Impact of COVID-19 Lock down period on Ocular Trauma

Introduction: This study investigated the effect of coronavirus disease 2019 (COVID-19) lockdown on the incidence of ocular trauma. Methods: In this retrospective cohort study, we collected data of patients who presented with ocular trauma in the emergency department during the lockdown period (from 22 March, 2020, to 30 April, 2020). In addition, we collected data of patients presenting with ocular trauma during the same period in the previous year. We compared the number of patients who underwent ocular surgery and the number of paediatric patients with ocular trauma between these two periods. A confounding factor may be the absence of patients from different districts who could not travel to the centre due to travel restrictions. Results: Between 22 March, 2019, and 30 April, 2019, a total of 76 patients presented with ocular trauma, of whom 28( 37.2%) required surgery. By contrast, between 22 March, 2020, and 30 April, 2020, a total of 78 patients presented with ocular trauma, of whom 33(42)% required surgery. Furthermore, 9% and 30% of the total patients in 2019 and 2020, respectively, belonged to the paediatric age group. Conclusions: COVID-19 lockdown exerted a signicant effect on the incidence of ocular trauma.


Introduction
Coronavirus disease 2019 (COVID-19) pandemic is disrupting the world and representing the most signi cant stress test for many national healthcare systems and services since their foundation. The supply-chain disruption and the unprecedented request for intensive care unit beds have created conditions typical of low-resource settings in Europe. The COVID-19 epidemic, which originated in Wuhan, Hubei Province, China, and has been rapidly spreading to other provinces in China and 190 countries worldwide, was declared a global pandemic by the World Health Organization on March 9, 2020, becoming a 'public health emergency of international concern'. Patients who are positive for COVID-19 infection are the main source of infection. Asymptomatic COVID-19 patients are extremely contagious, with a strong infectivity in the incubation period ranging from 1 to 14 days. The person-to-person transmission routes of 2019-nCoV include direct transmission, such as through coughing, sneezing, and droplet inhalation transmission, and contact transmission, such as through contact with oral, nasal, and eye mucous membranes. Whether COVID-19 transmission occurs through the faecal-oral route remains to be determined. Infection control measures are mandatory to prevent the virus from spreading and to help control the epidemic situation (1). Because of the rapid identi cation of infection infection during the diagnosis and treatment of ocular diseases, nonurgent outpatient ocular treatments were suspended, maintaining only crucial emergency situations.
The imposition of lockdown and social distancing measures are major actions implemented by many governments to prevent community spread (2, 3). The current study investigated the effect of COVID-19 lockdown on the incidence of ocular trauma. This multi-centre retrospective cohort study was conducted after obtaining approval from the hospital's ethics committee. In India, since the imposition of COVID-19 lockdown from 22 March, 2020, travel restrictions have been implemented and interdistrict transportation has been stopped. Accordingly, for this study, we retrieved data of patients who presented with ocular trauma to our emergency department between 22 March, 2020, and 30 April, 2020, from the electronic medical system of our hospital and those of two eye care centres located in different parts of India. In addition, we collected data of patients presenting with ocular trauma during the same period in the previous year. We determined the number of patients who presented with ocular trauma, the number of patients who required surgery, and the number of paediatric patients and compared these data between the two study periods.

Results
During the study period in 2020, we found that 148 patients presented in the emergency department. Of these patients, 78 experienced ocular trauma. Of 78 (52.7%) patients with ocular trauma, 24(30%) were children and 33(42%)-required surgical intervention. We compared these data with those during 2019 and found considerable differences. In 2019, a total of 157 patients presented to the emergency department.
Of these patients, 76 (48.4%) had ocular trauma. Of patients with ocular trauma, 7 (9%) belonged to the paediatric age group and 28(37.2%) required surgical intervention. (Table-1) Because our hospital is a tertiary eye care centre, patients from surrounding districts visit our hospital.
However, because of COVID-19 lockdown, patients only from one district in which the hospital is located visited the centre. Despite this confounding fact, many patients with ocular trauma presented, with most of them being paediatric patients.

Discussion
COVID-19 can have an ophthalmic manifestation and thus can be secreted in tears (3)(4)(5)(6). Coronaviruses can cause a wide spectrum of ocular diseases, including anterior segment diseases, such as conjunctivitis and anterior uveitis, and posterior segment diseases, such as retinitis and optic neuritis [51].

The current understanding regarding how SARS-CoV-2 spreads is largely based on what is known about
other similar coronaviruses. Currently, two types of SARS-CoV-2 (L and S) have been detected (2).
The lockdown was imposed to reduce human-to-human transmission of COVID-19. Many studies have examined the effect of COVID-19 lockdown in terms of disease prevention, (3-6) environment, and emotional and psychological conditions (7-10). The current study focused on the effect of COVID-19 lockdown on the incidence of ocular trauma. We found an increased incidence of ocular trauma, particularly in children. We could not nd any study reporting similar ndings.
Hamroush et al reported similar ndings; however, they did not compare their ndings with previous data and did not study surgical intervention and ocular trauma in the paediatric age group (11). Christine et al reported a decreased incidence of general trauma and admission, as well as about few cases who required faciomaxillary services during the lockdown period (12). Ida et al indicated that many patients presented with faciomaxillary injury during the lockdown period (13).
Furthermore, Nair and Honaver reported that the majority of ophthalmic surgeons in India are not performing elective surgery during the lockdown period; thus, all emergency cases are diverted to institutions (14,15).
The increase incidence of ocular trauma observed in the current study may be attributed to children being at home and limited mobility during the lockdown period. The incidence of ocular trauma and underlying reasons may not be the same in other countries because only a study from Britain has been published.
Because COVID-19 lockdown is being lifted from different countries, we may observe a reversal of this effect. Currently, we have minimal evidence of this COVID-19 effect on ocular trauma incidence, and we might observe additional data from multiple centres.

Conclusion
COVID-19 lockdown exerted a direct effect on the incidence of ocular trauma, particularly in the paediatric population.

Declarations
No nancial support was received from any company or institution.
This study has not been presented at any conference or meeting.