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Comment by Ningli Wang & Chunyan Qiao on:

82885 Review of hygiene and disinfection Recommendations for outpatient glaucoma care: A COVID era update, Shabto JM; De Moraes CG; Cioffi GA et al., Journal of Glaucoma, 2020; 29: 409-416

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Currently, the world is faced with severe challenges brought by COVID-19, and healthcare workers are at the frontline of this war against the pandemic.

Our study, published in Ophthalmology¹, found that the overall incidence of symptomatic COVID-19 among eye professionals across Wuhan's ten hospitals was 2.52% at the early stage of the COVID-19 outbreak, similar to the incidence among other subspecialties health workers. Ophthalmologists face a similar risk compared with healthcare workers of other subspecialties. Adequate personal protective equipment (PPE), hygiene and disinfection, are important in preventing disease transmission.

Clinical practice in most Chinese hospitals has returned to normal now, including our own. We limited the number of registered appointments to avoid congestion in our hospital. Except forurgent cases, all outpatients are required to make an appointment in advance. In our department, the daily number of outpatients is about half of the pre-COVID-19 number.

Many extra protective measures became regular practices. These include protection for healthcare workers, environment disinfection and screening patients. Most of them are the same as the recommendations in this article, and many of them are mandatory in our hospital.

Every healthcare worker must wear PPE during practice, including medical surgical masks, gloves and protective goggles. The additional disposable protective gown and N95 mask are required for emergency service. Strict hand disinfection (wash hands with soap or alcohol sanitizer) after examination and treatment of each patient should be performed. Most doctors use cotton swabs to avoid direct contact with patient's eyes. Social (physical) distancing of one meter is also required, but is difficult to achieve in times of crowding. A protective breath shield (self-made of used CT or X-ray film) is set up in front of every slit-lamp microscope to prevent splash of patient's secretions. The equipment touched by patients, such as mandibular rest, frontal rest and armrest of slit-lamp microscope are disinfected after examination of each patient. The ophthalmic instruments in contact with a patient's conjunctiva are fully and effectively disinfected before and after each examination to avoid cross-infection. The windows of consulting rooms are opened regularly to ventilate and let in fresh air every day, and the consulting room and corridor are disinfected twice a day.

Patients and accompanying persons are asked to wear masks in the hospital. Taking temperature is the first and mandatory step before they enter the hospital. The history is asked, particularly for travel, can be checked by personal smart phone before they enter the consulting room. Suspected COVID-19 cases are referred and reported as soon as possible.

For outpatient glaucoma care, in order to avoid close contact, we adopt alternative examination methods such as choosing hand-held indirect lenses before slit lamp, or fundus camera. Optical coherence tomography (OCT) for fundus examination is used instead of direct ophthalmoscopy, anterior segment optical coherence tomography (AS-OCT) for chamber angles examination instead of gonioscopy, and iCare for the measurement of intraocular pressure. We stopped using contact tonometry, and non-contact tonometry is still used in many Chinese hospital departments, including our own. Non-contact tonometers are placed in a well-ventilated room and disinfected with 75% alcohol after examination of each patient.

These practices have been implemented in our hospital since the outbreak of COVID-19. To date, neither staff nor faculty have been infected by SARS-CoV-2. In our experience, adequate PPE, strict hygiene and disinfection are necessary to limit exposure and transmission of infection in outpatient glaucoma clinics during the current COVID-19 pandemic.

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