Clinical FAQ

Like other health practitioners, optometrists are not legally obliged to treat patients unless it is an emergency or a contractual requirement. Discrimination laws prevent optometrists and staff from discriminating against patients on the basis of disability/impairment (e.g. COVID-19), race, religion, gender etc. However, you could refuse to see a patient if it is reasonably necessary to protect the health and safety of any person (including practice staff and your other patients). In determining whether discrimination is “reasonably necessary” you need to consider the up-to-date expert advice. Generally, if patients are presenting for appointments with virus symptoms, then they should be rescheduled for health and safety reasons.

Ideally, employers should arrange for communication to be sent to all patients, asking them not to attend the practice if they are unwell. And that patients should contact the practice to cancel or reschedule their appointment. That way, if a patient does present for their appointment with symptoms, it will be easier to manage the conversation.

Non-suspect patient: Has no respiratory symptoms, has not had contact with a COVID-19 positive person and has no history of overseas travel.

Suspect case: A patient whom has any one of the following;

• Recent travel to, including transit though, another country or state
• Any recent cruise ship travel
• Close or casual contact within the last 14 days with a confirmed case of COVID-19
• Respiratory illness symptoms or a fever

Confirmed case: A person who tests positive to a specific SARS-CoV-2 PCR test or has the virus identified by electron microscopy or viral culture, at a reference laboratory.

References:

• Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) WHO
• Interim advice on non-inpatient care of persons with suspected or confirmed Coronavirus disease (COVID19), including use of personal protective equipment (PPE), Australian Government Department of Health

• Those who have come into contact with a person confirmed COVID-19 case need to follow advice from the Department of Health regarding quarantine. They need to consider if their interaction with the confirmed case was “close contact”.  A close contact is someone who has been face to face for at least 15 minutes or been in the same closed space for at least 2 hours.  These people may enter a practice even when steps have been taken to exclude symptomatic and recently travelled patients as people may be contagious prior to becoming symptomatic.
• If this occurs, you must isolate yourself in your homes for 14 days after last contact with the confirmed case. While in isolation if you develop symptom of fever or respiratory infection you need to be tested for COVID-19.
• It is important to ensure that all staff that have been in “close contact” with the infected person also isolate themselves.
• Cleaning and disinfection protocols as per government adviceshould be followed to ensure that the practice is safe for staff and patients to return.

Optometrist along with other healthcare workers engage with higher risk populations and therefore should have a lower threshold for testing for COVID-19 if they provide direct care.  This applies for optometrists who see patients clinically, and does not apply to other staff.

Optometrists should be tested if they develop:

• a fever (≥37.5); AND
• symptoms of an acute respiratory infection (e.g. shortness of breath, cough, sore throat).

This is in addition to the standard requirements for isolation following travel.  More information.

The person who is suspected or confirmed to have COVID-19 must follow the Department of Health regarding isolation. Those who have come into contact with a person with confirmed COVID-19 need to follow advice from the Department of Health regarding quarantine.  Although there is limited information about COVID-19 it appears that people are contagious from 24-48 hours before symptoms appear to 1 day after symptoms cease.

It is important for those that have been face to face with the person for at least 15 minutes, or in the same closed space for 2 hours self-quarantine.  This is likely to be the other staff that have worked with the confirmed person.

This may also include patients if they have spent more than 15 minutes face to face with the confirmed COVID-19 individual.

Cleaning and disinfection protocols as per government advice should be followed to ensure that the practice is safe for staff and patients to return.

If tonometry cannot be deferred, options for measuring IOP include:

1. Using a disposable applanation tonometry prism

2. Using an iCare tonometer with disposable probe

3. High-level disinfection of reusable applanation prisms

A review of the literature^1,2 suggests current practices, including use of alcohol swabs and hydrogen peroxide, are no longer considered best practice. Possible disinfection options include: either sodium hydrochlorite or Tristel Duo OPH.

Sodium hypochlorite

1. Clean with mild pH neutral detergent or soap
2. Rinse with sterile water/saline before disinfecting
3. Soak in sodium hypochlorite (5000ppm) for 10 minutes
4. Rinse with sterile water/saline
5. Air dry or dry with sterile, soft disposable cloth

Note: The appropriate concentration of sodium hypochlorite is 5000ppm, approximately 0.5%.

Household bleach is 5-6% sodium hypochlorite, so a 1:10 dilution of bleach (1 part bleach, 9 parts water) equals 5000ppm, and this solution should be made daily.

Please note this is ‘off-label’ use for bleach products which are typically registered with the TGA for surface disinfection.

Tristel Duo OPH (chlorine dioxide)

1. Dispense 2 doses of Tristel Duo onto a Tristel Dry wipe or directly onto the instrument
2. Spread the foam over the surface of the instrument
3. Wait two minutes
4. Rinse with sterile water/saline
5. Air dry or dry with sterile, soft disposable cloth

According to recent research, Hydrogen Peroxide is not viricidal and does not have high-level effectiveness against viruses. It is no longer recommended by the CDC (USA) as it has been associated with adenovirus outbreaks. For more detail on this please read “Disinfection of Tonometers, A Report by the American Academy of Ophthalmology by Junk A, Chen P et al“

We understand that this may represent a change in practice, and as with all new things it can be difficult to implement a new routine. With the recent times, it has given everyone an opportunity to scrutinize infection control measures and ensure we adhere to best possible standards. For more information, there is a pandemic infection procedures factsheet in the upcoming June Pharma and on our COVID-19 infection control page. Our comprehensive Optometry Australia Infection Control Guidelines are also currently being updated to encompass the latest evidence based advice for pandemics.

References;

1. Junk AK, Chen PP, Lin SC et al. Disinfection of tonometers: A report by the American Academy of Ophthalmology. Ophthalmol 2017; 124(12): 1867-1875.
2. Centres for Disease Control and Prevention. Infection Control – Chemical Disinfectants. Available at https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html [Accessed 4 April 2020].”

The Royal College of Ophthalmologists and the Royal College of Optometrists in the UK reissued advice on Jun 16 2020 on use of NCT to advise that it does not pose a significant infection risk to staff or other patients when undertaken in patients without active COVID-related conjunctivitis.  They have additionally recommended the instrument head is wiped down with an appropriate disinfectant wipe between each patient and to perform three puffs to clear tip. Before restarting this procedure it would be prudent to perform a local risk assessment to consider infection rates at your location and to continue to follow infection control and other advice related to COVID-19 in the optometric setting (eg triage questions for patients with flu-like symptoms or risk factors so that consultations / NCT is also being avoided on this group).

(Updated 9 April 2020)

Australia Capital Territory

ACT Government has not yet relaxed their medical certification rules due to COVID-19. However, they are encouraging licence holders to:

• Renew online with a quick 5 step process (even if patient presents with a form requiring VA, it may still allow licence holder to renew online without VA, and certify via a tick box that they will need to complete a VA test within next 6 months).
• If online pathway is not allowed or possible (sometimes due to existing restrictions on their licence), the form needs to be completed as per usual.

New South Wales

Transport for NSW has deferred the need for drivers over the age of 75 to undertake a medical review to confirm they are fit to drive. During the deferral period, drivers over 75 who fall under a non-high-risk category are no longer required to undertake a medical review to renew their drivers’ licence. Drivers who are considered at high risk including those who require specialist review, police identified drivers, and heavy vehicle drivers are still required to undertake a medical assessment. The deferral is for a period of up to 12 months from Monday 23 March.

Website: https://www.rms.nsw.gov.au/roads/licence/health/fit-to-drive.html

Northern Territory

TBC

Queensland

Optometry QLD/NT division and members have strongly advocated to the QLD Government in this space.

For licence holders 75 and over, two changes will be in place from 10 April 2020:

• Medical certificates to drive that expired after 29 January 2020 will be considered valid until 6 months after the COVID-19 emergency ends.
• During the COVID-19 emergency period, drivers aged 75 or over won’t be committing an offence if they are driving without holding a valid medical certificate.

Licence holders who are 75 years or older and have an ‘M’ condition on their driver licence will need to call 13 23 80 or email medcert@tmr.qld.gov.au to have their medical certificate extended.

Website: https://www.qld.gov.au/transport/covid-19-transport/medical-review-changes-for-drivers-over-75

South Australia

The requirement to submit a certificate of fitness has been relaxed for some licence holders. Please note, this is a temporary measure and is dependent on licence class and type of medical condition (if any). Licence holders will be advised of their specific requirements once further measures are implemented.  License holders should call 13 10 84 to see if they meet the exemption criteria.

Website: https://www.sa.gov.au/topics/driving-and-transport/licences/drivers-licence/medical-fitness-to-drive

Tasmania

Licence holders 65 years of age and over whose licence is due for renewal from 1 April – 30 September 2020 will automatically have their licence renewed for one year at no cost using existing photos. Drivers will receive their licence via the post prior to their licence expiring. Registration and Licensing will contact all licence holders impacted.

A risk-based assessment of all medical fitness to drive requirements for licence holders has been undertaken.  Where low to medium risk is identified the requirement to provide the assessment will be deferred for 6 months and where applicable conditions added to a driver’s licence.

Licence holders with high risk conditions will still be required to provide a medical fitness to drive assessment. Patients will be advised if they are required to provide a medical fitness to drive assessment or have had conditions placed on their licence.

Licence holders can contact 1300 13 55 13

Website: https://www.transport.tas.gov.au/clientsupport

Victoria

VicRoads have suspended all light vehicle drive tests and computer-based license tests until further notice. For questions surrounding individuals with existing reviews, members and patients can contact the VicRoads Medical Review team at (03) 8391 3224 or medicalcasemanagers@roads.vic.gov.au In some cases, assessment may be deferred with the provision of a conditional licence while waiting for reports. Requirements are being reviewed frequently.

Website: www.vicroads.vic.gov.au/coronavirus

Western Australia

WA Government has issued a general statement to advise they are currently reviewing requirements for elderly driver medical assessments.

For those who have been issued a Fitness to Drive form (M106A/M107A/M108A) prior to the impact of Coronavirus, please direct them to contact 13 11 56 to discuss their circumstance.

Website: https://www.mediastatements.wa.gov.au/Pages/McGowan/2020/03/Temporary-licensing-changes-in-place-to-help-elderly-and-essential-workers.aspx

Many vulnerable communities are limiting access for non-essential visitors, including health personnel, in order to limit the impact of COVID-19 on population groups such as Aboriginal and Torres Strait Islander people, who are considered to be at greater risk. As such, requests for the postponement or cancellation of scheduled outreach optometry visits are likely. As a first step, we recommend that providers confirm with their jurisdictional VOS fundholder, or community contacts, whether visits are to go ahead as early as practical.

If visits are cancelled or postponed, Optometry Australia understands that the Department of Health has recently advised jurisdictional VOS fund holders that funding may be made available to cover any non-refundable expenses. We encourage optometrists who find themselves out of pocket with costs incurred in preparing for these visits (e.g. pre-booked flights and accommodation) to work with their Regional Coordinator to arrange appropriate reimbursement.

As the COVID-19 pandemic continues, the Australian Department of Health has confirmed that allied health practitioners can (and should) continue face-to-face services to homes and residential care facilities, to service vulnerable members of the public, such as the elderly and those with disabilities.  However, practitioners are urged to be vigilant for signs of COVID-19 so not to put themselves or these communities at further risk and to implement strict infection control. From 1 May 2020, all aged care workers and visitors (including visiting optometrists) must have been vaccinated against seasonal influenza to enter an aged care facility.

Patient alert posters and social media tiles are available from both Optometry Australia and the Department of Health. Some of Optometry Australia’s posters have editable fields to suit your practice preferences.

The Optometry Board of Australia (OBA) released advice on 3rd April 2020, noting that the OBA will not take action if optometrists cannot meet the CPD registration standard due to the COVID-19 pandemic when seeking to renew registration this year. While the OBA acknowledged that optometrists may have difficulty meeting CPD requirements this year as a result of withdrawn/denied leave requests, conference cancellations and the re-prioritization necessary to meet workforce needs, optometrists are still encouraged to continue to do relevant CPD.

Similarly, the OBA will also be flexible with regards to CPR training requirements during the pandemic – if you are due to complete CPR training this year, the OBA requests that you complete CPR training when there is no longer an unnecessary risk involved in participating in a course. The OBA will keep a close watch on the situation to determine whether the 2021 renewal year is also affected.

During the COVID-19 pandemic, Optometry Australia encourages members to visit our Institute of Excellence to access the full suite of high quality educational content online.

The Australian Government has advised that electronic prescribing is being fast-tracked as part of the National Health Plan for coronavirus (COVID-19). This guide for prescribers outlines the temporary arrangements available now that will help patients receive medicines via telehealth services. Essentially, as a prescriber, you will still create a paper prescription, during a telehealth consultation. This prescription will need to be signed as normal or using a valid digital signature. You can then create a clear copy of the entire prescription (a digital image such as a photo or pdf including the barcode where applicable) to send on to the patient’s pharmacy of choice via email, text message or fax. If your patient prefers to receive the legal paper prescription you will need to mail it to them. The copy can be sent via fax, email, or text directly to the patient’s pharmacy of choice. You will be required to retain the paper prescription for a period of 2 years for audit and compliance purposes. Visit the Australian Department of health website to read more.