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Review article
Medwave 2020;20(4):e7902 doi: 10.5867/medwave.2020.04.7902
Care of ophthalmological patients during the COVID-19 pandemic: A rapid scoping review
Manuel Vargas-Peirano, Pamela Navarrete, Traccy Díaz, Gabriel Iglesias, Martin Hoehmann
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Key Words: Ophthalmology, COVID-19, Coronavirus, Pandemics, Practice Guideline

Abstract

Introduction
A new type of coronavirus (SARS‐CoV-2) causes a respiratory distress syndrome called COVID-19 that has generated an un-precedented pandemic. Serious complications include pneumonia, and mortality ranges from 2 to 5%. Up until 26 March 2020, the World Health Organization (WHO) reports 462 684 confirmed cases and 20 834 deaths worldwide. Dissemination occurs from aerosols or respiratory droplets. Different scientific societies have published clinical practice guidelines regarding ophthalmic care in the COVID-19 pandemic, but the information is presented inconsistently, which makes decision-making difficult.

Methods
We conducted a sensitive bibliographic search in EMBASE and ophthalmic society webpages of the clinical practice guidelines of ophthalmic care in the COVID-19 pandemic. We extracted the recommendations, organizing them into three categories: "which patients to treat", "how should the clinic work", and "what interventions should be avoided". For each guideline, we assessed whether the search was systematic and whether the methodology Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was followed.

Results
Fourteen relevant articles were found. Fifty-one recommendations were extracted and are shown in a table summary. None are based on a systematic search for evidence, nor do any use GRADE to develop the recommendations.

Conclusions
All the clinical practice guidelines that we reviewed recommend rescheduling all non-urgent consultations and surgeries, reinforcing contact precautions, using personal protection elements, and disinfecting surfaces and instruments. The guidelines should be improved by incorporating a systematic search for evidence, using GRADE for recommendations, and the Appraisal of Guidelines for Research & Evaluation (AGREE II) for reporting.


 

Main messages

  • SARS-CoV-2 has been isolated in conjunctiva, and the ophthalmological examination is at 30 centimeters, making it a risky treatment. 
  • Multiple clinical practice guidelines on eye care provide recommendations on the COVID-19 pandemic but lack a systematic search for evidence and reporting methodology, which reduces its quality and makes its applicability difficult.
  • The increasing quantity of new information being published (and the possible updates to clinical practice guidelines) is a limitation of this study, which means the study should be evaluated with a degree of caution.
  • Using Google Translate may provide inaccurate translations.
Introduction

In late 2019 in Wuhan, China, several health centers reported cases of pneumonia[1]. The etiological agent was a new type of coronavirus (SARS‐CoV-2)[2],[3] and its disease (COVID-19)[4], has sparked a pandemic that until 26 March 2020 numbered 462 684 confirmed cases, and 20 834 deaths[5]. Respiratory symptoms are fever, cough, and dyspnea. Moreover, conjunctivitis was observed in 0.8 to 3% of cases[1],[6]. It is transmitted by aerosols or droplets[7]. The incubation period varies from 2 to 14 days[8],[9]. Due to the virus’ high transmission, it is necessary to use personal protection and keep a distance of at least 1 meter[10]. Since the virus has been isolated in conjunctival secretions and the ophthalmological examination is performed at 30 centimeters, it is a risky procedure[11]. Several medical societies have published clinical practice guidelines.

Methods

Design: we performed a quick scoping review[12]

Eligibility criteria: this year's clinical practice guidelines on ophthalmic care in the COVID-19 pandemic, prepared by medical societies or health institutions. Expert opinions were excluded. 

Data sources: EMBASE with strategy described in Annex 1, limited to the year 2020. We also search websites of medical associations. 

Selection: two authors screened the title and abstract. 

Extraction: by two authors. We translated into Spanish using Google Translate. The data was classified into: "which patients to treat", "how should the clinic work" and "what interventions should be avoided ". 

Analysis: For each clinical practice guideline the systematic search was investigated, as well as the use of GRADE methodology in the recommendations[13].

Results

Eight results were found in EMBASE. Only one article represented a medical society or health institution[14], and therefore it was the only article included. In searching manually for medical societies, 13 articles from eight countries were found: Spain[15], United States[16],[17], Argentina[18],[19], France[20],[21],[22],[23], United Kingdom[24], Netherlands[25], Canada[26] and Mexico[27]. In the case of France, Argentina, and the United States, the main guide’s recommendations of the country's ophthalmological society were extracted, since the rest are complementary algorithms[19] or recommendations in specific groups of patients[17],[21],[22],[23]. In this way, 51 recommendations were extracted from nine clinical practice guidelines, which are summarized in Table 1. None of the clinical practice guidelines reviewed performs a systematic search for evidence or incorporates GRADE methodology for recommendations.

Table 1. Summary of recommendations.

Discussion

The following general recommendations for managing the COVID-19 pandemic are repeated in all the reviewed clinical practice guidelines: strict cleaning of surfaces and equipment, rescheduling non-emergency eye care and elective surgery, and physical distancing between patients and health personnel. There are discrepancies regarding which clinical situations require the maximum personal protective equipment.

The Spanish guide suggests that personal protective equipment (N95 mask or similar, gloves, gown, lenses) should be used at all times, considering all potential patients with SARS-Cov-2, while the American and British guidelines consider clinical situations, where maximum personal protective equipment should be used only in cases of increased risk of contagion. This could be due to the fact that at the time of writing the guide, the virus circulation rate in those countries was still low. Considering the shortage of personal protective equipment reported by various services[28], local recommendations are likely to suggest the use of N95 masks or similar only in the riskiest cases. Evidence is lacking to consider all high-risk ophthalmic care, but the death of an ophthalmologist in China from COVID-19[29] and the physical proximity of the ophthalmic examination make it necessary to be vigilant of fatality reports of ophthalmic personnel. Furthermore, the shortage of even basic surgical masks must be considered, choosing which patients and personnel should use them and in what situations, depending on local availability.

As for tonometry, digital tonometry is not proposed as an alternative in any review as it is a low-cost alternative, which does not generate aerosols and allows working at a greater distance than Perkins tonometry—probably because it is a technique that in practice and in teaching has been stopped. Maastricht University Clinical Hospital’s guide draws our attention, because doctors in specialty training have a defined role in the clinical respiratory triage of patients, receiving highly suspected cases and confirmed cases, and coordinating with the prevention department of hospital infections. The recommendations will surely be adapted according to the pandemic’s course and the knowledge acquired from its advance, enhancing the rationalization of material and human resources.

None of the reviewed clinical practice guidelines follow the steps of the GRADE or AGREE II[30] groups for reporting the recommendations and the clinical practice guides respectively: probably due to the lack of evidence for various recommendations, the need to publish the guidelines quickly, and the lack of participation of methodologists in the elaboration of the clinical practice guidelines. Another element that complicates the applicability is that in some cases, such as Argentina and France, the same ophthalmic society has several documents of recommendations. It would be ideal if all of them were synthesized in just one consensus document. The large amount of new information that is being published and the consequent possible updates to the critical practice guidelines are the limitations of this study, which means that the information summarized here must be evaluated with caution. Another limitation is the use of Google Translate, which may contain inaccurate translations that could alter the authors’ intent for the critical practice guidelines.

Conclusions

The clinical practice guidelines are important in the systematization and improvement of healthcare quality. In the context of the COVID-19 pandemic, guidelines also ensure the rational use of resources, and above all they serve to educate health teams to respond in the best possible manner to scenarios never seen previously. The health emergency is a great challenge: changing our way of practicing medicine, making new priorities, leaving aside care and procedures, creating the ethical dilemmas involved in not treating our patients.

Thus, the guidelines must also be a consensus of medical societies, ensuring the best care for patients, considering the best available evidence, local reality, the opinion of our patients, and the safety of health teams. As the available evidence is not the best, as the pandemic is unprecedented, it is very important to contrast what is being done in other parts of the world so as to try to refine local protocols as much as possible. The revised clinical practice guidelines share the general principles of rescheduling all non-urgent consultations and surgeries, reinforcing contact precautions, the use of personal protection elements, and disinfection of surfaces and instruments. The critical practice guidelines should be improved by incorporating systematic searches for evidence and using GRADE methodology for recommendations and AGREE II for reporting.

Notes

Authorship contributions
MVP: conceptualization, methodology, data curation, writing (original draft preparation), writing (review and editing), visualization. PN: data curation, writing (original draft preparation), writing (review and editing), visualization. TD: data curation, writing (original draft preparation), Writing (review and editing), visualization. GI: data curation, writing (original draft preparation), writing (review and editing), Visualization. MH: conceptualization, data curation, writing (original draft preparation), writing (review and editing), visualization.

Funding
There was no external financing.

Competing interests
None of the authors declares conflicts of interest.

Ethics aspects
The study did not require a review by the Ethics Committee for using secondary data.

From the editors
The original version of this manuscript was submitted in Spanish and was the version that was peer reviewed. This English version was submitted by the authors and has been copyedited by the Journal.

Annex 1. Search strategy
1) covid .ti. 
2) covid19.ti 
3) covid-19 .ti. 
4) sars .ti. 
5) mers .ti. 
6) .ti coronavirus. 
7) 2019ncov .ti. 
8) exp sars virus / 
9) exp coronavirus infection / 
10) 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 
11) exp eye / 
12) exp ophthalmology / 
13) ophthal * .ti. 
14) 11 or 12 or 13 
15) 10 and 14

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

Introduction
A new type of coronavirus (SARS‐CoV-2) causes a respiratory distress syndrome called COVID-19 that has generated an un-precedented pandemic. Serious complications include pneumonia, and mortality ranges from 2 to 5%. Up until 26 March 2020, the World Health Organization (WHO) reports 462 684 confirmed cases and 20 834 deaths worldwide. Dissemination occurs from aerosols or respiratory droplets. Different scientific societies have published clinical practice guidelines regarding ophthalmic care in the COVID-19 pandemic, but the information is presented inconsistently, which makes decision-making difficult.

Methods
We conducted a sensitive bibliographic search in EMBASE and ophthalmic society webpages of the clinical practice guidelines of ophthalmic care in the COVID-19 pandemic. We extracted the recommendations, organizing them into three categories: "which patients to treat", "how should the clinic work", and "what interventions should be avoided". For each guideline, we assessed whether the search was systematic and whether the methodology Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was followed.

Results
Fourteen relevant articles were found. Fifty-one recommendations were extracted and are shown in a table summary. None are based on a systematic search for evidence, nor do any use GRADE to develop the recommendations.

Conclusions
All the clinical practice guidelines that we reviewed recommend rescheduling all non-urgent consultations and surgeries, reinforcing contact precautions, using personal protection elements, and disinfecting surfaces and instruments. The guidelines should be improved by incorporating a systematic search for evidence, using GRADE for recommendations, and the Appraisal of Guidelines for Research & Evaluation (AGREE II) for reporting.

Authors: Manuel Vargas-Peirano[1,2,3], Pamela Navarrete[1,3], Traccy Díaz[1,3], Gabriel Iglesias[1,3], Martin Hoehmann[1,3]

Affiliation:
[1] Servicio Oftalmología, Hospital Carlos Van Buren, Valparaíso, Chile
[2] Centro Interdisciplinario de Estudios en Salud (CIESAL), Universidad de Valparaíso, Valparaíso, Chile
[3] Cátedra de Oftalmología, Escuela de Medicina, Universidad de Valparaíso, Valparaíso, Chile

E-mail: mvargaspeirano@gmail.com

Author address:
[1] Angamos 655
Reñaca, Viña del Mar
Chile

Citation: Vargas-Peirano M, Navarrete P, Díaz T, Iglesias G, Hoehmann M. Care of ophthalmological patients during the COVID-19 pandemic: A rapid scoping review. Medwave 2020;20(4):e7902 doi: 10.5867/medwave.2020.04.7902

Submission date: 27/3/2020

Acceptance date: 20/4/2020

Publication date: 13/5/2020

Origin: Not commissioned.

Type of review: Externally peer-reviewed by three reviewers, double-blind.

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  1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Apr 30;382(18):1708-1720. | CrossRef | PubMed |
  2. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020 Feb 20;382(8):727-733. | CrossRef | PubMed |
  3. Gorbalenya AE, Baker SC, Baric RS, de Groot RJ, Drosten C, Gulyaeva AA, Haagmans BL, et al. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nature Microbiology. 2020;5(4): 536-544. | CrossRef |
  4. WHO. Novel Coronavirus(2019-nCoV) Situation Report – 22. [Internet] | Link |
  5. WHO. Coronavirus disease 2019 (COVID-19) Situation Report – 66. [Internet] | Link |
  6. Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol. 2020 Feb 26. | CrossRef | PubMed |
  7. Seah I, Su X, Lingam G. Revisiting the dangers of the coronavirus in the ophthalmology practice. Eye (Lond). 2020 Feb 6. | CrossRef | PubMed |
  8. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 Mar 10. | CrossRef | PubMed |
  9. Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. 2020 Feb 21. | CrossRef | PubMed |
  10. WHO. Management of ill travellers at points of entry – international airports, ports and ground crossings – in the context of the COVID-19 outbreak. [Internet] | Link |
  11. Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, et al. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol. 2020 Mar 31. | CrossRef | PubMed |
  12. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018 Oct 2;169(7):467-473. | CrossRef | PubMed |
  13. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr 26;336(7650):924-6. | CrossRef | PubMed |
  14. Society of Public Health Ophthalmology, Chinese Preventive Medicine Association; Beijing Ophthalmological Society and Youth Committee of Beijing Ophthalmological Society. [Suggestions from ophthalmic experts on eye protection during the novel coronavirus pneumonia epidemic]. Zhonghua Yan Ke Za Zhi. 2020 Feb 16;56(0):E002. | CrossRef | PubMed |
  15. Sociedad Española de Oftalmología. Recomendaciones para la atención a pacientes oftalmológicos en relación con emergencia COVID-19. [Internet] | Link |
  16. American Academy of Ophthalmology. Alert: Important coronavirus updates for ophthalmologists. 6 de mayo 2020. [Internet] | Link |
  17. American Retina Forum. Coronavirus Response. 2020. [Internet] | Link |
  18. Consejo Argentino de Oftalmología. COVID-19: Acciones de vigilancia y prevención recomendadas para instituciones y servicios de Oftalmología. 2020. [Internet] | Link |
  19. Consejo Argentino de Oftalmología. PROTOCOLO DE CONSULTA OFTALMOLÓGICA EN CONTEXTO DE PANDEMIA COVID-19. 2020. [Internet] | Link |
  20. ONSEIL NATIONAL PROFESSIONNEL D’OPHTALMOLOGIE Académie Française d’Ophtalmologie. Recommandations COVID pour les ophtalmologistes. 2020. [Internet] | Link |
  21. Société Française d’Ophtalmologie. Recommandations pour les consultations d’ophtalmopédiatrie – épidémie Covid-19 : Qui faut-il voir ? qui peut on reporter ?. 2020. [Internet] | Link |
  22. Société Française d’Ophtalmologie. Quelle conduite à tenir pour le suivi des patients glaucomateux en cette période d’épidémie de Covid-19 à virus SARS-CoV-2 ?. 2020. [Internet] | Link |
  23. Société Française d’Ophtalmologie. Quelle conduite à tenir adopter vis à vis des injections intravitréennes (IVT) dans cette période d’épidémie au Covid-19 - SARS-CoV-2 ?. 2020. [Internet] | Link |
  24. The Royal College of Ophthalmologists. Coronavirus RCOphth update – need to know points. 2020. [Internet] | Link |
  25. Maastricht UMC+. Maatregelen betreffende COVID-19-verdachte patiënten Oogheelkunde. 2020. [Internet] | Link |
  26. Canadian Ophthalmological Society (COS) Association of Canadian University Professors of Ophthalmology (ACUPO). Guidelines for Ophthalmic Care during COVID-19 Pandemic. 2020. [Internet] | Link |
  27. Sociedad Mexicana de Oftalmología. Recopilación de las recomendaciones para el manejo de pacientes que requieren atención oftalmológica durante la pandemia de SARS-CoV-2. 2020. [Internet] | Link |
  28. Mahase E. Covid-19: retired doctors could be asked to return to work, says Hancock. BMJ. 2020 Mar 2;368:m831. | CrossRef | PubMed |
  29. Coronavirus kills Chinese whistleblower ophthalmologist. American Academy of Ophthalmology. 2020. [Internet] | Link |
  30. Brouwers MC1, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al.AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839-42. | CrossRef | PubMed |
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Apr 30;382(18):1708-1720. | CrossRef | PubMed |

Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020 Feb 20;382(8):727-733. | CrossRef | PubMed |

Gorbalenya AE, Baker SC, Baric RS, de Groot RJ, Drosten C, Gulyaeva AA, Haagmans BL, et al. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nature Microbiology. 2020;5(4): 536-544. | CrossRef |

WHO. Novel Coronavirus(2019-nCoV) Situation Report – 22. [Internet] | Link |

WHO. Coronavirus disease 2019 (COVID-19) Situation Report – 66. [Internet] | Link |

Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol. 2020 Feb 26. | CrossRef | PubMed |

Seah I, Su X, Lingam G. Revisiting the dangers of the coronavirus in the ophthalmology practice. Eye (Lond). 2020 Feb 6. | CrossRef | PubMed |

Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 Mar 10. | CrossRef | PubMed |

Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. 2020 Feb 21. | CrossRef | PubMed |

WHO. Management of ill travellers at points of entry – international airports, ports and ground crossings – in the context of the COVID-19 outbreak. [Internet] | Link |

Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, et al. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol. 2020 Mar 31. | CrossRef | PubMed |

Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018 Oct 2;169(7):467-473. | CrossRef | PubMed |

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr 26;336(7650):924-6. | CrossRef | PubMed |

Society of Public Health Ophthalmology, Chinese Preventive Medicine Association; Beijing Ophthalmological Society and Youth Committee of Beijing Ophthalmological Society. [Suggestions from ophthalmic experts on eye protection during the novel coronavirus pneumonia epidemic]. Zhonghua Yan Ke Za Zhi. 2020 Feb 16;56(0):E002. | CrossRef | PubMed |

Sociedad Española de Oftalmología. Recomendaciones para la atención a pacientes oftalmológicos en relación con emergencia COVID-19. [Internet] | Link |

American Academy of Ophthalmology. Alert: Important coronavirus updates for ophthalmologists. 6 de mayo 2020. [Internet] | Link |

American Retina Forum. Coronavirus Response. 2020. [Internet] | Link |

Consejo Argentino de Oftalmología. COVID-19: Acciones de vigilancia y prevención recomendadas para instituciones y servicios de Oftalmología. 2020. [Internet] | Link |

Consejo Argentino de Oftalmología. PROTOCOLO DE CONSULTA OFTALMOLÓGICA EN CONTEXTO DE PANDEMIA COVID-19. 2020. [Internet] | Link |

ONSEIL NATIONAL PROFESSIONNEL D’OPHTALMOLOGIE Académie Française d’Ophtalmologie. Recommandations COVID pour les ophtalmologistes. 2020. [Internet] | Link |

Société Française d’Ophtalmologie. Recommandations pour les consultations d’ophtalmopédiatrie – épidémie Covid-19 : Qui faut-il voir ? qui peut on reporter ?. 2020. [Internet] | Link |

Société Française d’Ophtalmologie. Quelle conduite à tenir pour le suivi des patients glaucomateux en cette période d’épidémie de Covid-19 à virus SARS-CoV-2 ?. 2020. [Internet] | Link |

Société Française d’Ophtalmologie. Quelle conduite à tenir adopter vis à vis des injections intravitréennes (IVT) dans cette période d’épidémie au Covid-19 - SARS-CoV-2 ?. 2020. [Internet] | Link |

The Royal College of Ophthalmologists. Coronavirus RCOphth update – need to know points. 2020. [Internet] | Link |

Maastricht UMC+. Maatregelen betreffende COVID-19-verdachte patiënten Oogheelkunde. 2020. [Internet] | Link |

Canadian Ophthalmological Society (COS) Association of Canadian University Professors of Ophthalmology (ACUPO). Guidelines for Ophthalmic Care during COVID-19 Pandemic. 2020. [Internet] | Link |

Sociedad Mexicana de Oftalmología. Recopilación de las recomendaciones para el manejo de pacientes que requieren atención oftalmológica durante la pandemia de SARS-CoV-2. 2020. [Internet] | Link |

Mahase E. Covid-19: retired doctors could be asked to return to work, says Hancock. BMJ. 2020 Mar 2;368:m831. | CrossRef | PubMed |

Coronavirus kills Chinese whistleblower ophthalmologist. American Academy of Ophthalmology. 2020. [Internet] | Link |

Brouwers MC1, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al.AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839-42. | CrossRef | PubMed |