As the COVID-19 pandemic continues to pose challenges in providing optimal health care to patients, surgeons are adapting to new requirements to ensure the safety of patients and care teams when planning and performing surgery. While some surgeries can be safely delayed in patients who test positive for the virus, urgent conditions can’t wait.
“Certain surgeries—such as an intraocular foreign body, an uncontrolled intraocular infection, or an acute macula-on retinal detachment—must be done in short order, even if a patient has tested positive for COVID-19,” says Durga Borkar, MD, an ophthalmologist and retinal surgeon.
Borkar says there are additional safety measures and clinical considerations for vitreoretinal surgery in patients who have tested positive for COVID-19, beyond the common precautions of using proper personal protective equipment and adhering to physical distancing and isolation guidelines.
As part of Duke’s response to the COVID-19 pandemic, all patients scheduled for surgery are tested for the virus in advance, but that’s impossible for emergencies. “For urgent cases, it’s critical to do the testing quickly so we can properly plan for surgery and anesthesia,” says Borkar. “We use point-of-care testing in those cases and can have results in less than 30 minutes.”
Borkar recommends considering whether a patient with COVID-19 is systemically well enough to safely undergo surgery. “Many times, patients are asymptomatic, but some are very ill with respiratory problems that make it unsafe to undergo outpatient vitreoretinal surgery,” says Borkar. Another consideration is whether there’s a reasonable chance of restoring the patient’s vision. “It’s rare, but in severe trauma cases where a patient’s vision loss is likely permanent, we discuss the surgical risks and that regaining their vision is unlikely even with surgery. At that point, they may choose not to have the surgery.”
“Sometimes in routine cases, we’ll try monitored anesthesia care first and convert to general anesthesia if necessary during surgery,” says Borkar. “With COVID-positive patients, we need to be certain of the anesthesia choice before surgery because intubation is the highest risk time for the health care team, and changing course during surgery is difficult. If we think there’s a chance a patient will need general anesthesia, we opt for this up front in the most controlled way.”
“When surgery for an urgent retinal condition is complicated by COVID-19 infection, it’s particularly important to help patients manage their postoperative recovery,” says Borkar. She recommends talking with patients about where they will go after surgery, whether they live alone, and how they plan to return for postoperative office visits. She also advises involving a social worker, if possible, to provide resources to patients and families.
For patients who have undergone uncomplicated surgery, telehealth visits could be a good option for follow-up in the early postoperative period, says Borkar. “Even though we can’t get images or pressure readings via telehealth yet, when patients are doing well after vitreoretinal surgery, telehealth can be a good option, particularly for visits focused on reviewing postoperative instructions.”
When COVID-19-positive patients need an in-person postoperative visit, clinics should ensure the facility is set up to isolate those patients from others, says Borkar. She adds that those appointments should be scheduled during times of minimal clinic traffic with a separate designated entrance and a special cleaning protocol for everyone’s safety.