In reply to a presentation from Philip Bloom, president of the United Kingdom and Ireland Society of Cataract and Refractive Surgery on Managing a glaucoma service during COVID-19 (https://www.eurotimes.org/running-a-glaucoma-service-during-the-covid-19-pandemic/) and the position of UKISCRS on AGPs, we received correspondence from Rashmi Nigram. We have included Dr Nagram’s correspondence in this newsletter with Dr Bloom’s reply. We offer this as a scientific discussion.
Re: Managing a glaucoma service in a COVID pandemic
I read this article in your email https://www.eurotimes.org/running-a-glaucoma-service-during-the-covid-19-pandemic/ and am shocked that such bold statements about AGP are being applied to ophthalmic surgery without any reference to scientific evidence that cataract surgery, vitrectomy or glaucoma surgery with MMC are AGPs!
How did Dr. Bloom and his hospital come to this conclusion? It has vast implications for ophthalmic surgery and I would to know how he can make these statements without evidence. As far as I am aware, conjunctivitis has been associated with COVID-19 but no intraocular diseases. The virus is rarely even detectable in tears of infected patients.
The one study that I found was on cats and mice that had intraocular inoculation of the COVID into the brain or vitreous and subsequently had inflammation of the optic nerve, anterior segment, brain, and retina. (Seah Feb 2020 Ocular Immunology and Inflammation).
At present in our OR, AGPs (ie patients needing GA for ocular surgery) are being intubated, the surgical team can only enter the theater 60 min later, perform the surgery and then the patient must remain in the OR for 60 min after extubation. Urgent surgeries that are currently being performed under topical/peribulbar anesthesia are not being considered AGPs. There is no evidence that they are. If our standard ophthalmic surgeries are deemed AGPs then we would be able to perform 4 surgeries per day!!
I think that the statements in this article are irresponsible.
Rashmi Nigam MD, FRCSC
Response from Dr Philip Bloom to Dr Nigam
Dear Dr Nigam,
Thank you for your comments following my comments on running a glaucoma service in a COVID pandemic. I,of course, welcome dialogue as part of a professional debate about this important and emotive issue, though I am surprised that you were so shocked by my stated opinions and hold their expression to be irresponsible.
It is evident that there is little or no compelling high-quality scientific evidence in this area, but lack of evidence of efficacy does not equate to evidence of lack of efficacy.
There is an on-going global public and professional debate concerning personal protective equipment (PPE) and associated measures that healthcare professionals take to protect themselves, their patients and their families against workplace-related contraction of infection.
Until this debate has played out to a consensus view (and perhaps even after that), individual practitioners, hospitals and healthcare systems will make their own personal and economic decisions. This is an evolving area with advice rapidly evolving, changing sometimes on a daily basis.
As the American Academy of Ophthalmology (AAO) has stated: “ There is heightened controversy regarding what constitutes appropriate PPE for ophthalmologists performing ophthalmic examinations, particularly around the use of masks and goggles. Reports of ophthalmologist and otolaryngologist deaths in China and Italy, new data about environmental virus contamination and increased awareness of asymptomatic and pre-symptomatic spread of new infections all favour mouth, nose, and eye protection. However, global shortages of PPE and concerns about mask effectiveness with extended wear and reuse have thus far impacted widespread adoption. Consequently, U.S. hospital guidance has varied from forbidding physicians from wearing masks except in high-risk interactions, presumably for fear of shortages, to mandating all hospital staff and patients wear surgical masks to reduce asymptomatic transmission. … the sum of … reports points to asymptomatic and pre-symptomatic transmission as a significant source of spread ” (https://www.aao.org/headline/alert-important-coronavirus-context).
In view of the likelihood of not insignificant rates of asymptomatic disease, most UK practitioners err on the side of safety by treating all patients as if they are infected.
Similarly, pending formal mandated government advice, the Royal College of Ophthalmologists has recommended to treat a variety of surgical procedures as Aerosol Generating Procedures (AGP).
Advice has been published to consider as AGPs the procedures of phacoemulsification (https://www.rcophth.ac.uk/wp-content/uploads/2020/04/RCOphth-UKISCRS-COVID-cataract-surgery-guidance-FINAL-170420.pdf, joint advice with UKISCRS, the UK & Ireland Society of Cataract & Refractive Surgeons), vitrectomy (https://www.rcophth.ac.uk/wp-content/uploads/2020/04/Vitreoretinal-surgery-management-guidance-070420-1.pdf, joint advice with BEAVRS, the British & Eire Association of Vitreoretinal Surgeons) and also some forms of oculoplastic surgery (https://www.rcophth.ac.uk/wp-content/uploads/2020/04/NEW-PPE-in-Oculoplastic-procedures-170420.pdf).
Li Wenliang MD, the ‘whistle-blower’ ophthalmologist who sounded the initial alarms on coronavirus and later died from the disease, believed he was infected by an asymptomatic glaucoma patient.
There are further cogent published opinions in this area, one of which states “ … COVID-19 … transmission through the ocular surface must not be ignored ” (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30313-5/fulltext). Whilst there is as yet no consensus about the risk of infection during glaucoma surgery, irrigation produces a visible plume of droplets and common sense dictates that there is also finer aerosolised spread, so we choose to treat any such surgery as an AGP.
The COVID pandemic continues to pose incalculable human cost and suffering as well as enormous (but quantifiable) economic costs. There is no doubt that the workflow delays wearing cumbersome PPE and treating surgical procedures as AGPs will contribute to the financial costs. I am proud that the hospitals I work in have chosen to support myself and others staff by prioritising people over profit.
Philip Bloom MB ChB FRCS(Ed) FRCOphth FGS
Chair, International Glaucoma Association
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