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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 59  |  Issue : 1  |  Page : 23-27

A cross-sectional study to assess the knowledge, attitude, and practice toward eyecare among the ophthalmology postgraduates of Karnataka during COVID-19 pandemic


Department of Ophthalmology, KVG Medical College and Hospital, Sullia, Karnataka, India

Date of Submission18-Nov-2020
Date of Acceptance01-Jan-2021
Date of Web Publication27-Mar-2021

Correspondence Address:
Dr. Mahesh Babu
Quarter No B-26, Doctors Apartment, Near IPS School, Kurunjihag, Sullia, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_169_20

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  Abstract 


Aim: The aim of this study is to assess the knowledge, attitude, and practice toward eye care among ophthalmology postgraduate of Karnataka in coronavirus disease 2019 (COVID-19) pandemic. Methods: A self-designed questionnaire was prepared and sent to ophthalmology postgraduates in the various colleges in Karnataka using Google form platform as an online survey. The sample size was calculated to be 100. Results: Out of 100 participants, 80% were female with 84% aged between 26 and 30 years. The rates for correct answer for knowledge about COVID-19 ranged from 60% to 92%. In terms of practice, 65% of them showed good practice. Ninety-four percent of the participants told that COVID-19 has adversely affected their postgraduation training, especially the surgical training. Conclusion: The postgraduate residents of ophthalmology showed a satisfactory level of knowledge and attitude toward COVID-19 with an obvious difference in practice with regard to disciplines. Practice can be further improved by webinars, Continuing Medical Education Programs (CMEs), and guidance from the experts. Since the surgical training has been greatly affected, more frequent video-based surgical teaching programs, virtual simulation platforms, and practice on model eyes must be encouraged for the surgical training of the residents.

Keywords: COVID-19, eye care, pg resident


How to cite this article:
Mashitha M S, Babu M, Sudhakar N A, Bidari S. A cross-sectional study to assess the knowledge, attitude, and practice toward eyecare among the ophthalmology postgraduates of Karnataka during COVID-19 pandemic. TNOA J Ophthalmic Sci Res 2021;59:23-7

How to cite this URL:
Mashitha M S, Babu M, Sudhakar N A, Bidari S. A cross-sectional study to assess the knowledge, attitude, and practice toward eyecare among the ophthalmology postgraduates of Karnataka during COVID-19 pandemic. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Apr 23];59:23-7. Available from: https://www.tnoajosr.com/text.asp?2021/59/1/23/312302




  Introduction Top


The worldwide outbreak of the severe and acute respiratory coronavirus disease 2019 (COVID-19) caused by the coronavirus strain severe acute respiratory syndrome (SARS)-CoV-2 is currently the focal point of discussion due to the suffering this syndrome is causing to humanity. However, the ophthalmological implications of this syndrome have not yet been well described. Both eyes and tears as the portals of entry and sources of contagion have been the subject of debate by many authors.[1] The health-care providers particularly ophthalmologists are at high risk of COVID-19 infection through unprotected contact with tears and eye secretions during the routine eye examination which involves the use of direct ophthalmoscopy and slit lamp examination that allows close proximity of patients and doctor. Postgraduate residents are important health-care providers because they are the front-line doctors and often manage patients in major referral hospitals. Moreover, PG residents are responsible to create awareness and educate people about COVID-19 pandemic. Globally, we as ophthalmologists are facing an aging population and most ophthalmic clinic are busy and crowded. Elderly patients are also at increased risk of severe COVID-19 infection and mortality.

Since ophthalmic examination involves multiple investigations such as visual acuity, slit-lamp examination, intraocular pressure, pupillary dilatation, and others, the patients have a prolonged stay in the clinic to complete the whole examination. All these factors potentially increase the risk of cross infection between patients, between health-care workers and patients in outpatient clinics in ophthalmology than in any other clinical discipline.[2] With no proven vaccination or treatment, infection control measures are paramount. In this study, we aim to assess the knowledge, attitude, and practice (KAP) toward eye care during COVID-19 pandemic among the postgraduate residents of Karnataka.


  Methods Top


A cross-sectional study was conducted among postgraduate residents of ophthalmology department of various medical colleges of Karnataka to assess their knowledge regarding the ophthalmology practice during COVID-19 pandemic. The sample size was calculated based on a pilot study where it was seen that 90% of the participants had knowledge about COVID-19. Using the formula, 4pq/l2, where P = 90, q = 10, l = 6, sample size was 100. A self-designed questionnaire was formulated on the basis of review of literature. It was a structured, pilot tested, interview-based test with 22 close-ended questions. This was sent to ophthalmology postgraduates in the various colleges in Karnataka using Google form platform as an online survey. The questionnaire comprised two parts to collect the demographic details of the participants along with KAP toward COVID-19. The first part includes demographic details such as name, age, sex, institution name, year of residency, and marital status. The second part contains questions for KAP assessment. The questionnaire comprised six questions regarding knowledge, 3 for attitude and 9 for practice. Knowledge questions mainly deal with participants' knowledge about ocular symptoms in COVID-19, transmission route, prevention, and control of COVID-19. These questions were responded on a Yes/No/Not sure with an additional “other” option, if they have an alternative answer. After the preparation of the questionnaire, it was sent to some experts to consult their opinions regarding the validity of the questions followed by a small pilot study to test its simplicity and difficulty. However, the result of the pilot study is not included in the study. Informed consent was obtained from all participants before the study. The study was approved by the Institute's Ethics Committee and performed in accordance with the tenets of the declaration of Helsinki.

Knowledge was assessed using closed-ended questions, and the study participants were classified as having poor, average, and good knowledge depending on the score obtained. Data collected were entered in Microsoft Excel Office 2007, and data analysis was done using the SPSS software version 21 (IBM, US).


  Results Top


Majority of respondents were females (80%), and majority of them (84%) were aged between 26and 30 years [Table 1].
Table 1: Characteristics of the study population

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Recent studies showed that conjunctivitis could be a manifestation of COVID-19. Because the eye could be considered as a direct potential portal of entry for the virus, it is of interest to analyze the association between conjunctivitis and the severity of COVID-19, scarce and conflicting data have been reported.[3]

Majority (82%) of the participants are aware that COVID-19 positive can present with conjunctivitis without any systemic symptoms. However, only 28% of the participants commented that incidence of conjunctivitis has increased during COVID-19 pandemic. Forty-eight percent participants told there was no change in the number of patients presenting with conjunctivitis. Ninety-two percent of the participants know that SARS-COV2 can be transmitted through tears and ocular discharge. Only 59% of the students had correct knowledge about the transmission routes of the virus. The high percentage of the students (75%) agreed that with protective mask, direct fundoscopy is more dangerous than auscultation of chest during this pandemic. Forty-three percent of participants commented that small incision cataract surgery (SICS) is safer than phaco-emulsification during COVID-19 pandemic [Table 2].
Table 2: Results of knowledge survey

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Attitude

Nearly half of the participants reported that patients with mild ocular symptoms also come to outpatient department (OPD), whereas 16% commented only severe cases comes.

The suspension of elective cases during COVID surge was an important step for the safety of both patients and surgical teams. Viral transmission through aerosols and fomites and prolonged infectivity of virions in aerosols is a threat. A case series from China found that of 34 asymptomatic patients who underwent elective surgery during the incubation period of COVID-19, the mortality rate was an alarming 20%.[4]

Eighty-three percent of the participants are aware that COVID-19 testing is necessary for all patients before elective cataract surgery. Ninety-five percent of male participants agreed that it is necessary. However, Aggarwal et al. concluded that suspension of elective cataract surgical care during the COVID surge will have a significant and lasting impact on ophthalmology and will likely result in a large surgical backlog[4] [Table 3].
Table 3: Results of attitude survey

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Eighty-two percent of residents say that COVID-19 pandemic has affected their postgraduate training to a greater extent and 12% were affected to a lesser extent. Beyond its evolving impact on postgraduate training, COVID-19 threatens undergraduate ophthalmic teaching, exposure to which is increasingly limited.[5] Face-to-face teaching restrictions post-COVID-19 will require innovative and accessible learning materials[6] [Table 3].

Positive attitude was higher in males compared to females.

Practice

The first question asked was if there is any reduction in the number of patients attending the ophthalmology department after COVID-19 pandemic. Forty-nine percent of participants reported that the outpatients have reduced to 1/3rd the initial number. Forty-one percent said it has reduced to half the previous number.

Majority (82%) of the participants are aware that COVID-19 positive can present with conjunctivitis without any systemic symptoms. However, only 28% of the participants commented that the incidence of conjunctivitis has increased during COVID-19 pandemic.

Regarding type of fundoscopy preferred during Covid-19 pandemic, 73% of participants answered correctly the indirect fundoscopy using +20D. About tonometry, majority of the residents preferred noncontact tonometer (72%) followed by applanation tonometer (17%).

Fifty-four percent of the participants were using masks, gloves with goggles while examination patients in OPD, while 9% were using only masks. Ninety-five percent of male participants were using masks gloves and goggles while rest were using only masks and gloves.

Half of the participants reported that COVID-19 risk consent was taken before all elective surgeries, whereas 23% were not taking, but are planning to take in near future.

Only 31% of the participants commented about maintaining more than 20 min gaping between each surgery, whereas 40% of them said that they maintain 5–10 min of gaping between each surgery [Table 4].
Table 4: Results of practice survey

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Health education to patient/bystander about the eye care was given mainly through counseling (82%) by residents.


  Discussion Top


In this study, we assessed the KAP toward eye care among the postgraduate residents of ophthalmology department in Karnataka. Our findings indicate that most study participants were knowledgeable about COVID-19. Study participants achieved a mean of 61% in the knowledge questionnaire. However, no significant difference was found in mean knowledge or attitude scores with respect to any demographic variables. It is worth mentioning that sufficient COVID-19 knowledge scores, positive attitude, and adequate practice were found among the students.

Ocular manifestations of SARS-CoV-2 include follicular conjunctivitis and have been repeatedly noted as an initial or subsequent symptom of COVID-19-positive patients.[2] More than 80% respondents were aware that COVID-19 patients can present with conjunctivitis without any systemic symptoms.

Lai et al. reported that in order to reduce droplet transmission of COVID-19, installation of protective shields on slit lamps, frequent disinfection of equipment and provision of eye protection to staff were implemented. In our study, more than 80% of the participants were using protective shields on slit lamp bio microscopy. More than 50% of the participants were using mask, gloves, and goggles while examining the patient. High precautionary measures were seen among the males compared to female participants.[7]

Reddy et al. reported that fundus examination should be performed using indirect ophthalmoscope with a breath shield or using 90D or 78D lenses at the slit lamp. It is advisable to not to use a direct ophthalmoscope.[8] In our study, 73% of the participants opted indirect ophthalmoscopy with +20 D lens for fundus examination.

Sengupta et al. reported that it is mandatory to do screening chest X-ray for all patients before surgery.[9] In our study, 83% of the subjects told it is necessary to do COVID-19 testing before elective cataract surgery. In the absence of COVID-19 testing, 53% of the participants opted chest X-ray as an alternative test, whereas 20% choose computed tomography chest.

Sengupta et al. reported that, it should be assumed that phacoemulsification with excess blind source separation near the vibrating tip can generate aerosols. Hence, no two patients should be handled together. There should be a 20-min time out between each surgery.[10] In our study, only 43% of the participants were aware of the fact that SICS was comparatively safer procedure and only 31% of the participants was maintaining a minimum gap of 20 min between each surgeries.[9]

Research indicates that outpatient volume has drastically reduced during this pandemic. Nonurgent outpatient clinic appointments have been canceled. These visits are now being conducted over the phone or through video calls. These telemedicine visits do not include a traditional physical examination.[10] Eighty-two percent of the residents in our study reported that COVID-19 pandemic has affected their residency training, especially surgical training to a greater extent.[10] Hence, the more frequent video-based surgical teaching programs, virtual simulation platforms, and practice on model eyes must be encouraged for the surgical training of the residents. Practice of the postgraduate residents can be further improved by webinars, CMEs, and guidance from the experts. Furthermore, ophthalmic surgical simulators have to be recommended in all teaching institutions as a future training platform.[11]


  Conclusion Top


The postgraduate's residents of ophthalmology showed a satisfactory level of knowledge and attitude towards COVID-19 with an obvious difference in practice with regard to disciplines. Practice can be further improved by webinars, CMEs, and guidance from the experts. Since the surgical training has been greatly affected, more frequent video-based surgical teaching programs, virtual simulation platforms, and practice on model eyes must be encouraged for the surgical training of the residents.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Amesty MA, Alió Del Barrio JL, Alió JL. COVID-19 disease and ophthalmology: An Update. Ophthalmol Ther 2020;9:1-2.  Back to cited text no. 1
    
2.
Dockery DM, Rowe SG, Murphy MA, Krzystolik MG. The ocular manifestations and transmission of COVID-19: Recommendations for prevention. J Emerg Med 2020;59:137-40.  Back to cited text no. 2
    
3.
Loffredo L, Pacella F, Pacella E, Tiscione G, Oliva A, Violi F. Conjunctivitis and COVID-19: A meta-analysis. J Med Virol 2020;92:1413-4.  Back to cited text no. 3
    
4.
Aggarwal S, Jain P, Jain A. COVID-19 and cataract surgery backlog in Medicare beneficiaries. J Cataract Refract Surg 2020;46:1530-3.  Back to cited text no. 4
    
5.
Hill S, Dennick R, Amoaku W. Present and future of the undergraduate ophthalmology curriculum: A survey of UK medical schools. Int J Med Educ 2017;8:389-95.  Back to cited text no. 5
    
6.
Dhillon N, Dhillon B. On-line lessons learned post Covid-19: mater artium necessitas [letter]. BMJ Stel. 2020. Available from: https://stel.bmj.com/content/6/4/196.responses. [Last accessed on 2021 Feb 15].  Back to cited text no. 6
    
7.
Lai TH, Tang EW, Chau SK, Fung KS, Li KK. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: An experience from Hong Kong. Graefes Arch Clin Exp Ophthalmol 2020;258:1049-55.  Back to cited text no. 7
    
8.
Reddy JC, Vaddavalli PK, Sharma N, Sachdev MS, Rajashekar YL, Sinha R, et al. A new normal with cataract surgery during COVID-19 pandemic. Indian J Ophthalmol 2020;68:1269-76.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Sengupta S, Honavar SG, Sachdev MS, Sharma N, Kumar A, Ram J, et al. All India ophthalmological society-Indian journal of ophthalmology consensus statement on preferred practices during the covid-19 pandemic. Indian J Ophthalmol 2020;68:711-24.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Edigin E, Eseaton PO, Shaka H, Ojemolon PE, Asemota IR, Akuna E. Impact of COVID-19 pandemic on medical postgraduate training in the United States. Med Educ Online. 2020 Jan 1;25(1):1774318. doi: 10.1080/10872981.2020.1774318. PMID: 32493181; PMCID: PMC7448893.  Back to cited text no. 10
    
11.
Nayak B, Sen S, Parija S. Effect of COVID-19 on ocular diseases and ophthalmology residency training program – A developing country's perspective. Indian J Ophthalmol 2020;68:1491.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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