Personal Protective Equipment, Therapies, and Contact Lenses · = most common cause of acute...
Transcript of Personal Protective Equipment, Therapies, and Contact Lenses · = most common cause of acute...
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Conversations about COVID-19 For Eye Care Professionals
Personal Protective Equipment, Therapies, and Contact Lenses
Presenting sponsorApril 14, 2020
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For everyone at CooperVision, our values of partnering, and being
inventive, friendly and dedicated do not just apply during the best of
times, they’re even more critical in challenging times like these. Our teams
are examining every area of our business to identify opportunities to
support you, mindful that many of you as small business owners are
seeking additional resources to support your practices and your contact
lens-wearing patients.
CooperVision’s Promise
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• Free shipping for direct-to-patient orders
• Modified consumer rebate policies• Extended payment terms• Continued manufacturing &
shipping
• E-commerce contact lens services• Supporting patient education• CooperVision customer-facing team• Continuous communication
CooperVision’s Resources to Support Eyecare Practices
CooperVision has instituted the following in an effort to support your practices and your contact lens-wearing patients.
For more information, reach out to your sales representative or visit ECP Viewpoints.
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Additional Resources
• The U.S. Centers for Disease Control and Prevention (CDC) has issued guidance for contact lens wear and disinfecting. Here’s the link and you’ll find the two relevant tabs toward the bottom of the How to Protect Yourself section: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#How-to-Protect-Yourself
• A new paper published in Contact Lens & Anterior Eye authored by some of the world’s most respected experts concludes that there is no evidence to suggest an increased risk of contracting COVID-19 through contact lens wear compared to wearing prescription spectacles.
• Everyone at CooperVision wants to make sure that unbiased, accurate information is being communicated. With that being said, here are links to additional resources regarding COVID-19 and the safety of contact lens wear here.
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Conversations about COVID-19 For Eye Care Professionals
Personal Protective Equipment, Therapies, and Contact Lenses
Presenting sponsorApril 14, 2020
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Infection Prevention and COVID-19Marlene L. Durand, M.D.
Physician, Division of Infectious Diseases, Massachusetts General HospitalDirector, Infectious Disease Service, Massachusetts Eye and Ear
April 14, 2020
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Disclosures
• Stockholder, Pfizer
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Coronaviruses
• Enveloped, single-stranded RNA viruses
• “corona” = crown, formed by spikes of glycoproteins on the envelope
• These spikes allow viral entry into cells
• Coronaviruses can cause mild illnesses such as the common cold or severe illnesses such as MERS, SARS, or COVID-19
• COVID-19 (illness) is caused by SARS-CoV-2 (virus)
From NIAID
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Coronavirus = enveloped RNA virus
Image credit: Scientific Animations
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Viruses: non-enveloped vs enveloped, RNA vs DNA
ENVELOPED VIRUSNON-ENVELOPED VIRUS
P
Modified from Reddy, Sansom, researchgate.net; creative commons
membraneglycoprotein
RNA virus examples: rhinovirus, norovirusDNA virus examples: adenovirus
RNA virus examples: influenza virus, coronavirus, HIV, hepatitis CDNA virus examples: herpes simplex virus, herpes zoster virus
Non-enveloped viruses are more resistant to environmental degradation.
Enveloped viruses have a “greasy” lipid bilayerenvelope that can be destroyed by soap and water
Both enveloped and non-envelopedviruses have protein “shells” or “capsids”
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Infection Control and viruses• Non-enveloped viruses (compared with enveloped viruses): generally
harder to kill and survive longer in the environment
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Non-enveloped viruses
• Example • Norovirus = most common cause of acute gastroenteritis in U.S. • Each year in U.S.: 20 million cases, 56,000-71,000 hospitalizations, 800
deaths• highly contagious (requires <100 viral particles), spread by direct contact
with infected person, eating/drinking contaminated food/liquids, or hand-mouth contact with infected surfaces (fomite transmission)
• Infected person contagious during symptoms but ALSO for several days after symptoms resolve
• Wash your hands with soap and water• Norovirus survives on surfaces for weeks (CDC.gov/norovirus) without disinfection• Relatively hard to disinfect: use dilute (1000-5000ppm) bleach solution (CDC: e.g. 5-
25 Tbsp household bleach/gallon water) or other norovirus-approved disinfectants (see CDC list)
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Enveloped viruses
• Example • SARS-CoV-2 (COVID-19 virus). Per CDC, the major mode of
transmission is via close contact (within 6 feet) of infected person due to respiratory droplets (>5 μm) landing on face/mouth/nose/eyes. Fomite transmission (touch infected surface then touch face, mouth, nose, eyes) may also play a role but is thought to be less important
• Hand hygiene essential – all surfaces and between fingers• Can survive on surfaces for up to hours to 3 days: 4 hrs copper, 24 hrs
cardboard, 2-3 days plastic or stainless steel (van Doremalen, NEJM 3/2020)• Disinfect: EPA-registered disinfectant for SARS-CoV-2 (370 listed, see EPA), or
dilute bleach (per CDC, 5 Tbsp household bleach per gallon water) – see CDC.gov/coronavirus/2019-ncov
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Quiz: Do you think this virus is enveloped or non-enveloped?
• Originally isolated from adenoids (1953)
• Can survive on surfaces several weeks to 2 months (e.g. doorknobs x 2 months)
Transmission EM, Getty Images
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Adenovirus: non-enveloped
• Non-enveloped, dsDNA• Broad range of infections,
mild to severe• Examples: upper respiratory
tract infections, conjunctivitis (and keratoconjunctivitis), bronchiolitis, pneumonia –which can be very severe
• Outbreaks from failure to follow infection control practices
3 images above from Creative Commons, CC-BY-SA-4.0
From Cha et al, Korean J Radiol 2016;17:940-949
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EKC (epidemic keratoconjunctivitis)
• Usually adenovirus serotypes 8, 19, 37 but also others (most large outbreaks have been caused by type 8)
• Eye pain, redness; corneal findings can persist for months and affect vision
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A news article you do NOT want about your clinical eye practice
From Review of Optometry
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From Review of Optometry, Feb 11, 2020
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EKC – major modes of transmission in eye clinics
• Hands of healthcare providers (HCP)• in half of reported outbreaks, a HCP has become infected• adenovirus can be recovered from the hands of 50% of EKC patients so hands
of HCPs can also serve as source of transmission• Per CDC, person is contagious from a few days prior to symptom onset to 14
days after onset
• Ophthalmic instruments (tonometer tips, slit lamps)• Ophthalmic solutions from multidose vials• Environmental surfaces
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Infection Control – the goal is to prevent transmission of ALL infections (not just COVID-19)
“An ounce of prevention is worth a pound of cure”.
• Benjamin Franklin, 1736
1706-1790
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Infection Control in office practice
• Follow CDC guidance for Infection Control. Have a written clinic policy and follow Standard Precautions for ALL patients, transmission-based precautions for those with particular infections
• Standard Precautions – for all patients• Transmission-based Precautions – use as 2nd tier in addition to
Standard Precautions• Contact precautions (e.g. for MRSA) – gown and gloves• Droplet precautions (e.g. for the flu) – single room, door closed, mask on
patient, HCP wears mask. Droplet precautions for COVID-19 also includes eye protection.
• Airborne precautions (e.g. TB) – negative pressure room, patient wears surgical mask outside of room, HCP wears N95 mask
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CDC: Standard Precautions
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Hand Hygiene is very effective in preventing infection transmission
Images from CDC
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Hand hygiene
• Very important in preventing transmission of infections, including COVID-19
• Hand hygiene (soap and water x 20 seconds, or alcohol-based hand sanitizer).
• Always perform hand hygiene immediately before and immediatelyafter contact with the patient.
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From CDC (Centers for Disease Control and Prevention)
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PPE -- Glove use
• Use gloves for patients with conjunctivitis or other infections (e.g. MRSA, COVID-19), but use gloves FOR ONE PATIENT ONLY.
• Perform hand hygiene before putting gloves on and after taking gloves off.
• Why? Exam gloves are “leaky” and you cannot disinfect them.• They become even more leaky with application of alcohol-based hand rub –
never try to “disinfect” your gloved hands, always remove them after use on a single patient.
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Examination gloves are “leaky” including to viruses
• 1990 study of virus penetration polyethylene and polyvinyl gloves had failure rates of 40% and 22%, respectively. Following exposure to 70% alcohol, failure rates increased to 94% and 56%. Latex gloves are better but rarely used due to latex allergies in HCPs and patients. (Klein et al, Biotechniques 1990; 9:196-199.)
• 2004 study of viral (bacteriophage φ174) penetration of gloves: When 2 brands of non-latex (e.g. nitrile) examination gloves were “stressed” (e.g. after handling instruments) then tested, virus penetrated 29% and 36% of the gloves (O’Connell et al, Clin Micro Infect 2004;10:322-326)
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Office disinfection – disinfect all pathogens, not only COVID-19 • Tonometer tips (prisms)• Disinfection of surfaces
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Tonometer tips (prisms)
• Follow manufacturer recommendations for disinfection or reusable tonometer prisms, and in accordance with CDC guidance
• Example: 5-10 minute (timed) soak in dilute bleach solution followed by prolonged rinsing in water – but follow manufacturer IFU (instructions for use) EXACTLY
• Alternative: single use, disposable tonometer prisms
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AAO Recommendations – do not use alcohol wipes
Ophthalmology 2017;124:1867-1875.
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Disinfect surfaces – example of spread of EKC due to inadequate eye clinic disinfection• 2016 EKC outbreak on U.S. Virgin Islands related to 2 eyecare clinics –
78 people affected. CDC investigated (MMWR Aug 4, 2017)• CDC took samples from these 2 clinics, PCR testing• Positive samples for adenovirus:
• Door knob• eye occlude• Refractor• examination light• bathroom faucet• surface of multiuse eye drop bottle• waiting room chair.
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Disinfect surfaces
• Adenovirus: use same disinfectants as for norovirus (see CDC list, under Adenovirus section)
• For SARS-CoV-2 (COVID-19 virus) – CDC says:
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Infection Control for seeing COVID-positive in outpatient setting (see CDC.gov)• Defer appointment if possible (unless urgent)• Patient should wear a surgical mask; do not let patient wait in waiting
room; place in a single exam room and the close door. After patient leaves, keep door to room closed to allow air exchange (e.g. 1 hour).
• To enter room, HCP wears gown, gloves, N95 mask, eye protection (face shield or goggles; glasses alone are NOT sufficient). Surgical mask may be used in place of N95 if N95 is not available and if no aerosol-generating procedures (AGPs, e.g. intubation, endoscopy) will be performed. AGPs should be performed in negative pressure room if available.
• N95 mask must be fit-tested to be effective
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See CDC website for details
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N95 masks (“respirators”): you first need to be fit-tested• OSHA requires “respiratory clearance”
before fit-testing – list of questions, medical clearance by Occupational Health, records maintained for 30 years. Some people cannot wear an N95 mask due to medical conditions.
• Fit-testing: a mask that fits prevents the wearer from smelling the test substance (e.g. sweet or bitter).
• Without the appropriate fit and seal, leakage around sides of an N95 mask can occur and the mask will not perform as “N95”.
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Fit-testing an N95 mask: there are several brands/styles, and a person may fit only one style
YouTube 3M video
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Carefully remove PPE so you do not contaminate yourself (see CDC guidelines)
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COVID-19: U.S. hospitalizations through 4/4/2020
From CDC
65+
50-64
18-49
Overall
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Percentage of visits to ED for COVID-19 and influenza-like illness (from CDC)
COVID-like illness
Influenza-like illness
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Thank you
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Conversations about COVID-19 for Eye Care Professionals:Personal Protective Equipment, Therapies, and Contact Lenses
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Corona Hot Topics Samir Melki MD, PhD
No Financial Interest
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Financial DisclosuresNone
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Corona Hot Topics
•Testing soup•Miracle cures?
•Vaccine Saviors?•How does it end?
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Testing Soup
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Testing SoupApril 14th 2020
25 approved molecular tests1 Saliva Molecular test (yesterday)
0 Viral antigen tests1 approved antibody test (Cellex)
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Singapore – Case Tracing
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US – Case Tracing?
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Testing Soup
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Testing Soup
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Testing Soup
Will Antibodies be protective?What exposure level is protective?
How long do Antibodies last?
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Are antibodies protective?
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Are antibodies protective?
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Therapies
HydroxychloroquineRemdesivir
Actemra (Tocilizumab)Anticoagulants
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How does it kill you?
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How does it kill you?
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How does it kill you?
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Therapies
Hydroxychloroquine - VariousRemdesivir - Antiviral
Actemra (Tocilizumab) – Anti IL-6Anticoagulants - Antithrombotic
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TherapiesHydroxychloroquine Mechanism of actionIs it a miracle drug?
Retina toxicityProphylaxis?
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TherapiesHydroxychloroquine
1- Raises pH level of endosomes - entry2- Increases intracellular Zinc - replication
3-Immunomodulator4- Antithrombotic
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TherapiesHydroxychloroquine
1- No Randomized Clinical trial2- Risks of Arrythmias w Azithromycin
3- Shortage4- Retina Toxicity
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Hydroxychloroquine
Malaria Covid-19
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Therapies
Hydroxychloroquine - VariousRemdesivir - Antiviral
Actemra (Tocilizumab) – Anti IL-6Anticoagulants - Antithrombotic
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Vaccines – The Savior?
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Vaccines
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Vaccines
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Vaccines – The Savior?HIVZika
EbolaSARSMERS
No corona viruses vaccines on market
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Vaccines
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Vaccines
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How does it end?• Better drugs/protocols
• Extensive testing/tracing• Better PPE/Hospital capacity
• Social distancing• Vaccines
• Herd Immunity
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How does it end?
• https://youtu.be/o4PnSYAqQHU
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How does it end?• Better drugs/protocols
• Extensive testing/tracing• Better PPE/Hospital capacity
• Social Distancing• Vaccines
• Herd Immunity
•Respect – Not fear
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Conversations about COVID-19 for Eye Care Professionals:Personal Protective Equipment, Therapies, and Contact Lenses
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COVID-19 & CONTACT LENSES
Anita Gulmiri, OD, FAAO
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Disclosures: None
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COVID-19& Contact Lenses
• Conflicting and controversial information
• Ocular transmission of SARS-CoV-2 through tearsSun et. al (2020): “The eye is rarely involved by human CoV infection, nor is it a preferred gateway of entry for human CoVs to infect the respiratory tract” Jun et al (2020): “The results from this study suggests that the risk of SARS-CoV-2 transmission through tears is low”
• To date, there have been no lab studies reported on the ability of coronaviruses to adhere to contact lenses
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Contact Lens UseDuring a PandemicContact lens use during this time is SAFE for healthy individuals• Proper hand-washing must be conducted
• If soap & water not available, use a hand sanitizer with at least 60% alcohol• Clinicians can suggest patients use disposable gloves, ethanol or alcohol wipes to
disinfect their fingers before lens handling as an extra precaution
• Proper wear & care• Disinfect every evening or dispose daily lenses
• Avoid touching face, mouth, nose, and eyes with unwashed hands
• Discontinue contact lens wear if sick
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Contact Lens Disinfection• Hydrogen Peroxide Solutions
CDC: “Hydrogen peroxide-based systems for cleaning, disinfecting, and storing contact lenses should be effective against the virus that causes COVID-19”
• Multipurpose Solutions/Ultrasonic CleanersCDC: “Not enough scientific evidence to determine efficacy against the virus”
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In-Office Disinfection
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Eyeglass UseDuring a Pandemic• Eyeglasses safer that contact lens use?
CDC: “There is no evidence to suggest contact lens wearers are more at risk for acquiring COVID-19 than eyeglass wearers.”
• Do Eyeglasses offer protection against coronavirus transmission?AOA: “There is no scientific evidence that wearing spectacles or glasses provides protection against COVID-19 or other viral transmissions”CDC: “Goggles or disposable face shields for eye protection” for any HCP caring for patients suspected to have COVID-19. Personal eyeglasses are NOT considered adequate eye protection”
• Recommend frequent disinfection of eyeglasses
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Contact Lens RenewalsDuring a Pandemic• Fairness to Contact Lens Consumers Act
AOA: “No federal laws related to the Contact Lens Rule prescription verification process have been suspended or waived.”
• Continue supplying your patients with contact lensesOrdering through your practice whether online or phone
• Reach out to patients who are due for renewal
• Telehealth Evaluations
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Telehealth CL Evaluations• Contact lens evaluations
• Emergency or Triage for CL wearers
• Photo and video consultations
– High resolution photos• Back camera• Lighting
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Further Research• COVID-19 & contact lens materials
• SiHY vs. Hydrogel• GP materials
• Disinfecting systems
• Tear film & transmission
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References• Fonn D, Jones L. Hand hygiene is linked to microbial keratitis and corneal inflammatory events. Contact Lens Anterior Eye.
2019;42:132-35.• C. Sun, Y. Wang, G. Liu, Z. Liu, Role of the Eye in Transmitting Human Coronavirus: What We Know and What We Do Not
Know, Preprints In press (2020).• Jun I., Anderson D.E., Kang A.E., Wang L.-F., Rao P., Young B.E., Lye D.C., Agrawal R. Assessing Viral Shedding and Infectivity
of Tears in Coronavirus Disease 2019 (COVID-19) Patients. Ophthalmology In press. 2020• Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with
biocidal agents. D Hosp Infect. 2020;104:246-51.• Jones, Lyndon, et al. “The COVID-19 Pandemic: Important Considerations for Contact Lens Practitioners.” Contact Lens and
Anterior Eye, 2020, doi:10.1016/j.clae.2020.03.012.• World Health Organization. Coronavirus disease (COVID-19) advice for the
public. www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public.• Centers for Disease Control. How Covid-19 Spreads: “Frequently Asked Questions.” Centers for Disease Control and
Prevention, Centers for Disease Control and Prevention, 8 Apr. 2020, www.cdc.gov/coronavirus/2019-ncov/faq.html#How-COVID-19-Spreads.
• American Optometric Association “AOA Guide to Telehealth-Based Care during COVID-19.” AOA Guide to Telehealth Based Care During COVID-19 - American Optometric Assciation (AOA), www.aoa.org/coronavirus/aoa-guide-to-telehealth-based-care-during-covid-19.
• Walsh K. COVID-19 and contact lens wear: what do eye care practitioners and patients need to know? Contact lens Update. March 16, 2020.
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Conversations about COVID-19 for Eye Care Professionals:Personal Protective Equipment, Therapies, and Contact Lenses
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