Masks
Masks fitting should be checked thoroughly to ensure the seal is complete, whether using a fluid resistant surgical (type IIR) or a respirator filtering (type FFP3) mask, as the technique to check by respectively exhaling or inhaling is different for each.
Removal of PPE
I would recommend watching NHS videos how to do this as without training you could increase the risk to you and others regarding potential Covid-19 transmission. You need to remove your gloves first and use one glove to remove the other glove. Your apron is next, followed by any spectacles or face shield and finally your mask. Usual hand hygiene applies after removal of gloves and masks.
Disposal of PPE
Check your contracts with your waste management company and perhaps call them to ensure you are in compliance. As you are not seeing any Covid-19 patients with active disease through screening their calls before any in person contact, the equipment should not be contaminated. However, you may have a separate emergency Covid-19 contract set up by your health board if you have been designated to consult patients.
Scrubs
Following our local GPs, we are wearing scrubs as these are easily washed each evening after removal in the practice following any patient contact. Having multiple pairs or using t-shirts and cotton trousers which are quickly
washed and creates a safe environment.
Infection Control
The same surgical or filtering mask can be used to see many patents in a session using a slit lamp. However, you must not touch your face or the mask between patients and hand hygiene is essential after using different gloves and aprons for each patient. If forearms are bare this should also be washed, and all rings and watches removed, and any cuts covered up with a waterproof dressing to reduce contamination.
Slit lamp eyepiece misting
Rub your own spectacles or eyepiece lenses with anti-fog cleaner or spectacle cleaner to minimise surface tension and reduce fogging. If you are using a surgical mask, fold the top edge down and inward 1cm, which reduces the distance from the mask to your glasses or eyepiece lenses to allow your breath to dissipate more. You can also increase the BVD of your prescription or safety spectacles and heat them up using a frame heater to reduce the difference in temperature between the lenses and your breath, however, do not overheat the lenses especially if they have a MAR coat as you can crack the coating as it expands at a different rate to the base lens.
Teleoptometry
With shortages of on call services in secondary care, we have been sending anonymised pictures from slit lamps and OCT scans to colleagues to speed up decision making. An example of this was a patient, pictured above, who presented twice with a swelling under her eyelid and itchiness in the morning. Initial diagnosis was a chalazion with associated blepharitis. Hot spoon bathing and Blephasol was commenced. On the second visit the itchiness had gone, however, the foreign body sensation had stayed the same. Differential diagnosis was a conjunctival granuloma associated as a complication of the chalazion or a conjunctival papilloma. Treatment was changed to a one-month supply of doxycycline 100mg once per day and if the swelling reduced then the diagnosis of a chalazion would have been correct. However, if no change or growth were detected then a diagnosis of a papilloma would be correct and a referral for excision and histology would be made after the pandemic as no routine surgery is taking place at present in secondary care.
Patient self assessment
The College of Optometrists has made a home sight test chart for patients to be sent or downloaded so they can measure their vision at 3m which can assist in your diagnosis or management.
Screens
Purchasing or making screens for reception staff and slit lamps is good practice and this should be cleaned between patients. Patient contact should remain at 2m except where procedures dictate this is not possible.
Wellbeing
Both FODO and the AOP offer signposting to mental health support from stakeholders. In addition, I would recommend setting up new social media platforms to discuss local issues and referrals with colleagues to build a support network. This is particularly helpful for pathology as you may be dealing with cases which require you to up skill your knowledge and management daily.
Governance
I have been keeping a daily diary of all calls and assessments either remotely or in person. You can also use templates when supplying replacement spectacles or contact lenses by telephone as the common sense approach of what is in the patient’s best interests. •