With limited resources in place, cataract surgery in India has taken a back foot and there is a huge waiting list of patients ready to go in for the surgery. The need of the hour is to adopt new approaches to ensure that doctors and patients are safe during the procedure
Coping to get a doctor’s appointment during COVID-19 lockdown has been stressful for many patients with ophthalmic conditions as most hospitals and clinics restricted face-to-face consultants. So, people seeking cataract surgeries during this pandemic had the maximum setback.
Cataract is the second leading cause of preventable blindness. According to a survey conducted in 2019 by the National Programme for Control of Blindness & Visual Impairment (NPCBVI), under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, cataract leads to 66.2 per cent blindness cases, 80.7 per cent severe visual impairment cases and 70.2 per cent moderate visual impairment cases in the age group of above 50 years. Though there has been a drop in the prevalence of blindness in the population above 50 years to 1.99 per cent in 2018 from 5.3 per cent in 2001, the situation turned grave during the COVID-19 pandemic.
On one hand, patients had to wait long to get a date fixed for the cataract surgery while on the other hand, providing the required care to patients became very daunting for ophthalmologists.
Though the Government of India has given clearance for the functioning of eye care facilities, strict guidelines are to be followed by the eye care institutes while catering to the patients’ needs. The guidelines apply to all practice settings including tertiary institutions, corporate and group practices and individual eye clinics and are expected to evolve over the next few months, given the current circumstances.
Dr Kasu Prasad Reddy – Chief Surgeon and Founder, MaxiVision Group of Eye Hospitals, Hyderabad, informs that the numbers of cataract surgeries have come down drastically as patients attending the clinic are less due to various fear factors. According to him, only 40 per cent of the surgeries are being conducted now and during the lockdown period, approximately 655 surgeries were conducted.
Maxivision took all the normal preventive measures that were in practice but also, patients were advised to come with one attendant and were provided PPE at free of cost.
Nevertheless, since institutes have opened their doors to patients there has been some relief.
Dr Jagadesh Reddy, Head of Cataract and Refractive Service, LV Prasad Eye Institute, says, “If you look at the per cent decrease in the performance of cataract surgeries in comparison to same months in 2019, there has been some improvement. In April 2020, the decrease was 99.55 per cent over April 2019. In May 2020, it improved to 85.6 per- cent decrease over May 2019 and in June, it further improved to a 40.6 per cent decrease over June 2019.”
But this does not end the agony of healthcare institutes. Ophthalmologists at eye care institutes have had to adopt a slew of measures to cope with the pandemic crisis and resume patients on their safety.
Role of telemedicine
We are well aware of the role of teleconsultation and teleophthalmology has played during the COVID-19 lockdown. With patients unable to physically meet ophthalmologists, the role of telemedicine was a win-win situation for both the doctors and patients. Post surgeries online consultations helped patients get the required advise via video calls and the risk of contracting the coronavirus was mitigated. The attitude and perception of the doctors and patients have been changing gradually. Even patients in inaccessible areas got benefited due to telemedicine.
A survey conducted by All India Ophthalmological Society (AIOS) to assess the attitude of ophthalmologists in India towards teleophthalmology depicted a surge in attitude towards the integration of teleophthalmology into practice. Out of a total of 1180 responses, only 17.5 per cent were already using teleophthalmology. However, 98.6 per cent of all participants showed interest in incorporating it into their practice and 98.8 per cent of all participants were eager to adopt a dedicated mobile application (app)-based teleconsultation. 93.1 per cent were interested to use an affordable ophthalmology specific Electronic Medical Record (EMR) if AIOS was to develop it. 54.9 per cent of respondents had previously used EMR which would make adoption of this technology less challenging.
There some hospitals who even resorted to WhatsApp consultations. MaxiVision Group of Eye Hospitals informs that they ensured patients received all the necessary consultations through Whatsapp videos during the lockdown.
According to Dr Reddy has helped a lot in decreasing the need for physical consult thus avoiding the risk of cross-infection for patients and the healthcare professionals.
Dr Reddy adds, “Telemedicine has helped to identify patients who need physical consult for evaluation of cataract. After surgery, the number of physical visits to the clinic is restricted to only one visit. The other consultations are done through telemedicine.”
Though one of the vital barriers for use of teleophthalmology is unfamiliarity with its use for patients and doctors; however, adopting new technological innovations in telemedicine will be the new norm in future. Doctors can go in for formal training which will in some way help to get rid of the initial barriers. Besides, the availability of good Internet will play a key role in adopting telemedicine as the future mode of treatment.
Measures adopted by eye-care hospitals during the pandemic
Some eye care hospitals have adopted holistic approaches keeping in mind to safeguard both the patients and ophthalmologists and to minimise the risk of cross-infection.
LV Prasad Eye Institute, for example, ensured that while booking an appointment, the necessary history of the well-being of the patient and family members was emphasised upon. In the hospital premises, triage centre screens were set up for every patient to confirm whether there were any symptoms of COVID-19 with appropriate history and temperature measurement. On any patients being found to have any symptoms, isolation rooms were set up where the patients were examined.
All healthcare workers at LVPEI clinics took necessary precautions where personal protective equipment was provided. Digital payment methods and self-check-in kiosks have been made available in the clinic to minimise the physical contact with any object or personnel. The hospital also ensured staggered appointments to maintain social distancing in the waiting halls. All elderly patients (80 years and above) are examined on a high priority to minimise their stay in the hospital. Examination rooms are modified to minimise patient movement between rooms and the need for any test that requires contact with the patient.
“Staggered surgery appointments were given to minimise waiting in the hospital. Besides steps were taken to modify the surgeries that minimise the duration of the procedure or generation of aerosols. We ensured the use of disposable material wherever applicable, cleaning the operating room after every case and a necessary time gap of 20-30 min between each procedure”, Dr Reddy adds.
Post COVID strategies
In the case of eye hospitals, going back to normal will take time. Ophthalmic leaders and entrepreneurs need to devise strategies to ensure the speedy revival of their practice and come forward with innovative solutions to address several challenges.
Dr Kasu Prasad Reddy says, “For the next six months, we intend to continue the same protocol mentioned above by providing PPE to the patient and attendant and strictly adhere to it.”
Dr Jagadesh Reddy says, “Based on ICMR guidelines if there is a development of herd immunity or development of a vaccine for COVID-19, we can slowly revert to what we were practising before. This would be in a phased manner. At present we are working with the “new normal” guidelines.”
Hospitals need to look at new ways to provide better services. Most of the ophthalmologists still remain unclear about when and how to resume surgeries upon easing off of the COVID-19 related restrictions. Regulatory bodies should issue appropriate guidelines regarding the same. Also, upgrading of software and technology, online advice, teleophthalmology, will play a huge role as these will be the new normal for cataract surgery.