Changing drug regimen during COVID-19 pandemic lockdown: An experience from a Tertiary Eye Care Hospital as a cornea specialist

Bharat Gurnani¹, Kirandeep Kaur²,  
¹ Department of Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry, India
² Department of Pediatric Ophthalmology and Strabismus, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry, India

Correspondence Address:
Dr. Bharat Gurnani
Consultant Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry 05 007
India

Full Text



Sir,

As we all are aware now that the coronavirus disease 2019 (COVID-19) is a fatal acute respiratory infectious disease with a wide spectrum of complications caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-the SARS-CoV-2. The first case came from Wuhan City, Hubei of Chinese province, on December 30, 2019, and the World Health Organization recognized it as a global emergency on March 11, 2020.[1] On January 30, 2020, India reported its initial case of COVID-19 from Kerala and numbers began to rise in late March 2020 although at a low rate, forcing the government to implement a nationwide lockdown at an early stage of the pandemic.[2] Due to the extended lockdown and lack of transport services, we observed delayed presentation and upsurge in emergency cases such as moderate-severe vision-threatening corneal ulcers, open globe injuries, ophthalmia nodosa, severe conjunctivitis, and ocular foreign bodies and reduction in of less urgent cases such as dry eyes, keratoconus, corneal opacity, post keratoplasty, and corneal dystrophies. Posttreatment majority of the patients were either not able to follow-up or were given delayed follow-up intervals. Hence, there was a need for conceptual thinking, adaptation, and change in practice guidelines so that our patients benefit the most and should not lose vision. Patients who required urgent treatment-Corneal Ulcer-In vision-threatening corneal ulcer cases, instead of one vial we started supplementing two vials of important drugs such as 1 hourly use of Natamycin 5% suspension and 0.5% moxifloxacin hydrochloride as the follow-up was delayed by 10–15 days owing to lockdown. Conjunctivitis-Patients turning up with mild-moderate conjunctivitis were treated with a combination of antibiotics and lubricants, for example, 0.3% ciprofloxacin hydrochloride, 0.3% ofloxacin hydrochloride, or 0.5% moxifloxacin hydrochloride 4–6 times along with carboxymethyl cellulose 0.5% 4–6 times was given for 2 weeks. This combination was given to the patient as an already prepared kit so that it can be used by the patient immediately without the risk of transmission of virus. This obviated the need to go to the common pharmacy. Open globe injury-Open globe injuries and foreign body removal patients were admitted for daycare surgeries only, so we modified our approach of injectable drugs such as 1 g intravenous (IV) cefixime and 0.5 ml intramuscular tetanus. The stat dose of injectables was given at the hospital itself and home treatment was not preferred to avoid any untoward complication. Caterpillar hair (Ophthalmia Nodosa)-These patients were treated with caterpillar hair removal and antibiotic (moxifloxacin hydrochloride 0.5%) and lubricants (carboxymethyl cellulose 0.5%) combination was given as for conjunctivitis patients. Steroids were preferably avoided unless very necessary (Loteprednol 0.5%) except in cases of anterior chamber reaction. Routine patients-Dry eyes, corneal opacities, keratoconus, dystrophies, and post keratoplasty stable patients were given low dose steroids and lubricants such as 1% hydroxypropyl methylcellulose and 0.5% carboxymethylcellulose with a long duration of follow-up (6 months). Drugs that were used with precautions/avoided- Non Steroidal Anti Inflammatory Drugs-For adequate pain relief, ibuprofen was avoided as it has been documented that it deteriorates the systemic manifestations of Coronavirus infection[3] and oral paracetamol or diclofenac was given instead. Steroids-Topical steroids should be avoided as much as possible during the global pandemic, as it will be difficult to get the patients back for regular follow-ups and keep a check on intraocular pressure regularly. Even if advised, patients were given a low dose of 0.5% loteprednol with 1 week follow-up. Steroids penetrating the anterior chamber such as 1% prednisolone and 0.1% dexamethasone were prescribed only to stable keratoplasty patients. Oral and IV methylprednisolone was avoided as far as possible. Chloroquine and Hydroxychloroquine (HCQ)-oral HCQ effects multiply when used in combination with azithromycin. Various studies have also proposed that it decreases the systemic viral load in afflicted Coronavirus patients.[4] The Indian Council of Medical Research has recently approved oral HCQ for prophylactic use by health-care staff and those taking care of Coronavirus patients. However, special caution must be taken in those with glucose-6-phosphate dehydrogenase deficiency, cardiac arrhythmias, kidney/liver damage, already existing retinal pathology, and those on oral tamoxifen, hormonal replacement therapy, as it is known to cause serious side effects. Patients with autoimmune diseases who are on long-term administration should be monitored for bull’s eye maculopathy. The retinal toxicity is noted when daily dose of oral HCQ goes beyond 6.5 mg/kg and the total duration is beyond 5 years.[5] For treating these patients, we took informed consent and also All India Ophthalmological Society consent form can also be utilized for the same. Through this letter, we want to highlight that change is the rule of nature and adaptation is the key during tough situations. This practice can be adapted by all ophthalmologists based on the regional prevalence of the cases and this will also help all the pharmacologists to understand the demand and supply, the practice patterns, and the importance of these drugs in ophthalmology during COVID-19 pandemic.

Acknowledgments

Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References