Differences In SARS-CoV-2 Recommendations From Major Ophthalmology .

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Original researchAnne X Nguyen ,1 Kalla A Gervasio ,2 Albert Y Wu 3To cite: Nguyen AX,Gervasio KA, Wu AY.Differences in SARS- CoV-2recommendations frommajor ophthalmologysocieties worldwide. BMJOpen Ophthalmology2020;5:e000525. doi:10.1136/bmjophth-2020-000525 Additional material ispublished online only. To viewplease visit the journal online(http:// dx. doi. org/ 10. 1136/ bmjophth- 2020- 000525).Received 21 May 2020Revised 25 June 2020Accepted 29 June 2020 Author(s) (or theiremployer(s)) 2020. Re- usepermitted under CC BY- NC. Nocommercial re- use. See rightsand permissions. Published byBMJ.ABSTRACTObjective Since the WHO declared the COVID-19outbreak as a public health emergency, medical societiesaround the world published COVID-19 recommendationsto physicians to ensure patient care and physician safety.During this pandemic, ophthalmologists around the worldadapted their clinical and surgical practice following suchguidelines. This original research examines all publiclyavailable COVID-19 recommendations from twelve majorophthalmology societies around the world.Methods and analysis Twelve ophthalmology societiesrecognised by the International Council of Ophthalmologywere included in this study. One society per each WHOregion was included: the society selected was the one whohad the highest number of national COVID-19 confirmedcases on 11 May 2020. In addition to these countries,the major ophthalmology society in each G7 country wasincluded.Results Ten out of 12 major international ophthalmologysocieties from countries covering all six WHO regions havegiven recommendations regarding urgent patient care,social distancing, telemedicine and personal protectiveequipment when caring for ophthalmic patients duringthe COVID-19 pandemic. While all guidelines emphasisethe importance of postponing non- urgent care and takingnecessary safety measures, specific recommendationsdiffer between countries.Conclusions As there is no clear consensus onophthalmology guidelines across countries, thispaper highlights the differences in internationalophthalmic care recommendations during the COVID-19pandemic. Knowledge of the differences in ophthalmicmanagement plans will allow ophthalmologists and alleye care providers to consider the variety of internationalapproaches and apply best practices following evidence- based recommendations during pandemics.1Faculty of Medicine, McGillUniversity, Montreal, Quebec,Canada2Department of Ophthalmology,Wills Eye Hospital, Philadelphia,Pennsylvania, USA3Department of Ophthalmology,Stanford University School ofMedicine, Stanford, California,USACorrespondence toAlbert Y Wu; a wu1@ stanford. eduINTRODUCTIONAs of 11 May 2020, there have been morethan 4 million confirmed cases of the coronavirus disease 2019, known as COVID-19or severe acute respiratory syndrome coronavirus (SARS- CoV-2), around the world.1Since the emergence of this novel severeacute respiratory virus in November 2019,the number of patients with COVID-19 anddeaths have been escalating, which promptedthe WHO to declare the outbreak as a PublicKey messagesWhat is already known about this subject? To date, no study has examined COVID-19 esWhat are the new findings? All major ophthalmology societies from the G7countries in addition to Sociedad Española deOftalmología, All India Ophthalmological Society andOphthalmological Society of South Africa have provided valuable information regarding urgent patientcare, social distancing, telemedicine and personalprotective equipment for members on their websites.How might these results change the focus ofresearch or clinical practice? Knowledge of the differences in ophthalmic man-agement plans will allow ophthalmologists and alleye care providers to consider the variety of international approaches and apply best practices following evidence- based recommendations duringpandemics.Health Emergency of International Concern(30 January 2020).2Current evidence indicates that COVID-19is commonly spread by droplet transmissionand by asymptomatic carriers. Initial findings suggest that the virus may propagate viaairborne transmission (eg, aerosol contactwith conjunctiva and respiratory mucosa),especially in high- risk procedures like endotracheal intubation.3 While conjunctivitis hasless frequently been reported as a coronavirussymptom, it is still unclear if the virus can betransmitted through tears.4 5Physicians are at great risk of contractingthe virus due to their close proximity withpatients. The 230,000 ophthalmologistsaround the world are particularly susceptible,as they routinely perform surgeries and slit- lamp examinations at less than 20 cm frompatients. In order to ensure physician safetyand patient care, medical societies have issuedNguyen AX, et al. BMJ Open Ophth 2020;5:e000525. doi:10.1136/bmjophth-2020-0005251BMJ Open Ophth: first published as 10.1136/bmjophth-2020-000525 on 7 July 2020. Downloaded from http://bmjophth.bmj.com/ on July 8, 2020 by guest. Protected by copyright.Differences in SARS- CoV-2recommendations from majorophthalmology societies worldwide

Open accessMETHODSThis original research examines all publicly availableCOVID-19 recommendations from 12 major ophthalmology societies around the world. Twelve ophthalmologysocieties, covering all six WHO regions (African region,region of the Americas, Southeast Asia region, European region, Eastern Mediterranean region and WesternPacific region), were included in this paper. We selectedthe country with the highest number of confirmedCOVID-19 cases in each region on 11 May 2020: USA,Spain, India, South Africa, Iran and China.1 In additionto those countries, all G7 countries were examined: UK,USA, Canada, France, Germany, Italy and Japan. Developed in 1976, the G7 countries refer to a group of sevenindustrialised nations who meet annually to discuss avariety of global issues (ie, economy, environment andsecurity) (online supplementary table 1).The leading ophthalmology society in each of the 12countries was selected from the International Council ofOphthalmology repertoire, which contains 179 members.These ophthalmology societies are the most popularnational general ophthalmology societies in their respective countries, as per their number of members (table 1).The publicly available data displayed on these societies’official websites were extracted, translated into Englishwhen applicable (Sociedad Española de Oftalmología(SEO), Société Française d’Ophthalmologie (SFO), Deutsche Ophthalmologische Gesselschaft (DOG), SocietàOftalmologica Italiana (SOI), Japanese Ophthalmological Society (JOS), Iranian Society of Ophthalmology(IRSO) and Chinese Ophthalmological Society (CHOS))and analysed in this paper.It is important to note that this paper reflects the societies’ respective status as of 11 May 2020 and that theseguidelines are subject to change.Patient involvementPatients were not directly involved in the design of thisstudy.RESULTSOverview of ophthalmology societiesThe 12 ophthalmology societies examined includethe following: the Royal College of Ophthalmologists(RCOphth) in the UK,6 the American Academy ofOphthalmology (AAO),7 the Canadian Ophthalmological2Society (COS),8 SEO,9 SFO, DOG,10 SOI,11 JOS,12 the AllIndia Ophthalmological Society (AIOS),13 the Ophthalmological Society of South Africa (OSSA),14 CHOS15 andIRSO16 (table 1).Overview of COVID-19 informationEleven out of twelve societies have a website that releasesinformation for their members and patients. CHOS doesnot have its own website, as the description of the societyis found on the Asia- Pacific Academy of Ophthalmologyweb page and refers readers to the Chinese Medical Association (CMA) website.15 On the CMA’s website, thereare no guidelines for ophthalmologists in the contextof the pandemic. Out of these 11 societies, 10 websiteshad information regarding the COVID-19 pandemic asthere were no guidelines found on the IRSO webpage(table 1).Ophthalmology societies have promoted their firstCOVID-19 guidelines from 11 February (SOI) to 28March 2020 (AIOS) (figure 1). The actual effect of theguidelines used is variable when looking at reportedlaboratory- confirmed COVID-19 cases (online supplementary figure 1).Urgent versus non-urgent careTable 2 highlights examples of urgent and non- urgentprocedures provided by each society.For instance, RCOphth displays UK- based resources,like the Moorfields Eye Hospital National Health Service(NHS) Foundation Trust, and emits its own guidelines onurgent and non- urgent care. It also states that all routineophthalmic surgeries and face- to- face outpatient must bedelayed, except if patients are at elevated risk of harm.Ophthalmology accident and emergency departmentsmust remain open with appropriate support to ensureadequate patient triage and consultations.17AAO listed 53 suggestions of ‘urgent’ surgicalprocedures associated with indications. For example,ophthalmologists should perform brachytherapy forintraocular malignancy.18 COS, AIOS and JOS display thiscomprehensive list on their website but also publishedtheir own guidelines.AIOS provided a list of twenty ophthalmic emergencies, which are very similar to AAO’s. In addition to thoseemergencies, it provides a list of 11 complaints in orderto rule out emergencies (ie, chemical/thermal/mechanical eye injury, acute red eye, photophobia and suddenhalos/floaters/discharge/eyelid drooping).19While referring its members to AAO’s resources, JOShas its own list examples regarding urgent treatment,notably retinal detachment, ocular trauma and retinoblastoma. The list has then been updated to includemore examples of urgent care (ie, paediatric glaucoma,orbital fracture and bulging cataracts). Unlike the othersocieties that consider common adult cataract surgery asan elective treatment, JOS mentions that delaying cataract surgeries depend on each patient’s circumstances.12Nguyen AX, et al. BMJ Open Ophth 2020;5:e000525. doi:10.1136/bmjophth-2020-000525BMJ Open Ophth: first published as 10.1136/bmjophth-2020-000525 on 7 July 2020. Downloaded from http://bmjophth.bmj.com/ on July 8, 2020 by guest. Protected by copyright.recommendations about clinical and hospital- based practices to adopt during COVID-19.The purpose of this article is to assess the major international ophthalmology societies’ recommendationsregarding patient care, social distancing, telemedicineand the use of personal protective equipment (PPE) whencaring for ophthalmic patients during the COVID-19pandemic. The goal is to assist ophthalmologists and alleye care providers in understanding the diversity in international guidelines available and to apply best practicesbased on these recommendations.

Nguyen AX, et al. BMJ Open Ophth 2020;5:e000525. SOIJOS4,5277,2005,5802,95585430,0002,214# ofmembersWestern Pacific peWHO ww.sedesoi.com/https://www.dog.org/?cat OVID-19 portal pageOverview of international ophthalmology societies examinedUpdatesNoneFrequentDailyContinued11 notices concerning COVID-19 tailored forVariableophthalmologists and citizens, as well as a listof reputable sources of information concerningthe pandemic (WHO, CDC, Lancet and AAO).17 press releases from SOI President,Variableconcerning issues surrounding contact lenses,legal doctors, provision of FFP2 masks andpatient care.1 COVID-19 handbook in collaborationNonewith the Professional Association ofGerman Ophthalmologists eV. Referral toexternal resources on COVID-19: list ofrecommendations for medical professionals,guidelines from other ophthalmic societies andgeneral information on the pandemic.17 detailed recommendation sheets written by FrequentSFO, often in collaboration with other vision- related French organisations.5 detailed documents highlighting COVID-19recommendations for ophthalmologists,for patients and for medical professionalsconcerning the distribution of medicationrelated to COVID-19.COVID-19 Practice Resource Centre with23 resources: COS guidelines, subspecialtyposition statements, articles and videos fromAAO, CDC, UHN and learning opportunities(webinars).Comprehensive list of news and resourcesfor ophthalmologists in the USA and aroundthe world (clinical, advocacy and policy,telemedicine, practice management, articlesand outbreak statistics).Comprehensive list of resources forFrequentophthalmologists (PPE guidance, clinicalguidance, optometrist collaboration,telemedicine and information for trainees)written by RCOphth and list of references fromother national entities for additional clinicalguidance.COVID-19 resourcesBMJ Open Ophth: first published as 10.1136/bmjophth-2020-000525 on 7 July 2020. Downloaded from http://bmjophth.bmj.com/ on July 8, 2020 by guest. Protected by copyright.SocietyTable 1Open access3

Nguyen AX, et al. BMJ Open Ophth 2020;5:e000525. doi:10.1136/bmjophth-2020-0005251,76023319,846# ofmembersWestern Pacific 22,000EasternMediterraneanAfricaSoutheast AsiaWHO regionNo COVID-19 information available.No COVID-19 information available.UpdatesNone1 COVID-19 alert page: general information on NotCOVID-19, frequently asked questions section, frequentwebinars, in addition to the list of externalrecommendations (AAO COVID-19 updates,India’s latest COVID-19 statistics and globalupdates).COVID-19 f/5e788b26b09791041d2e7d8f 2- page statement on management ofophthalmic patients during COVID-19, andreferral to OSSA the COVID-19 CoronavirusSouth African Resource Portal produced bythe country’s department of navirus-updates-forophthalmologists.phpCOVID-19 portal pageRCOphth: The Royal College of Ophthalmologists (https://www.rcophth.ac.uk/).AAO: American Academy of Ophthalmology (https://www.aao.org/).COS: Canadian Ophthalmological Society (https://www.cosprc.ca/).SEO: Sociedad Española de Oftalmología/Spanish Society of Ophthalmology (https://www.oftalmoseo.com/).SFO: Société Française d’Ophthalmologie/French Society of Ophthalmology (https://www.sfo-online.fr/).DOG: Deutsche Ophthalmologische Gesselschaft/German Ophthalmological Society (https://www.dog.org/).SOI: Società Oftalmologica Italiana/Italian Ophthalmological Society (https://www.sedesoi.com/).JOS: Japanese Ophthalmological Society (http://www.nichigan.or.jp/).AIOS: All India Ophthalmological Society (https://aios.org/).OSSA: Ophthalmological Society of South Africa (https://www.ossa.co.za/).IRSO: Iranian Society of Ophthalmology (http://www.irso.org/).CHOS: Chinese Ophthalmological Society -society/ and http://www.cma.org.cn/).ChinaSouth nuedBMJ Open Ophth: first published as 10.1136/bmjophth-2020-000525 on 7 July 2020. Downloaded from http://bmjophth.bmj.com/ on July 8, 2020 by guest. Protected by copyright.4Table 1Open access

Open accessFigure 1 Timeline of the first COVID-19 recommendationpublished by major international ophthalmology societiesand number of COVID-19 confirmed cases per country.Figure 1 uses the logos of ophthalmology societies and isillustrated by coauthor AX- LN.In contrast to COS, AIOS and JOS, DOG did not recreatea list of suggestions and directly refers its members toexisting resources, like to AAO’s comprehensive recommendations. However, DOG does highlight that allelective interventions and consultations, including cataract surgery, must be avoided.20SEO used AAO’s list but translated it into Spanishand classified the different procedures into clinically relevant groups in order to create a list of urgentophthalmic surgical procedures for its members. SEOalso adapted Moorfields Eye Hospital NHS FoundationTrust, a resource displayed on the RCOphth’s portal, toShelter in place and telemedicineThe ophthalmology societies follow their national guidelines. All nine societies, except JOS, have mentioned thatpatients and physicians alike should always stay at home,except if absolutely necessary.20 JOS is the only societyexamined who acknowledges eye surgery risks andpossible disease transmission in asymptomatic people,but JOS does not insist on the importance of physiciansstaying at home as there is no lockdown rules in Japan.Table 3 lists the telemedicine resources available persociety. For example, RCOphth provides telehealthresources and compiled a telemedicine application listfor ophthalmology consultations to its members. Inits specific ophthalmic management plans, RCOphthmentions which cases can be managed virtually (eg, uveitispatients on immunosuppression).24 25 AAO also has anentire section dedicated to telemedicine resources26:tips for success,27 guide to start,28 coding for telehealthconsultations,29 teleworking considerations30 and statements from the academy and federal agencies.31 Othersocieties, like COS, simply recommend their members toconsider virtual platforms, such as telephone and videoconferences,32 and refer them to AAO.Nguyen AX, et al. BMJ Open Ophth 2020;5:e000525. doi:10.1136/bmjophth-2020-0005255BMJ Open Ophth: first published as 10.1136/bmjophth-2020-000525 on 7 July 2020. Downloaded from http://bmjophth.bmj.com/ on July 8, 2020 by guest. Protected by copyright.stratify the ophthalmological risk according to the type ofpathology (eg, glaucoma, uveitis and strabismus).Similarly to RCOphth, SFO uses national resources andwrites its own recommendations in association with otherFrench societies. SFO strongly recommended that itsmembers limit all surgical and medical elective surgeriesand provides distinctions between urgent, semiurgentand elective cases. Similarly to the previous societies,it mentions that retinal detachments that occurredwithin the past month and acute endophthalmitis withdecreased vision were deemed emergencies. However, itgives examples of elective cases, such as macular holesand posterior intraocular lens dislocation,21 and providesdistinctions between urgent and semiurgent. Semiurgentis defined as a risk of severe and permanent loss of visionwithout immediate surgery that is not as high as in urgentcases but management may only be delayed for a few dayswith very close monitoring. This includes retinal detachments of more than a month, as well as wounds of theglobe with or without an intraocular foreign body, whichare both deemed urgent by the AAO.In contrast to the other societies, SOI’s presidentused the video medium to explain differences betweenurgent and nonurgent care. The Italian video acts as acomprehensive ‘User Manual’ for medical eye care. Thepresident highlights that the hospitals are now dedicated to the care of patients with COVID-19, but therewill always be patients requiring immediate eye care (eg,patients with acute glaucoma).22OSSA recommended that ophthalmologists cancel orpostpone all non- essential surgeries and appointmentsbut did not give examples of such non- urgent procedures.23

Open accessSocietyExamples of urgent treatmentsRCOphth Glaucoma (acute, uncontrolled or rapidly progressive). Wet active age- related macular degeneration. Sight threatening treatable retinovascular disease. Acute retinal detachments. Severe active uveitis. Ocular and adnexal oncology – active, aggressive, uncontrolled or untreated lesions. Retinopathy of prematurity. Endophthalmitis. Sight- threatening trauma. Sight- threatening orbital disease (orbital cellulitis and severe thyroid eye disease).Giant cell arteritis affecting vision.AAO Acute chemical injury or acute Stevens Johnson syndrome. Acute lens complications. Appositional choroidal effusion, suprachoroidal haemorrhage or flat anterior chamber. Bleb leaks, wound leaks, overfiltration, underfiltration, bleb scarring or shallow anterior chamber. Complications with implanted devices in the cornea or anterior segment. Congenital cataract in the amblyopic period, monocular patients with documented vision loss precluding driving,reading or self- care, lens- induced glaucoma, angle- closure glaucoma, acute lens complications or severeanisometropia of fellow eye post recent lens extraction in first eye. Dacryocystocele. Displaced facial bone fractures. Endophthalmitis, corneal touch, corneal decompensation or exposed plate. Glaucoma when uncontrolled or absolute with a blind and painful eye, or when catastrophic or rapidly progressive. Haemodynamic instability or oculocardiac reflex. Impending corneal compromise. Implant/tube exposure that might be sight threatening, endophthalmitis, malpositioned tube endangering eye orexcessive inflammation, a tube that might worsen vision due to corneal oedema or iritis or cystoid macular oedemaor with a severe tube malposition causing rapid visual loss. Injury or trauma to the canaliculus, cornea or sclera. Intraocular malignancy. Lacerations of eyelid or face. Lacerations, blunt rupture or deeply embedded corneal foreign body. Lens- induced glaucoma or angle- closure glaucoma. Life- threatening or sight- threatening conditions (ie, congenital ptosis, hypotony due to trauma, infection, intractablepain, hyphaemia, progressive vision loss, uncontrolled intraocular pressure, suspected tumour or malignancy). Neonate with obstructive respiratory compromise. Ocular trauma, infection, intractable glaucoma, globe perforation, intractable pain or intraocular malignancy. Orbital cellulitis. Orbital tumour with impending vision loss. Pain due to ocular diseases causing significant compromise of quality of life. Paediatric patients with: retinoblastoma, endophthalmitis, Coats disease, uveitis, glaucoma, ocular trauma, retinaldetachment, presumed intraocular foreign body, corneal blindness in both eyes in their amblyopic period orretinopathy of prematurity. Presumed intraocular foreign body. Proliferative diabetic retinopathy, proliferative vitreoretinopathy, complex preretinal membrane or complex macularpathology. Retinal detachment, ocular trauma, intraocular infection, vitreous haemorrhage, retinal tear, intraocular foreign body,misdirected aqueous, ciliary block glaucoma, malignant glaucoma, a vitreous prolapse or a tube shunt that blocksfiltration. Suspected giant cell arteritis. Torn or lost extraocular muscle. Wound dehiscence or other wounds, including dislocated LASIK flaps.1COS Macula- threatening retinal detachment. Postoperative hypotony.7Referral to AAO recommendations for exhaustive list.1SEOMore than 60 examples of urgent cases inspired from the Moorfields Eye Hospital National Health Service FoundationTrust and more than 40 urgent procedures inspired from the American Academy of Ophthalmology.9SFO Wound of the globe with or without an intraocular foreign body. Retinal detachments of less than 1 month’s duration. Retained lens material. Acute endophthalmitis with decreased vision. Removal of non- absorbable synthetic implants resistant to antibiotic treatment.10Continued6Nguyen AX, et al. BMJ Open Ophth 2020;5:e000525. doi:10.1136/bmjophth-2020-000525BMJ Open Ophth: first published as 10.1136/bmjophth-2020-000525 on 7 July 2020. Downloaded from http://bmjophth.bmj.com/ on July 8, 2020 by guest. Protected by copyright.Table 2 Summary of recommendations on urgent care for ophthalmologists during the COVID-19 pandemic per internationalophthalmology society

Open accessSocietyExamples of urgent treatmentsDOGReferral to AAO website and other resources.8SOI Acute glaucoma patients.12JOS Diseases leading to blindness or complications: retinal detachment, bulging cataracts and retinopathy of prematurity. Malignant tumours: retinoblastoma, malignant melanoma, squamous cell carcinoma and orbital tumour. Ocular trauma: corneal perforation, conjunctival laceration, ocular rupture, orbital fracture, intraocular foreign body,intraocular foreign body, corneal foreign body, corneal foreign body and traumatic flap detachment after LASIKsurgery. Infectious diseases: postoperative intraocular inflammation, eyelid abscess, lacrimal sac inflammation and intraocularinflammation associated with filtration vesicle infection. Glaucoma: paediatric glaucoma, rapidly progressing glaucoma and lens- derived glaucoma. Other: corneal transplants, congenital cataracts requiring amblyopia treatment, traumatic cataracts, importantophthalmic surgery and intravitreal injections.13AIOS Chemical injuries. Blunt trauma or perforating injuries. Open globe injuries with or without foreign body. Lid trauma. Angle closure glaucoma. Neovascular glaucoma. Elevated intraocular pressure 38 mm Hg. History of recent onset sudden vision loss ( 2 weeks) – central retinal artery occlusion (CRAO), central retinal veinocclusion (CRVO), vitreous hemorhage (VH), retinal detachment. Retinal tears. Endophthalmis. Expulsive choroidal haemorrhage. Exposed infected buckle. Orbital cases with vision loss. Severe inflammation – lid/orbit. Tumour cases with vision loss. Corneal abrasion/superficial foreign body (including contact lens lost in eye)/ulcer. Postoperative follow- up. Patients requiring intravitreal injections with fresh bleed or those requiring for endophthalmitis. One eyed patients on anti- vascular endothelial growth factor (VEGF) with sudden loss of vision.14OSSANo examples provided.IRSONo COVID-19 information available.CHOSNo COVID-19 information available.RCOphth: The Royal College of Ophthalmologists (https://www.rcophth.ac.uk/).AAO: American Academy of Ophthalmology (https://www.aao.org/).COS: Canadian Ophthalmological Society (https://www.cosprc.ca/).SEO: Sociedad Española de Oftalmología/Spanish Society of Ophthalmology (https://www.oftalmoseo.com/).SFO: Société Française d’Ophthalmologie/French Society of Ophthalmology (https://www.sfo-online.fr/).DOG: Deutsche Ophthalmologische Gesselschaft/German Ophthalmological Society (https://www.dog.org/).SOI: Società Oftalmologica Italiana/Italian Ophthalmological Society (https://www.sedesoi.com/).JOS: Japanese Ophthalmological Society (http://www.nichigan.or.jp/).AIOS: All India Ophthalmological Society (https://aios.org/).OSSA: Ophthalmological Society of South Africa (https://www.ossa.co.za/).IRSO: Iranian Society of Ophthalmology (http://www.irso.org/).CHOS: Chinese Ophthalmological Society -society/ and http://www.cma.org.cn/).Ophthalmic management plans in the context of thepandemicRetinaRCOphth, AAO, COS and SFO each published guidelines for intravitreal injections and management ofretinal patients. RCOphth recommends that patients withknown wet age- related macular degeneration (AMD),diabetic macular oedema, branch retinal vein occlusion, central retinal vein occlusion and central serouschorioretinopathy have their appointments postponed.While panretinal photocoagulation (PRP) laser mightbe done with the appropriate PPE (masks, breathguardand so on), RCOphth suggests that one extensive PRPlaser be done in order to delay the following PRP session.RCOphth recommends deferring pars plana vitrectomywhen possible.25 33 In the USA, it is recommended thatthe retina clinic be restricted to indispensable visitsonly (ie, early postoperative visits, emergency cases andpatients receiving intravitreal injection therapy).34 35 COSand SFO give specific guidelines on intravitreal injections for diabetic retinopathy. CAN- OS recommendsthe ‘Treat and Extend’ approach for neovascular AMDNguyen AX, et al. BMJ Open Ophth 2020;5:e000525. doi:10.1136/bmjophth-2020-0005257BMJ Open Ophth: first published as 10.1136/bmjophth-2020-000525 on 7 July 2020. Downloaded from http://bmjophth.bmj.com/ on July 8, 2020 by guest. Protected by copyright.Table 2 Continued

Open accessSocietyExamples of telemedicine resourcesRCOphthRecommendedResources highlighted: Telemedicine Options for OphthalmologyConsultations.10 Norfolk and Norwich Hospital (NNUH) useof telemedicine during COVID-19.RecommendedResources highlighted: Telehealth Resources: Tips to Help YourPractice Succeed.23 Teleophthalmology: How to Get Started. Coding for Phone Calls, Internet andTelehealth Consultations.4 COVID-19 Moves Telemedicine to theForefront.5 Academy, Federal Agencies Issue NewTelehealth Guidance for COVID-19.6AAOCOSRecommendedReferral to AAO resources.8SEOTelematics (voice call and video call)recommended.9SFOTelephone calls recommended.11DOGRecommendedReferral to AAO resources.8SOIRecommended.12JOSNot indicated.AIOSRecommendedResources highlighted: Live Webinar: Telemedicine inOphthalmology – Current Platforms.1516 AIOS Telemedicine Practice Guidelines.OSSANot indicated.IRSOCHOSNo COVID-19 information available.No COVID-19 information available.RCOphth: The Royal College of Ophthalmologists (https://www.rcophth.ac.uk/).AAO: American Academy of Ophthalmology (https://www.aao.org/).COS: Canadian Ophthalmological Society (https://www.cosprc.ca/).SEO: Sociedad Española de Oftalmología/Spanish Society ofOphthalmology (https://www.oftalmoseo.com/).SFO: Société Française d’Ophthalmologie/French Society ofOphthalmology (https://www.sfo-online.fr/).DOG: Deutsche Ophthalmologische Gesselschaft/GermanOphthalmological Society (https://www.dog.org/).SOI: Società Oftalmologica Italiana/Italian OphthalmologicalSociety (https://www.sedesoi.com/).JOS: Japanese Ophthalmological Society (http://www.nichigan.or.jp/).AIOS: All India Ophthalmological Society (https://aios.org/).OSSA: Ophthalmological Society of South Africa (https://www.ossa.co.za/

The leading ophthalmology society in each of the 12 countries was selected from the International Council of Ophthalmology repertoire, which contains 179 members. These ophthalmology societies are the most popular national general ophthalmology societies in their respec-tive countries, as per their number of members (table 1).

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