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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 60  |  Issue : 1  |  Page : 2-5

Analysis of ophthalmic emergency visits during COVID-19 Lockdown in a tertiary eye care center in South India


1 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Chennai, India
2 Deputy Director, Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata, India

Date of Submission29-Jul-2021
Date of Decision21-Oct-2021
Date of Acceptance28-Oct-2021
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Soham Subodhchandra Pal
Reconstructive and Aesthetic Services, Sankara Nethralaya (A Unit of Medical Research Foundation), Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_118_21

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  Abstract 


Purpose: To analyze the profile of patients visiting the ophthalmic emergency department during coronavirus disease-2019 lockdown and analyze its impact on a tertiary eye care center in South India. Materials and Methods: Retrospective analysis of Electronic Medical records of all patients presenting in the period from March 24, 2020 to May 3, 2020 (lockdown group) and the same was compared with the data of patients from the same period in the previous year (prelockdown group). Data regarding their demographic details, presenting complaints, final diagnosis, medical treatment, and surgical interventions undertaken if any were scrutinized. Results: The total number of patients seen in the emergency services during the lockdown phase was 591. The number of patients coming to the emergency showed a decline of 35% compared to the previous year. The most common presenting complaint was defective vision (n = 112, 18.95). Review checkup was done in 128 patients (21.65%). The most common ocular diagnosis was conjunctivitis (n = 78, 13.19%). Emergency surgical interventions were advised in 30 patients (5.07%). Conclusion: A significant decline in the number of visits to the emergency in the lockdown period was observed probably due to the various constraints and hardships faced by patients.

Keywords: Coronavirus disease-19, emergency department, lockdown, pandemic


How to cite this article:
Pal SS, Alam MS, Giratkar SM, Mukherjee B. Analysis of ophthalmic emergency visits during COVID-19 Lockdown in a tertiary eye care center in South India. TNOA J Ophthalmic Sci Res 2022;60:2-5

How to cite this URL:
Pal SS, Alam MS, Giratkar SM, Mukherjee B. Analysis of ophthalmic emergency visits during COVID-19 Lockdown in a tertiary eye care center in South India. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 May 29];60:2-5. Available from: https://www.tnoajosr.com/text.asp?2022/60/1/2/340341




  Introduction Top


In late 2019, a cluster of cases of pneumonia of unknown cause was detected in Wuhan, China.[1] In early 2020, it was found that these cases were caused by a novel coronavirus, termed subsequently as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); and the disease was named coronavirus disease-2019 (COVID-19).[2] India reported the first case of COVID-19 on January 30, 2020, in the state of Kerala, where a student returning from Wuhan presented with respiratory symptoms.[3]

The Government of India imposed a country-wide complete lockdown of all nonessential services to curb the rapid spread of the disease on March 24, 2020.[4]

This lockdown had severe detrimental effects on the health-care facilities, both emergency and routine. There was a delay in the presentation of many patients owing to the strict lockdown. The present study was conducted to determine the impact of COVID-19 lockdown on ophthalmic emergency services at a tertiary eye-care center in South India and we compared the data with the corresponding period in the previous year, 2019. Previous studies based on the data evaluating the lockdown phase have concentrated more on the aspect of how there has been increase in teleconsultation during this phase but have not taken into account the drawbacks faced by teleconsultation in prompt management of emergency cases. With our study, we provide a peek into the efficient management of emergency cases from a tertiary eye care hospital even in times of a crisis facing the whole country.


  Materials and Methods Top


The patients presenting to our emergency department were retrospectively enrolled in the study from March 24 to May 3, 2020. Every patient was checked for thermal screening and was allowed entry into the campus as a precautionary measure. Only a single attendee was allowed per patient to comply with the social distancing criteria. Sanitizing booths were present at all major entry and exit points. The electronic medical records were scrutinized to retrieve data regarding their demographic details, presenting complaints, final diagnosis, medical treatment, and surgical interventions undertaken if any. These were compared with the corresponding period in 2019. The Institutional review board waived the need for formal approval due to the retrospective nature of the study. Data were entered into Microsoft Excel worksheet and statistical analysis was performed using IBM® SPSS® 20.0 software (New York, U. S. A).


  Results Top


The total number of patients seen in the emergency services during the lockdown phase was 591 (mean-14.8 patients/day). During the corresponding prelockdown phase in the year 2019, 905 patients reported to the emergency department (mean-22.62 patients/day). Thus, the number of patients reporting to the emergency showed a decline of 35%. Age (mean-37.94(019) vs. 44.04 (2020)) and sex (M: F = 66:34(019)vs. M: F = 57:43 (2020)) were comparable between the groups without any statistically significant difference [Table 1].
Table 1: Demographic characteristics of patients treated in emergency department during lockdown compared to 2019

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The proportion of patients presenting from the home city increased from 55.35% in 2019 to 85.61% in the lockdown period. The most common presenting complaints were defective vision (n = 112, 18.95%), red eyes (n = 84, 14.21%), ocular pain (n = 81, 13.70%), and mechanical trauma (n = 48, 8.12%) [Table 2]. Review checkup for a procedure done before lockdown was the cause of visit to the emergency in 128 patients (21.65%).The most common ocular diagnosis was conjunctivitis (n = 78, 13.19%), followed by retinal detachment (RD) (n = 54, 9.13%), chemical/thermal injury (n = 47, 7.95%), conjunctival/corneal foreign body (n = 45, 7.61%), and angle-closure/lens-induced glaucoma (n = 37, 6.26%), which were comparable with the prelockdown phase [Table 3].
Table 2: Common presenting complaints of patients presenting to emergency

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Table 3: Common diagnosis of patients presenting to ophthalmic emergency during lockdown

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All elective ophthalmic surgeries were postponed during the lockdown period. Emergency surgical interventions were advised in 30 patients (5.07%), whereas 174 (19.22%) emergency surgeries were performed during the prelockdown phase. The common indications for surgery were RD, corneal tear, traumatic cataracts in both groups [Table 4].
Table 4: Details of management in patients attending emergency in lockdown

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Though emergency interventions were needed in 30 patients, 20 could not undergo the same due to logistical issues [Table 5].
Table 5: Advised procedures in patients unable to undergo treatment

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  Discussion Top


COVID-19 is an ongoing pandemic caused by SARS-CoV-2. The virus spreads mainly through close contact and by small droplets produced when an infected patient coughs, sneezes, talks, or exhales. Ocular surfaces may be a potential mode for transmission.[5] This pandemic is one of the biggest crises the modern world has faced. To date, the virus has affected about 186 million people and lead to the death of more than 4 million people around the world.[6] Given the close physical contact nature of ophthalmologist's work and the modes of transmission of the virus, they are at greater risk for transmission of the disease. An eye clinic is a high-risk environment for both the examining doctor as well as the patient.[7] Lu et al. reported that the ocular surface may be a potential target for SARS-CoV-2 invasion.[8] The lockdown measures imposed to curb the growth of the COVID-19 pandemic brought the whole country to a standstill as all the public transport services were stopped, only the emergency and essential services were allowed to operate. Free movement of the public for non-essential work was restricted. With the announcement of lockdown, our hospital allowed only the emergency department to operate. The unavailability of managerial, administrative, nursing and other support staff posed logistical and operational challenges to running a health-care facility in times of a pandemic.

The emergency load in our hospital decreased to nearly 35% as compared to the corresponding time the previous year. Other authors have also reported a similar decrease in the number of patients presenting to the ophthalmologist. Babu et al. reported a dramatic decrease of 96.6% in outpatient department at tertiary eye care hospitals in South India.[4] Pellegrini et al. from Italy reported a 73% decrease compared to the same period of the previous year.[9]

Agrawal et al. reported a decrease of 58% of emergency patients from the previous year.[10]

We also noted a statistically higher proportion of older patients presenting during this lockdown compared to the corresponding period last year. This may be due to a decrease in the occupational injuries to the younger patients as most of the nonessential services were closed and reduction in road traffic accidents due to very strict lockdown. Another peculiar observation was a high proportion of people presenting with redness of eyes. Shetty et al. reported a similar observation with nearly 60% teleophthalmology consultations done for redness.[11] They attributed this to the use of alcohol-based sanitizers and termed the entity as sanitizer aerosol-driven ocular surface disease.[11] Many patients sought ophthalmologist's advice thinking it to be a sign of COVID 19 disease, as suggested by multiple reports.[12],[13] Babu et al. also reported a similarly high number of cases of red eyes.[4] Most of the patients who presented with redness of eyes were diagnosed with conjunctivitis, and most of these patients were lost to follow-up. Feng et al. from the United States identified a wide range of ocular signs and symptoms in hospitalized COVID patients. They found 9.5% of COVID-19 patients exhibited ocular signs and symptoms and concluded that ocular manifestations of COVID-19 should not be ignored, and physicians should routinely evaluate for ocular involvement in hospitalized COVID-19 patients.[14] The number of patients visiting for a review was almost similar during both years. Most of these patients came for routine postsurgical examination but were seen in the emergency department. The most common indications for emergency surgery at our center during this lockdown were RD, corneal tear, intraocular foreign body, and lens-induced glaucoma. Tang et al. reported that the majority of surgery at their center in Hong Kong were done for RD, open globe injury, and glaucoma.[15] Babu et al. reported open globe injuries, rhegmatogenous RD, and lens-related glaucoma as the most common indications for surgery.[4] Du et al. reported the most common indication for surgery at their center in China was glaucoma.[16] Sindal et al. concluded that travel restrictions and fear of contracting COVID-19 have resulted in a delay in patients receiving essential vision preserving treatment like anti-vascular endothelial growth factor injections.[17] Personal protective equipment, including a surgical mask or respirator, goggles, gowns, and gloves were used in the ophthalmic emergency services. One of the hallmarks and challenges of COVID-19 transmission is that it is spread by asymptomatic individuals. O'Brien et al. advocated the use of 0.5% povidone-iodine to prevent this transmission of infection, which can reduce some risk to the ophthalmologist.[18]

In a survey involving 1260 ophthalmologists to study the impact of the lockdown on ophthalmic practices, 72.5% of the respondents were not seeing any patients during the lockdown period.[7] This, in turn, led to limited accessibility of health-care systems to patients. The inability of patients to reach the hospital for timely treatment has been another big problem during this lockdown. This fact was corroborated in our study by the fact that the number of patients from outside the city dramatically decreased from 45% the year before to 14% during the lockdown.


  Conclusion Top


The evolving COVID-19 pandemic is a threat to health workers and patients seeking ophthalmologist consultation. Crucial measures were adopted to reduce the risk of infection among eye care providers and patients while continuing to serve them. Still, a significant number of patients could not get adequate treatment during the lockdown period. This study emphasizes the difficulties faced by the ophthalmic emergency services of a tertiary eye care hospital in treating patients and preventing morbidities. Moreover, it stresses the need for more planned and well-directed lockdown guidelines in case we face similar pandemic situations in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020;395:470-3.  Back to cited text no. 1
    
2.
Xia J, Tong J, Liu M, Shen Y, Guo D. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection. J Med Virol 2020;92:589-94.  Back to cited text no. 2
    
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Khanna RC, Honavar SG. All eyes on coronavirus – What do we need to know as ophthalmologists. Indian J Ophthalmol 2020;68:549-53.  Back to cited text no. 3
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4.
Babu N, Kohli P, Mishra C, Sen S, Arthur D, Chhablani D, et al. To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute. Indian J Ophthalmol 2020;68:1540-4.  Back to cited text no. 4
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Safadi K, Kruger JM, Chowers I, Solomon A, Amer R, Aweidah H, et al. Ophthalmology practice during the COVID-19 pandemic. BMJ Open Ophthalmol 2020;5:e000487.  Back to cited text no. 5
    
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Available from: https://covid19.who.int/. [Last accessed on 2021 Jul 25].  Back to cited text no. 6
    
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Nair AG, Gandhi RA, Natarajan S. Effect of COVID-19 related lockdown on ophthalmic practice and patient care in India: Results of a survey. Indian J Ophthalmol 2020;68:725-30.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Lu CW, Liu XF, Jia ZF. 2019-nCoV transmission through the ocular surface must not be ignored. Lancet 2020;395:e39.  Back to cited text no. 8
    
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Pellegrini M, Roda M, Lupardi E, Di Geronimo N, Giannaccare G, Schiavi C. The impact of COVID-19 pandemic on ophthalmological emergency department visits. Acta Ophthalmol 2020;98:e1058-9.  Back to cited text no. 9
    
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Agrawal D, Parchand S, Agrawal D, Chatterjee S, Gangwe A, Mishra M, et al. Impact of COVID-19 pandemic and national lockdown on ocular trauma at a tertiary eye care institute. Indian J Ophthalmol 2021;69:709-13.  Back to cited text no. 10
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Shetty R, Jayadev C, Chabra A, Maheshwari S, D'Souza S, Khamar P, et al. Sanitizer aerosol-driven ocular surface disease (SADOSD)-A COVID-19 repercussion? Indian J Ophthalmol 2020;68:981-3.  Back to cited text no. 11
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Yu AY, Tu R, Shao X, Pan A, Zhou K, Huang J. A comprehensive Chinese experience against SARS-CoV-2 in ophthalmology. Eye Vis (Lond) 2020;7:19.  Back to cited text no. 12
    
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Kumar K, Prakash AA, Gangasagara SB, Rathod SB, Ravi K, Rangaiah A, et al. Presence of viral RNA of SARS-CoV-2 in conjunctival swab specimens of COVID-19 patients. Indian J Ophthalmol 2020;68:1015-7.  Back to cited text no. 13
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Feng Y, Park J, Zhou Y, Armenti ST, Musch DC, Mian SI. Ocular manifestations of hospitalized COVID-19 patients in a tertiary care academic medical center in the United States: A cross-sectional study. Clin Ophthalmol 2021;15:1551-6.  Back to cited text no. 14
    
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Tang EW, Wong DH, Chan YY, Li KK. Emergency ophthalmic surgeries during COVID-19-a Hong Kong perspective. Graefes Arch Clin Exp Ophthalmol 2020;258:2867-8.  Back to cited text no. 15
    
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Du H, Zhang M, Zhang H, Sun X. Practical experience on emergency ophthalmic surgery during the prevalence of COVID-19. Graefes Arch Clin Exp Ophthalmol 2020;258:1831-3.  Back to cited text no. 16
    
17.
Sindal MD, Chhabra K, Khanna V. Profile of patients receiving intravitreal anti-vascular endothelial growth factor injections during COVID-19-related lockdown. Indian J Ophthalmol 2021;69:730-3.  Back to cited text no. 17
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O'Brien TP, Pelletier J. Topical ocular povidone-iodine as an adjunctive preventative practice in the era of COVID-19. Asia Pac J Ophthalmol (Phila) 2021;10:142-5.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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