With 2020 turning out to be the year of a pandemic, it seems nearly everyone’s plans have been turned upside-down and our new “normal” may be contributing to an influx of ocular problems.

An increased amount of time at home has meant a boost in hours of digital screen time and home improvement projects for millions of people across the globe. For some healthcare providers and essential workers, the pandemic has also meant an increased amount of time wearing a mask and frequent exposure to cleaning chemicals. In addition, heightened psychological and physical stresses due to sudden changes in routine schedules may play a role in the overall risk of some ocular pathologies seen during the pandemic.

Related: Homeostasis is the Holy Grail in dry eye disease

As an optometric provider partially available to emergency patients throughout the quarantine period (and full time since starting back in early May), I have noticed an interesting shift in ocular problems at my practice. Some of the common ocular “emergencies” have presented more frequently over the past several months, including dry eye disease (DED) associated with computer use and ill-fitting masks, corneal abrasions and foreign bodies due to home improvement projects, herpes simplex virus (HSV) and herpes zoster virus (HZV) flare-ups, along with episodes of central serous chorioretinopathy (CSC). 
 

Trying to avoid the virus that may be lurking on every doorknob, many companies and corporations have transitioned to work-at-home environments. This digital wave and virtual work world appears to be here to stay.

Related: Safe & effective ocular triage in the COVID-19 era

Considering the millions of people who now work on their computers and digital devices full time, it is not surprising to see increases in symptomatic complaints of burning, watering, ocular pain, eye strain, and intermittent blur.

Prolonged use of digital devices is likely associated with decreased blink rates and increased tear evaporation, which can lead to tear film instability and hyperosmolarity.1 This vicious dry eye cycle paired with computer use can eventually lead to a decreased tear break up time, worsening symptoms of 

.1To make matters worse, previous research suggests that subjective dry eye symptoms can be influenced by psychosomatic conditions including stress, anxiety, and depression.2

With an array of treatments, from artificial tears to punctal plugs to pharmacologic options that improve tear film stability, educating patients on the short- and long-term consequences of extended digital computer use can be helpful in stopping the cycle of DED.

Related: How one OD communicates with her team amid COVID-19

It may also be a great time to start sending dry eye questionnaires and information regarding DED associated with digital screen use to patients virtually before their exam. This can help toidentify potential DED factors or problems ahead of the appointment and decrease exposure time in office. 
 

With the addition of mask mandates across the world, dry eye signs and symptoms have also seemingly been on the rise since mid-March in my practice. Some patients, such as healthcare providers and essential workers, are now wearing masks or facial coverings for upward of 40 hours per week.

Especially worsened with ill-fitting masks, symptoms of mask associated DED is likely due to the constant flow of exhaled air on the exposed eye while breathing. Sometimes presenting with ocular pain and intrapalpebral corneal staining, the escaping air flow can create a windy obstacle affecting tear film stability. The frequency of mask-wearing seems to be correlated with increased frequency of DED recently seen in practice.

Mask-wearing is very effective in lowering the rate of viral transmission. It may be helpful to educate patients on the importance of a properly fitting mask to reduce airflow directed at the eyes. It may also be beneficial to ask questions regarding details of mask usage when considering overall risk factors for DED.

Related: Headache a key symptom of COVID-19

With additional time at home, more people than ever are completing projects and finishing up honey-do lists. Indoor and outdoor projects have resulted in more ocular injuries such as corneal abrasions and foreign bodies.

Ranging from “abrasion caused by mask” to “stick in eye while doing outdoor chores” to “metallic foreign body while grinding metal,” there seems to be an influx of ocular injuries since quarantines began.

As optometrists, it is especially vital to treat these ocular injuries and help keep these patients out of the emergency room, if possible. Of course, it is also important to discuss the importance of wearing safety glasses, but hindsight is 20/20. 


4. Herpes simplex virus (HSV) and herpes zoster virus (HZV)

Psychological and physical stresses associated with abrupt changes to daily life may play a role in the overall risk of some ocular pathologies seen in practice, especially in the midst of a pandemic.

Related: Optometry’s Apollo 13 moment during COVID-19

Stress has been thought to modulate an individual’s immune system through the release of certain molecules such as catecholamines, cytokines, and glucocorticoids.3,4 Such release signals other molecules to alter the host immune system, leaving it susceptible to a primary or recurrent viral infection.3,4

Stress is also thought to contribute to reactivation of latent herpes simplex virus (HSV) and has been considered a trigger for herpes zoster virus (HZV).4,5 This connection with stress and HSV/HZV has been supported by several, but not all, studies.3-5 It would be curious to investigate the effects of phycological and physical stress during a pandemic and its effect on HSV and HZV activation or reoccurrences.

Pre-pandemic, one clue to tip off the practitioner about increased risk for HSV-1 in the eye may have been the obvious fever blister noticed on the lip during an exam. For the time being, wearing a mask hides these important observational details; therefore, it may be important to ask about history of cold sores and fever blisters that may be hidden from view 
.

5. Central serous chorioretinopathy (CSC)

Predominantly, CSC affects young or middle-aged adults (25 to 50 years old) with men more frequently affected than women.6 Often presenting unilaterally with painless blurred vision and a shallow serous retinal detachment, some patients may even be asymptomatic.

Physiological stress is considered one of the most important risk factors for developing CSC.7 One study identified that stress scores, serum homocysteine levels, serum morning and evening cortisol levels, and systolic and diastolic blood pressure were all elevated in CSC patients.7

There have been several other independent studies over the past several decades concluding CSC occurs more frequently in “Type A” men with higher emotional stress, lower frustration tolerance threshold, and poor coping strategies for stressful events.6

The natural course of CSC is typically self-limiting with spontaneous resolution over many weeks or month and a good prognosis in 90 to 95 percent of cases.6 In addition to identifying the stressors, CSC patients should also consider a routine workup with stress score evaluation including measurement of blood pressure, serum homocysteine levels, and serum cortisol levels.7

In conclusion, our new “normal” during the midst of the pandemic may be contributing to an increase of ocular problems that optometrists should keep in mind as differentials.

Considering risk factors such as hours of digital screen time, mask wearing, and overall stress levels may be helpful in identifying those more susceptible to ocular problems.

Keep ocular emergencies that are presenting more frequently in mind—dry eye associated with computer use and ill-fitting masks, corneal abrasions and foreign bodies due to home improvement projects, herpes simplex virus (HSV) and herpes zoster virus (HZV) viral infections and central serous chorioretinopathy (CSC).

Post-pandemic, it will be interesting to seeretrospective data regarding the global incidence of ocular problems more frequently seen since quarantine. For now, it is of vital importance that optometrists treat patients and keep them out of the emergency room.

1. Kim KW, Han SB, Han ER, Woo SJ, Lee JJ, Yoon JC, Hyon JY. Association between depression and dry eye disease in an elderly population. 

2. Uchino M, Yokoi N, Uchino Y, Dogru M, Kawashima M, Komuro A, Sonomura Y, Kato H, Kinoshita S, Schaumberg DA, Tsubota K. Prevalence of dry eye disease and its risk factors in visual display terminal users: the Osaka study. 

3. Chida Y, Mao X. Does psychosocial stress predict symptomatic herpes simplex virus recurrence? A meta-analytic investigation on prospective studies. 

4. Sainz B, Loutsch JM, Marquart ME, Hill JM. Stress-associated immunomodulation and herpes simplex virus infections. 

5. Glaser R, Kiecolt-Glaser JK. Chronic stress modulates the virus-specific immune response to latent herpes simplex virus type 1. 

6. Semeraro F, Morescalchi F, Russo A, Gambicorti E, Pilotto A, Parmeggiani F, Bartollino S, Costagliola C. Central Serous Chorioretinopathy: Pathogenesis and Management. 

7. Agarwal A, Garg M, Dixit N, Godara R. Evaluation and correlation of stress scores with blood pressure, endogenous cortisol levels, and homocysteine levels in patients with central serous chorioretinopathy and comparison with age-matched controls

Articles

The pandemic is contributing to an influx of ocular problems.

5 common ocular problems seen during the pandemic

Vision Expo organizers, The Vision Council and Reed Exhibitions, announced the cancellation of the optometric conference Vision Expo West 2020 previously scheduled to take place in Las Vegas from September 23-26.

The decision comes after Vision Expo East and the American Optometric Association’s (AOA) Optometry’s Meeting 2020 were cancelled in March and June, respectively. Meeting organizers cite health and safety concerns as the main reason for the cancellation. Nevada Governor Steve Sisolak (D)announced Monday, June 26, that Nevada would remain in Phase 2 of reopening plans through the end of July due to current trends of the coronavirus infection.

“While certainly disappointing, the decision to cancel Vision Expo West 2020 is prudent and necessary following the announcement of the extension of Phase 2 in Las Vegas into the end of July,” says Fran Penella, event vice president, in a statement.

“Without having visibility on when the state of Nevada will be ready to roll into future phases or what the future phases will allow for, coupled with the unfortunate spiking of COVID-19 cases in the region, we know it is in the best interests of everyone in the vision community to not move forward.”

Attendees and exhibitors who had previously registered for the event may still take part in a digital platform that will virtually replace in-person experiences. Continuing education (CE) product showcases, and service and product sourcing will take place on the new platform.

More details on specific offerings and partners will be forthcoming, and personalized communications will be sent to each registered attendee this week from the Vision Expo team.

Related: AOA elects '20-'21 officer slate via virtual ballot

Vision Expo West 2020 cancelled due to COVID-19

most optometrists thought relatively little about ocular triage. Aside from an OD or staff worker fielding a phone call from a patient and deciding how urgently he needed to be seen, resources were typically greater than demand and there was little need to think deeply or systematically about principles of ocular triage.

Essentially, ODs’ doors were always opened, the welcome mat laid out, and the stakes relatively low.

However, COVID-19 turned the world, and eye care, upside down. With “routine” eye examinations suspended, ODs were forced to consider anew the practice of triage when a simple visit to the optometrist became a potentially lethal act for patients and the doctors and staff who care for them.

Although I am accustomed to triaging in my Department of Veterans Affairs practice where demand is often greater than resources, COVID-19 caught me flat-footed as well. Like everyone else, I scrambled to obtain personal protective equipment (PPE), institute new disinfection and screening protocols, and make plans for altered patient flow. What I have spent the most time doing is reviewing charts and deciding the “who, when, what, and how” of pandemic patient care.

I started the process with expectations of how I would proceed. In some cases, those expectations panned out; but the “new normal” also contained a few surprises.

Related: How doctors should handle crisis communication during COVID-19

This article is a summary of the lessons I have learned about ocular triage during the initial period of the COVID-19 epidemic and will cover four areas:

Defining triage and how the process applies to eye care

Discerning differences among “routine” eye care, ocular “urgencies,” and true ocular “emergencies”

Applying triage principles to surveillance of established ocular disease patients

Considering how COVID-19 impacts referrals to ophthalmology for secondary care and ocular surgery

The word “triage” is derived from the French word 

, which means “to choose, pick out, or separate from others, to sort” and was originally used in agriculture.

 Today, triage is almost exclusively used in a healthcare context and a formal definition is: allocation of a medical resource occurring under conditions of scarcity performed by a healthcare worker using an established system or plan.

 A simpler working definition is: the process of sorting through the sick and injured and choosing those with the best chance of benefiting from immediate care.

Historians trace the origins of triage to several ancient battlefield narratives, but they commonly place the first formal model in the early 19th century and attribute it to French military surgeon Baron Dominique-Jean Larrey, chief surgeon of Napoleon’s Imperial Guard.

Our conceptions of triage are shaped by culture and media, such as the popular TV shows “M*A*S*H*,” “China Beach,” and “ER” that depict triage under the stresses of acute battle injuries and the harried and demanding pace of the emergency department in an inner city public hospital. However, triage can apply to any specialty and setting, including inpatient or outpatient, in which demand is greater than available resources.

Triage carries a strong utilitarian connotation: to do the greatest good for the most and cause the least harm to the fewest.

 In the initial stages of the COVID-19 pandemic, public health officials decided the suspension of routine eye care and limiting face-to-face (F2F) care only to patients with ophthalmic urgencies and emergencies was necessary to “flatten the curve” of the pandemic to prevent overload of hospital critical care resources. Essentially, they considered slowing the spread of the coronavirus as the greatest good and the potential negative outcomes associated with delays in routine eye care as the least harm.

As of this writing, after an extended plateau in new cases and overall decline in the COVID-19 death rate for several weeks, the U.S. is experiencing a spike in new cases in 22 states located primarily in the Sun Belt and the West, as most state and local stay-at-home orders expire, businesses reopen, and public activities and gatherings increase. Public health officials point to pandemic “fatigue” and the desire to return to normal activities, recent street demonstrations and protests across the country, and poor compliance with wearing masks and social distancing as factors in this increase.

Related: Study brings fomites’ role in COVID-19 transmission to light

Routine eye care is also resuming but at a reduced volume and rate to allow for social distancing and disinfection. The pandemic’s ebb and flow will likely continue to impact our practices for an extended period. Reduced access to eye care because of the “speed bumps” of disinfection and screening protocols and/or the “throttle” of fresh spikes in new cases and more stay-at-home advisories or orders are optometry’s and ophthalmology’s “new normal” for the foreseeable future.

Decreased access has a domino effect, and what happens at the primary-care level also influences secondary care. For instance, ODs may discover that ophthalmologists may not as readily accept referrals for secondary treatment and surgery because MDs are also experiencing more constriction to patient flow and dealing with a larger-than-normal backlog of pent-up care created by the initial shutdown.

Principles of triage should continue to guide ODs’ thinking during the pandemic as they attempt to balance the vision needs and ocular health of their patients with public health concerns. This continuous process will involve deciding whether to see patients F2F or virtually, how long visits should last, what procedures and tests should be done in-office, and how far apart (or if) to schedule follow-up exams.

‘Routine’ versus ‘urgent’ versus ‘emergent’

Using the word “routine” to describe a comprehensive eye exam can be misleading. From experience, ODs know that they frequently detect and diagnose sight-threatening disease and life-threatening systemic conditions during a so-called “routine” exam. Patients often hesitate to speak up about “minor” symptoms until asked, and targeted follow-up questions often lead to an unexpected but timely diagnosis.

Patients vary in their tolerance of eye symptoms and blurred vision, and one’s occupation and activities of daily living (ADLs) can affect their perception of the urgency of their vision problems. ODs differ as well in how they triage and classify patient complaints and decide who should receive expedited care.

Related: COVID-19 antibodies can disappear in non-symptomatic individuals

In the pandemic’s early stages, numerous ophthalmic organizations offered triage guidelines about which ocular conditions had a high enough risk of vision loss to outweigh the risk of virus transmission and thereby warrant F2F visits.

While most protocols were in general agreement, there were some differences in rankings and prioritization, and little distinction was made between ocular “urgencies” and “true emergencies.”

One way to distinguish between the two is to consider how quickly morbidity and/or mortality could occur without intervention. Based on that criterion, a true ocular emergency could be classified as a condition that results in irreversible blindness and/or death 

Endophthalmitis, intraocular foreign bodies, chemical injury, secondary glaucoma (for example, inflammatory, hyphema, etc.) with extremely high intraocular pressure (IOP), acute angle closure glaucoma (AACG), orbital cellulitis, and open globe trauma could all be correctly classified as true ocular emergencies. Possible additions to that list could include central retinal artery occlusion (CRAO) if diagnosed within hours of onset, extraocular muscle entrapment with muscle necrosis, and signs and symptoms of a cerebrovascular event such as sudden onset diplopia, cranial nerve palsies, and sudden vision or visual field loss.

The majority of acute conditions and symptoms that typically present to optometrists such as flashes and floaters, external ocular foreign bodies, retinal tears and detachments, uveitis, corneal ulcers, contact lens-associated red eye, acute conjunctivitis, vitreous hemorrhages, choroidal neovascular membranes (CNV), and even arteritic anterior ischemic optic neuropathy (AAION) may be more correctly classified as “urgencies” because they can usually be diagnosed and managed within a matter of days and not result in irreversible blindness and/or death.

Related: AOA Optometry’s Meeting 2020 cancelled

Regardless of these distinctions, ODs should continue F2F exams or expedited referrals for patients who have the above conditions, even amid strict “stay at home” orders and quarantine, provided proper PPE is used, screening and sanitation protocols are followed, and the patient has not tested positive for COVID-19 and has no signs, symptoms, or multiple risk factors for the disease.

For patients who have tested positive for COVID-19, or who are persons under investigation (PUI), most guidelines recommend that ocular urgencies or emergencies be managed in a hospital setting more equipped to provide the highly specialized care and strict disinfection controls needed, or if the condition allows (for example, acute conjunctivitis), remotely via telemedicine.

Diagnosing and managing acute conjunctivitis during COVID-19 deserves special mention. Because of reports of the presence of the novel coronavirus in tear secretion and follicular conjunctivitis associated with COVID-19 cases,9,10 ODs should take special caution in dealing with “red eyes” in F2F visits.

Because the majority of cases of acute conjunctivitis are self-resolving, most recommendations have been to provide ocular telehealth care if possible and supportive therapy such as artificial tears, cool compresses, and oral non-steroidal anti-inflammatory drugs (NSAID) and/or acetaminophen to avoid the risk of a F2F visit. Contact lens wear may complicate matters and tip the scale toward an in-person office visit. Both optometrists and ophthalmologists have often used telemedicine by means of traditional phone calls and live televideoconferencing platforms to treat conjunctivitis during COVID-19.

Related: Hypochlorous acid: harnessing nature’s germ killer

However, not all patients and their problems fit into neat categories and boxes. Clinical judgement and case-by-case evaluation are always paramount. While refractions weren’t regarded as “essential” during the acute phases of the pandemic, a -6.00 D delivery truck driver whose glasses break and does not have a backup pair or contact lenses can quickly jump in priority from “routine” to “urgent.”

Prioritizing surveillance of established patients with ocular disease

In addition to triaging acute conditions, ODs should prioritize follow-up care for established patients with existing ocular disease. Factors to consider are the practitioner’s knowledge of the individual patient, the natural course of the condition, previous treatment, existing vision impairment, and markers of progression.

While not all-encompassing, I found it useful to order my thinking around what I coined the “big four” causes of vision loss in my clinic: glaucoma, diabetic retinopathy (DR), age-related macular degeneration (AMD), and cataracts.

When I started reviewing charts to prioritize care and reschedule patients, I assumed that because about 40 percent of my patient load consists of the diagnosis, treatment, and surveillance of primary open-angle glaucoma (POAG) patients and glaucoma suspects, these would comprise the bulk of my F2F follow-ups.

Counterintuitively, this turned out not to be the case.

Related: Virtual conferences not filling the gap of in-person meetings

Instead, I discovered the majority of my POAG patients were, inasmuch as I could discern, stable enough to defer a majority of their follow-up visits judging from functional measurements such as progression analysis data from serial visual fields and structural information gained from serial optic nerve assessments and retinal nerve fiber layer (RNFL) optical coherence tomography (OCT). Very few were progressing rapidly enough to warrant the risk of keeping an upcoming F2F follow-up visit during the early phases of the pandemic when cases were rising exponentially, and the majority were rescheduled for 2 to 4 months later.

During chart review, I found I was already comanaging with or had permanently transferred care to glaucoma specialists in most cases of advanced and poorly controlled cases of POAG and secondary glaucoma. I have a handful of very elderly patients with advanced or end-stage glaucoma and multiple systemic comorbidities who have already received maximum medical and surgical treatment and whose IOPs are as low as reasonably possible and can no longer preform reliable visual fields. For the most part, I deferred their F2F follow-ups and instead talked by phone with them or their caretakers and hoped for the best.

Lengthening the interval between follow-up visits these past few months is a continuation of a practice I adopted in recent years as I reconsidered the traditional, every 3 to 4 month glaucoma follow-up protocol and looked for patients with milder glaucoma and good compliance whom I could safely monitor with fewer in-office visits. I have the advantage in my practice of being able to monitor if patients are refilling their drops, an indirect—but not foolproof—measurement of compliance. Reviewing that information, refilling their drops, talking with patients by telephone to reinforce compliance and explain why we were deferring their care reduced F2F visits, and most likely, virus transmission.

New devices are now enabling home IOP measurement, and while these would enhance the quality of remote care, unfortunately they are not yet scalable and affordable enough to use on a widespread basis.

 While glaucoma tends to progress slowly, ODs must remember progression can vary widely and occur in a sudden and non-linear fashion, even in the presence of low IOP.

 As always, case-by-case clinical judgement is important, and the maxim “know thy patient” has never been truer than in the current moment.

In contrast to glaucoma, I discovered the need to keep a tighter rein on my patients with DR and left in place more of their scheduled F2F follow-up visits for serial dilated fundus exams and macular OCTs. This was particularly true for patients with higher risk of progression, especially those patients with moderate and severe nonproliferative retinopathy (NPDR) accompanied by non-centered diabetic macular edema (DME) and good central vision whom I were closely monitoring or co-managing with retinal specialists.

I reasoned that during the pandemic, DR patients would likely see their primary-care providers (PCP) less often and might experience discontinuity in their systemic care and monitoring of their disease, be more prone to poor compliance with treatment and diet, perhaps from “stress eating” under conditions of isolation and quarantine, and also become less physically active.

Follow-up visits with these patients confirmed my suspicions as many of them have shown progression of their retinopathy and worsening of their DME. Retinal specialists generally performed only the most critical intravitreal injections (IVIs) in the early phase of the pandemic, and now many are scrambling to perform more such procedures to alleviate the pent-up demand that has developed.

When assessing diabetic retinopathy patients during the pandemic, ODs should triage using DR severity, evaluating the severity and location of DME, blood glucose control and HbA1c, and DR natural history.

 Monitoring less sight-threatening diabetic retinopathy via fundus photos and ultra-wide field imaging (UWF) is an evidence-based alternative to dilated fundus exams (DFE) when care is less accessible or when patients prefer to reduce F2F care to reduce their risk of viral transmission.

Like DR patients, delaying care and deferring routine F2F follow-ups of AMD patients during COVID-19 can contribute to poor visual outcomes. AMD can convert from dry to wet forms and progress rapidly. If possible, ODs should closely monitor with F2F exams those patients with high-risk characteristics such as “soft,” confluent drusen, calcified drusen, previous wet AMD with a history of treatment, and existing severe vision loss in one eye.

One study showed optometrists and ophthalmologists in primary eyecare settings equally underdiagnose AMD, especially in subclinical and early stages, misjudge the stage of severity, and are often too passive in management and treatment.

Additionally, one study demonstrated the importance of adherence to follow-up exams in patients with exudative AMD and documented worse visual outcomes associated with longer follow-up intervals.

While home monitoring via Amsler grid and newer automated methods may be valuable,20 even patients who are engaged and vigilantly monitor their vision sometimes miss clinically significant changes marking progression in disease severity. There is no substitute for F2F visits with serial OCTs and DFEs for monitoring AMD progression, even in the COVID-19 era.

Because IVIs are considered essential and still available even under stringent stay-at-home orders and isolation, ODs should monitor AMD patients with in-person visits assuming the visits can be conducted safely.

In most cases, cataract surgery was considered “nonessential” and suspended during the early stages of COVID-19. Although ophthalmic surgeons are performing this and other elective procedures again, patients with milder vision loss and less effect on their ADLs may receive less priority and experience delays in scheduling surgery.

During the pandemic, ODs should make an even greater effort to inform patients of the risks versus benefits of cataract surgery. For those patients who can reasonably wait, ODs can update prescriptions and use various coatings, tints, and other options to tide over patients until their cataracts can be removed.

Public health authorities and eyecare providers may have considered refraction to be “routine” in the initial stages of COVID-19. However, ODs performed some “urgent” refractions for patients whose cataracts were very symptomatic and who needed better vision to enjoy reading, watching TV, and perform other ADLs needed to better cope with increased stress associated with the pandemic and home isolation.

No guideline is a “one-size-fits-all” solution. ODs should always exercise professional judgement in deciding what actions are in the best interest of their patients and the public at large.

Related: Fashion advice from an OD on the frontlines of COVID-19

Ophthalmology colleagues and consultants also face backlog and pent-up demand that may slow their ability to receive OD referrals. As they reopen and increase the inflow of patients into their offices, ODs should strive to better communicate and coordinate care with them by determining the priorities they use to schedule patients whose care was deferred. Sharing and discussing cases and images via telemedicine platforms and negotiating comanagement strategies could lead to better coordination of care, improved handoffs, better outcomes, and higher patient convenience and satisfaction.

Optometry as a profession has been trending toward a more “medical mindset” for many years, and the increased opportunities to monitor and manage chronic eye disease patients afforded by altered referral patterns in response to the pandemic may further accelerate this movement. Patients, ophthalmology colleagues, and the entire healthcare system are counting on ODs to stretch their comfort zones, step up their game to an even higher level, and do their part as essential members of the healthcare team to defeat the virus.

The significant morbidity and mortality generated by COVID-19 will continue for the foreseeable future. As patients return to OD offices, ODs will inevitably discover ocular and systemic morbidity resulting from deferred ophthalmic care and delays in treatment caused by the pandemic.

However, revisiting and practicing sound principles of ophthalmic triage can enable ODs to help minimize these losses and decrease the causality count in the war on COVID-19.

This generational challenge gives ODs an exclusive opportunity to carry forward the new techniques, technologies, and mindsets they have been forced to adopt out of necessity and use them to reshape eyecare delivery systems for maximum efficiency and safety in the post-pandemic “new normal.”

More by Dr. Brown: Optometry’s Apollo 13 moment during COVID-19

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How one OD made hard decisions during a time of emergent care.

Safe & effective ocular triage in the COVID-19 era

Connor Christensen from the University of Houston College of Optometry won top honors in Essilor’s 29th annual Optometry Student Bowl (OSB), which kicked off its game-show style tradition in 1992.

The competition takes place during the American Optometric Association’s Optometry’s Meeting every June. Due to COVID-19, this year’s in person-meeting was cancelled, resulting in the competition’s first ever virtual experience.

Over 1500 attendees tuned in to watch contestants, including students from 25 schools and colleges of optometry, buzz in with correct answers to optometry-related questions.

The winning school walked away with $1000, diagnostic lenses from Volk, the Ventura Cup, and a lifetime of bragging rights. The second-place winner, Alec Waters from Southern College of Optometry, received $750, and third-place winner, Katelyn Flood from University of Missouri St. Louis College of Optometry, received $500.

Each contestant collected a Volk Ran Retinal 2.2 blue-ringed lens, courtesy of Volk. In addition, Keeler provided every participant with a personal protective equipment (PPE) kit.

In addition to the main prizes, the Zoom Background Award went to The New England College of Optometry. The school will help produce next year’s competition’s “hype video” to kick off the competition.

A social media-based Virtual Spirit Award was awarded to The Massachusetts College of Pharmacy and Health Sciences School of Optometry for innovative social media posts during the event.

This year’s panel of expert judges included:

Lead Judge - Linda Casser, OD, FAAO, professor, Pennsylvania College of Optometry at Salus University

Diane Adamczyk, OD, professor at State University of New York College of Optometry.

Bob Layman, OD, President-Elect of the AOA

Dr. Sue Oleszewski, MD, retired professor emerita from Pennsylvania College of Optometry at Salus University

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Years ago, I treated a police officer who presented for a dry eye evaluation. While other doctors before me had treated him with tears and punctal plugs, I used steroids and cyclosporine (Restasis, Allergan) to control his ocular inflammation. Following any use of pepper spray, he would see the departmental doctor who would insert plugs to improve his extremely dry eye.

This would inevitably backfire, and within 2 weeks he would return to the office begging me to remove his plugs. Each time I would remove them, treat with a topical steroid taper, and maintain topical cyclosporine. Despite my written instructions on how to better treat his ocular surface following exposure, this cycle went on for years.

As healthcare providers, ODs may be called on to assist those who have been affected by tear gas, pepper spray, and other agents used during periods of unrest. It is not their job to judge but rather to assist these patients by resolving pain and promoting healing. While exposure to these irritants may be common to military medical personnel, civilian practitioners may not be as familiar. This article is not meant to incite political discussion regarding the intended or actual use of these agents. It is to educate readers on the history of and management of exposure to them.

To begin, a historical perspective on chemical warfare may be of value. Chinese armies used “stink pots” in 2300 BCE during warfare. They burned red peppers in hot oil to produce offensive smoke to burden their opposition prior to attack. Japanese fighters ground peppers to a fine dust and wrapped the dust in rice paper to throw into the faces of opponents.

Wood saturated with pitch and sulfur was burned to create offensive smoke in the Peloponnesian wars (431 BCE). “Greek fire,” a liquid containing sulfur, lyme, pitch, resin, and petroleum, was pumped into the water in front of ships and burned. Greek fire and hot oil were catapulted over walls in the Middle Ages.

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Chemical agents in grenades of clay and glass jars were first used in the 13th century. Separate containers would contain two different chemicals, resulting in a chemical reaction when mixed.

Bacteriolgical warfare was first used in 1422 in Italy when cartloads of horse manure were launched over city walls to the detriment of those inside the city of Tarantine.

The Civil War saw the first chemical warfare in America. Wood covered with pitch and sulfur was burned around cities. Greek fire was used on coastal cities.

A German chemist developed chloroacetophenone, a chemical lacrimator, in 1869. In 1912, the French used chemical agents in glass containers. A lacrimator called ethyl bromacetate causing severe tearing, blepharospasm, and painful foreign body sensation was used by the French in World War I. In retaliation, Germans used chlorine gas pumped into enemy trenches. British soldiers created gas masks using two surgical masks with sodium carbonate powder between them.

During World War I, omega-chloracetophenone (CN) was used to train soldiers using masks. In 1913, Germans used diphenylaminechlorarsine (DM) to make enemies sick, requiring removal of gas masks to strengthen exposure.

 This was later used by British police during civil disorders, resulting in several deaths.1 It was declared a war gas by the United Nations and banned for export from the U.S. in 1958.

In 1928, scientists developed orthochlorbenzalmalononitrile (CS), which irritated the skin and respiratory system as well as the eyes. Lacrimators and irritants were widely used during World War II. English scientists developed dibenzoxaprine (CR) in 1962, but leaking containers caused third-degree burns on military police so it was discontinued.

Oleoresin capsicum (OC) was introduced in 1982. This inflammatory agent is produced from cayenne or chili peppers. It causes lacrimation, blepharospasm, and capillary dilation. The mucous membranes are directly affected, causing swelling in the nose throat. Skin inflammation may result. It is the most commonly used agent in policing, riot and crowd control, and self-defense, including defense against attacking animals.

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General primary effects include lacrimation, conjunctivitis, sneezing, coughing, reduced vision due to tearing, nasal irritation, mild burning and itching of skin. Blepharospasm, salivation, nasal and throat congestion, dyspnea, nausea and emotional reactions are secondary. Productive cough, contact dermatitis, retching, epistaxis, diarrhea, pulmonary edema, distorted sense of taste may also occur.

High concentrations of CN may cause corneal damage, opacity, and permanent visual impairment. Papulovesicular dermatitis and superficial burns may affect periocular skin. Ingestion of food or water contaminated with CN may result in ulcers, nausea, vomiting and lower GI upset. Exposure to CS may result in abortion or premature labor and delivery in pregnant women. Hydrolysis of CN is slow in aqueous solution, difficult to decompose or decontaminate while CS can be easily inactivated using water with soap.

OC may cause more intense burning to eyes, nose, and respiratory tract than other products, with difficulty breathing due to throat closure, loss of motor skills, and inability to speak.

 OC is also associated with keratitis, conjunctivitis, corneal burns, and damage to nerve fibers.

A peptide neurotransmitter called substance P is generated by nerve endings within the central nervous system (CNS) to transmit pain signals. Upon contact with skin, capsicum causes depletion of substance P, telling the brain the body is suffering life-threatening pain and results in disorientation. When Substance P is applied to small areas, transmission of pain from the area may be reduced, and this treatment may be used to address chronic pain. In the eye, however, this effect may be catastrophic.

Subtance P is also considered a polypeptide neurotoxin because aerosol inhalation causes rapid loss of blood pressure and may result in loss of conscieousness within seconds. Direct skin contact results in a similar but delayed reaction (10 to 15 seconds). Note than those with darker skin will have a significantly delayed reaction of up to 5 minutes. Prior exposure to pepper products will increase response time.

The Scoville Heat Scale was used in the 1920s to assess the “hotness” of certain foods; the foods were mixed with a sugar solution and sampled by five trained testers. This process was abandoned due to subjectivity and replaced by science such as high-pressure liquid chromatography. The unit of measure is the Scoville Heat Unit (SCH). Examples of levels of potency using this measure are noted in Table 2.

Unfortunately, it is common to boost the “hotness” level of OC products without information on boosting released to the public. In addition, different products may be blended to enhance effect. OC/CS combinations are referred to as “Fortified Mace” or “Freeze+P.”

The molecular target of capsaicin TRPV1 is a transient receptor potential (TRP) ion channel expressed in nociceptors.

 These receptors are part of the pain-sensing sensory nerves of the trigeminal, vagal, and dorsal root ganglia (DRG). Nociceptors are located in the skin, cornea, and conjunctiva, as well as in mucous membranes of the respiratory system. TRPV1 promotes neuronal depolarization when activated, acting as a warning sensor for imminent tissue damage.

 TRPV1 is sensitized through signaling from a range of G protein–coupled receptors including bradykinin, prostaglandin, nerve growth factor, cytokine and chemokine receptors.

The tear gas agents CS, CN, and CR have been linked to a single target, TRPA1, despite being structurally dissimilar. TRPA1 is also a TRP ion channel expressed in nociceptors. Pain neurobiological research has demonstrated that TRPA1 is also the target of mustard oil, wasabi, and horseradish. This will not come as a surprise to anyone eating these foods by mistake.

Ocular and nasal pain are sensed almost immediately after exposure to CN, CR, and CS as well as OC due to activation of TRPV1 and TRPA1 receptors in trigeminal nerve endings in the cornea and nasal passages. Chronic TRPA1 activity creates nerve calcium overload and excitotoxicity. This results in chronic pain signaling and peripheral neurodegeneration, a loss of sensation, or altered sensations.

 When ligands of TRPV1 and TRPA1 are applied topically, extensive desensitization and remodeling of cutaneous nerve endings may occur.

Corneal TRPV1 and TRPA1 activation provides immune responses to noxious environmental stresses such as temperature fluctuations, rises in ambient osmolarity, mechanical stretch, decline in pH, tissue injury, and exposure to irritant ligands.

 Expression of TRPV1 is demonstrated in the corneal epithelial cell membrane in addition to corneal nerve fibers.

Water increases the effect of some pepper chemicals.

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