Email of the International Section of the American Academy of Ophthalmology

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E-mail of the International Department of Ophthalmology American Academy to the Ophthalmological Associations of Other Countries – June 4, 2020

Summary of the important points of the American Academy of Ophthalmology email to the ophthalmological associations of other countries

Translation and authorship: Dr. Parviz Eliassy
Specific Corona’s considerations in ophthalmology
Hello dear colleagues: About three weeks ago, the email of the American Eye Academy was sent to the World Ophthalmological Associations, including the Iranian Ophthalmological Association. The academy has provided information and solutions related to ophthalmology, and has requested information on its contents and the exchange of views of ophthalmologists. The important points of this email are as follows.

The role of tests and their interpretations before surgery
When testing – RT-PCR is positive
اIf surgery is unnecessary, it is best to delay it for 6 weeks.
If surgery is necessary, the choice of anesthesia is based on the patient’s general medical condition. In this case, the surgeon and staff must mask of N95 and Shield have eyes or face.
When the RT-PCR test is negative
If this test is done as a routine screening test in the absence of clinical suspicion of corona, surgery can be performed with protective measures.
When the Serology is positive
Corona antibodies usually appear in the first 1 to 3 weeks after infection. A negative serological test that rejects the infection is not active.
If the IgM is positive / IgG is negative: the infection is considered active.
If both are positive: a recent infection is present and may still be active.
If the negative IgM / IgG is positive: the infection is related to the past. But a single IgG test alone does not indicate that
The patient is no longer contagious or safe. In this case, RT-PCR testing is indicated unless the serological test is minimal
It was done a month ago.
For patients who have two negative PCR-RT tests or more than six weeks after the onset of symptoms, protective measures a standard person is enough for surgery.
Relevant considerations according to the type of action
Phaco operation
The presence of coronavirus in the anterior chamber is still unknown. At the beginning of Phaco, the clarity is replaced by viscoelastic material, which is also replaced with Bico Phaco. There may be some degree of aerosol formation at the incision site, which is serum aerosol.
BSS is not clarity. Accordingly, the risk of the virus interacting with the aerosol in Phaco will be very low.
posterior capsulotomy
It is not known whether Yag Laser can form an aerosol from the lacrimal layer during capsulotomy. Because it is assumed that the laser focus is on the posterior capsule. However, it is best to apply a 5% betadine drop to the eye after pouring tetracaine and just before starting the laser. The capsulotomy lens can also be disinfected with warm soapy water.
corneal transplantation
There is still no evidence of a virus in clarity or vitreous. Corneal transplantation should not be associated with increased risk for the surgeon. However, in the case of Phaco and open anterior vitrectomy, because it is not performed in a closed system, it can theoretically form an aerosol from intraocular fluid. Although each aerosol formed is diluted with BSS washing liquid, the risk of open sky methods is not definite.
Eye surface tumors and eyelash repair
The main risk of aerosol formation in eye surgeries is related to the use of couture. The use of betadine in Perdepr can inactivate any virus in the lacrimal layer or surface of the eye. Betadine can be used again during surgery if the anterior chamber is not opened and also before the cutter. Then, after the cutter, it should be washed a lot so that the BSS liquid dilutes any contamination.
Laser applications (LASIK, PRK, SMILE, PTK)
The safety of laser excimer on the surface of the eye about the coronavirus is not known. Conventional excimer devices have an aspiration system with HEPA filters, and at present, the risk of surgery is not definitive, but it is likely to below. In the case of fertilizers that perform tissue ablation in the stroma, the risk should be much lower. It is recommended to use betadine and then wash with plenty of serum before starting the operation.
Cross-link cornea
This is a relatively long procedure, and the purple laser used in it can disable the virus in the tear layer.
Glaucoma
Filtering surgery should be of little risk to the surgeon. The use of the cutter should be kept to a minimum, before using betadine, and after the cutter, a lot of washing should be done with the serum. In an iridotomy laser, it is not clear to what extent the Yag or Argon laser can form an aerosol. Therefore, after tetracycline and just before the laser, put a 5% betadine drop in the eye. The capsulotomy lens can be disinfected with warm soapy water. Beta-beta should be used before and during cyclofabulation.
retin surgery
So far, the virus has not been proven in vitreous. The virus has the ability to invade nerves, so it is theoretically possible for an intraocular virus. Unlike ficus, Parsplana vitrectomy is performed in a closed system and intraocular fluid is not replaced by viscoelastic. The formation of aerosols in the Pars Plana vitrectomy is possible, and due to the canopy system and the valve, it is expected that the aerosol will be inside the eye. Therefore, Parsplalana vitrectomy has little risk of transmitting the virus to the surgeon and staff. The use of external cutters should be kept to a minimum, and to dilute any aerosol should be accompanied by washing with serum. Standard surgical protection measures are sufficient.
In the case of intravenous injections, assuming that betadine is used, it does not appear to be associated with an increased risk of transmission from the surface of the eye. However, for surgeons who are very close to the patient during the injection, the N95 mask can be considered to reduce the risk of spreading through the patient’s exhalation. In the case of argon laser) PRP (pre-laser can be used with betadine, and if the operation is prolonged, betadine can be repeated during labor. But beware of corneal epitheliopathy.
Ecological plastic surgery
In all of these methods, such as tear duct surgery, repair of facial and eyelid fractures, erythema tumors, repair of nodules, ptosis, oral congestion, and. . . Aerosol formation is possible. The surgeon and staff must have a 95N mask and face shield unless the patient’s RT-PCR test is negative just before surgery.
Nasolacrimal surgery
The surgeon and staff must have a mask N95 and face shield unless the PCR-RT test is negative just before the operation.
Strabismus surgeries
The main concern is the use of couture. It is helpful to follow the steps outlined above.
Take a look at the general aspects of Corona for ophthalmologists
What you need to know
The virus can cause mild follicular conjunctivitis that is indistinguishable from other viruses and may be transmitted through contact with tears and conjunctivitis. However, any disease that is seen by an ophthalmologist can be contagious, regardless of the initial diagnosis, risk factors, cause of referral, or geographic location.
The virus is vulnerable to the same common alcohol-based disinfectants and bleach-based bleaching chemicals (commonly used by ophthalmologists).
It is strongly recommended that oral, nasal, and eye protectors be used in the event of an infection.
Background information
Corona is a single-stranded RNA virus with high transferability and significant mortality, especially in the elderly and those with concomitant diseases such as immunodeficiency, respiratory disease, and diabetes.
Symptoms usually begin 2 to 14 days after contact with the virus. Symptoms may include coughing, shortness of breath), or difficulty breathing (or at least two of the following symptoms: fever, chills, frequent tremors, muscle aches, headaches, sore throats, and decreased sense of taste or smell. Only lethargy and conjunctivitis have been reported. Diarrhea has also been reported, and conjunctivitis and severe eye pain have been reported.
Complications in severe cases include pneumonia, neuralgia, cardiomyopathy, stroke, and encephalopathy. In a study published in the Annals of Internal Medicine, the incubation period was 5 to 7 days, and patients were typically infected a few days before the onset of symptoms. More than 97% of those with symptoms were 11.5 days after the call, which was recommended.
The quarantine is valid for 14 days. The virus has recently been implicated in children with severe inflammatory syndrome involving several systems that overlap with Kawasaki disease and toxic shock syndrome.
Disease transmission
At present, its transmission is mainly through contact with the person through respiratory secretions during coughing or sneezing. Contact with infected surfaces or objects with the virus and then contact with the mouth, nose or eyes can also transmit the virus. The virus is also found in the feces of infected people and suggests the possibility of transmission from the feces / mouth.
Evidence suggests that it is most commonly spread by asymptomatic individuals, as well as in the early stages of symptoms. JAMA reports a case of an asymptomatic carrier that may have infected five members of the family despite normal lung cytoskeleton. Because unproven infections are more common than the level of a common test that indicates the disease, these infections may be a more important source of transmission than positively tested symptomatic carriers. In a study in outpatients RT-PCR was positive, the mean viral shedding time was 20 days and the longest time was 37 days. A Chinese ophthalmologist who announced the first warnings of the disease and later died of the disease believed that it was caused by a patient. asymptomatic glaucoma is infected.
Environmental contamination with the virus is another concern. In a study published in the journal New England, researchers were able to detect the live virus in aerosols that took three hours to form. However, these observations have not been made in a ventilated laboratory and do not necessarily reflect the behavior of the virus in real conditions. The study found that the virus could survive on cardboard for up to 24 hours, on copper surfaces for up to 4 hours, and on plastic and steel for 2 to 3 days. In the cruise ship, where the virus spread, 17 days after the shipwreck, passengers were able to test positive at various levels of the cabin. Find the RNA of the virus (not necessarily a sign of an infectious virus).
In an academic report, the researchers performed an RT-PCR test for room air, personal belongings, and the room environment of Corona patients’ hospital rooms. They found the RNA virus throughout the room, even on the edge and window sill, in the ambient air. However, they were unable to culture the infectious virus in the collected air samples. These findings emphasize the importance of personal protection and hygiene, hand washing, disinfection of surfaces and materials.
Treatment and vaccine
Remdesivir treatment is faster than a placebo. The FDA has issued an emergency permit for the treatment of suspected or proven laboratory cases in adults and children hospitalized with severe illness. Studies suggest that antiviral therapy can alter the course of the disease if given early enough.
Other methods are being used by the antagonist Antibadimenoclonal antagonist to control cytokine storms, the use of corona improved serum, and the use of anticoagulants to reduce the risk of thromboembolic events. There is currently no vaccine to prevent infection and there is a lot of effort going into it.
Chloroquine and hydroxychloroquine
Concerns about the potential side effects of these drugs have limited their use. The American Academy of Ophthalmology has no opinion on this. A study by the Asia-Pacific Vitre and Retin Association found that the recommended doses for these research groups were higher than the safe maximum daily dose), usually less than 5 mg of hydroxychloroquine per kilogram of actual weight (for long-term treatment of rheumatic diseases and It is another chronic disease.
The risk of irreversible maculopathy in the short-term use of these high doses is unknown. This complication should be reported to patients before starting treatment. In these cases, the need for a fundus examination or imaging is also unclear. Due to the short duration of use, additional diagnostic tests such as ERG may not be necessary before starting treatment with hydroxychloroquine. Also, performing ERG in these conditions carries the risk of transmitting the virus.

Findings related to ophthalmology
There are now many reports of corona artery disease patients who have been diagnosed with conjunctivitis as the first or only sign of the disease or who have suffered from conjunctivitis during hospitalization for severe coronary heart disease. In many of these cases, the virus was detected by an RT-PCR test on the conjunctival sample swab.
In one study, of the 30 patients admitted to Corona, one had conjunctivitis and the RNA virus was found in the patient’s own eye discharge and not the rest. This suggests that the virus may cause conjunctivitis and that virus-infected particles may be present in the tears of coronary artery disease patients with conjunctivitis.
In a larger study published in the journal New England in 0.8% of coronary patients, conjunctival congestion was observed. None of these patients were examined by an ophthalmologist and their tears were not sampled.
In a retrospective study of 38 confirmed patients in the Corona Clinical Hospital, 12 patients were diagnosed with ocular disorders, which were commonly characterized by comorbidity or ocular discharge. In two combined conjunctivitis patients, the virus was positive for RNA, one with conjunctival hypertension and the other with coma and epilepsy. Of course, we do not agree with the symptom of comorbidity in this case, because comorbidity in a critically ill patient is most likely a sign of fluid or third-spacing, not conjunctivitis.
In two other studies, there was a relatively small chance of an infectious virus in the tears of Corona patients. In one study, of the 72 proven Corona patients, two had conjunctivitis. One of the patients had conjunctivitis and the other 70 had no RNA virus in their tears. In another study, of the 63 proven Corona patients, only one had conjunctivitis in which the conjunctival swab was negative for RNA virus. In another patient the conjunctival swab was positive and in two patients it was likely to be reported.
In a report from Italy, the first coronary artery disease, in addition to fever and respiratory and gastrointestinal symptoms, also had conjunctivitis. test
Conjunctival RT-PCR, indicating RNA virus from day 3 to day 21 of hospitalization) One day after recovery from conjunctivitis (and again on day 27, on which day the nasal swab was negative. On the third day, the infectious virus was cultured. The cell was isolated.
In a CNN news report, a nurse who was present at Corona’s outbreak in the nursing home reported that a common early sign in elderly patients with corona was red-eye.
To prove all this, the data show that conjunctivitis is an uncommon symptom in corona. But because conjunctivitis is generally a common symptom of patients’ referrals and they often go to the emergency room or ophthalmology clinics, it should be remembered that ophthalmologists are usually the first to serve patients who are at risk for the virus. So far, almost all reports of conjunctivitis in Corona have been bilateral, mild, follicular, and without corneal involvement.
Recently, however, a patient with follicular and keratinocytic coarse conjunctivitis has been observed to have a positive RT-PCR test for his or her conjunctiva. A patient with Crohn’s disease on the cruise ship also suffered from double-sided conjunctivitis.
A third patient in France also suffered from bilateral hemorrhagic conjunctivitis. According to these studies, coronary eye disease with conjunctivitis can be contagious.
Therefore, when dealing with coronavirus-infected patients, protection of the mouth, nose, such as the use of the N95 mask (and eyes) such as goggles or shielded shields (recommended. Shield shielded slide shields are also useful for patient and physician protection.

Attention
Some malignant coronary arteries that are placed under the ventilator are placed on the abdomen to improve oxygen delivery.
Some experienced people believe that this condition may put patients at risk for vision loss.
The final point
The e-mail asked the associations to inform the academy of the names and details of the ophthalmologists who died of the virus. From Iran, the name of the late Dr. Saeed Azizi ( from Zabol ) can be seen asking for additional information about this deceased and other deceased colleagues in this regard.
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