EyeWorld Asia-Pacific June 2021 Issue

NEWS & OPINION 54 EWAP JUNE 2021 risk in the recognition and treatment of patients infected with SARS-CoV-2. Studies positively identified both ACE-2 and TMPRSS2 expression on the human ocular surface. The detection of viral shedding in the tear film raised awareness among eyecare providers that office-based transmission from infected patients to providers and their staff could involve more than just the commonly described aerosol droplet route. The transmission of SARS-CoV-2 from patient to provider is a common concern in the delivery of ophthalmic care due to the necessary close proximity of the interaction 2 . It is rarely considered, however, that this same interaction simultaneously introduces the risk that a provider might pose in transmission of virus to the ophthalmology patient. The ophthalmologist may be well protected, but can the same be said for the patient? Ophthalmologists routinely practice a variety of safety precautions for personal and patient protection. After administrative protocols have been established there are further protective maneuvers through environmental control and the use of personal protective equipment (PPE). Data indicate, however, that PPE and masks, while helpful in reducing risks, are not perfect. Infectious aerosols can pass through and around masks even with proper use and fit. This incomplete protection is especially relevant in ophthalmology where the patient’s exposed ocular surface is necessarily in close proximity (within the nominal hazard zone) to the eye care provider at almost every step. A direct ophthalmoscopic examination takes place at a distance of less than 5 cm between provider and exposed patient’s ocular surface. Barrier protection and PPE are beneficial, but do not provide an impermeable construct to the patient’s ocular surface. Evolving transmission reduction protocols for COVID-19 have been developed in almost every medical specialty. One major effort of adoption is complementary therapeutic strategies (CTS) that work alongside vaccines and PPE to reduce aerosolization and dispersion of transmissible particles. Nasal and oral antisepsis as an adjunct to the use of masks is increasingly being recognized as an important CTS, analogous to handwashing in addition to the use of gloves. Advocacy for dilute topical PVP-I as a means of CTS has been specifically recommended by ophthalmologists to protect mucosa of the eyes, nose, and mouth. 3 Low-dose PVP-I nasal and oral preparations show rapid anti-SARS-CoV-2 viricidal efficacy and clinical trials have been broadly supportive with respect to reducing viral load and titers. 4 The risk of inadvertent transmission of the SARS-CoV-2 from healthcare providers to at-risk patients and vice versa may be underappreciated. The ocular surface represents a large surface area that is contiguous with the nasopharynx and deeper respiratory tree. Ophthalmologists are duty driven to protect patients and providers during ocular care within the ophthalmic environment. Part of this protection may include using both the science of PVP-I and the intuition of a physician to disrupt infection before it can establish on the ocular surface and migrate along the eye- nasopharynx-lung axis. Routine topical ophthalmic antisepsis as specified in the recent Perspectives article in APJO, 1 may provide a more effective means of breaking the chain of viral transmission. EWAP Reference 1. O’Brien TP, Pelletier J. Topical Ocular Povidone-Iodine as an Adjunctive Preventative Practice in the Era of COVID-19. Asia Pac J Ophthalmol (Phila). 2021 Mar 23;10(2):142–145. doi: 10.1097/APO.0000000000000353. PMID: 33793439; PMCID: PMC8016473. 2. Kuo IC, O’Brien TP. COVID-19 and ophthalmology: an underappreciated occupational hazard. Infect Control Hosp Epidemiol . 2020 Oct;41(10):1207–1208. doi: 10.1017/ice.2020.238. Epub 2020 May 15. PMID: 32412403; PMCID: PMC7256213. 3. Pelletier JS, et al. Reducing transmission of SARS-CoV-2 in ophthalmology with nasal and oral decontamination. Ther Adv Ophthalmol . 2020 Aug 26;12:2515841420951392. doi: 10.1177/2515841420951392. PMID: 32923943; PMCID: PMC7453452. 4. Frank S, et al. In Vitro Efficacy of a Povidone-Iodine Nasal Antiseptic for Rapid Inactivation of SARS-CoV-2. JAMA Otolaryngol Head Neck Surg . 2020 Nov 1;146(11):1054-1058. doi: 10.1001/ jamaoto.2020.3053. PMID: 32940656; PMCID: PMC7499242. Editors’ note: Dr. O’Brien is Professor of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, U.S., and declared no conflicts of interest. Dr. Pelletier is a cornea and external disease specialist, Ocean Ophthalmology Group, North Miami Beach, U.S., and co-founder of Halodine, LLC.