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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 4
| Issue : 1 | Page : 23 |
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Vitreoretinal practice during the COVID-19 era in a tertiary care hospital in Central India
Rajesh Subhash Joshi, Vandana Akshay Iyer
Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India
| Date of Submission | 24-Dec-2021 |
| Date of Decision | 27-Mar-2022 |
| Date of Acceptance | 04-Apr-2022 |
| Date of Web Publication | 19-May-2022 |
Correspondence Address:
Vandana Akshay Iyer
Department of Ophthalmology, Government Medical College, Nagpur - 440 012, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/pajo.pajo_133_21
Aim: The aim was to study the impact of COVID-19 pandemic on vitreoretinal practice in a tertiary care government hospital in Central India.
Setting: This study was conducted at a tertiary care hospital in Central India.
Design: This was a retrospective, cross-sectional, observational, comparative study.
Patients and Methods: Records of all patients coming to the outpatient department of ophthalmology for vitreoretinal consultation from March 24 to September 30 in 2 consecutive years 2019 and 2020 were retrieved. Demographic profile and details of the diagnosis and treatment offered were noted and entered into the Excel sheet. Data were subjected to statistical analysis.
Results: The number of patients presenting to the retina department from March 24 to September 30 came down from 1748 in 2019 to 836 in 2020, representing a 47.8% drop. Similarly, the number of major procedures was reduced from 178 in 2019 to 50 in 2020. Minor procedures such as intravitreal injections showed a reduction from 103 in 2019 to 38 in 2020 (37.2%).
Conclusion: COVID-19 adversely impacted vitreoretinal practice in a tertiary care government hospital in Central India. This led to a severe loss of vision in several patients, affecting their quality of life.
Keywords: COVID-19 disease, macular diseases, vitreoretinal diseases
How to cite this article:
Joshi RS, Iyer VA. Vitreoretinal practice during the COVID-19 era in a tertiary care hospital in Central India. Pan Am J Ophthalmol 2022;4:23 |
How to cite this URL:
Joshi RS, Iyer VA. Vitreoretinal practice during the COVID-19 era in a tertiary care hospital in Central India. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 May 28];4:23. Available from: https://www.thepajo.org/text.asp?2022/4/1/23/345494 |
| Introduction | |  |
COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) changed life worldwide[1] and brought different economic challenges to all nations. The first case of COVID in India was recorded on January 30, 2020, and originated from China.[1]
The pandemic produced a severe impact on the Indian economy,[2] leading to a negative growth rate for the first time in decades. The pandemic brought significant setbacks and changes to public and private health services. All the non-COVID catering medical specialties went into a dormant phase and started working only on an emergent and urgent basis. Many private hospitals turned into COVID hospitals and government hospitals dedicated a major portion of its premises as well as staff to the attention of COVID-19 patients. Non-COVID specialties underwent a significant decrease in the number of patients presenting to the outpatient department (OPD) and the number of surgical procedures. Patients stopped reporting to hospitals due to lockdown, fear of contracting COVID-19 on the premises, lack of transportation, and other logistic issues. Due to a lack of workforce in the emergency medicine fraternity with respect to the growing needs of the COVID pandemic, other fields of medicine from preclinical, paraclinical, medical, and surgical fields were deployed to the COVID department.
With the center and state government diverting a major portion of its funds to the COVID cause, the running of non-COVID facilities became a greater challenge. Maintenance and repair of microscopes and machines and obtaining drugs and supplies became difficult due to lack of adequate funds/grants for non-COVID facilities.
The American Society of Retinal Surgeons[3] and American Academy of Ophthalmology as well as the All India Ophthalmological Society[4] gave guidelines on the list of urgent and emergent cases in ophthalmology and when to intervene. In addition, the Government of India Ministry of Health and Family Welfare laid down guidelines on safe ophthalmology practices in COVID-19 scenario which were published on August 19, 2020.[5] It was mandatory for all retina surgeons to postpone all elective surgeries and injections and pursue only sight-saving procedures on an emergency basis. Similarly, follow-up patients in the OPD were Counselled not to come for regular visits or to increase the interval between their visits.
The coping strategies of medical facilities with stay-home orders were dissimilar in different cities. In more developed cities, private hospitals went into teleconsulting[6] mode via the Internet, emails, video calls, messages, and WhatsApp, while government hospitals started treating on an urgent and emergency basis. In underdeveloped cities, non-COVID private hospitals/clinics completely shut down, while government hospitals continued to give direct consultations on a lower scale.
The total number of consultations in general ophthalmology and cataract surgeries drastically went down.[7]
Vitreoretina is an important branch of ophthalmology in which diseases require early detection and urgent intervention, in the absence of which patients can permanently lose their eyesight. There is a need to determine the impact of COVID-19 on vitreoretinal practice.
Vitreoretinal practice in India is divided into four types of setups, namely private hospitals, charitable associations, semi-charitable associations, and government hospitals. Private hospitals and semi-charitable hospital surgeries as well as OPD consultations nearly shut down during the lockdown period, while the charitable associations and government hospitals continued to perform some surgeries and see few OPD patients.
Overall retinal surgeries decreased,[7],[8] but there was still a good number of patients requiring urgent/emergency surgery for retinal detachment (RD) and nucleus drop. The number of intravitreal injections was reduced significantly.[7],[8]
The number of OPD visits of previously operated/lasers/injected/treated follow-ups significantly decreased.[8]
There is a paucity of data on how the COVID-19 pandemic impacted the vitreoretinal practice in India. Our study depicts the impact of COVID-19 pandemic in a tertiary care hospital in Central India.
| Patients and Methods | | |
A retrospective cross-sectional, observational, comparative case record review was performed on patients presenting to a vitreoretinal facility at a tertiary care hospital in Central India between two similar periods March 24, 2019–September 30, 2019, and March 24, 2020–September 30, 2020. This comparison was for a 6-month period between the non-COVID and COVID (2020) eras. The number of patients attending OPD each month and the number of patients undergoing vitrectomy, RD surgery, and intravitreal injections every month were studied and compared to the corresponding month of the previous year.
Statistical analysis
The data were extracted from the electronic medical record system and entered into the Excel spreadsheet. Data were analyzed using SPSS software. Analysis was done through paired two-tailed t-test for month-wise comparison between the 2 years.
| Results | | |
One thousand seven hundred forty-eight patients, 1075 males and 673 females, aged 13–84 years, mean 57.8 years, presented to the vitreoretinal OPD in 2019 as compared to a total of 836 patients in 2020, 524 males and 312 females, aged 15-80 years, mean 57.15 years. Of these 1748 patients, 1528 were residents of Nagpur and 220 from other communities [Table 1]. There was no significant difference in the age and gender distribution between the two groups l. | Table 1: Demographic profile of patients presenting to the vitreoretinal outpatient department in 2019 and 2020
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A comparison of presenting best-corrected visual acuity showed that 5 of 268 (1.8% of the patients) were 1 eyed and 97 of 59 (36% of the patients) had a presenting BCVA <6/60 in the better eye, while in 2020, 2 of 59 (3.38%) were 1 eyed and 33 of 59 (59% of the patients) had a visual acuity of <6/60 in the better eye [Table 2]. This difference was statistically significant. | Table 2: Presenting visual acuity (VA) of patients operated in 2019 versus 2020
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[Figure 1] depicts the comparison between the monthly number of patients presenting to the OPD in 2019 versus 2020 during the study period. 2019 showed a peak in the months of April-May and June- July while in 2020 there was a generalised dip in the peak showing less number of total OPD patients. The Curve Flattened in March and April; peaking again in May, June and July; with July being the highest; flattening again in August and September with the advent of the second lockdown. | Figure 1: Monthwise comparison of patients presenting to the vitreoretinal outpatient department in 2019 versus 2020, between 24th March and 30th September
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[Table 3] and [Table 4] depict the month-wise comparison of vitreoretinal OPD patients and operation theater procedures respectively between identical periods of March 24 and September 30, between 2019 and 2020. The initial lockdown period beginning in mid March 2020 saw a decrease in the number of procedures in March, falling to zero in April 2020. After a month, the number of cases in OPD and surgeries again increased during June, followed by a second decrease due to a second lockdown and an increase in the number of COVID-19 cases. The number of intravitreal injections for noninfectious conditions significantly decreased from 58 to 34 between 2019 and 2020. The number of intravitreal injections for endophthalmitis treatment also decreased despite being an emergency procedure since all procedures diminished due to lockdown. | Table 3: Month-wise depiction of outpatient department numbers in 2019 versus 2020
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 | Table 4: Month-wise numbers of patients undergoing any procedure, major/minor at the hospital under study
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| Discussion | | |
COVID era brought down the number of cases presenting to a general ophthalmology OPD worldwide.[7] Vitreoretinal practice, which is supposedly involving a maximum number of emergent and urgent cases, also got adversely affected. A large part of vitreoretinal practice also involves the management of complications of cataract surgeries such as nucleus drop, IOL drop, and endophthalmitis. Hence, a drop in the number of cataract surgeries directly reflects upon the number of vitreoretinal surgeries. Similarly, lockdown restricted the movement of patients within the city, as well as into the city from outside it.
Our study was a 6-month comparison for 2 consecutive years, based on a tertiary care government hospital, which is the main referral center in Central India. This study reveals a significant decrease in the number of vitreoretinal OPD consultations as well as the number of major and minor vitreoretinal procedures in a month-wise comparison between 2 consecutive years. In countries like ours, where people have strong cultural beliefs and practices, the number of eye surgeries in Central and North India generally goes down in May and June when the temperature is the hottest, and patients believe that the postoperative care would suffer due to perspiration. Similarly, surgery numbers go up in the more comfortable months from July to September. So, 6 months, month-wise comparison between two identical periods gave a more conclusive data because of a similar trend of rise and fall of cases in Consecutive years, and only the study parameter, namely “impact of COVID-19” is reflected. Due to the government-imposed lockdown, the number of cases suffering from COVID-19 that could have peaked in June 2020 got delayed to September 2020. Hence, the impact of COVID-19 in our study in March–April 2020 was more due to the restriction of movement during o the lockdown, while in September 2020, it was due to patients suffering from the disease itself.
The percentage of patients with presenting visual acuity of patients <6/60, as well as the percentage of one-eyed patients, went up in the COVID era. This reflects that the patients presenting to the OPD were only those who were in dire need of treatment. This does not mean that those not presenting to the OPD were not in need of treatment. A lot of people who did not present to the OPD due to various logistic reasons or were deferred treatment due to COVID positivity also lost their vision due to late access to treatment. Two such cases were revealed in the study. Many more such follow-up cases would have suffered the loss of vision due to similar reasons but did not report back to the hospital during our study period of 6 months.
Our study showed a 47.8% decline in the number of OPD encounters from 1728 in 2019 to 836 in 2020 during the identical study months from March to September, while the number of surgical procedures, major namely Vitrectomy for various indications and RD surgery and minor viz intravitreal injections like antiVEGF, antibiotics, antifungals, antivirals as well as steroids, declined from 268 to 59 (22.01%) [Table 6]. The decrease in intravitreal injections for noninfectious indications was from 58 to 34 (58.6%), while a decrease in intravitreal injections for infectious endophthalmitis was from 45 to 4 (8.9%). The decline in the number of major procedures such as RD surgeries was 21.3% [Table 5] and vitrectomy for various other indications was 91.4% [Table 4], [Table 5], [Table 6] [Table 7], [Table 8]. | Table 5: Depicting percentage of outpatient department patients operated in 2019 versus 2020
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 | Table 7: Comparison of number of laser procedures carried out in 2019 versus 2020
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The results were compared with those found in two multicentre cross-sectional studies conducted in the united states of America by Hamichi et al.[7] who conducted a study across 19 hotspot zones in over 5 months, in 3 settings viz, an academic setting, a private multispecialty clinic, and a solo vitreoretinal practice and by Breazzano et al.[8] across 17 centers. The comparison is depicted in [Table 9]. | Table 9: Interstudy comparison of the number of outpatient department encounters and injections Hamichi et al. versus our study
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The number of OPD cases in a vitreoretinal facility comprises old follow-ups, new cases, and referrals from other departments. The old follow-up became negligible, new cases also would follow up sparingly after the first visit, and few referrals continued to come from other departments, while babies for Retinopathy of Prematurity (ROP) screening, trauma patients, optic nerve disease, RD, and vitreous hemorrhage patients continued to present to OPD though their numbers reduced considerably. [Figure 2]. depicts the comparison in ROP screenings done in 2019 versus 2020 during the study period. The peak was in April May in 2019, flattening in the remaining months. The ROP curve remained flat in 2020, only peaking in May June 2020 transiently when the lockdown opened for a short period. The same is depicted in [Table 8]. Intravitreal injection and, postvitreoretinal surgery follow-ups completely stopped coming. Many patients did not report to the hospital on the pre-appointed date for surgery due to logistic reasons, lack of transport, and for the fear of contracting COVID from the adjoining COVID care hospital. Two patients requested cancellation of admission after going to the ward due to fear of contracting COVID. One patient was refused surgery due to the progression of the disease process to loss of light perception during the lockdown period. | Figure 2: Month-wise comparison of Retinopathy of prematurity screenings done between 24th March and 30th September in 2019 versus 2020. ROP: Retinopathy of prematurity
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Later after May 2020, real-time reverse transcription–polymerase chain reaction nasopharyngeal swab testing for COVID-19 became compulsory before any intraocular procedure. Those patients who were ready for surgery refused due to COVID testing prerequisite. Again, the patients refused surgery for fear of getting the test done due to the belief that the patient would be isolated in the COVID ward if found positive.
Number of macular lasers and indirect laser ophthalmoscopy patients decreased. A month-wise comparison could not be done because no lasers were performed after April 2020 due to technical reasons.
Subsequently, due to the over exhaustion of staff working in the COVID department, staff from other non-COVID specialties including the vitreoretinal surgeon was posted to the COVID department. This caused the further shutting down of essential vitreoretinal services.
This study only gives an idea about how vitreoretinal services suffered during the COVID period. A longer duration study involving 3 years could give a comprehensive picture of the gravity of the impact. The first and second waves of COVID-19 could also be compared. It would also depict the aftermath of the pandemic, namely the percentage of people who went blind due to lack of timely treatment. It would also be prudent to fill up questionnaires to find out why patients could not present to the vitreoretinal facility, how many were due to logistic reasons and how many due to fear, whether they themselves refrained from treatment, or they were refused treatment due to COVID positivity.
Such a study would help in making a contingency plan for future pandemics. Some of the suggestions are as follows. Essential services such as vitreoretina should not be shut down. The attending staff should be strengthened and not posted to the pandemic. The fears of the patient as well as the attending surgeons should be allayed. Insurance covers should be offered to the medical staff and their families in the event of any accident. Incentives and a proper work environment should be provided to the staff working during the pandemic, irrespective of COVID or non-COVID service. Proper funds should be allocated to the non-COVID emergency specialties, too ensuring maintenance and repair of essential equipment on time. OPD consultations could be supplemented by telephonic/WhatsApp/email consultations for the educated middle class and above patients who are computer, Internet, and smartphone savvy. Poor patients could continue presenting to the OPD on an emergent basis, observing due precautions such as hand sanitizing, masks, and social distancing.
| Conclusion | | |
COVID pandemic leads to a significant reduction in vitreoretinal OPD consultations and procedures, both elective and emergency. Vitreoretina is a branch of ophthalmology that requires early detection and urgent intervention for better visual results. Some of the vitreoretinal diseases are sight-threatening and can lead to irreversible visual loss if intervention is not done in time. In the event of a pandemic, alternate ways of telephonic or e-consultation with the help of WhatsApp, messaging, and video consultations should be sought. Patients should be educated and made aware of the warning signs of when to approach in cases of emergency through social media.
COVID-19 has brought about a grave impact on the vitreoretinal practice irrespective of the setup, government, private, charitable, and semi-charitable, completely shutting down their revenue generation, leading to huge socioeconomic loss. This was followed by loss of pay, loss of job, and loss of business growth. All this has led to extreme emotional and psychological turmoil of those adversely affected, namely medical, paramedical, nonmedical, managerial, and other staff contributing to the vitreoretinal practice. The greatest setback was to the patients who suffered intractable loss of vision loss due to treatment negligence. Contingency plans should be made and executed in case of future pandemics.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]
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