Table 2.

Recommendations for future research and consensus required for corneal transplantation during and beyond the COVID-19 pandemic

	Recommendations, considerations and consensus required
Donor exclusion due to confirmed COVID-19 infection or contact with confirmed cases	Exclusion: –Potential donor with confirmed COVID-19 infection –Positive contact history with person with confirmed COVID-19 infection. Consensus required: Duration from resolution of symptoms or first day of contact (currently varies from 14 days to 3 months). Recommendation: Discretionary inclusion of potential donors with duration of 28 days from resolution of symptoms or first day of contact or pending negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) PCR tests from respiratory sample.
Donor exclusion from suspected COVID-19 cases	Exclusion: –Acute respiratory illness (fever of 100.4 °F/38°C) and at least one severe common symptom of respiratory disease with no other aetiology that fully explains the clinical presentation within the last 28 days –Acute respiratory distress syndrome, pneumonia or pulmonary CT scanning showing ‘ground glass opacities’ (regardless of whether another organism is present) within the last 28 days Consensus required: –Significant travel history to ‘high-risk’ countries as defined by CDC, WHO or local governments –Those who have lived in areas of sustained community COVID-19 transmission (ECDC) –Contacts of suspected COVID-19 cases Recommendation: Discretionary inclusion of suspected cases with duration of 28 days with or without symptoms but with negative SARS-CoV-2 PCR tests from respiratory sample.
Routine testing of all potential donors	In conditions where testing is readily available for all hospitalised patients and/or community testing is performed, a record of a recent nose and throat SARS-CoV-2 PCR may be already performed or available within days. Serological testing for the presence of antibodies to SARS-CoV-2 may indicate previous or recent infection, but viral RNA has been detected in individuals despite the development of antibodies. Therefore, serology is currently not recommended as screening test for donors. Medical director review for final determination of donor eligibility in certain cases Recommendation: Considering current evidence and limited test kits, PCR testing may not be mandatory for donor selection. However, once performed a positive test should be exclusion criteria. While a negative test should be taken into consideration, a potential donor might still be excluded depending on signs/symptoms/history of contact. Research needed: Validation studies of SARS-CoV-2 PCR on cadaveric donor samples and donor storage medium
Precautions during cornea donor acquisition	–Full personal protective equipment for technicians including eye protection or goggles –Corneal donor disinfection with povidone iodine before removal and preparation –Corneal donor preparation with polyvinylpyrrolidone solution just before storage Research needed: –Evaluation of presence and viability of viral RNA on cornea and conjunctival donor tissue from SARS-CoV-2 infected individuals –Evaluation of presence and viability of viral RNA on cornea and conjunctival tissue after standard tissue acquisition and processing (with povidone iodine). –Development of methods of viral inactivation on corneal tissue
Precautions during corneal transplant procedure	Elective corneal transplants: –Recipients should be tested via PCR testing before undergoing surgery –Recipients should be confirmed SARS-CoV-2 PCR negative and in self isolation from testing until time of surgery –SARS-CoV-2 positive recipients would not be eligible for elective corneal transplants at this time and should be taken off the donor waiting list until two consecutive nose and throat PCR swab tests are negative and symptom-free. Emergency corneal transplants: –Recipients should be tested via PCR testing before undergoing surgery –For SARS-CoV-2 positive recipients undergoing emergency corneal transplants, all staff should be protected with full personal protective equipment with N95 –Full personal protective equipment with N95 for cases undergoing general anaesthesia as per guidelines, not for local anaesthesia cases –Standard personal protective equipment for cases under local anaesthesia, low risk of blood contamination or aerosolisation such as lamellar keratoplasty –Recipient eye disinfection with povidone iodine Consensus needed: Personal protection needed for suspected cases or possible asymptomatic carriers, role of serological testing or CT chest for recipients, requirements for eye protection as part of personal protective equipment for surgery on SARS-CoV-2 positive cases.
Other considerations	Consensus needed for recipient priority: –Patients with risk factors for severe COVID-19 complications (>60 years-old, systemic comorbidities) might consider having elective corneal transplants postponed –Patients with correctable visual acuity with minimal functional impact may consider having elective corneal transplants postponed
References: 1. Eye Bank Association of America (EBAA) guidelines (URL: https://restoresight.org/covid-19-updates/, accessed May 2020). 2. Coronavirus disease—2019 (COVID-19) and supply of substances of human origin in EU/EEA—first update (URL: https://www.ecdc.europa.eu/sites/default/files/documents/COVID%2019-supply-substances-human-origin-first-update.pdf).