RWC Series: "Facing Challenges from Around the Globe: Covid-19"

By: Şengül Özdek, MD , Professor in Ophthalmology, Gazi University, School of Medicine (Ankara, Turkey)

Affiliations: EVRS Secretary, ASRS, among others.
A Message from Şengül Özdek ~

Impact on Retina Practice

I am Dr. Şengül Özdek from Turkey. I work in Gazi University in Ankara. I also have private office work. The first case was announced at 11th of March. We have had the disease for 3 weeks in Turkey now and the number of cases has reached 25.000 and the death rate is approximately 2% in Turkey right now. The rate seems to be lower than in the other European countries. This is probably because we have a young population and the disease severity is less in young people.

Pandemics of the World

The world has faced many big pandemics throughout its history. The plaque is one of the worst. It was known to during the second century and it came back again and again killing millions of people all over the world. The plague of Justinian, one of the worst of plaque pandemics, started during the 6th Century in the Eastern Roman (Byzantine) Empire and is thought to have killed between 30 to 50 million people, which was half of the world's population at that time. The Black Death came back again originating in China during the 14th century and 25 million people died.

Smallpox (15th - 17th centuries, America continents, 20 million died), Cholera (19th century, India, millions died), Spanish Flu, or H1N1 (1918 – 1919, during 1st world war, infected 1/3 of world population and 50 million died), HIV/AIDS (1981 – present, 75 million infected, 32 million died), Swine Flu, Ebola and Zika are some of them that has scourged the world. The Covid-19 pandemic is not among the worst pandemics in the world’s history. The mortality rate is between 2-12% in different countries till now.

Precautions Taken in Social Life

Schools were closed since 2 days after the announcement of the first Covid-19 case in Turkey (on-line lectures started). Most of the shopping centers, barbers &h air-dressers, and fitness centers were closed. Football matches and other sports events were all canceled. Any concerts, weddings, parties, and other gatherings were cancelled. Discos, pubs, restaurants (only take out foods were allowed) were closed within 10 days after the first case. Curfew started for people over 65 and below 20 years of age. Stay at home messages and social distancing announcements have been everywhere. TV programs are all on the Covid-19 pandemia. All international flights were cancelled last week. Borders were closed. Bus services and any travel from one city to another were stopped. New sitting designs were created for social distancing in public transports. In spite of all of these measures, the curve upward is still too steep in Turkey!

My Approach

I have stopped my international travels since the beginning of February and stopped all others travels by the end of February. I stopped to accept new cases in my private clinic for the last 2 weeks. I am continuing my work in the University Clinic and operating only urgent and emergent cases. We called all the scheduled patients and canceled those which are not so mandatory. Interviews with patients via phone calls were made and home monitoring was emphasized and educating them about what is urgent about their disease. If from out of town, medical reports were sent to the patients to get their injections/control visits in their hometown if possible.

Secretary questions to the patients with phone call before their appointment:
-Any sign of disease: Fever? Cough? Gastroenteritis?
-Any recent contact with a coronavirus infected people?
-Exposure in a crowded place with close contact to people?

If they say yes to any of these questions, their appointment is postponed 2 weeks after quarantine if it is not an urgent case. The intervals between patient appointments is increased to prevent crowds.

Precautions During Exam

We use surgical masks, googles and protective face-shields routinely during examination.

We prefer a “no touch technique” for medical retina follow-up cases by assessing only VA, OCT and CF pictures to decide status and prefer indirect ophthalmoscopy more which provides more distance between you and the patient. I have not examined any known Covid (+) patient till now however, since the number of affected people grows every day, I think we should behave like all the patients were asymptomatic Covid cases and we should wear both surgical and N95 masks and the other personal protective equipment (PPE) properly during exams since we do a very close face to face exam which increase the risk of transmission of the disease.

Ocular Involvement and Possibility of Transmission Through Tears

Ocular transmission of COVID-19 is uncertain. In a study from Singapore (1), neither viral culture nor reverse transcription polymerase chain reaction (RT-PCR) detected the virus in 64 tear samples collected from 17 COVID-19 patients, suggesting a low risk of ocular transmission. However, in another study from China (2), 16.7% of patients were reported to have positive results for SARS-CoV-2 on RT-PCR from both conjunctival and nasopharyngeal swabs. They have also reported that one-third of patients with COVID-19 had ocular abnormalities, which frequently occurred in patients with more severe COVID-19. Almost 1/3 of these patients are reported to have ocular manifestations consistent with conjunctivitis, including conjunctival hyperemia, chemosis, epiphora, or increased secretions (2). It thus seems that transmission through tears may be possible.

Who to Operate? Emergent-Urgent Vitreoretinal Surgical Indications
We operate on the following: open globe injury, acute endophthalmitis with severe vision loss, ROP, acute retinal detachment, retained lens fragments, expulsive choroidal hemorrhage, dense vitreous hemorrhage in a monocular patient, vitreous hemorrhage in which a retinal tear or detachment is suspected. Similar lists have been announced by some societies like AAO, ASRS, and Turkish Ophthalmological Association (TOA) and can be made longer depending on the patient’s monocularity and social conditions.

Macular hole, dislocated intraocular implant lens, diabetic vitreous hemorrhage with no macula-threatening retinal detachment (if not monocular), retained silicone oil, macular epiretinal membrane, and vitreomacular traction are non-urgent, non-elective surgical indications and can be postponed.

On-going Clinics run for acute vision loss, painful eye, ROP screening, early postop surgical follow-up visits and some medical retina cases like intravitreal injections for wet ARMD who need fixed regular injections and cannot tolerate increased intervals. Other non-ARMD related active CNV cases were also given injections but we try to increase the intervals with treat and extend (T&E) regimens with looser criteria for activation. We are more relaxed with diabetic macular edema (DME) cases; if there is an established fixed schedule, it may be continued but we inform patients that it is not a big problem if one or two injections are skipped. This usually does not cause permanent damage.

Family Life: This is the best part of the pandemia. Staying at home, having more time with family, even having dinner together every day is a gift for me. Sleeping enough (I used to sleep 5 hours a day, but now 7-8 hours), completing many academic works waiting for me for a long time, writing papers, preparing online lectures (for students) are the things that I was seeking for a long time. Now I have more time for fitness and sports at home. I love to do it.

Future: Some of our residents have already been charged to Covid clinics in my University Hospital. Probably we will be charged to do the same during the upcoming weeks. We have to do what we have to do. I hope it slows down by summer, but, economic collapse will follow all over the world and crimes and robberies may increase during this period. Life will never be the same afterwards…

One last word: This pandemia has reminded us of something else: to slow down on all the work, to spare more time for ourselves and for loved ones, to put aside the little problems, to stop wasting the world and depleting it, to feel the value of freedom, and to hug the loved ones…

Hope to meet you all in healthy and good days again.
Big hugs to you all…

1.     Ivan Seah Yu Jun, Danielle E. Anderson, Adrian Eng Zheng Kang, Lin-Fa Wang, Pooja Rao, Barnaby Edward Young, David Chien Lye, Rupesh Agrawal. Assessing Viral Shedding and Infectivity of Tears in Coronavirus Disease 2019 (COVID-19) Patients: Ophthalmology (Apr 2020).

2.    Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, Wu K. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol. 2020 Mar 31. doi: 10.1001/jamaophthalmol.2020.1291. [Epub ahead of print]
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