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MARCH 31, 2020 -- Retinal specialists need to weigh the risk for vision loss against the risk for COVID-19 when deciding which patients should be seen urgently vs those whose treatment can be delayed, says new guidance from the American Society of Retina Specialists (ASRS).
The recommendations address aspects unique to the subspecialty as well as factors of concern both in the clinic and in the operating room.
The alert aims to facilitate the safety of patients and staff involved in retinal practices during the COVID-19 pandemic. This is far from easy and is where the "art of medicine comes in," said Sophie Bakri, MD, professor of ophthalmology, vitreoretinal diseases, and surgery at the Mayo Clinic in Rochester, Minnesota. Decision making "involves balancing the risk of vision loss without treatment, in the big picture of COVID spread, and the high risk of COVID complications in our patients, who are often older and more vulnerable, given their multiple medical comorbidities."
"[The situation] involves making very difficult decisions in these unprecedented times, for which we have no formal training," she added in an interview with Medscape Medical News. "Patients need to understand this difficult conundrum."
The guidance follows earlier recommendations from the American Academy of Ophthalmology urging ophthalmologists and other eye care providers not to operate on individuals for routine or elective cases and to not see patients for routine care.
The new ASRS guidance emphasizes that only patients who require essential treatment should be seen. These include new emergency patients, those receiving intravitreal injection therapy, and early postoperative follow-up patients. In addition, ASRS advises checking during telephone triage that new emergency patients are not at high risk for COVID-19.
Patients who are scheduled for injection-only visits should not undergo dilation or extensive examination if there have been no changes in visual acuity.
Bakri reinforced that for patients who are seen emergently, practitioners should implement protective measures in the office, such as sterilizing equipment and surfaces between patients, limiting accompanying visitors, and separating patients in terms of time and space.
Referring to the frequency of intravitreal injections, the alert highlights that "the retina specialty is unique in ophthalmology in that a significant percentage of clinic visits involve an intravitreal injection without which the patient is at risk for permanent vision loss."
When weighing the risk for infection exposure against the risk for vision loss, clinicians should consider the local prevalence of COVID-19, according to the ASRS.
If the visit is required, then slit-lamp shields and face masks help to minimize infection risk. Otherwise, telemedicine and use of home-monitoring devices may suffice in lieu of face-to-face examinations. Telehealth benefits are available via Medicare during the COVID-19 outbreak.
To help determine which procedures are elective and which are not, the guidance defines three categories: emergent; urgent; and nonurgent, nonelective. For emergent surgical indications, the risk for permanent vision loss without early intervention is high, and access to the operating room is vital. For urgent surgical indications, the risk for severe and permanent vision loss without immediate surgery is not as high, and treatment can be delayed. For nonurgent, nonelective indications, surgery can be delayed without significant risk for further vision loss, notes the ASRS alert.
Examples of emergent surgical indications include acute retinal detachment with macula attached (may be urgent, depending on location and character); acute retinal detachment; macula detached in a monocular patient (may be urgent, depending on location and character); and retained lens fragments with elevated intraocular pressure that is not controlled medically. A complete list of emergent conditions is available in the alert.
Bakri highlighted some concerns that are not addressed in the alert. In particular, if a patient requires general anesthesia for a retinal procedure, certain measures need to be taken because of possible aerosolization of SARS-CoV-2 during intubation and extubation procedures. "Hospitals have implemented guidelines for team members not involved in intubation/extubation to stay out of the room for a certain length of time, as well as specific guidelines for personal protective equipment," she said.
She also highlights a longer-term concern. "What concerns me the most is the unknown. How long will this last, what are the long-term potential consequences of COVID-19 to patients, both those asymptomatic and symptomatic, and their providers?"
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