|Year : 2021 | Volume
| Issue : 3 | Page : 162-168
Surgical performance and the positivity rate for novel coronavirus (severe acute respiratory syndrome coronavirus 2) in an ophthalmic setup during the coronavirus disease 2019 pandemic
Md Shahid Alam1, Suraj Mistry1, Sudipta Das1, Suchetna Mukherjee1, Amitabh Kumar1, Girish Shiva Rao2
1 Aditya Birla Sankara Nethralaya, Kolkata, West Bengal; A Unit of Medical Research Foundation, Chennai, Tamil Nadu, India
2 Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
|Date of Submission||05-Mar-2021|
|Date of Decision||30-Jun-2021|
|Date of Acceptance||01-Jul-2021|
|Date of Web Publication||20-Oct-2021|
Dr. Md Shahid Alam
Aditya Birla Sankara Nethralaya, Kolkata, West Bengal; A Unit of Medical Research Foundation, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
AIM: To describe, the impact of ongoing coronavirus disease 2019 (COVID-19) pandemic on ophthalmic surgeries at a tertiary eye care center of East India during and after the lockdown, and the positivity rate for novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]).
MATERIALS AND METHODS: A retrospective study of all ophthalmic surgeries performed during and after lockdown from April 1, 2020 to August 31, 2020, with comparison to the corresponding period in the previous year (2019) was done. Eligible patients were tested for novel coronavirus (SARS-CoV-2) preoperatively as per the institutional protocols.
RESULTS: A total of 569 surgeries were performed during the study period compared to 3458 performed in 2019, (P = 0.00001). The maximum number of surgeries were performed in June (191, 33.57%) and July (189, 33.22%) and in the subspecialty of vitreo-retina (337, 59.23%) followed by cataract (101, 17.75%). The most common vitreoretinal procedures were intravitreal injections (223, 66.17%) and retinal detachment surgery (56, 16.62%). Emergency surgeries performed were 30 (5.275%) compared to 76 (2.20%) during the same duration in the previous year (P = 0.00004). Ninety-four (16.52%) cases were screened for COVID-19. A total of 10 (10.64%) cases tested positive for SARS-CoV-2. Only one of these cases was symptomatic.
CONCLUSION: There was a drastic decline in the number of both elective and emergency surgeries during and after the lockdown period of the COVID-19 pandemic when compared to the corresponding previous year duration. The maximum number of surgeries was performed in the vitreoretinal subspecialty. The positivity rate for SARS CoV-2 amongst the patients tested was 10.64% and most of these patients were asymptomatic.
Keywords: Coronavirus disease 2019, ophthalmology, positive rate, severe acute respiratory syndrome coronavirus 2, surgical performance
|How to cite this article:|
Alam MS, Mistry S, Das S, Mukherjee S, Kumar A, Rao GS. Surgical performance and the positivity rate for novel coronavirus (severe acute respiratory syndrome coronavirus 2) in an ophthalmic setup during the coronavirus disease 2019 pandemic. Oman J Ophthalmol 2021;14:162-8
|How to cite this URL:|
Alam MS, Mistry S, Das S, Mukherjee S, Kumar A, Rao GS. Surgical performance and the positivity rate for novel coronavirus (severe acute respiratory syndrome coronavirus 2) in an ophthalmic setup during the coronavirus disease 2019 pandemic. Oman J Ophthalmol [serial online] 2021 [cited 2023 Mar 26];14:162-8. Available from: https://www.ojoonline.org/text.asp?2021/14/3/162/328611
| Introduction|| |
In December 2019, an outbreak of novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) occurred in Wuhan, China., Since then it has spread rapidly within China and globally., Despite all possible measures taken by China and other countries worldwide, there was an exponential rise in the cases which led the World Health Organization (WHO) to declare it a pandemic in March 2020. The first case in India was reported on January 30, 2020, and currently, it is among the worst affected countries worldwide. A nationwide lockdown was announced on March 25, 2020, with the intention of curbing the disease and preventing its further spread. Coronavirus can be transmitted by aerosol, fomites, and droplets and has also been reportedly isolated from the tears of COVID-19-positive patients., Infectious period of COVID-19 is long and the virus is contagious even during the incubation period. One percent of the laboratory-confirmed cases of SARS-CoV-2 infection, though asymptomatic carriers, can keep on transmitting the disease unknowingly.,, Because of the difficulty in availability of transport facilities and the ongoing fear of the rapid spread and contagiousness of the disease, various ophthalmic setups across the country and worldwide have witnessed drastic decline in the number of patients and the surgeries performed during the lockdown., Although few studies have reported regarding this decline in the Out Patient Department (OPD) and surgical numbers, to the best of the authors' knowledge there is no study till date which describes the positivity rate for SARS-CoV-2 amongst patients undergoing ophthalmic surgeries. The present study not only describes the surgical performance during this pandemic period (both lockdown and unlock periods) comparing it with the corresponding previous year, it also reports the rate of patients tested positive for SARS-CoV-2.
| Materials and Methods|| |
A retrospective comparative study of all ophthalmic elective and emergency surgeries performed during and after the lockdown (April 1, 2020–August 31, 2020) comparing it with surgeries performed during the corresponding period in the year 2019 was carried out. The study was conducted at a tertiary eye care center of Eastern India, after institutional review board approval and it adhered to the tenets of the Declaration of Helsinki.
The patients were triaged as emergent, urgent and routine cases as per the guidelines of All India Ophthalmological Society (AIOS), and only emergency surgeries were performed till May 6, 2020. After May 6, 2020 as the lockdown was partially lifted up, both emergency and elective cases were taken up for surgery. All patients underwent preoperative testing for SARS-CoV-2 with real-time reverse transcriptase-polymerase chain reaction (RT-PCR) according to the following criteria:
- All patients undergoing surgery under general anesthesia
- Following patients undergoing surgeries under local anesthesia:
- Major oculoplastic procedures including dacryocystorhinostomy (DCR)
- Patients with a history of interstate travel
- Patients with a history of multiple hospital visits
- Patients with a history of COVID-19 amongst one or more family members staying together, within the past 1 month
- Patients with significant comorbidities like being on dialysis, postcardiac angioplasty, post coronary bypass graft, postrenal transplant, etc.
All emergency procedures were taken up for surgery without any preoperative testing for SARS-CoV-2 to avoid delay.
Preoperative C reactive protein levels and chest X-rays were made mandatory for all patients apart from the routine preoperative investigations.
For all COVID-19-positive patients, surgery was deferred for 2 weeks and the patient was referred to a dedicated COVID center with proper documents after notifying the government health authorities. For bilateral pathologies, the second surgery was planned after 2 weeks following all of the above-mentioned protocols. Surgeries were performed following the standard operating procedure laid down by the institution without compromising the safety of the staff and patients.
The clinical data were taken from the electronic medical records system. At the end of the study, data including demographic and clinical profile, diagnosis, and interventional modalities were entered in Microsoft Excel spreadsheet. Continuous variables were presented as mean with standard deviation, median, and interquartile range. Categorical variables were presented in number and percentage (%). Chi-square test/Fisher's exact test verified the associations between the categorical variables. A P < 0.05 was considered significant.
| Results|| |
A total of 569 patients were operated on during the study period. The average number of patients operated per day was 3.72. The overall number of surgeries performed during the same period in the year 2019 was 3458 and the average number of patients operated per day was 22.60. The Ratio of surgeries performed during the years 2019 and 2020 was 6.08:1. This difference was statistically significant with a P value of 0.00001.
The mean age of patients was 48.19 ± 21.14 years (Median: 53, Range: 39–63). Sixty-nine (12.13%) patients were in the pediatric age group (≤16 years), and 200 (35.15%) patients were >60 years of age. The adult-to-pediatric ratio was 7.25:1. The number of males outnumbered the females (391 [68.72%] and 178 [31.28%]). The male-to-female ratio was 2.20:1. The right eye was involved in 281 (49.38%), left eye in 258 (45.34%), and both eyes in 30 (5.27%) cases. The details are shown in [Table 1].
|Table 1: Demographic details, surgical performance, and reverse transcriptase-polymerase chain reaction positivity rates for severe acute respiratory syndrome-coronavirus-2|
Click here to view
Seventy (12.30%) out of the total operated cases were performed under general anesthesia. Out of these 70 cases, maximum belonged to pediatric ophthalmology (24, 34.29%) followed by emergency surgeries (12, 17.14%), combined surgeries (11, 15.71%), vitreo-retinal surgeries (7, 10%), glaucoma surgeries (5, 7.14%), corneal surgeries (5, 7.14%), oculoplasty surgeries (4, 5.71%), and cataract surgeries (2, 2.86%).
The maximum number of surgeries was performed in the month of June (191, 33.57%) and July (189, 33.22%). The details of surgeries performed during each month of study period and its comparison with the previous year has been depicted in [Figure 1]. The decline in the number of surgeries in each month when compared to the previous year was found to be statistically significant. The vitreo-retina subspecialty operated the maximum number of cases (337, 59.23%) followed by cataract (101, 17.75%). The mean age of patients undergoing cataract surgery was 54.25 ± 14.19(Median: 56, Range: 48–64).
|Figure 1: Surgical performance during the study period and in the corresponding previous year duration|
Click here to view
The most common surgical procedures performed amongst different subspecialty were intravitreal injections (223, 66.17%), retinal detachment surgery (56, 16.62%), phacoemulsification (95, 94.06%), globe rupture repair (16, 53.33%), trabeculectomy with cataract surgery (9, 32.14%), lens aspiration ± intraocular lens implantation (16, 66.67%), and excision biopsy for lid and orbital tumors (7, 43.75%).
A total of 30 emergency surgeries were performed during the study period, out of which 8 were done during the lockdown phase and the remaining 22 in the post lockdown period. The most common indication was globe rupture repair (16, 53.3%) and evisceration (6, 20%) [Table 2]. The number of emergency surgeries during the corresponding period in the previous year was 76. The ratio of emergency surgeries in the year 2019 to the year 2020 during the study period was 2.53:1. The difference was found to be statistically significant (P value 0.0004). Even the difference in the number of surgeries between the lockdown and the post lockdown period was statistically significant (P = 0.03462).
|Table 2: Details of emergency surgeries performed during the study period and during the same duration in the previous year|
Click here to view
Ninety-four (16.52%) cases were screened for COVID-19 by RT-PCR test as per institutional guidelines. A total of 10 (10.64%) cases tested positive for SARS CoV-2. The details of these cases have been provided in [Table 3].
|Table 3: Details of the patients tested positive for severe acute respiratory syndrome-coronavirus-2|
Click here to view
| Discussion|| |
The COVID-19 pandemic has caused a significant impact on the number of surgeries being performed at different ophthalmic setups. The studies by Das and Narayanan and Babu et al. have shown the impact to be quite drastic during the lockdown period., The present study analyzes the surgical performance both during and after the lockdown and is the first to analyze the positivity rate for SARS-CoV-2 amongst patients undergoing surgeries at an ophthalmic setup. While we noticed almost a six-fold decline in the number of surgeries being performed, we also found a positivity rate of 10.36% for the SARS-CoV-2 amongst patients who underwent testing for the same as per our testing norms.
The decline in the number of surgeries during the study performed was found to be statically significant in each month when compared to the same duration in the previous year. The maximum decline was witnessed during April and May, which is quite expected because of the complete nationwide lockdown. A gradual increase was observed in June, July, and August (Early unlock period). This fall in numbers is attributed to the cancellation of all elective surgeries as per AIOS and Government of India (Ministry of Healthy and Family Welfare [MOHFW]) guidelines followed during the lockdown phase of the COVID-19 pandemic., Even after the resumption of elective surgeries post lockdown, lot of patients rescheduled their elective surgeries for a later date, probably both because of financial and psychological reasons. These parameters were not a part of the present study hence it would be difficult to comment upon the exact impact of the pandemic on the financial and psychological health of the patients.
Most of the surgeries were performed for vitreoretinal indications. The most common of these were intravitreal injections and retinal detachment surgery. Other surgeries included vitrectomies, silicone oil removal, and surgeries for retinopathy of prematurity. Vitreo-retinal conditions being most vision threatening and needing emergent or urgent intervention, it is understandable that this sub specialty witnessed the maximum number of surgeries.
Excluding cataract, Glaucoma was the subspecialty which performed the maximum number of surgeries after vitreo retina; though it was far behind (28 vs. 337). The most common surgeries performed for glaucoma were trabeculectomy with or without cataract surgery and diode cyclophotocoagulation. These patients had uncontrolled intraocular pressured despite being on maximum medical therapy and needed early intervention. Lens aspiration with or without intraocular lens implantation was the most common surgical procedure performed in the pediatric ophthalmology sub-specialty in view of progressive amblyopia developing in these small kids during the lockdown. It is noteworthy that not a single case of squint was operated during the whole 5-month period, again reflecting the patients' mindset to postpone conditions, which did not threaten the vision immediately. Though congenital esotropia requires early intervention, we are not sure how many such patients had reported to the hospital since we have not analyzed the OPD data.
Among oculoplasty, nearly half of the patients were operated for neoplastic causes. There was not a single case being operated for ptosis or DCR. This may be attributed to the cosmetic nature of ptosis surgery and the high risk of virus transmission while performing DCR., Though we did not analyze how many of such patients actually presented to the OPD which would have given a better idea regarding whether the surgery were not opted by the patients or were postponed by the surgeon. This is however out of the scope of the present study.
Not many major surgeries were performed in the Cornea subspecialty and this could be possible because of the unavailability of donor corneas for therapeutic or optical keratoplasty since no clear-cut guidelines had been laid down regarding eye retrieval. Though the AIOS published its guidelines regarding eye donation in the latter half of June, the implementation and adherence to these guidelines would definitely take some time.
Surprisingly, a large number of patients opted for cataract surgery (101, 17.75%), and the mean age of patients was 54.25 ± 14.19 years. Cataract surgery was the second most common surgical procedure performed after vitreoretinal procedures. Most of the cataracts were of moderate grade (LOCS nuclear sclerosis grade 2–3) but even then the patients opted for surgery. This could because of the uncertainty of future lockdowns, already waiting with the condition and the anxiety of further deterioration in near future. We however tried to postpone cataract surgeries in patients above 60 years of age with not so advanced cataract to avoid their risk of exposure.
Amongst emergency surgery, most commonly performed were globe rupture repair and evisceration followed by endophthalmitis surgery and lid tear repair. Although there was almost a two-fold decline in the number of emergency surgeries, the proportion in relation to the total number of surgeries performed was actually higher as compared to the previous year (5.27% vs. 2.20%, P = 0.00004). The number of emergency surgeries performed in the post lockdown period compared to those performed during the lockdown phase was also statistically significant (P = 0.03462). This is understandable, as the number of road traffic accidents would have come down to minimum because of almost nil transportation during the lockdown.
Studies conducted by Das and Narayanan and Babu et al. have also shown that the majority of the surgeries performed were for vitreo-retinal and trauma-related emergencies., Though the present study shows some similarities in this regard, it can not be completely compared with them since their study was solely limited to the lockdown phase.
The COVID-19 positivity rate for our patients was 10.64%. Ninety percent of our positive patients were asymptomatic with just one having symptoms that too after getting the test done. Interestingly 90% of these patients were males, and this could be because of the higher number of male patients being present in the study. Fifty percent of the cases underwent surgery after obtaining a negative report while the other half is yet to report to the hospital. A retrospective investigation of patient's person-to-person contacts with medical and nonmedical personnel was undertaken, to look for possible spread of infection and breach of hospital laid COVID-19 protocol if any, and none of the exposed doctors and paramedical staffs developed any symptoms in the next 14 days.
A COVID-19 positive patient who gets operated with his status being unknown is a risk not only for the health care workers but for the patient himself. Undergoing surgery is a major stress, irrespective of the type of anesthesia and there is a risk of worsening of disease if patients are operated without knowing their COVID-19 status. Also, there is a high chance of flaring up of ongoing asymptomatic COVID-19 disease.[20.21] A study conducted by Ashokka et al. showed that general anesthesia in COVID-19 positive patients might be risky with airway becoming more irritable and reactive. A study conducted by AIOS for preferred practices during the COVID-19 pandemic also mentions to prefer local anesthesia over general anesthesia and topical anesthesia over local anesthesia wherever possible, however testing for COVID-19 was recommended only for asymptomatic suspected patients. As per the latest guidelines by MOHFW for ophthalmology practice, presurgical COVID-19 test is not mandatory, but a through history taking and examination must be done to ensure that patient has the minimal probability of having COVID-19 infection. In an ideal scenario each and every patient should undergo COVID-19 testing before any surgery, but because of the cost constraints and the logistics of undergoing testing we formulated a protocol as described earlier. Although we could perform tests in only 16.52% of our study participants, there is the possibility that few more would have turned out to be positive had we tested all of them. However, the overall positivity rate would have come down. Studies conducted in other surgical specialties have shown 15%–16% positivity rate with RT-PCR and 34% positivity rate with chest CT scan of COVID-19 before elective surgeries.,
The time period between testing and surgery was shorter than the average incubation period of 5.1 days as published in the literature. Our patients were tested within 3 days of scheduled elective surgery. None of the surgeons or other operation theater staffs in our institution were diagnosed with COVID-19 symptoms or infection during this study period. This again re-emphasizes the importance of adequate personal protection in every step of patient care to ward off the disease spread.
This report is one of the first studies describing the ophthalmic surgical performance during and after the lockdown phase and positivity rate for novel coronavirus among tested patients. Till date, there is no clear-cut guideline for COVID-19 testing for ophthalmic surgeries. We believe that the present study can help ophthalmologists and different ophthalmic institutes across the country in laying down a protocol for COVID-19 testing.
| Conclusion|| |
There was a drastic decline in the number of both elective and emergency surgeries during and after the lockdown period of the COVID-19 pandemic when compared to the corresponding previous year. The maximum number of surgeries was performed in the subspecialty of vitreoretina and the number of emergency surgeries increased considerably in the post lockdown period. The positivity rate for SARS-CoV-2 among patients tested for the same was 10.64% and most of these patients were asymptomatic at the time of consultation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al
. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al.
Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.
Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al.
First case of 2019 novel coronavirus in the United States. N Engl J Med 2020;382:929-36.
Silverstein WK, Stroud L, Cleghorn GE, Leis JA. First imported case of 2019 novel corona virus in Canada, presenting as mild pneumonia. Lancet 2020;395:734.
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al.
Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
Seah I, Su X, Lingam G. Revisiting the dangers of the coronavirus in the ophthalmology practice. Eye (Lond) 2020;34:1155-7.
Yu P, Zhu J, Zhang Z, Han Y. A familial cluster of infection associated with the 2019 novel coronavirus indicating possible person-to-person transmission during the incubation period. J Infect Dis 2020;221:1757-61.
Loon SC, Teoh SC, Oon LL, Se-Thoe SY, Ling AE, Leo YS, et al.
The severe acute respiratory syndrome coronavirus in tears. Br J Ophthalmol 2004;88:861-3.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019(COVID19) outbreak in China: Summary of are port of 72314 cases from the Chinese center for disease control and prevention. JAMA 2020;323:1239-42.
Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al.
Presumed asymptomatic carrier transmission of COVID-19. JAMA 2020;323:1406-7.
Das AV, Narayanan R. Demographics and clinical presentation of patients with ocular disorders during the COVID-19 lockdown in India: A report. Indian J Ophthalmol 2020;68:1393-9.
] [Full text]
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.
] [Full text]
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 COVID19 pandemic. Indian J Ophthalmol 2020;68:71124.
Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist: Preliminary evidence-based review. Laryngoscope 2020;130:2537-43.
Ali MJ. COVID-19 pandemic and lacrimal practice: Multipronged resumption strategies and getting back on our feet. Indian J Ophthalmol 2020;68:1292-9.
] [Full text]
Sharma N, D'Souza S, Nathawat R, Sinha R, Gokhale NS, Fogla R, et al.
All India Ophthalmological Society - Eye Bank Association of India consensus statement on guidelines for cornea and eyebanking during COVID-19 era. Indian J Ophthalmol 2020;68:1258-62.
] [Full text]
Vaid S, Kalantar R, Bhandari M. Deep learning COVID-19 detection bias: Accuracy through artificial intelligence. Int Orthop 2020;44:1539-42.
Vaid S, McAdie A, Kremer R, Khanduja V, Bhandari M. Risk of a second wave of Covid-19 infections: Using artificial intelligence to investigate stringency of physical distancing policies in North America. Int Orthop 2020;44:1581-9.
Ashokka B, Chakraborty A, Subramanian B, Karmakar M, Chan V. Reconfiguring the scope and practice of regional anesthesia in a pandemic: The COVID-19 perspective. Reg Anesth Pain Med 2020;45:536-43.
Bianco A, Buckley AB, Overbey J, Smilen S, Wagner B, Dinglas C, et al.
Testing of Patients and Support Persons for Coronavirus Disease 2019 (COVID-19) Infection Before Scheduled Deliveries. Obstet Gynecol 2020;136:283-7.
Hernigou J, Valcarenghi J, Safar A, Ferchichi MA, Chahidi E, Jennart H, et al.
Post-COVID-19 return to elective orthopaedic surgery-is rescheduling just a reboot process? Which timing for tests? Is chest CT scan still useful? Safety of the first hundred elective cases? How to explain the “new normality health organization” to patients? Int Orthop 2020;44:1905-13.
Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al.
The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: Estimation and application. Ann Intern Med 2020;172:577-82.
[Table 1], [Table 2], [Table 3]