COVID-19 Prioritisation

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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.

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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):
Eyelid melanoma, Merkel cell carcinoma, medial canthal basal cell carcinoma invading orbit, rapidly growing squamous cell carcinoma and sebaceous gland carcinoma

Conjunctival tumours (category 2):
Conjunctival melanoma

Intraocular tumours (category 2):
Uveal melanoma, uveal metastasis, ocular lymphoma

Orbital tumours (category 2):
Lacrimal gland malignant tumours, (eg Adenoid cystic carcinoma but not Pleiomorphic adenoma), orbital metastasis, rapid onset orbital mass.

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



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