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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 83-90

Changes in ophthalmological practice during the COVID-19 lockdown period


1 Department of Ophthalmology, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission06-Aug-2020
Date of Decision01-Sep-2020
Date of Acceptance27-Oct-2020
Date of Web Publication24-Jun-2021

Correspondence Address:
MD Elham A Gad
Department of Ophthalmology, Benha University, Benha 13516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DJO.DJO_61_20

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  Abstract 


Background To limit the spread of coronavirus disease 2019 (COVID-19), the Egyptian Government had declared a national lockdown on March 24, 2020, with reduction of all governmental medical services.
Aim The aim of this study was to investigate the changes in ophthalmological medical and surgical practice as well as the changes in learning during the COVID-19 lockdown.
Patients and methods This is a cross-sectional study that included 263 working ophthalmologists from all over Egypt. They were asked to fill in a questionnaire about the changes in their clinical ophthalmic practice. The questionnaire was distributed as a Google form through e-mails and different social media platforms. Young ophthalmologists (<35 years) were compared with experienced ophthalmologists (>35 years) regarding the use of technology and E-learning during the lockdown of the pandemic. Ophthalmologists with private practice were compared with ophthalmologists without regarding the changes in real-life clinical practice during the same period.
Results The mean age of the participants was 45.6±12.96 years (range=27.0–68 years). Overall, 67.3% were males, and 52.1% had a private practice either alone or with governmental practice. Most participants (86.7%) were still seeing patients during the lockdown. However, 96.2% of them decreased the number of their working days, and 94.3% decreased the number of patients. Approximately 47% of the participants stopped all surgeries, whereas 9.9% performed only emergency surgeries and 42.6% performed any type of surgery. All participants wore facial masks, 88.6% used breath shields, 55.5% wore gloves, and 59.7% started online consultations. Experienced ophthalmologists significantly attended more scientific webinars, whereas for young ophthalmologists, webinars were very useful medically but not helpful for their surgical skills.
Conclusion The lockdown of COVID-19 did not stop ophthalmological practice in Egypt. It reduced the number of working days and the number of patients. All participants used different personal protective equipment, and more than half of them started online consultations. E-learning was very useful for young ophthalmologists but it did not help their surgical skills.

Keywords: COVID-19, lockdown, ophthalmology


How to cite this article:
Gad EA, Soliman SS, Wasfy T. Changes in ophthalmological practice during the COVID-19 lockdown period. Delta J Ophthalmol 2021;22:83-90

How to cite this URL:
Gad EA, Soliman SS, Wasfy T. Changes in ophthalmological practice during the COVID-19 lockdown period. Delta J Ophthalmol [serial online] 2021 [cited 2021 Sep 22];22:83-90. Available from: http://www.djo.eg.net/text.asp?2021/22/2/83/319181




  Introduction Top


Dr Li Wenliang, an ophthalmologist from Wuhan, China, tried to warn his colleagues from an unknown infectious disease outbreak, asking doctors to take care and to wear personal protective equipment (PPE) while examining their patients. Shortly after that, the disease turned into a global pandemic and was termed as coronavirus disease 2019 (COVID-19) [1]. On February 7, 2020, Dr Li Wenliang passed away owing to infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [2]. He was now considered an unusual hero for his efforts, as he was one of eight persons who tried to ring the alarm about this new respiratory illness [3].

The caution for possible ocular transmission of SARS-CoV-2 was first noticed by one expert who went to Wuhan on early 2020. Although being fully covered with protective gown and N95 mask, he was infected and his first symptom was unilateral conjunctivitis, with catarrhal symptoms and fever that occurred 2–3 h later [4].

Conjunctivitis is the most common ocular manifestation of SARS-CoV-2 and may present before pneumonia. Other ocular manifestations include epiphora, diminution of vision [5],[6], and rarely keratitis [7].

Infection through ocular secretions is currently uncertain, and it is unclear how SARS-CoV-2 aggregates in eye secretions. Theories include direct inoculation of the ocular tissues by droplets of respiratory system, traveling from the nasopharynx through the nasolacrimal duct, or blood spread via the lacrimal gland [8].

Ophthalmologists are at a great risk because of the close contact between them and their patients during direct ophthalmoscopy and slit-lamp examination. The American Academy of Ophthalmology has advised ophthalmologists to wear protective masks and eye protection during examining patients with conjunctivitis [9].

The lockdown caused by COVID-19 pandemic is a new event to the human population and has affected all aspects of human life across the globe. Health care workers are the front line of defense, and their practice has been greatly affected by the lockdown. It seems that this pandemic would cause oblivious and long-lasting changes in medical education and clinical practice of ophthalmology. So, this survey was planned to assess the changes brought about by COVID-19 lockdown on the clinical ophthalmological practice and ophthalmological education/training in Egypt.


  Participants and methods Top


This is a cross-sectional survey that was conducted during the last 2 weeks of June 2020. It included ophthalmologists from all over Egypt currently practicing ophthalmology. The study was approved by the Institutional Review Board, Faculty of Medicine, Benha University. An informed consent to participate and for publication of data was attached to the very first part of the questionnaire (the participant could not proceed to the questions without signing the consent). The questionnaire was completely anonymous, and the participant could withdraw from the questionnaire at any time. All data were kept confidential and were used only for research purposes.

Egyptian ophthalmologists who were aged 25 years or more were invited to participate. The participant must be currently practicing ophthalmology in an Egyptian health care facility either governmental (Ministry of Health including teaching hospitals and university hospitals) or in a registered private health care facility.

To assess the effects of COVID-19 lockdown on the ophthalmological education/training, the participants were classified according to their age into (a) young ophthalmologists who were aged 35 years or less and (b) experienced ophthalmologists who were older than 35 years. The participants were also classified according to their type of practice into (a) participants without private practice and (b) participants with a private practice (either with a governmental practice or without).

Study tool

The study stool was a self-administered questionnaire provided through Google forms in English language. The link to the form was shared through different online platforms that may be used by the participants. Each participant can fill only one form. The questions were prepared by the authors in the form of short answered, check boxes, or multiple-choice questions. The questions were then validated by three expert ophthalmologists (Cronbach’s alpha=0.84). A pilot study was done over 10 participants to test for any unclear terms or questions, but they were excluded from the main analysis. After making the necessary changes, the questionnaire consisted of the following:
  1. Part 1: sociodemographic data including age, sex, work affiliation, work area, and highest qualifications.
  2. Part 2: questions about the changes in ophthalmological education and training.
  3. Part 3: questions about the changes in clinical ophthalmological practice and patient care.


The sample size was calculated using EPI info 7 program (Centre for Disease Control and Prevention, Atlanta, Georgia, USA) and resulted in 263 required participants. It was calculated based on a 90% confidence level and 5% margin of error.

Statistical analysis

Data were presented as mean±SD, number, and percentages. The analysis was done using the Statistical Package for Social Science (SPSS), version 23 (SPSS Inc., Released 2015. IBM SPSS statistics for Windows, version 23.0; IMB Corp., Armonk, New York, USA). χ2 test was used to study the association between qualitative variables with Z test to compare column proportions. Whenever any of the expected cells were less than five, Fisher’s exact test was used. Two-sided P value of less than 0.05 was considered statistically significant.


  Results Top


The study included 263 ophthalmologists. Their mean age was 45.60±12.96 years (range=27.0–68.0 years). Most of them (67.3%) were males, and 77.2% were practicing in urban areas. Characteristics of the participants are detailed in [Table 1].
Table 1 Sociodemographic characteristics of the participants (N=263)

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There was no significant difference between young and experienced ophthalmologists regarding the time spent for online academic and scientific use (e.g. reading papers, case reports or browsing for scientific websites) (P=0.422) or the number of online sessions attended (P=0.525). Experienced ophthalmologists had significantly increased their attendance of online webinars than young ophthalmologists. However, young ophthalmologists attended significantly more medical webinars and found webinars very useful. Among the young ophthalmologists, 61.1% reported that the lockdown affected their surgical hand skills of the surgeries that they have already practiced before, and 66.7% reported that the lockdown stopped their surgical learning curve. Meanwhile, the experienced ophthalmologists were significantly less affected by the lockdown, as only 17.9 and 14.5% of them reported the same complaints, respectively ([Table 2]).
Table 2 Comparison between young and experienced ophthalmologists regarding the ophthalmological education and training

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[Table 3] details the changes in ophthalmological practice between participants with and participants without private practice. Most of the participants (86.7%) were still seeing patients at the time of this study, with no significant effect attributed to the type of practice (P=0.240). However, all participants with private practice had significantly decreased the number of work days in comparison with participants without private practice.
Table 3 Comparison between ophthalmologist without and with private practice regarding the clinical ophthalmological practice and patient care

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The number of the visiting patients decreased, as reported by 94.3% of the participants. However, 63.9% of the participants reported that most of their patients were visiting for cold ocular conditions. More than half (59.5%) of the participants without private practice had stopped performing surgeries, whereas more than half (55.5%) of the participants with private practice were still performing any type of ocular surgeries (either emergency or nonemergency). This difference was statistically significant (P<0.001). The majority (81.0%) of the participants reduced the number of patients they examined per work shift, and 92.5% of them restricted the number of patients’ relatives in the examination room, with no significant difference between participants with either type of practice. Significantly, more participants with private practice had activated telephone or online reservation services (P=0.045), whereas more participants without private practice kept a distance of 1–2 m between each patient in the waiting area (P=0.22, [Table 3]).

All participants with private practice and 96% of participants without private practice thought that ophthalmologists were at a high risk of infection by COVID-19. Subsequently, 89.1% of the participants with and 96.0% of the participants without private practice were keen to learn about infection control measures and the importance of PPE. The differences between both groups were statistically significant (P=0.024 and 0.033, respectively, [Table 3]).

All participants wore masks during the examination of their patients. Surgical masks were more significantly used by participants with private practice (92.7%), whereas face shields were more significantly used by participants without private practice (39.7%) (P=0.002 and P<0.001, respectively). Breath shield mounted to the slit lamp was used by most participants (88.6%), without significant difference between the % of participants with private practice or without. All the participants with and 96.0% of the participants without private practice asked their patients to wear masks (if they were not already wearing). This difference was statistically significant (P=0.024, [Table 3]).

Gloves were more significantly used by participants without private practice (P=0.013). Among participants who used gloves in either group, there was no significant difference regarding the frequency of their change (P=0.437), but most of the participants changed their gloves before each patient (60.0% of participants without and 52.65% of participants with private practice). Most of the participants washed their hands after each patient visit. However, 22.6% of the participants with private practice did not wash their hands and used gloves constantly instead. Gloves were more significantly used by participants without private practice (P=0.013). Among participants who used gloves, there was no significant difference regarding the frequency of changing gloves (P=0.437, [Table 3]).

More than half (157 participants, 59.7%) of the participants started online consultation without significant difference between either type of practice. Multiple online platforms were used by 38.2%, followed by WhatsApp only by 36.3% of the participants. However, 52.9% of the participants were not satisfied by this experience. [Figure 1]a, b shows the details in both groups.
Figure 1 (a) The online consultation and (b) the preferred online platform in each group. A questionnaire to investigate changes of ophthalmological practice during the COVID-19 lockdown period. COVID-19, coronavirus disease 2019.

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  Discussion Top


It was noted that most of the participating ophthalmologists (67.3%) were males and were working in urban areas (77.2%). To increase their income, 40.7% of the participants worked in both private and governmental facilities.

Since the lockdown, a surge has been noticed in the number of webinars and online continuous medical education programs in ophthalmology. Most of the experts and young ophthalmologists had more time to use and practice E-learning.

Conferences offer a precious opportunity to get expert opinions about how to develop and improve medical and surgical skills. However, to apply the ‘social distancing’ requirements, many conferences across the world have been postponed or canceled. Attendance of online webinars and classes during the lockdown has been encouraged by using technologies and applications in online academic and scientific use. Most of the attended webinars by young ophthalmologists (44.4%) were related to medical topics. This may be owing to the difficulty of learning surgical skills through watching online webinars. Most of the experienced ophthalmologists (76.9%) reported that these online webinars were somehow useful for them. This may be because they already have more skills and knowledge.

It is now obvious that in this year (2020), fellows and residents, not only in ophthalmology but also in all medical specialties, most probably will not be able to fulfill their log books and clinical rotations or to acquire the minimum required surgical skills. The effect of those incomplete experiences will be heavy on fellows/residents in their years of training [10]. As there is no alternative for learning and practicing techniques of clinical examination on patients and real-life surgical procedures, 61.1% of the young ophthalmologists thought that the lockdown affected their surgical hand skills of the surgeries that they have already practiced, and 66.7% of them thought that the lockdown stopped their surgical learning curve. Our questionnaire highlighted that the COVID-19 lockdown had ruined the schedules of the training programs and resulted in a negative noneducational-friendly environment for ophthalmology trainees across Egypt.

The same was reported by Mishra et al. [11] who surveyed 716 ophthalmology trainees in India. Most of their respondents (80.7%) felt that the lockdown negatively affected their surgical training and about more than half of them had an increased level of stress due to this issue. On the contrary, 75% of them found the online classes and webinars useful during the same period [11].

Other surgical specialties were also affected. A national survey in the United States directed to the general surgery residents found that most of the surveyed trainees reported a significant decline in the surgical cases they performed per week since the lockdown [12]. In the United Kingdom, cardiac surgery was reported to be greatly affected during the lockdown with great diminution in training opportunities [13].

In the present study, it was noted that 84.1% of the ophthalmologists working in governmental hospitals and institutes were still seeing and operating on patients. In addition, 89.1% of the standalone private practitioners had continued their activity in patients’ care. This can be understood as hospitals seem to be better equipped with staff, medicines, protective equipment, and inpatient requirements of isolation. Moreover, the lockdown in Egypt was not a full-time one. Both groups of ophthalmologists (without and with private practice) mentioned that their working days and the number of patients they have been seeing every working day were decreased. This happened owing to the effort of the Egyptian Government to apply social distancing rules through decreasing the number of human power at work place and raising the public awareness about the rapid spread of the disease. So, everyone avoided going out, especially in crowded places.

An Indian survey, including 1260 participants during the COVID-19 lockdown, showed a different situation, where 27.5% only of the respondents were still seeing patients and most of them were working in governmental and public institutes and were seeing only emergency patients [14].

Although ocular emergencies, such as trauma and other clinical conditions that require urgent care, were the most common procedures during the pandemic, it was surprising to note that at the time of fulfilling to the survey, 60.3% of ophthalmologists without private practice and 67.2% of ophthalmologists with private practice were still seeing cold ophthalmological cases.

The majority of the ophthalmologists in governmental work places stopped performing any surgeries according to American Academy of Ophthalmology guidelines. However, some of both groups (11.9% of ophthalmologists without and 8% of ophthalmologists with private practice) were still doing surgeries to ocular emergencies/urgencies as retinal detachment. There are few circumstances where cataract surgery may be considered as an emergency, such as subluxated/traumatic cataract or phacolytic glaucoma. However, more than half of the ophthalmologists with private practice (55.5%) were still performing any surgical condition (emergency and elective). The same was reported by Nair et al. [14], who found that emergency and nonemergency surgeries were still performed included intravitreal injections (9.1%) and cataract surgeries (5.9%).

The majority of ophthalmologist of both groups adhered to the social distancing rules in the form of reducing the number of patients they see per shift, keeping distancing of 1–2 m among patients in the waiting room, and restricting the number of patients’ relatives in the examination room. Social distancing also required activation of telephone or online reservation reach to prevent overcrowding and to inform the patients about the changes in their appointments.

Because of the close physical contact nature of their work and the modes of transmission of coronavirus through droplets, contacts, or fomites [15], ophthalmologists are considered among the high-risk medical specialists for COVID-19 exposure. Some anecdotal reports stated that ophthalmologists may be infected through patients with subclinical infection [16]. All these causes can increase the possibility of cross-infection, between the patients and between the health care workers and patients, in outpatient ophthalmology clinics than other clinical subspecialties. The results of this survey showed that Egyptian ophthalmologists consider themselves to be at a higher risk of infection with COVID-19 as compared with other medical specialties [17].

The PPE is of great importance during highly infectious situations. It could further eliminate the risk of exposure of health care providers to droplets coming out from a patient infected with COVID-19. Full PPE should include gloves, cap, isolation gown, mask, and eye protection. Approximately 80% of ophthalmologists without and 92.7% of ophthalmologists with private practice mentioned that they wear surgical masks. This may be because surgical masks are efficient in protection against SARS-CoV-2 virus, their prices are affordable, and ophthalmologists are already used to them. N95 respirators are rarely used as they are of single use and of high price and so, were not suitable for every day consumption. Fabric masks are economic but may not be so efficient as other types. Most of the participants in both groups did not prefer wearing face shield because of fogging and obscuration of vision by its scratches. They also may not be suitable to use with the slit-lamp or head-mounted examination appliances. On the contrary, most of the participants mounted breath shield to their slit lamps. Almost all of the participants asked their patients to wear masks.Approximately half of the participants put on gloves while examining their patients and most of them cleaned their hands (by either soap and water or hand sanitizers) after each patient visit. Here we should state that some of the participants used few pairs of gloves per shift or even one pair owing to economic causes.

Less than half of the participating ophthalmologists of both groups started online patient consultation by the time of answering the survey. The most common social media platform was WhatsApp, as it is easy to use and allows privacy to a greater extent. Many ophthalmologists used more than one platform, but about half of them were not satisfied with those consultations. This may be because ophthalmological examination depends on evaluating the eye structure through direct viewing with complicated instruments and not only the patients’ words or simple photographs. More online activity was reported by Nair et al. [14], as 78% of their respondents started telephone and web consultations like WhatsApp, telegram, or even video calls.

Like other surveys, we reported the inherent drawbacks of self-reported surveys.There are many details in the changes of ophthalmological practice to be evaluated during COVID-19 pandemic. Asking about all these details would have lengthened the time required to fill out the questionnaire and would have decreased the responses. Because COVID-19 lockdown is a recent and unique event, very few studies and research papers have been published about the effect of the pandemic over ophthalmological practice that can be used in our discussion.


  Conclusion Top


Although the lockdown of COVID-19 did not stop ophthalmological practice in Egypt, it had affected it greatly. Ophthalmologists had to reduce the number of their working days, the number of patients, and the number of surgeries performed. All participants have used different PPE, mainly masks and gloves, and half of them started online consultations. E-learning was very useful for young ophthalmologists; however, their surgical skills have been greatly affected.

Recommendations

Proper clinical organization and patient spacing in either time or place is mandatory for a safer ophthalmological practice. Some simple protective equipment like face shields should be obligatory at all ophthalmological facilities. Simple hand hygiene like washing with soap and water should be available inside all ophthalmology clinics. Online surgical education is not satisfactory for young ophthalmologists and other educational methods like simulation laboratories may be provided to help them in such a difficult time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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