Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong
Identifieur interne : 000263 ( Pmc/Corpus ); précédent : 000262; suivant : 000264Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong
Auteurs : Tracy H. T. Lai ; Emily W. H. Tang ; Sandy K. Y. Chau ; Kitty S. C. Fung ; Kenneth K. W. LiSource :
- Graefe's Archive for Clinical and Experimental Ophthalmology [ 0721-832X ] ; 2020.
Abstract
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.
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.
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.
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.
Url:
DOI: 10.1007/s00417-020-04641-8
PubMed: 31776657
PubMed Central: 7087729
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PMC:7087729Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong</title><author><name sortKey="Lai, Tracy H T" sort="Lai, Tracy H T" uniqKey="Lai T" first="Tracy H. T." last="Lai">Tracy H. T. Lai</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Ophthalmology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Department of Ophthalmology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</nlm:aff></affiliation></author><author><name sortKey="Tang, Emily W H" sort="Tang, Emily W H" uniqKey="Tang E" first="Emily W. H." last="Tang">Emily W. H. Tang</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Ophthalmology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Department of Ophthalmology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</nlm:aff></affiliation></author><author><name sortKey="Chau, Sandy K Y" sort="Chau, Sandy K Y" uniqKey="Chau S" first="Sandy K. Y." last="Chau">Sandy K. Y. Chau</name><affiliation><nlm:aff id="Aff3">Department of Pathology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</nlm:aff></affiliation></author><author><name sortKey="Fung, Kitty S C" sort="Fung, Kitty S C" uniqKey="Fung K" first="Kitty S. C." last="Fung">Kitty S. C. Fung</name><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Pathology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</nlm:aff></affiliation></author><author><name sortKey="Li, Kenneth K W" sort="Li, Kenneth K W" uniqKey="Li K" first="Kenneth K. W." last="Li">Kenneth K. W. Li</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Ophthalmology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Department of Ophthalmology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">31776657</idno><idno type="pmc">7087729</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7087729</idno><idno type="RBID">PMC:7087729</idno><idno type="doi">10.1007/s00417-020-04641-8</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000263</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000263</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong</title><author><name sortKey="Lai, Tracy H T" sort="Lai, Tracy H T" uniqKey="Lai T" first="Tracy H. T." last="Lai">Tracy H. T. Lai</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Ophthalmology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Department of Ophthalmology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</nlm:aff></affiliation></author><author><name sortKey="Tang, Emily W H" sort="Tang, Emily W H" uniqKey="Tang E" first="Emily W. H." last="Tang">Emily W. H. Tang</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Ophthalmology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Department of Ophthalmology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</nlm:aff></affiliation></author><author><name sortKey="Chau, Sandy K Y" sort="Chau, Sandy K Y" uniqKey="Chau S" first="Sandy K. Y." last="Chau">Sandy K. Y. Chau</name><affiliation><nlm:aff id="Aff3">Department of Pathology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</nlm:aff></affiliation></author><author><name sortKey="Fung, Kitty S C" sort="Fung, Kitty S C" uniqKey="Fung K" first="Kitty S. C." last="Fung">Kitty S. C. Fung</name><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Pathology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</nlm:aff></affiliation></author><author><name sortKey="Li, Kenneth K W" sort="Li, Kenneth K W" uniqKey="Li K" first="Kenneth K. W." last="Li">Kenneth K. W. Li</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Ophthalmology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Department of Ophthalmology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</nlm:aff></affiliation></author></analytic><series><title level="j">Graefe's Archive for Clinical and Experimental Ophthalmology</title><idno type="ISSN">0721-832X</idno><idno type="eISSN">1435-702X</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Purpose</title><p id="Par1">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.</p></sec><sec><title>Methods</title><p id="Par2">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.</p></sec><sec><title>Results</title><p id="Par3">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.</p></sec><sec><title>Conclusion</title><p id="Par4">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.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Chang, De" uniqKey="Chang D">De Chang</name></author><author><name sortKey="Xu, Huiwen" uniqKey="Xu H">Huiwen Xu</name></author><author><name sortKey="Rebaza, Andre" uniqKey="Rebaza A">Andre Rebaza</name></author><author><name sortKey="Sharma, Lokesh" uniqKey="Sharma L">Lokesh Sharma</name></author><author><name sortKey="Dela Cruz, Charles S" uniqKey="Dela Cruz C">Charles S Dela 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Graefes Arch Clin Exp Ophthalmol</journal-id><journal-id journal-id-type="iso-abbrev">Graefes Arch. Clin. Exp. Ophthalmol</journal-id><journal-title-group><journal-title>Graefe's Archive for Clinical and Experimental Ophthalmology</journal-title></journal-title-group><issn pub-type="ppub">0721-832X</issn><issn pub-type="epub">1435-702X</issn><publisher><publisher-name>Springer Berlin Heidelberg</publisher-name><publisher-loc>Berlin/Heidelberg</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">31776657</article-id><article-id pub-id-type="pmc">7087729</article-id><article-id pub-id-type="publisher-id">4641</article-id><article-id pub-id-type="doi">10.1007/s00417-020-04641-8</article-id><article-categories><subj-group subj-group-type="heading"><subject>Miscellaneous</subject></subj-group></article-categories><title-group><article-title>Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong</article-title></title-group><contrib-group><contrib contrib-type="author"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0002-0420-9456</contrib-id><name><surname>Lai</surname><given-names>Tracy H. T.</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Tang</surname><given-names>Emily W. H.</given-names></name><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Chau</surname><given-names>Sandy K. Y.</given-names></name><xref ref-type="aff" rid="Aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Fung</surname><given-names>Kitty S. C.</given-names></name><xref ref-type="aff" rid="Aff4">4</xref></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0001-9440-8063</contrib-id><name><surname>Li</surname><given-names>Kenneth K. W.</given-names></name><address><email>kennethli@rcsed.ac.uk</email></address><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Ophthalmology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</aff><aff id="Aff2"><label>2</label>Department of Ophthalmology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</aff><aff id="Aff3"><label>3</label>Department of Pathology, Tseung Kwan O Hospital, 2 Po Ning Path, Tseung Kwan O, Hong Kong SAR</aff><aff id="Aff4"><label>4</label><institution-wrap><institution-id institution-id-type="GRID">grid.417037.6</institution-id><institution-id institution-id-type="ISNI">0000 0004 1771 3082</institution-id><institution>Department of Pathology, United Christian Hospital,</institution></institution-wrap>130 Hip Wo Street, Kwun Tong, Kowloon, Hong Kong SAR</aff></contrib-group><pub-date pub-type="epub"><day>3</day><month>3</month><year>2020</year></pub-date><fpage>1</fpage><lpage>7</lpage><history><date date-type="received"><day>21</day><month>2</month><year>2020</year></date><date date-type="rev-recd"><day>25</day><month>2</month><year>2020</year></date><date date-type="accepted"><day>26</day><month>2</month><year>2020</year></date></history><permissions><copyright-statement>© Springer-Verlag GmbH Germany, part of Springer Nature 2020</copyright-statement><license><license-p>This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.</license-p></license></permissions><abstract id="Abs1"><sec><title>Purpose</title><p id="Par1">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.</p></sec><sec><title>Methods</title><p id="Par2">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.</p></sec><sec><title>Results</title><p id="Par3">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.</p></sec><sec><title>Conclusion</title><p id="Par4">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.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Coronavirus</kwd><kwd>COVID-19</kwd><kwd>Hong Kong</kwd><kwd>Infection control</kwd><kwd>Ophthalmology</kwd><kwd>SARS-CoV-2</kwd></kwd-group></article-meta></front><body><sec id="Sec1"><title>Introduction</title><p id="Par5">Coronavirus disease (COVID-19) has rapidly emerged as a global health threat. The name COVID-19, which stands for coronavirus disease 2019, was proposed by the World Health Organization (WHO) [<xref ref-type="bibr" rid="CR1">1</xref>]. The virus was officially named as ‘severe acute respiratory syndrome coronavirus 2’ (SARS-CoV-2) [<xref ref-type="bibr" rid="CR2">2</xref>]. The incubation period of COVID-19 falls within 2 to 14 days according to the Centers for Disease Control and Prevention (CDC) [<xref ref-type="bibr" rid="CR3">3</xref>], although the incubation period could be up to 24 days in rare cases [<xref ref-type="bibr" rid="CR4">4</xref>]. Symptoms of the infection include fever, cough, fatigue, myalgia, dyspnoea and diarrhoea. Computed tomography scans showed patchy shadows or ground glass opacities in the lungs. Complications include acute respiratory distress syndrome, arrhythmia and shock, and the mortality rate was 2.3% according to a large-scale retrospective study [<xref ref-type="bibr" rid="CR5">5</xref>]. SARS-CoV-2 is highly contagious and has evolved into a global health threat within weeks. As of 27 February 2020, there were 82,294 confirmed cases involving 47 countries [<xref ref-type="bibr" rid="CR6">6</xref>]. There were 92 confirmed cases of COVID-19 in Hong Kong, including both imported and local cases [<xref ref-type="bibr" rid="CR7">7</xref>]. This paper aims to share our local experience to help ophthalmologists globally to take necessary measures to minimise COVID-19 infection of both healthcare workers and patients.</p></sec><sec id="Sec2"><title>The risks of COVID-19 to ophthalmologists and patients</title><p id="Par6">According to the WHO, during previous coronavirus outbreaks such as SARS, human-to-human transmission occurred through droplets, contacts and fomites, suggesting that the mode of transmission of COVID-19 could be similar [<xref ref-type="bibr" rid="CR8">8</xref>]. As of 14 February 2020, 1716 healthcare workers in China were infected with COVID-19 and six of them died [<xref ref-type="bibr" rid="CR9">9</xref>]. One of them was Dr. Li Wenliang, an ophthalmologist at Wuhan Central Hospital. In early January, he contracted COVID-19 from an asymptomatic glaucoma patient and succumbed to the disease one month later [<xref ref-type="bibr" rid="CR10">10</xref>]. There were anecdotal reports suggesting that individuals may be infected by patients with subclinical infection [<xref ref-type="bibr" rid="CR11">11</xref>], either by droplets or by direct contact with secretions from infected cases followed by subsequent inoculation into mucous membranes. Anecdotal reports suggested that when no eye protection was worn, the virus could also possibly be transmitted by aerosol contact with conjunctiva and cause infection [<xref ref-type="bibr" rid="CR12">12</xref>–<xref ref-type="bibr" rid="CR14">14</xref>]. Hence the close proximity between ophthalmologists and patients during slit lamp examination and direct ophthalmoscopy may pose an infectious risk to ophthalmologists. Ophthalmologists may also be caught off guard as conjunctivitis, though uncommon, could be the first presenting symptom of COVID-19, before the appearance of other symptoms such as cough and fever [<xref ref-type="bibr" rid="CR12">12</xref>, <xref ref-type="bibr" rid="CR13">13</xref>]. The American Academy of Ophthalmology has issued an alert advising ophthalmologists to wear masks and eye protection when seeing conjunctivitis patients with respiratory symptoms and history of international travel [<xref ref-type="bibr" rid="CR14">14</xref>]. Moreover, in 2003, the SARS coronavirus was isolated from SARS patients’ tear samples [<xref ref-type="bibr" rid="CR15">15</xref>] and thus, it is possible that the novel coronavirus may also be present in tears of COVID-19 patients.</p><p id="Par7">Globally, we, as ophthalmologists, are facing an ageing population and thus, most ophthalmic clinics are extremely busy and crowded. Elderly patients also appear to be at increased risk of severe COVID-19 infection and mortality [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR16">16</xref>]. Furthermore, since ophthalmic consultations often involve multiple investigations, including visual acuity, intraocular pressure measurement, pupillary dilatation and others, it is not uncommon that patients have prolonged stay in the clinic to complete the whole examination [<xref ref-type="bibr" rid="CR17">17</xref>]. All these factors potentially increase the risk of cross-infection, between patients and between healthcare workers and patients, in outpatient clinics in ophthalmology than other clinical disciplines.</p></sec><sec id="Sec3"><title>Strategies to prevent transmission in ophthalmology outpatient clinics</title><p id="Par8">Since 25 January 2020, Hospital Authority, the public health service provider in Hong Kong, activated the Emergency Response Level in all public hospitals [<xref ref-type="bibr" rid="CR18">18</xref>]. To prevent transmission of COVID-19 in the eye clinic, we adopted the following measures in our ophthalmic clinics at the United Christian Hospital and Tseung Kwan O Hospital in Hong Kong. The two hospitals serve the eastern region of Kowloon peninsula of the Hong Kong Special Administrative Region with a catchment population of over 1,155,000. Both hospitals have inpatient isolation facilities and are responsible for management of COVID-19 infected cases within the region. The infection control measures implemented in ophthalmology were based on detailed risk assessment by both local ophthalmologists and infection control experts. They were based on a three-level hierarchy of control measures: (1) Administrative control, (2) Environmental control and (3) The use of personal protective equipment (PPE).</p><sec id="Sec4"><title>Administrative control</title><p id="Par9">This was the first and most important level of the hierarchy which involved the largest number of people. It was intended primarily to reduce the risk of exposure of uninfected people to people who had COVID-19 disease. These control measures included the following activities:</p><sec id="Sec5"><title>Lowering patient attendance and suspension of elective clinical services</title><p id="Par10">With a daily attendance of over 500 patients in our outpatient clinic, it is important to reduce the number of outpatient attendance to prevent cross-infection in this vulnerable group of patients, as it has been shown that even subclinical patients are capable of transmitting the virus [<xref ref-type="bibr" rid="CR11">11</xref>]. Informing a large number of outpatients to reschedule their appointments is often challenging. We took advantage of short message service (SMS) to send information to patients via their electronic mobile devices, at least one week in advance before their scheduled appointments, providing them with an enquiry phone number so they could call to postpone their appointments and consider drug-refill if appropriate. Out of 1117 SMS sent out during the first week of February 2020, we had an encouraging response rate of 23.5% (262 responses). 24.6% of patient attendance was reduced as a result. Medical records would be screened by ophthalmologists and new appointments were sent out by post.</p><p id="Par11">Non-urgent elective services and operations were suspended in order to reduce the risk of transmission due to people gathering, and to conserve resources such as inpatient beds, manpower and personal protective equipment to combat the outbreak of COVID-19. Such services included elective cataract operations, electrodiagnostic studies, and contact lens clinics etc. Emergency surgeries were maintained.</p></sec><sec id="Sec6"><title>Patient triage</title><p id="Par12">As the model of transmission is mainly by droplets, all personnel in the hospital were requested to put on face masks. Signage and broadcast advising respiratory hygiene and cough etiquette were set up. According to emerging studies, up to 98% of COVID-19 infected cases presented with fever [<xref ref-type="bibr" rid="CR19">19</xref>]. It is therefore necessary to ensure that fever patients are identified before they enter the clinical area. A triage station was set up at the entrance of eye clinic. All patients and their accompanying persons were screened using infra-red thermometers. Fever patients were provided with health advice pamphlets and were advised to seek medical attention and reschedule their eye clinic appointments if their eye conditions were non-urgent. Those with urgent eye conditions and fever were seen by the on-call ophthalmologist either at the Accident and Emergency Department, inpatient isolation rooms or inpatient wards after admission.</p><p id="Par13">For afebrile patients, questionnaires to screen for TOCC (<bold>T</bold>ravel to affected areas during the incubation period, <bold>O</bold>ccupation, <bold>C</bold>ontact of a suspected or confirmed case, <bold>C</bold>luster of cases) were administered by triage nurses (Fig. <xref rid="Fig1" ref-type="fig">1</xref>). Patients fulfilling the following criteria were also identified: (i) patients (or patients who have family members or accompanying persons) who travelled to outbreak areas within 14 days, (ii) patients with symptoms of upper respiratory tract infection, such as cough, and (iii) patients with acute conjunctivitis. If they fulfil any of the above criteria, their clinic appointments would be postponed for at least 14 days, which is current understanding of the incubation period of COVID-19 [<xref ref-type="bibr" rid="CR3">3</xref>]. Any patient who fulfilled any of the above criteria but required urgent ophthalmic attention would be diverted to a separate waiting area and seen by a designated ophthalmologist in a special room. Dedicated equipment and instruments were used and not shared with the other consultation rooms. Figure <xref rid="Fig2" ref-type="fig">2</xref> illustrates the patient triage workflow.<fig id="Fig1"><label>Fig. 1</label><caption><p>Questionnaire on Fever, Travel, Occupation, Contact and Clustering (FTOCC)</p></caption><graphic xlink:href="417_2020_4641_Fig1_HTML" id="MO1"></graphic></fig><fig id="Fig2"><label>Fig. 2</label><caption><p>Patient triage in the ophthalmology outpatient clinic. Abbreviations: A&E - Accident and Emergency Department; TOCC - Travel, Occupation, Contact and Clustering</p></caption><graphic xlink:href="417_2020_4641_Fig2_HTML" id="MO2"></graphic></fig></p><p id="Par14">To prevent cross-infection, inpatient consultations from other specialties were seen in respective parent wards instead of the outpatient eye clinic.</p></sec><sec id="Sec7"><title>Reduction of aerosol and droplet generation in ophthalmology</title><p id="Par15">As medical experts recently suggested that COVID-19 is capable of aerosol transmission [<xref ref-type="bibr" rid="CR20">20</xref>], routine aerosol generating procedures in ophthalmic practice should be suspended.</p><p id="Par16">Non-contact tonometry (NCT) is a potential source of microaerosol [<xref ref-type="bibr" rid="CR21">21</xref>]. Using a camera and flash that were electrically coupled to a NCT machine, Britt et al. [<xref ref-type="bibr" rid="CR21">21</xref>] studied the disruption of tear film when a pulse of pressurized air was blown towards the eyes. They reported tear film dehiscence and microaerosol formation. Therefore, it is prudent to suspend the use of non-contact tonometry in outbreak areas. Other ways of intraocular pressure measurement, such as i-Care tonometry or Goldmann applanation tonometry should be used instead. With the use of disposable tips in tonometry, the risk of cross-infection should be minimised.</p><p id="Par17">Ophthalmologists who performed endoscopic dacryocystorhinostomy often perform nasal endoscopy preoperatively and postoperatively. As nasal endoscopy may irritate the nasal mucosa and provoke sneezing, and often involves suction of nasal discharge, it poses an infectious risk to the operator and should be avoided as much as possible. If unavoidable, appropriate personal protection equipment should be utilised [<xref ref-type="bibr" rid="CR22">22</xref>].</p><p id="Par18">If ophthalmic surgery needs to be done, it should preferably be done under local anaesthesia and not general anaesthesia, as endotracheal intubation is of aerosol generating nature [<xref ref-type="bibr" rid="CR22">22</xref>]. If emergency operation under general anaesthesia is inevitable (e.g. macula-on retinal detachment repair), ophthalmologists should work closely with anaesthetists and internal physicians to ensure COVID-19 rapid test is done for fever and TOCC positive cases before proceeding under general anaesthesia [<xref ref-type="bibr" rid="CR23">23</xref>]. For patients who tested positive, patients who tested negative but were clinically suspicious, or in ultra-urgent cases when it was not feasible to wait for the test result, the operation would be performed in an isolation operating theatre and all staff would wear isolation gowns, N95 respirators and protective eyewear.</p></sec><sec id="Sec8"><title>Infection control training and staff monitoring</title><p id="Par19">All staff should undergo infection control training to familiarise themselves with the proper steps of hand hygiene and donning and doffing of personal protective equipment. All clinical staff were required to measure and report their own body temperatures before work, and report any symptoms such as fever, chills, myalgia, sore throat, runny nose, cough, vomiting, diarrhoea or pneumonia. Staff were encouraged to report their travel histories after returning from holidays.</p></sec></sec><sec id="Sec9"><title>Environmental control</title><p id="Par20">The aim of environmental control was to prevent the spread and reduce the concentration of infectious droplet in ambient air. Air ventilation at the waiting areas was enhanced via opening of the fresh air dampers in the air handling equipment to achieve a higher fresh air rate with improved air dilution. Mobile high efficiency particulate air (HEPA) units were added to augment the total air change rates in waiting areas where necessary.</p><p id="Par21">The close proximity between ophthalmologists and patients during slit lamp examination puts ophthalmologists at risk of infection, as droplets from a cough or sneeze can travel up to six feet [<xref ref-type="bibr" rid="CR24">24</xref>]. To lower the risk of transmission via droplets, protective shields (made of plastic) were installed on slit lamps (Fig. <xref rid="Fig3" ref-type="fig">3</xref>). These shields acted as barriers to droplets and they were cleaned and disinfected after every clinic session, or if the shields were visibly soiled or contaminated. Equipment such as slit lamps and binocular indirect ophthalmoscopes, and environmental surfaces that were frequently touched by healthcare workers and patients (such as doorknobs, phones, and computer keyboards) were disinfected according to local disinfection guidelines.<fig id="Fig3"><label>Fig. 3</label><caption><p>Protective shield installed on a slit lamp</p></caption><graphic xlink:href="417_2020_4641_Fig3_HTML" id="MO3"></graphic></fig></p><p id="Par22">To minimise gathering of staff for academic meetings, the use of video conference via personal mobile devices was helpful and encouraged. Appropriate distancing between diners in canteens should be adopted, for instance, staff were recommended to sit in one-way direction.</p></sec><sec id="Sec10"><title>Use of personal protective equipment (PPE)</title><p id="Par23">The first two control levels reduce the areas of exposure to SARS-CoV-2 but do not eliminate the risk in the areas where exposure could still occur (for example, isolation rooms housing COVID-19 patients, or treatment rooms in which aerosol-generating procedures were performed on COVID-19 patients). The use of personal protective equipment in these situations could further reduce the risk of exposure of healthcare workers to infectious droplets expelled from a patient with infectious COVID-19 disease.</p><p id="Par24">Under the Emergency Response level in Hong Kong, universal masking in all hospitals and clinics was practiced. Eye protection equipment such as visors or protective eyewear were provided to all ophthalmologists and surgical masks were worn by both ophthalmologists and patients. Ophthalmologist attending higher risk patients at designated areas took extra precautions and wore full personal protective equipment including isolation gown, gloves, cap, eye protection, and surgical mask (or N95 respirator when necessary). Hand hygiene is particularly important and ophthalmologists should practise hand hygiene using the WHO formula alcohol hand rub or hand washing after every patient encounter. If gloves were worn, they were removed followed by hand hygiene between cases.</p></sec></sec><sec id="Sec11"><title>Conclusion</title><p id="Par25">Hong Kong was hard hit by the SARS coronavirus in 2003, costing the lives of 299 Hong Kong people. A total of 405 healthcare workers were infected and eight of them succumbed to SARS [<xref ref-type="bibr" rid="CR25">25</xref>, <xref ref-type="bibr" rid="CR26">26</xref>]. 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. Nevertheless, due to variations in outbreak severity and individual hospital settings in different localities, we suggest ophthalmologists to consult their local infection control experts for detailed risk assessment before deciding on the extent of infection control measures to be implemented in their own clinical settings. As the novel coronavirus infection is still in uprising trend, it is of paramount importance to remain vigilant and start taking necessary measures to prevent its transmission.</p></sec></body><back><fn-group><fn><p><bold>Publisher’s note</bold></p><p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p></fn></fn-group><ack><title>Acknowledgements</title><p>The authors would like to dedicate this paper to all members of the Departments of Ophthalmology, Specialist Outpatient Departments, Infection Control Teams and Information Technology Departments of United Christian Hospital and Tseung Kwan O Hospital for their tremendous effort and contributions in combating COVID-19. The authors thank Ms. Monica Lee, Department Operations Manager of Ophthalmology, for her excellent coordination.</p></ack><notes notes-type="ethics"><title>Compliance with ethical standards</title><notes notes-type="COI-statement"><title>Conflict of interest</title><p id="Par26">All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.</p></notes><notes><title>Ethics approval</title><p id="Par27">This article does not contain any studies with human participants performed by any of the authors.</p></notes><notes><title>Informed consent</title><p id="Par28">Informed consent was not required as this article does not contain any studies with human participants performed by any of the authors.</p></notes></notes><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><mixed-citation publication-type="other">WHO Director-General's remarks at the media briefing on 2019-nCoV on 11 February 2020. 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