COVID‐19: ensuring safe clinical teaching at university optometry schools

The COVID‐19 pandemic has been spreading across the globe for several months. The nature of the virus (SARS‐CoV‐2) with easy person‐to‐person transmissions and the severe clinical course observed in some people necessitated unprecedented modifications of everyday social interactions. These included the temporary suspension of considerable elements of clinical teaching at optometry schools worldwide. This article describes the challenges optometry schools were facing in early to mid 2020. The paper highlights the experiences of six universities in five countries on four continents. Strategies to minimise the risk of virus transmission, to ensure safe clinical optometric teaching and how to overcome the challenges presented by COVID‐19 are described. An outlook on opportunities to further improve optometric education is provided.     

Managing vitreoretinal surgeries during COVID-19 lockdown in India: Experiences and future implications

Purpose:The study aims to describe the clinical and demographic profile of patients who required vitreoretinal surgeries during the novel coronavirus disease-2019 (COVID-19) lockdown in India. It also reports our operating protocols and initial experience while performing vitreoretinal surgeries during COVID-19 times at a government tertiary eye care hospital.Methods:This is a retrospective cross-sectional observational study of patients requiring emergent/urgent vitreoretinal surgeries between March 25, 2020 and May 31, 2020. A modified working protocol focussing on the enforcement of standard COVID-19 precautions, OT sterilization, and formation of dedicated infection control and disease surveillance committee was adopted. Patients underwent standard vitreoretinal procedures under general/local anesthesia. Relevant demographic and clinical data were recorded and analyzed. Surveillance data of healthcare workers (HCW) was also analyzed.Results:Eighty six patients were considered for vitreoretinal surgery in this period. Finally, 83 patients underwent surgery. The mean age of the patients was 38.4 ± 20.1 years (Range, 1 month - 75 years). Majority of them were males (66%) and adults (82.6%). Majority of them came from nearby hotspot areas. Most common indications were acute retinal detachment (38.5%) and diabetic vitrectomies (22.9%). Trauma-related cases (14.4%) were less. Surgery was deferred in 3 patients who turned out to be COVID-19 positive. 4 HCWs were quarantined but none of them developed COVID-19 disease.Conclusion:During COVID-19 lockdown, vitreoretinal surgeries were most commonly performed for retinal detachment and diabetic complications. Proper implementation of infection control protocols helps in delivering adequate patient care while ensuring the safety of caregivers during this pandemic.     

Adoption of newer teaching methods to overcome challenges of training in ophthalmology residency during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has disrupted training programs across all specialties. Surgical specialties, such as ophthalmology, that need continued microsurgical training are affected the most. The pandemic has resulted in ophthalmology residents being taken off their regular duties in ophthalmology and inducted into COVID duties. The focus on COVID care has de-emphasized training in ophthalmology. We highlight the challenges that teachers face in continuing the training programs of theory, clinical skill, and surgical skill transfer. Embracing technology is the need of the hour. We discuss the multiple options available to enable continued training programs and emphasize the need for all training institutes to include technology as an additional component of their training curricula.     

Current landscape of direct‐to‐consumer genetic testing and its role in ophthalmology: a review

The sequencing of the human genome has seen the emergence of the direct‐to‐consumer (DTC) genetic‐testing market, which allows individuals to obtain information about their genetic profile and its many health and lifestyle implications. Genetics play an important role in the development of many eye diseases, however, little information is available describing the influence of the DTC industry in ophthalmology. In this review, we examined DTC companies providing genetic test products for eye disease. Of all eye conditions, the majority of DTC companies provided susceptibility testing or risk assessment for age‐related macular degeneration (AMD). For the 15 companies noted to offer products, we found considerable variation in the cost, scope and clarity of informational content of DTC genetic testing for ophthalmic conditions. The clinical utility of these tests remains in question, and the American Academy of Ophthalmology recommendations against routine testing for many conditions probably still apply.     

All India Ophthalmological Society Financial Impact Survey on ophthalmology practice in India during COVID-19

Purpose:A survey was conducted by the All India Ophthalmological Society (AIOS) to document the initial coronavirus disease 2019 (COVID-19)-related financial impact on ophthalmology practice in India. It also assessed various measures taken by ophthalmologists and the possible role of AIOS in mitigating the economic crisis.Methods:An online questionnaire-based cross-sectional survey was conducted among its registered members from July to August 2020. The prevalidated questionnaire contained 25 items related to the impact of COVID-19 on patient volume, the extent of financial distress faced by the ophthalmologists, and various proactive measures taken by them. All valid responses were tabulated and analyzed.Results:Out of 1,026 respondents, more than 90% ophthalmologists faced a 25% or more reduction in outpatient and surgical volume. Nearly 59% reported that they can suffer from serious financial distress in near future due to COVID-19 pandemic-related losses. Those who are young (P < 0.0005), salaried (P < 0.0005), and practicing in private sector (P < 0.0005) and Tier 1 cities (P < 0.0005) are reported to be more vulnerable to become financially unstable. The major concerns were revenue losses (70%), preexisting debts (39%), and increased operating costs (27%). The majority (90%) believed that AIOS can help in alleviating the distress. There was also hesitancy regarding the adoption of teleophthalmology and home-based care.Conclusion:COVID-19 has significantly affected the financial sustainability of ophthalmologists practicing in India. Identification of vulnerable groups and timely advocacy efforts by AIOS can help in mitigating this financial crisis.     

Comparison of ocular trauma between normalized and the COVID-19 epidemic periods in China: a multi-center cross-sectional study

AIM: To compare the feature of ocular trauma between normalized period and the COVID-19 epidemic period in China, and to provide a profile for eye injuries in special times in future.METHODS: This is a multi-center cross-sectional study with 30 participated hospitals involving the China Ocular Trauma Society members. All hospitalized cases who visited the Ophthalmology Department in participated hospitals with eye injuries during the normalized period (2019) and the COVID-19 epidemic period (2020) were included in this study. Demographic characteristic of cases, date of injury, sites and types of injury were collected.RESULTS: This study involved 13 525 (61 cases with both eyes) injured cases. There were 7269 (53.74%) eye-injured cases and 6256 (46.26%) eye-injured cases in 2019 and 2020 separately. Compared with 2019, the incidence of ocular trauma in retirees, housewives and unemployed increased with year-on-year of 4.96%, 102.67%, and 11.64% among all occupations. In 2020, the incidence of eye injuries decreased in all injury sites except for an increase in home (30.29% year-on-year). The incidence of mechanical eye injuries decreased, while that of non-mechanical eye injuries (chemical/thermal/radiation) increased (47.45% year-on-year). There were 255 (3.51%, 255/7269) and 376 (6.01%, 376/6256) non-mechanical injured cases in 2019 and 2020 (Pearson Chi2=47.33, P<0.001) separately.CONCLUSION: During the COVID-19 epidemic period, the total cases of ocular trauma decrease but the proportion of non-mechanical ocular trauma increase. Penetrating is still the highest proportion among all types of mechanical ocular trauma. From a preventive point of view, protection for retired persons, housewives and unemployed persons should be improved during public health events period.     

Toxoplasma gondii protects against H2O2‐induced apoptosis in ARPE‐19 cells through the transcriptional regulation of apoptotic elements and downregulation of the p38 MAPK pathway

Purpose: Toxoplasmosis, which is caused by the protozoan parasite Toxoplasma gondii, can lead to severe visual impairment. T. gondii inhibits or delays programmed cell death caused by various apoptotic triggers; however, the mechanisms involved in the T. gondii‐induced suppression of apoptosis in retinal cells have not been analysed in detail. Methods: We investigated the role of T. gondii infection in H₂O₂‐induced apoptosis in human retinal pigment epithelial cells (ARPE‐19) by monitoring the activities of apoptosis‐regulating molecules and mitogen‐activated protein kinases (MAPKs), including p38 MAPK. We also examined the gene downstream from p38 MAPK. Results: T. gondii infection significantly inhibited the cellular toxicity of H₂O₂ (500 μm ) and increased cell viability in a multiplicity of infection (MOI)‐dependent manner by reducing DNA fragmentation and reactive oxygen species (ROS) generation in ARPE‐19 cells. Western blot analysis also showed that T. gondii infection prevented the host cell expression of pro‐apoptotic factors, such as Bad and Bax, and the activation of caspase‐3. Infection with T. gondii increased the expression of the anti‐apoptotic factor Bcl‐2 in ARPE‐19 cells under oxidative stress. In accordance with these findings, Toxoplasma infection was protective enough to suppress the phosphorylation of p38 MAPK following H₂O₂ treatment. Exposure to H₂O₂ increased the expression of heme oxygenase‐1 (HO‐1) in ARPE‐19 cells, and its expression was significantly inhibited in H₂O₂‐treated infected cells. Conclusion: The protective function of T. gondii infection against ROS‐induced apoptosis results from changes in the expression of apoptotic molecules and the downregulation of stress‐induced intracellular signalling.     

Psychosocial assessment among ophthalmic patients attending tertiary eye care centre during the lockdown in times of COVID-19 pandemic

Purpose:The coronavirus disease (COVID-19) pandemic continues to play havoc in our lives. During the first “ lockdown” in 2020, we were keen on assessing the anxiety levels of patients who sought ophthalmic care despite the lockdown. Public health actions, such as social distancing, were necessary to reduce the spread of COVID-19. As a result, most people felt isolated and lonely, thereby causing increased levels of stress and anxiety in them. We aimed to assess the anxiety levels using the Hamilton Anxiety Scale and personality assessment using the 57-point Eysenck’s Personality Inventory (EPI) questionnaire among patients visiting a tertiary eye care hospital during the lockdown period.Methods:Consecutive patients attending an ophthalmic tertiary care hospital during the COVID-19 pandemic and lockdown were approached to be a part of this prospective cross-sectional survey.Results:In total, 1,088 responses were analyzed during the 2-month study period with the mean age being 45.7 + 16.9 years. The majority had completed graduation (78%) with 15 years or more of formal education. The purpose of the visit was an emergency consultation in 42% (n = 455), a review appointment in 42% (n = 457), and the remaining (16%, n = 176) came for a routine consultation. The majority of the patients (>90%) did not report experiencing any of the 14 sets of symptoms. A mild level of anxiety was noted in 1,086 (>99%) respondents, whereas only 2 (<1%) respondents showed mild–moderate levels of anxiety. Financial concerns such as affordability of medications (6% vs. 3%, P = 0.05) and fear of losing their job (16% vs. 11%, P = 0.02) were significantly more in those experiencing any anxiety compared to those with no anxiety.Conclusion:Our study revealed that patients visiting a tertiary ophthalmic center during lockdown were graduates, sought eye consultation primarily for emergency or a review, and had no major anxiety symptoms. In those with anxiety, the affordability of medicines and loss of jobs were the main concerns.     

The Impact of the First Peak of the COVID-19 Pandemic on a Paediatric Ophthalmology Service in the United Kingdom: Experience from Alder Hey Children’s Hospital

Objective:The COVID-19 pandemic has led to significant service loss across the NHS, and ophthalmology is one of the greatest affected specialties. We attempt to quantify the impact of the first peak of the COVID-19 pandemic on a paediatric ophthalmology unit in a children’s hospital in the United Kingdom (UK) and report lessons learnt to aid in the recovery of the service.Methods and Analysis:Two eight-week periods of clinical activity were compared; one during the first UK peak of the COVID-19 pandemic and the other during a similar period the previous year. Four areas of clinical activity were included in the study: outpatient clinic appointments, theatre activity, outpatient referrals to ophthalmology and ward reviews. Appointment data was collected from departmental databases.Results:During the first peak of the pandemic, outpatient clinic appointments were reduced by 87.2%, ophthalmic surgery by 90.9%, outpatient referrals to ophthalmology by 50.2% and ward reviews by 50%. The number of actual cancelled appointments was 1377, of which 6.8% were triaged as suitable for teleophthalmology.Conclusion:The COVID-19 pandemic has dramatically restricted clinical activity in the ophthalmology service. Paediatric ophthalmology is vulnerable to capacity issues and the consequences of delayed or cancelled appointments. Departments must adapt quickly and maximise capacity to help reduce the backlog and treat patients effectively and safely. Solutions such as teleophthalmology have potential although can be difficult in the paediatric population.     

Resuming eye bank services during the COVID-19 pandemic: Experience and inferences

Purpose:The aim of this study was to formulate a methodological approach for resuming eye bank services during COVID-19 pandemic.Methods:Eye bank operations were temporarily halted in March after the government-mandated “Lockdown” in response to COVID-19 pandemic. Before restarting eye bank operations in May, we studied sources of exposure, performed risk assessment, instituted additional process validations and redefined the Standard Operating Procedures (SOPs) in consultation with the guidelines published by the Eye bank Association of India and All India Ophthalmological Society. The eye bank staff were rigorously trained before and after operations were restarted. We conducted a survey at the end of July to gauge staff attitude and reaction.Results:Eye banks services resumed on 20^th May 2020. Since reopening till the end of July total 41 keratoplasties have been done. 91.75% of all keratoplasties done were therapeutic surgeries and 17% of the surgeries were done using glycerine preserved tissues. No staff had COVID-19 symptoms when the operations restarted and none developed symptoms up to the end of July. All eye bank staff were aware of COVID-19 pandemic and 86% said they felt safe working at the eye bank. 86% of the staff said that they received adequate training and 66% of the staff expressed that they always received proper PPE and kits. Overall, 93% of the staff expressed that the measures taken by the eye bank ensured their safety.Conclusion:Based on our experience we suggest the following activities for planned resumption of eye bank services during the pandemic: Exposure Risk Analysis, Personal Protective Equipment usage training, SOP Revision and staff training on modified SOPs. Criteria based selection of donor sources, participatory planning involving the staff and double-checking at critical process junctions helped us in managing a smooth transition.     

Cyclo‐oxygenase‐2 expression in photon‐radiated and non‐radiated uveal melanomas

Purpose: To determine and compare cyclo‐oxygenase‐2 (COX‐2) expression in photon‐radiated and non‐radiated malignant uveal melanomas and to analyse the correlation between COX‐2 expression and prognosis. Methods: Immunohistochemical staining for COX‐2 was performed on 21 uveal melanomas that were endoresected after prior stereotactic radiotherapy with photons and on 22 tumours that were treated by endoresection without prior radiotherapy. COX‐2 staining was further analysed in respect to cell type, maximal prominence, time interval between radiotherapy and surgery, apoptotic index (AI), proliferative index (PI) and the development of metastatic disease. Results: There was no difference in COX‐2 expression between radiated and non‐radiated melanomas (P > 0.15). COX‐2 staining correlated with neither the tumour prominence (P > 0.40) nor the AI or the PI (both P > 0.35). Tumours with high COX‐2 expression were significantly more likely to develop metastasis (P = 0.022). Conclusion: Radiotherapy with photons does not induce COX‐2 expression in malignant melanomas of the uvea. But high COX‐2 expression may be a marker for poor prognosis.     

Needle‐based blocks for the 21st century ophthalmology

Acta Ophthalmol. 2011: 89: 5–9

Abstract.

Purpose: This paper reviews history of the needle orbital blocks used in the earlier centuries and how they have evolved towards safer anaesthesia in the modern clinical practice. Methods: Material is derived from literature searches from major ophthalmic and anaesthetic journals on the use of orbital needle blocks over earlier centuries. Results: Needle‐based anaesthetic techniques were described shortly after the invention of reliable medical needles. Atkinson popularized the classical retrobulbar block in a series of papers published in the early 20th century. This technique,which utilises a relatively long needle inserted towards the apex of the muscle cone behind the globe, has been criticized by some as unsuitable for modern 21st century ophthalmic surgery because of the extremely rare potential for serious complications. Satisfactory anaesthesia and akinesia can be obtained with short sharp or dull needles with slightly higher volumes of local anaesthetic agent placed in the farthest inferotemporal quadrant. Conclusion: Aside from relative safety, modern needle blocks offer the advantage of lid akinesia without a need for a second injection for the seventh nerve that is often performed con‐comitantly with retrobulbar block.