Since March 2020, COVID-19 has transformed ophthalmologic care, calling for the rapid development of protocols regarding screening of patients for COVID-19, physical distancing guidelines, use of personal protective equipment (PPE), and prioritization of non-elective surgeries. As clinics and surgery centers reopen in the midst of an ongoing pandemic, safe screening protocols must be implemented to provide care to patients yet ensure the safety of healthcare workers. Positive results of SARS-CoV-2 are common among asymptomatic patients who can transmit SARS-CoV-2^1,2 and contribute to pandemic spread.³ In this report, we describe a protocol for preoperative COVID-19 testing for patients undergoing elective ophthalmic surgeries.

The screening protocol for patients undergoing elective ophthalmic surgery at our institution as of July 1, 2020, is shown in Figure 1. We test for SARS-CoV-2 in all patients regardless of symptoms, about 3–5 days before elective surgery. Initially, the protocol was strongly recommended, but became mandatory on July 1, likely due to the non-zero rate of positive tests for SARS-CoV-2 in asymptomatic patients. The screening test is a real-time reverse-transcriptase polymerase chain reaction (RT-PCR) test that detects viral RNA from a nasopharyngeal swab. Patients who report COVID-19 symptoms or asymptomatic patients who test positive by RT-PCR are delayed and rescheduled. Symptomatic patients are not tested because of the high false negative rate⁴ and limited resources for testing. Those who test negative proceed with scheduled surgery. When testing occurred in house at our institution, standard testing results returned in approximately 10 hours, while STAT testing returned in about 4 hours. Our study period was from May 18, the day elective surgeries resumed, until June 19. This study met the tenets of the Declaration of Helsinki and was approved by Institutional Review Board of the Johns Hopkins University School of Medicine.

An Algorithm for Ramp Up of Ophthalmic Elective Surgeries Post-COVID-19

All authors

Yesha S. Shah , Sidra Zafar, Thomas V. Johnson, Divya Srikumaran, Michael X. Repka & Fasika A. Woreta

https://doi.org/10.1080/09286586.2020.1832236

Published online:

13 October 2020

Figure 1. The current screening algorithm for patients undergoing elective ophthalmic surgeries as of July 1, 2020

^aReal-time reverse-transcriptase polymerase chain reaction (RT-PCR) is performed on a nasopharyngeal swab collected from the patient.^bTesting for seropositivity is not required if an RT-PCR test is negative.^cTesting for seropositivity is not required after 28 days have passed from the first positive test or symptom onset.

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Over the first 5 weeks after reopening from May 18 to June 19, our institution scheduled 383 elective surgeries and tested 360 asymptomatic patients (94.0%). Two patients (0.6%) tested positive for SARS-CoV-2, which required cancellation of their surgeries. The first patient retested negative 14 days after the first positive test and their cataract surgery was rescheduled and completed. The second patient was canceled and will be tested after 2 or more weeks after the positive test. The median age of patients undergoing surgery in our study was 70.8 years (SD = 14.7, range 0.5–94) and the median time between testing and surgery was 3.0 days (SD = 1.8, range 0–15).

While 0.6% of asymptomatic patients testing positive for SARS-CoV-2 is low, if these patients had not been screened, they could have been a potential source of transmission in the operating room and post-operative examinations. Given the high risk of transmission to healthcare workers, patients,¹ and in particular ophthalmologists, testing in asymptomatic patients may be justified. The older median age of patients undergoing surgery confirmed that many of our patients are in the high-risk age group⁵ and vulnerable to the infection. Originally, our protocol highly recommended testing of asymptomatic patients, but it was not mandatory. Out of the 383 scheduled surgeries, 23 (6.0%) patients were not tested. This was due to a lack of access to testing sites able to provide timely results, financial barriers to getting to testing sites, or patient refusal, which will hinder the universal implementation of this protocol. Because our institution mandated testing as of July 1, there will likely be fewer cases of unavailable test results in the future.

As we continue to ramp up surgical volume, it is important to consider whether testing of asymptomatic patients for SARS-CoV-2 continues to be beneficial. Symptom screening, temperature checks, SARS-CoV-2 testing in asymptomatic patients, and physical distancing may allow for resumption of normal or near normal surgical volume and minimization of COVID-19 spread. Each surgical center should actively monitor positive cases and adjust their screening protocol based on the prevalence of COVID-19 in their region and the impact it has had on their economic status. While testing for SARS-CoV-2 in the near term is important to reduce transmission of the disease, excessive testing may prove to be a financial burden to patients and the healthcare system. The risk of spreading COVID-19 must be balanced with patient care and cost effectiveness.

In addition to a structured protocol, the proper use of PPE is important in reducing exposure to COVID-19. During surgeries at our institution, all patients are required to wear a surgical mask while ophthalmologists wear a surgical or N95 mask. Additionally, ophthalmologists are required to wear a face shield in the preoperative area. In clinics, our institution requires patients to wear a surgical mask, ophthalmologists to wear a surgical or N95 mask with a face shield, and the use of a barrier shield during a slit lamp exam. The use of PPE is especially important when an ophthalmologist comes into contact with a patient whose COVID-19 status is unknown and later tests positive. It is financially and practically unfeasible to test all members of a healthcare team that may have been exposed to COVID-19, especially when healthcare workers will likely experience multiple exposures. In this situation, adhering to strict PPE guidelines and stringent screening protocols will limit the exposure and spread of COVID-19 whenever possible.

The healthcare system will be challenged by COVID-19 for the foreseeable future as medically necessary surgery is performed. Resumption of elective surgery while maximizing patient and provider safety may be possible with universal precautions and strict screening protocols aimed to minimize exposure to patients with COVID-19. In addition, given that experts are wary of continued community presence or a second wave, it is important to outline a feasible screening strategy in preparation for any future rise in cases that may necessitate a similar cessation of elective surgeries. Our screening protocol revealed two asymptomatic patients scheduled for elective ophthalmic surgery that had positive RT-PCR testing for SARS-CoV-2, thus highlighting the importance of universal testing and adherence to proper use of PPE.