Amid the Pandemic

Safety Precautions Before and During Cataract Surgery by April Ingram

For more than six months, most regions around the world have been implementing social distancing measures, and the term “new normal” seems to be something we are settling into.

Maintaining a two-meter distance between people and avoiding crowded and congested areas are now the norm. Our hands require a minimum of 20 seconds of cleaning with a 70% alcohol-based solution or with soap and water. Proper use of a mask and other personal protective equipment (PPE) is essential.

It seems as though the COVID-19 virus is going to be with us for some time and has already demonstrated its strong potential to re-emerge, even if once effectively contained.

Eye care and pandemic measures

Despite the importance of pandemic measures, however, our patients continue to require regular eye care. And the need for cataract surgery has certainly not diminished.

In order to meet the need, healthcare systems and surgeons have had to be strategic and thoughtful about how to implement important changes in patient management and surgical practice to address the COVID-19 new normal.

The good news is that surgeons — especially ocular surgeons — are, and have always been, masters of infection control. In fact, one of the safest places that someone could be over the next few months would be in an operating theatre. The challenge is getting to that stage.

Overcoming challenges in patient management

Two cataract surgeons from very different parts of the world share their expertise and management strategies from the last few months and how they see cataract surgery moving forward from here.

Dr. Keith Yap is an ophthalmologist and surgeon in Kelowna, British Columbia, Canada. He shared that cataract surgeries were stopped by their local health region from the middle of March until mid-June this year. Although surgeons and all medical professionals looked to government and national societies, such as the Canadian Ophthalmological Society (COS), for recommendations and protocols, as Dr. Yap explained, some of the best information came from colleagues.

“The COS and provincial health authority did provide some guidance for ‘minimum standards’, which were fairly standard things. But one place that myself and fellow British Columbia ophthalmologists found really helpful was the BC ophthalmologists chat groups, where we could discuss what was happening, and bounce ideas off one another about how to best manage things,” shared Dr. Yap.

When cataract surgeries began again in June, very little has changed within the operating room, which has always been under strict protocols directed by the Kelowna General Hospital infection control committee. But those changes were more about how patient flow was managed.

“In general, cataract surgery has a low aerosolization risk, so we perform the procedure in much the same way. The big differences are that patients are masked, and temperatures are checked when they enter the hospital. Their drivers or caregivers are asked to wait outside until we call them back after the surgery is complete,” explained Dr. Yap.

“The waiting room has only one-third of the chairs, and cleaning of the area is done more frequently. We are all gowned and gloved and the patient enters the OR with their surgical mask. Once we are ready to proceed, I remove the patient’s mask and replace it with the plastic drape, because I think the mask and the drape might be claustrophobic for the patient. Once the surgery is done, I remove the drape and replace the patient’s mask,” concluded Dr. Yap.

“Symptomatic persons will not be allowed entry, and those who were once COVID-19 positive must be recovered and certified negative.”

– Dr. Boateng Wiafe

Measures to control the airborne transmission of the virus

Dr. Boateng Wiafe, an ophthalmologist and surgeon at Watborg Eye Services in Awutu Bereku, Ghana, agrees that the key to managing COVID-19 infections is to take serious measures to control the airborne transmission of the virus.

Similar to the practices in Canada, temperature and symptom checks are performed before the patient may enter the hospital. “Symptomatic persons will not be allowed entry, and those who were once COVID-19 positive must be recovered and certified negative,” Dr. Wiafe said. “We need to be vigilant because every person entering the hospital premises is a potential asymptomatic COVID-19 carrier.”

Patients in Ghana also wear masks inside the operating room, and they do one more additional step. “Just before coming into the operating theatre,

patients are asked to gargle with hydrogen peroxide,” shared Dr. Wiafe.

The Ministry of Health in Ghana instituted a total lockdown of surgeries in the region for more than a month. Since reopening, Dr. Wiafe said one of the biggest COVID-19-related changes in the operating room has been reducing the number of operating tables in each operating theatre to just one.

“Especially in low- and middle-income countries, in an effort to keep up with the demand for cataract surgeries and increase productivity, there had been more than one table per theatre, which has now been limited to one. The surgical procedure remains the same because infection prevention and control have always been one of the basic principles of eye surgery,” explained Dr. Wiafe.

He added: “Things are much slower with all of the new protocols in place. We used to perform three to four cataract surgeries per hour, and now it is one to two per hour. The backlog is currently about eight weeks and the cost per cataract has now doubled, which I worry will have a significant impact on the burden of blindness globally.”

Developing individual protocols

Surgeons agree that there is so much information available about practice management during COVID-19, but it can be difficult and time-consuming to sift through it all and figure out what can be most applicable to each individual situation. With that said, some regions are carefully developing protocols. But the process takes so long, and the situation is so fluid that it seems that “developing your own” is the popular choice.

Although in some places, people are not happy about being required to wear masks and all the extra safety measures. It’s not the case with most eye care patients. “The vast majority of patients are very happy to comply, and that seeing all the extra measures makes them feel safe,” shared Dr. Yap. public are getting used to using masks and other safety measures, there are still problems with people who keep removing them, and keep touching their face, nose and mouth. So educating people is still so important.”

Both of our surgeons acknowledge that the challenge now is to address the mountain of backlogged cases. Part of this could be adding more funding to staff additional operating rooms and everything else needed to perform the surgery.

Furthermore, there are additional budgetary implications of PPE for patients and staff and additional cleaning and disinfecting measures.

In Africa, surgeons and the health ministry are looking at planning surgical outreach centers, in addition to the usual fixed surgery days, in an effort to limit patient travel and reduce the number of patients assembling in one place.

The important role of telemedicine in today’s practice

A pleasant surprise has been how beneficial telemedicine can be in ophthalmology. “One of the biggest challenges during the pandemic is keeping people distanced, which is often a challenge in waiting rooms no matter how carefully you monitor the schedule,” shared Dr. Yap.

“The wait is rarely due to back-up with the ophthalmic technicians, and almost always is with the physicians. We have found it to be really beneficial for patients to come in and have their assessments like intraocular pressure (IOP), vision and imaging done by the technicians. Usually there’s no waiting time, just in and out. Then I review everything and have a telephone consultation with the patient later that day. It works well and the patients really like it. We are even able to conduct our post-op visits virtually as well,” he added.

Dr. Wiafe has also adopted telehealth, and teleconsultations are encouraged by his facility, particularly for followups. Not unexpectedly, both surgeons agree that what is now happening, as far as the new normal goes, is really what is supposed to be normal.

“There can be no shortcuts. What we are doing now to manage infection control is what it ought to be. COVID-19 has come to stay, and we all have to make the necessary adjustments to become COVID-19-compliant in all we do,” surmised Dr. Wiafe.

“With the new protocols at our surgical facilities, we are addressing all the elements of quality to make sure that the surgery is safe for the surgeon and the patient. This ensures the best outcomes and reduces infections to zero,” he concluded.

Contributing Doctors

Dr. Keith Yap, BMSC, MD, FRCSC is an ophthalmologist and surgeon in Kelowna, British Columbia, Canada. He performs cataract surgery at Kelowna General Hospital and his private surgical center, also in Kelowna. Dr. Yap completed his ophthalmology residency at the University of Alberta and a fellowship at the University of Iowa. He is board-certified in Canada with the Royal College of Surgeons of Canada. Dr. Yap and his wife, Dr. Mandy Wong, also a physician in Kelowna, are very active in the community and support numerous charitable causes. When not in the office or operating room, Dr. Yap enjoys many of the sports and recreation activities available in Kelowna and the Okanagan region, including tennis in the summer and hockey in the winter. He starts each day by waterskiing before heading to work.

editor@mediamice.com

Dr. Boateng Wiafe, MD, MSc (Community Eye Health), FGCP, is an ophthalmologist and surgeon at Watborg Eye Services in Awutu Bereku, Ghana. He currently serves as technical advisor for Operation Eyesight Universal and spent several years in other roles as their director of quality and advocacy and regional director for Africa. Dr. Wiafe is also the WHO master trainer for primary eye care, chair of the Ghana Eye Health Advocacy Steering Group, and chair of the International Agency for the Prevention of Blindness. Dr. Wiafe shares his operating theatre with his wife Ruth, a nurse at the hospital.

editor@mediamice.com