• People who might have had a travel history or possible contact with an infected person are asked to self-isolate or are quarantined. 8 Health care workers, especially in a hospital setting, are on the front line in the efforts against this pandemic. [9] [10] [11] There is considerable concern in the ophthalmic community about the risk of infection as there is increasing information that the initial infectious dose (amount of virus transmitted) and resulting high viral load may increase the risk of severe COVID-19 disease. 12, 13 Protecting yourself and your patients from COVID- 19 
The COVID-19 pandemic is having profound repercussions around the world. 1 
There are a number of guidelines on how to adapt services and adjust practice to limit the spread of infection in a clinical setting; however, the evidence is still limited. This uncertainty, the many differences between countries and individual clinical settings, and ongoing practical challenges such as shortages in personal protective equipment (PPE) means that things will be changing all the time and eye health workers will have to adapt and make the best of what is available to them at the time.
Guidelines are also changing constantly to reflect new research as it comes in. We encourage you to visit the websites given in the panel to receive further updates. The Centers for Disease Control (CDC) provides guidance for dealing with PPE shortages at https://bit.ly/PPEguide.
The particular context of an eye health service will influence how the guidelines can be put into practice, such as the availability of personal protective equipment (PPE), access to emergency care for known COVID-19 patients, and the available means of communication.
The current guidelines can be summarised as follows:
1 Cease providing any routine eye services other than urgent or emergency care 2 Protect health care workers 3 Reduce transmission to other patients, and between patients and health care workers 1. Cease providing any routine eye services other than urgent or emergency care
Postpone or defer any non-urgent eye appointments. Patients coming to an eye clinic or eye unit are at risk of exposure to COVID-19 infection, and many patients attending for eye care are elderly or suffer from underlying chronic medical conditions such as diabetes; they are at increased risk of severe COVID-19 and social distancing is therefore particularly important for them.
Also, reducing eye care services can release health workers to be deployed to other areas of health care where they may be able to play an important role during the pandemic.
Where there is an appointment system in place, defer pre-existing appointments by text message/phone message, letter or other means, as available. Conducting a telephone consultation may be helpful to give advice or, if necessary, decide whether a face-to-face review is essential. When issuing a prescription, follow local guidelines. Ideally, send patients written information about any appointment deferrals, the advice given and how new appointments will be made once the situation allows. If possible, set up pathways for urgent/emergency care together with measures to reduce transmission, as discussed in this article. Tell patients how they can gain access to such care.
There will be patients who need to be seen and treated urgently. Services should continue to be provided, where possible, to patients at high risk of visual loss without treatment. This may include people with the conditions such as these 18 Whether it is appropriate for patients to be seen for urgent/emergency eye care will depend on the individual patient, the risk of significant harm if treatment is delayed and the situation of the eye care provider. Having only one seeing eye would be a strong factor in favour of a patient being seen, for example. If possible, patients should stay away from eye health care settings if they are older than 70 years, have serious pre-existing health problems, or are immunosuppressed. 
Symptoms & when to self-isolate Symptoms of cough, fever, shortness of breath or flu-like symptoms are typical in COVID-19, but others are also common, including loss of taste and smell. 23 It is vital to inform patients and health care workers with symptoms of COVID-19 that they should not come to the hospital or clinic, but should self-isolate (i.e., stay at home and avoid contact with other members of the household) for seven days. The United Kingdom's National Health Service (NHS) guidelines state that people who still have a high temperature after 7 days of self-isolation must remain at home until their temperature returns to normal. 24 The incubation period for COVID-19 is thought to range from 1 to 14 days, with symptom onset typically around 5 days; these estimates will be updated as more data becomes available. 4 Patients may be infectious before showing any symptoms, and some may show no symptoms at all. A person who has been in contact with someone known to have COVID-19 should self-isolate for 14 days, until such time as WHO guidance is updated. 4 It is important to follow national guidelines. Communicate this information to patients as early as possible, so that patients who need to self-isolate do not travel to the unit in the first place. If they do arrive at the unit, there should be very clear information to prevent infection spread; e.g., telling patients to return home and self-isolate ( Figure 1 ). 
Some dental procedures (e.g. high-speed drilling) Non-invasive ventilation (e.g., CPAP and laryngeal masks)
• High-frequency oscillatory ventilation (HFOV) • Induction of sputum • High-flow nasal oxygen
Defer surgical procedures where possible. If surgery cannot be avoided, this should be done under local anaesthesia if possible, taking full precautions. General anaesthesia is an 'aerosol-generating procedure' (AGP) which creates a high-risk environment for virus transmission. However, even surgery under local anaesthesia will involve significant exposure between medical personnel and patient and should be considered high risk. If surgery must be undertaken, then full PPE should be used for all patients.
Self-care and personal protection • Wash hands regularly and thoroughly; normal soap is adequate. Use alcohol-based (>60% ethanol or >70% isopropyl alcohol) hand sanitiser or hand gel if hands are visibly clean and water is not available.
• Staff members and patients/visitors must wash their hands using soap and water or alcohol-based hand sanitiser or hand gel on entering the unit.
• Avoid touching your eyes, nose and mouth.
• If available, use appropriate PPE. Guidelines are constantly being updated; however, there is an increasing recognition of the role of eye protection ( Table 2 ). This is something that may be dictated by health management at a higher (regional/national) level.
• Clinical staff not in uniform who are in close contact with patients should wear surgical scrubs. These should be laundered daily in accordance with the unit's policy on the safe laundering of clinical garments.
• The same surgical mask may be worn for multiple patients to be seen at the slit lamp. However, scrupulous care must be taken not to transmit the virus on the front of the mask via hands or clothes. If using the same mask, do not take on and off between patients and do not allow it to dangle on the chest. Never touch the front of the mask.
• Put on and remove PPE in an order that minimises the potential for self-contamination (see panel).
• The use of a cloth face covering does not replace a surgical mask or respirator, however, they may be better than no covering at all. 29, 30 COMMUNITY EYE HEALTH JOURNAL | VOLUME 33 | NUMBER 108 | 2020 S4 • Prominent information posters at the entrance to the unit should alert anyone who arrives to return directly home if they have symptoms and to stay at least 2 metres away from others. If urgent/emergency care is required, they should be directed to an isolation area where they can be examined by health care personnel wearing protective equipment.
• A health care worker should ask patients about possible symptoms on arrival at the booking-in or reception area and direct them appropriately.
• Patients and visitors must wash their hands using soap and water alcohol-based (>60% ethanol or >70% isopropyl alcohol) hand sanitiser or hand gel on entering the unit.
• Some countries advise that patients wear masks to limit transmission to medical personnel or other patients. [25] [26] [27] [28] • The use of a cloth face covering does not replace a surgical mask or respirator, however, they may be better than no covering at all. 29, 30
C. While examining the patient • Minimise patient contact time by reviewing the notes beforehand.
One suggestion is for the patient to be placed in one room and the clinician in another and for them to talk via a phone or a tablet computer. The clinician then enters the patient room, conducts the examination as swiftly as possible (without talking) and exits the room.
• Avoid shaking hands, or any other patient contact, as much as possible.
• Use slit lamp barriers (breath guards or breath shields), Figure 3 .
These may be available commercially or they can be made from materials such acetate sheets (used for overhead projectors), clear plastic or Perspex. Cut holes for the slit lamp eyepieces; it may help to use a cardboard template. • Remember to clean the breath guard, on/off switch and any controls or buttons when cleaning the slit lamp.
• Keep waiting rooms as empty as possible, with preferably at least 2 metres between individuals.
• Prevent overcrowding in the examination room by restricting entry by accompanying persons where possible.
• Routine daily cleaning of the clinic environment with appropriate disinfectants is vital.
Reusing eye protection COVID-19 can cause conjunctivitis and virus particles may be found in ocular secretions. 31 There is debate as to whether conjunctivitis is a high-risk feature for COVID-19. Although a follicular conjunctivitis can be caused by the virus, this seems to be a relatively uncommon and a non-specific sign that presents later in the clinical course. However, a health care worker who was part of an expert task force to visit Wuhan developed conjunctivitis as the first symptom of COVID-19 despite being fully gowned with protective suit and N95 respirator. 32 Health care workers have subsequently been urged to wear eye protection when in close contact with patients; this is also reflected in recently updated guidance. 15, 33 Many cases of conjunctivitis do not actually require review and it is important that patients with possible symptoms of COVID-19 are instructed to self-isolate unless they require hospital in-patient care. If a patient does present with any conjunctivitis, it would seem sensible to wear full PPE until more is known.
The CDC acknowledges that eye protection is often reusable, not disposable, and provides the following guidelines on re-use. 34 When manufacturer instructions for cleaning and disinfection are unavailable, consider these steps:
1 While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a cleaning wipe or a clean cloth saturated with pH-neutral detergent solution.
2 Use a wipe or clean cloth saturated with a registered hospital disinfectant solution to wipe the outside of the face shield or goggles carefully.
3 Wipe the outside of face shield or goggles with clean water or 70% alcohol to remove residue.
4 Fully dry (air dry or use clean absorbent towels).
5 Remove gloves and perform hand hygiene. 