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 Table of Contents    
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 136-143  

Systematic review: SARS-COV-2 contagion prevention measures in vision health professionals

1 Institute of Ophthalmology Conde de Valenciana, Mexico City, Mexico; CAIPaDi, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
2 Centre for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, México
3 Institute of Ophthalmology Conde de Valenciana, Mexico City, Mexico
4 Department of Epidemiology, National Cancer Institute, Mexico City, Mexico

Date of Submission01-May-2021
Date of Decision21-Jun-2021
Date of Acceptance12-Aug-2021
Date of Web Publication20-Oct-2021

Correspondence Address:
Prof. Liliana Perez.Peralta
Institute of Ophthalmology Conde de Valenciana, Mexico City, Mexico, CAIPaDi, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_134_21

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The disease, which originated from the SARS-CoV-2 virus, is primarily transmitted by direct contact with infected individuals. Visual healthcare professionals perform clinical practices that pose a significant risk of infection due to their proximity with patients during the examination. This systematic review aims to identify preventive measures that will aid in reducing the risk of infection during standard appointments between patients and visual health professionals. A systematic review was done for articles published in indexed journals from December 2019 to December 2020. The search for these articles was done in 3 electronic databases. As part of the search criteria, articles were selected if they had the keywords (SARS-CoV-2), (COVID-19), and coronavirus combined with ophthalmology, optometry, eye care, and the eye. Once duplicated and unrelated items were eliminated, 36 articles of interest were selected. Seven sections were described in detail: telephone screening, (COVID-19) triage, decreasing transmission within shared spaces, hand washing, use of personal protective equipment Personal Protective Equipment (PPE), cleaning of diagnostic instruments, and use of telemedicine. This paper helps healthcare professionals to better understand the context of the “new normal” clinical practice. Visual health professionals and their patients must adhere to norms and use the indicated PPE during the consultation to safeguard each other.

Keywords: Coronavirus, COVID-19, infection prevention, ophthalmology, optometry, SARS-CoV-2, vision health professionals

How to cite this article:
Perez.Peralta L, Sauceda-Valenzuela AL, La Parra DR, Suarez-Ajoleza AA, Beauregard-Escobar AM, Torres-Dominguez JA. Systematic review: SARS-COV-2 contagion prevention measures in vision health professionals. Oman J Ophthalmol 2021;14:136-43

How to cite this URL:
Perez.Peralta L, Sauceda-Valenzuela AL, La Parra DR, Suarez-Ajoleza AA, Beauregard-Escobar AM, Torres-Dominguez JA. Systematic review: SARS-COV-2 contagion prevention measures in vision health professionals. Oman J Ophthalmol [serial online] 2021 [cited 2022 Dec 3];14:136-43. Available from: https://www.ojoonline.org/text.asp?2021/14/3/136/328599

   Introduction Top

In December 2019, there was a report of an outbreak of a new virus of the ß-coronavirus family. It was named SARS-CoV-2 and was identified as capable of infecting humans and to be transmitted from person to person.[1] When writing this article (March 18, 2021), in our country, there have been records of 3,613,590 cases for COVID-19, a death toll of 196,606 people, and an ascending tendency in the rate of confirmed cases in our country.[2] Since the virus outbreak, the risk of infection for health professionals is very clear.[3] Ophthalmologist Li Wenliang was the first to try and bring attention to what he described as “a virus with similar characteristics to SARS.”[4] Ophthalmologists and optometrists are among the professions with a higher risk of infection due to the necessary interpersonal distance required for clinical examination, direct contact with ocular surfaces,[5],[6],[7] the use of ophthalmic drops for making diagnoses supplied to several patients from the same container, and adaptation of contact lenses. The ocular spread of COVID-19 was described as less frequent but possible.[8],[9],[10],[11] Preventive measures in future ophthalmic and optometry practices carry a significant weight when it comes to avoiding nosocomial transmission once these practices are routine consultations in private offices, clinics, and hospitals are reopened under the context of the “new normal.”[12],[13]

This review aims to compile prevention practices to stop and reduce infection of COVID-19 during the day-to-day practice for visual health professionals and patients.

   Methodology Top

A systematic review was done for articles published in indexed journals from December 2019 to December 2020. The search for these articles was done in the electronic databases PUBMED, Scopus, and Biotechnology Source. As a search criterion, the articles selected had the keywords SARS-CoV-2, COVID-19, and coronavirus combined with ophthalmology, optometry, eye care, and eye. We excluded editorials, opinions of health professionals, and nonpeer-reviewed articles.

The title and abstract were reviewed to determine their relevance and the topic of this study. The study was performed under the PRISMA guidelines.

   Ethical Aspects Top

The information used for this article is public. The authors declare that they have no conflict of interest and they have not received benefits of any kind that could affect the results described. As it is a retrospective study that used secondary data sources, it does not incur in any normative aspect of medical ethics.

   Results Top

We identified 361 records through the search of electronic databases. After removing duplicate or unrelated articles, 80 articles were included, of these, 61 were discarded following their full-text read [Table 1]. Twenty-five articles were excluded. No individual or inter-study biases were identified. PRISMA flowchart shows the screening process [Figure 1].
Table 1: Review of literature to preventive measures of COVID-19

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Figure 1: Criteria for inclusion and exclusion of literature

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   Telephone Screening Top

It is recommended that service hours should be reduced, and patients' appointments rescheduled when their postponement does not pose a risk for visual loss if the social distancing strategies imposed by the health authorities of each country are still being observed.[14],[15],[16] The American Academy of Ophthalmology and the “Moorfield's Ophthalmological Risk Stratification and Implementation Guide,” offer a means of making decisions depending on the ophthalmological procedures, both urgent and nonurgent.[17]

Before an appointment, it is suggested to call patients by phone and ask a series of questions to classify the risk they pose of transmitting COVID-19:[18],[19],[20],[21]

  • Has the patient presented symptoms of COVID-19 in the last 14 days? (Fever, coughing, difficulty breathing, myalgia, anosmia, fatigue, headaches, phlegm, diarrhea, or conjunctivitis)
  • Has he been in close contact with people diagnosed or suspected of having COVID-19?
  • Has he had conjunctivitis symptoms (the most frequent ocular manifestations in COVID-19 include stinging or pain, itching, secretion, sensibility to light, and red eyes)?

A flowchart for the ophthalmic health care services is shown [Figure 2], there are three different endpoints according to the risk for infection with COVID-19 or risk of visual loss.
Figure 2: Flowchart for eye care services during COVID-19 pandemic

Click here to view

Patients with the highest risk of COVID-19 infection must be examined for their check-up in a prepared and isolated space, while personnel must wear masks, ocular protection, lab coats, and disposable gloves.[22],[23]

In addition, patients who attend their check-up in person must be informed about companion restrictions. They will only be allowed for underage patients, senior citizens who require assistance, and patients with disabilities. Both patient and companion will be screened at the COVID-19 triage.[20]

   COVID-19 Triage Top

Patients must be questioned for the presence of COVID-19 symptoms when they schedule a visit. COVID-19 triage is recommended for the detection of patients who might have COVID-19, and the relevance of their visit should be evaluated. Trained personnel from the clinic or office can carry out this procedure before the patients ultimately enter the medical space. It is necessary that the number of entries to the health center are limited to as few as possible, and professionals make use of personal protection equipment (PPE).[25],[26] Suggested questions at the COVID-19 triage are: [16],[27]

  • Have you had contact with people diagnosed with COVID-19 in the past 2 weeks?
  • Have you made an international trip in the last 2 weeks? (This information may be less relevant in cases where local transmission is the primary source of infection)
  • Have you had any of the following symptoms: Fever, dry cough, sore throat, nasal secretion, muscle pain, fatigue, headaches, diarrhea, loss of smell, loss of taste, difficulty breathing, or nausea?

In addition, body temperature is taken with noncontact thermometers (temperatures above 37.8°C are reasons for suspecting infection).[15] In case, the answers to the questions above are negative, and body temperature is <37.8°C, the patient will be admitted and must always wear a surgical mask with a minimum protection level of 1 (American Society for Testing and Materials classification), while also following hand hygiene protocol for entry.[28]

All health professionals must be screened and examined at the respiratory triage to report COVID-19 symptoms to the epidemiology service for treatment.

   Decreasing Transmission within Shared Spaces Top

To limit unnecessary contact between people, the following actions are suggested: [17],[24],[29] Reduce the number of entries into the clinic, limit them to only the ones that are strictly needed, and include a COVID-19 triage at those access points.

  • Always maintain 1–2 m between patients and health professionals, except during the examination period, at which PPE must be worn
  • Ensure that the waiting rooms have the least amount of patients as possible by delaying appointments based on the risk stratification for urgent and nonurgent procedures
  • Comply with social distancing by spacing seats in the waiting room
  • Only allow two people in the space where the medical consultation takes place (healthcare professional and patient)
  • Sterilize the air by physical or chemical methods, avoid air conditioners, and opt for natural ventilation.

The air conditioner that does not have this system must be sterilized with ultraviolet light or using any other methods.

  • Prepare an isolated space where people who are suspected of being infected with COVID-19 or conjunctivitis can be examined (even in the absence of respiratory symptoms).

The efficacy of some cleaning products against coronavirus has been proven, for example, 1.70% concentration ethanol, sodium hypochlorite (0.05–0.5), sodium chloride (0.23), povidone-iodine, glutaraldehyde, Isopropyl alcohol, benzalkonium chloride (0.05), and formaldehyde (0.7). These products disinfect surfaces effectively. Up to 70% of ethanol may be used on surfaces that could be damaged by sodium hypochlorite.[12],[26]

   Hand Washing Top

Once a suspect patient has been cleared of having COVID-19 at the (COVID-19) triage, he must disinfect his hands and be given a mask for mandatory use.[20]

It is recommended that both health professionals and patients frequently engage in hand hygiene measures. Handwashing and hand hygiene measures should be carried out for at least 20 s both before and after patient evaluation.[22],[28] The World Health Organization and The Centers for Disease Control and Prevention (CDC) consider the use of ethanol or isopropyl alcohol-based disinfectants to be effective, with the added advantage that their relatively immediate application following an activity favors the maintenance of good hand hygiene. The use of latex gloves is not a substitute for handwashing; indeed, the opposite is true, and therefore handwashing should be carried out before and after gloves are worn. Similarly, gloves should not be used for long periods of time.

   Use of Personal Protective Equipment (PPE) Top

Protective eyewear, such as goggles, face shields, safety glasses, and full-face protectors, are an effective method for preventing the ocular surface from coming into contact with droplets that patients emit when speaking sneezing, coughing, or exhaling. However, the conventional use of eyeglasses or spectacles is no substitute for goggles protection, which are not considered a form of protection against COVID-19 during a consultation.[20],[28] During the COVID-19 epidemic in China, a guideline advising the use of protective eyewear highlighted the importance of preventing them from fogging up and hindering the patient's attention due to poor visibility. Among these recommendations, the following are also highlighted:

  • To disinfect protective eyewear after each use with a solution that contains chlorine (1000–2000 mg/L), more than an hour before they are then used again
  • To use protective eyewear large enough to avoid fogging but without compromising comfort during use
  • The use of liquid soap (for domestic use) and anti-fogging spray used in swimming can also be useful to avoid fogging during extensive use.

The use of N95 masks in high-risk scenarios (direct contact with COVID-19 suspected or confirmed patients) is recommended by the WHO. It is reported that asymptomatic and presymptomatic patients may spread SARS-Cov-2 to healthy individuals. Thus, universal use of surgical masks is recommended since they can filter up to 98% of particles.[26] A different scenario takes place when aerosols are produced (e.g. Air tonometry, general anesthesia in surgical procedures, vitrectomy, phacoemulsification, oncology ocular surgeries, and nasolacrimal duct surgery),[30] where only N95 masks protect sufficiently enough against these particles. N95 masks must be replaced regularly with maximum use of 3 consecutive days.[31] In ophthalmic and optometric care, the use of surgical or N95 masks is one of the most effective actions to prevent the spread of COVID-19. The use of a particular mask will depend on the procedure to be performed,[32] the confirmation of COVID-19 and the rate of virus spread at each country (if the spreading rate is high, patients should be considered positive until proven otherwise).[3]

Patients must be reminded that the use of medical masks is mandatory in spaces where medical consultation takes place (cloth masks do not protect in hospital settings and increase the risk of infection versus surgical masks or N95 respirators).[33],[34] In cases in which the mask does not offer sufficient protection, the hospital or clinic must be ready to provide extra protection to subjects.[29]

   Considerations in the Use and Cleaning of Diagnostic Instruments Top

The survival period of (SARS-CoV-2) varies depending on the material on which it is found. Due to possible transmission via fomites, surfaces, and diagnostic instruments must be disinfected immediately after use using ethanol and isopropyl alcohol-based products (or similar) in concentrations of between 60% and 80%.[22],[29],[35] Similarly, it is recommended that direct ophthalmoscopy is avoided. The use of an ICare or Goldmann tonometer in which disposable tips can be used or reuse implies cleaning using an alcohol solution of 70%.[15] Air tonometers should be avoided as the “shot” of air against the lacrimal film produces micro-aerosols (a collection of smaller droplets in the air). These particles remain suspended in the air for up to 3 h.[16] Diagnostic lenses which come into direct contact with the eye's surface can be disinfected in a solution of diluted bleach 1:10 with sodium hypochlorite or hydrogen peroxide at 3% for at least 5 min.[31]

The distance between the patient and examiner during examination using a slit lamp is approximately 50 cm. As a result, the use of specially adapted protective, transparent screens alongside the use of masks and constant handwashing is suggested.[36] Limited use of slit lamp is recommended. They should only be used when essential, and patients and examiners must avoid speaking during the procedure (regardless of whether they are using masks or not) to prevent the spread of respiratory particles.[15],[26] Just as with all equipment, protective screens must be constantly disinfected to prevent them from becoming a fomite.[37]

When assessing visual acuity, it is recommended that eye occluders are either disposable or exhaustively cleaned after being used by patients. The application of ophthalmic drops for diagnostic use must be performed using gloves, and preferably, single-dose products should be used. When multi-dose drops are used on patients with a suspected or confirmed diagnosis of COVID-19, they must be disposed of after use.[27]

   Use of Telemedicine Top

During the period in which the greatest number of COVID-19 cases were active, certain visual health appointments were restricted to emergencies. During the pandemic, the use of online platforms by hospitals was formulated with the following objectives: To provide continuity in ophthalmological and optometric care; to carry out phone screening of COVID-19 (as previously mentioned); to detect urgent eye conditions in need of urgent face-to-face examination and to alert patients to the mandatory use of masks before attending a consultation.[29],[39]

The remote care scheme reduces the risk of cross-contamination between healthcare professionals and patients during clinical or administrative patient care (such as the renewal of prescriptions). During the pandemic, some of the most frequent eye conditions reported by the remote consultation have been nonurgent inflammatory conditions found on the ocular surface (43.3%) and eyelids (36.1%).[40]

Advances in telemedicine have emerged as an option that enables the evaluation of clinical tests such as visual acuity and visual field tests and ocular surface and fundus photography in which virtual platforms enable the examiner to obtain test results at the same time as the consultation. Williams and colleagues[18] have recently reported that only 61.4% of patients manage to complete the necessary tests due to their lack of willingness to use the platform at the time of the virtual appointment.[41] In addition, elements related to the age of patients (older adults may face greater difficulty in engaging with this type of medical virtual appointment) and access to a smartphone, a computer, or Internet at home for those with limited resources must be recognized as obstacles to the healthcare system that need to be overcome.

   Discussion Top

Diverse institutions and researchers have shown their experiences in hospitals and clinics, as well as their protocols for preventing COVID-19 infection. The number of these publications is vast and growing; this study's strength is that we compile in a systematic review the most relevant information published during last year. We included the three main topics related to the SARS-CoV-2 contagion preventive measures in vision health professionals:

  1. Medical consultations should be conducted based on the risk of visual loss and suspicion or a high risk of contracting COVID-19. Authors like Hu and Lai[14],[16] suggest face-to-face visits only on those necessary cases and to classify visits according to the risk. Our group suggests extreme protection when transmission rates are high even in the absence of symptoms. Additionally, recommendations will change in response to new information. This is dependent on the regulatory provisions and the specific epidemiological moments of different countries (example. community transmission is relevant to pose the highest risk of infection during our practice consultation)
  2. Patients can be in several places before their visit (during their commute to the clinic, in the waiting room, the reception desk, and other surfaces), which increases the risk of infection; therefore, Soumen and Shabto et al.,[26],[35] recommend cleaning surfaces after each patient's examination. Disinfection of medical equipment should be scheduled and frequent. Spaces such as waiting rooms, restrooms, desks with computers, and chairs may be an essential source of transmission
  3. Hygiene measures and the use of PPE should be adopted during the consultation of vision health professionals. Tang et al. and Lam et al.[30],[31] recommend the universal use of surgical or KN95 masks to prevent SARS-CoV-2 infection in eye care services. However, if PPE is scarce, it is suggested to implement CDC recommendations to increase the time a mask can be used (surgical or KN95) when necessary.

An essential limitation of this article is that 73% of the papers included are descriptive. This fact is inherent to the sudden start of the pandemic and the urgent need of collecting the experience from different countries, the experts' opinion, and recommendations of international organizations in decreasing the transmission of the virus in the practice of health care professionals.

This methodology has the disadvantage of not being capable of measuring the real impact of preventive measures. It also has the inconvenience of proposing measures that may not apply to all countries.[38] One example is telemedicine's use to avoid transmission in places where telecommunications are not available, Scanzera et al. and col.[41] also conclude that one of the most significant challenges to remote care in the context of a pandemic is social and economic inequality among the population in need of eye care.

The present pandemic will continue to be a public health problem for the months to come. The pandemic requires responsible habits from the general population and health professionals to prevent further cases. It is possible that over time the recommendations mentioned above will change in response to new information or that new recommendations will also emerge. This depends on the regulatory provisions and the specific epidemiological situation of the country.

Vaccination among healthcare professionals is common in many countries.[42] This population is a priority group in the vaccination programs worldwide.[43],[44] Other novel problems are the low availability of vaccines and the rejection of some social groups towards vaccination.[45],[46],[47]

Vaccination against COVID-19 is a cost-effective measure for the control of the pandemic.[48] It is essential that besides the vaccination of health care professionals, preventive measures and protocols are kept active in the “new normal” era since new COVID-19 variants represent a potential risk.[49] Further information about vaccination may change actual recommendations.

   Conclusions Top

SARS-CoV-2 infection may continue over the following months and even years. Preventative measures in visual health professionals are necessary to limit the infection risk. This systematic review contributes to the already existing information and aims to help healthcare professionals to better understand the context of the “new normal” within their clinical practice. Unquestionably, eye care professionals must establish norms and adapt on how to use personal protection equipment during the visual consultation to safeguard themselves and third parties following recommendations derived from available scientific evidence.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1]


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