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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 121-127

Ophthalmological practices in COVID pandemic during first and second wave: Learnings and new beginnings

Department of Opthalmology, Regional Institute of Ophthalmology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Submission07-Jun-2022
Date of Decision22-Jul-2022
Date of Acceptance27-Jul-2022
Date of Web Publication2-Sep-2022

Correspondence Address:
Vivek Singh
Regional Institute of Ophthalmology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jigims.jigims_23_22

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Purpose: TO study the impact of covid 19 in a tertiary eye care hospital.
Study type: single centre retrospective observational study.
Method: Novel corona virus “COVID-19” is now an established global Pandemic. Index case of Novel Corona virus “COVID-19” virus was first reported from Wuhan, People's Republic of China on 31 December 2019. Bihar with a population of 120 million is one of the most densely populated and least developed states in India. With 1 doctor/29,000 persons and1 hospital bed/8,645 people, it was expected to be one of the worst hit state in COVID-19 pandemic. All patient visiting an ophthalmologist were seen with full precaution and with a practical Standard Operating Protocol (SOP), advised by World Health Organization (WHO), Centre for disease control (CDC), MOHFW, American Academy Of Ophthalmology(AAO) and All India Ophthalmological Society(AIOS). Patient visiting and treatment protocol followed in a tertiary care hospital were analysed.
Results: 3617(2432 males ,1185 females) new patients and 3145(2149 males, 996 females) old/follow up patients visited RIO OPD from lockdown (25 march 2020) till unlock 4(30 September, 2020) which is about 85.41% decrement in comparison to last year in same period 21747(13335 males, 8412 females) new patients and 24610(15508 males, 9102 females).
Conclusion: Proper use of n95 masks, gloves, caps, face shield, PPE kit while examining patients and operating them were few important precautions. Regular use of sanitizer, hand washing, minimizing patient doctor contact time, minimal hospital stays, use of artificial intelligence are few other ways practiced to prevent exposure to COVID 19. This pandemic has taught us a lot about people unity cooperation, what is important in life, ophthalmologically tele-ophthalmology will play a big role in future an evident in this pandemic.

Keywords: COVID, ophthalmological, pandemic

How to cite this article:
Singh V, Anand A, Kumar VB, Eqbal S, Raj P. Ophthalmological practices in COVID pandemic during first and second wave: Learnings and new beginnings. J Indira Gandhi Inst Med Sci 2022;8:121-7

How to cite this URL:
Singh V, Anand A, Kumar VB, Eqbal S, Raj P. Ophthalmological practices in COVID pandemic during first and second wave: Learnings and new beginnings. J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2023 Mar 27];8:121-7. Available from: http://www.jigims.co.in/text.asp?2022/8/2/121/355317

  Introduction Top

”The secret of change is to focus all of your energy, not on fighting the old, but on building the new.”

– Socrates

Novel coronavirus “COVID-19” is now an established global pandemic. Index case of novel coronavirus “COVID-19” virus was first reported from Wuhan, the People's Republic of China on December 31, 2019.[1] World Health Organization (WHO) on January 30, 2020, announced an outbreak of Public Health Emergency of International Concern and on March 11 declared COVID-19 a global pandemic. Globally, as of 4:22 pm, chemical exchange saturation transfer, May 25, 2022, there have been 524,339,768 confirmed cases of COVID-19, including 6,281,260 deaths, reported to WHO. As of May 22, 2022, a total of 11,752,954,673 vaccine doses have been administered.[2] The first confirmed case of COVID-19 was reported in India in Kerala on January 27, 2020, in a 20-year-old female with a travel history of Wuhan city, China,[3] Bihar got its first proven case of corona on March 22, 2020, in a 38-year male with a travel history from Qatar.[4] The government of India imposed a national lockdown on March 25, 2020, after a trial of “junta curfew” on March 22 following which hospitals were supposed/instructed to provide emergency services only. India's COVID-19 response scored a perfect 100 on the “Oxford COVID-19 Government Response Trackers[5]” which compared various government's responses to the coronavirus pandemic.

Bihar with a population of 120 million is one of the most densely populated and least developed states in India. With 1 doctor/29,000 persons and 1 hospital bed/8645 people,[6] it was expected to be one of the worst hit states in the COVID-19 pandemic. This precarious situation was further tested by the wave of migrant population returning to rural areas of Bihar postMarch 25, 2020, nationwide lockdown.[7]

Worldwide health-care workers (HCWs) were almost 5–10 times[8] more susceptible to infection.[9] The risk is higher in health personnel's working close to head end of patients such as ENT surgeons, dental specialists, and ophthalmologists.[8] “Li Wenliang” regarded, as “whistleblower” of COVID-19 was a Chinese Ophthalmologist who worked at Wuhan Central Hospital, contracted COVID-19, from an asymptomatic patient of glaucoma and finally succumbed to COVID-19 pneumonia on February 7, 2020, at age 33, was awarded by Government of China as national hero posthumously. Many retrospective studies have documented that approximately 1% of COVID patients display eye symptoms such as conjunctivitis, dry eye, itching, or posterior segment complication such as retinal hemorrhage, retinitis, and neuritis, and ophthalmologists can be the first point of contact. SARS CoV 2 RNA has been identified in asymptomatic cases[10] as well as in tears and conjunctival secretions[11] in patient with conjunctivitis. We as ophthalmologists were in high[12] risk category of COVID-19 infection due to the presence of virus in the tear fluid, proximity of encounter, and deceiving symptoms.[12]

Napoleon Hill once said “The starting point of all achievement is desire.” we will review the various modifications in ophthalmology practices including various check mechanisms[13],[14] which we had placed to effectively deliver quality emergency and semi-emergency ophthalmic services during the lockdown and afterward considering our HCWs safety.

All patients visiting an ophthalmologist were seen with full precaution and with a practical standard operating protocol (SOP), advised by WHO,[15] Centre for disease control,[16] MOHFW,[17] American Academy Of Ophthalmology (AAO),[18] and All India Ophthalmological Society (AIOS).[19]

In the first phase of implementation, outpatient department (OPD) numbers were restricted. Patients visiting the OPD were screened using the Indian Council of Medical Research (ICMR) self-declaration questionnaire and thermal screening.[20] Social distancing, face shield, and sanitizer were the three pillars for the prevention and spread of the virus. A simple cloth mask or a modified mask made from a towel or dupatta was even allowed due to the general profile of patients visiting from rural backgrounds. Examination from a distance of 1–2 m was encouraged. Slit lamps were modified with an added screen guard to prevent direct aerosol exposure to the HCWs. Initially, in the first phase, all HCWs were encouraged to wear 80-g personal protective equipment's (PPEs) with a two-layer mask (inner N95 mask with an outer three-ply mask) as per MOHFW guidelines.[21] Everyone was trained about donning and doffing of PPE kits in demarcated areas. PPE kit was advised for personnel involved in either active management of COVID-19 positive or suspected patients or person involved giving clinical services >15 min.[21] It was left on the voluntary choice of individual HCWs regarding donning of PPE in OPD and it was soon concluded that in tropical countries, it was impractical to wear PPE for prolonged hours. PPEs gave way to cloth OT gowns along with gloves.

Hand hygiene with soap and sanitizers was promoted. Sterilization of instruments and hands with isopropyl alcohol was mandatorily carried out in OPD. For inpatient care, all patients were triaged into three categories: emergency, semi-emergency, and routine according to the AAO[16] and AIOS guidelines.[19] [Flowchart 1] broadly outlines the patient management roadmap that was followed at the Regional Institute of Ophthalmology (RIO), IGIMS-Patna during the first and second waves.

Guidelines followed at RIO, IGIMS.

  Division of Labor Top

HCWs involved in providing eye services were especially vulnerable to COVID-19 cross infection while doing routine clinical procedures. Visual acuity assessment, refraction, slit-lamp examination, and indirect ophthalmoscopy all required prolonged contact and verbal interaction with patients. Pools of HCW's including doctors were divided into three groups and rotated on 1-week clinical duties and 2-week mandatory quarantine period. Every HCWs morning temperature and digital index finger PaO2 data was maintained. Within the three groups, three subgroups or units were made [Flowchart 2].

  Seating Arrangement, Patient Management, and Monitoring Top

Patient and their attendants visiting the hospital were at more risk of getting exposed to the COVID-19 virus. SOPs and ICMR questionnaires were implemented to minimize the risks. All patients postregistration were subjected to infrared thermal screening using a Hand-held Thermometer, pulse oxygen saturation using a handy Pulse Oximeter and mandatory hand hygiene/sanitization. Patient waiting and seating area were moved to a well-ventilated area with doors and windows open all the time. The use of fan was promoted. Air conditioning system was avoided in the waiting hall. Chairs were arranged at 1-m distance with alternate seating space and seats between two were blocked by stickers. All furniture and area were sanitized for 6 h with 1% sodium hypochlorite as per protocol. Hand sanitizer with no touch foot-based dispenser was provided. Efforts were undertaken to increase patient education and awareness regarding the corona pandemic using large posters, playing videos on the television display system, and regular interval announcements encouraging social distancing and promoting hand hygiene [Figure 1] and [Figure 2].
Figure 1: Patients seating area

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Figure 2: HCWs in protective kits. HCWs: Health-care workers

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  OPD Interface Top

After the initial screening of patient and referring the suspected patient directly to FLU clinic, the rest were evaluated by optometrists and doctors. The risk of exposure was reduced by the use of mike, minimum verbal interaction, avoiding handling of patient files to bare minimum, history taking, and counseling from a distance. We ourselves devised a Slit Lamp Breath Shield with discarded CT/MRI scan film and also a plastic shield made of overhead projector sheet for indirect ophthalmoscope. Slit lamp and doctor station were separated from each other with the provision of sanitizer, gloves, and disinfectant at each station. All OPD instruments such as slit lamps and autorefractometers were sanitized as per their protocol by the company.[17] Other measures such as paperless work implementation, minimal attendant, and minimum contact time were also practiced [Figure 3].
Figure 3: HCWs in PPE with slit lamp breathe shield. HCWs: Health-care workers, PPE: Personal protective equipment's

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  Investgation Wing Top

All procedures having a risk of aerosol generation (noncontact tonometry) or closed spaces (Humphrey field analyzer) were avoided. Optical biometry was preferred over A-scan (contact with tears). Fluorescein fundus angiography, ocular coherence tomography, B-scan, and laser's procedures were done only for emergency cases if indicated. Post availability of reverse transcription–polymerase chain reaction test for COVID-19 and Rapid Antigen Kit test all routine tests were performed postnegative result. During surge in cases and it was dynamic in nature, i.e., with increase in cases, we increased the testing. Strict mask protocol was always followed [Figure 4] and [Figure 5].
Figure 4: B-scan with proper precaution

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Figure 5: ROP laser done with full precaution. ROP: Retinopathy of prematurity

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  Ward Arrangement Top

Number of beds in the ward was decreased and maintained at least a distance of 1 m between each bed. Patient once admitted to wards were allowed with only one attendant and were not allowed to leave bed and group talk with others. Wards were sanitized with 1% sodium hypochlorite 6 h per protocol of isolation area; beds were thoroughly cleaned and sanitized before allotting the next patient.

  OT Protocol Top

High air outflow, minimal staff, minimal time, and one surgery at a time were few precautions practiced in OT to prevent virus spread. Strict sanitization protocol was followed which included pre- and postsurgery sanitization with 1% sodium hypochlorite, operating microscope and other instruments and table were covered with disposable sterile covers. Cases in general anesthesia carried a higher risk of aerosol generation and were performed using standard COVID protocol. There was a separate area for donning and duffing of PPE kit.

  Teleophthalmology Top

Before the COVID-19 pandemic, the facility of teleophthalmology was underutilized, but this pandemic led us to an indigenous teleophthalmology unit in our department with limited technical support and devices. Cross-pollination of ideas is critical for innovations in processes for greater efficiency, leveraging of technology, and drafting roadmaps for better patient safety and satisfaction. We ourselves made an operational teleophthalmology using WhatsApp, mobile, and computer with Internet. Advertisement was given in local newspapers, and central telecommunication was also started for information to all patients. We found this mini nascent version of teleophthalmology worked well. Initial few days were challenging but gradually the number increased, benefitting patients, and preventing routine hospital visits. It emerged as a blessing in disguise and became an important tool in indirect prevention of the spread of the virus [Figure 6].[22],[23]
Figure 6: Use of teleophthalmology

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  Teaching Practices in Ophthalmology Top

Teaching is an important part of any medical facility, which was also hit hardly. However, it had marked the beginning of online classes, a modality that comes to the rescue of students at times of similar crisis. A central online teaching laboratory was made so that students can learn while remains safe from COVID.

  Specific Measures for Subspecialties Top

RIO, IGIMS-Patna is a tertiary superspeciality center catering to all superspecialists of ophthalmology. A lot of our patients in specialty clinics are referred from private practitioners and government hospitals serving at district or talukas. Overall, at the peak of the first and second wave, ophthalmic patient's number had decreased at all levels which translated into decreased referrals. However, in the intermittent periods of normalcy, the patients who visited in various superspeciality clinics were in an advanced state of various progressive diseases.

Cornea Services: Patients requiring cornea consultation were encouraged to undergo regular teleconsultation and smartphones at patient's end were used as portable telescreening devices. Standard triaging of cases was done, and all emergency cases such as active keratitis, corneal ulcers, corneal perforation, corneal graft rejection, and foreign bodies were taken up with SOP in place. Due to delay in primary consultation and delayed referral corneal ulcers either in advanced stage or totally nonsalvageable were increased in proportion than normal. Organ donation and retrieval were badly affected during the first and second wave and patients whose eyes could be salvaged with therapeutic keratoplasty were given alternative treatment such as Gunderson flap or prolonged medication due to nonavailability of tissue.

Glaucoma services: All glaucoma patients were promoted to have regular teleconsultation. Patients were sensitized on compliance of glaucoma medications, signs of uncontrolled IOP, and self-monitoring. Telescreening of established glaucoma patients was one of the most difficult parts, and a smartphone-based visual field analyzer or mobile IOP monitoring device was sorely missed. Post first and second wave, many patients presented with advanced glaucomatous damage due to lost follow-up.

In retinal services also patients were triaged and treated, all nonurgent patients were postponed and advised on teleophthalmology. COVID-related retinal diseases such as central retinal vein and artery occlusions, acute macular neuroretinopathy, paracentral acute middle maculopathy, and various forms of posterior uveitis were observed. Retinal hemorrhages, cotton wool spots, dilated veins, and tortuous vessels were also seen.

  Eye Banking and Corneal Transplantation-”Hardest Hit Part of Ophthalmology” Top

Initially, corneal retrieval was stopped, elective surgeries such as optical keratoplasty were postponed, emergency therapeutic and tectonic keratoplasty were tried with alternatives such as glycerin-preserved cornea, tissue adhesive (small perforation), conjunctival hood, and complete tarsorrhaphy. On August 19, 2020, MOHFW issued guidelines on Safe Ophthalmology Practices in the COVID-19 Scenario which allows eye banking activities through Hospital Cornea Retrieval Program in non-COVID-19 cadavers. However, all activities were done as per the guidelines, with proper precautions and cleaning of all equipment's, instruments, and bags such as donor forms and documents are to be exposed to UV light for 30 min.

  RIO, IGIMS Experiences Top

Three thousand six hundred seventeen (2432 males and 1185 females) new patients and 3145 (2149 males and 996 females) old/follow-up patients visited RIO OPD from lockdown (March 25, 2020) till unlock 4 (September 30, 2020) which is about 85.41% decrement in comparison to last year in same period 21747 (13,335 males and 8412 females) new patients and 24,610 (15,508 males and 9102 females). Furthermore, a decrease of 89.97% (2233 from March 25 to September 30, 2019, and 224 from March 25 to September 30, 2020) in numbers of patients taken for surgery/interventions in OT was noted. A total of 224 patients, 136 (60.7%) adults, 99 (44.2%) males and 37 (16.5%) females, and 88 (39.3%) children (age <18 years, 64 [28.6%] males and 24 [10.7%] females) were taken up for surgery. Six patients (other than mentioned above) were admitted in the isolation ward (five children and one adult) due to the COVID-19-positive report and were notified and transferred to the COVID-19 treatment center. Majority of cases were of traumatic perforation and injury (73, 32.6%), followed by those require VR surgery (35, 15.6%) like of retinal detachment, endophthalmitis, extracapsular cataract extraction/small-incision cataract surgery (27, 12.1%) for complicated cataracts, intravitreal injections of anti-vascular endothelial growth factor (27, 12.1%), and some were of tumors such as retinoblastoma (7, 3.1%) requiring enucleation, tumors requiring biopsies (7, 3.1%), and evisceration (7, 3.1%). One doctor, two nurses, and one optometrist become COVID-19 positive; on contact tracing, it was found that they acquire infection outside the hospital and not during duty hours. They all were in home isolation and recovered. Out of six patients who were COVID-19 positive, two cases (retinoblastoma and retinopathy of prematurity) return back for treatment after they become COVID-19 negative and were treated afterward.

  Conclusion Top

As ophthalmologists, we have to deal with taking care of patient while balancing costs of investment, and running hospitals, especially private practice. We have to prevent the spread of COVID among HCWs and patients, and follow guidelines as advised and revised time and again by the government and infantile experiences. Proper use of N95 masks, gloves, caps, face shields, and PPE kit while examining patients and operating them were few important precautions. Regular use of sanitizer, hand washing, minimizing patient–doctor contact time, minimal hospital stays, and use of artificial intelligence are few other ways practiced to prevent exposure to COVID-19.

  New Beginning Top

This pandemic has taught us a lot about people unity cooperation, what is important in life. Ophthalmologically, teleophthalmology will play a big role in future as evident in this pandemic. There is a need to take mental health seriously. Moreover, it also paved a way for newer gadgets and equipment with more safety profiles. As said by Robert H. Goddard “It is difficult to say what is impossible, for the dream of yesterday is the hope of today and the reality of tomorrow.”

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Conflicts of interest

There are no conflicts of interest.

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