Prof. Mario Romano tells us about the ocular aspects of COVID19 infection and describes how the Department of Ophthalmology at the Humanitas Gavazzeni/Castelli Hospital in Bergamo is experiencing the pandemic emergency.
Our entire country is experiencing an emergency that in terms of drama and seriousness is comparable only to those of wartime. In the imagination of all of us, most probably, the frames that have remained most impressed and that have most deeply shaken our emotions are those of the army trucks in Bergamo picking up the bodies of deceased patients in numbers now exceeding the crematorium's capacity to handle.
Words in such a tragedy can ring hollow and annoying, but we thought that the direct testimony, professional and human, of an ophthalmologist, the Prof. Mario Romanowho operates in one of the biggest epicentres of the infection, as he heads the Department of Ophthalmology at the Humanitas Gavazzeni/Castelli Hospital in Bergamo.
O.I. Prof. Romano try to tell us what it is like to be a 'doctor' in a context where science still does not seem to be able to provide the answers to which the progress of pharmacological research, medical and genetic therapy has accustomed us in recent decades.
I summarise my thoughts in one sentence: 'End of the delusion of omniscience. We can only contain or let ourselves be affected. We see a community that united struggles, weeps, clutches at an invisible enemy, waiting for the restart. A restart that unfortunately some will not see, just as they will not see the last goodbye of loved ones, the last embrace that even the worst of enemies will not deny.
COVID-19 unfortunately goes further, forcing a friar to give comfort by placing the phone on the bodies and praying with the relatives of the victims remotely. The real value of so much sacrifice will be the clear perception that a community has entered into communion, that solidarity and unity have prevailed, that the things that really matter are very few.
O.I. Can you tell us something about the involvement of the ocular district in COVID19 infection?
We are in the full development phase of the pandemic, therefore, our statements can only be based on the data acquired so far. At the moment, it is considered possible transmission for conjunctival routebut not all possible ocular involvement of the virus is known.
However, numerous ocular involvement (conjunctivitis, uveitis, neuritis, retinitis) in animal models and a case of conjunctivitis and bronchiolitis in a patient with CoV-NL639 was reported.
If we consider the structures and distribution of cell receptors in the ocular and respiratory systems, we can assume that in SARS-CoV-2 infection there is a risk of transmission via the lacrimal and conjunctival route.
Although SARS-CoV-2 infection has recent origins, the first studies have already been carried out, albeit on rather small samples, on patients who tested positive for the new coronavirus in tears and conjunctival secretions. In particular, a study published on 19 February 2020 in the Journal Of Medical Virology, hypothesised that the new virus could be detected in the conjunctival secretions of positive patients with conjunctivitis. The researchers succeeded, in fact, in isolating viral RNA in tears and conjunctival reverse transcription PCR (RT-PCR), in a positive patient with conjunctivitis; none of the patients without conjunctivitis, however, had viral RNA in the eye.
Also not insignificant could be the potential damage associated with the therapies used to date for in-patients, and in particular ritonavir and hydroxychloroquine, which in literature are associated with damage of the retinal pigment epithelium and telangiectasias etc.
O.I. Based on what you have just told us, how risky can a visit to a patient whose COVID19 positivity is not yet known be for ophthalmologists?
We can certainly state that subjecting even asymptomatic SARS-CoV-2 infected patients to eye examinations carries a risk of infection. Many cases of ophthalmologists infected during routine examinations have already been reported in the literature.
SARS-CoV-2 is a highly contagious pathogen and is mainly transmitted through direct or indirect contact with infected persons via respiratory secretions (droplets) through coughing or sneezing; these droplets can, in fact, come into contact with mucous membranes of people in the vicinity and thus be inhaled into the lungs.
The respiratory tract, however, is probably not the only route of transmission of the new SARS-CoV-2, which is why all doctors should wear appropriate PPE (Personal Protective Equipment) when visiting suspected cases, also bearing in mind that the virus may be present on surfaces on which initial data shows a different half-life: less than 3 hours in aerosols, 3.5 hours on copper, less than hours on cardboard, 13 hours on steel and 16 hours on plastic.
For eye pressure measurements, it is recommended to disinfect the tonometer tip with 70% alcohol solutions, which seem to be sufficient to remove SARS-CoV-2. However, as alcohol would not be sufficient to remove adenoviruses, the best solution may be the use of disposable tonometer tips. Sanitising with bleach may also be a safe and acceptable practice. The best option is certainly the use of the tonometer no contact.
When using the slit lamp, there is close contact with the patient, ophthalmologists should therefore wear protective goggles
O.I. How you manage patient triage in the Department of Ophthalmology during this emergency?
At our hospital we perform two types of triage:
- Telephone triage: patients in need of an ophthalmological consultation are asked a series of questions by telephone before they come to the hospital, in order to minimise the number of people attending the ophthalmological check-up at the facility. The aim is to reschedule appointments with ophthalmic patients, accepting only emergencies.
Patients should also be asked a few triage questions before entering the waiting room about symptoms that could be related to COVID-19 infection, such as fever, cough, dyspnoea, myalgia, anosmia (loss of the ability to perceive odours) or fatigue. Less frequent symptoms such as sputum, headache, haemoptysis and diarrhoea should also be checked.
Bear in mind that some patients present to the ophthalmic emergency room precisely because of conjunctival congestion. - Triage patients: for all those entering the hospital, either from the main entrance or through the triage tents, this procedure is recommended: temperature measurement, hand disinfection and provision of surgical face mask (SM) and gloves to the patient. If the patient tests positive for the symptoms or has a fever, he/she is asked to return home and call the dedicated numbers so that appropriately trained healthcare personnel can go to the patient's home to test for COVID-19.
O.I. Would you like to tell us how your staff, especially the younger ones, experience this emergency?
The doctors and nurses with the specific skills in internal medicine and resuscitation in this pandemic found themselves in the trenches at any moment, and to them goes a feeling of gratitude from everyone for their great sense of responsibility and capacity for sacrifice.
In a situation where the 'frontline' health personnel is not sufficient to contain the pandemic, many have volunteered to perform tasks other than their usual ones, but still useful and necessary to deal with the emergency.
O.I. Has your ophthalmology department undergone a reorganisation of its staff?
The reorganisation of personnel was a necessity imposed by the emergency.
Since the number of outpatient activities is almost zero with the exception of sporadic emergencies, some staff members in the Department of Ophthalmology, on a voluntary basis, have been reassigned to different departments, with mainly administrative and support activities, as needed and after specific training.
In a potential reorganisation, a key aspect is to divide the staff into clearly distinct teams: the first working with COVID-19+ patients and the second with COVID-19- patients, the two teams must be kept absolutely separate in order to minimise the risk of infection.
In particular, colleagues who are in contact with people at higher risk (including pregnant women, immunocompromised persons or patients in very poor health) should be allocated to areas with a low risk of infection.
O.I. We want to close with a message of hope: what do you feel like telling our readers?
Fortunately, we all retain a momentum of positive planning for the near and distant future, filled with a positive existentialism that nourishes our unconscious search for divine traces in helping our neighbour, a resonance of joy, love and serenity. And so everyone, the healed sick, doctors, nurses, the uninfected, all will carry within them, at the end of this profound experience, an awareness of being better men.
This is the only hope, this is the wish we can take today as we look forward with confidence.
Ada Puglisi
Editorial staff
The Italian Ophthalmologist
Mario Romano MD Ph
Director of Ophthalmology Department
Humanitas Gavazzeni - Castelli, Bergamo
Associate Professor of Ophthalmology
Humanitas University, Milan
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