Canadian Retina Society (CRS) Position Statement on Intravitreal Injections and the Management of Retinal Diseases during the COVID-19 Crisis

March 19, 2020

The Executive of the CRS has reviewed recommendations from local, national and international Medical and Ophthalmology groups regarding the management of patients and the risks to health care workers during this COVID crisis. The CRS provides the following commentary. These comments and recommendations are based on the “conditions on the ground” that exist today at the time of this writing.
It is clear that eye care providers are facing a difficult challenge in balancing their Hippocratic Oath, as doctors, to provide critical care to those under their care at risk of vision loss with the risk of disease and death to their patients and the global community. Several Ophthalmologists have already died from COVID-19. The global concern about the rapid consumption of personal protective equipment (PPE) for front line health care workers and ICU staff is a valid reason for reducing or stopping provision of certain non-essential medical services. It is clear that governing bodies SHOULD be helping to define what should be considered ESSENTIAL office-based and surgical services and should provide comment and suggestions as to how to mitigate risk while providing these services. An essential service is defined as a medical service, which, if withheld, will result in permanent loss of life, or function of limb or organ. We each have a responsibility to our patients and to the global community to limit the spread of COVID-19. No one can say, with any certainty, how long these care restrictions will need to be in effect and so plans will need to be regularly re-evaluated.
The American Society of Retinal Specialists (ASRS) has provided guidance in defining how retinal surgical cases should be categorized, defining emergent, urgent and non-urgent case types. They indicated that emergent cases should be operated on within 24 hours, urgent cases within 1 week and non-urgent retinal cases within 3 months, as longer delays would lead to permanent and irrecoverable vision loss in the affected eyes. The presence of monocularity is an obviously important cofactor in these designations. The CRS fully endorses the recommendations of the ASRS for management of retinal surgical cases (Appendix A).
Suggestions for the management of retinal disease patients requiring intravitreal anti-VEGF agent injections mandates similar categorization and clear and evidence-based decisions on
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optimal treatment algorithms. These treatments are essential services as if these retinal
diseases are left untreated or are undertreated, irreversible vision loss is likely to occur.
The Canadian Retina Society suggests the following during the COVID-19 crisis:

  1. That only urgent, time sensitive retinal patients are brought in for examination and
    treatment visits.
  2. That all eyecare providers and staff maintain social distancing and use optimal available
    PPE.
  3. That appointments are staggered and numbers of patients significantly decreased to
    ensure limited waiting room exposure for patients. We should strive to have far fewer
    patients in our waiting rooms. We strongly suggest there be at least 2 meters between
    seated patients. We suggest at least a 50% reduction in daily patient visits in order to
    maintain the principles of social distancing.
  4. This should be coupled with improved “office flow” so that patients spend significantly
    less time in the office or hospital environment awaiting their examinations and
    treatments. This may mean adjusting or decreasing what diagnostic testing or other
    services are done on each patient to limit eyecare provider and patient exposure.
  5. That patients be asked to limit conversation.
  6. That patient caregivers and accompanying persons be restricted from office entry unless
    it is deemed essential to providing the care. This is done to limit the number of people in
    the waiting room area.
  7. That proper cleaning of examination room equipment is completed between patients.
  8. That, under the current circumstances, all injecting ophthalmologists should do their
    best to extend intervals to the maximal tolerated. The optimal injection schedule must
    be individualized for each patient. We recommend progressively extending responsive
    patients by at least two weeks and we suggest consideration of extending intervals
    beyond what we have accepted as the maximal limits in the past.
  9. That retinal specialists and staff do their best to directly communicate with their retinal
    patients to alleviate patient concerns, eliminate unnecessary visits and provide
    reassurance and guidance.

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