Dr Neeraj Jain MD, Chairman, Department of Chest Medicine Sir Gangaram Hospital ,New Delhi

Prof. (Dr) Rupak Singla MD, Head, Department of TB & Respiratory diseases, National Institute of TB & Respiratory diseases, New Delhi

Q1

JSB: How is COVID-19 infection different from other flu infections

NJ: The current corona virus infection is no different clinically in its initial presentation from the other ‘ flu ‘ viruses,although it differs in transmissibility . It presents with fever, cough, symptoms of rhinitis. Breathlessness of present is a worrying symptom and warrants urgent evaluation by a physician. A word of caution is in patients with other co morbidities esp chronic lung disease, cardiac disease, diabetes, kidney disease, patients with cancer or on immunosuppressants, elderly etc. These are patients who are more prone to serious complications especially respiratory failure.

RS: COVID-19 is caused by SARS-CoV-2 virus and is different from other flu infections by its transmissibility. It is very rapidly transmissible from one person to another. That is why it has spread across the world very fast in a short period of time. Secondly commonest symptoms of COVID-19 are fever, cough and difficulty in breathing. Cold / nasal stuffiness is uncommon here. In other flu infections commonest symptoms are cough, cold nasal stuffiness with/without fever.

Q2

JSB: Do all patients with fever and common cold require investigations for COVID-19?

NJ: Any patient with flu like symptoms needs to rest completely, isolate oneself and take proper barrier as well as sanitisation precautions. Most will not require investigation for corona virus except those with a history of travel to or from affected areas, those who have been in contact with diagnosed patients or those at risk of serious complications. The purpose of testing is to do effective contact tracing and prevent spread. There is as yet no proven specific treatment for this infection. It is therefore crucial that we all impose strict self discipline.

RS: No. Not all patients with fever and common cold require investigations for COVID-19. Govt. of India is issuing guidelines from time to time, whom to investigate. Currently patients should be investigated for COVID-19 in following circumstances: -

• All symptomatic individuals (fever, cough, difficulty in breathing)who have undertaken international travel in the last 14 days:
• All symptomatic contacts of laboratory confirmed cases.
• All symptomatic health care workers.
• All hospitalized patients with Severe Acute Respiratory Illness (fever AND cough and/or shortness of breath).
• Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact.(Direct and high-risk contact include those who live in the same household with a confirmed case and Healthcare workers who examined a confirmed case without adequate protection as per WHO recommendations.)
• All patients with pneumonia are also to be notified to NCDC so that they can be tested for SARS-CoV-2

Q3

JSB:  Do all patients of positive tested COVID-19 require hospitalisation? If not, what are the indications for hospitalisation?

NJ: All Patients with diagnosed infection donot need hospitalisation.They should be isolated in hospital or at a place where proper supporting & treatment facilities are available Although, it is a self limiting condition with full recoveryin majority of patients, if one rests, isolates, stays hydrated and nourished However, If there is breathlessness/ hypoxaemia then patients need admission to hospital. Similarly if there is evidence of multiorgan failure patients will need hospitalisation

RS: At present as per the advisory by MOHFW, all lab confirmed covid 19 patients are to be admitted at govt. created isolation facility. They may require admission to the ICU if developing respiratory failure.

Q4

JSB: What are indications for home quarantine in context of COVID-19?

NJ & RS: At present home quarantine is applicable to

• All contacts of a suspect or confirmed case of COVID-19 if asymptomatic.
• All travellers returning from abroad from covid affected countries, even if asymptomatic, to quarantine themselves at home for at least two weeks

Q5

JSB: There is some controversy regarding mode of transmission. Is it by surface/fomites only or aerosol spread as well?

NJ: The commonest mode of transmission is aerosols from a patient who is coughing out the virus. This is the main reason why a 6 feet distance is so important as most of the droplets will settle on the ground or another surface. The risk of transmission via fomites is real. There is some data on how long the virus survives on various inanimate surfaces so it is good to avoid unnecessary touching/ contact with any surface and frequent hand washing as well as use of alcohol based sanitisers

RS: It is by both. 

• With droplet transmission, virus is released in the respiratory secretions when a person with infection coughs, sneezes, or talks. It can infect another person in vicinity if he or she inhales these infected droplets
• Infection can also occur if a person touches an infected surface/fomites and then touches his or her eyes, nose, or mouth.

Q6

JSB: What changes in lung parenchyma in COVID-19 are different from other pneumonias?

NJ: Viral pneumonias cause severe interstitial inflammation / ARDS. Bacterial pneumonias usually involve the whole lung parenchyma in a segmental or labor fashion but can be extensive without anatomical barriers especially in the immunocompromised

RS: Difference on imaging- Patients with COVID-19 most commonly demonstrates ground-glass opacification with or without consolidative abnormalities, consistent with viral pneumonia. Chest CT abnormalities are more likely to be bilateral, have a peripheral distribution, and involve the lower lobes. Less common findings include pleural thickening, pleural effusion, and lymphadenopathy.

Whereas other pneumonias like bacterial may have unilateral (Lobar) or bilateral (Bronchpneumonia) consolidations with or without cavitation. Empyema may be present in untreated patients as a complication.

On lab findings, in patients with COVID-19, the white blood cell count can vary. Leukopenia, leukocytosis, and lymphopenia have been reported, although lymphopenia appears most common. Elevated lactate dehydrogenase and ferritin levels are common. On admission, many patients with pneumonia may have normal serum procalcitonin levels whereas patients of bacterial pneumonias usually have leukocytosis with raised polymorphs with raised Procalcitonin levels.

Q7

JSB: If a COVID-19 patient in ICU has ocular involvement in the form of conjunctivitis, does his management change in anyway?

NJ: The medical management of such patients in the ICU does not change. It probably is like any other viral conjunctivitis best managed by the ophthalmologist

RS: No, the treatment remains same. He needs to be treated for conjunctivitis as well as for COVID-19. Only strict precaution is to be taken that patient as well as the health care staff do not touch the eye of the affected patient during medication otherwise conjunctivitis can spread to other staff in ICU.

JSB: AAO recommends  protecting your mouth, nose (e.g., an N-95 mask) and eyes (e.g., goggles or shield) is recommended when caring for patients potentially infected with COVID-19.Treat it as any other viral conjunctivitis with lubricants & topical antibiotics to prevent superadded infection .

In addition, use slit-lamp breath shields for protection .

Q8

JSB: Please comment on efficacy of hydroxychloroquine vs. chloroquine/lopimavir/Ribonavir/ramdecivir/ Azithromycin+HCQ in Indian scenario.

NJ: There is no hard evidence to recommend hydroxychloroquine as a preventive or therapeutic agent alone or in combination with azithromycin/ antiviral agents. 

However based on sketchy initial data and extrapolation from past knowledge healthcare professionals in high risk areas may take HCQS as prophylaxis. Seriously affected patients may be given HCQS along with azithromycin as therapy with or without antivirals. This is along with all other supportive measures

RS: Published studies from India in this regard are not available. After analysing the experience and literature available in India as well as from abroad, ICMR has suggested use of Hydroxy-chloroquine for prophylaxis of SARS-Cov-2 infection to following categories of people: -

• Asymptomatic health care workers involved in the management of suspected or confirmed COVID-2 patients. They are to be given 400 mg Hydroxy-chloroquin twice a day on day 1 followed by 400 mg once a week for next 7 weeks
• House hold contacts of laboratory confirmed COVID-19 patients. They are to be given 400 mg Hydroxy-chloroquine twice a day on day 1 followed by 400 mg once a week for next 3 weeks.

Q9

JSB: Rampant use of CQ/HCQ has ophthalmic side effects. Do you advise ophthalmic screening before starting treatment? After how long should ophthalmic examination be repeated after starting treatment?

NJ: HCQS is widely used in autoimmune diseases like SLE and rheumatoid arthritis. It is also used long term in sarcoidosis. There is no indication for routine eye examination in patients on HCQS. Chloroquine has more toxicity and should be supervised / monitored for various side effects

RS: In normal circumstances all patients to be given Hydroxy-chloroquine should receive ophthalmic screening before starting treatment. But in current situation of lock down in the country, it may be difficult to arrange for that. Patients younger than 15 years of age and those with known case of retinopathy or allergy to hydroxy-chloroquine should not be prescribed this drug. Otherwise hydroxy-chloroquine may be started in relevant cases and monitored for any adverse drug reactions.

JSB: A baseline fundus examination should be performed to rule out preexisting maculopathy. Since the drug is to be given for short duration, follow up ophthalmic screening / examination is not required in absence of major risk factors like renal disease or concurrent use of tamoxifen.There is lower risk with doses upto 5 mg/kg real weight & in patients of Asian heritage .

Q10

JSB: Do you advise routine ophthalmic OPDs to be shut down as ophthalmic examination such as slit lamp examination, fundus examination or even torch examination requires close contact of less than one metre?

NJ: It is advisable to shut down non emergency ,routine OPD .  Patients attending ophthalmology clinics should answer questions related to recent travel and exposure to patients with flu. They should be made to wash hands/ use a sanitiser and preferably wear a mask. If a patient is coughing and the eye problem is not an emergency the assessment should be deferred

RS: Yes, all routine ophthalmic OPDs may be shut down. However, emergency facilities for eye injuries, acute eye infections and other eye conditions requiring acute care should be made available to the public.

Q11

JSB: If a patient of COVID-19 is one eyed and suffers from

a) Semi emergency like Diabetic macular edema that requires intravitreal injections, can it be given immediately or after his systemic condition improves?

NJ: These patients can be considered for treatment with HCQS along with Azithromycin and an antiviral before being taken up for any procedure or surgery. Obviously systemic complications will have to be assessed and dealt with in their own merit

RS: Here one has to assess the risk and benefits of intervention. Since the patient has only one eye and ophthalmologist feels that delay in treatment may lead to loss of vision, the required treatment be given immediately as apparently there is no contraindication with COVID-19 treatment. Basic precautions to prevent the spread of COVID-19 should be strictly adhered to.

b) Emergency like retinal detachment, perforating  injury: can they be immediately operated?

NJ,RS: As it is an emergency, patient may not be denied the treatment. However, all basic precautions to prevent the spread of COVID-19 should be strictly adhered to.

JSB: Can do emergency surgical procedures .The patient should remain in the hospital setting .If the patient is not hospitalized at the time of referral, the patient is best referred to other hospital-based facility equipped to manage both COVID-19 and eye care.Transmission precautions^† for treating ophthalmologists include wearing an N-95 mask, gown, gloves and eye protection (face shield or goggles).

Follow the important steps as follows :

• Develop a dedicated COVID-19 OR to control the spread of the disease
• Empty OR of all nonessential materials
• Consider a negative pressure anteroom with separate access if possible
• Special PPE for OR (N95 or OR powered air-purifying respirator (PAPR), goggles or face shield, gown, boot covers)
• Must use N95 for all aerosol-generating procedures
• Extubation should occur in a negative pressure intensive care unit (ICU)/ward room if possible
• Recover patient in the negative pressure ICU/ward room or in the dedicated COVID-19 OR if negative pressure room not available
• Consider dedicated OR teams to manage COVID-19 patients in the OR with detailed education

Q12

JSB: What is your message to the community in general and as an Ophthalmologist in particular?

NJ: Please be responsible. Do not conceal any facts. COVID can affect any one of us and be potentially fatal. Isolate yourself for the requisite 2 weeks, take strict barrier precautions. 

Do not put your life in jeopardy for short term gains. It is our responsibility to protect our families, friends, neighbours

All medical and paramedical workers need to follow guidelines laid down when treating patients

RS: We should not create panic about COVID-19, but at the same time we need to be very careful to take adequate precautions to prevent the spread of this disease. Frequent proper hand washing as per guidelines is very important. We need to follow the guidelines issued by the Govt. of India from time to time.

Q13

JSB: Considering the fact that amongst Doctors treating COVID 19, mortality among Ophthalmologists in particular has been quite high. What steps should be taken by Ophthalmologists?

NJ, RS: All routine eye examinations are to be avoided. However, in acute eye conditions eye examination should be carried out with full precautions to prevent the spread to the doctors. Frequent hand washing as per guidelines is very important.

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Interview Taken By 

Dr Jatinder Singh Bhalla 
MS,DNB,MNAMS  
HOD (Ophthal)DDU Hospital,New Delhi
Member Scientific Committee AIOS

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