. Intracameral cefuroxime will be used in all cases as usual and the surgery will be completed. The patient will be handed over to the ward nurse outside the theatre with the patient notes. Once the patient has left the theatre, the theatre team will doff the PPE as per Department of Health’s policy.
The patient will have a pre-prepared pack of postoperative drops and written instructions on how to use them with a plastic shield and some saline pouches to take home. The patient will be given this pack and sent home immediately. They will be asked to contact the ward if they have any further questions regarding the use of drops or any new symptoms. He will be called by a ward nurse on the following day to ask a set of questions to assess if he is settling as per plan. A further follow-up phone call will be arranged in two-to-three weeks to do the same before he can be advised to visit the optician for glasses. If the patient reports any symptoms during this stage, he will be encouraged to visit a local optician in first instance and if necessary, the optician can refer this patient to eye casualty for him to be seen by a doctor.
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