International survey on COVID‐19 pandemic: personal protective measures during fundus examination
2021-05-21

Due to the close distance and the need for thorough examinations, ophthalmologists are at increased risk of acquiring the SARS-CoV-2 virus during the current pandemic (Raevis et al. 2021). Although wearing a nose-mouth mask (NMM) is effective at preventing infections (Chu et al. 2020), fogging of the indirect lens, spectacles and oculars can compromise the quality of the fundus examination. We report on the results of an open online survey among ophthalmologists. The international enquiry was designed with an open-source web tool (LimeSurvey version 3.24.3, Germany) and advertised during November 2020 (Media MICE, Singapore: 68 482 deliveries, open/response rate: 7.3%/0.8%; Texere Publishing Inc, USA: 10 026 deliveries, open/response rate: 20.0%/1.4%; CGO Gerling, Germany: 10 180 deliveries; 2312 personal mails). After 1.122 accesses to the survey, 687 ophthalmologists gave answers on their behaviour. The majority of participating physicians (84.0%) practised in Europe. Descriptive statistics using SPSS (IBM SPSS Statistics version 27.0.0.0, IBM Corporation, USA) confirmed an even distribution of all age groups and genders. Participating ophthalmologists mostly did not wear spectacles (48.8%), whereas 11.8% said they wore them sometimes and 39.5% stated they had glasses (Maragakis et al. 2020). With regards to the fogging of the indirect lens, closing off the upper rim of the patient's NMM was ranked as the most important measure (n = 225), while additional disinfection was mentioned most frequently overall (n = 484) (Fig. 1). 375 ophthalmologists had their patients take the NMM off or place it under the chin; this behaviour was reported by significantly more ophthalmologists under 40 years old than over 40 years old. One third reported having reduced the number of fundus examinations (n = 295). Especially older colleagues switched more often to the head ophthalmoscope with a greater distance between indirect lens and the cornea. Regarding the ophthalmologists' spectacles and oculars, 35% reported a reduction in retinal examinations to a minimum. However, the most frequently mentioned answers included measures to influence the escape of one's own breathing air (tight NMMs, stopping breathing, masking). One third of the spectacle wearers took their NMMs off for the examination. Some of the feedback, and possibly the low participation rate, indicated that not all ophthalmologists experienced fogging eyepieces as a relevant problem. During the COVID-19 pandemic, fogging of lenses and glasses has made thorough retinal examinations more difficult. An important factor is probably the type and the air-tight closure of the NMM. Touching the upper part of the mask may expose to more significant virus load in individual patients (Deng et al. 2020). Other approaches to prevent fogging are patching and changing the temperature of instruments. Anti-fog coatings and fluids of different materials such as proteinoid polymers are available. Although physical proximity without a sealing patient's mask is likely to increase the risk of COVID-19 infection, it seems to be a part of ophthalmic practice: Removal of the mask of patients was reported even more frequently by the ophthalmologists than removing their own mask. Both measures must be viewed critically because the risk of aerosol exposure is likely to increase immediately. Similarly, the effectiveness of several other methods (e.g. breath holding) has yet to be assessed, and the survey responses should in no way be taken as recommendations. The renunciation of fundus examinations, just like the impairment caused by a reduced view, increases the risk that lesions requiring treatment or clinically relevant lesions are likely to be more frequently overlooked during the pandemic. This could result not least in treatment errors and malpractice claims, as telehealth offers better applications in diseases related to cornea and external disease diagnoses (Portney et al. 2021). Future studies still need to investigate whether the use of tape, preheated and prepared lenses (clips) or wide-angle photography for targeted questions represent a safe and suitable approach.