The Implications of COVID-19 to Ophthalmology.

The coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to ophthalmology. At least 16 ophthalmologists worldwide have succumbed to COVID-19. It reflects the susceptibility of ophthalmologists to COVID-19 infection as they are in close proximity to patients. This chapter provides an overview of the ocular manifestations of COVID-19, risks of COVID-19 to ophthalmologists and patients, clinical service adjustments due to COVID-19, and infection control measures to minimize the transmission of COVID-19 in ophthalmic practice.

The use of short message service (SMS) to reduce outpatient attendance in ophthalmic clinics during the coronavirus pandemic.

PURPOSE: In order to minimize the risk of transmission of coronavirus disease 2019 (COVID-19), many clinic appointments were postponed to lower patient attendance. Actively calling patients to postpone appointments is a labour-intensive process. We were the first ophthalmic clinics in Hong Kong to use short message service (SMS) to dispatch messages simultaneously to a large number of patients to offer postponement of appointments. The aim of this study is to evaluate whether SMS is an effective method to reduce outpatient attendance during the COVID-19 pandemic. METHODS: This is an observational study reviewing data on SMS messages sent to all patients attending ophthalmology clinics of a tertiary eye centre in Hong Kong. All SMS were sent at least 5 days before the scheduled appointments. The text message included an enquiry hotline for postponement of appointments and offered drug refill. The study included data from February to April 2020. Two hundred patients were invited to take part in a questionnaire on satisfaction level and reason(s) for appointment rescheduling. RESULTS: During the study period, a total of 17,028 SMS were sent. The overall response rate was 23.6%. 14.3% postponed their appointments. This led to an overall 13.9% reduction of clinic attendance. The overall satisfaction was high (96%). The main reason for postponing appointment was worries about infection risk (93.1%). CONCLUSION: SMS was an efficient and cost-effective flow-control method which was well accepted by patients and can reduce outpatient attendance. The time saved can potentially allow healthcare workers to conduct other infection control measures during the COVID-19 pandemic.

Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong.

PURPOSE: Coronavirus disease (COVID-19) has rapidly emerged as a global health threat. The purpose of this article is to share our local experience of stepping up infection control measures in ophthalmology to minimise COVID-19 infection of both healthcare workers and patients. METHODS: Infection control measures implemented in our ophthalmology clinic are discussed. The measures are based on detailed risk assessment by both local ophthalmologists and infection control experts. RESULTS: A three-level hierarchy of control measures was adopted. First, for administrative control, in order to lower patient attendance, text messages with an enquiry phone number were sent to patients to reschedule appointments or arrange drug refill. In order to minimise cross-infection of COVID-19, a triage system was set up to identify patients with fever, respiratory symptoms, acute conjunctivitis or recent travel to outbreak areas and to encourage these individuals to postpone their appointments for at least 14 days. Micro-aerosol generating procedures, such as non-contact tonometry and operations under general anaesthesia were avoided. Nasal endoscopy was avoided as it may provoke sneezing and cause generation of droplets. All elective clinical services were suspended. Infection control training was provided to all clinical staff. Second, for environmental control, to reduce droplet transmission of COVID-19, installation of protective shields on slit lamps, frequent disinfection of equipment, and provision of eye protection to staff were implemented. All staff were advised to measure their own body temperatures before work and promptly report any symptoms of upper respiratory tract infection, vomiting or diarrhoea. Third, universal masking, hand hygiene, and appropriate use of personal protective equipment (PPE) were promoted. CONCLUSION: We hope our initial experience in stepping up infection control measures for COVID-19 infection in ophthalmology can help ophthalmologists globally to prepare for the potential community outbreak or pandemic. In order to minimise transmission of COVID-19, ophthalmologists should work closely with local infection control teams to implement infection control measures that are appropriate for their own clinical settings.

Occlusion therapy in amblyopia: an experience from Hong Kong.

OBJECTIVES. To review the results of patching for amblyopia management in Hong Kong. DESIGN. Retrospective case series. SETTING. Regional hospital, Hong Kong. PATIENTS. Records of all patients attending Paediatric Ophthalmology Clinic at United Christian Hospital, Hong Kong from 1 January 2009 to 31 March 2009 were retrospectively reviewed. Records of all children who underwent patching for amblyopia in the study period were evaluated. RESULTS. The mean age of 50 children (50 eyes) was 4 (standard deviation, 1; range, 2-7) years and mean pretreatment visual acuity was 0.35 (0.15; 0.02-0.63) [~20/60]. The values for mean, standard deviation, and range of treatment duration were 27, 16, 4-67 months respectively, and corresponding values for prescribed patching per day were 4, 1, 2-8 hours. The mean, standard deviation, and range of visual acuity at final post-treatment assessment were 0.66, 0.16, 0.1-1.0 (~20/30), respectively. The overall success rate (ie final visual acuity >0.7 or 20/30) was 62%. Children with moderate amblyopia (20/40-20/80) and severe amblyopia (20/100-20/400) had success rates of 74% and 55%, respectively. The mean visual acuity improvements for moderate and severely amblyopic children were 2.3 lines and 5.8 lines, respectively. The mean, standard deviation, and range of patching prescriptions for moderate and severely amblyopic children were 5, 1, 2-7 hours and 5, 1, 3-6 hours, respectively. Recurrence ensued in 7% of the children with moderate amblyopia and 46% of those with severe amblyopia. Reported compliance was good (>75% of the time) in 68% of the children. CONCLUSION. Occlusion therapy is the mainstay of treatment in Hong Kong. The overall success rate was comparable to that achieved in the Amblyopia Treatment Study. Recurrence was more common in patients with severe amblyopia, for whom maintenance therapy may reduce the risk of recurrence. The duration of treatment was much longer in our locality than in western countries. Reported compliance was suspicious possibly due to traditional cultural contexts. It is important to emphasise compliance to all parents.

Presumed bilateral choroidal metastases from mucoepidermoid carcinoma of the submandibular gland.

PURPOSE: To report a case of presumed bilateral choroidal metastases from mucoepidermoid carcinoma of submandibular gland. METHODS: Case report. A 52-year-old lady with history of left submandibular gland mucoepidermoid carcinoma developed bilateral choroidal metastases unresponsive to chemotherapy. She presented with a 3-week history of left eye pain. Fundoscopy revealed bilateral yellowish choroidal lesions associated with inferior exudative retinal detachment. B-scan ultrasonography showed high internal reflectivity of both lesions. Fluorescein angiography revealed pinpoint foci of hyperfluorescence over the choroidal lesion with late leakage. The patient declined positron emission tomography scan, radiotherapy, and surgical intervention. She eventually succumbed 5 months after the initial presentation. RESULT: Our case is the first case report on clinically presumed bilateral choroidal metastases from mucoepidermoid carcinoma of the submandibular gland. CONCLUSION: There are few reported cases of ocular metastasis from salivary gland tumors, mostly adenoid cystic carcinoma. To the best of our knowledge, this is the first reported case of bilateral choroidal metastases from mucoepidermoid carcinoma of the submandibular gland.

Double peel using triamcinolone acetonide and trypan blue in the management of myopic macular hole with retinal detachment: a case-control study.

PURPOSE: To evaluate the safety and efficacy of double peel using triamcinolone acetonide (TA) and trypan blue (TB) in removing epiretinal tissues in vitrectomy for myopic macular hole with retinal detachment (MHRD). METHODS: Prospective interventional case control study. Patients with myopic MHRD underwent vitrectomy with TA-assisted adherent cortical vitreous (ACV) removal followed by TB-assisted internal-limiting membrane (ILM) peeling and gas tamponade. The results were compared with historical control group without the use of any vital dye or TA. RESULTS: Ten eyes of 10 study cases were compared with nine eyes of nine control cases. Mean axial length was 28.3 ± 1.4 mm and 29.6 ± 2.4 mm and mean follow-up period was 15 months and 42 months for the study group and the control group, respectively. Reattachment rate was 70% in the study group and 44% in the control group. Mean logMAR visual acuity improvement was 0.02 at 6 months and 0.01 at 12 months for the study group (P < 0.05). Transient intraocular pressure rise was observed in seven eyes in the study group and five eyes in the control group. No other complication was noted. CONCLUSION: Double peel using TA and TB appeared safe and effective in facilitating removal of ACV and ILM in MHRD. It has higher surgical success rate compared with conventional vitrectomy with epiretinal membrane peeling and gas tamponade.

Safety enhanced photodynamic therapy for chronic central serous chorioretinopathy: one-year results of a prospective study.

PURPOSE: To evaluate the efficacy of a safety enhanced photodynamic therapy (PDT) protocol with half-dose verteporfin for treating chronic central serous chorioretinopathy (CSC). METHODS: Forty-eight eyes of 48 patients with symptomatic chronic CSC underwent indocyanine green angiography guided PDT with half dose (3 mg/m) verteporfin. Outcome measures included logMAR best-corrected visual acuity (BCVA), central retinal thickness, and angiographic changes during the 12-month study period. RESULTS: The mean CSC duration was 8.2 months (range, 3-40 months). At 12 months after PDT, the mean logMAR BCVA improved from 0.31 to 0.15 (P < 0.001). The mean improvement was 1.6 lines and 45 (95.8%) eyes had stable or improved vision. Eyes without pigment epithelial detachment (PED) had significantly greater visual improvement compared with eyes with PED (P = 0.031). Patients with CSC of 6 months or less or younger than 45 years were more likely to gain vision by two or more lines after treatment (P = 0.007 and P = 0.018, respectively). Forty (83.3%) eyes had complete resolution of serous detachment at 3 months, with 43 (89.6%) eyes at 12 months. CONCLUSIONS: The safety enhanced PDT protocol appeared to be beneficial for patients with chronic CSC. Further controlled study is warranted to evaluate the safety and efficacy of this treatment option.

Pseudomonas aeruginosa choroidal abscess in a patient with bronchiectasis.

PURPOSE: To report a case of Pseudomonas aeruginosa endophthalmitis with choroidal abscess formation in a patient with bronchiectasis. METHODS: Case report. RESULTS: A 75-year-old gentleman with bronchiectasis and P. aeruginosa pneumonia developed painless loss of right eye vision. The patient had previously undergone bronchoscopy to exclude pulmonary neoplasm. Slit-lamp examination revealed intense anterior chamber inflammation with hypopyon and B-scan ophthalmic ultrasound showed a choroidal mass consistent with choroidal abscess. Systemic and topical antibiotics did not prevent further progression of the infection. Patient declined pars plana vitrectomy and opted for enucleation. Polymerase-chain-reaction-based restriction fragment-length polymorphism (PCR-RFLP) of the enucleated eye confirmed P. aeruginosa to be the causative organism. CONCLUSION: P. aeruginosa cannot be completely eradicated by systemic antibiotics, and bronchial colonization of P. aeruginosa can remain a potential source for metastatic infection. P. aeruginosa choroidal abscess, previously reported only in patients with cystic fibrosis, can also occur in bronchiectasis. Physicians should therefore have a high index of suspicion of endogenous endophthalmitis and treat aggressively, especially in patients with subretinal invasion and abscess formation.

Corneal injury by wild taro.

We report a case of crystalline keratopathy caused by Alocasia macrorrhiza. The diagnosis was made based on the observation of needle-like crystals in the corneal stroma following injury to that eye. The condition resolved in 3 months with the disappearance of the crystals confirmed by follow-up confocal microscopy.

Encapsulated triamcinolone cyst after subtenon injection.

The authors report the formation of a subtenon cyst following subtenon triamcinolone injection for chronic recurrent uveitis in Behçet's disease. The steroid was inadvertently placed superficially in the anterior subtenon space and was encapsulated eventually to present as a subtenon cyst. The episode of uveitis recurrence, which did not regress, required treatment with a repeat posterior subtenon injection 2 months later. The cyst was removed 4.5 months after the initial subtenon injection, when the patient underwent a trabeculectomy for refractory glaucoma. Histological examination of the cyst revealed a fibrous encapsulated cavity filled with small birefringent crystals, consistent with an encapsulated triamcinolone collection. Fibrous encapsulation of triamcinolone crystals can arise after a superficially placed anterior subtenon injection and this may impede the absorption of the corticosteroid and hamper its effectiveness in treating ocular inflammatory diseases.

The use of peribulbar anaesthesia in paediatric cataract surgery (age 7-15 years) in a mobile eye camp in China.

AIM: To evaluate the feasibility and acceptability of the use of peribulbar anaesthesia (PA) in paediatric cataract surgery in rural areas in China, where there are limitations in expertise and equipment for general anaesthesia (GA). METHODS: We prospectively evaluated the feasibility and acceptability of carrying out paediatric cataract surgery under PA in children aged 7-15 years. Informed consent was obtained from the subjects and their parents. Children were assessed for their suitability for PA. Peribulbar anaesthesia was given as a peribulbar block using a 2% lidocaine, 0.5% bupivacaine-hyaluronidase mixture administered before lens aspiration with intraocular lens implantation. The acceptability of the PA was evaluated by questionnaire. RESULTS: A total of 19 patients were recruited. Their mean age was 12 +/- 2 years (range 7-15 years). None required conversion to GA. All subjects regarded PA as either totally acceptable (63.2%) or acceptable (36.8%). The mean pain scores (from 0 to 100) during the injection and surgery were 28 +/- 26 and 6 +/- 8, respectively. Seventeen patients (89.5%) said they would prefer PA if choices in anaesthesia were offered again. CONCLUSIONS: Peribulbar anaesthesia can be considered as a viable option in selected children undergoing cataract surgery when facilities for safe and optimal general anaesthesia are unavailable.

Intravitreal triamcinolone for diabetic macular oedema in Chinese patients: six-month prospective longitudinal pilot study.

AIM: To evaluate the safety and efficacy of intravitreal triamcinolone (IVTA) in Chinese patients with diabetic clinical significant macular oedema (CSMO). METHODS: Eighteen eyes of 17 consecutive patients with CSMO were prospectively recruited and treated with a 4 mg injection of IVTA. Best-corrected visual acuity (BCVA) on the ETDRS chart and central macular thickness (CMT) on optical coherence tomography were measured at baseline weeks 1, 2, 3, and months 1, 2, 3, 4, 5 and 6. Side-effects were monitored. RESULTS: All patients completed 6 months of follow up. The mean baseline BCVA and CMT were 1.20 +/- 0.31 logMAR units and 552 +/- 179 microm, respectively. Improvements in CMT and BCVA were observed as early as at 1 and 2 weeks, respectively (P < 0.05). Mean BCVA peaked at 2 months (0.97 +/- 0.38 logMAR units) while mean CMT was maximally reduced at 3 months (326 +/- 145 microm). Improvements in BCVA and CMT were less afterwards but still statistically significant at 6 months; the final mean BCVA and CMT were 0.99 +/- 0.36 logMAR units and 427 +/- 145 microm, respectively. A total of 5/18 (28%) eyes developed a transient increase in intraocular pressure. Cataract progression was noted in 2/12 (17%) of the phakic eyes. CONCLUSIONS: Intravitreal triamcinolone appeared generally safe and effective in Chinese patients with CSMO. Although the improvements in BCVA and CMT were transient, there were residual benefits at 6 months. Due to the transient nature of IVTA, re-treatment seems necessary but the optimal timing and dosage will require further investigations.