Conversations about COVID-19 For Eye Care Professionals Strategizing the Return to Practice – Part 2 May 5, 2020 Presenting sponsor Conversations about COVID-19 for Eye Care Professionals

Jason Brenner, MD Matthew Forgues, OD Amy Moy, OD Cornea and Refractive President, Director, Health Surgeon Massachusetts Society of Center Network Boston Eye Group Optometrists New England College Boston Laser of Conversations about COVID-19 for Eye Care Professionals

Speakers have no Financial Disclosures to Report Equipment – Safereyecare.org Disinfection – Masks

1. Time 2. Heat 3. UVGI 4. VHP 5. Microwave?

www.n95decon.org How long does it last?

Storage in cold temp (below 22 C) may prolong life

Viral load dependent

IMO, for eye clinic 7 day rotation is adequate Masks - Heat

1. 70 for 5 minutes (Lancet) 2. 70 at 50-85% RH for 30 minutes (CDC) ℃ *Moisture ℃seems to be key for adequate sterilization Masks - UVGI

(NIAID)

• 260-285 nm • ≥1.0J/cm

• Very hard for UV to hit all surfaces

• It is available! UVGI Equipment Sanitation

Bleach Alcohol* UV GI (5 tbsp /gallon)

Chlorhexidine Betadine

Zeiss: 70% IPA for HFA Equipment Sanitation Office Sanitation $$$ Disinfection

Art by: Stefanie Trilling Disinfection of Office (COVID-19)

Current CDC recommendations specific to COVID-19 include: ● Diluted household bleach ○ 5 tablespoons bleach per gallon of water ● Alcohol solutions with at least 70% alcohol. ● Common EPA-registered household disinfectants currently recommended for use against SARS-CoV-2: ○ Clorox brand products (e.g., disinfecting wipes, multi-surface cleaner + bleach, clean up cleaner + bleach) ○ Lysol brand products (e.g., professional disinfectant spray, clean and fresh multi-surface cleaner, disinfectant max cover mist), ○ Purell professional surface disinfectant wipes and more. ● The EPA offers a full list of antimicrobial products expected to be effective against COVID-19 based on data for similar viruses (EPA 2020) https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 Disinfection Guidelines

For cleaning of general surfaces, use EPA’s updated list of disinfectants, which include:

● Hydrogen peroxide ● Lysol Brand All-Purpose Cleaner ● Clorox Multi-Surface Cleaner + Bleach ● Clorox Disinfecting Wipes ● Cidex Wipes ● Cavi-Wipes ● Purell Professional sanitizing wipes ● Oxivir Disinfection of Office (COVID-19)

Items to Disinfect: ● Slit lamps, including controls and accompanying breath shields, should be disinfected, particularly wherever patients put their hands and face (AAO 2020). ● Doorknobs ● Exam Chair Seat and Arms ● Phoroptor ● Occluder, Near Point Cards ● Wipe down keyboards and computer mouse with disinfectant wipes as well. ● PPE should be disposed of in biohazard bin if known contamination, otherwise in trash can. Common Areas

● Remove all magazines and toys ● Post signs reminding of social distancing ● Remove pens from counters ● Hands-free hand sanitizer dispensers if possible ○ Provider can handle pump to dispense sanitizer for patient ● Assess air flow/circulation

Artwork by: Stefanie Trilling Some tips from our Chinese colleagues in Wenzhou, China

● Air Flow ○ Open windows when possible ○ A/C has been shown to circulate the virus ● Disinfection of exam room after wiping down all instruments ○ UV light for entire room (must leave room due to high radiation), takes 2 hours ● Social distancing--slowly double patient capacity every 2 weeks, pending continued decrease of COVID cases Tonometry

● Avoid using Non-Contact Tonometry, especially with patients with red eyes

● Disposable tonometer tips, or use 10% bleach solution for disinfection. ○ Other options: 3% Hydrogen Peroxide: rinse with cold running water for 5 min ○ *10% Household Bleach: rinse with cold running water for 10 min; This is the only disinfectant recommended by both the CDC and the manufacturers. ○ Dakin solution ○ Disposable tips: more expensive, but best for infectious patients Humphrey Visual Field and Optos HVF: ● New guidelines to use 70% isopropyl alcohol spray solution with shielding of vulnerable gaps in the HVF unit. ● Unit should be on during disinfection in order for solution to circulate with normal airflow. Optos: ● Use 70% isopropyl alcohol to disinfect areas of patient contact. ● Not necessary to clean the inner bowl, which does not ● have patient contact. A tip from our Chinese colleagues in Wenzhou, China Video in waiting room that discusses new flow of exam: ● No unnecessary communication with doctor ● Cough/Sneeze etiquette ● No talking while in slit lamp ● Doctor will open doors ● No direct contact with doctor Other options: front desk explains flow of exam when scheduling appointment, automated appt reminder has recorded information for patient DISINFECTION

• Products I have used over the years • Alcohol • Cavacide • Diluted Bleach • Wipes • Hydrogen Peroxide Wipes • Hypochlorous Acid • We have always stressed disinfection – We need to take it to a new level • Research commercial cleaning companies in your area DISINFECTION – HYPOCHLOROUS ACID

• Wound care and lid care (Avenova) • Hand Prep • Surface Prep • Dry time • Ques of stability/longevity DISINFECTION: MORE OPTIONS

• UV Disinfection • Far – UVC – light • Air Purifiers • Electrostatic Cleaning • Microsure DISINFECTION: UV

• Wands • Room cleaners • Cabinets • Human Exposure concerns • Far – UVC – Light – safer DISINFECTION: ELECTROSTATIC DISINFECTION

• Provides a broad-spectrum approach to disinfecting a complete surface area and entire room • Way to quickly and evenly coat a surface with disinfecting solution • Electrostatic applicator that gives negative charge to solution as it exits the nozzle • Charged molecules repel each other to evenly distance but will attract to surface applied to DISINFECTION: MICROSURE

• 8 hour disinfection sanitizer • Traditional mode of actin is to attack the germ and use chemicals to destroy outer membrane = “chemical kill” • Microsure – uses millions of nanoscopic structures to form a new surface that results in a “mechanical kill” – Kills cells of the bio threat trying to attach to the object • Modify the surface to prevent adhesion, prohibit colonization, reproduction, and proliferation • Will not degrade or discolor - not harm by water

Donning and Doffing PPE Putting on your PPE

General flow for putting on: Taking off:

● Wash hands/apply hand ● Remove gloves and dispose sanitizer properly ● Put on surgical mask ● Wash hands/apply hand ● Put on goggles/face shield sanitizer ● Put on gloves ● Remove goggles/face shield ● Remove mask ● Wash hands/apply hand sanitizer Donning and Doffing a Surgical Mask

Source: https://www.humanresourcesonline.net/h ow-and-when-to-wear-a-surgical-mask- during-the-wuhan-virus-outbreak How to reuse a mask

● Mark the outside of the mask so you can tell which is the outside of the mask. ● Store the bag in a paper bag or a plastic Ziploc-style sandwich bag. Never store in a purse or pocket. ● When storing, fold the mask in half so the outer surfaces are touching each other. Seal the bag if using a paper bag, but leave open if using a plastic bag (because it’s not breathable). ● Always use hand hygiene before and after handling mask. ● When pulling the mask back out of bag, grasp by the ear loops. Donning and Doffing Gloves

Source: freepix.com Donning and Doffing Goggles Donning: Place over face and eyes and adjust to fit.

Avoiding fogging: ● Soap residue ● Anti-fog material ● Anti-fog spray

Image: slideplayer.com Elective Surgery – Where are we now?

RSA Survey 4/24-5/3 225 Surgeons (43 States) Elective Surgery – When are we going?

RSA Survey 4/24 - 5/3 225 Surgeons (43 States) Elective Surgery – Where are we going?

RSA Survey 4/24-5/3 225 Surgeons (43 States)

Intentional Limitations Upon Opening Elective Surgery – Referral Tips

• 2-3 month backlog of cases • ORs will need to decompress also (less cases/day) • Hospital ASCs may remain closed

• Consider a telehealth consultation if your local surgeon does them • Cataracts • 85 y/o grandma with 20/30 NS • 60 y/o working individual who may fail drivers test

• Don’t wait on glaucoma, retina referrals Elective Surgery – LASIK

• Ignore the optics, these are very low risk patients

• Masks are creating issues for glasses • Economics will dictate a drop off anyway 😞😞

• Much easier to control and restrict workflow in LASIK suite than a surgery center • We are considering surgery on Saturdays when no one else is in clinic

• Really no evidence of virus in tears of asymptomatic patients STAFFING

• This is not legal advice: Consult and HR attorney and CPA • Reminder: stay at home order through 5/18, Statewide mask order 5/6 • States are opening in Phases: 1-4 • Currently in stage 1: essential only • Stages 2-4: low risk to high risk • MSO will send out notifications • Opening your office in stages • Demand • Reduced schedules STAFFING

• Timing to bring back staff • Build in training time: at home, in office • Have written staffing protocols in place • PPP • UE • Prepare for staff disappointment – Returning to work STAFFING

• Staff may not want to come back – educate them • UE • Safety – Make your employees feel safe • Stress protocols – PPE – CDC guidelines • Consider risk factors when bring employees back into office (age, medical Hx) • Work at home options (phones, billing, training, marketing and social media) • Be flexible with assignments – consider staggered shifts • *****Staff Temp start each shift – Update: maintain as private information STAFFING: PATIENT OR STAFF COVID +

• Exposure to COVID positive patient or staff • CDC and OSHA regulations • Notifying Patients • Will not be good for business if you have to close your office. Be proactive OPTICAL

• “The new normal” • Protocols for re-opening – during higher risk time • Plan for the long term • Flow • Optimize Safety: Patients, Staff • Optimize social distancing • Patient Reminders • Social distancing markers • Policy/Reminders prominently posted OPTICAL: PATIENT PERSPECTIVE

• Patients – Goal: Create an atmosphere so they feel safe • Show patients you are taking every precaution • Tell them you are taking every precaution • PPE available, hand sanitizer station • Market to them you are taking every precaution OPTICAL: STAFF PERSPECTIVE

• Protocols in place • Create atmosphere that your optical staff feels safe • PPE • # of patient interactions • Meet often, make them part of the solution • Screen patients • COVID questions, temp OPTICAL

• Barriers • Every office has different needs • Rely on vendors for options • Sharing ideas - examples • Prepare for short supply • Be creative OPTICAL: PD MEASUREMENTS

• Barriers at dispensing desk • Pupillometer – protective shields • Utilizing technology • Visioffice, Myeyefit OPTICAL

• Optical staff should control flow • Control products that are touched • Patient handle • Optical staff handle • Trays • Disinfection in front of patient OPTICAL: DISINFECTION

• This will be the new normal • Hot soapy water – Enveloped virus • Chemical disinfection • Air dry • UV cabinets • Damage to frames • Far - UVC – light – electrostatic cleaners - microsure OPTICAL: UV CABINETS OPTICAL: UV OPTIONS

Be careful of products that may not adequately disinfect OPTICAL: HOW WE ALWAYS DONE IT

• Think of changes to improve patient safety, efficiency • Scheduling optical • Mailing product • Curbside pick-up • Repair box • Virtual optical – my fitting box • Market, Market, Market - Increased competition Optical Considerations

Art by: Stefanie Trilling Optical Considerations

● Only one patient in the optical at a time ○ May need to schedule optical visits instead of taking walk-ins Optical Considerations

● Frame Adjustments ○ Requires close contact ● Pupillary Distance measurement: ○ Ruler vs Pupillometer vs ○ DIY Pupillometer Shield ● Trying on frames ○ Consider asking patient to limit to 3 frames to try on (especially for Masshealth frames, which are frequently used) ○ Clean and Dirty baskets ● Disinfecting Frames ○ Can use alcohol, but be careful of rubbing off frame info ○ Hydrogen peroxide ○ Bleach solution spray Contact Fittings

Art by: Stefanie Trilling Contact Lens Fitting Considerations

● Wear gloves for insertion and removal ● Remove gloves immediately after fitting process, wash hands, and change to fresh pair ● Trials being re-used by multiple patients must Source: newsweek.com be properly disinfected. ○ Soft Contact ○ Rigid Gas Permeable (RGP) – standard RGPs and Sclerals ○ Hybrid Contact Lenses -RGP center with outer skirt of SCL material Contact Lens In-Office Cleaning/Disinfection

References: https://www.gpli.info/wp-content/uploads/2020/03/2020-01-15-in-office-disinfecting-of-diagnostic- lenses.pdf Slide courtesy of Anita Gulmiri, OD, FAAO CONTACT LENS: FLOW

• Time demand • Already faced with reduced schedules • Dedicated contact lens room/area • Minimize patient movement in the office • handwashing • With extending CL Rx may have an initial rush of patient needing CL services CONTACT LENS: IN OFFICE EFFICIENCY

• Talk with patient on phone pre-visit – telemedicine • Difficult to maintain distance with CL services • Video training • Vendors • Create content • Written patient instruction • Contact lens vendor support • Training, shipping, rebates CONTACT LENSES: SAFETY

• NECO presentation week 2 • Hydrogen Peroxide systems • Protocols for trials in office • Cross-contamination pulling trials • Exam room ideas: • Slit lamp precautions/barriers • A/R over-refract • Phoropter fogging is a problem – be ready CONTACT LENS: REMOTE SERVICES

• Offer remote services • Reduce patient time/exposure in office • Patient flow – efficiency • At home training/education • Email videos, patient education material • Virtual check-ins Conversations about COVID-19 for Eye Care Professionals: Strategizing the Return to Practice – Part 2

Recorded Webinars: https://www.neco.edu/academics/continuing-education/online-ce

Re-open Resources: https://www.maoptometry.org/