By: Lim Lik Thai
Date prepared: 13/06/2020
When COVID-19 first gained international mentioned back in December 2019 (at that time it was first referred to as the ‘Wuhan virus’), never would I imagine that this problem will become such a menacing international pandemic affecting almost the entire world population and claiming hundreds of thousands of lives thus far. Furthermore, the whistle blower was a Chinese ophthalmologist who unfortunately succumbed to the virus itself, which begged me to ask the question—was it just a coincidence that he happened to be the first person to recognize this problem or was it that his work might have put him at extra risk of exposure to the virus? The answer became clear when published research revealed that an ophthalmologist is definitely at a higher risk of exposure of the virus. It is not surprising, given the fact that the eye examination is mainly slit-lamp based where the examining ophthalmologist is in very close proximity in direct confrontation with the patient. In addition, further research showed that common eye surgery such as cataract surgery (especially phacoemulsification) and pars plana vitrectomy are aerosol-generating procedures. This means that the operating ophthalmologist will have a higher risk of exposure to COVID19 if the patient was positive for the virus. Assisted and backed by all these facts, various ophthalmologists-representing establishments came out with sets of recommended guidelines to help ophthalmologists lower the risk of exposure. These establishments included the American Association of Ophthalmology (AAO) and locally, the Malaysian Ministry of Health and the Malaysian Society of Ophthalmology.
My hometown, Kuching in Sarawak was not spared the wrath of the COVID-19, whereby Kuching was a red-zone for a considerable length of time at the peak of the problem. When cases started to rise in Kuching (and Sarawak), I was wondering to myself how safe it was to continue practicing ophthalmology in the usual manner, or are there any additional precautions we should be taking to protect ourselves. Not long after that, the Malaysian government announced the Movement Control Order (MCO) from 18 March 2020. Being with a government university and doing visiting sessions in a private eye centre, I followed strictly to the directives of my university to work from home. I work from home throughout the MCO and the Conditional MCO (CMCO), with the exception of eye emergencies, especially retina detachments (since Sarawak is still very lacking of vitreo-retinal surgeons), whereby I will be called upon to operate on them. So, when I went in to attend to these patients I always thought to myself—what were the risk of me getting exposed to COVID-19? Although the clinic had the usual screening in-place, we know for a fact that most COVID-19 infected patients are asymptomatic. I had to wear the personal protective equipment (PPE) which was really warm and made me sweaty. On top of that, examining the fundus under the slit-lamp through a goggle took time to adjust as well, not to mention the visualization was not as clear (but adequate to make diagnosis). All patients prior to surgery would be requested to undergo the COVID-19 swab rt-PCR test and would only operate on them if the results were negative (knowing that a negative result was not always conclusive). Wearing PPE with N95 mask operating on a long case did make me feel more exhausting than usual, with the warm sweaty condition despite being in a cool operating room, and the N95 mask pressing tightly on the nose-bridge and face. Thankfully, such emergency cases were just a handful.
In view of the situation at hand, it was fortunate that the post-op patients were kindly being followed up with the referring ophthalmologists, although I am contactable if the need arises. And I was also fortunate enough that my follow up patients were mostly stable and their routine follow up in clinic could be postponed with the provision that should they feel something amiss, to contact me directly for a tele-consult and if need be a review. Needless to say, on occasions, I have been running pro-bono teleconsultation clinics, which I didn’t mind. The fact that I know that my patients were not in any immediate or pending danger, would made me feel reassured. There are obvious limitations to tele-consult which would mean it was safer to review the patients in some cases, but thankfully such instances are not frequent.
Patients referred to me from other divisions in Sarawak would have to obtain referral letters to present to the police to get permission to travel inter-division by-land to Kuching for treatment because during MCO and CMCO, virtually no commercial flights were available to connect the divisions within Sarawak and inter-division travel was prohibited (with exceptions such as emergencies). But as gas endotamponade may be used for retinal detachment cases, flying back after the surgery was not advisable anyway if that were the case. Sometimes the delay in getting to Kuching for treatment might have contributed to the worsening of the retina detachment and hence influence the risk and success rate of the surgery.
After the implementation of the Recovery MCO (RMCO) from 19 June 2020 (supposedly till 31 August 2020 in the first instance), it was almost business as usual for many sectors. However, unfortunately COVID-19 is still lurking around posing risk, with the potential of newer waves of spikes. With that in mind, I am gradually re-starting more regular clinic sessions by appointment only, still observing the safety precautions as before. In my practice, any surgery, emergencies, or routine cases, will need to undergo the COVID-19 swab rt-PCR test first and will only operate, if the results are negative.
For the remaining time, apart from clinical work, I found that I have been spending increasingly more time on the computer conducting online teaching and student assessments as directed by the government, and attending webinars to keep up-to-date with the current ophthalmic developments around the world.
This COVID-19 has certainly forced us to alter the way we do things in many ways, relying more on technology than we used to, and at times testing our patience which we don’t have the luxury to lose. On the other hand, it did make us discover new skills and ideas which can help us do things better, a sort of silver lining. But let us all hope that we can get through this COVID-19 era unscathed, enhancing our cooperation and unity during these trying times for a better future together, wherever we are.
This article is also made available at College of Ophthalmologists, Academy of Medicine, Malaysia website - http://www.coamm.org.my/files/Ophthalmology_practice_in_the_era_of_COVID19.pdf