Coronavirus disease (COVID-19) has emerged as a global health threat and presented significant challenges to eye care provision. The World Health Organization (WHO) announced this disease to be a pandemic on 11th March 2020 due to rapidly increasing number of new cases outside of China. As of 26th June 2020, there were 9,473,214 cases with 484,249 deaths worldwide (1). Healthcare systems throughout the world have been overwhelmed with increasing demand for specialist care (2). It has become clear that there is no single approach in addressing the challenges posed and each unit has to adapt according to their locally available resources.
In the United Kingdom (UK), the National Health Service (NHS) has had to undergo extensive changes to combat the surge of patients presenting with COVID-19 symptoms. The NHS has been greatly strengthened by the return of over 10,000 healthcare professionals. Additionally, 27,000 student nurses, medical students and other health professionals started their NHS careers earlier than expected. The NHS also had 607,000 people sign up to be NHS volunteers (3). A great deal of work was done in partnership with the local government, social care, the voluntary sector, the military, hospices and the private sector (3).
The challenges faced did not solely concern the care of COVID-19 patients. Self-isolation and social distancing measures were also developed in order to provide a safe environment for the treatment of non-COVID-19 patients. All routine outpatient activities were reduced to 25 percent capacity following the implementation of teleconsultations and efficient triage played a significant role. This reduced the risk of exposure of COVID-19 to staff and patients while enabling the provision of safe patient care. All elective surgical activities were suspended to enable training and redeployment of staff to meet the growing needs.
In Ophthalmology, a change in patient demographics, disease presentations and patient preference has led to a steady increase in the demand for emergency eye care over the years (4). A publication from the Royal College of Ophthalmologists (RCOpth) in 2017 showed that the incidence of new eye casualty attendances was around 20–30 per 1000 UK citizens per year with eye emergencies making up 1.46-6% of all accident and emergency (A&E) attendances (4).
The Manchester Royal Eye Hospital (MREH) is one of the largest eye tertiary referral centres in the UK with a 24-hour on call service and a walk-in emergency eye department (EED) that opens between 8 am to 8 pm. In view of the COVID-19 pandemic, we have had to modify the processes by which how urgent eye-care is delivered. Limited local optometrist services and face-to-face general practitioner consultations due to the COVID-19 pandemic placed additional burden on the EED. A number of strategies were developed to reduce the transmission risk. These included training of staff to screen for patients with potential COVID-19 at triage, appropriate personal protective equipment, use of slit lamp breath shield, equipment disinfection, staff risk assessment, staff uniforms that are washable at high temperatures and supervised entry to the hospital premises to control visitor numbers.
A new pathway for patient flow through the emergency eye department was devised to separate any potential COVID-19 positive patient from others (Fig. 1). Telephone consultations were increased to ensure patient advice and care could be delivered remotely and minimize any unnecessary hospital visits. A pre-triage area was set up to screen for any patients with potential COVID-19 in a designated area. All patients were asked about COVID-19 symptoms including fever, cough, breathlessness and contact with COVID-19 positive people. Any suspected COVID-19 patients were treated in an isolation room in this area. If the patient was not suspected to have COVID-19, they were given a pass to enter the EED. In the EED, patients were triaged and then given an electronic pager to wait outside the clinical area prior to being seen. The seating arrangement in the waiting area in EED was altered to allow at least 2 meters between seats. This process minimised the number of people in EED and promoted social distancing.
As for the patients requiring follow-up care, those who were deemed as low risk were given telephone consultations known as welfare calls instead of being seen in the acute follow up clinics that were available in the PCP. For the patients who were at higher risk, they were given face-to-face appointments in subspecialty clinics. After welfare calls, some patients still needed to re-attend EED or a subspecialty clinic if they required ongoing follow-up. For the patients who were admitted or required surgery, they were swabbed for COVID-19. For patients who required an interpreter, the use of telephone interpreters was encouraged instead of face-to-face interpreters. In addition to EED presentations, there were approximately 150 daily outpatient attendances in MREH.