Cataract Surgery Trends during Lockdown and Unlocking Periods of COVID-19 Pandemic: A Cross-sectional Hospital-based Study

Introduction: Coronavirus Disease-2019 (COVID-19) has affected healthcare access to population around the world. India also had its own set of problems for patients with disruption of healthcare services during the pandemic. This also brought in unique challenges for ophthalmologists who adapted to new challenges to provide quality care to the patients including those reporting for cataract surgery. Aim: To find out cataract surgery trends and demographic variables during lockdown and unlocking periods of COVID-19 pandemic. Materials and Methods: This cross-sectional hospital-based study was conducted at Ophthalmology department of a tertiary care centre in eastern India, from January 2020 to March 2022. Trends of cataract surgery including numbers, demographic factors, visual acuity at presentation, difference during first and second lock and unlock periods etc were compared during various lock and unlock period over more than two years. Results: A total of 3,843 patients were planned for surgery and 3,594 patients underwent cataract surgery. A total of 218 patients reported being positive for COVID-19 preoperatively and voluntarily dropped out from surgery. A total of 24 patients were found to be positive during preoperative Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) workup and were excluded from surgery. Seven patients didn't report for the surgery. A total of 59 patients reported febrile illness during one month postoperative period. There was dip in cataract surgery during lockdown periods (from 178.33 every month in pre COVID-19 period to near zero during first lockdown period) but recovery was much faster during second unlock period compared to first unlock period. Conclusion: The study concludes that there was drastic decrease in number of patients undergoing cataract surgery during COVID-19 pandemic. Predominantly young, male patients who had advanced morphology of cataracts with poor visual acuity accessed healthcare set-up for cataract surgery during initial lock and unlock period. Similar trend was seen during second lock and unlock period with rapid recovery of numbers and demography of cataract surgery patients to pre-COVID-19 levels. [ FROM AUTHOR] Copyright of Journal of Clinical & Diagnostic Research is the property of JCDR Research & Publications Private Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Impact on corneal morphology after cataract surgery with intracameral moxifloxacin in neglected hard cataracts.

AIM: To evaluate corneal morphology after use of 0.5% intracameral moxifloxacin (ICM) in cataract surgery in patients who presented late with hard cataracts. METHODS: Cross-sectional study conducted from June-2021 to December-2021 at a tertiary eye-care center. 90 patients over 60 years with high-risk characteristics for Covid-19, who presented late with higher grades of nuclear-sclerosis (NS), were included. They underwent phacoemulsification and 0.5%moxifloxacin (0.1 ml) was injected intracamerally at the end of surgery. Best-corrected visual acuity (BCVA), intraocular pressures (IOP), endothelial cell density (ECD), coefficient of variation in cell-area (CoV), hexagonality (Hex) and central corneal thickness (CCT) were measured preoperatively and postoperatively on day1, day7 and day30. Statistical analysis was done by Anova test. p-value<0.05 was considered significant. RESULTS: Mean age of presentation was 65.26±8.3 years. Mean preoperative BCVA (1/60-to-6/60), IOP (16.7±2.3 mm of Hg), CCT (523.93±39.6µ), ECD (2547±302.08cells/mm2), Hex (47.04±5.7%) and CoV (37.57±3.9) changed to BCVA (6/9-to-6/6), IOP (17.5±2.1 mm of Hg), CCT (538.42±36.9µ), ECD (2388.40±339.25cells/mm2), Hex (44.44±5.6%) and CoV (39.09±4.5) at day30 postoperative. Average rate of change at day30 was increase in CCT (2.89%), ECD loss (6.4%), decrease in Hex (4.9%) and increase in CoV (4.6%), though clinically insignificant. No case of endophthalmitis or toxic-anterior segment syndrome seen. CONCLUSION: 0.5% moxifloxacin (0.1 ml) is safe as intracameral antibiotic to prevent postoperative infection in high-risk patients. The reported changes in the corneal parameters were within the range of any routine surgeries of hard senile cataracts. No specific effect could be attributed to ICM.

US National Trends in Ophthalmic Procedures During the COVID-19 Pandemic

Purpose : To evaluate the relationship between COVID-19 case volume and ophthalmic procedural volume during the pandemic. Methods : A retrospective cohort study using TriNetX (Cambridge, MA, USA), a federated electronic health records research network comprising multiple large health organizations in the United States. Monthly Current Procedural Terminology (CPT)- specific volumes per HCO were clustered chronologically to calculate average volumes into three-month seasons to calculate average volumes. Seasonal averages from a combination of 2018 and 2019 data were used to provide a baseline comparison to pre-pandemic procedural volume. An aggregate of the total pandemic period (March 2020-August 2021) was compared to the corresponding figures in pre-pandemic timeframes. Results : 670,541 unique ophthalmic procedures from among 573 HCOs between March 2018 and August 2021 were included. Intravitreal injections was the most prevalent procedure with 320,106 occurrences. Phacoemulsification cataract surgery was the second most prevalent (N = 176,095) procedure with 144,816 uncomplicated (82.2%) and 31,279 complicated (17.8%). Intravitreal injections had the highest mean seasonal volume per HCO for each of the five COVID-19 pandemic seasons. From March 2020-August 2021, a mean pandemic volume of 266.7 (SD = 15) was observed, a 5% decrease (p<0.05) in procedures compared to pre-pandemic mean of 280.8 (SD = 26.1). During the five COVID-19 pandemic seasons, the seasonal mean volume almost always differed from pre-pandemic comparisons. Spring 2020 exhibited the sharpest seasonal decrease in procedural volume (88%). Spring 2021 had the largest count of significant increase in procedure volume (18%). Aggregate mean volume per HCO showed significant decreases for 11 out of 17 procedures in the 12-month March 2020-February 2021 timeframe and significant decreases for 10/17 procedures over the 18-month March 2020-August 2021 timeframe. A relative inverse relationship between COVID-19 case volume and ophthalmic procedure volume was observed. Conclusions : This study highlights the relative inverse relationship between COVID-19 cases and ophthalmic procedure volume in the US. Reduction in procedural volume may result in delayed care with potential for vision loss. Awareness and understanding of these trends could help ophthalmologists prepare should a similar cycle occur in the setting of the omicron and future variants.

Suprachoroidal hemorrhage during phacoemulsification surgery associated with recent COVID-19: A report of two cases.

To report two cases of suprachoroidal hemorrhage during otherwise uncomplicated phacoemulsification, in whom COVID-19 was documented with a positive PCR test about 1 month before the surgery and the importance of postponing elective surgeries for several months after infection.

Micro-pulse Transscleral Laser Therapy and ‘Topical-plus’ Anaesthesia: Ideal for Glaucoma Management During COVID-19

Micro-pulse transscleral laser therapy (MP-TLT) is a non-invasive laser procedure for the treatment of glaucoma, and was introduced in 2015. The aim of the procedure is to achieve a reduction in intraocular pressure while minimizing collateral tissue damage. The favourable risk profile of this non-cyclodestructive procedure makes it applicable to a broad spectrum of glaucoma cases, including patients with good central vision, and does not limit its usability to late-stage refractive cases. In 2019, a revised delivery device simplified the procedure, and more recently, a ‘topical-plus’ anaesthesia protocol has been introduced. The revised delivery system and topical-plus protocol reinforce the utility of MP-TLT as a practical treatment option in an office setting or procedure room, with minimal patient discomfort during and after treatment. Additionally, with minimal follow-up requirements, MP-TLT is ideal for glaucoma management during COVID-19 social restrictions. The following article provides an overview of the use of MP-TLT under topical anaesthesia (topicalplus), the potential role of MP-TLT in the glaucoma treatment algorithm during the COVID-19 pandemic, and the advantages of the revised MicroPulse P3® probe (IRIDEX Corporation, Mountain View, CA, USA).

Changing trend in the morphology of cataracts at a tertiary eye care centre in South India due to COVID-19-pandemic related national lockdown.

Purpose: To study the changing trends in the morphology of cataracts at a tertiary eye care center in South India due to COVID-19 pandemic-related national lockdown. Methods: A retrospective study conducted at a tertiary eye care center in Andhra Pradesh state of South India, which included 1724 patients (1753 eyes) who underwent cataract surgery at our center during April 2019-July 2019 (1298 eyes of 1271 patients) and April 2020-July 2020 (455 eyes of 453 patients). Factors studied included preoperative lens status, associated phacodonesis or subluxation, pupil size, other eye lens status, associated retinal problems, glaucoma, and complications during surgery. Postoperative uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), corneal clarity, intraocular pressure (IOP), and disc status at postoperative day 1, 1 week, and 1-month visits were compared. Results: A significantly lower proportion of nuclear sclerosis (decreased from 83.2% in last year before lockdown to 55.2% during lockdown) and significantly higher proportions of mature, brown, or black cataract and phacomorphic, phacolytic, or Morgagnian cataract (increased from 15.5% in last year before lockdown to 43.8% during lockdown) were observed. The proportion of small-incision cataract surgery decreased significantly (from 63.2% to 57.4%), whereas the proportion of phacoemulsification increased significantly (from 35.9% to 41.5%) during lockdown as compared to last year. A significantly higher proportion of eyes with small pupils and association with retinal pathology were also observed during the lockdown. Conclusion: During the national lockdown, there was a shift from nuclear sclerosis grade toward mature, brown, black grade of cataracts. In addition, the proportion of small-incision cataract surgery decreased significantly whereas the proportion of phacoemulsification increased significantly during the lockdown. More number of cataracts with small pupils and associated retinal pathology were observed during the lockdown.

A simple do-it-yourself model of phacoemulsification for resident training.

COVID-19 has immensely affected the training of ophthalmology residents; wet-lab training thus becomes of utmost importance. A simple cost-effective model for cataract surgery training of residents becomes the need of this hour. Hence, we aim to describe a new 'Do It Yourself' model with easily available material for beginners.

Preoperative COVID-19 Testing for Elective Ophthalmological Procedure in a Tertiary Health Care Centre: Our Experience During the Pandemic.

BACKGROUND: To study the prevalence of coronavirus infection among asymptomatic patients requiring eye surgery and the role of screening in prevention of spread of infection among the healthcare workers. DESIGN: The prospective observational study was conducted in the Ophthalmology department of a tertiary care center in Delhi from September 2020 to December 2020. SETTING: Patients requiring elective ophthalmological procedures in a tertiary care hospital were screened for coronavirus using the RT-PCR method. Testing methods and results were documented. RESULTS: Among the 218 asymptomatic patients posted for elective surgery in that period, 16 (7.3%) were found to be positive for COVID-19. Those who tested positive were advised home isolation and surgery was postponed for the next 14 days. No complications were reported in these patients. One health-care worker also tested positive for COVID-19 during our study period. CONCLUSION: In our study, 1 out of 14 asymptomatic patients were found to be carriers for the novel virus. Asymptomatic COVID-infected patients may lead to transmission of the virus inside the hospital among the visiting patients and hospital staff while they have no adverse effect on the surgery and its outcome.

Restarting cataract surgery during the COVID-19 pandemic; a prospective study analysing 30 day outcomes after elective cataract surgery in the United Kingdom.

BACKGROUND: Cataract is a significant cause of preventable blindness in the United Kingdom and worldwide. Prior to the COVID-19 pandemic, cataract surgery was the most commonly performed operation by the National Health Service in the United Kingdom. The aim of this study is to evaluate the safety of elective cataract surgery performed in the United Kingdom in a COVID-19 free hospital during the COVID-19 pandemic. METHODS: Single centre prospective observational cohort study of consecutive patients undergoing elective cataract surgery in the United Kingdom over a 3 month period from May to August 2020. Electronic medical records were reviewed and patients were contacted at 30 days post-operatively. Data collection included symptoms suggestive of COVID-19 infection, hospital admission, mortality, intra-operative and post-operative surgical complications. RESULTS: A total of 649 elective cataract surgeries were performed. Two patients (0.3%) developed worsening dyspnoea during the 30 day post-operative period, but tested negative for COVID-19 infection. Three patients (0.5%) were hospitalised, unrelated to COVID-19 infection, of which one patient (0.2%) passed. Four patients (0.6%) suffered posterior capsular rupture. 601 (93.2%) had no post-operative complications. CONCLUSION: This study demonstrates a safe model for the resumption of elective cataract surgery during the COVID-19 pandemic, providing strict infection control measures are in place.

Effect of COVID-19-related lockdown on ophthalmic practice in Italy: A report from 39 institutional centers.

BACKGROUND/OBJECTIVES: To compare the number of eye surgical procedures performed in Italy in the 2 months following the beginning of lockdown (study period) because of COVID-19 epidemic with those performed in the two earlier months of the same year (intra-year control) and in the period of 2019 corresponding to the lockdown (inter-year control). METHODS: Retrospective analysis of surgical procedures carried out at 39 Academic hospitals. A distinction was made between elective and urgent procedures. Intravitreal injections were also considered. Percentages for all surgical procedures and incidence rate ratios (IRR) for rhegmatogenous retinal detachment (RRD) events were calculated. A p value <0.05 was considered significant. RESULTS: A total of 20,886 versus 55,259 and 56,640 patients underwent surgery during the lockdown versus intra-and inter-year control periods, respectively. During the lockdown, only 70% of patients for whom an operation/intravitreal injection was recommended, finally underwent surgery; the remaining patients did not attend because afraid of getting infected at the hospital (23%), taking public transportation (6.5%), or unavailable swabs (0.5%). Elective surgeries were reduced by 96.2% and 96.4%, urgent surgeries by 49.7% and 50.2%, and intravitreal injections by 48.5% and 48.6% in the lockdown period in comparison to intra-year and inter-year control periods, respectively. IRRs for RRDs during lockdown dropped significantly in comparison with intra- and inter-year control periods (CI: 0.65-0.80 and 0.61-0.75, respectively, p < 0.001 for both). CONCLUSION: This study provides a quantitative analysis of the reduction of eye surgical procedures performed in Italy because of the COVID-19 epidemic.

Aerosolization and Fluid Spillage During Phacoemulsification in Human Subjects.

BACKGROUND: Concerns had been raised for the potential hazard of SARS-CoV-2 transmissions via aerosols and fluid droplets during cataract surgeries amid the COVID-19 pandemic. This study aims to evaluate the rate of visible aerosol generation and fluid spillage from surgical wounds during phacoemulsification in human subjects. METHODS: This is a prospective consecutive interventional case series. High-resolution video captures of 30 consecutive uncomplicated phacoemulsification surgeries, performed by 3 board-certified specialists in ophthalmology, were assessed by 2 independent and masked investigators for intraoperative aerosolization and fluid spillage. Water-contact indicator tape was mounted on the base of the operating microscope, around the objective lens, to detect any fluid contact. RESULTS: No visible intraoperative aerosolization was detected in any of the cases, irrespective of different surgical practices among the surgeons with regard to wound size and position, lens fragmentation technique, power settings and means of ocular lubrication, or the different densities of cataract encountered. Large droplets spillage was noted from the paracentesis wounds in 70% of the cases. For all cases where fluid spill was detected on video, there was no fluid contact detected on the water-contact indicator tape. CONCLUSION: Visible aerosolization was not detected during phacoemulsification in our case series. Although the rate of fluid spillage was high, the lack of detectable contact with the indicator tape suggested that these large droplets posed no significant infectious risks to members of the surgical team.

Rethinking Elective Cataract Surgery Diagnostics, Assessments, and Tools after the COVID-19 Pandemic Experience and Beyond: Insights from the EUROCOVCAT Group.

The progressive deterioration of the visual function in patients on waiting lists for cataract surgery has a negative impact on their quality of life, especially in the elderly population. Patient waiting times for cataract surgeries in many healthcare settings have increased recently due to the prolonged stop or slowdown of elective cataract surgery as a result of coronavirus disease 19 (COVID-19). The aim of this review is to highlight the impact of such a "de-prioritization" of cataract surgery and to summarize some critical issues and useful hints on how to reorganize cataract pathways, with a special focus on perioperative diagnostic tools during the recovery phase and beyond. The experiences of a group of surgeons originating from nine different countries, named the European COVID-19 Cataract Group (EUROCOVCAT), have been combined with the literature and recommendations from scientific ophthalmic societies and healthcare institutions. Key considerations for elective cataract surgery should include the reduction of the number of unnecessary visits and examinations, adoption of precautionary measures, and implementation of telemedicine instruments. New strategies should be adopted to provide an adequate level of assistance and to guarantee safety conditions. Flexibility will be the watchword and regular updates would be necessary following scientific insights and the development of the pandemic.

Decoding fluid droplet generation during phacoemulsification and pars plana procedures in the COVID-19 era-An experimental study.

PURPOSE: The purpose of this study is to evaluate fluid droplet spray generation during phacoemulsification (PE), pars plana vitrectomy (PPV), and fragmatome lensectomy (FL) and assess factors affecting these. METHODS: This is an experimental study. PE through 2.2 and 2.8 mm incisions was performed in six goat eyes and four simulator eyes using both continuous and interrupted ultrasound (U/S). PPV and FL were performed in three goat eyes. Generation of visible fluid droplet spray was analyzed from video recordings through the microscope camera and an external digital camera. Hydroxypropylmethylcellulose (HPMC) was applied over the incision site during PE and FL. RESULTS: When PE was performed through both incision sizes, there was no visible fluid droplet spray if the phaco tip was centered in the incision, without sleeve compression. When there was phaco tip movement with the phaco sleeve sandwiched between the tip and the incision wall, there was visible fluid droplet spray generation. It was more difficult to induce fluid droplet spray with 2.8 mm incision, and spray was lesser with interrupted U/S. During PPV, there was no droplet spray. During FL, fluid droplet spray was only seen when U/S was delivered with the fragmatome tip close to the sclerotomy. HPMC impeded droplet spray. CONCLUSION: Fluid droplet generation during PE can be minimized to a large extent by keeping the phaco tip centered within the incision, avoiding sleeve compression. Smaller incision and continuous U/S were more prone to droplet generation. FL should be performed away from sclerotomy. HPMC over incision is recommended.

Microdroplet and spatter contamination during phacoemulsification cataract surgery in the era of COVID-19.

IMPORTANCE: Determine phacoemulsification cataract surgery risk in a Covid-19 era. BACKGROUND: SARS-CoV-2 (Covid-19) transmission via microdroplet and aerosol-generating procedures presents risk to medical professionals. As the most common elective surgical procedure performed globally; determining contamination risk from phacoemulsification cataract surgery may guide personal protection equipment use. DESIGN: Pilot study involving phacoemulsification cataract surgery on enucleated porcine eyes by experienced ophthalmologists in an ophthalmic operating theatre. PARTICIPANTS: Two ophthalmic surgical teams. METHODS: Standardized phacoemulsification of porcine eyes by two ophthalmologists accompanied by an assistant. Fluorescein incorporated into phacoemulsification irrigation fluid identifying microdroplets and spatter. Contamination documented using a single-lens reflex camera with a 532 nm narrow bandpass (fluorescein) filter, in-conjunction with a wide-field blue light and flat horizontal laser beam (wavelength 532 nm). Quantitative image analysis using Image-J software. MAIN OUTCOME MEASURES: Microdroplet and spatter contamination from cataract phacoemulsification. RESULTS: With phacoemulsification instruments fully within the eye, spatter contamination was limited to <10 cm. Insertion and removal of the phacoemulsification needle and bimanual irrigation/aspiration, with irrigation active generated spatter on the surgeons' gloves and gown extending to >16 cm below the neckline in surgeon 1 and > 5.5 cm below the neckline of surgeon 2. A small tear in the phacoemulsification irrigation sleeve, presented a worse-case scenario the greatest spatter. No contamination above the surgeons' neckline nor contamination of assistant occurred. CONCLUSIONS AND RELEVANCE: Cataract phacoemulsification generates microdroplets and spatter. Until further studies on SARS-CoV-2 transmission via microdroplets or aerosolisation of ocular fluid are reported, this pilot study only supports standard personal protective equipment.

Effects of the first month of lockdown for COVID-19 in Italy: A preliminary analysis on the eyecare system from six centers.

PURPOSE: To compare the number of eye surgical procedures performed in Italy during the first month of lockdown with those performed in the same period in 2019. METHODS: Review of the surgical procedures performed from 10 March to 9 April 2019 and from 10 March to 9 April 2020 (the first month of lockdown because of the COVID-19 outbreak) at six academic institutional centers of Italy. A distinction was made between urgent procedures: any trauma repairment, trabeculectomy/drainage implant for glaucoma, any operation for rhegmatogenous retinal detachment (RRD) repair, pars plana vitrectomy (PPV) for vitreous hemorrhage (VH), macular hole, or retained lens fragments; elective procedures: corneal transplant, phacoemulsification for cataract extraction, silicone oil removal, and PPV for epiretinal membrane; and intravitreal injections (either anti-vascular endothelial growth factor [VEGF] or dexamethasone) to treat exudative maculopathies. The main outcome measure was the rate of reduction in urgent and elective surgeries performed. RESULTS: Overall, 3624 and 844 surgical procedures were performed from 10 March to 9 April 2019 and from 10 March to 10 April 2020, respectively (-76.7% in 2020 compared to 2019, p < 0.0001). Urgent and elective surgical procedures and intravitreal injections of anti-VEGF drugs or dexamethasone reduced significantly in 2020 in comparison to 2019 (p < 0.0001 for urgent and elective surgeries and 0.01 for intravitreal injections). CONCLUSION: A significant reduction in the rate of urgent and elective surgeries and intravitreal injections was recorded during the first month of lockdown compared to the same period in 2019. With this analysis, the authors hope to provide some preliminary insights about the consequences of lockdown for the eyecare system in Italy.

A new normal with cataract surgery during COVID-19 pandemic.

Cataract is the second leading cause of preventable blindness on the globe. Several programs across the country have been running efficiently to increase the cataract surgical rates and decrease blindness due to cataract. The current COVID-19 pandemic has led to a complete halt of these programs and thus accumulating all the elective cataract procedures. At present with the better understanding of the safety precautions among the health care workers and general population the Government of India (GoI) has given clearance for functioning of eye care facilities. In order to facilitate smooth functioning of every clinic, in this paper, we prepared preferred practice pattern based on consensus discussions between leading ophthalmologists in India including representatives from major governmental and private institutions as well as the All India Ophthalmological Society leadership. These guidelines will be applicable to all practice settings including tertiary institutions, corporate and group practices and individual eye clinics. The guidelines include triage, use of personal protective equipment, precautions to be taken in the OPD and operating room as well for elective cataract screening and surgery. These guidelines have been prepared based on current situation but are expected to evolve over a period of time based on the ongoing pandemic and guidelines from GoI.