© 2020 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

Evolving consensus on managing vitreo-retina and uvea practice in post-COVID-19 pandemic era

Vishali Gupta, Anand Rajendran1, Raja Narayanan2, Shobhit Chawla3, Atul Kumar4, Mahesh Shanmugam Palanivelu5, NS Muralidhar6, Chaitra Jayadev7, Rajeev Pappuru2, Manoj Khatri8,

Manisha Agarwal9, Ajay Aurora10, Pramod Bhende11, Muna Bhende11, Prashant Bawankule12, Pukhraj Rishi11, Anand Vinekar7, Hemant Singh Trehan13, Jyotirmay Biswas11, Rupesh Agarwal14, S Natarajan15,

Lalit Verma16, Kim Ramasamy17, A Giridhar18, Ekta Rishi11, Dinesh Talwar16, Avinash Pathangey19, Rajvardhan Azad20, Santosh G Honavar21

Access this article onlineWebsite: www.ijo.inDOI: 10.4103/ijo.IJO_1404_20PMID: *****

Quick Response Code:

The COVID-19 pandemic has brought new challenges to the health care community. Many of thesuper-speciality practices are planning to re-open after the lockdown is lifted. However there is lotof apprehension in everyone’s mind about conforming practices that would safeguard the patients,ophthalmologists,healthcareworkersaswellas takingadequatecareof theequipment tominimize thedamage.Theaimofthisarticleistodeveloppreferredpracticepatterns,bydevelopingaconsensusamongstthe leadexperts, thatwouldhelp the institutesaswellas individualvitreo-retinaanduveitisexperts torestarttheirpracticeswithconfidence.Asthesituationremainsvolatile,wewouldliketomentionthatthesesuggestionsareevolvingandlikelytochangeasourunderstandingandexperiencegetsbetter.Further,thesuggestionsareforroutinepatientsasCOVID-19positivepatientsmaybemanagedindesignatedhospitalsasper localprotocols.Also thesesuggestionshave tobe implementedkeeping incompliancewith localrulesandregulations.

Key words:COVID-19,preferredpracticepatterns,retinopathyofpremat,Uveitis,Vitreoretina

AdvancedEyeCentre,PostGraduateInstituteofMedicalEducationandResearch,Chandigarh, 1AravindEyeHospitalChennai, 2LV PrasadEye Institute,Hyderabad, 3PrakashNetraKendr,Lucknow,4Dr.RP.CentreforOphthalmicSciences,AllIndiaInstituteofMedicalSciences,NewDelhi, 5Sankara EyeHospital, Bengaluru, 6Retina InstituteofKarnataka,Bengaluru,7NarayanaNethralayaEyeInstitute,Bengaluru,8EydoxEyeHospital,Chennai,9ShroffCharityEyeHospital,NewDelhi,10VisionPlusEyeCentre,NOIDA,11SankaraNethralaya,Chennai,12SarakshiNethralaya,Nagpur,13ArmyHospitalR&R,DhaulaKuan,NewDelhi,14NationalHealthcareGroupEyeInstitute,TanTockSengHospital,Singapore,15AdityaJyotEyeHospital,Mumbai,16CentreforSight,NewDelhi,17AravindEyeHospital,Madurai,18Giridhar Eye Hospital,Kochi,19LVPrasadEyeInstitute,Visakhapatnam,20Regional InstituteofOphthalmologyIndiraGandhiInstituteofMedicalInstituteofMedicalSciences,Patna,21CentreforSight,Hyderabad,India

AllAuthorscontributedequallytothemanuscript

Correspondenceto:Prof.VishaliGupta,Vitreo-RetinaandUveaServices,AdvancedEyeCentre,PostGraduateInstituteofMedicalEducationandResearch,Chandigarh, India.Email: vishalisara@yahoo.co.in; vishalisara@gmail.com

Received:08-May-2020 Revision:09-May-2020Accepted:09-May-2020 Published:25-May-2020

TheglobalCoronavirusdisease2019(COVID-19)pandemichasbroughtinseveralunprecedentedchallengesthattheworldhasnoexperienceindealingwith.TheAllIndiaOphthalmologicalSociety(AIOS)–IndianJournalofOphthalmology(IJO)recentlypublishedaconsensusstatementonpreferredpracticesduringtheCOVID-19pandemic and suggested that thesegeneralpracticesbefollowedduringthepost-lockdownperiodaswell.[1] However,asthesuperspecialtyclinicsaregearinguptoresume

theirpractices,therearelotofqueriesbeinggeneratedthatneedtobeaddressedbothbyevidenceandconsensus.Thepandemichashighlightedgeopoliticaldifferences inmanagementandscreeningprotocols.Thus,althoughthereareguidelinesbeingissuedbyseveralinternationalophthalmicsocieties,itmaynotbepossible toapply themuniformly toa country like Indiawithsocialandeconomicconstraints.[2]Moreover,thepracticepatternsmaybeinfluencedbyfactorslikethesizeoffacility,numberofpatientsbeinghandled, strengthof the staffandfacilitiesavailablebesides their capabilityandpreparednesstohandleCOVID-19positivepatients.Thepresentpreferredpracticepatternshavebeenformulatedbyaleadinggroupofexperts constituted from the representativesofVitreoretinalSocietyof India (VRSI),UveitisSocietyof India (USI), iROPandfrommajorinstitutesandtheIJOleadership.Thesepracticepatterns arebeing formulated tohelp restart vitreo-retinalservices amongst tertiary institutions, corporate andgrouppractices aswell as individual eye clinics.The suggestionsareforroutinepatientsasCOVID-19positivepatientsmaybemanagedindesignatedhospitalsasperlocalprotocols.

Cite this article as: Gupta V, Rajendran A, Narayanan R, Chawla S, Kumar A, Palanivelu MS, et al. Evolving consensus on managing vitreo-retina and uvea practice in post-COVID-19 pandemic era. Indian J Ophthalmol 2020;68:962-73.

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For reprints contact: reprints@medknow.com

Preferred Practice

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MethodsThis consensus was developed in continuation to theprevious publication by Sengupta et al.[1] The experts included the representatives ofVRSI,USI, iROP aswellas the retina chiefs frommajor centres in India.Thebasedocumentwas prepared by the allocation of sections todifferentexperts.Thepaperwasthencompiledandreviewedby theentire committee. In case therewasanydifferenceofopinion,amutualconsensuswasreachedbydiscussionamongstalltheexperts.Thefinalversionofthedocumentwasapprovedbyalltheauthors.

Practice Guidelines for Vitreo- Retina ServicesI. Tele-counseling for triage and appointmentsThegroupencouragestheuseoftele-consultstomaintaincommunication with patients and provide staggeredappointmentstoavoidcrowdingintheclinic.Withregardto new patients, this can also be used to fill up patientdetails, prior topatient’s arrivals in the clinic. Each cliniccandesignaflowcharttosuittheirpracticetodirectpatientflow.A sample flow chart is shown inFig. 1. Encouragetele-consultation to prioritize patients aswell as reducewalk-ins.Anypatientdirectlyaskingforaretinalconsultationmayneedtobequestionedfurthertoascertaintheurgencyofthecondition.Atrainedassistant/fellowcanbegiventheresponsibilityoftalkingtothepatienttoseeiftheyneedtobeseenurgently.

Thefollowinglististohelpprioritizationforthosewithlargenumber of patients to avoid the overcrowding. Theclinicswith lesser number of patients, however, can seepatientswhohavebeenlistedundersemi-urgentordelayedappointments:

A.Urgent:Thefollowingcomplaintswouldneedtoattendedonurgentbasisattheearliest:i. Suddenorrapidlossofvision

ii. AcuteonsetFlashes,floaters,iii.Painfullossofvision,iv.Recentonsetmetamorphopsia/readingdifficulty.v. Conditionsneedingurgent surgery[2] e.g., openglobeinjuries, rhegmatogenous retinal detachment (RRD),recentonsetmaculartractionalretinaldetachment(TRD)or combined RD, endophthalmitis, recent onsetsubmacular haemorrhage, nucleus drop or retainedcortical matter with secondary glaucoma as perguidelinesofAIOS-IJO.[1]

vi.New cases of retinoblastoma, ocular tumours orRetinopathyofPrematurity(ROP)

vii.Conditionswhereearlysurgeryshouldbeconsideredincluding bilateral vitreous haemorrhage, vitreoushaemorrhageinone-eyedpatientetc.

Oranyotherconditionwhere treatingphysicianfeelstheurgencytoseethepatient.

B. Semi-urgentAppointmentsThenextprioritywouldbethepatientswithfollowingcomplaints:i. Patientswithdiabetesmellituswithcomplainsofslowonsetofvisionloss.

ii. Anypatientwhohasbeentreatedwithinjectionsrecentlyelsewhere/operatedelsewhereseekingconsultation.

iii.Any retina case referredbyanother colleague canbeconsideredassemiurgentandgivenanappointment.

iv.Patientsreceivinginjectionsforneovascularagerelatedmaculardegeneration(AMD)andpolypoidalchoroidalvasculopathy(PCV).

v. Patients receiving injections for nonAMDchoroidalneovascularmembrane(CNV)

vi.RetinalVeinOcclusion (RVO) andDiabeticMacularEdema(DME)patientsneedingfrequentinjections,andmono-ocularpatients.

vii.Patientsoperatedwithinthelast3monthsandwhohavesiliconeoilwillneedtobereviewedsoon.

viii.Patients onanti-glaucomamedications alsoneed tobeseenearly.

Figure 1: Flow chart demonstrating the triage during teleconsult

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C.DelayedAppointments:Thefollowingpatientscanbegivenappointmentslater,dependingupontheslotsavailableandgiventele-consultinthemeantime:i. Allpatientswhohavebeenreceivingregularinjectionsbutarestable

ii. RoutinefollowupforwetAMD,DMEandRVOiii.Patientwhoisstableandhasnotneededinjectioninthe

last visitiv.Regular patients withNon proliferative diabeticretinopathy (NPDR) and Proliferative DiabeticRetinopathy(PDRstable)postLaser/surgery

v. StablepostRDsurgery.

Patientswhohavemaintainedstablevisionwithinfrequentinjectionsarecandidatesfortelephonicconsultation.COVID-19testing is notmandated forOPD examination, Lasers orIntravitrealinjections.

II. Techniques of retinal examination

A.HomeversusclinicdilationDilationatthehospitalmayincreasethepossibilityofspreadofinfectionduringapandemicdueto:1. Inadvertentspreadbytheassistanttaskedtoinstiltheeyedropsifthedropperortheassistant’sfingerscomeincontactwithaninfectedperson

2. Patients areusually clusteredat thedilationareaof thehospitalwhichincreasestheirtimeinhospitalandriskofexposure.Thisriskcanbemitigatedbyhomedilation.

RevisitPatients:Homedilationisthusadvisableforreviewpatients where information regarding prior history of allergy todilatingdropsandhistoryofsystemichypertensioncanbeobtained fromtheircaserecords.Anelectronicprescriptiondetailingtheabovemaybegiven.Thepatientandfamilycanpreferablybecounselledaboutthepropertechniquethroughappropriatevisualaidssuchasavideooragraphic.

NewPatients: Innewpatientsand in thosewherehomedilationisnotpossible,dilationatthehospital isnecessary,werecommendfollowingprecautions:1. Theassistantshouldbewearingglovesandafaceshieldanddisinfecther/hishandappropriatelyaftereachpatient

2. Non-touch technique of applying the di lat ingdrops–requestingthepatienttoretractthelowereyelidandextendingtheneck,insteadoftheassistantretractingthelidortouchingtheheadofthepatient[Fig.2a].Inthoseunabletoself-retractthelid,adisposablecottontippedapplicatormaybeusedtoretractthelid,takingcarenottotouchtheendthathascomeincontactwiththepatient[Fig.2b].Thecottontippedapplicatoristhendisposedappropriately

3. Dilation shouldbeperformed in anairy, openarea, thepatientsbeingseatedwithdistancingnormsbeingfollowed.[1] Wecanalsoconsiderdilatingthepatientintheclinicareaitselftoavoidunnecessarymovementofthepatient.

B.Slit-lampexaminationAll precautions regarding the breath shield disinfectionof slit lamp and lenses to be followed as perAIOS-IJOrecommendations.[1] Indirect ophthalmoscopymay bepreferred.Incaseofslitlampbiomicroscopy,thelensesusedforretinalexaminationcanbecoveredwithclingfilmthatcanbecleanedeasilywithoutdamagingthelenssurface.

C.PreferredmethodforRetinalexaminationRetinal examination during the pandemic need not besignificantlydifferentexceptforsomeprecautions:1. Contactlensexaminationofthefundusshouldbeavoidedifpossible

2. A face shieldmountedon the indirect ophthalmoscopeor on the examiner’shead is recommended in additionto thepersonalprotectiveequipment (PPE).The indirectophthalmoscopemounted shieldwith a cut out for theeyepiece,offersbettervisualizationofthefundus[Fig.3].Patient shouldwearamaskduring theexamination, theupperborderofwhich canbe securedwithanadhesivetape if ill-fitting tominimize the riskofpatient’sbreathcontaminatingtheexaminer’shands

3. It ispreferable tousealcohol sanitizationof thehandsprior towearing the indirect ophthalmoscopeandalsopriortoremovingittominimisetheriskofitbecomingafomite

4. Scleraldepressiontobeavoidedunlessessentialinagivencase.Cotton-tippedapplicatormaybeusedasdisposabledepressor

5. Minimal or no talking during fundus examination isadvisable.Thedesireddirectionofgazeduring indirectophthalmoscopycanbeindicatedtothepatientbygentlytapping,withaglovedhand, theappropriateperiocularregion,ratherthanvoicingit.

D.ClinicalExaminationversusImagingA clinical examperformedwith adequate precautions ispreferabletorelyingonanimage.Limitationofimagingare:1. Even awide-angle fundus image is not as thorough asan indirectophthalmoscopic examination.Awide-anglefunduscameraisrarelyavailabletomostpractitionersaswell

2. Mediaopacitiescancompromiseanimagewhileanindirectcanmostoftencircumventit

3. Usinganimagingdevicecanresultinclusteringofpatients,whichistobeavoided.

Ontheotherhand,animagingdevicewouldbeparticularlyusefulfortele-consultationconsideringthelimitationtotravelduringthepandemic.

III. Retinal imaging1. Clinicians should exercise cautionwhiledecidingaboutinvestigations. Essential and critical investigationsmaypreferablyberesortedto

2. Non-invasive investigativemodalities that are lesstime-consumingorhavenopatientcontactarepreferred.Both optical coherence tomography (OCT) and opticalcoherencetomographyangiography(OCTA)canbeusedasanalternativetodye-basedangiography.Simpleprotocolsthatcanbedoneinfewsecondsarepreferred

3. Requesttestsonlywhencriticaltomakeaclinicaldecision.ProcedureslikeIndocyanineGreenAngiogram(ICG)whichinvolvelongerchairtimearebestavoidedandshouldbeperformed only when other investigative modalities do not give the required information for adefinitediagnosisordecisivetreatmentstrategy

4. B-scanultrasonography, thoughnon-invasivemodality,hascontactoftheprobewiththepatient’seye.Ifthescan

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becomesmandatory,extracleansingprecautionsshouldbetaken

5. Electrophysiologicaltestsarebestavoidedunlessabsolutelyessential.

IV. Retinal lasersA.IndicationsandpriorityWhiletheindicationsforlasertreatmentwouldremainsame,wemayhavetoprioritisetheminpracticesthatareoverloaded

andwishtoreducethenumberofpatientsonanygivenday.Weshouldprioritisethem,ascapturedinTable1too,inthefollowingway:[1,3-6]

Earlylaserstobedoneonprioritybasis1. ActiveProliferativeDiabeticRetinopathy(PDR)2. ROPlaser3. Retinaltearsorbreaks(e.g.,Horseshoetears)4. Laserbarragewhereverrequirede.g.,maculaonRD,subclinicalRD

5. ExtrafovealCNVM.

Lasersthatcanbedelayedtonextavailableappointments1. Diabeticmacularedema2. Macularedemaofothercauses.

InpatientswithDME,Antivascular endothelialgrowthfactor (VEGF) injections may be preferred over laserphotocoagulationandphotodynamictherapy(PDT)laseraswell,whereverindicated.

B.LaserdeliverymodesThere are twomodesof laserdelivery: a)Contactdeliverysystem-slit lampdeliverysystems-singlespotormultispotlaserandb)Non-contactlaserdelivery-Indirectlaserdeliverysystem (ILO). The following consensus could be reachedamongstexpertsonthepreferredmodeofdelivery:1. Prefernon-contactlaserdeliverysystemoverslitlampfornon-macularlasers

2. Ifnon-contactindirectlaserdeliverysystemisnotavailable,then multispot laser is preferred over single spot laser in order tomaketheprocessfasterwithlessernumberofsittings

3. AvoidsharingofdropssuchasParacaine1%eyedropsandprefertoinstiladropofbetadineinthecul-de-sacofthepatientaftertheremovalofthecontactlens

4. The laser contact lensesor20dioptre lens tobewashedwith soap and water after every use or dip in sodium hypochlorite(0.5%)solution.

Figure 2: (a) Patient self‑retracting her lower lid during instillation of dilator drop. (b) Using cotton tip applicator to retract lower lid

ba

Figure 3: Face shield mounted on Indirect Ophthalmoscope

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V. Intravitreal injections (IVI)The guidelines for Intravitreal injections during theseunprecedentedCOVID-19 times areonly suggestedwherehighvolumepracticeshavetousepreferences.Thesecanbemodifiedbasedonthepatientloadineachhealthcarefacilityandthepresumedtransmissibilityofthevirusintheregion.Theprioritizationofthese,asencapsulatedinTable1,canbedoneasfollows:[7-9]A.EmergentNeedforIVI(injectwithin1week)1. NeovascularAMD,PCV:New/Follow-up2. Neovascularglaucoma3. New-onsetcentralretinalveinocclusion(CRVO)withmacularedema

4. ROPrequiringIntravitrealinjectionofanti-VEGF5. ActivePDR,neverlasered,recentVitreousHaemorrhage,

These patients will need PRP too6. TreatmentnaivepatientswithPDRandmacularedemamayneedIVIfollowedbylaser.

B. UrgentNeedforIVI(injectwithin3weeks)1. DME,monocularpatient,RecentdropinVA<6/122. SevereNPDR,neverlaseredwithmacularedemaandrecentdropinVA

3. StableneovascularAMDwheretheroutineIntravitrealinjectionhasbeendeferredduetolockdown

4. CNVMonTreatandExtendregime.C.RoutineNeedforIVI(maydeferinjectionsby≥4weeks)1. StableDMEwithVA >6/12: can bemaintained onobservation, goodmetabolic control and receivesintravitrealinjectionlateron(ProtocolV)[1]

2. Branchedretinalveinocclusion(BRVO)withMacularEdema3. StableCRVOMacular Edema, having hadmultipleintravitrealinjections

4. CNVMcases,stableontreatandextend.

Inadditiontothestandardpracticesbeingfollowedinthepost-COVID-19era,fewadditionalconsiderationsare:1. All ourprotocols for Intravitreal injections shouldbe insyncwiththemeasuresbeingtakenbytheauthoritiesandthe consensus statement onpreferredpracticesduringCOVID-19pandemicbyAIOS[1,7]

2. Theinjectionsshouldbegivenwithpatientwearingamask,drapedandthepersoninjectingshouldweargown,N95,

faceshield(Personalprotectiveequipment-PPE)oraspertheirinstitute’sprotocol

3. Between the injections 10-15minutes time canbegivenduringwhichscrubbingcanhappen

4. TheinjectionsmustnotbeloadedandkeptonthetrolleyinadvanceforalltheIntravitrealinjectionsscheduledthatday

5. Duringthepre-COVID-19times,numerousinstitutionshavecreatedseparateareas(followingallnorms)forIntravitrealinjectionsintheOPDtopreventdisruptionofOTworkflow.Ifthisisnotpossible,intravitrealinjectionsshouldbegivenin the operation theatre

6. Longeractingdrugsmaybepreferred to reducehospitalvisits.

Follow-upafterintravitrealinjectionsThemainaimoffollow-upistoensurethatthepatientdoesnotdevelopanypostinjectionintraocularinflammation.Ideally,thepatientmaybecalledforreviewin24-72hours.However,intheseCOVID-19times,patientcanbeaskedtogiveacallnextday.Incasethepatientiscomfortable,he/shecanbecalledafter4-8weeksdependingonthedrugusedandthediseaseprocess.Patientshouldalsohavethefreedomtoconnectwiththehealthcarefacilityincaseofanyproblemin-between.

VI. Cleaning and maintenance of equipment and lenses: Special considerationsContact Lenses forLaser andExamination:Asmentionedpreviously,theseshouldbeavoided.Ifoneneedstousethem,thecontactsurfaceofthelenswashedwithdetergentandrunningwaterfor20secondspriortoapplyingitonthecornea,repeatingthewashingaftertheexamination.Thelenscanbedisinfectedbyimmersingthecontactsurfacein0.5%sodiumhypochloritefor10minutesafterwashing.Laserlensescanbecoveredwithclingfilmthatcanberemovedattheendofprocedure[Fig.4].

Lens for Indirect Ophthalmoscopy and slit lampbiomicroscopy: The condensing lens iswashedwith soapandwaterorwipedwith95-99.9%isopropylalcoholbetweenpatients. Please refer tomanufacturer’s instructions forsterilizationregardingthetimeofcontactandalsosomemayprohibittheuseofalcohol.Tominimizetheriskofdamagingthecondensinglens,Shanmugamet al.havemodifiedthelens

Table 1: Prioritisation list of medical retina procedures

Emergency procedures (< 1 week) Semi-emergency procedures (1-3 weeks) Elective procedures (≥ 4 weeks)

Intravitreal injections for Neovascular AMD, other CNV, PCV, Neovascular Glaucoma,. (Treat and extend to maximum interval possible).Intravitreal Injections in One Eyed patients with severe vision reduction with Diabetic or other causes of Macular EdemaActive proliferative diabetic retinopathy requiring treatment (PRP laser or intravitreal‑anti VEGF)Barrage lasers for HSTs, Macula threatening RDsLasers for extrafoveal CNVMsMalignant hypertensive retinopathyROP screening, lasers and anti‑VEGF treatment

Macular edema requiring treatmentSevere NPDR, never lasered with macular edema and recent drop in VAStable neovascular AMD where the routine Intravitreal injection has been deferred due to lock downCNVM on Treat & Extend regimeAcute CSCR

Stable Macular Edema (DME, BRVO, CRVO) on followup AntiVEGF therapyStable CNVM on followup AntiVEGF therapyChronic or stable CSCRMacular telangiectasiaStable PDR post PRPScreening for macular drug toxicityNon‑neovascular (dry) AMDLow‑risk DRScreeningRetinal DystrophiesAngioid streaksHypertensive retinopathy (non‑malignant)Choroidal Folds

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bymountingitontoacustomdesignedholderwithaclearplastic barrier at the end facing thepatient (https://www.youtube.com/watch?time_continue=1&v=BC8DCTDkcog&feature=emb_title).Thisplasticbarrierandthelensmountcanbewipedwithalcoholinbetweenexaminations.

SlitLamps,Lasers,OCTandOCTA:Protectingthelensoftheseequipmentfromdropletcontaminationcanbedonebywrappingaclingfilmoverthelens.Thesurfaceofthefilmiscleanedwithanalcoholbaseddisinfectantorischangedaftereverypatientor the lensof themachinemaybecleanedbythetechniquerecommendedbythemanufacturer.Laserfrontlenstoocanbecoveredwithclingfilmthatallowsreasonablequalityofplacementoflaserburns[Fig.5].

FundusCameras:Clingfilmcausescompromiseinimagequalityandthusfunduscamerascanbeleftuncoveredwhiletherestofthedeviceiscoveredwithclingwraptoallowformore frequentcleaning.Thecleaningof the foreheadband,chinrest,lens,thehandlesandthetablewhichcomesincontactwiththepatienthastobedonewithalcoholwipesroutinelyinbetweencases.

TouchScreenDevices:Alltouchscreendevicesalsofunctionwellwithaclingwrap

Bscanprobe:Sinceitisacontactprocedure,pleasecleantheprobewithalcoholwipesbetweenscans.Acapandmaskshouldbewornbythepatientwhiletheprocedureisbeingdonewithminimalornopatientcontact.

Electrophysiology:Cleaningofequipmentbetweenpatients,useofdisposableelectrodesandnon-contactlenstype.

VII. Paediatric retina: Special considerationsVirtually all pediatric examinations and procedures arepotentialaerosolgeneratingprocedures(AGPs),therefore

the utmost care should be takenwhilemanaging thesechildren.

Fewextraprecautionsinclude:[10,11]1. Onlyonepersonmaybeallowedtoaccompanythechildforconsultation

2. Sinceallchildrenmaynotholdamaskontheface,socialdistancingbecomesevenmoreimportant

3. ItisrecommendedtoclosetheplayingareaforchildrenintheOPDAllthesofttoysmustberemovedfromtheofficeastheycanserveaspotentialfomites[10,12]

4. ForaretinaspecialistseeingaregularOPDschedule,allchildren should be prioritised tomaximize safety andefficiency

5. Homedilationisnotencouragedinchildrenbecausetheexaminationshave tobe staggered (within thepediatricgroup)andtheremaybevariationsintheschedule

6. Older childrenwith documented ‘stable’ status canhave non-contactwide-angle extended gaze fundusphotographs (Optos/Clarus or Fundusphoto-montage)whereverpossible and itmayavoid examinationunderanaesthesia(EUA)inmanysuchpatients,dependingonphysiciandiscretion

7. Counselling theparents/otherNeonatal IntensiveCareUnit(NICU)staffmustbedoneatadistanceof6feetormore.Thiscanbeaccomplishedeitherinthesameroomorthroughtele-consultationviaintercom/videocall

8. EUAs forpatientswith ongoing care canbe scheduleddirectly in the operating room (OR) list of the treatingphysician.

VIII. ROP screeningNew Standard operating procedures (SOP)s redefiningRetinopathyofPrematuritymanagement.

UnlikeSOPs forother retinal conditions,RetinopathyofPrematurity(ROP)screeningandtreatmenthassomecriticaldifferenceswith respect to delay resulting in permanentblindnessandmedico-legalconsiderationsforfailingtoexecutethewell-definedprotocols.[12,13]

To address the issue of ROPmanagement, the IndianRetinopathyofPrematurity (iROP)Society,has formulatedguidelinesinMarch2020,[12]withthecaveatthatitisdynamicand requires to be customized for regional settings andin concurrencewith evolving guidelines for COVID-19management issuedby theGovernmentof Indiaandotherprofessionalbodies.WiththeaimofreducingthenumberofscreeningvisitsandrestrictingthemtohavethehighestyieldofdetectionofvisionthreateningROP,thefollowingmodificationtothescreeningschedulearesuggestedandsummarizedin

Figure 4: Cling film to wrap the various ophthalmic lensesFigure 5: Application of  laser without cling film (left) and with cling film (right)

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Table2.Additionally,thefollowingpointsmaybekeptinmindwhiledealingwiththesepretermbabies:1. Motherswithinfantsmustmaintainsocialdistancewhile

waiting for dilatation2. Themotherplacestheinfantonasanitizedsurfaceortableandmovesmore than6 feetbefore the teamapproachesandhandles thebaby.Theprocedure is repeated for thenextbaby.

3. During counseling, social distancing normsmust bemaintained

4. Indirectophthalmoscopywith20or28Dlensorwide-fieldROPcamerascanbeusedandsanitizedbetweenbabiesasper the standard guidelines

5. Infantspeculumanddepressorifusedmustbesingleuseorsanitized/autoclavedbetweenbabies

6. Tele-medicinemustbeencouraged.

ROPtreatmentmodificationsThemodificationstoROPtreatment(outsideearlytreatmentforROP(ETROP))duringthisperiodaredetailedinTable3.Whereverpossible,PPEprescribedbytheICMRmustbeused.

IX. Intraocular tumours and ocular metastasis1. Prior assessment of fundus photographs and imagingstudies in casesof suspectedmalignancyoranestablish

caseoftreatedintraoculartumourcanbeassessedoveravideoconsultation foran initialassessment,and therebyhelpinreducingtheconsultationtimewhenthepatientisphysicallypresentintheclinic[14-16]

2. Pa t i en t s wi th metas tas i s to the eye may beimmunocompromised.These cases shouldbe evaluatedonanindividualbasiswhileassessingtheirvisualpotentialforconsideringoculartreatment

3. Casesof intraocular lymphomamaycontinue to receivesystemic chemotherapyandbebrought in the clinic forperiodic intraocular injections.Alternately, this can bearrangedwith the local retina specialist.Also, for suchpatients, converting the treatment to external beamradiation therapy (EBRT)maybe considered.However,newpatients suspectedofvitreoretinal lymphomamustbepromptlyseen

4. EUAfornewlysuspectedretinoblastomaandenucleationforretinoblastomashallbeperformedwithinaweek

5. EUAforchildrenwithactiveretinoblastomaundergoingtreatmentmust follow continued care every 3-4weeks.Systemicchemotherapyandfocalconsolidation/localoculartreatmentcancontinue

6. EUA for childrenathigh risk for retinoblastomadue tofamily history or known RB1mutation orwith stable

Table 2: Suggested ROP follow-up guidelines by the Indian ROP Society during COVID-19 restrictions

Finding in either eye with respect to zone Next follow up Comment

Immature retina in zone 3 and zone 2 anterior

3‑4 weeks or more If the PMA is less then 34 weeks/ < 1500 grams / sick and admitted infant, consider a closer follow‑up

ROP in Zone 3 and Zone 2 anterior 3‑4 weeks Spontaneously regressing ROP can be watched

ROP in Zone 2 Posterior 2 weeks Unless associated with treatment requiring features (see below)

ROP in Zone 1 Urgent / less than a week / treat Have a low threshold for treatment

Pre‑plus Consider early treatment or early follow‑up if pupil does not dilate well and media is not clear

Individualize for each case based on the tempo of disease and PMA

Pre‑plus With good pupillary dilatation and clear media and other low risk features

Can delay the next screening by an additional 1 week from the current guidelines

Table 3: Suggested ROP treatment guidelines by the Indian ROP Society during COVID-19 restrictions

Disease Comment

Type 1 ROP (ETROP) Treat as soon as you possible, preferably on the day that screening was done. Laser recommended

Any Zone 1 disease Consider treatment as soon as possible

Aggressive Posterior ROP / Hybrid ROP Treat as soon as possible. Laser if disease is amenable. Intravitreal injections can be used, but caution to be exercised since follow‑up may be a critical issue with travel restrictions for the family

“Less than Type 1 ROP” ROP Stage 2 with pre plus, ROP Stage 3 with no or early plus, high risk for APROP (but not yet full fledged), borderline Zone 1 disease / poor pupil dilatation, unclear media with pre‑plus

Given the difficulty to closely follow‑up consider treatment a ‘little earlier’ than classical Type 1 ROP

Stage 4A and 4B ROP Surgery must be performed as soon as treating ROP specialist feels it is required with adequate precautions taken while providing anesthesia (as per prescribed guidelines)

Stage 5 ROP Surgery is not urgent. Case‑to‑case based decision must be considered.

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disease,whoreceivedtreatmentwithinthepast6monthscanbeperformedwithin1-2months

7. Intraocularinjectionofchemotherapyagentsforhigh-gradeneoplasia (e.g.,Rituximab/Methotrexate for Intraocularlymphoma)canbeperformedwithin1-2months

8. Systemic chemotherapy for adult patientswith ocularmetastasismaycontinuewiththeconsultationofmedicalOncologist.

X. Vitreo retinal (VR) surgery in post COVID eraIt is emphasized thatbestpracticeprotocols inVR surgerywillbeinfluencedbythepracticesituationofeachfacilityandsurgeon.Thesesuggestionsareadvisoryinnatureandaimtoprovidemeanstoachievesafecareinthebestmannerpossible.1. PreoperativeCOVID-19Testing:Due to thedifficultiesaroundobtainingCOVID-19tests,theyieldtimeandthepresenceofasymptomaticcarriers,itisunlikelythateveryinfectedpatientwill bedetectedpreoperatively.Hence,each surgeonandhospital administratorwouldbewelladvisedtoassumethateverysurgicalpatientisapotentialCOVID-19 spreader and the followingpracticepatternsdevolvefromthispremise.• Emergency surgeriesmay be undertakenwithoutmandatingaCOVID-19testuniversally.Averystrongsuspicion,however,basedonhistoryorsymptomsmaypromptanurgent referral to aCOVID-19designatedcenter

• DefinitivelyprovenCOVID-19 (Reverse transcriptionpolymerasechainreaction(RTPCR))positivepatientsshould not be taken for ophthalmic surgery innon-designatedCOVID-19centers

• Asymptomaticpatients,RTPCRnegativepatientsandthosewhohavenothadthetestdone–allthesepatientsaretobeconsideredaspotentiallyCOVID-19positiveandalldueprecautionsshouldbetakenduringsurgery

• Centresmay considermandating COVID-19 testspreoperativelyinpatientswhohavebeeninquarantineorhavehadpeopleintheirpremiseswhohavebeeninquarantineinthepastonemonth.

2. PrioritizationofSurgeries:Theurgencyofsurgeryshouldbeanophthalmologists’discretiontakingintoconsiderationthepatient’sclinicalsituationandtheprevalentCOVID-19zonestatusandcircumstancesatthatgiventimeintheirlocale.Needless to say, emergency caseswould takeprecedenceandhave tobeprioritized for surgeryat theearliest. Thepriority list forVR surgeries isdetailed inTable4,adaptedfromtherecentAIOS–IJOpublication.[1]

3. OperationTheaterEngineering SinceVR surgeries areprolonged, extra cautionmayberequiredasthetimeofexposuretothesurgeonandteamisprolonged.a. OTdesignationandflow:InMultispecialtyhospitals,thedesignatedsurgicalOTwillbeearmarkedbytheHospitaladministration.Inophthalmichospitalsandclinics,thefacilityshoulddesignateadonninganddoffingareaforeachOT.ThedoffingareashouldadjointheOTbutnotbeaconsiderabledistancetoavoidwalkingoutsidetheOTinpotentiallycontaminatedgarments.Thedonningofprotectivegearcouldbedoneintheusualwashingareabutwillneedadequatespace.IncaseofsurgeriesunderGA,thesurgeonshouldnotentertheOTuntilthepatientisfullystabilizedontheanesthesiacircuitandthesurgicalteamisadequatelyprotected.[17]

b. OTAirconditioning: i. It is not a practical solution to switch off air

conditioning in our environment. The consensusofthiscommitteeisthatairconditioningshouldbeoperationalduringsurgerywithincreasedrateofairexchangesandincreasedratiooffreshairmixingintheAirHandlingUnits(AHUs).NegativePressureOTsarenotconsideredmandatoryandPositivePressureOTsmaycontinuetobeusedif it isnottechnicallypossibletoconverttoanegativepressurefacility

ii. If positivepressure air-conditioning is continued,careshouldbetakentoswitchofftheair-conditioningmomentarily at times of patient entry and exit[18]

iii.NegativepressureOTscanbecreatedwithinexistingfacilities by use of damper, altering fan speedsandvarious other engineeringmodifications. It isunderstoodthatthiswillbeanadhocmodificationthatcanonlybetesteduptotheextentofasmoketesttoconfirmthepresenceofnegativepressureintheOT.Ifanexhaustsystemisadded,theexhaustedair should be expelled after passing through ahigh-efficiencyparticulateair(HEPA)filter.[19,20]

4. Patient-relatedProtocols:a. Patientsbeingoperatedshouldwearasurgicalmaskifbeingoperatedunderlocalanesthesia.Ifthepatientisuncomfortable,anydevicetokeepthedrapesawayfromthenosecanbeused.UnderGeneralanesthesia,the respiratory tract is isolated by the anesthesiacircuit.

b. It is all themore critical, in thisCOVID-19period, tomandate that 5%Povidone iodinebe instilled in theconjunctival sac 5-10minutesbefore the surgeryandalsousedforprepping.Povidoneiodineisvirucidalanddisinfectstheocularsurfaceandconjunctivalcul-de-sacin15seconds.[21]

5. Personalprotectiveequipment:a. Thedonning sequencediffers significantly from thatusedforusualPPEwearinmedicalwardsandclinics.ThechangeinsequenceisnecessitatedbytheneedtoweartheN95mask,bootcoversandgogglesbeforehandwashing,soastomaintainsterility

b. It isevident thatcoverallsaresignificantlydifficult towearinasterilemanner,thereforeitissuggestedthatGownsbeworn for surgery, alongwithN95masks,gogglesandahoodandbootcovers.Faceshieldarenoteasilycompatiblewithsurgerythroughamicroscope;therefore,gogglesarepreferredandmustbewornbeforethehoodsothatthehoodfitsnicelyaroundthegogglesanddoesnotfallovertheeyes.Ifthehoodiswornfirst,it tends to ride over the eyes and the goggles then do notpushitback.IfanyofthecomponentsofthePPEmentionedaboveareunavailable,acoverallcanbeused,and a sterile gown worn over it

c. Thedoffing sequence is almost identical to standardprotocols,butgogglescanbereusedafterdecontaminationandN95masksifreusedonthesamedaymustnotbetouchedor reworn between cases. If anN95with arespiratory valve isworn, itmaybe coveredwith asurgicalmaskwhichmayalsodecreasethecontaminationonitssurface

d. Weare aware that some institutionsmaymodify thePPEmade available to the surgical teamdepending

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upontheperceivedriskbuturgethatthisbedonewithduedeliberationafterconsideringtheconsequencesofinadequateprotection.

6. SterilizationProtocolsandRe-usePractices: Thereisnoneedtoalterconventionalpresetinstitutionalprotocols regarding sterilization of the instrumentsthat ideally should complywith themanufacturer’srecommendations.• Itispreferablenottore-sterilizeorreuseresidualsiliconeoilandperfluorocarbonliquids

• ItisadvisabletouseafreshbottleofRingerLactateorbalancedsaltsolution(BSS)/BSSPlusforeachcase

Sterile surgical consumables (trocar-cannulas, cutters,tubings,cassettes,endoilluminator,endolaserprobesetc.)tobeusedineachcaseundergoingretinalsurgeryandallprecautionstopreventcross-infectionamongstconsecutivesurgicalpatientsneedtobestringentlyfollowed

• IthasbeensuggestedthatusingUltraviolet(UV)lightfor15minutesaftercleaningtheOT,betweencases,mayhaveabeneficialeffect.

7. Surgicaltechniquemodifications:a. Draping:Itisimportanttoensurethatthedrapingisdoneproperly.Theedgeofthedrapeshouldbeadequatelyandproperlystuckaroundtheeyetocreatewatertightsealing.Thiswillminimizechancesofaerosoldispersionfrom nose and mouth

b. Post draping, the betadinemaybe instilled into theconjunctivalsacbyusingthesyringewithoutcannulatominimizeaerosolgeneration

c. Valvedvs.Non-valvedcannulas:Itispreferabletousevalvedcannulasasmuchofthefluidspillsandbubblingduringfluidairexchangemaybeavoided.Non-valvedcannulasystemcancausespillageoffluidorairoverthesurgeonandassistant(s)especiallywithIOPcontrolledmachinesorahighbottleheight.Atpresentthereisnosubstantialevidencetosuggestpresenceorabsenceofvirusinintraocularfluids.Hence,itisadvisedtoavoidorminimizecontactwithintraocularfluidasfaraspossibleandvalvedcannulasarerecommended.

• Ifavalvedcannulasystemisnotavailable,reducethe bottle height or intraocular pressure duringinstrument exchange to minimize sclerotomyleakage.

• Preferabletouseviscoelasticsoverirrigationofeyetokeepcorneawet.

• Non-contactviewingsystemstobepreferredoverthecontactsystems.

d. Diathermy:Aknownsourceofaerosolization,anystepneedingdiathermyshouldbeconsideredcarefullyandasuctiontubingusedtoevacuatethesmokefromthesurgicalfield[22]

e. ScleralBucklevs.Vitrectomy:Scleralbucklinginvolvesmoretissuecontactanddiathermyandwouldthereforebeconsideredtheoreticallymoreofanaerosolgeneratingprocedurethanvitrectomywhichtakesplaceinaclosedchamber.AtpresentthereisnosubstantialevidenceofCOVID-19transmissionthroughbloodorbodyfluids.Thechoiceofprocedureshouldbedictatedprimarilybytheeyeconditionincludingpatientageandlensstatus.Importancetobegiventotimeandminimalinterventionwhenchoicesareeven

Duringaparsplanavitrectomy,thestepsthatmeritcarearepreventionoffluidspill,preventionofhighpressurebubblingattheportsorthefluteneedleduringFluidairexchange.Thiscanbeavoidedbyusingactiveratherthanpassiveaspiration.Minimizeinstrumentexchangesasmuchaspossible

f. Experiencedsurgeonsshoulddothesurgerieswheneverpossible.Overtime,asprotocolsarecrystallized,traineesurgeonswouldbeexpectedtoalsooperate.

8. Resourcemanagementa. Duetothelonghiatusandchangedprotocols,itisnolongeradvisabletooperatemorethanonecaseatatimein one operation theatre

b. Surgicalcampsshouldbedeferred,andsurgicaltimesarelikelytobeprolongedduetothenecessitytocleananddecontaminatetheOTaftereachsurgery

c. Also,expendablesare likely toexpiredue toreducedcaseloads and fresh suppliesmaynot fructifydue tobrokensupplychains.Therefore,inventorymanagementatsuchatimeassumesimportance

d. Extraitemsmaybekeptininclosedcupboardsintheoperationtheatretoavoidacirculatingnursegoingbackandforthtotheinstrumentroom.However,thiswillneedtobebalancedwithkeepingexcessitemsintheOTwhichwillresultinalltheseextrasbeingconsideredexposed

Table 4: Prioritization of VR Surgeries

Emergency Surgeries (Few Days) Semi-emergency Surgeries (1-3 weeks) Elective Surgeries (≥ 4 weeks)

Acute retinal detachmentSuspected retinal tearsOpen globe injuries: Including IOFBAcute endophthalmitisVitreous hemorrhage (dense, requiring, vitrectomy)Dropped nucleus requiring vitrectomy/lensectomySubmacular hemorrhage requiringvitrectomyAqueous misdirection requiringvitrectomyComplex surgery post‑operative (minimize visits)Diagnostic vitrectomy for infectious or oncological causes Surgery for ROPDrainage Surgery for appositional choroidal effusions, suprachoroidal hemorrhage or flat anterior chamber

Acute full‑thickness macular holesSevere vitreomacular tractionsyndromeMyopic traction maculopathy with foveal detachmentHeavy liquid removalExposed scleral buckles at risk of infection

Epiretinal membranesSilicone oil removal (unless developing complications such as emulsification)Secondary Intraocular lens Fixation proceduresSymptomatic vitreous opacities

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andneedingdecontaminationaftertheOT.AsuggestedtechniqueistokeepalltheextraitemsinacommonZiplocbagoratransparentboxsothattheexternalsurfaceoftheboxiscleanedaftertheprocedureandeveryitemdoesnotthenneedtobeindividuallywipeddowniftheboxremainsunopenedduringthesurgery.

XI. Financial impact of new SOPsThere is a genuine fear of an increased expenditure thatwouldneed to be incurred for the new set of SOPs.Alsothe patient inflowmaydecrease due to fear of travelingor visiting thehospital, reducedfinancial resources in thepost-COVID-19economyanddecreasedhealthcarecapacity.Thiscanbeovercomebyincreasingthenumberofworkinghours to compensate for reducednumberofpatients seenper hour as per physician’s discretion, use of electronicmedicalrecordswithautomationwhereverpossible,onlineprepaymentportalandpre-registrationthroughonlineportalsorWhatsApp. The additional cost including sanitization,cleaning,providing 3-plymask topatient andPPE asperguidelinestoophthalmologistshasbeencalculatedtobeaboutRs88/patient.Thisincludesthecostofsanitizer:Rs.16/-(forpatientandattendant)+Rs.16/-forcleaninginstruments+Rs.16/-forcleaningfloorsandfomites+Rs.40/-cleaningpersonsalary.Thecostoffaceshields(variesfromRs75/-to200/-),andgoggles (100/- to 300/-) is a one time.The estimateofthe added cost canbedemystifiedand remove the fear inpeoples’minds.Thus,thepotentialextracostperpatientisanestimatedRs.88/-thatcanbeaddedtotheconsultationfeewithaddedprecautions.Thisisthenlikelytobecompletelyrevenueneutral.Theseestimatesarebeingprovidedasausefulyardstickandmaybevariable.

XII. Telemedicine and artificial intelligence (AI) for retinal disorder screening: Expanding role in post COVID-19 eraTelemedicine and artificial intelligence (AR) are two ofthe promising aspects of retina practice evolving in therecent yearswhich can provide safer alternatives overconventional examination in various case scenarios in thepostCOVID-19era.[23-29]

The utility of telemedicine has beenwell establishedfor screeningofDR,AMDandROP.[24-29] A wide variety of non-mydriaticfunduscamerashavebeeninusewithvaryingefficacyas faras imagequalityandfield is concerned.[23] In thecurrentscenario,hospitalscanpromotemoreofscreeningthrough telemedicine in order to avoid congestion andunnecessary hospital visits at tertiary eye care centers.Dependingon the available resources,hospitals can installsuitablefunduscamerasandarrangeforonlineconsultationwithretinaspecialists.Non-mydriaticultra-widefieldcameraslikeOptosorClaruscanhelpdetectawidevarietyofretinalpathologies,apartfromDR,ARMDandROP,althoughcostcanbeafactorfortheirinstallationbygeneralophthalmologists.[28] TertiaryeyecarecenterswhichlackROPscreeningthroughtelemedicinecanestablishthesamebasedonhighlysuccessfulexistingmodels.[24]

AlothasbeendoneintherecentpasttoexploretheutilityofAIinenhancingtheefficacyoftelemedicine.Conventionalmachinelearninghasfacilitatedrecognitionofabnormalitieslikemacularedema,exudates,cotton-wool,microaneurysms,neovascularizationonopticdisk, drusens andgeographic

atrophy.[27]Deep learning algorithmshavebroughthighersensitivity and specificity indiagnosing retinalpathologieswithhigheraccuracy.However,mostofthemneedvalidationinlargerpatientcohorts.[27]

Chatbot,whichusesafieldofAIcallednaturallanguageprocessing,canbeyetanotherwayofbringingAItoouraidinthecurrentscenariotoavoidtheburdenofroutinequestionsfrompatients’phonecalls,andalsotoeasethetaskoftriagingpatientswhoneedurgentvisitataretinaclinic.[29] It has the potential to resolveminor issues and complaints ofmanyretinapatients,whothenneednotmakeahospitalvisit,oncetheirqueriesareresolvedonChatbot.Itcanbedevelopedbythe individualhospitalswithappropriate technical supportonvariousavailableplatformsandcan coverawide rangeof topics, right from thevariousocular complaints sufferedby thepatient to thepossiblediagnosisand its seriousness.Italsoprovidesthenecessarypatientdetailsas thepatientsanswertothequestionnairesandthepatientscanbedirectedtoonlineconsultationorappointment,iftheneedbeso,basedontheirresponsetothequestionnaires.Consultationthroughvideo-conferencing can also be a usefulway to re-assurepost-operativepatients and routinepatientsof retina clinicwithminorissues.[1]Recently,thegovernmenthasgiventheguidelinesfortelemedicinemakingitallthemorelegalandalsoencouragingitsuseespeciallyinthiscrisisperiod.[30]

XIII. Managing uveitis in post-COVID-19 eraGeneral ophthalmologists aswell asuveitis specialists arenowfacedwiththedilemmaabouttheusageofsteroidandimmunosuppressiveagents.Therearenopublishedguidelinessofarregardingthis.ThefollowingconsensusisbeingacceptedbytheInternationaluveitisstudygroup(IUSG),InternationalOcular Inflammation Society (IOIS) and Foster OcularInflammationSociety(FOIS)havejointlyreleasedanevolvingconsensusexperiencewithuveitis at the timeofCOVID-19infection(latestversionApril3rd2020).[31]

FewspecificpointsaboutUveitismanagement:A.Anterior uveitis: Topical steroidsmay be started orcontinuedatthediscretionofthetreatingdoctor

B. Intermediateuveitis/posterioruveitis/panuveitis

1.Guidelinesforanewpatientofuveitis:• Topreferlocaltherapyintheformofposteriorsub-tenontriamcinoloneorintravitrealdexamethasoneimplantoversystemiccorticosteroids

• Intravenousmethyl prednisolone is best avoided andoneshouldpreferlocaltherapy(periocularorintravitrealsteroids) alone or in combinationwith lower doses ofsystemicsteroids

• Avoid starting high dose oral corticosteroids orimmunosuppressants in high risk patients defined as thefollowing:age≥70years,severechronic lungdisease(e.g., asthma, bronchiectasis, cystic fibrosis, chronicobstructivepulmonarydisease(COPD),etc.),severeheartdisease,CD4count<200,historyofdiabetes/hypertension/smoking/cardiovascularevent

• Anyone-eyedpatient or onewith a vision threateningcondition requiring the initiation of corticosteroids orimmunosuppressantsmaybestartedonthetreatmentatthediscretionofthetreatingdoctorandafterevaluationbyaphysician

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• Strictvigilancehastokeptonthebloodcountsofthepatientwithaspecialprecautiontomaintainwhitebloodcountiskeptabove>4000permicroliter.

2. TheCOVID-19pandemic is not a contraindication forthe initiation of immunosuppressants. Patients need tobe explained regarding the additional riskof secondaryinfectionsatthetimeofstartofthetherapyincludingthefollowingprecautions:

• Handandpersonalhygiene.• Avoidingcrowdsandworkingfromhome• Tohavethefacemaskonatalltimes• Iftheyaresickwithfever,malaisethenshouldcontacttheinfectioncontrolspecialistandifadvisedthentoconsiderstoppingthetherapy.

3. Guidelinesforuveitispatientsonmaintenancetherapya.OnCorticosteroids• Patientisstablethenonemayconsideragradualtaperandstoppingofthedrugormaintainatalowdose<10mg/day.Howeverifthereisahighriskofrecurrenceatitmightbevisionthreateningthenonemaycontinueatthesamedosage(asperthediscretionofthetreatingdoctor)

• Strictmonitoringofbloodsugarandbloodpressureisrecommended

• In case of any illness or symptoms suspicious ofCOVID-19thentobereferredtoaninfectioncontrolclinic

• In a case of recurrence, then toprefer local therapy(sub-tenonorintravitreal)oversystemiccorticosteroids.

b. OnImmunosuppressantsi. PatientwithsystemicimmunosuppressionwithoutsignofCOVID-19infectionornegativewithCOVID-19test:• IfthepatienthasbeenstableforthelasttwovisitsandonewasconsideringthestoppageofthedrugsthenitmaybedoneatthediscretionofthetreatingdoctorhowevertheydonotneedtobediscontinuedduetoCOVID-19pandemic

• Inaddition,theyshouldstrictlyfollowtheprecautionslikea)stayingathomeasmuchaspossibleb)practicesocial distancing approximately 6 feet from otherindividuals c)wearing amask d)washing handsfrequentlywith soap or alcohol based sanitizer. Ifsuchpatientsfeelsicktheyshouldcontacttheirdoctorimmediately

• Patientsonimmunosuppressantsarealreadyprimedtomonitortheirbloodcountsregularly,howeverwemayneedtoreiteratetheimportanceofthesameagain

• Strictvigilancehastokeptonthebloodcountsofthepatientwith a special precaution tomaintainwhitebloodcountiskeptabove>4000permicroliterandteleconsultationmaybeusefulforthesame

• Apatientonimmunosuppressantifdevelopssymptomssuspicious ofCOVID-19 infection, thenneeds to bereferred to infection control specialist and if they feelnecessarytostoptheongoingmedication,itmaybedoneattheirdiscretion.

ii. Patientwith systemic immunosuppression in eitherconfirmed COVID-19 infection or clinical signs’ ofCOVID-19infection• Thesepatients shouldnot bedeniedof treatment. Ifthepatient is asymptomatic, theymay continuewith

immunosuppressive agents along with monitoring of bloodcountsundertheclosemonitoringof infectiousdisease expert

• Symptomatic patients should temporarily stopimmunosuppressiveagentsorbiologics.PatientstakingantiTumornecrosisfactor(TNF)agentslikeinfliximaboradalimumabshouldomittheirnextdoseuntiltheyfullyrecovered.Insuchcaseslocaltreatmentoptionslikeintravitrealinjectionshouldbeconsidered

• I t i s to be remembered that pat ients wi thimmunosuppressive agentswill have altered bloodparameterslikedecreaseoflymphocytecount,decreasealbumin,decreasehaemoglobin, increaseC- reactiveprotein,increasederythrocytesedimentationrate(ESR),increased lactatedehydrogenase (LDH)and increaseD-dimer.

Patientsontocilizumabmaybecontinuedonthesameasitreducesthecytokinestorm.

StandardprecautionsshouldbefollowedinuveitispatientslikeotherophthalmicpatientsinthisCOVID-19pandemic.

XIV: Training of the residents, fellows and students during the COVID-19 pandemicAs training the residents andpost-graduates is oneof theintegral component ofmedicine, special attention needstobegiven to thepotentialdeficit in conventional trainingopportunitiesforthestudentsduringthisCOVID-19era.Newnormsneedtobeestablishedtotraintheresidentsandfellows.Innovativemethodsfocussedtrainingthroughwebinars,onlinedidactics, casepresentations, reviewof electronicmedicalrecordsmaybe consideredasmeansof imparting teachingandengagingstudents.

ConclusionTo conclude, ourpractices aregoing tobedifferent in thepost-COVID-19 era andwehave tomakemodifications ineveryway that suits our practice, taking the governmentregulationsandlocalrulesunderconsideration.Itisimportanttokeeptrainingthestaffonaregularbasis,sothatweareableto manage these patients in a safe environment and prevent ocularmorbidityasmuchaspossible.

AcknowledgementWewouldliketoacknowledgeAIOSgoverningCouncilDr.MahipalSachdev,ProfNamrataSharma,Dr.ParthaBiswas,Dr.ChitraRamamurthyandProfRajeshSinhafortheirhelpinformulatingtheseguidelines.

Declaration of patient consentTheauthors certify that theyhaveobtainedall appropriatepatient consent forms. In the form thepatient(s) has/havegivenhis/her/theirconsentforhis/her/theirimagesandotherclinicalinformationtobereportedinthejournal.Thepatientsunderstandthattheirnamesandinitialswillnotbepublishedanddue effortswill bemade to conceal their identity, butanonymitycannotbeguaranteed.

Financial support and sponsorshipNil.

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June2020 973Gupta, et al.: Vitreoretina and Uvea practice in COVID-19 era

Conflicts of interestTherearenoconflictsofinterest.

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