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The new normal for cataract and refractive surgery due to COVID-19 (SARS-CoV-2)

Kohnen, Thomas MD, PhD, FEBO

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Journal of Cataract & Refractive Surgery: June 2020 - Volume 46 - Issue 6 - p 809-810
doi: 10.1097/j.jcrs.0000000000000240
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In Memoriam

Li Wenliang, Ophthalmologist, Wuhan, China

October 12, 1986–February 7, 20201

May we all be as courageous in our commitment to the profession of healing.

Last updated on May 22, 2020

Shutdown, Lockdown, Quarantine, Self-Isolating, Social-Distancing, The Great Pause. The restrictive measures required to combat COVID-19 have many labels and far-reaching effects, curtailing our private lives and greatly disrupting our profession. With the exception of some emergency anterior surgeries, cataract and refractive surgery is considered to be elective in most countries, forcing many of us to either stop or greatly reduce our workload and send many employees home. These necessary restrictions caused a loss of revenue and possibly patients but were effective in slowing down the spread of the virus.

Now that infection rates are more stable, most of us are exploring how we can reopen our doors and cautiously resume treating patients, as Shih et al. describes from Hong Kong in this issue (pg. 921). Our workloads will be decided by the local and regional rates of infection. Our clinical routines will be fraught with regulations and guidelines, which are likely to shift from week to week, if not daily, and that are dependent on local authorities and resources available. This is the new normal for cataract and refractive surgery. The way forward is to collectively develop long-term surgical strategies to enhance the safety of cataract and refractive surgeries in the era of COVID-19. Now more than ever, our patients need to know that their safety in clinics and outpatient centers is our top priority.

Some of the needed changes are structural, others procedural. Since March 15, the Goethe University Hospital in Frankfurt has made mouth–nose face masks for all employees and visitors mandatory and has restricted access to patients only. The hospital was also able to restructure departments, allowing us to dedicate one building solely to the treatment of COVID-19 patients. In addition, we are working on separating outpatient and inpatient surgeries to reduce patient exposure. Teleophthalmology is being implemented worldwide. For example, in the U.S. William Dupps, Jr, MD, PhD, Cleveland Clinic Cole Eye Institute, U.S., and new Editor of JCRS, stated that between March 16 and April 27, his group saw surgical volumes reduce to 20% of their previous levels and virtual visits increase to one third of total visits. On April 9, ASCRS and ASOA cosponsored a webinar hosted by Ranya Habash, MD, Medical Director of Technology Innovation and Assistant Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute, covering teleophthalmology in the U.S. and how some consultations could be performed remotely.2

A procedural change we have made in Frankfurt is to test all patients for COVID-19 before admittance to the hospital. We are questioning whether all ambulatory patients should be tested preoperatively, particularly if simpler and quicker tests become available. Another procedural change that could reduce patient exposure is to perform cataract surgery bilaterally, when possible. This is currently not the norm, nor is it preferred practice, but perhaps it is an adjustment that would facilitate treatment while reducing and managing risk during the COVID-19 pandemic.

We must also consider improvements to our equipment and how it is used. Aman Chandra, MD, Southend University Hospital, UK, shared an innovative idea of creating a microscope drape to reduce aerosol transmission during intraocular surgery.3 A how-to video is posted on the ESCRS website. Now more than ever, we must work closely with manufacturers to communicate our needs for improved safety. In this issue is an example of how our colleagues Peyman et al. have quickly adapted their slitlamps in Iran with a shield to protect the patients and ophthalmologist (pg. 919).

Although the degree of risk is not yet known, it is widely accepted that contact lens wearers are at a higher risk of infection because of probable contact with the eye tissue. This could be a reasonable argument for the permanent correction of refractive errors with surgery. On the ESCRS COVID Global site, Lucio Buratto, MD, posted an informative and instructional outline for contact lens use during the COVID-19 pandemic, “COVID-19 and contact lenses: Instructions and advice to follow only during the pandemic period.”4

Liliana Werner, MD, PhD, Moran Eye Center and Associate Editor, U.S., for JCRS, reported on anterior segment research during COVID-19. Werner stated that the number of IOLs explanted around the world and sent to Moran Eye Center for analysis is considerably reduced, to almost none. Researchers at the University of Utah are permitted to continue in vivo studies so long as time spent in the laboratory is kept to a minimum and social distancing recommendations are observed. Analyses of data, reports, and so on are performed remotely from home. Research related to human eyes obtained postmortem (particularly research using nonfixated human tissue) has stopped until issues such as screening of tissue for the presence of the virus are clarified.

Obviously, the education and training of cataract and refractive surgery is also impacted. For those in training, Nick Mamalis, MD, Director of the Ophthalmic Pathology Laboratory at University of Utah and Editor Emeritus for JCRS, suggests going over surgical videos and using surgical simulators, if possible.5,6 This is also an ideal time to publish and network within the ophthalmological societies. JCRS has seen an increase in submissions during the past six weeks, which is great to see. In addition, the young minds of the newer generations could be instrumental in the path forward. Sathish Srinivasan, FRCSEd, FRCOphth, FACS, European Associate Editor and the President Elect of the UK and Ireland Society of Cataract Surgery, has been leading the efforts in providing evidence-based updates through the national society for ophthalmology trainees on the impact of COVID-19 in relation to ophthalmology, and has been chairing webinars on post-COVID-19 planning, exploring the role of teleophthalmology going forward in the UK. Your ideas and suggestions are invaluable and most welcomed.

It is inspiring how ESCRS and ASCRS members have already been sharing clinical strategies and adaptive techniques that impact cataract and refractive surgery through updates posted daily on their websites. We encourage all of you to share your struggles and successes on the respective platforms so that we can all support one another in finding the best way forward. Emotions and stress levels are high at this time, but building a logical and reasonable path that is applicable to your clinic/institution/hospital will help bring some calm to the uncertainty of the new normal.


1. Buckley C. Chinese doctor, silenced after warning of outbreak, dies from coronavirus. The New York Times. Available at: Accessed April 30, 2020
2. Implementing tele-ophthalmology during covid-19 pandemic. ASCRS. Available at: Accessed April 28, 2020
3. Extra microscope draping for intraocular surgery. ESCRS EuroTimes. Available at: Accessed April 30, 2020
4. Buratto L. COVID 19 and contact lenses: Instructions and advice to follow during the pandemic period. ESCRS EuroTimes. Available at: Accessed April 28, 2020
5. Clinical education. ASCRS. Available at: Accessed April 28, 2020
6. ESCRS Player. Available at: Accessed April 28, 2020.
Copyright © 2020 Published by Wolters Kluwer on behalf of ASCRS and ESCRS