The COVID-19 outbreak has changed not only the number of patients but also the nature of the surgeries performed in ophthalmology, as in many areas. In our hospital, arrangements were made for elective interventions in line with the TOA recommendations, and surgical interventions not included in the emergency category were postponed according to this guideline. However, as a result of the allocation of ophthalmology clinics to COVID-19 patients in many centers in Istanbul, an increase was observed in trauma patients referred to our clinic compared to previous periods.
In our center, several steps were taken to overcome the ongoing need for surgical intervention care during this epidemic period and to ensure that patients are examined and treated in a safe environment as possible. Each case was assessed for risk of visual loss and emergency. Operating room and emergency room teams working alternately were formed to prevent cross-contamination. Necessary applications were performed in order to provide environmental disinfection between operations performed on the same day.
The routes of transmission of COVID-19 are thought to include droplet, contact, and contaminated surfaces, as well as the ocular surface. Ophthalmologists are in the high-risk group in terms of transmission not only because they are in close proximity to patients during the examination, contact with conjunctiva and tears, but also because of the high daily number of outpatients and emergency patients.8 Furthermore, studies suggest that virus particles can survive in droplets for a few hours and can survive on surfaces for several days.9 Therefore, to reduce human-to-human virus transmission in the struggle against the COVID-19 pandemic, national ophthalmology associations in many countries have recommended that any treatment other than emergency or urgent should be avoided. The frequencies and distributions of ophthalmological procedures performed during the pandemic have been discussed in the literature.1–3, 5, 6 However, as far as we know, there are no studies in the literature that evaluate epidemiologic and clinical features of a large patient series, as our patient series, during the lockdown period, and report anterior segment surgical interventions performed in Turkey.
In our study, when ophthalmic emergencies were examined in terms of etiology, corneal perforation was the most common by 18.1%. When the study conducted by Tang et al10 between February and April 2020 in a tertiary center in Hong Kong was evaluated in terms of anterior segment surgery, corneal perforation repair was the most common by 15.8%. Unlike the Tang et al study, in which no evaluation was made in terms of etiology, in our study, corneal penetration was the most common etiology, but AMT was the most common procedure. The reason for this difference is that AMT was also applied in etiologies such as keratitis, spontaneous perforation, corneal melting, and persistent epithelial defect in our cases.
In a study in which all emergency ophthalmological surgeries were evaluated by Du et al6 in the period from December 2019 to March 2020, during which measures began to be taken after the first COVID-19 case, it was reported that the most common surgery was glaucoma surgery andeye traumas were rarely observed. The fact that our center is a tertiary branch hospital, the closure of ophthalmology departments due to COVID-19 in some of the other health institutions, and the high number of patients referred to our hospital within and outside the province are among the reasons for performing the high number of eye trauma surgeries during the quarantine period in our hospital.
Pediatric patients diagnosed with congenital cataracts, elderly and weak patients over the age of 70, and patients diagnosed with phacomorphic glaucoma constituted the group with phacoemulsification and intraocular lens implantation surgery performed in our clinic during this period. In ophthalmology practice, while the patient group undergoing elective surgery constituted the majority of the patient population undergoing cataract surgery, the reasons for not delaying surgery in these patients included the primary evaluation of pediatric patients due to the risk of amblyopia, uncontrollable intraocular pressure elevation due to phacomorphic glaucoma, and possible optic nerve destruction.7 In pediatric cataract cases, the timing of cataract surgery has significant effects on ultimate visual acuity, amblyopia management, and stereopsis.11, 12 In cases with phacomorphic glaucoma, phacoemulsification and IOL implantation are effective in improving visual acuity and in the control of IOP.13 Furthermore, in a study by Shih et al14 in which elective cataract surgery performed during the pandemic period was evaluated, it was reported that elective surgeries should continue even at low capacity in cases that may cause morbidity in phacomorphic glaucoma cases.
When the cases included in our study were examined in terms of the ranking of referral centers, it was observed that 61.4% of the cases were referred to our hospital after their application to two or more health institutions. In a study conducted by Al-Kharsen et al15 in which emergency ocular surgeries performed between April 2019 and April 2020 were compared, it was reported that 36% of all patients who underwent ocular surgery were referred from an external center. Moreover, we considered that the reason 56.3% of the cases applied to our hospital for the first time was due to the closure of ophthalmology clinics of the surrounding centers.
This study has some limitations. Firstly, this study has a retrospective design. Secondly, although the data were obtained from our center with the highest number of patients within the boundaries of Istanbul, they may not fully reflect the ophthalmology cases across the country. Furthermore, the results of this study may not completely apply to other countries in the world, where restrictions imposed during the quarantine period may differ.
The COVID-19 outbreak has significantly affected patient selection and surgical interventions in Turkey, our hospital, and all over the world. The number of surgical interventions performed in our hospital decreased significantly, and only emergency cases were intervened. Each patient was considered a potential carrier of COVID-19 and examined by taking necessary measures before and after surgery. While the first examination was performed in the isolation room in emergency cases known to have a positive COVID-19 test, maximum measures were taken to prevent contamination during and after surgery. While this period caused unique difficulties for patients and surgeons, we were able to provide safe surgical care for the patients in need with the arrangements we made in our hospital in accordance with the TOA recommendations.
In conclusion, during this quarantine period, while corneal perforation was the most common indication among ocular emergencies requiring surgery, amnion membrane transplantation was the most performed intervention. The struggle against COVID-19 is still ongoing. Special arrangements are required to reduce the risk of transmission for healthcare professionals and patients and to ensure continuity of healthcare services for ophthalmology patients. New emergency treatment algorithms can be developed for similar situations that may occur in the future.