Information for Clinicians: Uveitis and COVID-19

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Uveitis Clinical Study Group Guidance for Management of adults and children with ocular inflammatory disease

Updated 29th May 2020

This guidance for  the management of patients with inflammatory eye disease during the COVID-19 pandemic has ben updated. There is now a clinically extremely vulnerable category for those at highest risk and updated NICE guidance for children who are immunocompromised. Although, we anticipate that immunosuppressed patients are at increased risk, there has been little evidence from rheumatology cohorts during the pandemic to date indicating that immunosuppressed patients have had poorer outcomes or appear to be more susceptible to infection. In unpublished audit data from 720 uveitis patients on immunosuppression, none had a hospital admission for COVID-19.  On 30 June, shielding formally ends except for the most clinically vulnerable group. See NHS Digital risk criteria and shielding.  A paper explaining the development of risk stratification guidance has been published by authors from BSR and BSPAR. See ‘Resuming Services Uveitis CSG Guidance for detailed information about resuming your service, training service design and technology. There is a newly- published guidance on social distancing for everyone in the UK.The definition of shielding has changed and is more relaxed than earlier in the pandemic.

See www.uveitisstudygroup.org for resources,clinical guidance and patient information.

Contents

  1. General principles
  2. Case Prioritisation: when and how should I be seeing my patients
  3. Risk Stratification, clinically extremely vulnerable group and shielding
  4. Systemic steroids, adrenal insufficiency and steroid sick days
  5. Managing  immunomodulatory therapy in uveitis patients during the pandemic
  6. Can immunomodulatory therapy be started for sight-threatening disease?
  7. Managing  children on immunomodulatory therapy
  8. Testing for COVID-19
  9. What should I do if an asymptomatic patient on immunosuppression believes they have been exposed to COVID-19
  10. Patient information
  11. What should I do if I am showing symptoms suggestive of COVID-19?
  12. Resources


1. General principles for hospital appointments for uveitis patients.

During the recovery phase of the COVID19 pandemic, most departments are gradually seeing more patients. At this stage physical distancing requirements are 2m between patients and limit the number of patients who can be seen in hospitals. Telephone/ video-consultations will continue for triage of new cases and  virtual clinics either in hospital or the community and face to face appointments. In Scotland and some optometry practices in England/ Wales, IOP checks in the community may form an additional care pathway.  Children who have unstable ocular inflammatory  disease and those with newly diagnosed juvenile idiopathic arthritis require face to face consultations.  

A local strategy should continue for the delivery of prescription drugs, essential blood test monitoring and a phone number to contact in the hospital eye service for patients on immunosuppression. It is essential

2. Case prioritisation: when and how should I be seeing my patient?

It is likely that at least 50% of patients will be continued to be managed by a combination of videoconsultations/ telephone consultations or virtual clinics  should be managed with a telephone or video consultation. See Table 1 and 2 for case prioritisation and allocation to appointment modalities. To reduce the number of face-to-face consultations for new referrals to tertiary centres, one option is video-consultation between Opthalmologists or image-sharing. Aim to provide a one-stop service providing procedures such as intravitreal steroid implants to avoid the need to return for further appointments. Surgery in ocular inflammation should be restricted to emergencies, which includes the diagnosis of suspected malignancy. When theatre capacity increases,  patients with uveitic cataracts who cannot return to employment without surgery should be prioritised.

Table 1

Guide for case prioritisation and follow up frequency
Update due Thanks for your patience

Table 2 Allocation of appointment modality*

This is a suggested guide and your case allocation may vary.

 

Telephone/Video

Could be done by an AHP/ shared care with an optometrist

F2F/Virtual alternating appointment*

F2F*

Anterior uveitis (normal IOP)

Inflammatory CNV

1st attendance/ vulnerable adults/ one eye

Scleritis follow up

Multifocal choroiditis / PIC

Endophthalmitis

Episcleritis

Peripheral vasculitis

Active panuveitis

Counselling/ discussion about IMT

Ocular cicatricial pemphigoid

Corneal inflammatory disease

Prepare history prior to consultation day

Toxoplasmosis

Vasculitis at the posterior pole

 

Anterior/Intermediate Uveitis with cystoid macular oedema

Active uveitis  with secondary ocular hypertension/ glaucoma**

 

Post intravitreal implant**

Asymptomatic uveitis eg JIA+

 

Quiescent panuveitis, IU, posterior uveitis

Unexplained reduced vision/ high risk of visual loss in follow up

* New patients may be seen F2F and followed up in alternating F2F/virtually.  Virtual dataset: VA, IOP, OCT for CMO, AF and Optos  for choroidal disease.** IOP measurement may be performed in the community.+See section on Children

Children

Children with JIA who are no immunosuppression, or on etanercept monotherapy, will require a face-to-face visit for their first screening examination, and may continue to require subsequent face-to-face screening visits if their arthritis started before the age of 5 years. Consider involving allied health professionals in undertaking screening.  Face-to-face appointments will be required for new paediatric referrals and for children with asymptomatic, unstable disease. Unstable disease can be defined as disease which has required a treatment change within the preceding 10 weeks for active inflammation or which is associated with ocular hypertension or other ocular comorbidities.

For stable patients or follow-up JIA screening, appointment intervals may be extended  or managed with telephone consultations.

 

3. Risk Stratification, clinical extremely vulnerable group and shielding.

A total of 2.2 million people  have been notified by NHS digital, GPs or secondary care clinicians that they are within the shielding group throughout the United Kingdom. The terminology for those at highest risk of severe outcomes as a result of COVID-19 has been changed to ‘clinically extremely vulnerable'. This group  includes individuals living in long-term care homes or who have special needs. See British Society of Rheumatology risk stratification guide for people on immunosuppression which Uveitis CSG has adopted.
 
Shielding for high risk groups formally ends on 1 August 2020 when it is anticipated that the rates of community transmission will continue their current trajectory and  be low enough to allow most people to return to normal activities with physicial distancing in relative safety. However, transmission rates vary nationally. The definition of shielding has changed and is more relaxed than previously.

It has been left to clinicians to to advise patients whether they should continue to shield and discuss concerns with those patients who feel vulnerable and wish to continue to shield. It is important to have knowledge of the patient's past medical history to facilitate this conversation and information should be requested from GP surgeries.

  • Invite high risk patients e.g.by letter/phone, for telephone consultation to discuss options.
  • Consider inviting patients, via your website, who are not sure if they are in the clinically vulnerable group to contact you.
  • Assess risk status, co-morbidities, the impact of isolation on mental,  physical well-being, socio-economic challenges.
  • If patients  continue to shield, arrange further appointment to and review this decision within a few weeks. 
  • Encourage swab testing in the community.
  • Direct patients to Uveitis CSG patient information on www.uveitisstudygroup.org or here.

At present, the high-risk patient category for adults includes those patients fulfilling one or more of the following criteria:

  1. Corticosteroid dose of ≥20mg (0.5mg/kg) per day for more than 4 weeks
  2. Any two agents among immunosuppressive medications biologic/monoclonal or small molecule including JAK inhibitors with a co-morbidity
  3. Cyclophosphamide (any route) within the last 6 months
  4. Corticosteroid dose ≥5mg prednisolone plus another IMT.

The risk of developing severe COVID 19 disease is increased by:

  • Comorbidities, including cardiovascular disease, hypertension, COPD, asthma and diabetes mellitus
  • Active systemic inflammatory disease activity  
  • Age 70 years or over
  • BMI > 40


For children, the high risk/ clinical extremely vulnerable group includes children on ≥0.5mg/kg prednisolone for 4 or more weeks, within the last 4 weeks or children on cyclophosphamide

Therapies which confer no/ very little risk of  infection are hydroxychloroquine, sulfasalazine, IVIg and intravitreal steroid implants.


4.    Systemic corticosteroids, steroid sick days and adrenal insufficiency?

Aim for the minimum systemic corticosteroid dose to keep disease stable. If practicable, use local corticosteroids and use a topical antihypertensive if steroid-induced ocular hypertension is a concern in order to limit follow-up. When starting systemic steroids, the therapeutic goal is to induce remission and taper rapidly to 20 mg prednisolone; a more gradual taper can then be followed. If a maintenance dose of corticosteroids is required, this should be achieved with 5 mg prednisolone or less wherever possible.

Patients who are have adrenal insufficiency/ on long term steroids require an increase in dose to cover moderate intercurrent infection according to Royal Society of Endocrinology 'Steroid Sick Day' guidance .


5.  Managing  immunomodulatory therapy in uveitis patients during the pandemic

If your patient is asymptomatic of COVID 19, continue the IMT along with blood monitoring, but observe caution and consider dose reduction, if the WCC falls below 4

If your patient is symptomatic of COVID 19, they should contact NHS 111 with a list of their medications, confirming that they are immunosuppressed and in a high risk group for infections.  They should temporarily stop their conventional IMT and/or biological therapy (except for interferon and tocilizumab). For patients on adalimumab, including biosimilars, this will mean omitting the next planned subcutaneous doses until they are recovered. Clinicians should consider local therapy to cover potentially sight-threatening disease.

Corticosteroids should not be stopped abruptly on developing mild symptoms consistent with COVID 19.  For guidance about adrenal insufficiency/ steroid sick days see Royal Society of Endocrinology guidance
 

6.  Can immunomodulatory therapy be started for sight-threatening disease?

Initiation of IMTs should be on a case-by-case basis. It is likely to be required where there is sight-threatening disease which has been refractory to other measures and which is unsuitable for other measures such as local therapies. There is no evidence so far to show that immunosuppression is associated with more severe  outcomes in COVID 19 or that more patients contract COVID 19 beause of immunosuppression.

7.    Managing  children on immunomodulatory therapy

Children, in general, exhibit milder COVID-19 disease than adults, so cessation of IMT is not recommended.  Flares of anterior uveitis should be managed with topical steroids as far as possible throughout the COVID-19 outbreak. Avoidance of steroids is key to avoiding the need to shield children , so new IMT may be started on a case by case basis.

Switching from infliximab to adalimumab can reduce hospital interactions, but this may not be appropriate as  many children on infliximab have failed adalimumab so this is not advised.  However, dose frequencies can be modified to minimise hospital visits.  

As a general rule, consider keeping those in a period of treatment reduction at same level of medication for a further 3 months before reviewing and reducing further.

8. Who is currently being tested for COVID 19?

UK government policy for testing for COVID-19 is currently limited. Testing within the community for individuals with with symptoms consistent with COVID-19 patients is now available as well as testing for asymptomatic care home, healthcare and essential workers. Testing is available in hospital for symptomatic patients and prior to specific surgeries according to local guidance.


9. What should I do if an asymptomatic patient on immunosuppression believes they have been exposed to COVID 19?

We do not recommend modification of treatment unless there are extenuating circumstances. Immunosuppression cessation/ treatment holidays in asymptomatic patients who believe they may have been exposed to COVID-19 will not have an immediate effect as most drug effects persist for several weeks.  Any decision to reduce treatment should take into account the risk of a disease flare and attendant risk of hospital exposure.

If the patient has a household contact that is symptomatic of COVID19 they must isolate in accordance with government guidelines and refer to NHS 111 online.


10. What information should I give patients?

Uveitis CSG patient information for adults and parents of children with ocular inflammatory diseases with many helpful links to sources of information for adults and children is here or direct them to www.uveitisstudygroup.org. This contains up to date information about shielding.

For parents and children:

12th June 2020 guidance for the return-to-school period here

https://wordday.org/wp-content/uploads/2020/03/WORDday2020-CORONA-PReS-guidelines.mp4

COVID-19 resources are availale from kids with arthritis which was written with input from ophthalmologists. https://www.ccaa.org.uk/coronavirus-support-resources/

Up to date guidance  on social distancing and stay at home guidance for households with possible coronavirus infection is available.

 

11. What should I do if I am showing symptoms suggestive of COVID 19?

If you are showing any symptoms and you think you might have coronavirus or you've been in close contact with someone who has it:
●    stay at home for seven days if you live alone, or self-isolate your entire household for 14 days

●    avoid close contact with other people

●    do not go to a GP surgery, pharmacy or hospital

●    use the online 111 coronavirus service to find out what to do next

●    Call 999 if you are very unwell.