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SARS warning sign outside Toronto General Hospital.

OPHTHALMIC surgery has been severely curtailed in Toronto, Ontario as Canadian health authorities attempt to deal with the worst outbreak of Severe Acute Respiratory Syndrome (SARS) so far reported outside Asia.

Near the end of March, all hospitals in the greater Toronto area were ordered to suspend non-essential services, including non-urgent ophthalmic procedures.

Shortly afterwards, the World Health Organisation (WHO) took the unprecedented step of advising the public against travelling to Toronto because of the SARS outbreak, but a week later lifted the travel advisory because the situation there has improved.

The WHO also issued travel advisories for Guangdong Province, Hong Kong Special Administrative Region, Beijing and Shanxi Province- all in China.

The hospital suspensions, among other directives, came from the Canadian province's Ministry of Health in an effort to contain the SARS outbreak. A ‘code orange’ alert cancelled all elective surgeries and outpatient procedures.

“Ophthalmologists are worried about their practices and not being able to see patients. Those who have their offices inside the hospitals are scrambling to be able to work in some of the community offices. Physicians in general are all pretty stressed about this,” said Jeffrey Hurwitz MD, Ophthalmologist-in-Chief, Mt Sinai Hospital, Toronto.

Overall, delayed surgeries and the postponement of other procedures are putting a huge strain on an already overburdened health care system, he added.
The move by the province came after three SARS -related deaths and numerous suspect cases occurred as a result of the infection spreading through the Scarborough Grace Hospital in one of Toronto's suburbs. The index case was a patient there who had recently returned from a visit to Hong Kong.

The hospital was temporarily closed to new patients on March 23 by the Ministry of Health after two SARS patients died. People who had contact with the patients including hospital staff, other patients and visitors have been put into voluntary home quarantine.

In some ways, ophthalmology hasn’t been hit as hard as other medical specialties like cardiology, where the rates of urgent cases needing hospital care have been much higher, Dr Hurwitz noted.

“In the field of ophthalmology in Toronto, a lot of the university people are part-timers.
They have their other offices outside where they can see their patients,” he said.
Retinal specialist Robert Devenyi MD has a different view. His patients are referred to him by ophthalmologists from across the province.

“It has been crazy. Certainly in retinal surgery nothing we deal with is elective, everything is urgent, and everything that is pretty urgent after a time becomes an emergency. The cases are mounting and we don't know how to deal with them.

“Instead of 15 operating rooms going a day at our hospital, there's one. If someone is going blind we can compete with a lot of things. But we can't compete with life threatening emergencies. It’s a very, very inadequate situation,” Dr Devenyi said.
He pointed out that while nine people have died from Sars, there are likely to be follow-on effects from the hospital restrictions. For example, current restrictions delay the delivery of vital chemotherapy, cancer therapy, coronary artery bypass surgery and brain tumour surgery.

Like numerous other eye specialists in the city, Dr Hurwitz is now doing much of his administrative work at home. His clinical and administrative secretaries are working out of their homes too and everyone is in touch by telephone and email.
“Thank god for computers - otherwise we'd be totally sunk,” he said.
Dr Hurwitz is finding that at some of the meetings he attends, most attendees are participating through teleconferencing rather than in person. An annual ophthalmology medical education day at a downtown hospital expected to attract 150 people was cancelled.

He said the restricted hospital access was “a nightmare” for the ophthalmology residency training programme because the residents have nothing to do.
The SARS restrictions are also felt at the office level. Current Ministry of Health directives require all patients and visitors to wash their hands before entering medical offices. Patients must fill out questionnaires asking about travel, contact with people with SARS, and any symptoms they might have. People with suspect symptoms are immediately directed to go to a SARS clinic.

When asked if the restrictions represented an overreaction, Dr Hurwitz responded: “It's hard to know when you don't know what we're dealing with. People are compliant with the directives, but not grudgingly so.”

On April 23, 2003, Canadian authorities reported 330 probable or suspect cases of SARS, with the numbers continuing to increase. Sixteen patients have died, of which almost half have occurred in Ontario. All cases have occurred in people who have travelled to Asia or had contact with SARS cases in the household or in a health care setting.

Hospitals outside the greater Toronto area are not operating under code orange, but were ordered to impose restricted access. All hospitals must have security guards at the entrances and there are tight limits on who can enter.
Only visitors going in to visit an admitted child or someone close to death are allowed in and all must be screened for SARS. The outlying hospitals can provide elective services and must plan for the creation of isolation units, if needed, for suspect SARS patients.

The consequences of the SARS outbreak extend beyond the provision of medical care. At least one large international medical conference, the American Association for Cancer Research, cancelled its annual meeting in Toronto at the last minute, forcing 16,000 people to changer their plans. The Registered Nurses Association of Ontario also cancelled its annual general meeting, which was to bring in 700 nurses from across the province.

Two elementary schools were closed when suspect cases of the disease appeared. Students and teachers from both have been placed into voluntary home-based quarantine. The Red Cross is delivering masks to help people in households protect themselves in case anyone under quarantine turns out to be a true case.
The Ministry of Health won’t release the total number of people in quarantine, but media reports suggest the number is in the thousands. Two people who refused to stay in quarantine were ordered into mandatory isolation.

Five of Canada's top infectious diseases experts from Mt Sinai Hospital, all working on containment of the outbreak, were themselves placed under 10-day quarantine since March 31 after one of their own doctors Allison McGeer MD, developed symptoms. She has been in respiratory isolation there, recovering from the disease for the past week.
“I'm the poster child for why you need to comply with precautions,” she told one newspaper from her hospital room. She said precautions work.

A residence for senior citizens in Richmond Hill was ordered closed after an elderly resident was diagnosed a suspected SARS case. A second hospital, York Central, was ordered closed to new patients and hundreds of its employees were asked to stay at their homes for a 10-day quarantine.

The risk of getting the disease appears to be relatively small, with most cases occurring in people who had direct contact with other infected people. Mortality rates are actually similar to those from influenza, especially among elderly and high-risk populations. So far, mortality from SARS ranges from 4% to 7% of cases, depending on the country reporting.

Jeffrey Hurwitz MD
Chair of Ophthalmology, University of Toronto, Canada
Email: jhurwitz@mtsinai.on.ca

Robert G Devenyi MD, FRCSC, FACS
Associate Professor of Ophthalmology, University of Toronto, Canada
Email: rdevenyi@mobile.rogers.com