The College of Optometrists primary eye care COVID-19 guidance: Red phase

  • 1 Apr 2020

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1. Background

How the virus is transmitted
As it is a new disease, transmission of COVID-19 is not yet fully understood, but we believe that coronaviruses are transmitted mainly by coming into contact with respiratory droplets or – directly or indirectly – with infected secretions. It is potentially transmissible through contact with aerosol droplets from the tears of infected patients. Isolation, standard cleaning and disinfection should be practised to help prevent transmission.

The aim of this guidance is to help you to continue to run your practice, by adapting it to make it as safe as possible for you, your staff and your patients, and reduce the likelihood of contracting or spreading the virus.  As more is learnt about the virus, and its transmissibility (or not) in optical practice, it is likely that this guidance will change, so please check back regularly for updates.
 

2.  Adapting your practice

2.1 Environment

  • Lock the door so that patients are seen by appointment only.
     
  • Maintain social distancing.
     
  • Space out the chairs in the waiting and dispensing areas.
     
  • Limit the number of people in the practice and consulting room at any one time by spacing out appointments.
     
  • Ask patients to use their own pen to sign any forms, or sanitise any pen used. Similarly, sanitise any clipboards that patients touch when signing forms.
     
  • Use a cough guard on your slit lamp. The Royal College of Ophthalmologists has advice on how to make a temporary cough guard.
     
  • Wear appropriate PPE if you need to see patients at a distance of less than 2 metres. National guidance states that, even if the patient is not currently a possible or confirmed case of COVID-19, clinicians should wear single-use disposable aprons and gloves and change these for each patient. 
     
  • In addition to gloves and aprons, practitioners are advised to risk assess whether they feel they need to wear a fluid-resistant surgical face mask (type IIR) and/or eye/face protection if there is an anticipated or likely risk of contamination with splashes, droplets of blood or body fluids. Masks and/or eye/face protection can be worn for the whole session (‘sessional use’) rather than changed for each patient, unless they become soiled, damaged or uncomfortable. 
     
  • We recommend that all optometrists working within two metres of patient choose to wear a surgical mask. The same surgical mask may be worn for examining multiple patients, but you must be fastidious to avoid transmitting the virus on the front of the mask via your hands or your clothes. Do not take the mask on and off between patients and do not allow it to dangle on your chest. Read instructions on how to put on and take off PPE, or watch videos on primary care PPE procedures and the removal and disposal of PPE
     
  • Do not deliver face-to-face care at less than two metres if you do not have appropriate PPE. Instead, direct the patient to a service that does.
     
  • Wipe clinical equipment and door handles after every patient, as well as other surfaces that may have been contaminated with body fluids, using a suitable disinfectant such as an alcohol wipe. All surfaces must be clean before they are disinfected.
     
  • Sanitise frames before patients try them on. If you need to focimeter patients’ spectacles, ask the patient to take them off and provide the patient with a wipe to sanitise their frames before you touch them.
     
  • Support good tissue practice (catch it, kill it, bin it) for patients and staff by having tissues and covered bins readily available.

2.2    Patients

  • See patients by appointment only, and only those who have urgent eye- or sight-related symptoms which cannot wait. These may be patients who would be seen using a MECS-type service, or sight tests for symptomatic patients where these are clinically necessary and cannot safely be postponed. Do not see patients without eye- or sight-related symptoms for routine sight tests. We have a poster you can display on the entrance to your practice, tailored to those in England, Northern Ireland, Scotland or Wales.
     
  • Ask patients to confirm that they are well and that no one in their household is exhibiting relevant symptoms (a new, continuous cough and/or a high temperature and/or loss of, or change in taste or smell (anosmia)). Patients with these symptoms should not attend the practice, and should self-isolate.
     
  • Use a telephone or video triage system to determine whether a patient needs to be seen, in order to minimise social contact for both of you. As routine outpatient appointments in the HES have been suspended, a patient with cataract symptoms will not be seen in the hospital, so there is little need for them to have an eye examination until lockdown is over. Similarly, patients with conjunctivitis symptoms are likely to self-resolve. Providing the patient has no symptoms of concern, reassuring them that the condition is not serious and will resolve itself is all that is required, and avoids having them leave home unnecessarily.
     
  • If a patient reports a serious eye condition that requires urgent or emergency hospital treatment you should direct them to the HES without asking them to come to your practice. The Royal College of Ophthalmologists advise that patients who need to be seen and treated urgently include suspected:
    • Glaucoma
      • Acute glaucoma
      • uncontrolled very high IOP >40mmHg or rapidly progressive glaucoma
    • Wet active age-related macular degeneration
    • Sight-threatening treatable retinovascular disease (proliferative diabetic retinopathy and CRVO)
    • Acute retinal detachments (macular on, macular off <4weeks)
    • Uveitis – severe active
    • Ocular oncology - active, aggressive, uncontrolled or untreated lesions
    • Retinopathy of prematurity (screening and treatment)
    • Endophthalmitis
    • Sight-threatening trauma
    • Sight-threatening orbital disease e.g. orbital cellulitis, severe thyroid eye disease
    • Giant cell arteritis affecting vision.
       
  • To avoid seeing patients unnecessarily, the GOC has issued advice on issuing spectacles and contact lenses to patients who have overdue appointments. We have a remote consultation template you can use.
     
  • Ask patients to decontaminate their hands on entering the practice by providing them with hand sanitiser or hand-washing facilities.

2.3 Routine

Reduce physical contact

  • Adapt your routine to reduce close contact with patients. For example, using SL-BIO instead of direct ophthalmoscopy, or fundal imaging if that is an acceptable alternative.
     
  • Have any discussions with the patient (e.g. symptoms and history, advice given) at a safe distance.
     
  • You should use good hand hygiene before and after any patient contact, but try and avoid touching the patient where possible. For example, you could ask the patient to open their eyes wide when looking down doing SL-BIO, or use a cotton bud to lift their lids if you need to.
     
  • Other things you can do to minimise physical contact with patients include: 
    • asking the patient to remove their spectacles themselves
    • asking contact lens patients to insert and remove their lenses themselves (if possible)
    • asking patients to pull their lower lids down themselves if you are instilling eye drops, or using a tissue between your finger and their lid if you need to pull it down.
       
  • We anticipate that you will only need to refract patients rarely, but if you do need to, use your professional judgement to decide in how much detail you need to refine your refraction, in order to minimise the time spent close to the patient. For example, do you really need to worry about the 0.25 cylinder?

Infection control

  • If you do need to touch a patient, be scrupulous about your hygiene before and after, and ensure you decontaminate any equipment used appropriately.

Aerosol generating procedures

  • Because of the risk of aerosols, do not use Alger brushes.  If you need to remove a rust ring, use a needle instead.

Referrals and dispensing

  • Consider referrals carefully. Non-urgent patients will not be seen by the hospital, so only refer patients with urgent conditions (see examples above).
     
  • Consider whether you need a patient to come in for dispensing. If they simply need a reglaze or have broken their spectacles, can you repair or reglaze them by post, or make a duplicate pair from the information you already have on file?
     
  • If the patient needs new spectacles, post these to the patient rather than asking them to come in for collection.

Record-keeping

  • Make it clear from your clinical record that a patient was seen during the COVID-19 pandemic, to help explain your decision-making where necessary.

Last updated: 19 May 2020

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