Beta corona virus disease is a relatively new entity caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2); also known as 2019 novel corona virus disease (COVID-19) was first identified in China on December 3, 2019.1, 2 In India COVID-19 was detected first time on January 30, 2020 Since, then it has spread across the globe to become one of the most serious pandemics.3 The World Health Organization (WHO) has declared COVID-19 outbreak as a public health emergency of international concern on January 30, 2020.4 By June 2, 2020, its outbreak was wide spread internationally causing 6,28,7771 infections and 3,79,941 deaths in several counties. In India, the total number of confirmed COVID-19 cases exceeded 2,07615 and 5845 deaths as of June 2, 2020.5
The human-to-human transmission is confirmed. As compared with other types of corona virus like SARS & MERS, this virus has high risk of transmissibility and infectivity, despite of low mortality rate.6, 7 The virus is mainly transmitted through direct contact of respiratory droplets or by touching a contaminated surface or objects via nose, mouth and eye.8 Transmission via ocular surface is also reported. The transmission due to aerosol contact with conjunctiva in unprotected eyes has also been reported.9, 10
Elderly, immunocompromised patients and patients with pre-existing co-morbidities like diabetes, cardiovascular diseases, hypertension and cancer are at greatest risk of mortality. Along with cancer it has become the second leading cause of death worldwide. COVID-19 infection is likely to increase cancer related mortality to a great extent. Wenhua Liang et at. analyzed 2007 cases from 575 hospitals in China and found that patients with cancer had higher risk of severe COVID-19 infection than those without cancer.11 McGoogan WZ reported that COVID-19 fatality rate was about 5.6% among cancer patients as compared with 2.3% in general population.12 Cancer patient are prone to COVID-19 because of immunocompromised condition due to both malignancy and anticancer chemotherapy.
The only way to prevent virus infection/transmission is by social distancing and isolation, to control virus epidemic, due to unavailability of effective treatment and vaccine. In Indian prospective, the complete lockdown was enforced at midnight of March 24, 2020 with total travel bans and schools and universities were indefinitely closed.13 During lockdown all routine outpatient departments across the hospitals and clinics were to be shut and only emergency services continuing to function. The COVID-19 outbreak is the leading unprecedented consequence on cancer care. It may have direct or remote consequences on patients and health care providers. The Ocular oncology practice during the COVID-19 pandemic related lockdown is quite challenging. Cases of COVID-19in India are still increasing at a great pace even during 5th lockdown, started from June 1, 2020.
Table 1
Levels of urgency in ocular oncology according to AAOOP recommendations
Table 2
Practical health vigilance recommendation adopted by modena cancer centre
Recent Chinese study shows that most of the cancer patients are at a higher risk in developing severe events in COVID-19 due to immunosuppressed status.7 Many patients of ocular malignancies are also immunocompromised from cancer therapy and are at risk of contracting COVID-19. The patients of active retinoblastoma receiving intra arterial chemotherapy are at major risk due to associated neutropaenia.14, 15 As the pandemic worsens, there is a need to reduce the risk of virus transmission and to protect the patients of ocular cancer and their attendants or family members accompanying a minor and healthcare provider including doctor and paramedical staff. Therefore the major strategies should be postponing of adjuvant therapies, elective surgeries, routine follow-up and cancer prevention appointment for less aggressive ocular cancers. However delaying and denying oncological interventions may lead to progressive disease, non-resectable tumor leading to poor survival particularly in potential fatal ocular malignancies such as retinoblastoma, orbital rhabdomyosarcoma and uveal Melanoma etc.16 Thus oncologist should provide only urgent or emergent care during covid-19. The cancer care cannot be postponed only on the basis of the risk of infection. Prioritization of cases must be done according to guidelines for triage for cancer surgery patients by American College of surgeons.17
A guideline for prioritization of ocular oncology cases given in Table 1. [Recommendations endorsed by Board of Directors of American Association of Ophthalmic Oncologist and Pathologists (AAOOP) and the International Society of Ocular Oncology (ISOO)] must be followed.18 According to (AAOOP) recommendations ocular oncology cases have been divided into (i) Emergent (should be performed within 24hr) (ii) Urgent (should be performed within a week), (iii) Semi urgent (should be performed within one to two months) and (iv) Non urgent (should be deferred for at least two to three months). In the COVID-19 pandemic situation malignant tumors are given priority over benign tumors and highly malignant tumors leading to death or disability like retinoblastoma, uveal melanoma and rhabdomyosarcoma etc are prioritized over less aggressive malignancies like basal cell carcinoma (BCC) of eyelid and OSSN etc.18
The patients who are at low risk, benign and non urgent tumors are given the choice of telemedicine consultation or to delay their visit and treatment. The general survey with reference to Indian prospective reported that 77.5% ophthalmologist could use some form of telemedicine which could be in the form of a simple phone call or a video- call, short message service (SMS) and whatsup chat. Telemedicine helps to decide whether patient requires urgent intervention or not.19 Documentation of phone calls and telemedicine consultation in medical record is essential. Ideal ocular oncology cases for telemedicine consultation are conjunctival lymphoma, OSSN, benign conjunctival melanosis (being externally located and slow growing) and benign or low malignant eyelid tumors like eyelid BCC.20 In COOG survey (collaborative ocular oncology group survey) 100% respondents were managed new patients as with active disease (having proptosis /Pain) within last 3 months as emergency.21
Interventions like detailed examination of retinoblastoma under general anesthesia where intubation is necessary or surgical procedures in which possibilities of aerosolization of virus carries high risk for transmission of SARS-CoV-2 requiring special precautions, including presurgical COVID-19 testing, use of full PPE kit etc.to minimize the risk of virus exposure to healthcare providers. Modena Cancer Centre adopted practical health vigilance recommendation for cancer management (Table 2) which is to be followed during ocular oncology procedures.22 Many institutions adopted COVID-19 testing of patients and their care taker /family members before admission. Sometimes second round PCR testing is also required due to high level of false negative results.
Protection of professionals is most sensitive issue during cancer management in covid-19 pandemic. Several reports are available from India where health care workers got COVID-19 infection during cancer care. On April 7, 2020 in Delhi State Cancer institute (DSCI), 18 health workers including two doctors were found COVID-19 positive.23 On April 14, 2020 two doctors and 2 nurses were found COVID-19 infected in Asian Cancer institute, Mumbai.24 Thus preventive barriers are mandatory for all professionals involved in cancer care.
