“No matter how much falls on us, we keep plowing ahead. That’s the only way to keep the roads clear.” - Greg Kincaid
COVID-19, a black swan event, has profoundly affected us personally and professionally. The need for resources for the management of the pandemic in its first wave was so demanding that the delivery of elective healthcare was severely curtailed. That, coupled with the pervading fear of going to the hospitals, and the generalized economic distress consequent to the lockdown, resulted in a dramatic reduction in ophthalmology practice all over the world. Just as the pandemic seemed to stabilize and ophthalmic practices were returning to normal, the second wave has hit us hard – very rapidly and ferociously so. Epidemiological and mathematical models predict that the second wave may be more infective and lethal, geographically far widespread, affect the younger population, and last several months.
A public health crisis is living underneath the pandemic
Inability to access ophthalmic care can result in irreversible blindness and have severe and long-term socioeconomic implications. Specifically, mature cataract and consequent complications, corneal infections, uncontrolled glaucoma, and interruption in the timely management of diabetic retinopathy and age-related macular degeneration, can all lead to irreversible blindness. Disruption of eye-banking and corneal transplantation programs can result in an unsurmountable waitlist. Delayed care in malignant tumors of the eye and adnexa can have life-threatening implications.
Do we let our patients go blind and let our ophthalmic practices succumb to the second wave of the pandemic? Or, having learned from the first wave, and with our inherent preparedness for the new normal, can we ride the second wave confidently yet cautiously and emerge out unscathed and much stronger?
What has changed in a year?
From the position of absolute ignorance and panic a year ago, we have come a long way. We have by now understood the epidemiology, transmission, infectivity, and the spectrum of manifestations of COVID-19, host risk factors for severe disease, and have devised reasonably effective treatment algorithms. We have improved logistics and experienced personnel. We are aware of the biosafety precautions and preventive measures. Massive vaccination is underway to protect against the infection. Over 80% of healthcare workers in India have been vaccinated already. Most of the high-risk populations have been vaccinated by now and vaccination of all the adults is underway. With such preparedness, the continuation of well-triaged and prioritized ophthalmic care should be feasible. The prevalence of COVID-19 in asymptomatic, elective surgical patients during a second wave is very low - approximately 1 in 833, as reported by an Australian study. Routine preoperative RT-PCR helps detect such patients and reduce the risk substantially. The All India Ophthalmological Society has published guidelines for triage and ophthalmic care during COVID-19 times. Policies and precautions inherent in the guidelines for emergency care will continue to be applicable, and the same can be extrapolated to routine medical and surgical care [Fig. 1].
Think global, Act local!
Generic guidelines need to be tempered to local circumstances and interpreted in the context of the prevailing regulatory environment. The honorable Prime Minister of India has emphasized that a national lockdown will only be the last resort and will indicate the failure of all other pandemic control strategies. Assuming that it will only be a very remote possibility, what one needs to comply with are the local- and region-specific policies. In cities and states with a high incidence of COVID-19, there may be temporary restrictions on elective care to help conserve manpower, consumables, and infrastructure and thus, preserve capacity in the strained healthcare system. However, even under such circumstances, emergency care can still be provided for potentially blinding diseases.
Safe, sustainable, responsive, and responsible eye care strategy
A sustainable strategy incorporating the safety of patients and healthcare workers as a non-negotiable component, yet, continuing to provide optimal ophthalmic care for emergent and prioritized electives seems to be the current need. This, coupled with judicious use of telemedicine, will not only help preserve our patient care teams and practices, maintain a decent revenue cycle, build momentum for future growth, provide much-needed training to our residents and fellows, but also will ensure that our patients do not suffer irreversible blindness while awaiting access to care. Let us pivot forward toward a safe, sustainable, responsive, and responsible eye care initiative.
“We have survived, but we will need to adapt and adjust to learning how to thrive again.” – Richard Lindstrom
1. Toro MD, Brézin AP, Burdon M, Cummings AB, Evren Kemer O, Malyugin BE, et al. Early impact of COVID-19 outbreak on eye care:Insights from EUROCOVCAT group Eur J Ophthalmol 2021 31 5 9
2. Best MJ, McFarland EG, Anderson GF, Srikumaran U The likely economic impact of fewer elective surgical procedures on US hospitals during the COVID-19 pandemic Surgery 2020 168 962 7
3. Myles PS, Wallace S, Story DA, Brown W, Cheng AC, Forbes A, et al. COVID-19 risk in elective surgery during a second wave:A prospective cohort study ANZ J Surg 2021 91 22 6
4. 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 COVID-19 pandemic Indian J Ophthalmol 2020 68 711 24