Protecting patients and staff in Primary Care

We welcome the Royal College of Ophthalmologists’ statement of 25 March on Hospital Ophthalmology Services during COVID-19, which sets out a priority framework for all ophthalmology clinics to ensure patients who require urgent ophthalmological care continue to receive this, whilst at the same time reducing clinical capacity by around 80% to 90% to protect staff and all patients.

Primary eye care has already suspended all routine eye examinations and is now only providing essential and urgent care. This combined with the social distancing measures and our current advice, including not seeing any patient with signs or symptoms of COVID-19, has greatly reduced the number of patients being seen.

We have updated our guidance on the use of PPE, in line with The Royal College of Ophthalmologists. This sets out that:

• Clinicians should wear standard surgical masks when examining or treating patients at the slit lamp. Gowns and gloves are not recommended.
• Plastic breath shields attached to slit lamps provide some protection but must be disinfected between patients because studies show that the COVID-19 virus is viable for up to 72 hours on plastic surfaces
• Avoid speaking at the slit lamp.

With far fewer patients now seen in primary care settings and in need of slit lamp examinations, the risk in primary care is further reduced, but the PPE advice we issued today should be adhered to.

As primary eye care practices continue to provide essential and urgent care, however, the Royal College recommendations are not directly applicable to primary eye care in that:

1. Secondary care by nature of its location and patient access will involve clinicians coming into contact with more patients and others who are positive with COVID-19.
2. Secondary care has fewer clinicians overall and may have reduced capacity due to redeployment, isolation or illness during the crisis, this is not the case to the same degree in primary care.
3. In primary care there is significant overlap between the presenting symptoms of a number of patients with less serious eye problems and those with genuine emergency needs and so triage will avoid a lot of unnecessary attendance at practices,
4. Many essential/key workers will approach primary care as they require spectacles and contact lens to enable them to carry out their roles.

With this in mind, primary care will, where possible, see patients for remote consultation using telephone and video services. Where safe and appropriate to do so, optical professionals will see those patients who require face to face appointments to reduce the burden on our colleagues in secondary care. It is clear that a number of the conditions listed under the specific exemptions in the Royal College’s statement will have similar clinical presentations to less serious conditions and can be suitably separated triaged before accessing hospital services by the primary care workforce. 

• Wet, active age-related macular degeneration: A common initial presentation is new/sudden onset distortion. Primary care can filter these patients using OCT with onward referral where needed.
• Acute retinal detachments: Presentation of flashes and floaters should be seen as per normal practice in primary care, unless symptoms are highly suggestive of detachment.
• Uveitis: The symptoms of early uveitis have considerable overlap with less severe ocular surface disease and anterior eye disorders. The differential diagnosis and triage of these conditions should continue to be provided in primary care.