BLOG: COVID catch-22: Managing emergent eye cases in a global pandemic
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Patient 1, a 78-year-old man with a history of rheumatoid arthritis, interstitial lung disease and scleromalacia perforans, presents with severe, progressive scleral thinning in a melted scleral patch graft in his only seeing eye.
You plan to take him to the operating room for emergent repeat patch graft and tarsorrhaphy with fear of imminent scleral perforation. The OR is set, tissue ordered — and the patient tests positive for COVID-19. He is adamant that he is at his baseline, denies any symptoms of coronavirus and wants to go to the OR immediately for surgery. Certainly, your plan was to do this under general anesthesia because any movement could result in perforation. Your options are:
1. Take the patient to the OR under general anesthesia. After all, he is symptom-free, and oxygen saturations are normal.
2. Take him to the OR but try to do a block or topical anesthesia and pray for no perforation.
3. Hold off on the OR and do an in-clinic tarsorrhaphy to help stabilize the sclera until the patient is out of the COVID window.
What do you do?
Patient 2, a 36-year-old man who is morbidly obese, presents with concern for an open globe injury and is found to have a small scleral laceration with questionable uveal prolapse.
Visual acuity is 20/20. The eye is Seidel negative with IOP of 18 mm Hg. The OR is set for a globe exploration and repair — and the patient tests positive for COVID-19. He endorses some shortness of breath, and upon observation, oxygen is desaturated to the mid 80% level when laying at any angle less than 45°. Oh, and he is also deaf and mute. Your options are:
1. Take the patient to the OR under general anesthesia. He technically has an open globe, and anesthesia is willing to intubate him.
2. Take him to the OR under topical and do a very gentle block. However, the patient desaturates to 85% when you even think about laying him flat.
3. Inject him with antibiotics at the bedside and watch him very closely until he clears the COVID window.
What do you do?
After extensive multidisciplinary discussions with numerous subspecialty teams including anesthesia and family members (via FaceTime through ASL), neither of these patients were taken to the OR. We placed a tarsorrhaphy in patient 1 and sent him to the ED for closer evaluation given his infection and multiple comorbidities. The ED discharged him only to be readmitted 4 days later, where he passed away in the ICU of respiratory complications of his COVID-19 infection. Had we taken him to the OR, he may never have come off the ventilator. That realization is terrifying. Patient 2 was injected with antibiotics and monitored closely. He remains 20/20 and was on oxygen for a short time before recovering fully from his COVID-19 infection.
Dealing with COVID-19 has undoubtedly presented unforeseen challenges, from which ophthalmology is no exception. These two situations were exact patients (I couldn’t make these up if I tried) I had to care for within 2 weeks of each other and have illustrated to me exactly how challenging these decisions, previously straightforward decisions, are in the setting of a global pandemic. I gleaned four key lessons that I think apply to all of our patient decision-making.
1. Complex patients require multidisciplinary discussions with all medical teams involved. These conversations take a lot of time, coordination and work. It would have been much faster to just take both of these patients to the OR as planned rather than spending several days facilitating discussions; however, their outcomes may have been drastically different. Patient 1 may never have come off of his ventilator, and his death could have been on our hands.
2. Complex patient situations should also involve the patient and their family members in the decision-making process. Ultimately, you are tasked with providing your patient with as much information as to the risks, benefits and alternatives to your management of their disease, but their wishes should be considered as well as our limitations in knowledge shared.
3. Ask for help from those who have more wisdom and experience than you. It may take an extra five phone calls to reach the rheumatologist taking care of your sick patient, but it is so important to have each player involved in these difficult decisions.
4. Sounds cheesy and I know you have heard this before, but what would you want if you were in the patient’s shoes or if this was your father with rheumatoid arthritis and a new COVID diagnosis? Suddenly, things become very clear.
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