Preoperative COVID-19 RT-PCR Testing of Asymptomatic Patients for Ophthalmic Surgery: Experience from Two Tertiary Referral Centers

Purpose: The aim of this study was to evaluate how prevalent asymptomatic SARS-CoV-2 virus infection (COVID-19) is among patients undergoing ophthalmic surgery at two tertiary referral hospitals. Material(s) and Method(s): This retrospective study included patients without COVID-19 symptoms who underwent preoperative screening using reverse transcription-polymerase chain reaction (RT-PCR) before ophthalmic surgery at the Kocaeli University and Gaziantep University departments of ophthalmology [between September 1, 2020, and December 15, 2020 (group 1);between March 1, 2021, and May 30, 2021 (group 2)]. Patients scheduled for surgery and followed up in the retina, glaucoma, pediatric ophthalmology and strabismus, cataract and refractive surgery, and cornea departments were examined. Result(s): RT-PCR was positive for SARS-CoV-2 in 12 (1.4%) of 840 patients in group 1 and 7 (1.1%) out of 600 patients in group 2. None of the patients were symptomatic of COVID-19. The majority of the patients were scheduled for retina or cataract and refractive surgery in both groups (group 1;retina: 29.2%, cataract and refractive: 57.0%, group-2;retina: 31.3%, cataract and refractive: 54.5%). SARS-CoV-2 RT-PCR testing was positive for seven patients in group 1 (7/245, 2.9%) and five patients in group 2 (5/188, 2.6%) who were scheduled for retinal surgery. Conclusion(s): The necessity, availability, and practicality of COVID-19 RT-PCR testing prior to ophthalmic surgeries varies depending on the protocols of each institution. COVID-19 RT-PCR testing is suggested especially before vitreoretinal surgeries and general anesthesia procedures, because of the difficulty in managing postoperative complications.Copyright © 2023 Gazi Eye Foundation. All rights reserved.

Impact of personal protective equipment on the clarity of vision among trachoma survey graders and trichiasis surgeons in the context of COVID-19

Background/aimsThe COVID-19 pandemic necessitated the use of personal protective equipment for those involved in trachoma survey grading and trichiasis surgery. We sought to determine which configuration of a face shield would be less likely to impact grading accuracy and ability to conduct trichiasis surgery. The research also included assessment of comfort, ease of cleaning and robustness.MethodsThere were three research phases. In phase 1, assessment of four potential face shield configurations was undertaken with principal trachoma graders and trichiasis surgeon trainers to decide which two options should undergo further testing. In phase 2, clarity of vision and comfort (in a classroom environment) of the two configurations were assessed compared with no face shield (control), while grading trachomatous inflammation—follicular (TF). The second phase also included the assessment of impact of the configurations while performing trichiasis surgery using a training model. In phase 3, face shield ease of use was evaluated during routine surgical programmes.ResultsIn phase 2, 124 trachoma graders and 28 trichiasis surgeons evaluated the 2 face shield configurations selected in phase 1. TF agreement was high (kappa=0.83 and 0.82) for both configurations compared with not wearing a face shield. Comfort was reported as good by 51% and 32% of graders using the two configurations. Trichiasis skill scores were similar for both configurations.ConclusionThe face shield configuration that includes a cut-out for mounting the 2.5× magnifying loupes does not appear to impact the ability or comfort of trachoma graders or trichiasis surgeons to carry out their work.

Реорганизация алгоритмов работы офтальмохирургической клиники в условиях пандемии новой коронавирусной инфекции (COVID-19)

Purpose. To analyze changes in work of the Khabarovsk branch of the Fyodorov Eye Microsurgery Federal State Institution (Khabarovsk branch) caused by combination of elective and emergency ophthalmic care in the context of a pandemic of the novel coronavirus disease (COVID-19). Material and methods. The article presents the organizational restructuring of activities medical units of the Khabarovsk branch, due to need for additional performance of functions emergency ophthalmological service in connection with closure of the regional ophthalmological center of the City Clinical Hospital no. 10, which previously performed this function. Complex of organizational anti-epidemic measures taken to prevent the spread of COVID-19 in pandemic is presented, their feasibility is analyzed, the results of the clinic's activities in new conditions of the COVID-19 pandemic are reflected. Results. The COVID-19 epidemic required a significant organizational restructuring of the Khabarovsk branch. In addition to large volumes of elective surgery, emergency ophthalmosurgical care was added, performed in a round-the-clock hospital. All this was superimposed on the organizational restructuring of patient flows, created to minimize their interpersonal contacts. Conclusion. The Khabarovsk branch fully coped with the tasks set, stable work was organized in the new pandemic conditions, effectively combining planned and emergency algorithms of ophthalmic surgical care. The measures taken made it possible to provide emergency ophthalmic care in full throughout the entire period of the epidemic, to resume the provision of planned ophthalmic care in full, without compromising the safety of patients' stay in the clinic.

Keratoconus management: Lessons learned from an unusual time: Timely access to effective diagnosis and cross-linking are key to positive outcomes

The article discusses how the coronavirus disease 2019 (COVID-19) pandemic affected keratoconus (KC) diagnosis and management. Topics explored include the delay in the delivery of ophthalmic care during the early days of the pandemic due to service suspensions, the visual acuity lost by patients due to the delayed KC diagnosis and treatment, and the necessity of in-person evaluation of patients for KC to ensure accuracy of diagnosis.

Increased Screen Time as a Cause for Further Myopia BoomFollow up Study of School Health Survey

Background: Myopia is a major health issue around the world. The World Health Organization estimates that half of the population of the world may be myopic by 2050. In the present years, insufficient time spent in outdoor activities has been recognized as a major risk factor for myopia development. The duration and intensity of near work are also associated with myopia progression. Aim(s): To study the increase in myopic shift in school going children during covid 19 pandemic due to increased screen time. Material(s) and Method(s): A prospective cross sectional study was done as a follow up after 2 years (in March 2021) from a school health survey done in May 2019. 150 students, of ages 7-15 were included and spherical equivalent refraction was recorded for each child and progression of myopia was documented in dioptres. Children wearing contact lenses, with h/o any ocular surgery and children with pathological myopia were excluded from study. Result(s): Out of 145 children called for follow up, only 123 children reported in the OPD for follow up. The mean refractive error(spherical equivalent) had increased by +2D in children of ages 7-10 and by +1D in children from ages 11-13 and somewhat remained constant in older ages. The parents reported an increase in time spent on digital devices and prolonged near work and all this had a positive correlation with an increase in myopic shift. Conclusion(s): Shorter viewing distance, increased screen time and lesser outdoor activities is also associated with myopia progression, especially in younger children. Younger children's refractive status may be more sensitive to environmental changes than older children, as they are in a more important period for myopic development and progression. Copyright © 2022, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Estimating Societal Costs Associated With Vision Loss And Delayed Cataract Surgery: The Potential Impact Of The COVID-19 Pandemic

IntroductionCataract surgery is the most commonly performed surgical procedure in the UK (approx. 472,000 annually). The suspension of interventions due to the COVID-19 pandemic, has had a devastating impact on patients' access to care. In the UK a complete cessation of elective cataract surgery during the crisis has been an unfortunate reality and encompassed a 14 week hiatus to services in the National Health Service. Patients on prolonged waiting lists may experience negative outcomes during the wait period, including vision loss, increased risk of falls, and ultimately, poorer health-related quality of life (HRQoL). The objective of this research was to estimate the potential societal costs associated with vision-loss related to prolonged waiting times for cataract surgery, as a consequence of COVID-19 in the UK.MethodsIn this analysis, we present estimates relating to two cohorts: a hypothetical cohort of 1,000 cataract surgeries and quarterly estimates of cataract surgeries in the UK. Quarterly estimates (n=122,969) were chosen to reflect a suspension of cataract surgeries for 14 weeks during the COVID-19 crisis. UK cataract surgery numbers were attained from EUROSTAT. Estimates for decreasing visual acuity for those waiting for surgery were attained from the literature, as were the cost estimates associated with cataract-related sight-loss, which were made up of direct, indirect and intangible costs. Five scenarios (at 20% intervals) were simulated for the cost estimates, assuming from 20 percent to 100 percent clearing of waiting lists.ResultsFor cohort 1 (1,000 patients), the societal costs associated patients remaining on waiting list for one year, ranged between GBP 237,765 (EUR 279,533) (20% of patients remain untreated) to GBP 1.18m (EUR 1.39m) (100% remain untreated). For cohort 2 (n=122,969) cost estimates are in the region of GBP 29.23m to GBP 146.18m (EUR 34.36m to EUR 171.73m). Estimates consist of direct (15.6%), indirect (28.7%) and intangible costs (55.6%).ConclusionsCataract surgery is a sight saving procedure and its impact on HRQoL is overwhelmingly positive. Prolonged waiting times for cataract patients due to COVID-19 is likely to be associated with significant societal costs.

A service improvement to normalise conversation regarding cornea donation within a hospice inpatient unit between the healthcare professional, patient and those close to them

BackgroundCornea donation is regarded as a positive act which can potentially improve the quality of life of another person by restoring their sight (Willis & Draper, 2012. Int J Palliat Nurs. 18: 5;Madi-Segwagwe, Bracher, Myall et al., 2021. Palliat Med Rep. 2: 175). The compatibility of cornea donation to palliative care is well documented, however, barriers become evident when considering communication regarding donation between health care professionals and service users. Barriers include: lack of knowledge;fear of distress and lack of confidence. The absence of such communication resulting in a lack of patient knowledge, choice and opportunity, also fails to support the current cornea shortfall (Carrigan, Deane & Brady, 2018. BMJ Support Palliat Care. 8: A46;Madi-Segwagwe, Bracher, Myall et al., 2021;National Health Service Blood and Transplant, 2019;Willis & Draper, 2012).AimsTo introduce a service improvement which will normalise discussions regarding cornea donation with suitable donors within a hospice inpatient unit. Development of staff knowledge will support the improvement as this communication becomes part of Advance Care Planning (ACP) (Rietjens, Sudore, Connolly, et al., 2017. Lancet Oncol. 18: 543), allowing patients the opportunity to make an informed choice, supporting their autonomy.MethodApril-July 2021: Service evaluation, literature review, networking National Health Service Blood and Transplant (NHSBT), training material development, patient information leaflet produced, data codes identified for audit/evaluation. June – July 2021: staff training and support. July – November 2021: launch of cornea conversations with donor appropriate patients. Monthly feedback NHSBT. December 2021: evaluation.ResultsJuly - November (inc.) 2021 = 121 patients admitted donation suitable. 29 conversations conducted, 22 patients consented donation (76%). 21 referrals made to NHSBT after patient death. 15 eye retrievals conducted at the hospice. Positive staff feedback regarding conversations with patients. Patients were not upset by the conversation.ConclusionImprovement evaluation identifies positive results including: cornea conversation engagement, enabling patient choice, supporting patient legacy, enhancing cornea resources and restoring recipient sight. The COVID-19 pandemic heightened workplace pressures during implementation which was considered to impair overall performance. Use of the Plan, Do, Study Act cycle will support further project enhancement.Innovation/interest of this project?This project is vital considering the positive outcomes for the donor and the recipient of both cornea donation and transplantation (keratoplasty). Keratoplasty, considered the world’s most frequently performed transplantation, holds a high success rate, however, a dilemma presents considering the most frequently performed transplantation carries the highest donor refusal rate (NHSBT, 2021).

Building surgical skills for the ophthalmology trainee in times of a global pandemic

Purpose: The eye surgeon's unique microsurgical skillset is developed over time from repeated and meticulous training on delicate ophthalmic tissue. The impact of COVID-19 on the delivery of regular ophthalmology services has impacted the exposure and available opportunities for skills development in the trainee. Adopting ophthalmic surgery teaching models and simulators as training resources provides solutions to enhance microsurgical skills of the trainee operating in a pandemic. Method(s): A literature search was performed to identify ophthalmic surgery skills training resources. We included prosthetic, harvested produce, non-live animal, and virtual reality and simulation devices. Human cadaveric models were excluded. Result(s): Several established and novel ophthalmic surgery training resources were identified. Low-cost prosthetic models and tissue substitutes are available to develop basic microsurgical and tissue handling skills. Harvested produce, non-live egg, porcine products, and sophisticated virtual reality devices imitate various aspects of ophthalmic tissue to allow simulation of ophthalmic surgery of varying complexity including cataract, corneal, glaucoma, vitreoretinal and strabismus surgeries. The use of ophthalmic skills training devices improved skills of trainee eye surgeons. Conclusion(s): A wide range of ophthalmic surgery training resources are available to both the individual trainee and the training organisation, and provide a wide range of accessible, evidenced solutions to augment surgical skill development not only during the pandemic but also beyond.

Impact of COVID-19 on ophthalmic surgery in Australia

Purpose : The effect of coronavirus disease 2019 (COVID-19) on ophthalmic surgical case numbers in Australia and globally remains poorly characterised. Increased incidence of COVID-19 in Australia between March and April 2020 led to a national lockdown and elective surgery restrictions. The aim of this population-based study was to quantify the early impact of COVID-19 on ophthalmic surgery in Australia, comparing surgical service rates in 2019 and 2020. Methods : Retrospective analysis of the number of ophthalmic surgical services in 2019 and 2020 in all Australian States and Territories, as recorded by Medicare (Australian Government-funded universal health insurance scheme subsidising healthcare costs for Australian residents). Monthly surgical service rates were calculated and Poisson regression was used to compare the change in service rates between months. Results : Between March and April 2020, surgical service rates decreased for: cataract surgery (by 71%, 95% CI: 70-72%), cataract surgery with minimally invasive glaucoma surgical device insertion (by 71%, 95% CI: 65-75%), pterygium removal (by 67%, 95% CI: 60- 72%), corneal transplantation (by 31%, 95% CI: 9-48%), and collagen crosslinking for corneal ectasias (by 35%, 95% CI: 18-48%). Comparatively, service rates for these surgeries did not differ or decreased less between March and April 2019. Interestingly, glaucoma filtration surgery rates decreased between March and April in 2020 (by 44%, 95% CI: 29- 56%) and also in 2019 (by 45%, 95% CI: 31-55%), whilst retinal detachment surgery rates were unchanged between these months in 2020 (crude decrease 9%, 95% CI: -28 to 16%) and 2019 (crude decrease 11%, 95% CI: -26 to 9%). Conclusions : Despite relatively low rates of COVID-19 community transmission in Australia in 2020, ophthalmic surgical service rates decreased during months in lockdown and with restrictions, largely for non-time-critical conditions. These data may have health planning implications as the pandemic continues, with future lockdowns and restrictions possible, especially as COVID-19 variants emerge.

Trends in California ophthalmology surgical volume during the COVID pandemic

Purpose : Pandemic era restrictions on non-essential travel, redistribution of healthcare resources, and nursing shortages have impacted the ability of ophthalmologists to deliver care. California had among the strictest 2020 restrictions during the pandemic with reallocation of non-essential surgical resources. This study assesses changes in surgical volume of common ophthalmic procedures in California since the COVID-pandemic. Methods : The California Health and Human Services Agency (Office of Statewide Health Planning & Development) maintains ambulatory and emergency room procedural databases. Common ophthalmic procedures and surgical volumes were extracted for 29 CPT codes from 2014-2020. Procedures with fewer than 100 cases were excluded. Results : Overall, ophthalmology surgical volume decreased by 19% from 2019 to 2020. Greatest declines were for anterior lamellar corneal transplant (39%) and pterygium with graft (38%). Simple cataract surgeries declined by 29% in 2020, compared to an average annual decline of 3% from 2014-2019. Volume increased only for two surgeries: aqueous shunt with graft (2%) and complex retinal detachment (0.2%). Temporal artery biopsies, historically stable with 0.2% average change from 2014-2019, declined by 28% in 2020. Retinal detachment repairs declined by 20% and 17% (with and without vitrectomy, respectively). In comparison, laparoscopic appendectomy only declined by 2% in 2020. Limitations of this study include role of population changes and changes in annual coding practices. Conclusions : COVID era declines were noted across almost all ophthalmic surgeries with steep drops in perceived non-urgent procedures such as pterygium and cataract. However, delays in cataracts and other conditions can result in increased disease burden and morbidity for patients. Uniquely, tube shunt procedures increased, perhaps due to progression of glaucoma from delayed routine care. For vision-preserving surgeries such as retinal detachment repair, lack of accessible care during the pandemic is especially concerning.

Predicted backlog in ophthalmic surgeries associated with COVID-19 pandemic in Ontario: a time series modelling analysis

Purpose : Health systems' responses to the coronavirus disease 2019 (COVID-19) pandemic created a surgical backlog of unknown size, limiting the ability to develop strategies to effectively address the backlog. We assessed the volume of deferred ophthalmic surgeries associated with the COVID-19 pandemic from March-December 2020 and suggested strategies and duration to clear the backlog in Ontario, Canada. Methods : Ontario Health Insurance Plan physician billing data from 2017-2020 were analyzed. The ophthalmic surgical backlog associated with the pandemic was estimated using time series forecasting models on training set (115 weeks), validation set (52 weeks) and forecasting set (42 weeks). Clearance time was calculated based on the queuing theory using various scenarios. Results : In 2020, there were 5.13 million ophthalmologist services, a reduction of 22% compared to the 6.60 million services in 2019. This included a 27% decrease in ophthalmic surgeries that require the use of operating rooms (OR) and a 6% decrease in anti-VEGF (vascular endothelial growth factor) injections (a common procedure for macular degeneration) that can be done in clinics. From March 16 to December 31, 2020 (a pandemic period), the estimated backlog in ophthalmic surgeries requiring an OR was 92,150 surgeries (95% prediction interval [PI] 71,288-112,841), increasing on average by 2,194 surgeries per week. Roughly 90% of the delayed surgeries were cataract surgeries and 4% were retinal detachment surgeries. Nearly half of the provincial backlog (48%, 44,542/92,150) involved patients from the West health region. Estimated provincial clearance time was 248 weeks (95% confidence interval [CI] 235-260) and 128 weeks (95% CI 121-134) if 10% and 20% of OR surgical capacity per week were added, respectively, based on the weekly ophthalmic surgical volume in 2019. Furthermore, an estimated 23,755 (95% PI 14,656-32,497) anti-VEGF injections were missed. Conclusions : The magnitude of ophthalmic surgical backlog in Ontario in 2020 alone raises serious concerns for meeting the ophthalmic surgical needs of patients. As the pandemic continues the accrued backlog size is likely increasing. Planning and actions are needed urgently to manage the collateral impact of the pandemic on the ophthalmic surgical backlog in Ontario.

Corneal innervation changes after Sars-Cov-2 Infection. An In vivo Confocal Microscopy Study

Purpose : To measure the innervation of the corneal subbasal nerve plexus of Covid-19 patients and compare the results with values of healthy patients. Methods : A prospective, observational study was conducted analyzing 39 eyes of patients who had overcome Covid -19 and 46 eyes of healthy volunteers included as a control group (verified by antibody analysis and negative qPCR result) which underwent in vivo confocal microscopy with Rodstock Cornea Module© attached to Heildelberg HRT3© . Ocular surgery procedures, previous ocular infections or systemic diseases that could cause alteration in corneal innervation were exclusion criteria. At least 5 non overlapping images of each eye were selected and only one eye of each patient was included in the study. Following sub basal nervous plexus parameters were measured with ACC Metrics © software: Corneal Nerve Fiber Density (CNFD), Corneal Nerve Branch Density (CNBD), Corneal Nerve Fiber Length (CNFL), Corneal Total Branch Density (CTBD), Corneal Nerve Fiber Area (CNFA), Corneal Nerve Fractal Dimension (CNFrD). Data analysis was performed with SPSS® software for Windows 22.0 (SPSS® Inc, Chicago, IL.). The differences of age and sex between groups were checked with T-test and chi-square tests. The normality of the sample was checked with the Shapiro-Wilk test and the results were compared with the T test or the Man-Whitney U test based on the distribution of the data. The differences were considered statistically significant for p<0.05. Results : There was no difference in the sex distribution between the groups (p= 0.248). The average age (± standard error) was 46.61±17.55 years for Covid-19 patients and 43.11±16.95 years for healthy control group (p=0.353) The mean of the analyzed variables (± standard error) from Covid-19 patients versus control group were CNFD: 16.09±6.92 and 23.03±8.31 fibers/mm2 (p=0,00008), CNBD: 21.93±15.37 and 28.93±17.84 branches/mm2 (p=0.064), CNFL: 11.61±3.61 and 14.05±3.71 mm/mm2 (p=0.002), CTBD: 38.48±20.02 and 43.29 ± 23.94 (p=0.41), CNFA: 0.0057±0.0017 and 0.006±0.0023 mm2 /mm2 (p=0.853), CNFrD: 1.46±0.041 and 1.47±0.037 (p=0.007). Conclusions : According to the data obtained, corneal subbasal nerve plexus is decreased in Covid-19 patients compared to the healthy control group, statistically significant for density, length, and fractal dimension. The results show the presence of possible small fiber neuropathy induced by Covid-19 disease.

Impact of COVID-19 on surgical specialist training as quantified by trainee complication rates for cataract surgery

Background: Reduction in elective surgeries during the COVID-19 pandemic has negatively impacted surgical specialist training. Posterior capsule rupture rate (PCR), a complication of cataract surgery, is an objective measure of the quality of ophthalmic surgery. This study aimed to compare PCR pre- and post-COVID-19 in trainees and consultants. Methods: A single-centre consecutive case series of cataract surgeries performed at Groote Schuur Hospital, between 1 February 2017 and 31 May 2021 were analysed. Our main outcome measure was the effect of the volume of cataract surgeries on PCRs between ophthalmology trainees and consultants before and after the COVID-19 reduction in elective surgeries on 23 March 2020. Results: During the study period, 4 157 cataract surgeries were performed (3 493 in the 38 months pre-COVID-19 and 664 in the 14 months post-COVID-19). Fourteen ophthalmology trainees and six consultants performed 2 919 and 1 238 cataract surgeries, respectively. In the trainees the PCR was 4.4% pre-COVID-19 and 10.0% post COVID-19 (odds ratio [OR] 2.44;p < 0.001;CI 1.71–3.47;relative risk [RR] 2.29). The PCR of consultants remained unchanged with a PCR of 3.4% pre- and post-COVID-19 (OR 1.02;p = 0.97;CI 0.42–2.46;RR 1.02). Conclusion: COVID-19 has caused a marked reduction in the volume of cataract surgery which has resulted in a deterioration in the performance of trainees, but not consultants, and quantifies the negative impact of the pandemic on surgical training in ophthalmology. This highlights the need to develop plans to improve surgical training during the COVID-19 recovery period.

Patient Impact and Economic Burden of Waiting for Cataract Surgery in Canada: A Targeted Literature Review

Objectives: To collate and review published evidence to assess patient impact and economic burden of cataract surgery wait times in Canada. Methods: A targeted literature search was conducted using PubMed from January 1, 2007–December 10, 2021, and supplemented by grey literature search. Included studies were those reporting Canada-specific data. Results: Overall, six publications were included. All 6 reported patient impact related to waiting for cataract surgery in Canada, including decline in visual acuity(n=4);greater risk of falls(n=4), motor vehicle accidents(n=3), and depression(n=3);reduced quality life(n=3);interference with treating other eye diseases such as glaucoma, diabetic retinopathy, and AMD(n=1);permanent disability(n=1);and even increased risk of death(n=1). Eye Physicians and Surgeons of Ontario (2018) also highlighted challenges recent ophthalmology graduates face to secure operating room time. This can potentially lead to a lack of surgical competency resulting in more complications, greater incidence of unsuccessful surgeries, decline in ophthalmologists able to perform cataract surgery, and ultimately longer wait times. Canadian Council of the Blind reported an estimated 143,000 necessary eye surgeries missed or delayed in 2020 due to COVID-19, resulting in increased risk of vision loss (vision loss costing $27,251/person/year). It’s also projected from 2021 to 2023, costs of vision loss due to additional wait times of ophthalmic surgeries (most specifically cataract surgery) will be $520.2 million annually in Canada;owing 85% of these costs to loss of well-being ($442.2 million/year) and the remainder to direct healthcare system costs ($78 million/year). Further, average costs incurred by someone with vision loss until they receive surgery is $54/day. Conclusions: Increased cataract surgery wait times in Canada has negative implications, including worse patient outcomes and increased patient and healthcare system costs. There remains an urgent need to reduce wait times to ensure timely treatment access for individuals undergoing cataract surgery in Canada.

Robots in healthcare: now and in the future

Purpose Robotic systems are increasingly applied in healthcare (HC) but are confined to heavy load tasks (e.g. within a hybrid OR), are used for undemanding services (e.g. transport and supply) or as master-slave systems aim at increasing the precision of interventional procedures. Only minor they have become substitutes of medical personnel, only minor they have improved the quality of health care delivery and only minor they have truly been integrated in our clinics. The future health system is facing some critical problems, with the shortage of personnel and the maintenance of the quality of care being first in line. Robots offer quite attractive features to cover with these problems but need to be designed accordingly, have to provide autonomous tasks and have to become full team members. The article aims at the identification of weak points of the health care system and how robots can be used to shape its future. Methods The results and thoughts presented herein do originate from expert discussions and studies of the available literature, but do also originate from experiences made in course in daily practice. Also, aspects which were elaborated during the work on the patient hub concept [1] and have been debated in panel discussion on the OR of the future and on robots in healthcare are included. Still, the presented theses are speculative and visionary and thus cannot be based on a fully scientific background. Results Personnel shortage The most pressing challenge we are facing for the healthcare system is the shortage of personal, which became even more obvious during the COVID-19 pandemia. As it foreseeable, that we will not be able to replace missing workers by human personnel, care delivery must become les human depending and missing work craft has to be replaced by autonomous systems. Autonomous robotic systems represent a core technology in this respect and can help to take over simple and repetitive tasks, e.g. for the handling of medical goods, for bedding and mobilizing patients and rehabilitation. Climate change The HC system will also be affected by the warming of the atmosphere, as it is responsible for almost 5% of CO2 emissions. Transport and delivery of medical goods in this regard are the main contributors and could be optimized by reducing the rate of single-use devices and scaling down supply chains. Increasing the in-hospital sterilization capacities and implementing local fabrication facilities of medical devices might offer a solution here, however, would require human resources. Robots again can play a decisive role here and become an enabling technology, e.g. during the reprocessing of sterile goods and for 3D printing based manufacturing lines. Demographic change The aging of the population is becoming a relevant burden for society due to the increasing number of disabled people and people in need of care. Since families and the HC system cannot cope with this development, solutions must be found that support the independence and self-subsistence of the elderly. Care robots, mechatronic extraskeletons and smart assistive technologies for the home are key elements for caring for elderly people in a way that is gentle on staff and can also help to maintain their quality of life. Specialization and precision medicine The healthcare system is driven by striving for improved quality of service and precision medicine. Currently available systems, mainly master-slave devices have failed in contributing here as no superiority has been shown for robotic assisted surgeries so far. Nevertheless, robots are the most powerful solution for further reducing the access trauma, for miniaturizing devices and for the realization for autonomous capabilities by coupling with smart imaging solutions. As it was demonstrated with OCT-based microrobotic solutions for eye surgery, comparable solutions might be a driving technology for example for endovascular surgeries, brain surgery and endoscopic interventions. While surgeons become more and more specialized which maks their individual performance of high va ue assistive systems to take over less-demanding tasks (e.g. skin suturing, retraction, suction) could become a meaningful and resource-sparing aid and once again could be realized by robotic solutions. Multi-drug resistance and isolation As observed by patients suffering from multi-drug resistance even before the current pandemia an increasing number of patients are requiring isolated care. The isolated care is not only demanding in terms of personnel, but also produces enormous amounts of waste, which have a negative effect on CO2 emissions. Robots again offer here a valuable solution as they can remain in an isolated environment, as they can be disinfected which makes additional protective measures unnecessary and as they strictly follow to standard operative procedures thereby reducing the risk of unintended contamination. Conclusion Solutions to overcome the pending, or already present challenges in the HC system are urgently required and must provide autonomic functionalities to save personnel, have to reduce the amount of waste and HC related traffic to lower the Co2 emission and should enable us to develop smarter and less invasive approaches for the treatment of an increasing number of sick and care-depending patients. Numerous robotic solutions to cope with this problems have already been introduced [2], but need to be further adapted according to these requirements and fully integrated into a cooperative environment. The alignment between human and robotic tasks and the maintenance of ethical and legal aspects still have to be taken as unsolved problems for the further involvement of robots, however when solved could open up the basis for a highly efficient patient centred HC system.

Highlights from this issue

Economic, clinical and social impact of simple limbal epithelial transplantation for limbal stem cell deficiency (see page 923) A comprehensive literature survey, questionnaire-based survey and economic analysis indicates that simple limbal epithelial transplantation is a better alternative to cultivated limbal epithelial transplantation in terms of anatomical success, cost and accessibility. Association between body mass index and diabetic retinopathy in Asians: the Asian eye epidemiology Consortium (AEEC) study (see page 980) In a pooled analysis including 10 010 Asian adults with diabetes from 12 cross-sectional studies across six Asian countries, obesity was inversely associated with both any diabetic retinopathy and vision-threatening diabetic retinopathy, independent of potential risk factors. Efficacy of a novel personalised aflibercept monotherapy regimen based on polypoidal lesion closure in participants with polypoidal choroidal vasculopathy (see page 987) We report the results of a novel personalised anti-vascular endothelial growth factor monotherapy regimen for the management of polypoidal choroidal vasculopathy which achieves comparable outcomes to a fixed 8-weekly regimen and high polypoidal lesion closure rate.

Personalised model to predict keratoconus progression from demographic, topographic and genetic data

*Correspondence – Olivia Li: o.li@nhs.netTo generate a personalised prognostic model to predict keratoconus progression to corneal collagen cross-linking (CXL).Methods and AnalysisIn this retrospective cohort study, we recruited 5,025 patients (9,341 eyes) with early keratoconus between January 2011 and November 2020. Genetic data from 926 patients was available. We evaluated both change in keratometry or CXL as indices of progression and used the Royston-Parmar method on the proportional hazards scale to generate a prognostic model. We calculated hazard ratios (HR) for each significant covariate, with explained variation and discrimination.ResultsAfter exclusions, model-fitting comprised 8,701 eyes, of which 3,232 underwent CXL. For early keratoconus CXL provided a more robust prognostic model than keratometric progression. The final model explains 33% of the variation in time-to-event age HR [95% confidence limits] 0.9 [0.90–0.91], maximum anterior keratometry (Kmax) 1.08 [1.07–1.09], and minimum corneal thickness 0.95 [0.93–0.96] as significant covariates. Single nucleotide polymorphisms (SNPs) associated with keratoconus (n=28) did not significantly contribute to the model. The predicted time-to-event curves closely followed the observed curves during internal-external validation.ConclusionsA prognostic model to predict keratoconus progression could aid patient empowerment, triage and service provision. Age at presentation is the most significant predictor of progression risk. Candidate SNPs associated with keratoconus do not contribute to progression risk.

Nasopharyngeal COVID-19 Testing – Simple as ABC(SF Leak)?

Introduction: Routine nasopharyngeal swabbing for Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) testing for SARS-COV-2 (COVID-19) has become the recommended test for safely delivering both emergency and elective patient care. To date over 256 million tests have been conducted in the UK. Whilst the advantages of routine COVID-19 swabbing are evident, it is important to acknowledge the associated common complications as well as unusual ones such as a Cerebrospinal Fluid (CSF) Leak. Methods: We report a case of a 69-year-old female who underwent nasopharyngeal swabbing in preparation for routine elective surgery. At the 8-week follow up the patient complained of a runny nose, which was positive for Beta-2 Transferring thus confirming a CSF leak. The likely area of concern for the CSF leak was in the region of the left fovea ethmoidalis where the bone was extremely thin with a solitary fluid filled air cell. The patient did later report right eye surgery 2 years previously which resulted in postoperative ethmoidal sinusitis managed with antimicrobials. This may have predisposed her to the CSF leak. Results: Nasal swabbing has been shown to be the cause of a CSF leak in a handful of cases, only four thus far have been reported in the literature. This rare but important complication has a significant morbidity with risk of meningitis reaching 19 % in some reports. Conclusions: It is the author's intention to raise awareness of CSF leak as a potential complication of COVID19 Swabbing to ensure these are recognised promptly and managed in a timely manner.

Patient Experiences and Insights on Chronic Ocular Pain from a Social Media Listening Study

Objective: To identify the perceived causes for chronic ocular pain (COP) (≥3 months pain duration), its impact on quality of life (QoL) and understand the patient journey from social media posts. Methods: In this retrospective study, publicly available social media conversations were identified from searches triaged by a combination of automated relevancy keyword algorithm and manual review, and subsequently analyzed post anonymizing for COP content. Twitter, forums, and other (Facebook, Blogs, etc.) platforms were leveraged for the time period February 2020 to February 2021. Results: A total of 464 (UK=208, US=175, Canada=65 and Australia=16) patient/caregiver conversations on COP were identified. Top discussion points were symptoms (62%) and causes of COP (58%). Ocular factors (including dry eye disease, thyroid/Graves’ disease, and ocular surgeries) contributed to ∼46% of causes identified, while non-ocular factors (including migraine, COVID, and side-effects/withdrawal of medications) contributed to ∼54%. The most commonly mentioned symptoms (555) were headache/head pressures (96), dry/gritty eyes (67), light sensitivity (34), insomnia (29), and redness/pink eyes (28). Symptoms impacted all aspects of patients’ QoL: physical day-to-day activities such as reading, driving, and sleeping;emotional wellbeing such as depression/hopelessness, frustration/anger, fear, and suicidal thoughts;functional wellbeing such as difficulty at work/study place, reduced productivity or having to quit their job;social impacts such as being irritated around people, and having a less active social life. Eye drops (58/140 mentions) are the most commonly mentioned treatment option. Common coping strategies mentioned were blue-light filter glasses/eyeglasses (17), and hot compresses (11). Key unmet needs mentioned by patients were failed, improper, delayed diagnosis (62), and lack of effective treatments or appropriate management (30). Conclusion: Insights from this study reported patients’ experiences, concerns, and the adverse impact on overall QoL. The results can help in better understanding the patients’ perspective, which can be considered during drug development.

Negative pressure drainage relieves respiratory discomfort for patients with medical face masks under ocular surgeries during COVID-19

AIM: To report our precaution practices for ocular surgeries under local anesthesia during COVID-19 outbreak and evaluate the respiration situation among the patients with medical face masks under ocular surgeries. METHODS: Sixty Chinese patients needed eye surgery treatment were recruited and given medical face masks as one of the COVID-19 precaution practices during eye surgery with local anesthesia. Oxygen supplementation and negative pressure drainage were applied to relieve the potential respiratory discomfort, and the respiratory comfort score was evaluated. RESULTS: Patients with medical face masks experienced mild to moderate respiratory discomfort with an overall mean score of 2.34±0.73. Supplementation of oxygen together with negative pressure drainage relieved this discomfort (overall mean score of 0.15±0.75;P<0.001). There is no gender and operation time difference on respiratory discomfort or discomfort relieve. Failure in negative pressure drainage led to severe respiratory discomfort. CONCLUSION: Negative pressure drainage could maintain the respiratory circulation in patients with medical face mask under eye surgery with local anesthesia. Application of medical face masks in patients under surgeries is recommended to protect the medical practitioners during the operations within COVID-19 outbreak. Copyright 2021 by the IJO Press.