Since December 2019, the global pandemic caused by SARS-CoV-2 has induced unprecedented changes in medical practice .
The lockdown that began in France on March 17, 2020 induced a remarkable and a disturbing decrease in ophthalmic emergency department visits.
RFH is a hospital dedicated to head and neck diseases. During P3, its organization changed dramatically to accommodate patients with COVID-19 in medicine and intensive care units. The outpatient clinic closed, but the OED and the Stroke Unit remained open. The overall number of OED attendances have approximately halved during the lockdown (P3) which is consistent with the drop in the overall number of patients presenting to the emergency departments. The significant decrease in the number of consultations in P3, greater during the second and the third week, was explained by the fear to catch the virus by hospital attendance, the fine for breaking confinement rules, the reduction in public transportation, and the fact that some patients were confined at home or tested positive to the virus. Also, the decrease in outside activity can explain the reduction of minor emergencies such as conjunctivitis or corneal foreign body, which are the most frequent causes for consultation in emergency. The reduction in the number of conjunctivitis can also be explained by hygiene measures such as frequent hand washing, social distancing, and the lower frequency of wearing contact lenses during the lockdown period.
During P4, we noticed an increase of total visits (87 per day VS 52 in P3). However, neither the proportion of patients consulting for severe disease (12.8% during P3 vs 11.1% after), nor the proportion of admitted patients for the more severe emergencies was significantly different (4.3% VS 3.6%). This stability is maybe related the absence of significant consultation delay for patients with severe ophthalmic diseases. However, the considered post lockdown period of 4 weeks could be too short to highlight such a delay. We also could hypothesize that there was a balance between decrease in severe emergencies and increasing in other emergencies during these 2 periods. Compared to Period 1 and 2, the number of daily consultations was reduced by more than 50% in P3 and by 30% in P4, suggesting that people were still afraid of the virus after the lockdown period. However, the rate of hospital admission in 2018, 2019, and 2020 was stable. This stable rate seems low but is similar to the rate reported in an eye related emergency department in the USA (2.8%) Another large retrospective American study of more than 370 000 people reported that 23% of enrolled visited the OED for non-urgent ocular condition and only 6.7% had severe ocular pathologies, but there is no mention of how many patients were hospitalized.
In a recent publication coming from Taiwan concerning more than 5000 patients consulting an eye related emergency department, 10.3% were admitted to the ophthalmology ward.
These differences may be related to the emergency consultation habits, which vary from one country to another.
We didn’t notice a significant rise of the average age after the lockdown (p=0.50), suggesting that, if needed, elderly people visited the OED during P3 and P4; furthermore, during P3, the absence of trauma related to outdoor activities was balanced by the relative rise of domestic injuries.
Among the severe diseases, neuro-ophthalmic diseases (optic neuropathies, idiopathic intracranial hypertension, pupil abnormalities…) and the visual manifestations of stroke were the most common, which can be explained by the specificity of our hospital specialized in neuro-ophthalmology combined with a stroke Unit. Their proportion did not differ during P3 and after. However, more MRIs were performed in emergency during P3 (n=187: 6.4%) than after (P4: n: 127: 4.8%); this difference is statically significant (p< 0,001) and may be explained by the fact that during the P3, new procedures were used to avoid multiple consultations and extended medical workup to be performed at time of presentation, when needed. The number and proportion of MRI performed in the same period in 2018 (0.9%) and 2019 (1.6%) is lower, which can be explained both by the changes in the diagnostic and treatment protocols, but also by the acquisition of 2 additional 3T-MRI allowing faster acquisition protocols, which made their use more frequent.
However, among the other severe ophthalmic diseases, and even if the number of patients is not high for each pathology, we found that the proportion and the number of some pathologies are quite different between the 2 periods P3 and P4:
Neovascular glaucoma were twice as common during post lockdown period, which suggested a delay in the consultations for central venous occlusions (p=0.08).
Likewise, the significant increase in patients with a graft reject consulting in our OED during post lockdown period (p<0.001) could be linked to a delay in the follow-up consultations of the corneal grafts performed before.
Conversely, the frequency of the open globe injuries decreases by half during P4 compared to P3 (p=0.03), probably because of a decrease in “do it yourself work” at home. Because of the cancellation of during P3, no endophthalmitis was observed in the month following the lockdown.
Compared to 2018 and 2019, the rate and number of surgical retinal detachments during the P3 was significantly lower (p<0.001). This can be related to the decrease of outdoor activities and reduction of trauma, or to delays in patients’ presentation. The same low rate was seen at the start of P4, suggesting that this could be explained by the reduction of sports and violence with a progressive resumption of outdoor activities, but, again a period of 4 weeks may be too short to affirm the absence of delay of consultation.
Two other European studies, concerning the impact of COVID-19 pandemic and lockdown on eye emergencies have been published recently. In both articles, the authors compare the lockdown period in 2020 with an equivalent period in 2019. In the United Kingdomand in Italy the authors reported a reduction in the number of consultations similar to ours, i.e. around 50% and no difference in the demographic profile of the patients. Similarly, in the UK study, there was a significant reduction in the number and the overall incidence of retinal detachment in 2020 vs. 2019 while vitreo-retinal disorders increased in the Italian study. The recruitment of these two centers is however different from ours, since neuro-ophthalmologic emergencies are much less frequent. A third study concerning the same period was published in India, with different demographic characteristics, i.e., 30% of children and 73.5% of male patients consulting in emergency during the lockdown. In this study, the eye emergency services decreased by 32.25%, with and increasing proportion of microbial keratitis and conjunctivitis amplified by 1.25 times 2 times, respectively.
Our study had some limitations: some patients groups are small, the P4 is short, and the return to a normal activity happened gradually, which does not allow us to conclude firmly on the possible existence of consultation delays, their importance and their impact in terms of loss of chance; finally, we did not compare all the categories of severe ocular emergencies in the same period of 2018, 2019 and 2020.