15
views
0
recommends
+1 Recommend
1 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Proposed algorithm during COVID-19 pandemic for patient management in medical retina clinic

      research-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background Over the last few months, the outbreak of coronavirus disease 19 (COVID-19) has affected an increasing number of Countries all over the world, and the United Kingdom (UK) is one of the most hit nations in Europe. The severe acute respiratory syndrome coronavirus 2 (SARS–CoV- 2), causing COVID-19, is thought to be transmitted through droplets, fomites, fecal material, and tears [1–3]. The absence of validated therapies and a vaccine has forced governments of many nations to implement lockdown and to apply the rules of social distancing (at least 1–2 meters between people). The detection of SARS-CoV-2 in tears and conjunctival secretions of infected patients with conjunctivitis and the short distance between patient and ophthalmologist during eye examinations and procedures, put eye doctors in high risk of being infected although not involved in the frontline. American Academy of Ophthalmology (AAO) on its website updated on a daily basis the recommendations to increase the protection of ophthalmic team members and patients during any visit, and highlighted some eye conditions that should be always monitored and treated [4]. In addition, many macular and retinal sight-threatening diseases require non-deferrable treatments that usually are performed in patients with systemic underling conditions (i.e. old age, diabetes, autoimmune diseases). This makes these patients at high risk for COVID-19. Royal college of ophthalmologists proposed guidelines on how to proceed specifically in Medical Retina (MR) clinic [5]. The World Health Organization (WHO) gave us technical guidance of the clinical management and important precautions that need to be set up during a pandemic [6]. Many reports suggested keeping patients at high risk of vision loss under defined treatment schemes [7–9]. Initially we reviewed the measures taken by health systems in Singapore and Hong Kong as published by Wong et al. [10] and by Lai [11]. We tried to match these guidelines in order to offer the best care possible to our patients. The purpose of this paper is to describe how the MR clinic at the Western Eye Hospital, Imperial college NHS trust in London, faced the COVID 19 pandemic. Our MR service is a tertiary referral centre for degenerative and vascular retinal diseases (such as age related macular degeneration (AMD), diabetic macular oedema (DMO), retinal vascular occlusion (RVO)) and other retinal disorders. During the 2019, in our clinic we provided around 15,500 visits. In Table 1 data about our clinical activity are described with comparison between the lockdown period in the UK so far, compared with the same period of the last year. In particular, between the 23rd of March and the 3rd of May 2019, 2345 patients attended our MR clinic for face-to-face consultations with an average of 55,83 patients per day. Of these patients, 882 (37,6%) received intravitreal (IVT) injections and 60 (2,56%) retinal laser treatments. Our aim is to propose a possible algorithm in order to minimize the patients visit maximising their visual outcome. It is important to highlight the features of our clinical practice that helped us during this period: Our clinic is a one-step MR clinic. This means that we are able to provide intravitreal injections to patients on the same day of the ocular examination, without any delay. Intravitreal (IVT) injections are performed in dedicated clean rooms and not in theatres. This reduces the waiting time for patients in the hospital. For wet AMD patients we were currently using treat and extend (TEX) regime. During this emergency, this scheme of treatment maybe helped us to protect patients with macular condition probably more easily compared to pro-re-nata (PRN). We have a Virtual clinic service for stable patient that do not need to be seen in the “face-to-face” clinics. Electronic Medical Records (EMR) represents a very helpful tool for clinicians. They allow doctors to access clinical records easily and remotely if needed. Table 1 Number of consultations intravitreal injections (IVT) and laser treatments done in the lockdown period so far, compared to the same period of the last year (2019) From the 23rd of march to the 3rd of may 2019 From the 23rd of march to the 3rd of may 2020 Face-to-face consultations 2345 510 IVT injections 882 456 Retinal laser procedures 60 12 Telephone consultations – 1830 Face-to-face consultations including patients underwent treatment such as IVT or retinal laser procedures Measures taken during Covid-19 pandemic The complexity of these days has been highlighted by the lack of data published in literature. Reports from national and international societies are at the moment the most important guidelines and following their indications, we categorized our patients in 3 main groups on the basis of the possible irreversible complications due to a long deferment of the treatment [4, 5, 7–9, 12]: High Risk Patients (HRP): including patients who need to be seen urgently, as suggested by some international ophthalmic societies [5, 7–9]. In this category we grouped patients affected by wet AMD or secondary macular choroidal neovascularization (CNV), only eye patients with any macular disorder, and patient with active proliferative diabetic retinopathy (R3) [12]. Low risk patients (LRP): including patients who may need to receive ocular treatment (such as IVT injections or laser), but it can be deferred over time with lower risk of permanent eye damage compared to the HRP group. This group included patients affected by RVO, DMO or central serous chorioretinopathy (CSCR) (5). Non urgent Patients (NUP): including patients who usually do not require treatments such as affected by retinal dystrophies, choroidal nevus and hydroxychloroquine screening patients. All our patients were contacted by the NHS England by means of text messages in order to cancel all the scheduled appointments. All doctors in the team went through the EMR on a daily basis of every expected patient. HRPs were contacted and, after a telephone triage (Table 2), were suggested to attend their scheduled appointments if no suspicious symptoms for COVID 19. Other scheduled patients were deferred and a telephone consultation carried out for each of them. Patient are asked to respond to some questions (Table 2) and, based on their previous notes and subjective evaluation of their vision, their appointment was rescheduled. The algorithm we propose is created in order to help to avoid permanent visual loss in HRPs as well as to reduce the waiting/exposure time in department with less interactions which help to protect our vulnerable patients. As suggested from international societies and from international literature, we took all the measures to reduce the risk of COVID 19 infection for our patients and staff [4, 10, 11]. These included social distancing of 1.5 m between patients in the waiting area, surgical masks for patients and disposable protective personal equipment (PPE) for all the members of the MR team (surgical masks, face shields, scrubs, aprons, and gloves). We also promoted hand hygiene and ensured regular environmental sanitation. For pragmatic exposition we will make another distinction between new patients and follow up patients. Regarding the clinical management, for both groups of patients RCOphth clinical guidelines have been followed [5], and also some suggestions from other international societies have been taken into account [7–9]. Table 2 Questions done for every phone consultation Questions Management Did you travel outside UK in the last 3 months? If Yes, where about? If yes and if in any high risk area, patient not allowed to come to the clinic Do you think you get in contact with somebody that resulted positive for coronavirus? If yes, patient not allowed to come to the clinic Are you self-isolating? If yes, patient not allowed to come to the clinic Do you have any cough, fever or shortness of breath? If yes, patient not allowed to come to the clinic Did you notice any change in your vision? Did you note any distortion on your Amsler Chart? If yes to both of the questions, patient asked to come to the clinic For patients affected by wet AMD, are you keen to come to have the injection done? If not, explain to the patient the possible risks of suspending the intravitreal injections New patient pathways New patients can be referred to our clinic via the Accident and Emergency (A&E) or General Practitioners (GPs). Wet AMD patients who came in our clinic for the first time underwent: Best Corrected Visual Acuity (BCVA) evaluation, intraocular pressure (IOP) check, optical coherence tomography (OCT), OCT angiography (OCTA) and wide-field retinal imaging. Clinician then reviewed patients’ records and imaging and an Aflibercept IVT injection were administered in the clean room. In addition, other appointments were arranged for the second and the third IVT injections every 4 weeks (loading dose). Another appointment to see the clinicians were then scheduled after 8 weeks since the last injection. Patients affected by DMO referred to the clinic, were suggested to attend only if graded as R3 or only eye patients and were treated with panretinal photocoaugulation (PRP) laser and/or IVT Aflibercept injection if also DMO present. Every other diabetic patients needing IVT injection were deferred for 2 months. Although we considered patients affected from RVO as low priority, we evaluated patient with new diagnosed Central RVO (CRVO) in order to rule out an ischemic subtype needing urgent treatment, otherwise they were deferred for 2 months. In addition we started a monthly loading dose of Aflibercept in new CRVO patients if macular oedema present. Patient with Branch RVO (BRVO) were rescheduled after 2 months. Other patients affected by disease not needing an urgent treatment such as inherited retinal diseases or CSCR were rescheduled at least after 6 months. A summary chart is reported in Fig. 1. Fig. 1 New patient pathway organized according to their retinal conditions Follow up pathways We made telephone consultations for all the patients with a clinical appointment recorded. Appointment for LRPs were deffered and, instead, HRPs were invited to attend the clinic for treatment if no suspect COVID 19 symptoms detected during the telephone triage. For wet AMD or macular CNV patients we decided to inject with Aflibercept regardless to previous type of anti-vascular endothelial growth factor (VEGF) agents given because of its longer duration of action compared to other anti-VEGFs [13]. During the telephone triage we advised patients that no BCVA measurement, IOP check and imaging will be performed. We explained them that their appointment only included the administration of the treatment. Another follow up appointment was arranged after 2 months. All the patients who were not keen to come for the injections were advised of the possible risks of non-receiving IVT injection and, if still they did not want to come, we gave them another appointment in 4–8 weeks. They were also advised to attend our A&E department for any visual deterioration. Patients affected by DMO were not considered urgent and because of it the injections were deferred for 2 months. The only exceptions, as mentioned before, were R3 and only eyes patients affected by proliferative diabetic retinopathy that may benefit from retinal photocoagulation. Patients affected by RVO were rescheduled in 2 months if no record of new vessels on the disc or elsewhere or in the iris was recorded in their medical notes. For patients with CRVO complicated with chronic macula oedema PRP laser was considered if they already received at least 6 IVT injections. Patients affected by inherited retinal dystrophies and CSCR were called and booked for another appointment in at least 6 months. In Fig. 2 is reported the chart for follow up patients. Fig. 2 Follow up patient pathway organized according to their retinal conditions Conclusions Although telephone consultation has significant positive effects such as reassuring patients that emergency services are available for any visual deterioration or discussing their feeling during isolation, it presents also some issues. First of all, patients cannot be fully evaluated with imaging and functional tests, such as BCVA or IOP check, but we can only base our clinic decision on data reported by them. In addition, rarely this tool may present some communication difficulties in particular with patients with systemic underling conditions affecting their speech skills. Another factor to consider is the protection of patients’ data. Some measures need to be carried out in order to avoid sharing patient information to unauthorized persons: we always verify full name of the patient by phone, their date of birth and last attendance in our clinic before starting the consultation. In general, our protocol did allow us to deliver the necessary treatment to the HRPs with a significant safety profile for patients and staff as it reduced the patients’ visit time to around 30 min. In addition, by means of telephone triage for COVID 19, we avoided that patient with suspect symptoms attending our clinic, as recommended by the Netherlands Ophthalmological Society [14]. In particular, 1830 patients received only telephone consultations, and 510 needed face-to-face consultation (average of 17 patients per typical clinical day). Of the last patients, the large majority received non-deferreable treatments: 456 (89,41%) IVT injections and 12 (2,35%) retinal lasers. No complications for patients receiving only telephone consultations or cases of patients infected by COVID 19 after attending our clinic have been reported so far. Further improvement may be added to clinical practice in medical retina clinics, such as telemedicine arrangements and videophone consultations, but at the moment we think that this scheme can be used in many countries that are facing lockdown restrictions. Our algorithm has some limitations: first of all the limited data available due to the short period of time during the lockdown, secondly the lack in literature available, especially in the beginning of the pandemic and, finally, the absence of evaluation of the outcomes that will need to be done after the end of the pandemic. In conclusion, our protocol allowed our patients needing sight saving measures to be keep under a safe regimen scheme and avoided that patients with low/medium risk eye diseases would be exposed to COVID 19 infection.

          Related collections

          Most cited references6

          • Record: found
          • Abstract: found
          • Article: found

          Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore

          Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, in December 2019 and has spread globally with sustained human-to-human transmission outside China.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: found

            Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS‐CoV‐2 infection

            Abstract Objective This study aimed to assess the presence of novel coronavirus in tears and conjunctival secretions of SARS–CoV‐2‐infected patients. Methods A prospective interventional case series study was performed, and 30 confirmed novel coronavirus pneumonia (NCP) patients were selected at the First Affiliated Hospital of Zhejiang University from 26 January 2020 to 9 February 2020. At an interval of 2 to 3 days, tear and conjunctival secretions were collected twice with disposable sampling swabs for reverse‐transcription polymerase chain reaction (RT‐PCR) assay. Results Twenty‐one common‐type and nine severe‐type NCP patients were enrolled. Two samples of tear and conjunctival secretions were obtained from the only one patient with conjunctivitis yielded positive RT‐PCR results. Fifty‐eight samples from other patents were all negative. Conclusion We speculate that SARS‐CoV‐2 may be detected in the tears and conjunctival secretions in NCP patients with conjunctivitis.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found

              2019 Novel coronavirus infection and gastrointestinal tract

              1 Since December 2019, several cases of pneumonia of unknown etiology have been reported in Wuhan, Hubei Province, China. On 7 January 2020, a novel coronavirus was identified from a throat swab sample of a patient by the Chinese Center for Disease Control and Prevention, and was subsequently named 2019 novel coronavirus (COVID‐19) by the World Health Organization. As of 21 February 2020, nearly 75 114 cases of human COVID‐19 infections have been confirmed in China, with at least 2239 reported deaths. Additional cases have spread to other countries in Asia, Europe, America, Oceania, and Africa. Six coronaviruses species are known to cause human diseases, among them severe acute respiratory syndrome coronavirus (SARS‐CoV) and Middle East respiratory syndrome coronavirus (MERS‐CoV) are both zoonotic in origin, which can cause severe respiratory illness and high mortality. And COVID‐19 is the seventh. Phylogenetic analysis of the complete viral genome (29 903 nucleotides) has shown that the COVID‐19 is most closely related (89.1% nucleotide similarity) to a group of SARS‐like coronaviruses.1 This fact could partly explain the behavior of this novel coronavirus in human infection. Retrospective studies from Wuhan, China have indicated that the main clinical manifestations of COVID‐19 are fever, cough and dyspnea. Less common symptoms include the production of sputum, headache, hemoptysis and some gastrointestinal symptoms. It seems that gastrointestinal symptoms, such as diarrhea (2%‐10.1%), and nausea and vomiting (1%‐3.6%), are not very common at present.2, 3 However, a significant proportion of patients presented initially with those atypical gastrointestinal symptoms. There is evidence not only of animal‐to‐human transmission but of human‐to‐human transmission of COVID‐19 among close contacts or through virus‐laden aerosols. Although more evidence is needed, Zhang et al4 from the People's Hospital of Wuhan University have reported the presence of viral nucleic acids in the fecal samples and anal swabs of patients with COVID‐19. Therefore, there is a possibility of fecal–oral transmission in COVID‐19 infection. More attention should be paid to the hand hygiene and disinfection of patients' vomitus, feces, and other bodily fluids. Previous studies have uncovered several receptors to which different coronaviruses bind, such as angiotensin‐converting enzyme 2 (ACE2) for SARS‐CoV. One study showed by molecular modeling that there is a structural similarity between the receptor‐binding domains of SARS‐CoV and COVID‐19, which means that COVID‐19 may use ACE2 as the receptor despite the presence of amino acid mutations in the COVID‐19 receptor‐binding domain.5 This finding was subsequently verified by another study which suggested that liver abnormalities might also occur in patients with COVID‐19 because the cholangiocytes are targeted by these viruses through ACE2.6 ACE2 is known to be abundant in the epithelia of the lungs and intestine in humans, which might enhance the evidence of this possible route for COVID‐19. Yet other authors have indicated that the expression of ACE2 is primarily located on the luminal surface of differentiated small intestinal epithelial cells, whereas lower expression has been observed in the crypt cells and the colon.7 They have also linked the amino acid transport function of ACE2 to the microbial ecology in the gastrointestinal tract in which ACE2 mutants exhibit decreased expression of antimicrobial peptides and show altered gut microbial composition. Therefore, we speculate that COVID‐19 may, to some extent, be related to the gut microbiota. However, the connection between the lung and the gastrointestinal tract is not completely understood. It is well known that the respiratory tract houses its own microbiota, but patients with respiratory infections generally have gut dysfunction or secondary gut dysfunction complications, which are related to a more severe clinical course of the disease, thus indicating gut–lung crosstalk. This phenomenon can also be observed in the patients with COVID‐19. Numerous studies have shown that modulating gut microbiota can reduce enteritis and ventilator‐associated pneumonia, and it can reverse certain side effects of antibiotics to avoid early influenza virus replication in lung epithelia.8 Currently, there is no direct clinical evidence that the modulation of gut microbiota plays the therapeutic role in the treatment of COVID‐19, but we speculate that targeting gut microbiota may be a new therapeutic option or at least an adjuvant therapeutic choice. In early February, the guidance (version 5) established by the China's National Health Commission and National Administration of Traditional Chinese Medicine9 recommended that in the treatment of patients with severe COVID‐19 infection, probiotics may be used to maintain the balance of intestinal microecology and prevent secondary bacterial infection, which shows that the Chinese government and first‐line medical staffs accept the importance of the role of gut microbiota in COVID‐19 infection. Huge efforts from the Chinese government and accelerated related research have been done over this period. Although no specific antiviral treatment has been recommended to date, we speculate that probiotics may modulate the gut microbiota to alter the gastrointestinal symptoms favorably and may also protect the respiratory system. Further studies may focus on this point. It would be interesting to investigate whether the benefits of ACE2 on pulmonary disease may be mediated via modulation of gut and/or lung microbiota. Finally, we call upon all first‐line medical staffs to be cautious and pay more attention to atypical patients with an initial presentation of gastrointestinal symptoms, especially those from the epidemic area. We hope that, with the joint efforts and great support, COVID‐19 will soon be overcome. 2 CONFLICT OF INTEREST None.
                Bookmark

                Author and article information

                Contributors
                polcorazza@gmail.com
                Journal
                Int J Retina Vitreous
                Int J Retina Vitreous
                International Journal of Retina and Vitreous
                BioMed Central (London )
                2056-9920
                3 June 2020
                3 June 2020
                2020
                : 6
                : 20
                Affiliations
                GRID grid.417895.6, ISNI 0000 0001 0693 2181, Western Eye Hospital, , Imperial College Healthcare NHS Trust, ; 171 Marylebone Rd, NW1 5QH London, UK
                Author information
                http://orcid.org/0000-0002-6865-7362
                Article
                226
                10.1186/s40942-020-00226-z
                7268184
                029b0aa8-aa09-4d96-9d38-6142c3cff141
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 23 April 2020
                : 27 May 2020
                Categories
                Original Article
                Custom metadata
                © The Author(s) 2020

                Comments

                Comment on this article