Contact lens practice in the time of COVID-19
2020 was supposed to be the year of vision, which we approached with great excitement. Never in our wildest dreams did we expect to face what we’re experiencing now. And who knows what the future will bring?
Now that most of us have reopened our practices, we need a solid strategy to maintain their profitability. Perhaps even more importantly, we need guidelines and protocols that protect our patients, our staff and ourselves.
As restrictions are lifted and we return to patient care and clinical instruction, this article outlines the protocols for optometrists, interns and office staff designed to provide safe and efficient care to our patients, especially for practices specializing in contact lenses. I will demonstrate these issues by discussing changes that I have implemented into my own specialty contact lens practices at Miami Contact Lens Institute and Weston Contact Lens Institute.
What we know about routine care
Patients with COVID-19 present with several flu-like symptoms: fever, chills, sore throat, cough, shortness of breath, and a loss of the sense of taste and smell. COVID-19 can also cause conjunctivitis and can, therefore, theoretically be transmitted by contact with tears and other ocular secretions. The CDC has delegated the recommendations for safe return to routine health care to CMS.
Protection for the mouth and nose (surgical masks) should be used in all clinical settings until further notice. In some instances of direct contact with patients, greater protection may be required, such as N95 masks for the mouth and nose and goggles for the eyes. Additionally, clinicians should continue universal precautions by wearing gloves whenever they are in direct contact with patients’ bodily fluids or secretions.
All office staff not involved in direct patient care (ie, at check-in, check-out, and care and referral coordination) should wear surgical masks (and gloves, if indicated, as above) when interacting with patients or their escorts.
In the office, hand sanitizer and other sanitizing products should be readily available for employees and patients throughout the facility. Offices should continue to use germicidal wipes or spray to clean commonly touched surfaces, such as workstations, counters, railings, door handles, clipboards, pens, chairs and other public area surfaces. After every patient encounter, all instruments, equipment and examination chairs should be sanitized, gloves thrown away, and hands washed.
Hands should be washed with soap and water prior to diagnostic contact lens disinfection and throughout the disinfection process, as needed. Gloves are also recommended for handling diagnostic lenses if their sterility can be maintained. You should prepare and maintain a clean and disinfected workspace before, during, and after the disinfection process.
Maintain a log to monitor each use of the diagnostic lens and each disinfection cycle a trial lens receives.
If diagnostic lenses are used on a possible or confirmed positive COVID-19 case, the lens should be discarded as biohazard waste. Here is the American Optometric Association/American Academy of Optometry in-office disinfection protocol for multi-patient use diagnostic contact lenses:
- Place diagnostic lens in non-neutralizing case with 3% hydrogen peroxide;
- Disinfect for 3 hours;
- Rinse well with multipurpose solution;
- Dry trial lens gently with lint-free wipe and store dry in corresponding diagnostic lens case; and
- Diagnostic lens case should be handled appropriately to prevent contamination. If needed, it can be cleaned with an alcohol pad or replaced.
Application, removal plungers or tools
If possible, patients should be instructed to bring their own application and removal (A/R) plungers. If a patient is unable to do so, the practitioner may choose to either sell or give patients a new set.
For new patients without their own set of plungers, or when plungers must be provided by your office, disinfection is required after each use. If an autoclave is available, it can be used. If not, plungers can be soaked, fully submerged in 3% hydrogen peroxide for 3 hours. Rinse thoroughly with sterile saline and dry with a lint-free wipe.
Scleral lens protocols
Scleral lens patients should apply and remove their own lenses in a designated, disinfected workspace using their own A/R plungers, whenever possible. For new or inexperienced scleral lens patients, the practitioner may apply or remove the lenses but must wear a mask and gloves.
When evaluating scleral lenses, you should limit the “settling time” as much as possible to reduce the patient’s time in your office. If more settling time is needed, the patient should wait outside the office, and you should have the examination room disinfected according to proper standards.
Training in applying, removing scleral lenses
The trainer should wear a mask, protective eye wear (including a face shield, if possible) and gloves. In lieu of gloves, hands should be washed with soap and water for at least 20 seconds prior to and after interacting with the patient. The patient should wear a mask or cloth face covering. If possible, a physical barrier between the patient and the trainer is recommended. New A/R plungers or tools must be used for each training session.
The entire work area, including solutions, mirrors and table surfaces, should be disinfected after each training session. All patients should receive a new lens case and educational materials on COVID-19 infection control for scleral lenses. Scleral lens office staff should wear masks and gloves when handling diagnostic lenses. Disinfection of diagnostic lenses should be performed in accordance with the recommendations of the AOA/AAO. Scleral lenses should be shipped directly to the patient whenever possible.
For home care, patients are instructed to wash and dry their hands prior to handling lenses on all occasions for application, removal, or cleaning and disinfection and to repeat the hand washing afterward. They should wash their hands thoroughly with soap for at least 30 seconds, dry with an unused paper towel and then throw it away.
Patients should clean and disinfect their scleral lenses nightly, as per your instructions. If they are unclear of the correct cleaner/disinfectant or are unable to obtain the previously prescribed solutions, they should contact you for further guidance. They should not “top off” any solution, but always use fresh solution when placing lenses in their case, always discarding the old solutions when the lenses are removed. They should replace their lens cases every 1 to 3 months. PROSE cases (BostonSight) do not need to be replaced monthly, but the catalyst should be replaced every 2 months.
Multidose, preservative-free saline bottles should be replaced every 2 weeks or sooner. Unit-dose, preservative-free saline should be discarded within 24 hours after opening.
A/R plungers and other tools should be dried thoroughly, wiped with an alcohol pad and left to air dry in a safe, sanitary area after each use. The patient should ensure that no residual liquid remains inside the plunger after use. Plungers should be replaced every 6 months. The patient should not use tap water on scleral lenses, cases or A/R tools.
If patients experience symptoms or have a positive diagnosis of COVID-19, they should discontinue lens wear until symptoms resolve. Patients with medically necessary scleral lenses should contact their prescribing doctor to determine if discontinuing lens wear is appropriate. Regular soft contact lenses should be disposed of safely, and new lenses should be used once symptoms have ceased. Medically necessary contact lenses (scleral, corneal gas-permeable, custom soft or hybrid lenses) should be disinfected and stored appropriately. The patient should consider getting new lenses and contact his or her doctor for further instructions. Patients should safely dispose of and replace plungers, cases and other tools and should always follow the lens care recommendations of their eye care provider.
Gas-permeable lens fitting
Gas-permeable (GP) lenses should be fit empirically, whenever possible, to minimize lens handling and potential contamination. Typically, this recommendation applies to certain corneal designs, including spherical, toric, aspheric multifocal and orthokeratologic lenses.
It is important that the independent laboratories assist you and your GP lens patients during this transition period. This assistance can be provided by extending lens warranties on GP lenses and by directly shipping the lenses to the patients. The need for assistance should diminish and eventually disappear as offices return to a normal schedule and can evaluate all patients who were not seen during the period of office closure or limited care. However, in the interim, it may still be necessary to direct ship lenses to patients in need.
Laboratories are committed to providing a safe work environment for their employees, including following the CDC and Occupational Health and Safety Administration (OSHA) guidelines. This commitment includes social distancing and good hygienic practice with employees, continually disinfecting all work areas and wearing proper personal protective equipment at all times.
Contact lens safety
Contact lenses are safe to wear during the pandemic, as long as normal wear and care guidelines are followed. These guidelines have been developed by the AAO Section on Cornea, Contact Lenses & Refractive Technologies and the AOA Contact Lens and Cornea Section.
A useful document on contact lens safety during the pandemic available is available from the GP Lens Institute at https://www.gpli.info/pdf/gpli-covid19.pdf.
An excellent YouTube video on contact lens safety is also available at https://youtu.be/BuZaAbtonKE
For more information:
Elise Kramer, OD, who is residency-trained, practices at Weston Contact Lens Institute and specializes in ocular health and disease, ocular surface disease, and regular and specialty contact lens fitting. Over the last few years she has created a unique scleral lens practice.