5 Ways COVID-19 Is Changing Clinical Ophthalmic Care

Treatment of a cataract by a surgical method.
The current COVID-19 pandemic requires rethinking some procedural protocols in ophthalmology practice.

The COVID-19 crisis is changing American life in innumerable ways — especially for healthcare workers. Research shows that 11% of all US cases of COVID-19 occur in healthcare workers.1 For ophthalmologists, protective measures against the virus may require more than donning personal protective equipment (PPE) and following standard sterilization protocols. It may, in fact, necessitate modifying every aspect of ophthalmic care. As the pandemic progresses with no end in sight, the academic literature continues to find new ways to protect physicians, staff, and patients while medical care is delivered. 

Here, Ophthalmology Advisor shares 5 ways ophthalmologists can help limit the spread of the virus while continuing to provide quality patient care.

1. Embrace Immediately Sequential Bilateral Cataract Surgery

Even before the pandemic had us limiting our exposure to the outside world, researchers have been advocating for immediately sequential bilateral cataract surgery (ISBCS) for both its economic benefit and its safety profile.2,3 

According to an opinion piece by by Iqbal “Ike” Ahmed, MD, et al in September’s Ophthalmology, ISBCS can help minimize nonessential exposure.4

Although the risk of bilateral postoperative endophthalmitis or toxic anterior segment syndrome (TASS) may be a concern, the authors argue that, when proper aseptic technique are followed, no cases of either bilateral endophthalmitis or TASS following ISBCS exist in the literature.4

2. Opt for a Smaller Phaco Tip, Corneal Coating

According to a Bristol Eye Hospital-affiliated study, visible aerosol is generated during phacoemulsification when using a 2.75-mm tip but not with a 2.2-mm tip.5 The research also shows that visible aerosol production can be stymied by first coating the cornea with hydroxypropyl methylcellulose (HPMC).5 

Phacoemulsification, according to the authors, may create a vapor plume, which has some researchers classifying it as an aerosol-generating procedure that could potentially spread the virus.5 But the new study suggests that the effect can be squelched with the right tools.5 Using HPMC also eliminated visible aerosol production, and this effect lasted for an average of 67±8 seconds of continuous phacoemulsification.

3. Tape Insecure Face Masks

The greatest risk of transmission of SARS-CoV-2 probably comes from coughing, sneezing, and talking — which is why mask policies have been widely implemented.6 But when patients are receiving intravitreal injections, improperly worn masks may harm more than help.7

Researchers report that patients wearing most types of surgical face masks were found to experience air jets that radiate toward their eyes, delivering potentially infectious flora from their own mouths, nose, and face to the injection site.7 Improperly sealed masks focused the air jets upward toward the eyes in 81% of patients wearing 3 types of surgical masks.1 Although rare, this kind of contamination can lead to endophthalmitis, the authors say. The team suggests taping the upper edges of face masks with medical adhesive tape or using an adhesive surgical drape around the injected eye.1

To establish the presence of these air jets, researchers employed thermal cameras. The masks investigated included surgical face masks with 4 tying strips, surgical face masks with elastic ear loops, and 2200 N95 tuberculosis particulate face masks. The leaks were detected across all 3 mask types.7

Improperly sealed masks were also criticized for their propensity to aggravate dry eye.8 “When a mask sits loosely against the face, the likely route is upwards. This forces a stream of air over the surface of the eye, creating conditions that accelerate tear film evaporation, leading to dry spots on the ocular surface and discomfort” authors for the Centre for Ocular Research and Education reported.9 That group also advised taping masks down for long-term use.9

4. Update Your Slit Lamp Etiquette

Slit lamps put practitioners face-to-face with patients. Before COVID, doctors may not have considered wearing items such as disposable gowns that provide coverage of the shoulders and arms, gloves, and surgical caps for these examinations. But a new study into particle spread suggests doing precisely that. In addition, it strongly advocates adding a breath shield to the slit lamp.10 However, breath shields are not fail-safe and should not be used in place of other PPE. Additional research shows sneezes can skirt these devices up to 54% of the time.11

Perhaps it’s too much to simply ask your patients not to sneeze, but you can ask them to keep conversation to a minimum, especially while they are positioned at an instrument, as the virus can remain stable for several days on plastic chin rests and stainless steel surfaces, opening up the potential for spread between patients.12 That’s why leaders of the American Academy of Ophthalmology are advocating for a “no-talking” policy while at the slit lamp.13

5. Pack Up Your Puff Tonometer 

Researchers have long known that noncontact tonometry, which uses a forced puff of air, can generate microaerosol droplets.14 When patients are carrying virus in their tears or conjunctiva, the forced air can spread these droplets around the room, leaving virus particles that may hang in the air. In the case of SARS-CoV-2, research shows it can remains viable in aerosols for up to 3 hours.15  Additionally, investigators have found that SARS-CoV-2 is present in the tears of patients both with and without associated viral conjunctivitis.16 So, screening patients for conjunctivitis as a means to determine if puff tonometry is appropriate will not necessarily protect your staff. While patients may find it preferable to contact-tonometry, they will certainly appreciate remaining coronavirus-free. Researchers suggest using a disposable device to evaluate a patient’s intraocular pressure instead.13 

No precautions are guaranteed to prevent viral spread. Keeping yourself, your staff, and your patients safe from infection in your office requires a sophisticated, multipronged attack. SARS-CoV-2 is reshaping the world, but with scientific research guiding the way, it can still be a world where ophthalmologists offer excellent care safely.


  1. Papoutsi E, Giannakoulis V, Ntella V, Pappa S, Katsaounou P. Global burden of COVID-19 pandemic on healthcare workers. ERJ Open Res. 2020;6(2):00195-2020. doi: 10.1183/23120541.00195-2020
  2. Herrinton L, Liu L, Alexeeff S, Carolan J, Shorstein N. Immediate sequential vs. delayed sequential bilateral cataract surgery: retrospective comparison of postoperative visual outcomes. Ophthalmol. 2017;124(8):1126-1135. doi: 10.1016/j.ophtha.2017.03.034
  3. Rush SW, Gerald AE, Smith JC, et al. Prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the United States. J Cataract Refract Surg. 2015;41:732-739. doi: 10.1016/j.jcrs.2014.07.034
  4. Ahmed I, Hill W, Arshinoff S. Bilateral same day cataract surgery: an idea whose time has come #COVID-19. Ophthalmol. [Published online September 1, 2020]. doi: 10.1016/j.ophtha.2020.08.028
  5. Darcy K, Elhaddad O, Achiron A, et al. Reducing visible aerosol generation during phacoemulsification in the era of COVID-19. Eye. doi: 10.1038/s41433-020-1053-3
  6. Koshy ZR, Dickie D. Aerosol generation from high speed ophthalmic instrumentation and the risk of contamination from SARS COVID19. Eye. Published June 4, 2020. Accessed September 7, 2020. doi: 10.1038/s41433-020-1000-3
  7. Hadayer A, Zahavi A, Livny E, et al. Patients wearing face masks during intravitreal injections may be at a higher risk of endophthalmitis. Retina. 2020;40:1651-6. doi: 10.1097/IAE.0000000000002919.
  8. Moshirfar M, West WB, Marx DP. Face mask-associated ocular irritation and dryness. Ophthalmol Ther. 2020;9(7):397-400. doi: 10.1007/s40123-020-00282-6
  9. CORE alerts practitioners to mask-associated dry eye (MADE). Centre for Ocular Research & Education (CORE). University of Waterloo’s School of Optometry & Vision Science. https://core.uwaterloo.ca/news/core-alerts-practitioners-to-mask-associated-dry-eye-made/. Published August 31, 2020. Accessed September 7, 2020. 
  10. Felfeli T,  Mandelcorn E. Assessment of simulated respiratory droplet spread during an ophthalmologic slitlamp examination. JAMA Ophthalmol. [Published online August 18, 2020]. doi:10.1001/jamaophthalmol.2020.3472
  11. Liu J, Wang A, Ing E. Efficacy of slit lamp breath shields. Am J Ophthalmol. [Published online May 11, 2020]. doi: 10.1016/j.ajo.2020.05.005
  12. Seitzman GD, Doan T. No time for tears. Ophthalmol. 2020;127(7):980-981. doi: 10.1016/j.ophtha.2020.03.030
  13. Stevenson S. AAO: New recommendations to eyeMDs for urgent, nonurgent care amid COVID-19. Ophthalmology Times. https://www.ophthalmologytimes.com/view/aao-new-recommendations-eyemds-urgent-nonurgent-care-amid-covid-19. March 18, 2020. Accessed September 7, 2020.
  14. Britt JM, Clifton BC, Barnebey HS, Mills RP. Microaerosol formation in noncontact ‘air-puff’ tonometry. Arch Ophthalmol. 1991;109(2):225-8. doi: 10.1001/archopht.1991.01080020071046
  15. van Doremalen N, Bushmaker T, Morris D, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020;382(16):1564-1567. doi:  10.1056/NEJMc2004973
  16. Valente P, Federici M, Petroni S, et al. Ocular manifestations and viral shedding in tears of pediatric patients with coronavirus disease 2019: a preliminary report. Journal of AAPOS. [Published online June 9, 2020]. doi: 10.1016/j.jaapos.2020.05.002