BACKGROUND:The use of web-based search and social media can help identify epidemics, potentially earlier than clinical methods or even potentially identifying unreported outbreaks. Monitoring for eye-related epidemics, such as conjunctivitis outbreaks, can facilitate early public health intervention to reduce transmission and ocular comorbidities. However, monitoring social media content for conjunctivitis outbreaks is costly and laborious. Large language models (LLMs) could overcome these barriers by assessing the likelihood that real-world outbreaks are being described. However, public health actions for likely outbreaks could benefit more by knowing additional epidemiological characteristics, such as outbreak type, size, and severity. OBJECTIVE:We aimed to assess whether and how well LLMs can classify epidemiological features from social media posts beyond conjunctivitis outbreak probability, including outbreak type, size, severity, etiology, and community setting. We used a validation framework comparing LLM classifications to those of other LLMs and human experts. METHODS:We wrote code to generate synthetic conjunctivitis outbreak social media posts, embedded with specific preclassified epidemiological features to simulate various infectious eye disease outbreak and control scenarios. We used these posts to develop effective LLM prompts and test the capabilities of multiple LLMs. For top-performing LLMs, we gauged their practical utility in real-world epidemiological surveillance by comparing their assessments of Twitter/X, forum, and YouTube conjunctivitis posts. Finally, human raters also classified the posts, and we compared their classifications to those of a leading LLM for validation. Comparisons entailed correlation or sensitivity and specificity statistics. RESULTS:We assessed 7 LLMs for effectively classifying epidemiological data from 1152 synthetic posts, 370 Twitter/X posts, 290 forum posts, and 956 YouTube posts. Despite some discrepancies, the LLMs demonstrated a reliable capacity for nuanced epidemiological analysis across various data sources and compared to humans or between LLMs. Notably, GPT-4 and Mixtral 8x22b exhibited high performance, predicting conjunctivitis outbreak characteristics such as probability (GPT-4: correlation=0.73), size (Mixtral 8x22b: correlation=0.82), and type (infectious, allergic, or environmentally caused); however, there were notable exceptions. Assessing synthetic and real-world posts for etiological factors, infectious eye disease specialist validations revealed that GPT-4 had high specificity (0.83-1.00) but variable sensitivity (0.32-0.71). Interrater reliability analyses showed that LLM-expert agreement exceeded expert-expert agreement for severity assessment (intraclass correlation coefficient=0.69 vs 0.38), while agreement varied by condition type (κ=0.37-0.94). CONCLUSIONS:This investigation into the potential of LLMs for public health infoveillance suggests effectiveness in classifying key epidemiological characteristics from social media content about conjunctivitis outbreaks. Future studies should further explore LLMs' potential to support public health monitoring through the automated assessment and classification of potential infectious eye disease or other outbreaks. Their optimal role may be to act as a first line of documentation, alerting public health organizations for the follow-up of LLM-detected and -classified small, early outbreaks, with a focus on the most severe ones.

PRÉCIS:This cross-sectional survey study evaluated the current treatment preferences of US glaucoma specialists for open angle glaucoma, finding that most preferred selective laser trabeculoplasty over topical medications for treatment-naive patients with ocular hypertension and open angle glaucoma. PURPOSE:To describe US glaucoma specialists' preferences regarding the use of selective laser trabeculoplasty (SLT) versus topical glaucoma medications for the treatment of open angle glaucoma. METHODS:Actively practicing glaucoma specialists from the American Glaucoma Society were invited to participate in a survey assessing treatment preferences and influencing factors. Multivariable logistic regressions were performed to determine predictors of preference for SLT. RESULTS:Of 136 eligible respondents, 65%-71% preferred SLT for treatment-naive patients with ocular hypertension, mild-to-moderate primary open angle glaucoma (POAG), pseudoexfoliation glaucoma, or pigmentary glaucoma. For mild-to-moderate POAG on one medication, 75% of respondents favored SLT. For advanced POAG on maximum medical therapy, 57% of respondents favored surgery and 38% preferred SLT. Respondents indicated that reducing medication nonadherence (93%), suitable glaucoma type or stage (88%), and experience performing SLT (83%) were key facilitators in recommending SLT to their patients. In contrast, patients' inability to position for the procedure (78%), unsuitable glaucoma type or stage (67%), and comorbidities or contraindications to SLT (55%) were primary reasons to not recommend SLT. Physicians in private practice, those who completed fellowship training more recently, and those who see more treatment-naive glaucoma patients were significantly more likely to prefer SLT over medication. CONCLUSION:The majority of US glaucoma specialists report a preference for SLT over medication for open angle glaucoma treatment, demonstrating that acceptance of SLT has increased over the past several years, especially for treatment-naïve patients. Statistically significant predictors of SLT preference were practice setting, practice duration, and patient volume.

Conjunctivitis outbreaks can herald pandemics. However, their relationships with weather and air pollution factors are not well understood. Kathmandu in Nepal has defined wet–dry seasons and lies in a bowl-shaped valley that traps air pollutants with levels many-folds higher than recommended by World Health Organization (WHO). From 2021 to 2023, we collected conjunctival samples from patients with presumed infectious conjunctivitis in Kathmandu, Nepal, for pathogen identification. With publicly available weather and air quality databases, we assessed the relationship between environmental factors and the prevalence of different pathogen types by performing binary logistic regression model building and cosinor regression analysis. High precipitation was associated with an increased odds of RNA virus infection (odds ratio [OR] = 1.82; 95% CI = 1.24–2.72; P = 0.003), whereas higher ozone levels were associated with decreased odds of RNA virus infections (OR = 0.46; 95% CI = 0.29–0.69; P <0.001). The odds of bacterial infection increased 4.2-fold for every 1 SD µ g/m 3 increase in ozone (SD = 11 µ g/m 3 ; 95% CI = 1.75–11.67; P <0.001), and the odds of fungal infection increased 1.62-fold for every 1 SD µ g/m 3 increase in nitric oxide (SD = 0.97 µ g/m 3 ; 95% CI = 1.02–2.49; P = 0.041). Cases associated with different taxa peaked at different times: pre-monsoon season for bacteria, during monsoon season for RNA viruses, and post-monsoon season for fungi. Our results suggest the importance and varying influence of local climate and air quality conditions on the etiology of conjunctivitis.

High-quality evidence regarding suppressive valacyclovir treatment in herpes zoster ophthalmicus (HZO) is necessary to guide care. To determine whether suppressive valacyclovir compared with placebo delays the occurrence of new or worsening stromal keratitis (SK), endothelial keratitis (EK), iritis, or dendriform epithelial keratitis (DEK) during 12 months of treatment and if treatment benefit persisted at 18 months (secondary end point). The Zoster Eye Disease Study (ZEDS) was a randomized clinical trial conducted in 95 sites from November 2017 to June 2024. Immunocompetent, nonpregnant adults with a history of an HZO rash, documented active keratitis or iritis within 1 year, and an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater were eligible. After determined to be eligible, participants were randomized in 4 strata: age at onset (<60 years vs ≥60 years) and disease duration (<6 months vs ≥6 months). A total of 12 months of double-masked daily valacyclovir, 1000 mg, or placebo. The primary outcome was time to first occurrence within 12 months of new or worsening SK, EK, iritis, or DEK. A total of 527 participants (median [IQR] age, 60 [50-68] years; 266 female [50.5%]; 266 in the valacyclovir group; 261 in the placebo group) were randomized in 4 strata; 481 completed 12 months, and 460 completed 18 months. Data were analyzed by intention to treat. At 12 months, primary end points occurred in 86 participants (33%) assigned to placebo and 74 (28%) assigned to valacyclovir, and at 18 months in 104 participants (40%) assigned to placebo and 86 (32%) assigned to valacyclovir. The hazard ratio (HR) of the primary end point at 12 months was 0.77 for participants taking valacyclovir vs placebo (HR, 0.77; adjusted 95% CI, 0.56-1.05; P = .09) and 0.73 at the secondary end point at 18 months (HR, 0.73; adjusted 95% CI, 0.55-0.97; P = .03). There was a reduction of multiple other secondary end points at 12 months (HR, 0.70; 95% CI, 0.52-0.95; P = .02) and 18 months (HR, 0.72; 95% CI, 0.55-0.95; P = .02). Although the primary outcome did not show a benefit of suppressive valacyclovir treatment, secondary study outcomes showed treatment superiority at the 18-month end point and reduced number of multiple episodes of keratitis or iritis at both 12 and 18 months. These results support consideration of 1 year of suppressive valacyclovir treatment for HZO. ClinicalTrials.gov Identifier: NCT03134196

In ophthalmic practices in the Intelligent Research in Sight (IRIS) Registry, 1.6% of eyes with viral anterior uveitis underwent anterior chamber paracentesis. When performed, anterior chamber paracentesis was associated with a change in diagnosis in 42% of cases.

Purpose. To identify weather variables associated with pathogens contributing to infectious conjunctivitis globally. Methods. Sample collection and pathogen identification from patients with acute infectious conjunctivitis was performed from 2017 to 2023. We linked pathogens identified from 13 sites across 8 countries with publicly available weather data by geographic coordinates. Mixed effects logistic regression analysis was performed to estimate the associations between temperature, precipitation, and relative humidity exposures, and the prevalence of infection types (RNA virus, DNA virus, bacteria, and fungus). Results. In total, 498 cases from the United States, India, Nepal, Thailand, Burkina Faso, Niger, Vietnam, and Israel were included in the analysis. The 8-day average precipitation (mm) was associated with increased odds of RNA virus infection (odds ratio [OR] = 1.47, 95% confidence interval [CI]: 1.12 to 1.93, P = .01) and decreased odds of DNA infection (OR = 0.62, 95% CI: .46 to .82, P < .001). Relative humidity (%) was associated with increased odds of RNA virus infections (OR = 2.64, 95% CI: 1.51 to 4.61, P < .001), and fungal infections (OR = 2.35, 95% CI: 1.19 to 4.66, P = .01), but decreased odds of DNA virus (OR = 0.58, 95% CI: .37 to .90, P = .02) and bacterial infections (OR = 0.42, 95% CI: .25 to .71, P < .001). Temperature (degrees C) was not associated with ocular infections for any pathogen type. Conclusions. This study suggests that weather factors affect pathogens differently. Particularly, humidity and precipitation were predictors for pathogens contributing to conjunctivitis worldwide. Additional work is needed to clarify the effects of shifts in weather and environmental factors on ocular infectious diseases.

Importance:Infectious conjunctivitis can lead to corneal involvement and result in ocular morbidity. The identification of biomarkers associated with corneal involvement has the potential to improve patient care. Objective:To identify biomarkers in patients with acute infectious conjunctivitis. Design, Setting, and Participants:This cross-sectional study took place from December 2016 to March 2024. Analyses were performed in 3 phases. First, logistic regression and machine learning algorithms were used to predict the probability of demonstrating corneal involvement in patients with presumed infectious conjunctivitis. Second, quantitative reverse transcription polymerase chain reaction (RT-qPCR) was used to confirm the most important biomarker gene identified by the algorithm. Third, the biomarker gene was validated in prospectively collected conjunctival samples of adult patients from 3 outpatient centers in Thailand and 1 in India. Patients with signs and symptoms of infectious conjunctivitis and onset within less than 14 days were eligible. Exclusion criteria were the inability to consent, presumed toxicity, or allergic conjunctivitis. Exposures:Acute infectious conjunctivitis. Main Outcomes and Measures:The identification and validation of ocular surface gene expression associated with corneal findings on slitlamp examination. Results:Thirteen genes exhibited a 1.5-log2 fold change in expression in patients with corneal involvement compared to patients without corneal involvement. Using the 13 genes to train and cross validate, logistic regression produced the highest mean area under the receiver operating characteristic curve (AUROC; 0.85; 95% CI, 0.84-0.86) for corneal involvement. The removal of apolipoprotein E (APOE) from the gene ensemble led to a decline in predictive performance of the logistic regression classifier (from mean AUROC 0.85 [95% CI, 0.84-0.86] to 0.74 [95% CI, 0.73-0.75]; adjusted P = .001 [Tukey test]). Orthogonal testing of APOE expression level with RT-qPCR showed that APOE expression was higher in patients with corneal involvement compared to patients without (median [IQR], 0.23 [0.04-0.47] vs 0.04 [0.02-0.06]; P = .004 [Mann-Whitney U test]). Using a Youden index of 0.23 Δ threshold cycle, APOE had a sensitivity of 56% (95% CI, 33-77) and a specificity of 88% (95% CI, 79-93) in 106 samples with conjunctivitis at Aravind, India (P < .001 [Fisher exact test]). When applied to a different patient population in Thailand, the same criteria could discriminate between disease states (58 samples; sensitivity, 47%; 95% CI, 30-64 and specificity, 93%; 95% CI, 77-99; P = .001 [Fisher exact test]). Conclusions and Relevance:The results from this study suggest that the host conjunctival immune response can be meaningfully interrogated to identify biomarkers for ocular surface diseases.

Abstract Background Healthcare restrictions during the COVID-19 pandemic, particularly in ophthalmology, led to a differential underutilization of care. An analytic approach is needed to characterize pandemic health services usage across many conditions. Methods A common analytical framework identified pandemic care utilization patterns across 261 ophthalmic diagnoses. Using a United States eye care registry, predictions of utilization expected without the pandemic were established for each diagnosis via models trained on pre-pandemic data. Pandemic effects on utilization were estimated by calculating deviations between observed and expected patient volumes from January 2020 to December 2021, with two sub-periods of focus: the hiatus (March-May 2020) and post-hiatus (June 2020–December 2021). Deviation patterns were analyzed using cluster analyses, data visualizations, and hypothesis testing. Results Records from 44.62 million patients and 2455 practices show lasting reductions in ophthalmic care utilization, including visits for leading causes of visual impairment (age-related macular degeneration, diabetic retinopathy, cataract, glaucoma). Mean deviations among all diagnoses are 67% below expectation during the hiatus peak, and 13% post-hiatus. Less severe conditions experience greater utilization reductions, with heterogeneities across diagnosis categories and pandemic phases. Intense post-hiatus reductions occur among non-vision-threatening conditions or asymptomatic precursors of vision-threatening diseases. Many conditions with above-average post-hiatus utilization pose a risk for irreversible morbidity, such as emergent pediatric, retinal, or uveitic diseases. Conclusions We derive high-resolution insights on pandemic care utilization in the US from high-dimensional data using an analytical framework that can be applied to study healthcare disruptions in other settings and inform efforts to pinpoint unmet clinical needs.

Background Studies suggest diurnal patterns of occurrence of some eye conditions. Leveraging new information sources such as web-based search data to learn more about such patterns could improve the understanding of patients’ eye-related conditions and well-being, better inform timing of clinical and remote eye care, and improve precision when targeting web-based public health campaigns toward underserved populations. Objective To investigate our hypothesis that the public is likely to consistently search about different ophthalmologic conditions at different hours of the day or days of week, we conducted an observational study using search data for terms related to ophthalmologic conditions such as conjunctivitis. We assessed whether search volumes reflected diurnal or day-of-week patterns and if those patterns were distinct from each other. Methods We designed a study to analyze and compare hourly search data for eye-related and control search terms, using time series regression models with trend and periodicity terms to remove outliers and then estimate diurnal effects. We planned a Google Trends setting, extracting data from 10 US states for the entire year of 2018. The exposure was internet search, and the participants were populations who searched through Google’s search engine using our chosen study terms. Our main outcome measures included cyclical hourly and day-of-week web-based search patterns. For statistical analyses, we considered P<.001 to be statistically significant. Results Distinct diurnal (P<.001 for all search terms) and day-of-week search patterns for eye-related terms were observed but with differing peak time periods and cyclic strengths. Some diurnal patterns represented those reported from prior clinical studies. Of the eye-related terms, “pink eye” showed the largest diurnal amplitude-to-mean ratios. Stronger signal was restricted to and peaked in mornings, and amplitude was higher on weekdays. By contrast, “dry eyes” had a higher amplitude diurnal pattern on weekends, with stronger signal occurring over a broader evening-to-morning period and peaking in early morning. Conclusions The frequency of web-based searches for various eye conditions can show cyclic patterns according to time of the day or week. Further studies to understand the reasons for these variations may help supplement the current clinical understanding of ophthalmologic symptom presentation and improve the timeliness of patient messaging and care interventions.

Background Recurrent conjunctivitis epidemics are prevalent worldwide. Aetiologies are often undetermined. Methods We surveyed conjunctivitis researchers about perceived trends in prevalence, incidence and aetiologies of conjunctivitis epidemics. Results Of the 155 participants, 7% endorsed globally variable and dynamic microbial aetiologies of conjunctivitis epidemics. Increased incidence of conjunctivitis epidemics over the last decade were reported by 21% of respondents. Peak seasons differed between the northern and southern hemispheres. Conclusions There is regional equipoise regarding the increasing incidence and emerging underlying aetiologies of epidemic conjunctivitis. Further investigation of global surveillance and microbial characterization of conjunctivitis outbreaks could improve prevention and outcomes.

PURPOSE:To describe a unique case of LASIK flap fungal keratitis confirmed by next generation sequencing.OBSERVATIONS:A 56-year-old female presented with refractory keratitis involving her LASIK flap 21 years after surgery. Confocal was positive for filamentous structures. The patient underwent immediate flap amputation followed by topical antifungal treatment. Corneal culture was positive for Acremonium sp. Metagenomic deep sequencing confirmed Acremonium as the primary source of infection and also identified Fusarium as a likely contributor of a mixed fungal infection. Sequencing also identified hay as the likely source of the infection. Treatment resulted in eradication of the infection. The patient's final best corrected visual acuity was 20/30 with rigid contact lens overrefraction.CONCLUSIONS:Metagenomic deep sequencing is a novel diagnostic tool that is increasingly being utilized for diagnosis of refractory keratitis. This case demonstrates the diagnostic potential of deep sequencing for identifying post-LASIK keratitis and reinforces the utility of LASIK flap amputation in the setting of tectonic flap instability due to keratolysis.IMPORTANCE:This case highlights several important clinical points for treating LASIK flap keratitis and highlights the emerging role metagenomic sequencing has in the diagnosis of infectious keratitis. This is first known case using next generation sequencing to diagnose a post-LASIK infectious keratitis.

It has been more than 18 months since the first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was reported in December 2019. The coronavirus disease 2019 (COVID-19) pandemic remains ongoing, with more than 150 million cases and 3 million deaths worldwide.1World Health OrganizationWHO coronavirus (COVID-19) dashboard.https://covid19.who.int/tableDate: 2021Google Scholar COVID-19 has had a significant impact on health care, the economy, and society. Clearly, COVID-19 poses a significant risk to ophthalmologists and patients, and disrupts the routine delivery of ophthalmic care. The initial response to the pandemic involved the cessation of all nonurgent ophthalmic services; the American Academy of Ophthalmology released a statement recommending this on March 18, 2020. This temporary cessation was intended to preserve scarce personal protective equipment and to reduce the risk of transmission of the virus. As it became apparent that the pandemic was going to persist, along with the ever-present need to provide timely ophthalmic care for patients at risk of visual morbidity, the American Academy of Ophthalmology called for the careful and calibrated reopening of ophthalmic care approximately 1 month later. Around the world, most ophthalmic institutions followed similar patterns, with initial closures followed by careful reopening of services in subsequent months. At the time, some early reports of conjunctivitis occurring in COVID-19 infection appeared, and a few reports of SARS-CoV-2 RNA detected from ocular secretions of these patients also appeared.2Xia J. Tong J. Liu M. et al.Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection.J Med Virol. 2020; 92: 589-594Crossref PubMed Scopus (830) Google Scholar, 3Chen L. Liu M. Zhang Z. et al.Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease.Br J Ophthalmol. 2020; 104: 748-751Crossref PubMed Scopus (265) Google Scholar, 4Guan W.-J. Ni Z.-Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (19775) Google Scholar This limited, but concerning, information on the potential risk of COVID-19 transmission via the eye, and the lack of clear consensus guidelines, resulted in a large variation in practice patterns among ophthalmic practices globally. We published an editorial in May 2020 surveying risk mitigation strategies to prevent COVID-19 transmission in various ophthalmic practices around the world.5Olivia Li J.-P. Shantha J. Wong T.Y. et al.Preparedness among Ophthalmologists: during and beyond the COVID-19 pandemic.Ophthalmology. 2020; 127: 569-572Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar At the time, it was unclear how long the COVID-19 pandemic would last. More than one year later, it is clear that the pandemic will persist beyond 2021, but there have also been significant new developments in the fight against COVID-19. Therefore, we provide herein an updated review of practice patterns across a diversity of ophthalmic clinics and institutions globally, to better inform risk mitigation measures around the world. The most significant development in the last year has been the successful development of effective vaccines against the virus. The BNT162b2 mRNA vaccine developed by Pfizer and BioNTech SE was the first vaccine against COVID-19 approved for emergency use by the Medicines and Healthcare Products Regulatory Agency in the United Kingdom on December 2, 2020, and by the Food and Drug Administration in the United States on December 11, 2020.6Polack F.P. Thomas S.J. Kitchin N. et al.Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine.N Engl J Med. 2020; 383: 2603-2615Crossref PubMed Scopus (8969) Google Scholar Multiple other vaccines against COVID-19 have been approved since for emergency use and are in use worldwide. To date, more than 1.4 billion doses of COVID-19 vaccines have been delivered worldwide.1World Health OrganizationWHO coronavirus (COVID-19) dashboard.https://covid19.who.int/tableDate: 2021Google Scholar Achieving widespread vaccination is seen as a key pillar in the overall strategy to combat the pandemic.7World Health OrganizationCOVID-19 strategic preparedness and response plan.https://www.who.int/publications/i/item/WHO-WHE-2021.02Date: 2021Google Scholar Nevertheless, the relative scarcity of COVID-19 vaccines and unequal access to vaccination programs have resulted in a significant geographic variation in population vaccination rates worldwide. Furthermore, local COVID-19 incidence and transmission are dependent on a multitude of factors, including vaccination rates, public health control measures, social distancing restrictions, and international travel patterns, along with other as-yet unknown factors. This has also led to a significant geographic variation in the incidence of COVID-19 in different countries—with numbers of new COVID-19 cases reported over 7 days per 100 000 population varying from 0 in some countries, to more than 1000 in others.1World Health OrganizationWHO coronavirus (COVID-19) dashboard.https://covid19.who.int/tableDate: 2021Google Scholar Therefore, health care systems in certain countries, such as India, were recently overwhelmed by surges in COVID-19 cases, resulting in widespread shortages in hospital beds and oxygen supply, whereas other countries, such as Israel, have (at the time of writing) returned primarily to non-COVID-19 patient care and are currently almost going about “business as usual.” Nevertheless, even in countries with currently low levels of COVID-19 incidence, the possibility of resurgent waves of infection exists. More recently, the emergence of new COVID-19 variants has threatened to derail some of the progress made toward gaining control over the pandemic. Some new COVID-19 variants are more transmissible, whereas early data suggest that current vaccines may have minimally reduced rates of efficacy against these variants.8Boehm E. Kronig I. Neher R.A. et al.Novel SARS-CoV-2 variants: the pandemics within the pandemic.Clin Microbiol Infect. 2021; 27: 1109-1117Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar,9Abu-Raddad L.J. Chemaitelly H. Butt A.A. National Study Group for COVID-19 VaccinationEffectiveness of the BNT162b2 Covid-19 vaccine against the B.1.1.7 and B.1.351 variants.N Engl J Med. 2021; 385: 187-189Crossref PubMed Scopus (636) Google Scholar The impact of these variants on ocular transmission remains unclear. Design of new vaccines and updates to current vaccines are thought to be important strategies to deal with emerging dominant variants, in addition to potentially achieving herd immunity. Initial case reports of conjunctivitis occurring as a feature of COVID-19, and SARS-CoV-2 RNA being detected in ocular secretions, led to early recommendations for eye protection with goggles or shields for health care providers examining patients.2Xia J. Tong J. Liu M. et al.Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection.J Med Virol. 2020; 92: 589-594Crossref PubMed Scopus (830) Google Scholar,3Chen L. Liu M. Zhang Z. et al.Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease.Br J Ophthalmol. 2020; 104: 748-751Crossref PubMed Scopus (265) Google Scholar Since then, larger series have confirmed that bilateral follicular conjunctivitis is the most common ocular manifestation of COVID-19, with isolated reports of other, much rarer, manifestations, including hemorrhagic or pseudomembranous conjunctivitis, keratitis, and retinal abnormalities.10Jevnikar K. Jaki Mekjavic P. Vidovic Valentincic N. et al.An update on COVID-19 related ophthalmic manifestations.Ocul Immunol Inflamm. 2021 Apr 7; (Online ahead of print): 1-6https://doi.org/10.1080/09273948.2021.1896008Crossref PubMed Scopus (26) Google Scholar Various published series have reported the prevalence of conjunctivitis in COVID-19, with a typical range being from 0% to 8%.4Guan W.-J. Ni Z.-Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (19775) Google Scholar,11Aiello F. Gallo Afflitto G. Mancino R. et al.Coronavirus disease 2019 (SARS-CoV-2) and colonization of ocular tissues and secretions: a systematic review.Eye (Lond). 2020; 34: 1206-1211Crossref PubMed Scopus (79) Google Scholar,12Zhou Y. Duan C. Zeng Y. et al.Ocular findings and proportion with conjunctival SARS-COV-2 in COVID-19 patients.Ophthalmology. 2020; 127: 982-983Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar One study reported ocular involvement in 31.6% of COVID-19 patients, but this high prevalence rate is a far outlier and likely related to cohort selection, because the study included only hospitalized, mostly ill patients, without a corresponding control group.13Wu P. Duan F. Luo C. et al.Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China.JAMA Ophthalmol. 2020; 138: 575-578Crossref PubMed Scopus (876) Google Scholar A recent meta-analysis provided an overall prevalence estimate of 6.2% for conjunctivitis among patients with laboratory-confirmed COVID-19, although even this was skewed heavily by the aforementioned outlier.14Sopp N.M. Sharda V. An eye on COVID-19: a meta-analysis of positive conjunctival reverse transcriptase-polymerase chain reaction and SARS-CoV-2 conjunctivitis prevalence.Optom Vis Sci. 2021; 98: 429-436Crossref PubMed Scopus (10) Google Scholar The overall consensus from the existing literature is that ocular manifestations of COVID-19 are uncommon.4Guan W.-J. Ni Z.-Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (19775) Google Scholar,11Aiello F. Gallo Afflitto G. Mancino R. et al.Coronavirus disease 2019 (SARS-CoV-2) and colonization of ocular tissues and secretions: a systematic review.Eye (Lond). 2020; 34: 1206-1211Crossref PubMed Scopus (79) Google Scholar,12Zhou Y. Duan C. Zeng Y. et al.Ocular findings and proportion with conjunctival SARS-COV-2 in COVID-19 patients.Ophthalmology. 2020; 127: 982-983Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar,14Sopp N.M. Sharda V. An eye on COVID-19: a meta-analysis of positive conjunctival reverse transcriptase-polymerase chain reaction and SARS-CoV-2 conjunctivitis prevalence.Optom Vis Sci. 2021; 98: 429-436Crossref PubMed Scopus (10) Google Scholar In addition, only a small minority (estimated 2.7% in the same meta-analysis) of these patients will have detectable SARS-CoV-2 RNA in their ocular secretions.11Aiello F. Gallo Afflitto G. Mancino R. et al.Coronavirus disease 2019 (SARS-CoV-2) and colonization of ocular tissues and secretions: a systematic review.Eye (Lond). 2020; 34: 1206-1211Crossref PubMed Scopus (79) Google Scholar,14Sopp N.M. Sharda V. An eye on COVID-19: a meta-analysis of positive conjunctival reverse transcriptase-polymerase chain reaction and SARS-CoV-2 conjunctivitis prevalence.Optom Vis Sci. 2021; 98: 429-436Crossref PubMed Scopus (10) Google Scholar,15Ciloglu E. Dogan N.C. Ozdemir E. et al.The presence of SARS-CoV-2 in conjunctival secretions of COVID-19 patients.Ocul Immunol Inflamm. 2021 May 5; (Online ahead of print): 1-4https://doi.org/10.1080/09273948.2020.1869270Crossref PubMed Scopus (2) Google Scholar Nevertheless, data that have emerged from multiple in vitro studies on conjunctival explants and postmortem tissues seem to demonstrate clearly that SARS-CoV-2 does exhibit tropism for tissues of the ocular surface and that the ocular surface is possibly a portal for entry and transmission of COVID-19.16Hui K.P.Y. Cheung M.-C. Perera R.A.P.M. et al.Tropism, replication competence, and innate immune responses of the coronavirus SARS-CoV-2 in human respiratory tract and conjunctiva: an analysis in ex-vivo and in-vitro cultures.Lancet Respir Med. 2020; 8: 687-695Abstract Full Text Full Text PDF PubMed Scopus (371) Google Scholar, 17Collin J. Queen R. Zerti D. et al.Co-expression of SARS-CoV-2 entry genes in the superficial adult human conjunctival, limbal and corneal epithelium suggests an additional route of entry via the ocular surface.Ocul Surf. 2021; 19: 190-200Crossref PubMed Scopus (92) Google Scholar, 18Eriksen A.Z. Møller R. Makovoz B. et al.SARS-CoV-2 infects human adult donor eyes and hESC-derived ocular epithelium.Cell Stem Cell. 2021; 28: 1205-1220.e7Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Therefore, the American Academy of Ophthalmology continues to recommend the routine use of slit-lamp shields, as well as eye protection (goggles or shields) when examining patients “to the extent practical,” acknowledging that wearing eye protection is not feasible during certain aspects of ophthalmoscopy and examination.19Chodosh J. Holland G.N. Yeh S. Important coronavirus updates for ophthalmologists.https://www.aao.org/headline/alert-important-coronavirus-contextDate: 2020Google Scholar Guidelines published by other professional ophthalmic bodies such as the Asia Pacific Academy of Ophthalmology, the Spanish Society of Ophthalmology, and the All India Ophthalmological Society provide similar guidance.20Wong R.L.M. Ting D.S.W. Wan K.H. et al.COVID-19: ocular manifestations and the APAO prevention guidelines for ophthalmic practices.Asia Pac J Ophthalmol (Phila). 2020; 9: 281-284Crossref PubMed Scopus (27) Google Scholar, 21Gegúndez-Fernández JA, Llovet-Osuna F, Fernández-Vigo JI, et al. Recommendations for ophthalmologic practice during the easing of COVID-19 control measures. Acta Ophthalmol. 2021 Jan 12;10.1111/aos.14752. https://doi.org/10.1111/aos.14752. Online ahead of print.Google Scholar, 22Sengupta S. Honavar S.G. Sachdev M.S. et al.All India Ophthalmological Society—Indian Journal of Ophthalmology consensus statement on preferred practices during the COVID-19 pandemic.Indian J Ophthalmol. 2020; 68: 711-724Crossref PubMed Scopus (108) Google Scholar, 23Tang S.W.K. Romano M.R. Wong D.H.T. et al.The use of personal protective equipment in clinical ophthalmology during corona virus disease-2019: a review of international guidelines and literature.Curr Opin Ophthalmol. 2020; 31: 435-446Crossref PubMed Scopus (13) Google Scholar, 24Lam D.S.C. Wong R.L.M. Lai K.H.W. et al.COVID-19: special precautions in ophthalmic practice and FAQs on personal protection and mask selection.Asia Pac J Ophthalmol (Phila). 2020; 9: 67-77Crossref PubMed Scopus (40) Google Scholar, 25Khor W.B. Yip L. Zhao P. et al.Evolving practice patterns in Singapore’s public sector ophthalmology centers during the COVID-19 pandemic.Asia Pac J Ophthalmol (Phila). 2020; 9: 285-290Crossref PubMed Scopus (21) Google Scholar However, it remains to be seen if these guidelines will be modified in the future for clinicians and patients who are fully vaccinated. Given the absence of overall consensus guidelines, we anticipated that significant heterogeneity and variation in COVID-19 mitigation measures remain among ophthalmic institutions worldwide. We also expected that the COVID-19 pandemic might have catalyzed the increased adoption of digital health solutions in ophthalmic practice, in efforts to reduce face-to-face consultations. Therefore, we set out to survey practice patterns for COVID-19 risk mitigation in a number of diverse ophthalmic practices, clinics, and institutions around the world. Members of the COVID-19 Ophthalmology Interest Group were surveyed via e-mail in May 2021 and were asked to detail the COVID-19 mitigation measures in their respective ophthalmic institutions in mid 2020 and to detail latest practice in 2021. A summary of these measures for 2020 and 2021 can be found in Tables 1 and 2, respectively. Recognizing that local factors such as COVID-19 incidence and vaccination rates are likely to influence the intensity of these measures significantly, the countries in Table 2 have been categorized into low-risk, moderate-risk, and high-risk locations based on the number of new COVID-19 cases reported over 7 days per 100 000 population from the World Health Organization COVID-19 Dashboard, which was accessed on May 23, 2021.1World Health OrganizationWHO coronavirus (COVID-19) dashboard.https://covid19.who.int/tableDate: 2021Google ScholarTable 1Mitigation Measures Adopted by Ophthalmic Institutions around the World in 2020, at the Height of the Coronavirus Disease 2019 PandemicCountriesOphthalmologistsDigital Health SolutionsOutpatientsCommentsFace MaskGlovesGogglesCapSlit-Lamp ShieldTemperature ScreeningDigital Contact Tracing MeasuresVirtual ClinicArtificial Intelligence-Enabled CareDigital Home MonitoringFace MaskTemperature ScreeningDigital Contact Tracing MeasuresAsia-Pacific AustraliaSydney (Sydney Eye Hospital)YOONYYYYNNYYYSydney (Westmead Hospital)YNNNYYYLNYYYYDigital home-monitoring for IOP only ChinaBeijing (Peking Union Medical College Hospital)YYYYYYYYNYYYNHong Kong (C-MER Dennis Lam & Eye Partners Eye Center)YNNNYYNYNNYYNShenzhen (C-MER [Shenzhen] Dennis Lam Eye Hospital)YNNNYYNYNNYYN IndiaChennai (Sankara Nethralaya)YNNYYYYYNYYYY IndonesiaJakarta (Jakarta Eye Center)YNYYYYYYNNYYY IsraelTel Aviv (Tel Aviv Medical Center)YYYNYNNYYYYYN JapanKagoshima (Kagoshima University Hospital)YONNYYNNNNYYNOsaka (Osaka University Hospital)YYYNYYYNNNYNYTokyo (Tokyo Medical and Dental University)YYYNYNNNNNNNN SingaporeSingapore (Singapore National Eye Centre)YNNNYYYYNLYYY TaiwanTaoyuan (Chang Gung Memorial Hospital)YYYYYYYNNYYYY ThailandBangkok (Rajavithi Eye Clinic, Rajavithi Hospital)YOOOYYNNNNYYYEurope DenmarkOdense (Odense University Hospital)YNNNYNNNNNYNN GermanyHeidelberg (Medical Faculty Mannheim, Heidelberg University)YNNNYNNNNNYNN ItalyForlì (Ospedali Privati Forlì “Villa Igea”)YYNNYYYNNNYYY SpainBarcelona (Institut Clinic de Oftalmologia, Hospital Clinic de Barcelona)YYYYYNNYNNYYN United KingdomCambridge (Addenbrooke's Hospital)YYNNYNNYNNYNNLiverpool (St. Paul's Eye Unit)YYNNYNYYNNYNYLondon (Moorfields Eye Hospital)YYYNYYNYNNYYNUnited States of America Atlanta, GA (Emory Eye Center)YNYNYYNYNNYYN Boston, MA (Massachusetts Eye and Ear)YNYNYNYYNYYNY Cleveland, OH (Cleveland Clinic)YNNNYYNYNNYYN Durham, NC (Duke Eye Center)YOOOYYNONNYYN Los Angeles, CA (USC Roski Eye Institute)YYNNYNNYNNYYY Miami, FL (Bascom Palmer Eye Institute)YNNNYNNYNYYNN Milwaukee, WI (The Eye Institute, Medical College of Wisconsin)YNNNYYNYNNYYN Omaha, NE (Truhlsen Eye Institute)YNYNYYNYNNYYN Palo Alto, CA (Byers Eye Institute, Stanford University School of Medicine)YYYNYYYYNYYYY Philadelphia, PA (Wills Eye Hospital)YYNNYYNYNYYYNIOP = intraocular pressure; L = limited; N = no; O = optional; USC = University of Southern California; Y = yes.Vaccination against coronavirus disease 2019 (COVID-19) was not available until December 2020. In some locations, vaccination against COVID-19 started in December 2020. However, this table represents mitigation measures and practice patterns in mid 2020, at the peak of the COVID-19 pandemic, and therefore vaccination has not been included in this table for any of these institutes. Mitigation measures and practice patterns are specific to the ophthalmic institutions listed in this table, and are not representative of other ophthalmic institutions in the respective cities or countries. Open table in a new tab Table 2Mitigation Measures Adopted by Ophthalmic Institutions around the World in May 2021, 18 Months after the First Reported Cases of Coronavirus Disease 2019CountriesOphthalmologistsDigital Health SolutionsOutpatientsCommentsFace MaskGlovesGogglesCapSlit-Lamp ShieldTemperature ScreeningDigital Contact Tracing MeasuresVaccinationVirtual ClinicArtificial Intelligence-Enabled CareDigital Home MonitoringFace MaskTemperature ScreeningDigital Contact Tracing MeasuresVaccinationAsia-Pacific Australia∗low-risk (< 10),Sydney (Sydney Eye Hospital)YNNNYYYYYNNYYYYSydney (Westmead Hospital)YNNNYYYYLNYNYYYDigital home monitoring for IOP only China∗low-risk (< 10),Beijing (Peking Union Medical College Hospital)YONOYYNYYNNYYNYPublic vaccination only partialHong Kong (C-MER Dennis Lam & Eye Partners Eye Center)YNNNYYNYYNNYYNYShenzhen (C-MER [Shenzhen] Dennis Lam Eye Hospital)YNNNYYNYYNNYYNY India‡high-risk (≥100) categories.Chennai (Sankara Nethralaya)YNNYYNYYYYYYNYY Indonesia†moderate risk (10–<100), andJakarta (Jakarta Eye Center)YNYYYYYYYNNYYYY Israel∗low-risk (< 10),Tel Aviv (Tel Aviv Medical Center)YYYNYNNYYYYYYNY Japan†moderate risk (10–<100), andKagoshima (Kagoshima University Hospital)YONNYYNYNNNYYNYOsaka (Osaka University Hospital)YYYNYYYYNNNYYYYTokyo (Tokyo Medical and Dental University)YYYNYNNYNNNNNNY Singapore∗low-risk (< 10),Singapore (Singapore National Eye Centre)YNNNYYYYYNLYYYY Taiwan†moderate risk (10–<100), andTaoyuan (Chang Gung Memorial Hospital)YYYYYYYYNNYYYYNPublic vaccination not yet started Thailand†moderate risk (10–<100), andBangkok (Rajavithi Eye Clinic, Rajavithi Hospital)YOOOYYNYNNNYYYYEurope Denmark‡high-risk (≥100) categories.Odense (Odense University Hospital)YNNNYNNYNNNYNNNHealth care workers have been prioritized for vaccination Germany†moderate risk (10–<100), andHeidelberg (Medical Faculty Mannheim, Heidelberg University)YNNNYNNYNYNYNNY Italy†moderate risk (10–<100), andForlì (Ospedali Privati Forlì “Villa Igea”)YNNNYYYYNNNYYYY Spain†moderate risk (10–<100), andBarcelona (Institut Clinic de Oftalmologia, Hospital Clinic de Barcelona)YNNNYNNYYNNYNNYPublic vaccination only partial United Kingdom†moderate risk (10–<100), andCambridge (Addenbrooke's Hospital)YYNNYNNYYNNYNYYLiverpool (St. Paul's Eye Unit)YYNNYNYYYNNYNYYLondon (Moorfields Eye Hospital)YNNNYNNYYNNYYYYUnited States of America†moderate risk (10–<100), and Atlanta, GA (Emory Eye Center)YNYNYYNYYNNYYNY Boston, MA (Massachusetts Eye and Ear)YNYNYNYYYNYYNYY Cleveland, OH (Cleveland Clinic)YNNNYYYYYYYYYYY Durham, NC (Duke Eye Center)YOOOYNNYNNNYNNY Los Angeles, CA (USC Roski Eye Institute)YYNNYNNYYNNYYYY Miami, FL (Bascom Palmer Eye Institute)YNNNYNNYYNYYNNY Milwaukee, WI (The Eye Institute, Medical College of Wisconsin)YNNNYYNYYNNYYNY Omaha, NE (Truhlsen Eye Institute)YNNNYYNYNNNYYNY Palo Alto, CA (Byers Eye Institute, Stanford University School of Medicine)YYYNYYYYYNYYYYY Philadelphia, PA (Wills Eye Hospital)YYNNYYNYYNYYYNYIOP = intraocular pressure; L = limited; N = no; O = optional; USC = University of Southern California; Y = yes.Values in boldface indicate a change from 2020 practice. Mitigation measures and practice patterns are specific to the ophthalmic institutions listed in this table and are not representative of other ophthalmic institutes in the respective cities or countries.Rows for each country are coded based on the number of new coronavirus disease 2019 (COVID-19) cases reported over 7 days per 100 000 population from the World Health Organization COVID-19 Dashboard (accessed on May 23, 2021) into∗ low-risk (< 10),† moderate risk (10–<100), and‡ high-risk (≥100) categories. Open table in a new tab IOP = intraocular pressure; L = limited; N = no; O = optional; USC = University of Southern California; Y = yes. Vaccination against coronavirus disease 2019 (COVID-19) was not available until December 2020. In some locations, vaccination against COVID-19 started in December 2020. However, this table represents mitigation measures and practice patterns in mid 2020, at the peak of the COVID-19 pandemic, and therefore vaccination has not been included in this table for any of these institutes. Mitigation measures and practice patterns are specific to the ophthalmic institutions listed in this table, and are not representative of other ophthalmic institutions in the respective cities or countries. IOP = intraocular pressure; L = limited; N = no; O = optional; USC = University of Southern California; Y = yes. Values in boldface indicate a change from 2020 practice. Mitigation measures and practice patterns are specific to the ophthalmic institutions listed in this table and are not representative of other ophthalmic institutes in the respective cities or countries. Rows for each country are coded based on the number of new coronavirus disease 2019 (COVID-19) cases reported over 7 days per 100 000 population from the World Health Organization COVID-19 Dashboard (accessed on May 23, 2021) into A number of trends in practice patterns were noted from 2020 to 2021. First, in general, a de-escalation of the initial COVID-19 mitigation measures seems to have occurred in 2021. In terms of personal protective equipment, most institutions that initially mandated the use of gloves, caps, and eye protection for ophthalmologists since have ceased this practice. This is likely because of the overall reduction in COVID-19 incidence compared with the peak of the pandemic in 2020. In certain institutions, eye protection is still recommended, but is not used frequently in practice because of difficulties with regard to examination. A number of institutions also have ceased routine temperature screening for both staff and patients. Second, despite an overall de-escalation, certain measures remain virtually universal. These include mandatory use of face masks for all staff, face masks for all patients (except for 1 center in Australia, which had very low levels of community transmission at the time of the survey), and use of slit-lamp shields, which are in line with current published professional guidance.19Chodosh J. Holland G.N. Yeh S. Important coronavirus updates for ophthalmologists.https://www.aao.org/headline/alert-important-coronavirus-contextDate: 2020Google Scholar, 20Wong R.L.M. Ting D.S.W. Wan K.H. et al.COVID-19: ocular manifestations and the APAO prevention guidelines for ophthalmic practices.Asia Pac J Ophthalmol (Phila). 2020; 9: 281-284Crossref PubMed Scopus (27) Google Scholar, 21Gegúndez-Fernández JA, Llovet-Osuna F, Fernández-Vigo JI, et al. Recommendations for ophthalmologic practice during the easing of COVID-19 control measures. Acta Ophthalmol. 2021 Jan 12;10.1111/aos.14752. https://doi.org/10.1111/aos.14752. Online ahead of print.Google Scholar, 22Sengupta S. Honavar S.G. Sachdev M.S. et al.All India Ophthalmological Society—Indian Journal of Ophthalmology consensus statement on preferred practices during the COVID-19 pandemic.Indian J Ophthalmol. 2020; 68: 711-724Crossref PubMed Scopus (108) Google Scholar,24Lam D.S.C. Wong R.L.M. Lai K.H.W. et al.COVID-19: special precautions in ophthalmic practice and FAQs on personal protection and mask selection.Asia Pac J Ophthalmol (Phila). 2020; 9: 67-77Crossref PubMed Scopus (40) Google Scholar,26Ong S.C. Yap J.X. Tay T.Y.F. et al.Considerations in the use of slit lamp shields to reduce the risk of respiratory virus transmission in coronavirus disease 2019.Curr Opin Ophthalmol. 2020; 31: 374-379Crossref PubMed Scopus (8) Google Scholar Third, vaccination of staff also seems to have been adopted universally, with almost all countries having prioritized vaccination for health care workers. However, vaccination levels of outpatients vary significantly based on availability and access in different countries. Finally, survey of practice in 2021 does seem to suggest increased adoption of digital health solutions. Furthermore, most centers that did adopt virtual clinics and digital home monitoring in their ophthalmic care for patients at the peak of the pandemic in 2020 do seem to have continued these practices into 2021, although the degree to which these digital health solutions are used is unclear. In 2020, the COVID-19 pandemic necessitated drastic reductions in ophthalmic service delivery, with reductions of up to 70% to 99% seen in outpatient visits and elective surgical procedures.27Ting DSJ, Deshmukh R, Said DG, Dua HS. The impact of COVID-19 pandemic on ophthalmology services: are we ready for the aftermath? Ther Adv Ophthalmol. 2020; 2020 Oct 20;12:2515841420964099. https://doi.org/10.1177/2515841420964099. eCollection Jan-Dec 2020.Google Scholar,28Babu N. Kohli P. Mishra C. et al.To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute.Indian J Ophthalmol. 2020; 68: 1540-1544Crossref PubMed Scopus (51) Google Scholar This forced reduction in traditional face-to-face consultations for provision of ophthalmic care accelerated the development and implementation of digital health solutions such as virtual consultations, artificial intelligence-enabled care, and digital home monitoring in many ophthalmic centers worldwide.29Kalavar M. Hua H.-U. Sridhar J. Teleophthalmology: an essential tool in the era of the novel coronavirus 2019.Curr Opin Ophthalmol. 2020; 31: 366-373Crossref PubMed Scopus (28) Google Scholar For example, virtual consultations were used successfully to triage and manage acute ophthalmic conditions during the height of the pandemic in London, United Kingdom.30Li J.-P.O. Thomas A.A.P. Kilduff C.L.S. et al.Safety of video-based telemedicine compared to in-person triage in emergency ophthalmology during COVID-19.EClinicalMedicine. 2021; 34 (Epub 2021 Apr 5): 100818https://doi.org/10.1016/j.eclinm.2021.100818Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Li et al30Li J.-P.O. Thomas A.A.P. Kilduff C.L.S. et al.Safety of video-based telemedicine compared to in-person triage in emergency ophthalmology during COVID-19.EClinicalMedicine. 2021; 34 (Epub 2021 Apr 5): 100818https://doi.org/10.1016/j.eclinm.2021.100818Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar demonstrated that video consultations for emergency ophthalmic diseases could reduce effectively the subsequent need for traditional face-to-face review by 45%. More importantly, the video consultation method exhibited a safety profile (0% harm rate) equivalent to the face-to-face review, with perfect intergrader correlation and high patient satisfaction. In terms of home-based monitoring, Mansouri et al31Mansouri K. Kersten-Gomez I. Hoffmann E.M. et al.Intraocular pressure telemetry for managing glaucoma during the COVID-19 pandemic.Ophthalmol Glaucoma. 2021; 4: 447-453Abstract Full Text Full Text PDF Scopus (9) Google Scholar used data from an ongoing multicenter study in Switzerland, Germany, and the United Kingdom to show that home-based monitoring of intraocular pressure in patients with glaucoma was feasible, impacted clinical decision-making such as adjustment of glaucoma medical therapy, and helped to avoid in-person consultations during the COVID-19 pandemic. Artificial intelligence algorithms have been shown to be powerful automated diagnostic tools for a wide range of anterior and posterior segment diseases in ophthalmology. Together with virtual consultations, artificial intelligence algorithms have immense potential as effective triaging tools in the COVID-19 pandemic as well as any other future widespread pandemics.32Tham Y-C, Husain R, Teo KYC, et al. New digital models of care in ophthalmology, during and beyond the COVID-19 pandemic. Br J Ophthalmol. 2021 Mar 22;bjophthalmol-2020-317683. https://doi.org/10.1136/bjophthalmol-2020-317683. Online ahead of print.Google Scholar, 33Cheng C.-Y. Soh Z.D. Majithia S. et al.Big data in ophthalmology.Asia Pac J Ophthalmol (Phila). 2020; 9: 291-298Crossref PubMed Scopus (29) Google Scholar, 34He M. Li Z. Liu C. et al.Deployment of artificial intelligence in real-world practice: opportunity and challenge.Asia Pac J Ophthalmol (Phila). 2020; 9: 299-307Crossref PubMed Scopus (23) Google Scholar The COVID-19 pandemic clearly has provided an impetus for rapid implementation of digital health solutions in ophthalmology. We hope that these positive changes will continue to be used for better ophthalmic service delivery for our patients, even in the “new normal” of the COVID-19 aftermath. Collaborative efforts by ophthalmic institutions in the United States, United Kingdom, India, and Singapore are ongoing to develop a global interinstitutional teleophthalmology program to share best practices, new technical innovations, and regulatory approaches to teleophthalmology. Nevertheless, significant barriers to more widespread adoption of digital health solutions remain, including technology access and country-specific payment or reimbursement mechanisms. Furthermore, the large variety of emerging digital health solutions available to us necessitates some clear guidance in the near future to determine which types of digital solutions are most appropriate for which kinds of ophthalmic visits in the aftermath of the pandemic, or in the next widespread public emergency. In conclusion, despite the development of effective vaccines, better understanding of the relationship between COVID-19 and the eye, and the implementation of digital health solutions in ophthalmology, significant challenges lie ahead of us. Inequalities in vaccine access, the threat of resurgent waves of infection, and the emerging new variants are some of the ongoing challenges that ophthalmology practices will face in the second year of this pandemic. With greater international collaboration, sharing of best practices, and a continued push toward innovation in ophthalmic care delivery, we can continue to provide the highest quality ophthalmic care for our patients, while also safely mitigating the risks relating to COVID-19. The authors thank the following, who have contributed information on practice patterns at their respective eye institutions from 2020 and 2021: Massimo Busin (Ospedali Privati Forlì “Villa Igea,” Forlì, Italy), Andrew Chang (Sydney Eye Hospital, Sydney, Australia), Youxin Chen (Peking Union Medical College Hospital, Beijing, China), Sharon Fekrat (Duke Eye Center, Durham, NC), Adrian Fung (Westmead Hospital, Sydney, Australia), Jakob Grauslund (Odense University Hospital, Odense, Denmark), Ranya Habash (Bascom Palmer Eye Institute, Miami, FL), Simon Harding (St. Paul’s Eye Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom), Allen C. Ho (Wills Eye Hospital, Philadelphia, PA), Jost B. Jonas (Department of Ophthalmology, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany), Ryo Kawasaki (Osaka University Hospital, Osaka, Japan), Judy E. Kim (The Eye Institute, Medical College of Wisconsin, Milwaukee, WI), Dennis Lam (C-MER Dennis Lam & Eye Partners Eye Center, Hong Kong, China, and C-MER [Shenzhen] Dennis Lam Eye Hospital, Shenzhen, China), Linda A. Lam (USC Roski Eye Institute, Los Angeles, CA), Jui-Yen Lin (Chang Gung Memorial Hospital, Taoyuan, Taiwan), Anat Loewenstein (Tel Aviv Medical Center, Tel Aviv, Israel), Darius M. Moshfeghi (Byers Eye Institute, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA), Kohji Nishida (Osaka University Hospital, Osaka, Japan), Kyoko Ohno-Matsui (Tokyo Medical and Dental University, Tokyo, Japan), Rajiv Raman (Sankara Nethralaya, Chennai, India), Paisan Ruamviboonsuk (Rajavithi Eye Clinic, Rajavithi Hospital, Bangkok, Thailand), Taiji Sakatomo (Kagoshima University Hospital, Kagoshima, Japan), Andrew Schachat (Cleveland Clinic, Cleveland, OH), Sharita Siregar (Jakarta Eye Center, Jakarta, Indonesia), Louisa Wickham (Moorfields Eye Hospital, London, United Kingdom), Wei-Chi Wu (Chang Gung Memorial Hospital, Taoyuan, Taiwan), Patrick Yu-Wai-Man (Addenbrooke’s Hospital, Cambridge, United Kingdom), and Javier Zarranz-Ventura (Institut Clinic de Oftalmologia, Hospital Clinic de Barcelona, Barcelona, Spain). The authors also thank the following, who have contributed valuable content to the section on digital health solutions in ophthalmology: Ranya Habash (Bascom Palmer Eye Institute, Miami, FL) and Darren S. J. Ting (University of Nottingham, Nottingham, United Kingdom).

Studies have suggested a possible association of coronavirus 2019 (COVID-19) with conjunctivitis, chemosis, and other ocular symptoms such as red or sore eyes.1–5 The estimated proportion of those with ocular symptoms, some consistent with conjunctivitis, ranges widely, from less than 1% (Centers for Disease Control and Prevention Coronavirus 2019-Associated Hospitalization Surveillance Network) to more than 30%,1,5 suggesting that conjunctivitis could be a disease feature and potentially a useful diagnostic sign.

A foldable acrylic intraocular lens (IOL) with a 6.0 mm optic was removed through a 2.2 mm corneal incision as a single piece with minimal wound trauma. By viscodissection, the IOL was freed from its position in the capsular bag and moved into the anterior chamber. Vannas scissors were introduced through a 2.2 mm corneal incision. A 4.5 mm straight slit was cut at each optic-haptic junction on opposite sides, perpendicular to each haptic shaft. This pair of parallel cuts generated 3 IOL segments in an S configuration that remained connected. The IOL was grasped by 1 haptic and removed as a single piece.

Purpose To compare the effects of the Ahmed glaucoma valve (AGV; New World Medical, Rancho Cucamonga, CA) with sulcus versus anterior chamber (AC) tube placement on the corneal endothelial density and morphology over time. Design Nonrandomized, interventional study. Participants This study included 106 eyes from 101 pseudophakic patients who had the AGV tube placed in the AC (acAGV) and 105 eyes from 94 pseudophakic patients who had the AGV tube placed in the ciliary sulcus (sAGV). Methods All patients underwent preoperative specular microscopy, which was repeated postoperatively in 2019. The patients' demographic information, glaucoma diagnoses, and basic ocular information were obtained on chart review. Anterior segment OCT was conducted for patients who underwent sAGV to evaluate the sulcus tube position. Gonioscopy was performed to document peripheral anterior synechiae (PAS). Linear mixed-effects models were used to compare the different ocular and endothelial measurements between the 2 groups and to identify risk factors for endothelial cell density (ECD) loss over time. Main Outcome Measures Monthly change in corneal endothelial measurements, including ECD and coefficient of variation (CV), calculated as the difference between preoperative and postoperative measurements divided by the number of months from the time of surgery to postoperative specular microscopy. Results The acAGV and sAGV groups were comparable in all baseline characteristics except that the acAGV group had longer follow-up (37.6 vs. 20.1 months, respectively, P < 0.001). Mean monthly loss in central ECD was significantly more in the acAGV group (mean ± standard deviation: 29.3±29.7 cells/mm2) than in the sAGV group (15.3±20.7 cells/mm2, P < 0.0001). Mean monthly change in CV was similar between the 2 groups (P = 0.28). Multivariate analyses revealed that younger age and tube location in the AC were associated with faster central ECD loss (P = 0.02, P < 0.0001, respectively). For patients with sAGV, while PAS was associated with faster central ECD loss (P = 0.002), a more forward tube position tenting the iris was not (P > 0.05). Conclusions Compared with anterior segment placement, ciliary sulcus tube implantation may be a preferred surgery approach to reduce endothelial cell loss in pseudophakic patients.

AbstractImportanceStudies suggest diurnal patterns of some eye conditions. Leveraging new information sources such as online search data to learn more about such patterns could improve understanding of patient eye-related conditions and well-being and improve timing of clinical and remote eye care.ObjectiveTo investigate our hypothesis that the public is likely to consistently search about different eye conditions at different hours of the day or days of week, we conducted an observational study using search data for terms related to eye conditions such as conjunctivitis. We asked if search volumes reflected diurnal or day-of-week patterns and if those patterns were distinct from each other.DesignHourly search data for eye-related and control search terms for 2018 were analyzed and compared.SettingData from 10 USA states.ExposureInternet search.ParticipantsPopulations that searched Google’s search engine using our chosen study terms.Main Outcome MeasuresCyclical hourly and weekly online search patterns.ResultsDistinct diurnal (p<0.001 for all search terms) and day-of-week search patterns for eye-related terms were observed but with differing peak time periods and cyclic strengths. Some diurnal patterns represented reported clinical patterns. Of the eye related terms, “conjunctivitis” and “pink eye” had the strongest diurnal cyclic patterns based on peak-to-trough ratios. Stronger signal was restricted to and peaked in mornings, and amplitude was higher on weekdays. In contrast, “dry eyes” had a higher amplitude diurnal pattern on weekends, with stronger signal occurring over a broader evening to morning period and peaking in early morning.Conclusions and RelevanceThe frequency of online searches for various eye conditions can show cyclic patterns according to time of day or week. Further studies to understand the reasons for these variations may help supplement current clinical understanding of eye symptom presentation and improve the timeliness of patient messaging and care interventions.Key PointsQuestionDo online public search engine queries for different eye-health terms follow hourly or daily patterns and do the patterns differ from each other or reflect what is known clinically?FindingsUnique hourly and day of week eye health related search patterns appear diurnal and can reflect what has been observed clinically.MeaningOnline search data may reflect timing of eye conditions and could improve clinical understanding of eye-related symptom occurrence, including outside of clinics. Knowing precisely when patient’s eye condition interests increase holds promise -for example to optimize timing and availability of local or remote eye care resources.

Purpose: Delaying cataract surgery is associated with an increased risk of falls, but whether routine preoperative testing delays cataract surgery long enough to cause clinical harm is unknown. We sought to determine whether the use of routine preoperative testing leads to harm in the form of delayed surgery and falls in Medicare beneficiaries awaiting cataract surgery. Design: Retrospective, observational cohort study using 2006-2014 Medicare claims. Participants: Medicare beneficiaries 66thorn years of age with a Current Procedural Terminology claim for ocular biometry. Methods: We measured the mean and median number of days between biometry and cataract surgery, calculated the proportion of patients waiting >= 30 days or >= 90 days for surgery, and determined the odds of sustaining a fall within 90 days of biometry among patients of high-testing physicians (testing performed in >= 75% of their patients) compared with patients of low-testing physicians. We also estimated the number of days of delay attributable to high- testing physicians. Main Outcome Measures: Incidence of falls occurring between biometry and surgery, odds of falling within 90 days of biometry, and estimated delay associated with physician testing behavior. Results: Of 248 345 beneficiaries, 16.4% were patients of high-testing physicians. More patients of hightesting physicians waited >= 30 days and >= 90 days to undergo surgery (31.4% and 8.2% vs. 25.0% and 5.5%, respectively; P < 0.0001 for both). Falls before surgery in patients of high-testing physicians increased by 43% within the 90 days after ocular biometry (1.0% vs. 0.7%; P < 0.0001). The adjusted odds ratio of falling within 90 days of biometry in patients of high-testing physicians versus low-testing physicians was 1.10 (95% confidence interval [CI], 1.03-1.19; P = 0.008). After adjusting for surgical wait time, the odds ratio decreased to 1.07 (95% CI, 1.00-1.15; P = 0.06). The delay associated with having a high-testing physician was approximately 8 days (estimate, 7.97 days; 95% CI, 6.40-9.55 days; P < 0.0001). Other factors associated with delayed surgery included patient race (non-White), Northeast region, ophthalmologist <= 40 years of age, and low surgical volume. Conclusions: Overuse of routine preoperative medical testing by high-testing physicians is associated with delayed surgery and increased falls in cataract patients awaiting surgery. (C) 2020 by the American Academy of Ophthalmology

In 1978, the American Academy of Ophthalmology was established as an independent body drawn from the American Academy of Ophthalmology and Otolaryngology. It is less well remembered that the Academy’s peer-review journal, Ophthalmology, actually preceded the independent academy. Some stealth was involved: the name was adopted on the cover in 1975, whereas the legal title remained Transactions of the American Academy of Ophthalmology and Otolaryngology. Indeed, in 1973, the Transactions had been split into 2 volumes, so that there was one that presented exclusively ophthalmologic content. The original charge of this bimonthly journal was to offer, in print, material that had been presented at the annual meeting of the academy. However, soon after the name “Ophthalmology” was adopted, the academy leadership and the journal’s editor, Stanley M. Truhlsen, made the decision to develop an editorial board and to begin accepting what they termed “free papers” that had not been presented at the annual meeting. This allowed Dr. Truhlsen and the board to accomplish 2 objectives: to select freely for the journal only meeting presentations that were of the highest quality and that they believed would survive the test of time and to capitalize on the substantial increase in high-quality investigation beyond that presented at the annual meeting. Academy leadership believed that the volume of such work exceeded the capacity of the existing major eye journals, the American Journal of Ophthalmology and the Archives of Ophthalmology.1The American Academy of Ophthalmology and Otolaryngology. Oral History Recollections of Past and Present Leaders. Vols 1–3. Berkeley, CA: University of California, in cooperation with The Foundation of the American Academy of Ophthalmology and The Regents of the University of California; 1998:280. https://digitalassets.lib.berkeley.edu/roho/ucb/text/ophthalmology_amer_assoc.pdf; Accessed 11.02.20.Google Scholar A deliberate decision was made to publish work that, as Dr. Truhlsen described it, “could be utilized immediately in practice.” In the late 1970s, by and large this represented descriptive studies, observational case series, and clinicopathologic correlations. However, the face of clinical research to produce knowledge that “could be utilized immediately in practice” was evolving rapidly and, indeed, was led by ophthalmology. The value and power of clinical observations shared with the community and subjected to critical review still cannot be denied, but the evolving tools of the clinical trial presented new opportunities to bring rigorous science to a clinically oriented journal. The science collected in this commemorative edition reflects the broad span of clinical research and provides examples of the profound value that these various lines of inquiry can bring to our understanding of disease and our clinical decision-making paradigms. These articles also demonstrate the astonishing breadth of the journal’s influence over the decades. One of the most highly cited articles is a most elegant observational study paired with meticulous histologic evaluation: Harry Quigley and Richard Greene’s classic study of glaucomatous cupping and retinal ganglion cell loss.2Quigley H.A. Green W.R. The histology of human glaucoma cupping and optic nerve damage: clinicopathologic correlation in 21 eyes.Ophthalmology. 1979; 86: 1803-1827Abstract Full Text PDF PubMed Scopus (276) Google Scholar At the other end of the spectrum—an early example of the contemporary randomized clinical trial—is the Herpetic Eye Disease Study, which has changed profoundly the way that herpetic eye disease is treated and undoubtedly helped to reduce the burden of blindness associated with this condition.3Wilhelmus K.R. Gee L. Hauck W.W. et al.Herpetic Eye Disease Study: a controlled trial of topical corticosteroids for herpes simplex stromal keratitis.Ophthalmology. 1994; 101 (discussion 1895–1896): 1883-1895Abstract Full Text PDF PubMed Scopus (197) Google Scholar We learn a great deal from the expert and thoughtful commentaries that our contributors have provided. Chodosh reminds us that before the Herpetic Eye Disease Study reported in Ophthalmology in 1994, the use of corticosteroids—now recognized on the basis of that study to be salutary under specific conditions—was for some influential authorities of the time utter anathema (see page S3). Controversy regarding the use of topical corticosteroids extended to the treatment of children with juvenile idiopathic arthritis-related uveitis, and Kramer and Tomkins-Netzer acknowledge the invaluable clinical guidance provided by the 2010 study from Thorne et al4Thorne J.E. Woreta F.A. Dunn J.P. Jabs D.A. Risk of cataract development among children with juvenile idiopathic arthritis-related uveitis treated with topical corticosteroids.Ophthalmology. 2010; 117: 1436-1441Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar in managing such patients (see page S21). Landmark randomized controlled clinical trials represented in this retrospective edition include an analysis of the Optic Neuritis Treatment Trial5Beck R.W. Cleary P.A. Backlund J.C. Optic Neuritis Study Group. The course of visual recovery after optic neuritis: experience of the Optic Neuritis Treatment Trial.Ophthalmology. 1994; 101: 1771-1778Abstract Full Text PDF PubMed Scopus (193) Google Scholar that, as Newman reminds us, was the first multicenter collaborative clinical trial in neuro-ophthalmology to be funded by the National Eye Institute (see page S172). It also includes the National Institutes of Health-funded prospective study of orbital radiotherapy for Graves’ ophthalmopathy.6Gorman C.A. Garrity J.A. Fatourechi V. et al.A prospective, randomized, double-blind, placebo-controlled study of orbital radiotherapy for Graves’ ophthalmopathy.Ophthalmology. 2001; 108: 1523-1534Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar Mombaerts eloquently describes how this reflected the complexities of our current models of thyroid eye disease (see page S158). Many of these trials have produced insight that go well beyond the primary question posed. An excellent example is found in the recognition from the Ocular Hypertension Treatment Trial that central cornea thickness plays a key role in informing risk assessment in patients with ocular hypertension and glaucoma.7Brandt J.D. Beiser J.A. Gordon M.O. et al.Central corneal thickness in the Ocular Hypertension Treatment Study (OHTS).Ophthalmology. 2001; 108: 1779-1788Abstract Full Text Full Text PDF PubMed Scopus (512) Google Scholar Higgenbotham makes a compelling case that this specific measure certainly supersedes race as a risk factor (see page S70). We are grateful to our many commentators who have brought a scholarly historical perspective to the retelling of these stories in science. As a society and a profession, we can be proud that we support so well a journal that has remained committed over the decades to presenting the highest-quality science, enabling informed clinical decisions in the very best care of our patients, and to advancing and disseminating this knowledge. At a time when demand for abbreviated online “executive summary” distillations of scientific work is increasing, Ophthalmology’s success demonstrates the value of and our colleagues’ appetite for complete, scholarly manuscripts that stimulate reflection, commentary, changes in clinical behavior, and, wonderfully, even more new science. Risk of Cataract Development among Children with Juvenile Idiopathic Arthritis-Related Uveitis Treated with Topical CorticosteroidsOphthalmologyVol. 127Issue 4PreviewWe sought to investigate the risk of cataract development among patients with juvenile idiopathic arthritis (JIA)-associated uveitis treated with topical corticosteroids. Full-Text PDF The Herpetic Eye Disease Study: Topical Corticosteroid Trial for Herpes Simplex Stromal Keratitis: A Paradigm Shifting Clinical TrialOphthalmologyVol. 127Issue 4PreviewHerpes simplex virus (HSV) type 1 is an enveloped DNA virus with broad tissue tropisms and a propensity to establish latent infection in the trigeminal and other sensory nerve ganglia. Primary infection by HSV type 1 can occur through intimate contact with a person with active infection or with one who is shedding virus during spontaneous, clinically silent, viral reactivation. Herpes simplex virus type 1 infection is ubiquitous, and the prevalence of infection increases with age, such that by 60 years of age, more than 90% of the population has been infected (reviewed in ref. Full-Text PDF Coloring between the Treatment Guidelines for Graves’ OrbitopathyOphthalmologyVol. 127Issue 4PreviewGraves’ orbitopathy (GO) is arguably an enigmatic disease. The thyroid-related autoimmune disorder affects the soft tissues of both orbits and may lead to irreversible injury to the orbital fat, extraocular muscles, eyelids, and at worst, the optic nerve and cornea. The resulting visual disturbance, double-vision and disfiguring exophthalmos, widened palpebral fissures (eyelid retraction), and eyelid swelling cause considerable morbidity with impaired quality of life. The goal of therapy is to extinguish the inflammation that, untreated, may last several years, with the ultimate aim to recover to the predisease baseline condition. Full-Text PDF The Optic Neuritis Treatment TrialOphthalmologyVol. 127Issue 4PreviewOptic neuritis has been recognized for centuries, as has its relationship with multiple sclerosis (MS) and its frequent role as a harbinger of that disease. Treatment of optic neuritis with corticosteroids was commonplace beginning with the introduction of these drugs into clinical practice in the 1950s. A 1986 United States survey of ophthalmologists and neurologists revealed that 65% of ophthalmologists and 90% of neurologists treated their optic neuritis patients with corticosteroids, 90% of the time in oral standard dosing, despite a dearth of prior evidence demonstrating efficacy. Full-Text PDF A Transformative Concept: Central Corneal ThicknessOphthalmologyVol. 127Issue 4PreviewWhen Goldmann and Schmidt described an applanation tonometer in the middle of the 20th century, the title of their seminal article could have been similar to the title of this Commentary. Thus, one can imagine the following heading, “A Transformative Concept: Goldmann Applanation Tonometry.” A novel tonometer based on variable force and a fixed area was destined to become the gold standard for measuring intraocular pressure for many decades. This device was based on the modification of the Imbert-Fick law, which asserts that the pressure within a sphere can be estimated if a known force is applied to a fixed area. Full-Text PDF

On February 7, 2020, Dr. Li Wenliang, a fellow ophthalmologist from Wuhan, China, died of infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; now termed COVID-19). Several months earlier, Dr. Li had attempted to warn his colleagues of a potential infectious disease outbreak, urging doctors to wear personal protective equipment while examining patients.1Parrish 2nd, R.K. Stewart M.W. Duncan Powers S.L. Ophthalmologists are more than eye doctors: in memoriam Li Wenliang.Am J Ophthalmol. 2020; (Mar 9 [Online ahead of print]. https://doi.org/10.1016/j.ajo.2020.02.014)Abstract Full Text Full Text PDF Google Scholar As 1 of 8 whistleblowers who attempted to sound the alarm about this unusual respiratory illness, Dr. Li is now considered a national and international hero for his efforts. In fewer than 4 months, the outbreak has escalated rapidly from a World Health Organization Public Health Emergency of International Concern to the formal declaration as a Pandemic on March 11, 2020. As of March 26, 2020, there are 413 467 confirmed cases and 18 433 deaths worldwide.2World Health OrganizationCoronavirus disease 2019 (COVID-19). Situation report—65.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200322-sitrep-62-covid-19.pdf?sfvrsn=f7764c46_2Date: 2020Google Scholar A recent widely cited modeling study from Imperial College London suggests that without intervention, 8 of 10 people may be affected, resulting in 510 000 deaths in the United Kingdom and 2.2 million deaths in the United States by the end of the pandemic.3Ferguson N.M. Laydon D. Nedjati-Gilani G. et al.Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand.https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdfDate: 2020Google Scholar In the midst of this chaotic pandemic, the health care systems and its providers are endangered. In particular, front-line health care workers—emergency medicine physicians, intensivists, anesthesiologists, nurses, and many others—have continued to care for massive surges of COVID-19 patients in the setting of health systems ill-prepared for the current level of disease severity. Providers are placed in danger because of worldwide shortages of personal protective equipment (PPE) and lack of well-established protocols that might attenuate health worker risk. Over 9000 health care workers have developed infection internationally, including 3400 in China4The Lancet Editorial BoardCOVID-19: protecting health-care workers.Lancet. 2020; 395: 922Abstract Full Text Full Text PDF Scopus (831) Google Scholar and more than 6200 in Italy,5Stickings T. 37 Italian doctors have died of coronavirus and 6,205 medical workers have been infected, latest figures show. MailOnline.https://www.dailymail.co.uk/news/article-8155987/37-Italian-doctors-died-coronavirus-6-205-medical-workers-infected.htmlDate: 2020Google Scholar as well as hundreds of infections in United States personnel. During this time of a global health emergency, rapid communication, international collaboration, and transparency are critical to inform and adapt better the guidance of precautionary measures when new evidence becomes available. Countries around the world have responded in different ways in managing risk to ophthalmologists and patients in the absence of signs or symptoms of COVID-19. Preparedness through risk mitigation strategies for the public, patient, and providers are warranted and should be informed by available evidence and by our collective, global experience. The gaps in evidence that we face also need to be addressed during this pandemic to guide international consensus and to inform preparedness measures for future outbreaks. The rapidly growing number of COVID-19 patients throughout the world has prompted state and federal authorities to institute measures to contain, suppress, and mitigate the pandemic. Advisory measures include social distancing, working from home, and safe hygiene practices. Legal measures have included global travel restrictions, reduction or postponement of elective and nonurgent health services and surgeries, and government-mandated lockdowns and curfews.6Parodi S.M. Liu V.X. From containment to mitigation of COVID-19 in the US.JAMA. 2020; (Mar 13 [Online ahead of print]. https://doi.org/10.1001/jama.2020.3882)Crossref Scopus (176) Google Scholar Limiting ambulatory care services to time-sensitive or urgent conditions, particularly in high-volume specialties such as ophthalmology, also have been recommended to reduce the potential for transmission in the community and physician offices. However, measures within the clinic also are needed to mitigate risk for patients with urgent or emergent symptoms and those who require routine evaluations as the outbreak abates. Within the ophthalmology clinic, measures can be broadly divided into clinic management, staff protection, and environmental precautions.6Parodi S.M. Liu V.X. From containment to mitigation of COVID-19 in the US.JAMA. 2020; (Mar 13 [Online ahead of print]. https://doi.org/10.1001/jama.2020.3882)Crossref Scopus (176) Google Scholar, 7Chodosh J. Holland G.N. Yeh S. Alert: important coronavirus updates for ophthalmologists.https://www.aao.org/headline/alert-important-coronavirus-contextDate: 2020Google Scholar, 8Li J.O. Lam D.S.C. Chen Y. Ting D.S.W. Novel coronavirus disease 2019 (COVID-19): the importance of recognising possible early ocular manifestation and using protective eyewear.Br J Ophthalmol. 2020; 104: 297-298Crossref Scopus (207) Google Scholar Contacting patients before their appointments to ask those with fever or respiratory symptoms not to attend the clinic is essential. Cessation of elective care with telemedicine implementation in suitable eye conditions further reduces clinic crowding. Active screening of all patients and very limited companions can be instituted via a targeted questionnaire and noncontact temperature check at the clinic or hospital entrance. After check-in, having patients wait in their cars or in open spaces outside the office for cellular phone notification are options, as well as increased spacing between patients in office waiting rooms. For patients with respiratory symptoms or a fever and an urgent or emergent visual symptom, masking the patient, expedient patient movement to the examination room, a prompt focused examination by a provider, and equipment disinfection are critical. With the reduction in patient numbers, an accompanying reduction to only essential personnel limits staff risk. Conversion to virtual meetings often can meet administrative and educational priorities. Leaves of absence for respiratory symptoms or self-quarantine for individuals returning from high-risk travel advisory locations are necessary, whereas health declaration and temperature monitoring of staff should occur daily for those who are in the clinic. Judicious use of PPE, proper training in donning and doffing protocols, and avoidance of physical contact with patients should guide staff–patient interactions. For persons under investigation and those with a confirmed COVID-19 diagnosis, a mask for the patient and full PPE for the provider, including a single-use N95 mask and eye protection, are required. Droplet and fomite precautions are essential when managing patients with urgent or emergent eye disease. In all cases, a disinfection protocol for all potentially contaminated equipment (i.e., slit-lamp biomicroscope, surfaces, indirect ophthalmoscope, lenses) is needed. Large breath shields on slit lamps may act as a barrier to respiratory droplet transmission. Within the United States, strategies are evolving rapidly to develop expert panel subspecialty guidelines that stratify the urgency of in-person examination. Moreover, the use of telemedicine, including home visual function testing, transmission of image and video, and face-to-face interactions via widely available applications, can provide ophthalmologists with opportunities to provide limited care and counseling. Importantly, these interactions may provide reassurance to patients about their disease or may identify symptoms that require an in-person evaluation. To broaden access through widespread use of technology, federal authorities in the United States have waived normal privacy guidelines with categories of telemedicine (Medicare telehealth, virtual check-in, and E-visits).9Centers for Medicare and Medicaid ServicesMedicare telemedicine health care provider fact sheethttps://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheetGoogle Scholar Risk reduction strategies during this outbreak should follow Centers for Disease Control and Prevention standard precautions and transmission-based precautions for contact and respiratory routes of transmission of SARS-CoV2. However, an imperative also exists to use PPE judiciously, given the worldwide shortages for front-line providers. Patients with SARS-CoV-2 infection may be asymptomatic,10Lu X. Zhang L. Du H. et al.SARS-CoV-2 Infection in children.N Engl J Med. 2020; (Mar 18 [Online ahead of print])Crossref Scopus (1782) Google Scholar, 11Pan X. Chen D. Xia Y. et al.Asymptomatic cases in a family cluster with SARS-CoV-2 infection.Lancet Infect Dis. 2020; 20: 410-411Abstract Full Text Full Text PDF PubMed Scopus (416) Google Scholar, 12Luo S.H. Liu W. Liu Z.J. et al.A confirmed asymptomatic carrier of 2019 novel coronavirus (SARS-CoV-2).Chin Med J (Engl). 2020; (Mar 6 [Online ahead of print])Crossref Scopus (38) Google Scholar and shedding seems to be highest in the earliest stage. Thus, asymptomatic carriers of SARS-CoV-2 may confer a particular risk to ophthalmologists during examination.12Luo S.H. Liu W. Liu Z.J. et al.A confirmed asymptomatic carrier of 2019 novel coronavirus (SARS-CoV-2).Chin Med J (Engl). 2020; (Mar 6 [Online ahead of print])Crossref Scopus (38) Google Scholar Specific factors may place ophthalmologists at increased risk of infection during examination of patients compared with the risk experienced by clinicians in other disciplines. Specialties that also may be at higher risk of infection include anesthesiologists, who are routinely exposed to aerosolized respiratory secretions, and otorhinolaryngologists involved in sinus and nasopharyngeal procedures. During the ophthalmic examination, the face-to-face proximity of the slit-lamp biomicroscopic examination may place the ophthalmologist at a higher risk of aerosolized particles from respiratory droplets and contact.13van Doremalen N. Bushmaker T. Morris D.H. et al.Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.N Engl J Med. 2020; (Mar 17 [Online ahead of print])Crossref Scopus (6525) Google Scholar Of the health care workers who died of COVID-19 in Wuhan, 3 were Chinese ophthalmologists who worked in the same unit that included Dr. Li Wenliang, who believed that he had been infected while treating an asymptomatic glaucoma patient.1Parrish 2nd, R.K. Stewart M.W. Duncan Powers S.L. Ophthalmologists are more than eye doctors: in memoriam Li Wenliang.Am J Ophthalmol. 2020; (Mar 9 [Online ahead of print]. https://doi.org/10.1016/j.ajo.2020.02.014)Abstract Full Text Full Text PDF Google Scholar The route of transmission in these cases is unknown, but the upper respiratory system and nasopharynx are a major site of viral infection, and likely present a higher risk to the ophthalmologist than exposure to tear film harboring SARS-CoV2. Recent studies have shown that viral RNA may be observed in association with the small minority of patients who demonstrate conjunctivitis (i.e., <1% of patients with COVID-19 demonstrated conjunctivitis at presentation). Viral RNA has not been identified in the tear film of COVID-19 patients without conjunctivitis to date, but data representing sampling performed early in the disease course when viral load is highest are lacking.14Xia J. Tong J. Liu M. et al.Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection.J Med Virol. 2020; (Feb 26 [Online ahead of print]. https://doi.org/10.1002/jmv.25725)Crossref Scopus (830) Google Scholar, 15Seah I. Anderson E. Kang A. et al.Assessing viral shedding and infectivity of tears in coronavirus disease 2019 (COVID-19) patients.Ophthalmology. 2020; 127https://doi.org/10.1016/j.ophtha.2020.03.026Abstract Full Text Full Text PDF Scopus (323) Google Scholar, 16Seittzman G.D. Doan T. No time for tears.Ophthalmology. 2020; 127 ([In Press] https://doi.org/10.1016/j.ophtha.2020.03.030)Google Scholar The World Health Organization and United States Centers for Disease Control and Prevention have recommended the use of full PPE for the examination of persons under investigation and COVID-19 patients. The face masks can be divided into N95 respirators and surgical masks, and both have different uses. The N95 respirator is designed with filtration requirements to prevent inhalation of small airborne particles and to minimize leakage from the facial seal.17Radonovich Jr., L.J. Simberkoff M.S. Bessesen M.T. et al.N95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial.JAMA. 2019; 322: 824-833Crossref PubMed Scopus (338) Google Scholar As such, it protects the wearer from the inhalation of viral particles. Surgical masks often are fitted loosely but can prevent respiratory droplet transmission and prevent hand-to-face contact. They are considered to be more effective in preventing spread from an infected person wearing the mask to another than in protecting the wearer from infection. In a randomized clinical trial, the use of N95 respirators and surgical masks were found to have comparable outcomes in protection from influenza virus in outpatient settings17Radonovich Jr., L.J. Simberkoff M.S. Bessesen M.T. et al.N95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial.JAMA. 2019; 322: 824-833Crossref PubMed Scopus (338) Google Scholar; however, N95 respirators are the preferred option when dealing with persons under investigation or COVID-19 patients. Countries around the world have responded in varying ways (Table 1) to managing the risk to ophthalmologists and patients in the absence of respiratory symptoms. Within countries, policies may vary regionally (e.g., Milan, Lombardy, may vary from Bologna, Emilia-Romagna). Most ophthalmic clinics have restricted their practices to urgent and emergent cases only, although some practices have suspended ophthalmic services completely.18Henahan S. Italian ophthalmologists facing disaster.https://www.eurotimes.org/italy-in-crisis-after-covid-19-4/Date: 2020Google ScholarTable 1Protective Measures Adopted in Different Eye Hospitals Internationally to Mitigate the Risks of COVID-19 during the Examination of Asymptomatic Routine Eye PatientsCountryOphthalmologistPatientFace MaskGlovesGogglesCapGownSlit-Lamp Biomicroscope ShieldTemperature ScreenFace MaskTemperature ScreenSingle Accompanying Person per PatientReduction in Nonurgent EncountersScreening QuestionsAustralia——————X—XXXXChina (Zhongshan Ophthalmic Center, Guangzhou)X—XXXXXXXXXXItaly (Ospedali Privati Forlì, University of Ferrara)XX———XXXXXXXKorea (Seoul National University)X————XXXXXXXSingapore (Singapore National Eye Center)X————XXX∗In patients with recent travel history in high-risk countries or recent respiratory illness.XXXXUnited Kingdom (Moorfields Eye Hospital)X————XXX∗In patients with recent travel history in high-risk countries or recent respiratory illness.XXXXUnited States Massachusetts Eye and Ear, BostonX————XXXXXXX Emory Eye Center, AtlantaX————XXXXXXX University of California, San FranciscoX————X—X—X†Zero visitors are allowed.XXX = yes; — = no.The practice patterns are limited to only the specific hospital listed on the table and are not representative of all the eye hospitals in the respective country.∗ In patients with recent travel history in high-risk countries or recent respiratory illness.† Zero visitors are allowed. Open table in a new tab X = yes; — = no. The practice patterns are limited to only the specific hospital listed on the table and are not representative of all the eye hospitals in the respective country. In most countries, ophthalmologists and patients are required to wear surgical face masks instead of N95 respirators. On-site temperature screening and regular hand hygiene are required broadly for both patients and doctors. Given the rapid surge of COVID-19 and mortality rates, some countries (e.g., China) have taken a “make no mistake” approach in which ophthalmologists are required to wear full PPE (including N95 masks) for all patients. Many practices (United States, United Kingdom, Europe, China, Korea, Singapore, and Australia) are adopting custom-designed or commercially available slit-lamp breath shields to minimize respiratory droplet transmission during the ophthalmic examination. However, custom-made barriers also could become a potential source of contamination,7Chodosh J. Holland G.N. Yeh S. Alert: important coronavirus updates for ophthalmologists.https://www.aao.org/headline/alert-important-coronavirus-contextDate: 2020Google Scholar and care must be taken to sterilize them properly between each patient encounter. Scientific evidence regarding the effectiveness of these shields is unavailable. In the context of a disease in which person-to-person spread occurs through infected respiratory droplets, the appropriate use of facemasks is particularly contentious, especially when supply constraints must be factored into policy decisions. Within some hospitals in the United States, United Kingdom, and Australia, standard precautions (e.g., wearing surgical face masks for doctors and patients, routine hand hygiene and washing, temperature screening) are taken for asymptomatic patients. In addition, some hospitals actively prohibit the use of surgical masks by doctors and patients within hospital premises. In Singapore, one nuanced approach involves segregation of all doctors to work in 1 location exclusively. Health personnel are divided further into 2 teams to ensure proper isolation between team members. The variation in practice patterns worldwide points to the need for a network of international ophthalmology partners to develop evidence-based consensus on risk mitigation protocols that adequately protect the public, patients, staff, and ophthalmologists. Clear consensus statements with regard to operational issues such as clinic flow protocols, instrument cleaning protocols, and the appropriate use of PPE under different circumstances will help systems in the appropriate allocation of scarce resources. In addition, the mandate to gather evidence during this pandemic that will guide our approach to this, and future outbreaks is clear. After the tragic loss of life and health during the severe acute respiratory syndrome (SARS) epidemic of 2003, many countries have used lessons learned to inform their policies during the current COVID-19 pandemic. We must all do the same. As we face the unique, extraordinary challenges of this pandemic, rapid adaptations are required in the United States and around the world. While in the throes of managing the acute pandemic, we also must not lose sight of the need to prepare our profession, and the medical profession in general, to emerge capable of fully meeting the needs of patients with ophthalmologic conditions that threaten their vision, their independence, and their quality of life. This will require not only a functioning general health infrastructure (people, organizations, facilities, and funding), but also assistance from governmental authorities to recover those elements of the system devastated by the medical and economic consequences of the pandemic. The world’s population, for example, will still need cataract surgery, glaucoma care, corneal transplants, and management of vitreoretinal diseases. Dr. Li Wenliang and other ophthalmology colleagues paid the ultimate price after alerting the world about this global public health crisis.1Parrish 2nd, R.K. Stewart M.W. Duncan Powers S.L. Ophthalmologists are more than eye doctors: in memoriam Li Wenliang.Am J Ophthalmol. 2020; (Mar 9 [Online ahead of print]. https://doi.org/10.1016/j.ajo.2020.02.014)Abstract Full Text Full Text PDF Google Scholar The challenges we face as a discipline are of profound public health impact. By taking action now, we can protect our patients, fellow front-line health care workers, and ophthalmology colleagues. Experience with the COVID-19 pandemic also will inform our ability to protect vision globally in the future as infection threats of varying scale inevitably recur. The authors thank Dr Nikhil Bommakanti for cross-checking the references for the editorial piece. No Time for TearsOphthalmologyVol. 127Issue 7PreviewThe potential for transmission of the 2019 novel coronavirus (SARS-CoV-2) through ocular fluid is a concern for ophthalmologists. In this issue, Seah et al,1 (see page 977 ) from the National Health Care Group Eye Institute in Singapore, report that they were unable to detect SARS-CoV-2 in the tears of 17 patients diagnosed with COVID-19. They conclude the risk of transmission of SARS-CoV-2 through tears likely is low. Although the results are reassuring, risks to ophthalmologists remain because a few caveats must be considered. Full-Text PDF Assessing Viral Shedding and Infectivity of Tears in Coronavirus Disease 2019 (COVID-19) PatientsOphthalmologyVol. 127Issue 7PreviewSevere acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread rapidly across the globe to cause a pandemic. Although it is known to be transmitted via droplets, alternative modes of transmission remain unknown. Transmission through infected ocular tissue or fluid has been a controversy.1,2 It is hypothesized that the nasolacrimal system can act as a conduit for viruses to travel from the upper respiratory tract to the eye. Hence, ocular tissue and fluid may represent a potential source of SARS-CoV-2. Full-Text PDF CorrigendumOphthalmologyVol. 127Issue 8PreviewThe authors of “Preparedness among Ophthalmologists: During and Beyond the COVID-19 Pandemic” (Ophthalmology. 2020;127:569-572) would like to note the following correction to their author listing as it appears in PubMed (corrections in bold): Full-Text PDF Coping with COVID-19: An Italian Perspective on Corneal Surgery and Eye Banking in the Time of a Pandemic and BeyondOphthalmologyVol. 127Issue 9PreviewAs Italy became ground zero for Europe’s coronavirus crisis, our practice was suddenly thrust into a new reality. Similar to most institutions in our country, we currently provide ophthalmic services strictly for urgent cases, including ocular infection, trauma, cancer, and preventable vision loss. During the nationwide lockdown, we have seen 3 to 4 patients in the clinic each day and have performed a limited number of surgeries, thus far only including these 4 procedures: Gundersen conjunctival flap for microbial keratitis refractory to medical therapy, intracameral injection of antibiotics for infection occurring after endothelial keratoplasty, trabeculectomy for uncontrolled glaucoma occurring after penetrating keratoplasty, and urgent keratoplasty such as for infection after multiple failed grafts or impending perforation. Full-Text PDF