In a special webinar organised by the UK and Ireland Society of Cataract and Refractive Surgeons (UKISCRS), Philip Bloom, President of UKISCRS and Chair of the International Glaucoma Association (IGA) spoke about his experience as a consultant ophthalmologist at the Western Eye Hospital and Hillingdon Hospital
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We have been operating similarly to many other glaucoma units throughout the country. The call came to stop all elective activity, so we had to decide how we were going to manage that. The units that had already employed risk stratification were at an advantage but it helped that Moorfields Eye Hospital shared their very prescriptive system of risk stratification and the Royal College of Ophthalmologists’ guidance came out that all routine ophthalmic surgery and all face-to-face consultations should be postponed wherever possible. This is particularly appropriate as age is a major risk factor for glaucoma, and also for the most serious sequelae of COVID-19 infection. We implemented the recommendations straight away.
I was fortunate in that both the sites that I work at use a colour-coded risk stratification system (red, amber and green for high risk, medium risk and low risk respectively) that was electronically accessible. Patients who are classed as “red” still have to be seen, whereas green patients can be postponed for anything from three-to-six months; amber patients are considered on a case-by-case basis. Fortunately, glaucoma is usually a stable and very slowly progressive disease. We are still seeing those patients that absolutely need to be seen in the A&E department and in the clinics.
One of the difficulties has been changing advice: as of last week, we now treat every patient as if they were infected with COVID-19. This makes it simpler because we no longer have to try to determine if they are likely COVID-19 positive or not. We wear the same protective gear for everyone. Unless we are operating, we have single-use disposable gloves and gown, sessional-use fluid-resistant surgical mask and eye protection, and a breath shield on the slit lamp or any similar equipment we are using. We wear scrubs in the outpatient clinic and talk as little as possible whilst within 2m of patients.
For IOP detection we are using single-use, disposable, sterile tonometers for applanation tonometry. We avoid pneumo-tonometry (air puff, including ORA), which might be an aerosol-generating procedure (AGP), whereas we think rebound tonometry is acceptable as it probably is not an AGP. When we operate on patients, we did not initially consider phacoemulsification or vitrectomy as AGPs but the decision has now been made to do so. Similarly, in glaucoma surgery when we irrigate mitomycin C, there is a spray that comes off so we now classified all glaucoma surgery as AGPs. It is best to be cautious and err on the side of safety.
Of course, all of this postponement of elective surgery means we will see a huge ‘bow-wave’ of demand when services start to return to normal. Considering that practically all glaucoma units were already struggling with capacity before the COVID-19 pandemic, the immediate post-COVID period will be challenging indeed for all glaucoma services.
