COVID-19 Prioritisation
The challenges presented to all ophthalmologists during the COVID-19 pandemic are enormous. Oculoplastic surgeons also face potentially high degrees of viral exposure in clinic and theatre from droplet and aerosol spread. Viral transmission may, or may not, occur from the tears and conjunctiva, but protection of the mouth, nose, and eyes is essential when examining or operating on patients.
BOPSS both supports, and have contributed to, the Royal College of Ophthalmologists’ guidelines. We encourage all our members to refer to their website which contains a wealth of information including;
Protecting Patients Protecting Staff UPDATED 30/03/20
which sets out our core principles of organising ophthalmology services during COVID-19.
This and related documents provide relevant sources of ophthalmology specific guidance and national advice from healthcare organisations and government.
There are also details on appropriate PPE.
Nevertheless, whilst routine procedures are cancelled, there will remain conditions which require immediate or urgent treatment. These are dictated by clinical judgement, but for illustration, some specialty specific examples are in the table below.
| Urgently | Soon | |
| Eyelid | Upper lid entropion or retraction in the presence of progressive sight-threatening corneal exposure | Repair of eyelid lacerations
Repair of severe amblyogenic ptosis with uni or bilateral brow suspension Botulinum toxin injections in case of severe blepharospasm |
| Orbit | Canthotomy and cantholysis for sight-threatening orbital haemorrhage
Drainage of an orbital or periorbital abscess Exenteration in life-threatening infection Orbital incisional or excisional biopsy for life or sight-threatening conditions Repair of orbital fracture in presence of oculo-cardiac reflex |
Evisceration for severe, untreatable infection
Optic nerve sheath fenestration for progressive visual loss Thyroid Eye Disease: Orbital decompression in case of optic neuropathy or uncontrolled orbital congestion Temporal artery biopsy in suspected giant cell arteritis |
| Lacrimal | Decompression of dacryocoele in a neonate
Drainage of an infected mucopyocoele |
Tumour management will also be subjected to delays. In line with Maintenance of Essential Cancer Surgery during the COVID-19 emergency published by NHSE, categorisation of surgical patients will be into 3 levels dependent on the nature of the tumour.
| Priority level 1a
Priority level 1b |
Emergency surgery needed within 24 hours to save life.
Urgent operation needed with 72 hours |
| Priority level 2 | Elective surgery with the expectation of cure, prioritised to within 4 weeks to save life/progression of disease beyond operability
|
| Priority level 3 | Elective surgery can be delayed for 10-12 weeks will have no predicted negative outcome
|
The following suggests a framework appropriate for oculoplastics and all units are encouraged to identify where the cancer hub is for their areas.
| Tumour site | Within 1 month | Within 3 months |
|
Ophthalmology |
Paediatric tumours (category 1): Retinoblastoma, Rhabdomyosarcoma, neuroblastoma, leukemic infiltrates
Eyelid tumours (category 2): Conjunctival tumours (category 2): Intraocular tumours (category 2): Orbital tumours (category 2): CT guided fine needle biopsy can be considered instead of surgery in elderly patients |
Slow growing or long-standing eyelid Basal Cell Carcinoma, squamous cell carcinoma or pagetoid sebaceous gland carcinoma which may not alter long term prognosis (potentially confusing – please clarify). Topical imiquimod can be used in elderly patients with periocular SCC/ BCC as first line instead of surgery
Conjunctival MALToma and squamous cell carcinoma can be treated with topical options such as interferon injections/drops Orbital tumours such as lymphoma, optic nerve glioma, meningioma (compressive neuropathy), Langerhan’s histiocytosis, carcinoid metastasis, etc |
