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 Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 304-308  

Year 1 of COVID-19 pandemic in India: Effect of lockdown and unlock on the presentation of patients with ocular and periocular tumors at a referral center


1 Department of Eye Smart EMR and AEye; Indian Health Outcomes, Public Health and Economics Research Center, L V Prasad Eye Institute, Hyderabad, Telangana, India
2 Ocular Oncology Services, The Operation Eyesight Universal Institute for Eye Cancer (SK), L V Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission15-Sep-2021
Date of Decision26-Mar-2022
Date of Acceptance06-Apr-2022
Date of Web Publication02-Nov-2022

Correspondence Address:
Swathi Kaliki
The Operation Eyesight Universal Institute for Eye Cancer, LV Prasad Eye Institute, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.ojo_273_21

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   Abstract 


PURPOSE: The purpose of the study is to describe the impact of lockdown and unlock phases of the COVID-19 pandemic on the presentation of ocular and periocular tumors at a referral center in India.
MATERIALS AND METHODS: This cross-sectional, hospital-based study included 5811 patients presenting between March 25, 2017, and March 31, 2021. The data on the patients diagnosed with ocular and periocular tumors in one or both eyes presenting during the lockdown and unlock phases were compared with the respective time periods in the previous 3 years before COVID-19.
RESULTS: The patient numbers dropped by 85% (45/295) of pre-COVID-19 volumes during the lockdown phase. This was mainly because of a 33% reduction in patients requiring inter-state travel. There was complete recovery of the outpatient numbers to 105% (139/132) of pre-COVID-19 volumes by March 2021. This gradual incremental trend was seen in patients with malignant tumors (145%) and was lower in those with benign tumors (89%) than pre-COVID-19 volumes by March 2021. There was an increase in the patients presenting with malignant tumors (49%; P = 0.45) during the lockdown phase. The proportion of patients requiring inter-state travel showed a near-complete recovery to 88% of pre-COVID-19 distribution by March 2021.
CONCLUSION: The 1st year of the COVID-19 pandemic saw a significant decline in the number of patients presenting with ocular and periocular tumors. There was an increase in the proportion of malignant tumors and a decrease in benign tumors during the lockdown phase. During unlock period, there was a near-complete recovery in the patients requiring inter-state travel to access eye care services.

Keywords: Big data, COVID-19 pandemic, India, ocular oncology


How to cite this article:
Das AV, Kaliki S. Year 1 of COVID-19 pandemic in India: Effect of lockdown and unlock on the presentation of patients with ocular and periocular tumors at a referral center. Oman J Ophthalmol 2022;15:304-8

How to cite this URL:
Das AV, Kaliki S. Year 1 of COVID-19 pandemic in India: Effect of lockdown and unlock on the presentation of patients with ocular and periocular tumors at a referral center. Oman J Ophthalmol [serial online] 2022 [cited 2022 Dec 2];15:304-8. Available from: https://www.ojoonline.org/text.asp?2022/15/3/304/360410




   Introduction Top


The COVID-19 pandemic is currently raging worldwide with the discovery of new variants and characterized by aggressive second waves.[1] The enforcement of the national lockdown in India last year brought in a significant number of new challenges in the access to health-care services for patients across the country.[2] Studies from India have shown a drastic reduction in the outpatient numbers during the lockdown phase and patients with ocular tumors albeit smaller numbers accessed eye care services.[3],[4]

In a survey by 1260 Indian ophthalmologists, it was noted that majority of the ophthalmologists were either not seeing any patients (72.5%) or were attending to only emergency services (27.5%) during the lockdown phase in India.[4] Delayed seeking of healthcare may not cause any adverse effects in nonemergency or elective cases, but oncology is a branch of medicine where delayed diagnosis severely affects the course of treatment, potentially leading to poorer outcomes. During this ongoing COVID-19 pandemic, there has been an attempt to maintain a balance between patients' and health-care professionals' safety and continuation of care for the patients with ocular and periocular tumors, by modification of ocular oncology practice guidelines.[5],[6]

With this background, the authors describe a comparative report of the effect of lockdown and unlock of the COVID-19 pandemic on the presentation of patients with ocular and periocular tumors at a tertiary eye care center in India.


   Materials and Methods Top


Study design, period, location, and approval

This cross-sectional, observational, hospital-based study included patients presenting between March 25, 2017, and March 31, 2021, to a referral center located in India.[7] A standard consent form for electronic data sharing for research purposes was signed by the patient or the parents or guardians of the patient at the time of registration. None of the identifiable parameters of the patient information were used for the analysis of the data. The study adhered to the Declaration of Helsinki and was approved by the institutional ethics committee. The clinical data of each patient who underwent a comprehensive ophthalmic examination were entered into a browser-based electronic medical record system (eyeSmart EMR) using a standardized template by trained ophthalmic personnel and supervised by an ophthalmologist.[8]

Data retrieval and processing

A total of 5811 patients of all ages diagnosed with ocular and periocular tumors in one or both eyes at the referral center during the study were included in this study. A subgroup analysis of the patients based on the characteristic of the tumor and its anatomical location was performed to assess the trends. The data of these patients were retrieved from the EMR database and segregated in a single excel sheet (Microsoft Excel®). Data on patient demographics, ocular diagnosis, and tumor characteristics were used for analysis. The excel sheet with the required data was then used for analysis using the appropriate statistical software. The study duration was divided into three categories: pre-COVID-19 between March 25, 2017, and March 24, 2020; lockdown (phase 1–4) between March 25, 2021, and May 31, 2021; and unlock (phase 1–10) between June 1, 2020, and March 31, 2021.[9] The geographic categorization was performed in relation to the location of the patient and the eye care center at presentation. The patients presenting from the same location of the eye center were classified as “intra-city,” those from outside the city but from the same state of the eye center were classified as “intra-state,” those from outside the state were classified as “inter-state,” and those from outside India were classified as “international” patients. The demographic distribution and clinical presentation of the patients in these three categories were used for comparative analysis.

Statistical analysis

Descriptive statistics using mean ± standard deviation and median with interquartile range (IQR) were used to elucidate the demographic and clinical data using Microsoft Excel 2019 (Microsoft Corporation, Redmond, USA). The P values calculation using the Chi-square test and subgroup analysis was performed. Pairwise comparisons between pairs of proportion with Holm's correction were used for multiple dataset testing.


   Results Top


Overall trend of ocular and periocular tumors

Overall, 5811 patients diagnosed with ocular and periocular tumors in one or both eyes presented during the study. Compared to the pre-COVID-19 phase with an average of 4 (4853/1096) patients per day, the number of patients seen during the lockdown phase with this diagnosis was significantly lower with an average of <1 (47/68) per day which increased to an average of 3 (911/303) during the unlock phase. From March 25 to May 31, 2017, 2018, 2019, and 2020, there were 353, 324, 303, and 47 patients, respectively, who visited the clinic for ocular and periocular tumors. On comparison, the difference in the number of patients seen during the lockdown phase was significantly lower than in the pre-COVID-19 phase (P = 0.001). There was a slight increase in the mean age of the patients (31 ± 24 years vs. 30 ± 22 years) and median (31 [IQR: 7–50] years vs. 28 [IQR: 8–48] years) during the COVID-19 phase (lockdown and unlock phases) as compared to the pre-COVID-19 phase which was not statistically significant (P = 0.1104). There was a slight decrease (35%) in the proportion of pediatric patients (≤16 years) during the COVID-19 phase as compared to the pre-COVID phase (37%), which was not statistically significant (P = 0.4183). There was no significant difference in access to care among male patients (54% vs. 53.82%; P = 0.861697) and female patients (45.62% vs. 46.18%; P = 0.846251) during pre-COVID-19 versus COVID phases, respectively. There was an increase in access to eye care services among the first-time visit patients (77% vs. 70%; P = 0.12568) and a decrease in follow-up patients (23% vs. 30%; P = 0.004017) during the COVID-19 compared to the pre-COVID-19 phase. There was an increase in the proportion of patients with malignant tumors (49% vs. 29%; P = 0.04) and a decrease in patients with benign tumors (51% vs. 71%; P = 0.197785) during the lockdown phase. The trend of patients with ocular and periocular tumors over the three phases is detailed in [Figure 1].
Figure 1: Overview of patients with ocular and periocular tumors presenting during the pre-COVID-19, lockdown (phase 1–4), and unlock (phase 1–10) in India

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With regard to place of origin, a proportional reduction of 33% was seen in patients requiring inter-state travel, and an increase was seen of 40% in intra-city and 13% in intra-state patients during the lockdown phase. There was a near-complete recovery in the proportion of outpatients to 88% for inter-state and an incomplete recovery to 37% for international patients during the unlock phases. The detailed comparison of the geographic presentation in all the three phases is described in [Figure 2]. There was a statistically significant increase in patients with conjunctival tumors (30% vs. 26%; P = 0.02) during the COVID-19 phase compared to the pre-COVID-19 phase. A detailed comparison of the anatomical location of the tumors in the two phases is described in [Figure 3].
Figure 2: Geographic distribution of patients with ocular and periocular tumors presenting during the pre-COVID-19, lockdown (phase 1–4), and unlock (phase 1–10) in India

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Figure 3: Overview of the anatomical location of the ocular and periocular tumors during the pre-COVID-19 and COVID-19 phases in India

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Specific trends of ocular and periocular tumors

The averaged-annual frequency of ocular and periocular tumors during the pre-COVID-19 phase was 1618 which reduced to 958 during the COVID-19 phase, while the averaged-monthly frequency also reduced from 135 to 80 patients. For patients presenting with benign tumors, the averaged-annual frequency decreased from 1141 to 568 patients, while the averaged-monthly frequency decreased from 95 to 47 patients and never matched the pre-COVID-19 monthly average by March 2021. For patients presenting with malignant tumors, the averaged-annual frequency decreased from 477 to 390 patients, while the averaged-monthly frequency from 40 to 33 patients and exceeded the pre-COVID-19 monthly average by September 2020. A detailed comparison of the monthly trends of the ocular and periocular tumors in the pre-COVID-19 and COVID-19 phase is described in [Figure 4].
Figure 4: Monthly trends of patients with ocular and periocular tumors during the pre-COVID-19 and COVID-19 phases in India

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   Discussion Top


This study sought to describe the impact of lockdown and unlock phases of the COVID-19 pandemic on the presentation of patients with ocular and periocular tumors at a tertiary eye care center in India. We analyzed the pattern, distribution, and clinical profile of patients with ocular and periocular tumors in year 1 of the pandemic, with the averages of the preceding 3 years to have a better comparative understanding.

The significant decline in the patient numbers during the lockdown phase is concerning since it can negatively impact patient outcomes due to delayed diagnosis, especially in a cancer set-up. This trend of decline in patient numbers during the pandemic has been seen globally. In a literature review of 87 articles about changes in cancer care during COVID-19, it was noted that globally, there was a reduction in the clinical visits by 26% and delay in treatment by >50%.[10] The effect of the pandemic on the patient numbers has been greater in India. In a study of 41 cancer centers across India between March and May 2020, there was 54% reduction in new patients, 46% reduction in follow-up patients, and significant reduction in treatment uptake.[11] In our study, the effect of COVID-19 and lockdown was greater with 85% decrease in patient numbers during the lockdown period.

In the postlockdown period, there is an expected increase in patient numbers where more patients may visit the health-care facilities for continuation of cancer care or for the purpose of diagnosis or initiation of treatment.[12] This may in fact lead to overcrowding of the health care system. Similar trend was seen in our set-up where the patient numbers during the unlock phase increased to 105% of pre-COVID-19 volumes with significant increase in patients with malignant ocular conditions, reaching 145% of pre-COVID-19 volumes. However, it should be noted that this delay in clinical care due to lockdown, especially for malignant cases, can have adverse effects on the outcomes. It is predicted that the effect of this pandemic can be devastating, in general, and, more so, on cancer patients, with 20% increase in mortality due to delayed diagnosis and delayed treatment for cancer.[13] The mortality risk in cancer patients is further increased to 78% when associated with more than one comorbidity.[13] There is a need to identify the vulnerable group of patients who are unable to access essential eye care services for the diagnosis and treatment of eye cancer in challenging times such as this pandemic. It is interesting to note that there was no gender disparity in the access to care in the current study, and there is a need to address the pediatric population whose proportion saw a slight decrease during the pandemic phase. The proportion of patients with benign tumors never matched the pre-COVID-19 monthly average even by March 2021, indicating a nonemergent perspective of the patients who may have deferred the clinical examination due to the travel restriction imposed during the pandemic across the country. The external nature of the conjunctival lesions and increased visibility may have contributed to an increased presentation for evaluation and treatment. The exact effect of this changing trend on the number of patients with ocular and periocular tumors and the treatment outcomes in our setup due to the pandemic is yet to be known. This study brings a few crucial insights that have helped identify the pattern of presentation of patients, while the severity of the eye cancer and the impact of delayed presentation on the outcomes need to be further explored in future studies.


   Conclusion Top


The 1st year of the COVID-19 pandemic saw a significant decline in the number of patients presenting with ocular and periocular tumors. There was an increase in the proportion of malignant tumors and a decrease in benign tumors during the lockdown phase. There was a near-complete recovery in the patients requiring inter-state travel to access eye care services. With the expected cycles of lockdown and unlock period during this pandemic, patients with ocular and periocular tumors may be adversely affected with advanced disease at presentation, delay in timely diagnosis and timely treatment, and poorer outcomes with respect to vision, globe, and life salvage. There is a need to strengthen patient counseling about the periodic review and plan strategies for appropriate outreach help with teleophthalmology services in selective cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Das AV, Kammari P, Vadapalli R, Basu S. Big data and the eyeSmart electronic medical record system – An 8-year experience from a three-tier eye care network in India. Indian J Ophthalmol 2020;68:427-32.  Back to cited text no. 8
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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