DOI: https://doi.org/10.21203/rs.3.rs-1380413/v1
Objective:
As with any healthcare practice, elective surgeries had to be postponed since the start of the Covid-19 pandemic. This study aimed to examine the characteristics of ophthalmology outpatients and eye surgery admissions during the COVID-19 pandemic and, also to compare the pandemic and re-pandemic periods.
Methods:
This retrospective study included patients admitted to the ophthalmology clinic of a tertiary hospital from April through June 2020. A similar control sample was formed using the registries from the same interval in the previous year. The primary endpoint was the number and distribution of type of surgical procedures (e.g., group A and group B surgery) during the pandemic. The secondary endpoint was the comparison between the pre-pandemic and pandemic period.
Findings: A total of 116 operations were performed in 2020 (mean age: 42.3±25.6 years, male: 63.8%). In 2019, 873 surgeries were performed in the same period of the year (mean age: 56.6± 20.2 years, male: 48.8%), indicating a 86.7% decrease during the pandemic. While the proportion of group A surgeries was 10.3% in the total number in 2019, it was 25.9% in 2020 (p<0.001). The rate of group B surgeries also increased from 5.4% to 17.24% (p<0.001). Although the total number of surgeries decreased after the pandemic started, the rates of both A and B group surgeries increased significantly compared to the previous year.
Conclusion: This study showed a striking reduction in eye surgery during the early period of the Covid-19 pandemic. However, an increase in trauma related surgeries were found during the pandemic.
The primary mode of transmission among SARS-CoV-2 individuals is direct respiratory or droplet transmission, but infection can also be transmitted through the nose, eyes, and mouth by touching surfaces contaminated with the virus [1]. SARS-CoV-2 has also been detected in non-respiratory samples, including stool, blood, ocular secretions, and semen, although the role of these sites in the transmission is unclear [2]. Although many published studies have described the biology, transmission, and diagnosis of COVID-19, its clinical features, and the progress of vaccines and therapeutics, still more data on the impact of COVID-19 on the national health systems are needed [3]. In this context, the impacts on access to eye care and salvage treatments for vision, which can cause disability for many patients, needs to be explored. It is considered crucial to determine the potential risks, reduce unnecessary outpatient visits, and perform elective surgiries timely, especially in elderly patients and patients with comorbidities. This study examined how routine eye surgery practice has been influenced during a global pandemic. In this way, awareness can be increased to take precautions and avoid excessive costs.
Turkey has taken necessary measures across the country from April 2020 to prevent the transmission of SARS-CoV-2. A curfew was introduced, restricting all outdoor movements except essential services. Regions were managed with local measures in line with the decisions of the provincial sanitation boards according to the prevalence of COVID cases [4]. In line with the measures taken, elective surgeries were postponed not only to protect the patients and healthcare staff, but also to meet the increasing need for beds. Therefore, the number of surgeries reduced, reserving the limited space for the emergency cases.
In light of above mentioned practice changes during the pandemic, our aim in this study was to investigate how eye surgery was affected by the COVID-19 pandemic, to examine its surgical features and to compare it with the pre-pandemic period. The data to be obtained may be useful in planning more effective health care delivery.
We conducted a retrospective study using outpatient and inpatient admissions at the Gülhane Training and Research Hospital, Ankara, Turkey. We determined the total eye surgeries performed in April, May, and June in pre-pandemic 2019 and compared them with the number of surgeries in the same months in the pandemic year 2020. Patients who were aged 18 years and older were admitted either for an emergency or as an outpatient. Patients under the age of 18 were excluded, and no other exclusion criteria were applied. The study was approved by the institutional review board (08/07/2021, Code: 46418926), and the study design complied with the principles outlined in the revised version of the Declaration of Helsinki.
Demographic data, number of surgeries, type of surgery, and length of hospital stay were recorded. Patients who underwent eye surgery during the pandemic period in 2020 were classified as the "Pandemic Group", and patients who underwent surgery in the same period in 2019 were named the "Pre-pandemic Group". The two groups were compared for the study outcomes. Admissions to the retina, cornea, lens, oculoplasty, strabismus, glaucoma, ocular oncology, low vision aids, neuro-ophthalmology, contact lenses, and pediatric ophthalmology units were screened.
Surgeries were grouped into 4 groups. Cataract and related surgeries were grouped as “Phaco”, emergency surgeries for trauma patients as “Trauma”, retina and related surgeries were grouped as “Retina”, and eyelid and adnexal surgeries were grouped as “Eyelid”. In addition, five groups (A, B, C, D, E) were formed based on the classification according to the size of the surgery with a scoring system made by the Turkish Ministry of Health. Group A referred to major special surgeries and interventions, Group B to special surgeries and interventions), Group C to major surgeries and interventions, Group D to middle surgeries and interventions), and Group E to minor surgeries and interventions.
The length of hospital stay was the period between the day of hospitalization of the patient in the emergency service or the ophthalmology clinic and the day of postoperative discharge.
R Studio (Version 3.6.2) was used for statistical analysis. Continuous variables were given in mean ± standard deviation. Two proportions of the Z-test were used to compare surgery proportions. P < 0.05 was considered statistically significant.
The number of surgeries performed in 2020 was 116 (mean age: 42.3 ± 25.6 years, male: 63.8%), whereas 873 surgeries (mean age: 56.6 ± 20.2 years, female: 48.8%) were performed in 2019 (Table 1). The reduction in the number of surgeries was 86.7% in the first three months of the Covid-19 pandemic. Male predominance was observed in the pandemic period, while the gender distribution was similar in 2019. Also, mean age of the patients was markedly younger in the pandemic period.
| Pre-pandemic year (2019) (n = 873) | Pandemic year (2020) (n = 116) | |
|---|---|---|
| Age, years, mean ± SD | 56.6 ± 20.2 | 42.3 ± 25.6 |
| Male, n (%) | 426 (48.8) | 74 (63.8) |
| Female, n (%) | 447 (51.2) | 42 (36.2) |
| Length of Hospitalization, mean ± SD | 3.95 ± 11.9 | 9.87 ± 23.6 |
Phacoemulsification (PHACO) was the most common type of surgery in both 2019 (n = 357) and 2020 (n = 15). On the other hand, Phaco surgeries decreased remarkably and significantly from 2019 to 2020 (p < 0.001). The number of trauma operations was 27 and 19 in 2019 and 2020, respectively. Although the number of trauma surgeries was lower in 2020, its overall proportion among all surgeries increased significantly in 2020 (p < 0.001). Surgeries due to trauma (immediate non-deferrable surgeries) was particularly related to firearm injuries during the pandemic. This may be caused by the long-standing role of our hospital as a referral center for the wounded military staff. Retina surgeries also decreased from 100 in 2019 to 43 in 2020. Similar to the trauma surgeries, despite lower numbers recorded in 2020, the proportion of retina surgeries increased from 11.9% in 2019 to 37.1% in 2020 among the total number of surgeries. The number of eyelid surgeries reduced from 117 in 2020 to one in 2020 (p < 0.001) (Table 2). While 19 strabismus surgeries were performed in 2019, no record was found in 2020.
| Pre-pandemic year (2019) | Pandemic year (2020) | Z-Statistics | p-value | |
|---|---|---|---|---|
| Phaco, n (%) | 357 (40.9) | 15 (12.9) | 5.739 | < 0.001 |
| Trauma, n (%) | 27 (3.1) | 19 (16.4) | -6.150 | < 0.001 |
| Retina, n (%) | 100 (11. 9) | 43 (37.1) | -7.229 | < 0.001 |
| Eyelid, n (%) | 127 (14.6) | 1 (0.9) | 3.978 | < 0.001 |
Evaluation surgery classifications
The number of operations across surgical groups also showed differences in the pandemic period compared with the pre-pandemic period (Table-3). The number of group A, B and E surgeries increased significantly in 2020.However, there was a significant decrease in the number and percentage of group C and D surgeries compared with the same period in 2019 (Table 3).
| Pre-pandemic year (2019) | Pandemic year (2020) | Z-Statistics | p-value | |
|---|---|---|---|---|
| A, n (%) | 90 (10.3) | 30 (25.9) | -4.669 | < 0.001 |
| B, n (%) | 47 (5.4) | 20 (17.2) | -4.578 | < 0.001 |
| C, n (%) | 436 (49.9) | 36 (31.0) | 3.732 | < 0.001 |
| D, n (%) | 267 (30.6) | 20 (17.2) | 2.866 | 0.004 |
| E, n (%) | 33 (3.8) | 10 (8.6) | -2.160 | 0.031 |
| Total | 873 (100) | 116 (100) |
Contrary to the expectations, the duration of hospitalization during the pandemic period increased significantly from 3.95 ± 11.9 days to 9.87 ± 23.6 days. This may be caused by the fact that, as mentioned earlier, the number of surgeries due to trauma and retina disease increased during the pandemic, while Phaco surgeries reduced. The former two surgeries require a longer inpatient observation, whereas the latter is mostly a one-day intervention.
The Pandemic and quarantine have created a wide range of challenges for healthcare services. While restrictions and worries of getting infected by the virus concerned the patients and overall population, even more distress influenced the healthcare professionals, limiting the routine outpatient and inpatient practice. An online survey showed that most ophthalmologists did not examine patients and that elective surgeries were almost completely stopped during the early stages of the pandemic [5–6]. Other studies from different countries have evaluated the impact of quarantine on healthcare and especially ophthalmic services [7–8]. There are also studies examining the effects of the pandemic on ocular trauma and emergency trauma cases A recent report by the CovidSurg Collaborative predicted that 28.4 million surgeries worldwide were canceled or postponed in 2020 [9]. Elective surgeries have also decreased significantly in branches where planned surgeries are predominant, such as the eye department. On the other hand, reviewing all scheduled procedures should not necessarily entail canceling all elective surgery cases. Given the uncertainty about how long COVID-19 will last thoughtless elective surgery cancellations may have a more dramatic and immeasurable impact on the public than the morbidity and mortality caused by the Covid-19.
Surgical procedures can require a significant allocation of equipment and resources, not only in the operating room but also in post-operative care units. Therefore, the need to limit operative capacity to only emergency procedures was reasonable in the earlier periods of the pandemic. However, guidelines were quickly managed by the national surgical societies for triage in eye care during the resource shortages. Nevertheless, many non-urgent elective eye surgeries become urgent at some point depending on how long the COVID-19 epidemic will continue.
As with any other healthcare facility, our hospital has continued to provide care for COVID patients along with daily services. Nevertheless, there were disruptions in the provision of routine patient care. In our study, we also evaluated trauma cases while examining the surgical application. While the number and variety of patients admitted to emergency services varied, it was also highlighted that most patients had delayed admissions for medical help because of the risk of exposure to the virus and quarantine practices. The average number of cases has increased as the restrictions were partially softened in June 2020. There was a decrease in follow-up compliance, probably due to the difficulty of reaching the hospital during the quarantine.
In our study, male predominance (63.8%) and younger age (average 56.6 in the previous year, 42.3 in 2020) were recorded during quarantine. This may be due to the closure of schools, the start of the teleworking system, and the fact that many people, especially those over the age of 65, have to stay at home due to the risk of infection. This information is similar to that reported in a past study conducted in a tertiary hospital during quarantine [10]. The authors of another study conducted at the eye institute also reported a 41.8% reduction in mechanical trauma cases during quarantine [11]. We did not observe a decrease in trauma cases. In our study, while 27 trauma operations were performed in the three months of 2019, 19 trauma operations were performed in the relevant period of 2020. The most important factor here may be the habit of being sent to us for the treatment of these patients during the pandemic period, as we are a former military hospital.
Because of the close contact between the surgeon and patient during the pandemic year, there was a concern about surgical management for both sides. All patients undergoing elective surgery were tested for COVID the day before the surgery, and the operations were postponed for patients positive for COVID. In emergency cases such as open globe repair, even if the patient tested positive for COVID, the surgery was performed after all necessary precautions were taken. After the surgery, their treatment was done in the COVID-19 clinics. These measures were also recommended by hospital health administrations in many countries [11].
Our hospital also has a special eye bank for cornea collection and processing. During the lockdown, all eye bank-related operations have been suspended due to fears of COVID transmission. During the 2019 study period, a total of 94 donor corneas were collected, of which 97.8% (n = 92) were transplanted. However, in 2020, due to the pandemic and restrictions throughout the year, 47 donor corneas were collected and 85.1% (n = 40) could be transplanted, comprising a 50% reduction. Another hospital-based research that included an eye bank in India reported a 99.61% reduction in the corneal collection since the quarantine was announced [7].
To provide safe health services, both manpower and resources need to be managed appropriately. Our hospital is an educational research institution that provides academic education as well as health service delivery. Clinical and surgical learning was also adversely affected due to the suspension of routine services during the pandemic period [12–13]. Education continued remotely on an online platform. In addition, ophthalmologists were assigned roles in the COVID clinics. such measures caused disruptions in ophthalmology services and academic education. Training and education in refractive surgery and cataract were also affected [17]. Nick Mamalis, Director of the Utah Ophthalmic Pathology Laboratory and JCRS Honorary Editor, recommended reviewing surgical videos for those in education and using surgical simulators whenever possible [18–19].
The current study showed us how trends have changed in ophthalmology clinics. Our practices should change accordingly during the pandemic process. Sourcing and management are very important factors that need to be investigated.
The pandemic and the ensuing lockdown have certainly impacted disease prognosis, healthcare delivery, and resource pooling. Understanding the changing trends will help to be more prepared if a similar cycle is to be repeated in the future. It is necessary to develop long-term surgical strategies to increase the safety of elective surgeries such as cataracts and refractive surgery, which should be performed during the pandemic period. It should be questioned whether all outpatients should be tested preoperatively, especially if faster tests are present [14]. Another practice change that may decrease patient exposure is to make bilateral cataract surgery if possible [17]. This is not the chosen practice, but it could facilitate treatment while decreasing the risk during the COVID-19 pandemic. Our patients need to know more than ever that their safety in outpatient clinics and clinics is our preference.
The protection of healthcare personnel is also extremely important. New methods should be developed in both respects. As an example of the methods developed for this purpose; Aman Chandra, MD, University Hospital Southend, UK, shared a new idea of forming a microscope shroud to decrease aerosol transmission during intraocular surgery [18]. From Iran, Peyman et al. have developed and rapidly adapted a shield in biomicroscopes to protect patients and the ophthalmologist [19]. We need many more changes like this in our new normal, the pandemic. An important contribution to pandemic medicine was to raise awareness about telemedicine [15]. Telemedicine had already progressed to a great extent in recent years. The COVID-19 pandemic has accelerated the legal adoption of telehealth practices in many countries, at least temporarily, helping to further increase its availability [16–21].
Likewise, awareness of teleophthalmology will most likely provide that no patient will for primary treatment because of the pandemic. In terms of eye health and to prevent disability, one should be aware that delays in the treatment of patients for weeks or months may lead to irreversible vision loss. With continued advances in teleophthalmology and artificial intelligence, patients can benefit from better detection and earlier treatment of eye diseases through telehealth screenings and diagnosis using artificial intelligence algorithms, resulting in better care and better visual outcomes for patients. Effective planning is necessary to provide the smooth delivery of healthcare that is secure for the public. In cases that could lead to a worldwide public health crisis, we must search for the optimum use of our available resources to prevent higher costs.
To sum up, this study emphasizes that, under pandemic conditions, the delay of elective ophthalmologic surgeries was inevitable, and the number of patients that applied to clinics decreased significantly. Nevertheless, this can lead to an increase in preventable visual disorders throughout the world. To avoid the effect of the pandemic, we must benefit from Artificial Intelligence, an important agenda item in the near future that has now become a necessity in ophthalmology to improve the diagnosis processes. By providing eye care for the patients at their homes, their fear of getting infected by COVID can also be reduced. It seems imperative to design and implement algorithms focused on community health and patient safety, both for appropriate surgical care and to guide the decision-making process.
We thank Emre Dünder, Assoc. Prof. for assistance with statistical tests which improved the manuscript.