aao, aios, mohfw and other guidelines specially for ophthalmic stabilishments.

1. Guidelines for Ophthalmic
Establishments During
COVID-19 Pandemic
Dr. Ombir Singh Tyagi

2. Important considerations
1.Virus containing Respiratory droplets from coughing,
sneezing, loud conversation or direct contact when reach
another person's eyes, nose or mouth, causes COVID19.
2.Healthcare workers must use appropriate PPE, even if
they remain more than 1 meter away from a
symptomatic patient.
3.Carriers may be asymptomatic or in incubation period ,
so presume that every patient and attendant is a
potential source of infection.
4.Precautions need to extend way beyond the lockdown
period and cannot stop even if the incidence curve of
COVID19 flattens or falls.
Ong, Sean Wei Xiang, et al. "Air, surface environmental, and personal protective equipment contamination by
severe acute respiratory syndrome coronavirus 2 (SARSXCoVX2) from a symptomatic patient." JAMA(2020)

3. Ophthalmology practice : A high risk zone
 Conjunctivitis could be presenting or associated feature
 Insufficient distancing between patient and examiner : SLE,
REFRACTION, DIRECT OPHTHALMOSCOPY
 Long stay in clinic due to multiple investigations Vn, Tn, R/R,
SLE, fundus, imaging.
 Small examination rooms / dark rooms with absent or restricted
natural ventilation
 Closed vent and central air conditioning without HEPA filtration
1.Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
Lancet 2020;395:497-506.
2. Turgut B. Role of ophthalmologists in combating with the Coronavirus disease 2019. Adv Ophthalmol Vis Syst.
2020;10(2):31‒34. DOI: 10.15406/aovs.2020.10.00378

4. WHO and MOHFW (Govt. of India) recommendations
• Physical barriers such as glass or plastic windows
panels, should be used in reduce exposure to the
COVID-19 virus.
• Guards at the gate should wear surgical masks and
maintain hygiene.
• Alternate seats can be strapped down the middle with
string or tape to maintain social distancing.
• Waiting in a vehicle is safer than waiting in a clinic.
• AC should run open to outside air mode.
• Aerosol generating procedures should be done only in
emergency.

5. • High risk areas OT, Registration, Counselling room, Consultation
room, waiting areas, Lifts, Washrooms should be mopped with 1%
sodium hypochlorite solution 2 hourly.
• Door handles, side rails on stairs, reception counter cleaned with 1
% Sodium Hypochlorite ( 4Times /Day).
• Chair in the waiting area (head end, arm rest etc) , Electronic /IT
equipment like monitor, Key board, Mouse etc must be done with
alcohol swab every two hourly
• Fogging of entire hospital shall be done on weekly basis
• Sanitising spray should not be used as it may create splashes that
can further spread the virus.
• Hand sanitising stations should be installed near the entry and near
high contact surfaces.

6. Infection control measures in
ophthalmology
Three-level hierarchy of control measures:
• (A) Administrative control
• (B) Environmental control
• (C) Personal control (PPE)
Tracy H. T. Lai, Emily W. H. Tang et al, Stepping up infection control measures in ophthalmology
during the novel coronavirus outbreak: an experience from Hong Kong. Graefe's Arc Ophthal
2020 https://doi.org/10.1007/s00417-020-04641-8

7. Administrative control
1. Patient scheduling
2. TRIAGE
3. FTOCC Questionnaires
4. Avoiding unnecessary procedures
5. Paperless workup
6. Social distancing
7. Infection control training
8. Staff monitoring

8. 1. Patient scheduling
• Avoid routine telephonic appointments if not
necessary.
• Urgency is determined by the ophthalmologist’s
judgment and must always consider individual
medical and social circumstances.
• Separate examination room for strongly
suspected cases.
• Bed side consultations for cross referrals.

9. 2. TRIAGE
All persons (patients, attendant, visitor & Staff) coming to hospital shall PASS the “THERMAL
SCREENING” (Based on history and non-contact thermometer, if available )

10. 3. FTOCC Questionnaires

11. 4. Avoiding unnecessary procedures
• Formulate new protocols for examination.
• Avoid contact procedures as much as possible.
• Routine aerosol generating procedures in
ophthalmic practice should be suspended. Eg.
NCT, intubation and extubation in GA.
• No routine AR & refraction for each patient.
• Discourage CL use and CL trial discontinued.
• All non-essential, non-critical examinations
should be avoided and patient explained need
for more elaborate testing in future as feasible

12. 5. Paperless work
• EMR work up.
• Avoid touching patients old prescription and
reports.
• Reducing instances of hand to hand transfer
(handing over of bills/prescriptions)
• Avoid cash transaction
• Plastic folders to be discontinued to avoid
multiple touching.

13. 6.Social distancing
• Patients and staff shall be greeted with “Namaste” (No handshakes)
• Screening Desk: 1 meter distance must maintained at the screening
desk by marking on floors by temporary marker.
• Registration Desk: 1 meter distance must be maintained at
registration counter by any mode Eg. Line on floor at 1 meter
• Patient Waiting areas: 1 meter distance must be maintained by
either way Chalk marks on sofas/Chairs to be used for sitting
• Virtual Meetings may continue through Zoom, Skype or any other
software.

14. 7. Infection control training
• For all hospital staff.
• Proper steps of hand hygiene , donning and
doffing of PPE.
• Staff should be encouraged to report their
symptoms and travel histories after returning
from holidays
8. Monitoring
• Monitoring to be initiated and reinforced by
Quality team.

15. Environmental control
1. Ventilation
2. Disinfection tunnel
3. S/L Shields
4. Frequent cleaning
5. Minimize gathering

16. 1. Ventilation and HEPA filters
• Open door policy at all locations (except
operating room)
• Mobile high efficiency particulate air (HEPA)
units to augment the total air change rates in
waiting areas where necessary.

17. 2. Disinfection tunnel
• At entry/exit gate.

18. 3. S/L Shields
• Made of plastic
sheet.
• Cleaned and
disinfected 2 Hourly,
or if the shields were
visibly soiled or
contaminated.

19. 4. Frequent cleaning
• All indoor areas such as entrance lobbies,
corridors and staircases , meeting rooms,
cafeteria should be mopped with 1%
sodium hypochlorite solution or phenolic
infectants 4-8 hourly.
• High contact surfaces such as elevators,
handrails, public counters, telephones
should be cleaned twice a day with 1%
sodium hypochloride or 60-70% alcohol
sanitizer.

20. 5. Minimize gathering
• Preferably a patient screening desk should be
functional with staff available with best
available methods of PPE.
• Quick response and earliest possible
consultation.
• Avoid routine dilatation in all cases.
• ONE attendant per patient policy.
• Permit only patient to clinic if possible.

21. Personal control
1. Mask
2. Caps, Gowns and Gloves
3. Goggles or large frame spectacles
4. Face shields
5. Hand hygiene

22. 1. Mask
• Mask is mandatory for all health care provider
as well as patient and attendants.
• N-95 or surgical mask preferred.
• Home made cotton mask or scarf can be used
in unavailability of mask.
• https://youtu.be/buyKfZD8J6M (Short video
on Reuse of N-95 MASK by MOHFW)

23. 2. Caps, Gowns and Gloves
• Add extra layer of protection.
• Should be used during touching patients.

24. 3. Goggles or large frame spectacles
• Conjunctiva is a mucosal surface.
• Potential route of viral entry directly.
• Virus may reach to nasopharynx though tears
also.

25. 4. Face shields
• Can use home made
with plastic sheet.
• We should use mask
under it.
• Provide extra layer of
protection for
aerosol.

26. 5. Hand hygiene
• After touching a
patient.
• Before touching face,
wearing or removing
PPE, after washroom
use and before eating.
• Use soap water or
alcohol based
sanitizer.

27. Precautions at Ophthalmic Evaluation
and OPD Procedures
1. Protection for mouth, nose, and eye (with triple
layered/N95 masks if available , goggles/ face shield)
2. Slit lamp barriers or breath shields
3. Alcohol based hand sanitizer before and after
examining each patient
4. Speak as less as possible
5. Disposable gowns, gloves

28. Continue…..
6. Avoid nasolacrimal syringing if possible
7. Avoid all aerosol-based procedures including NCT
8. Disinfect (using standard protocols) all instruments
and probes used in direct contact to the patient’s tear
film and ocular surface before re-use
9. Patients with conjunctivitis should be seen in a
designated OPD room with full PPE

29. Continue…..
10. All Health care workers (HCW) should change into
scrubs at hospital and change out to street clothes at
exit. Take a soap bath at once reach home.
11. Optimize support staff and HCW allocation ( half of
the regular staff per day)
12. Prophylaxis: ICMR has advised oral HCQ 400mg BD
on day 1, followed by 400 mg OD weekly for 7 weeks.*

30. Precautions at Surgery
• Routine screening Chest X-ray before each
surgery, if possible
• Try to avoid GA unless mandatory, Prefer topical
over local
• Stop positive ventilation in theatre during
procedure and for at least 20 minutes after the
patient has left theatre
• No two patients should be handled together.
There should be a 20-min time out between each
surgery
• Minimum possible staff in OT
• All should use PPE

31. Conclusion
• Consider all patients and attendants infected in
view of asymptomatic carriers and incubation
period.
• Resources should be prioritized and optimised.
• Avoid unnecessary exposure of healthcare
personnel to (potentially) infected patients and
vice versa.
• The number of visits should be minimum
essential.
• Follow PPE measures.

32. Thank you