On 9 April 2020, the International Centre for Eye Health (www.iceh.org.uk) and the Royal College of Ophthalmologists (www.rcophth.ac.uk) hosted an online conference for over 270 eye health professionals to discuss the most recent COVID-19 guidelines and protocols and share their experience. In this presentation, Elanor Watts discusses the guidelines and practical aspects of preventing transmission of COVID-19 in the eye unit. London, UK. 9 April 2020. For more information, including presentations and audio recordings, please visit our news page: www.cehjournal.org/news. The Community Eye Health Journal (www.cehjournal.org) also published a detailed article on 9 April, called 'How to protect yourself and your patients from COVID-19 in eye care.' Read it here: www.cehjournal.org/news/new-article-protecting-yourself-and-your-patients-from-covid-19-in-eye-care/ Download the Community Eye Health Journal App - on Google Play: https://bit.ly/CEHJ-Android - on the App Store: https://bit.ly/CEHJ-iOS

1. Preventing Transmission of
COVID-19 in the Eye Unit
Dr ElanorWatts, BA BMBCh
Current MSc Student – Public Health for
Eye Care, LSHTM

2. On Arrival to the Clinic

3. Before the Patient Enters – Triage
Source:Laietal.–TheHongKongGuidelines
Ayebareetal.–AdoptionofCOVID-19triagestrategies
forlow-incomesettings

4. Before the Patient Enters - Triage

5. • Wash hands for at
least 20 seconds with
soap and water, or
hand gel (>60%
ethanol or 70%
isopropanol)
• Everyone on arrival to
the clinic (including
patients and escorts)
• Before and after
every patient, putting
on or taking off PPE
On Arrival – Hand Hygiene
ImageSource:WHO

6. • Keep waiting rooms well ventilated if possible
• Reduce numbers of patients in waiting rooms, with ideally 2m between
waiting patients
– No visitors, and no more escorts than necessary
On Arrival – Distancing
Imagesource:RippleAfrica

7. In the Clinic – Types of Face Mask
Image sources: fortunespharmacy.ie, protectivemasksdirect.co.uk, respiratorshop.co.uk, seton.co.uk, 5minutesformom.com
Fluid-resistant surgical mask
Homemade fabric mask
Filtering
facepiece (FFP) 2
respirator ≈ N95
FFP3

8. Fit testing the FFP
Image sources: HSE and CDC

9. RCOphth Guidelines

10. Personal Protective Equipment
Imagesource:PublicHealthEnglandposter–COVID-19SafeWaysofWorking,Avisualguidetosafe
PPE
Order for Putting on PPE
1. Gather PPE
2. Hand hygiene
3. Gown/apron
4. Mask/respirator
5. Goggles/face shield
6. Gloves
Order for Removing PPE
1. Gloves
2. Goggles/face shield
3. Gown/apron
4. Mask/respirator without
touching the front
5. Wash hands immediately
If hands become contaminated at any
point, wash
High risk of contamination
when taking off PPE if done
incorrectly

11. • Instructions for making a breath guard from e.g. old X-ray films/acetate are available at:
– RCOphth guidance
– VariousYouTube videos e.g. https://youtu.be/pXm624pBDUM
• Free slit lamp breath shields are being offered by:
– Zeiss (www.zeiss.com/breathshield) – currently only shipping to EU, UK, USA, Canada,
Singapore, Malaysia, Thailand, Vietnam, Philippines, and Indonesia
– Topcon – to current customers (https://info.topconhealthcare.com/request-free-breath-shields/)
Slit Lamp Breath Guards
ImageSource:RCOphth
ImageSource:Zeiss

12. Are we following this guidance in the UK? –
BEECS survey

13. • ?Patients wear masks
• Goggles can be decontaminated with detergent
AND hospital disinfectantAND clean water/alcohol,
and re-used
• Face shields/visors, and slit lamp guards, can be
home made
• Hand gel can be made locally, from: ethanol (or
isopropyl alcohol), hydrogen peroxide, and glycerol
• If no disposable isolation gowns are available,
alternatives include disposable lab coats, washable
gowns/coats
• Lots of guidance available onCDC website (see last
slide)
Applying the Guidance to Different Settings:
e.g. What if we run out?
Image source: WHO

14. 1)Take measurements:
- temple to temple
-head circumference
- forehead/brow to sternal region
2) Cut transparent material using
measurements above. It should cover Rt to Lt
temple (width) and forehead to chest (length)
3) Cut the belt (length is 15cm+head
circumference), then into two equal halves.
4) Place material on a flat clean surface
5) Staple/stitch belts to both upper ends of the
material
6) Cut soft foam/fibre (about 4cm wide and
long enough to cover forehead) - this is for
comfort on the forehead skin
Making Face Shields - UITH, Nigeria
ImageSource:UITH,Ilorin

15. • Don’t shake hands/hug
• Look through notes/find out history before patient comes into room
• Remain 2m away from patient when possible
• Only do pertinent parts of examination, and when close to patient for
examination, ask them not to speak unless necessary, and to touch the
examination equipment as little as possible
• Use single-dose eye drops
• AVOID:
• Air puff tonometry – only do tonometry if needed, and ideally
use e.g.Tonopen/i-Care/Goldmann with disposable tip
• Direct ophthalmoscopy – use indirect
• Close examination for longer than necessary, inc. investigations
• General anaesthetic (= aerosol-generating procedure), unless
essential
• Nasal endoscopy
Examining the Patient

16. • Wear disposable gloves to clean
• Recommended disinfectants include:
• Diluted household bleach (5tbsp per
gallon of water)
• OR at least 70% alcohol
• OR various household cleaning
products, verified to kill viruses
• Clean:
• Surfaces in the room, inc. door handles,
panels, phones
• Examination equipment, inc. the slit
lamp, breath shield, controls, handles
and chin/forehead rest
• Tonometer tip (while 70% alcohol will
not sterilize against adenovirus, it will
against SARS-CoV-2)
After each interaction – Cleaning Surfaces
Source: Spanish Society of Ophthalmology Guidelines

17. • CEHJ article - Protecting yourself and your patients from COVID-19 in eye care
https://cehjournal.org/wp-content/uploads/COVID-19-1.pdf
• RCOphth guidance: PPE and staff protection requirements for ophthalmology.
https://www.rcophth.ac.uk/wp-content/uploads/2020/03/NEW-PPE-RCOphth-
guidance-PHE-compliant-WEB-COPY-030420-FINAL.pdf
• WHO Guide to Local Production ofWHO-recommended Handrub Formulations
https://www.who.int/gpsc/5may/Guide_to_Local_Production.pdf
• CDC Strategies to Optimize the Supply of PPE and Equipment
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html
• WHO Rational use of personal protective equipment for coronavirus disease
(COVID-19). https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-
nCoV-IPCPPE_use-2020.2-eng.pdf
Useful sources of information