Optometric Physician

A weekly e-journal by Art Epstein, OD, FAAO


Volume 20, Number 14

Monday, March 30, 2020


Inside this issue: (click heading to view article)
######### Off the Cuff: Whiplash
######### Contact Lens Practice in the Time of COVID-19
######### The Possibility of Covid-19 Transmission From Eye to Nose
######### News & Notes

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Off the Cuff: Whiplash

Last week I said I wasn’t going to focus on COVID-19, but like the outbreak itself, things change with each passing day; sometimes with each passing hour. The magnitude of the crisis is hard to fathom as I worry about my many friends throughout the US and in heavily impacted countries throughout the world. The continuing uncertainty gives life a surreal quality that is grotesquely uncomfortable and unfamiliar. I pride myself on being prepared, and I was as well prepared as anyone could have been. Yet I was still totally unprepared. All of the N95 masks, the stored food, the hand sanitizer, and all of the guns and ammunition in the world have no value if I can’t use them to protect the people I most care about.

This miserable virus has forced pause in what was a non-stop life. It feels odd to not be in an airport traveling somewhere or in the office seeing patients. Virtually everything normal has come to a standstill, and what remains has taken an entirely different track. It has made me realize how closely knitted we are to each other and how important the people in my life are. Old friendships suddenly have more meaning; people I respect, I now respect even more, and the people I love are more important to me than they have ever been. This damn virus has made me even more committed to my family, friends and my community. I will keep on going, doing as much as I can until we get to the other side of this. I will do my best to help others.

I realize that it is hard to think about the future when the present seems so bleak. But our nature is to persevere and, ultimately, to prevail. For those of you considering giving up, I urge you not to. Certainly not yet and absolutely not without a fight. Yes, many things will change, from social norms to the very nature of the profession. The economy will struggle, but in the end, most all of us will survive, and many will be better for it.

Please keep a few things in mind. COVID-19 is extremely contagious. Some research suggests that beyond contact from contaminated surfaces and direct droplet transmission, aerosolized virus can remain suspended in air for quite some time. It is extremely variable in virulence. Current data shows about a 1.5% mortality rate among confirmed cases in the US, and it has been even more deadly in other countries. Age is no longer considered a major factor for likelihood of infection, and young people are dying. For those who are still seeing patients, keep in mind that patients can be infected, and transmit the virus without having any signs or symptoms. If you are seeing patients, effective disinfection of surfaces and equipment, and protective gear such as N95 masks and slit lamp breath shields are critical for the safety of you, your staff and your other patients. Social distancing is a major protective variable. Make sure that this precaution is observed. I also recommend that patients be screened for fever on entering the office. iHealth has a superb no-touch thermometer currently in stock for $43.99.

On a personal note, I have been blown away by so many in the eye care industry who are working tirelessly to support our profession and our patients even while they struggle with the same issues we are all dealing with. I strongly advise that you listen to this week’s Gary Gerber’s Power Hour podcasts featuring advice, wisdom and perspective from industry leaders. I also want to express my appreciation for the amazing AOA response to the COVID-19 outbreak. Kudos to AOA President Barb Horn and the AOA leadership for a superb job the entire profession should be proud of.

Finally, Shannon and I were humbled by our practice being selected as one of CooperVision’s Best Practices Honorees for 2020. We appreciate this recognition more than words can convey. I will have more to say about it as things return to normal. For now, stay safe. Stay well.

Arthur B. Epstein, OD, FAAO
Chief Medical Editor


Want to share your perspective? Write to Dr. Epstein at artepstein@optometricphysician.com.

The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of the editorial board, Jobson Medical Information LLC (JMI), or any other entities or individuals.



Contact Lens Practice in the Time of COVID-19

It is unfortunately apparent that we are in the middle of an ongoing outbreak of the coronavirus disease that, according the World Health Organization, has now been characterized as a pandemic. It appeared to have started in December 2019 when the first cases of pneumonia of an unknown cause were detected in Wuhan (Hubei, China). This led to a rapid outbreak due to a novel strain of the coronavirus called SARS-CoV-2, which stands for severe acute respiratory syndrome coronavirus 2. The associated disease, now referred to as COVID-19, rapidly spread in mainland China and then in the rest of the world. According to the US Center for Disease Control and Prevention and the European Centre for Disease Prevention and Control, the virus is thought to spread mainly from person-to-person via respiratory droplets transmission. An infected person produces droplets containing viable virus and relays them by sneezing, coughing, or exhaling. The SARS-CoV-2 (as other coronaviruses) can survive for several hours on object surfaces. Although this is not considered the main way the virus spreads, it may be possible that a person can get the virus by touching a surface that has the virus on it and then touching their own mouth, nose or eyes. Of particular concern for ophthalmic practitioners, it should be noted that SARS-CoV-2 has been detected in the tears and conjunctival secretions in COVID-19 patients with conjunctivitis. Contact lens (CL) practice can be particularly exposed to these modalities of transmission.

CL practice involves face-to-face communication, close examination of the patient and need to directly touch a patient's eyelids. Some CLs are still fitted using trial sets, which will need to be cleaned thoroughly between patients. In terms of patient management, efforts should be made to lower patient attendance to CL practices. Each patient should be contacted by phone or email for rescheduling of non-urgent appointments. In the case of a patient attending an appointment, it is important to evaluate the risk that the patient may pose, such as patients who travelled to outbreak areas within 14 days, and patients with cough or conjunctivitis. If patients are deemed to have increased risk factors, postpone appointments for at least 14 days, which is the current understanding of the incubation period of COVID-19. If someone presents with suspected COVID-19 then they should be isolated, and local health services must be informed. Exam rooms, waiting areas and optical areas should be thoroughly cleaned as well as assuring safe distance between patients in the waiting rooms. Personal protective equipment such as eye protection, water-resistant gloves with long tight-fitting cuffs and surgical-style face masks should be adopted. Installation of protective shields on slit lamps and disinfection of CL equipment and CL trial sets is advised. Hand sanitization must be performed via hand washing before and after significant contact with any patient even when gloves are worn. Hand sanitization includes cleansing hands with an alcohol-based hand rub, soap and water, or both. Practitioners must avoid touching their own face, nose, mouth and eyes. Patients should be reminded to clean their CLs correctly, disinfecting fully between usage and not using disposable CLs longer than they are intended. Patients should seek advice if sick and discontinue CL use if they have any malaise.

This outbreak is evolving rapidly, the impact to the public health risks to be massive, with huge economic and social disruption. In the time of coronavirus, CL practice will become more difficult. As CL practitioners, we have the responsibility to minimize the transmission of COVID-19 in CL practice based on current scientific evidence.

SOURCE: Zeri F, Naroo SA. Contact lens practice in the time of COVID-19. Cont Lens Anterior Eye. 2020; Mar 19. [Epub ahead of print].

The Possibility of Covid-19 Transmission From Eye to Nose

The Coronavirus Disease 2019 (COVID‐19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), is not only spreading throughout China but has reached more than 20 countries, and has already posed threats to global health and economy. So far, the number of people infected in China has climbed to more than 70,000. Of them, at least 3,019 healthcare workers have been infected. However, the specific causes of infection among healthcare workers in hospital environments are unclear. It has been confirmed that COVID‐19 is mainly transmitted through both respiratory droplets and direct contact. Aerosols are another possible transmission route requiring attention. In February 2020, a report in The Lancet raised the issue that ocular surfaces may be a potential target for SARS‐CoV‐2 invasion. However, two recent studies do not fully support this assumption. The reason is that although a small number of COVID‐19 patients have conjunctivitis, not all of them show positive test of SARS‐CoV‐2 nucleic acid in conjunctival sac swabs. In addition, some patients did not have conjunctivitis despite positive test results for the SARS‐CoV‐2 nucleic acid in their conjunctiva sac swabs. Interestingly, the medical history of the clinical physicians with COVID‐19 revealed that neither of them used eye goggles when examining (physician 1) and intubating infected patients (a high‐risk procedure to produce aerosol) (physician 2).

Studies show that, like the severe acute respiratory syndrome coronavirus (SARS‐CoV) that caused SARS, SARS‐CoV‐2 binds to human angiotensin‐enzyme II (ACE2), using it as a cell entry receptor to invade respiratory and lung epithelium through the spike (S) protein. However, ACE2 is mainly expressed in posterior tissues of the eye, such as the retina and the retinal pigment epithelium, not in the human conjunctival and corneal epithelium. We presume that these previous studies ignored the characteristics of lacrimal drainage. Tears are constantly renewed by the lacrimal system. Therefore, we speculate that the virus enters the tears through droplets, which may pass through the nasolacrimal ducts and then into the respiratory tract. Combined with all this information, we assert that, when coming into contact with confirmed or suspected cases of COVID‐19, healthcare workers should wear eye safety goggles. This should become one of the critical measures for preventing the spread of COVID‐19. The authors hope this topic is helpful for work in the outbreak area.

SOURCE: Qing H, Li Z, Yang Z, et al. The possibility of COVID-19 transmission from eye to nose. Acta Ophthalmol. 2020 Mar 18. [Epub ahead of print]


News & Notes
Reichert Signs Exclusive Deal for CATS Reusable Tonometer Prisms
Reichert Technologies, a unit of AMETEK’s Ultra Precision Technologies Division, announced its exclusive partnership with CATS Tonometer to distribute the CATS Reusable Tonometer Prism in the United States. The patented CATS Tonometer Prism represents a breakthrough in intraocular pressure accuracy over the traditional Goldmann prism. The CATS Tonometer Prism was designed with a patented dual-curved surface that “cups” the cornea and effectively nullifies IOP measurement errors caused by corneal biomechanics and corneal thickness. The CATS also features a rolled outer edge that minimizes the tear film adhesion—an obstacle for traditional Goldmann prisms. Seamless integration into any existing Goldmann or Perkins tonometer helps enable doctors to easily transition from the Goldmann prism to the CATS Tonometer Prism with no additional training or downtime additional or downtime. Read more.

MicroSurgical Technology Acquires IP & Assets of IRISS Medical Technologies
MicroSurgical Technology has acquired the IP and assets of IRISS Medical Technologies Limited, a United Kingdom private limited company, related to the Volk Eye Check product and additional technology and intellectual property. The Volk Eye Check is a handheld ocular measurement device. It measures and analyzes parameters used to screen and document ocular characteristics such as pupil diameter, horizontal visible iris diameter, interpupillary distance, pupil eccentricity and strabismus angle for contact lens fitting, eyelid surgery, and general diagnostic purposes. This acquisition adds a diagnostic capability to accelerate MST’s digital product development roadmap. Read more.

MyEyeStore Aids in Practice Fulfillment of Patient Products
MyEyeStore can help optometric practices during these difficult times through rapid deployment of an e-commerce website. Patients are able to order contact lenses, dry eye products and more online to be safely delivered to their homes. The site handles fulfillment and inventory, and can help build an online store, handle orders and inventory, and tracking and notifications. Practitioners select products and pricing. Learn more.

ImprimisRx Enters Into Agreement with Doxy.me for Telemedicine Services
Harrow Health and ImprimisRx, a wholly owned subsidiary of Harrow, announced they entered into an exclusive agreement with Doxy.me, a full-service telemedicine solution. This agreement will provide all ImprimisRx ophthalmology, optometry and wellness practices with the Clinic level Doxy.me telemedicine solution at no charge. Doxy.me is a telemedicine software solution providing video, audio and text through which patients and healthcare providers can seamlessly communicate remotely. Read more.

Heidelberg Brings Back In Vivo Corneal Microscope Due to High Demand
Heidelberg Engineering reintroduced its HRT3 Rostock Cornea Module to offer in vivo corneal confocal microscopy in its anterior segment product portfolio. HRT3 RCM is a compact ophthalmic device that uses confocal scanning laser microscopy to provide high-resolution images of the cornea, the conjunctiva or the limbus at the cellular level. Read more.


Optometric Physician™ Editorial Board

Chief Medical Editor
Arthur B. Epstein, OD, FAAO

Journal Reviews
Shannon Steinhäuser, OD, FAAO

Contributing Editors
• Katherine M. Mastrota, MS, OD, FAAO
• Barry A. Weissman, OD, PhD, FAAO (Dip CL)

Editorial Board
• William Jones, OD, FAAO
• Alan G. Kabat, OD, FAAO
• Bruce Onofrey, RPh, OD, FAAO
• John Schachet, OD, FIOS
• Joseph Shovlin, OD, FAAO



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