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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 6-11

Social impact on ophthalmic services during first wave of corona pandemic in sub-himalayan tertiary institute

Department of Ophthalmology, IGMC, Shimla, Himachal Pradesh, India

Date of Submission08-Feb-2021
Date of Acceptance24-Sep-2021
Date of Web Publication29-Nov-2021

Correspondence Address:
Dr. Kalpana Sharma
Department of Ophthalmology, IGMC Shimla, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijosr.ijosr_1_21

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Introduction: The novel coronavirus (CoV) known as severe acute respiratory syndrome-CoV-2 has engulfed the entire world. The nations worldwide are engaged in carrying out several research, treatment, and vaccine trials to relieve the world from the shackles of this global pandemic. This pandemic has not only strained health-care facilities but also has psychosocial repercussions. Objective: The objective of the study was to find out the effects of lockdown on ophthalmological services in coronavirus disease (COVID) era and its psychosocial impact. Methods: Retrospective analysis of data in the department of ophthalmology of tertiary care institute from March 2020 to August 2020 was done. This period was compared with corresponding months of previous year 2019. The services affected and the pattern of social behavior during different phases of complete and partial lockdown periods were studied. Results: Strict administrative execution of lockdown and curfews led to the reduction in the number of patients visiting the hospital and accounted for a drastic dip in the number of patients visiting outpatient department and operating procedures. The initial mental defense phases of apprehension, denial, and projection in lockdown period were eventually followed by displacement and suppression in unlockdown period. Conclusion: The number of COVID-positive patients in India has risen exponentially. As per the WHO, this global pandemic is likely to stay longer, the standard protocol for patients and health-care workers needs to be adhered strictly and revised from time to time, as there is an expected surge of patients with visual threatening situations for number of patients who have been deprived of treatment in restriction phases of lockdown. The psychosocial behavior as a result of mental defense mechanisms should also be maneuvered along the pandemic control.

Keywords: Coronavirus, ophthalmic services, psychosocial impact

How to cite this article:
Sharma RL, Sharma K. Social impact on ophthalmic services during first wave of corona pandemic in sub-himalayan tertiary institute. Int J Soc Rehabil 2019;4:6-11

How to cite this URL:
Sharma RL, Sharma K. Social impact on ophthalmic services during first wave of corona pandemic in sub-himalayan tertiary institute. Int J Soc Rehabil [serial online] 2019 [cited 2023 Jun 5];4:6-11. Available from: https://www.ijsocialrehab.com/text.asp?2019/4/1/6/331419

  Introduction Top

The novel coronavirus (CoV) has affected the entire world. In December 2019, there was an outbreak of severe acute respiratory syndrome (SARS) in Wuhan city of Hubei Province, and on March 11, 2020, it was declared as a global pandemic.[1] Currently, there is no available treatment and vaccine for SARS CoV. Various trials are being carried out to evaluate numerous antivirals, immunotherapies, monoclonal antibodies, and vaccines. The nations worldwide have been forced to impose lockdown to mitigate its effects which are not only physical but also have psychosocial ramifications. There has been fear from the disease and scare due to curfew, containment, and curtailing of outdoor activities. Several recommendations for the prevention of disease and various standard operating procedures (SOP) have been issued by World Health Organizations, International and National Health Organizations.

To curtail the spread of virus, there was a postponement of all routine outpatient department (OPD) procedures and elective surgeries. The alternative modes of patient care were adopted such as telemedicine, social media, phone calls, and various apps. Due to postponement of routine elective surgeries, few patients have to pay the price in form of delayed emergency presentation such as phacomorphic glaucoma, hypermature cataract, and delaying consultation in conditions requiring urgent intervention.

  Methods Top

Retrospective analysis of data to find out the effects of lockdown on ophthalmological services in COVID era in the department of ophthalmology of tertiary care institute from January 2020 to June 2020 was done. The medical records of these patients were studied and their diagnosis, treatment, and surgical interventions were analyzed. The patient data were analyzed for number of patients visiting OPD and number of procedures carried out during the various phases of lockdown and unlock period [Table 1]. This period was compared with corresponding months of previous year 2019. The services affected during different phases of complete and partial lockdown periods were studied.
Table 1: Ophthalmic services from March to August 2020

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The SOPs were laid down for the department for the doctors and staff in OPD, operation theater (OT), and wards as per AIOS guidelines [Table 2], [Table 3], [Table 4].[2] Instructions were also issued for the patients and attendants in local language [Table 5] and [Table 6]. These SOPs were displayed in OPD, and various places to ensure implementation. The norms of personal hygiene, social distancing, and protection kit wearing were followed. The pattern of social behavior during this common social stress or life-threatening pandemic was also analyzed in relation to defenses for extreme stress. Individuals and society tend to react to this extraordinary situation of stress and conflict by adopting various psychosocial defenses. The statistical analysis was performed using STATA Statistical Software. Continuous variables were expressed as percentages.
Table 2: Instructions for doctors and staff

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Table 3: General instructions for outpatient department

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Table 4: Waiting hall guidelines

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Table 5: Instructions for operation theater staff

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Table 6: Instructions for patients

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  Results Top

There were about 9641 patients who attended the eye OPD from March to August (2020). The data were compared with the previous year's eye OPD data from March to August (2019). It was observed that there was a drastic decrease in the number of patients attending eye OPD in March and April 2020 [Graph 1]. The number of patients undergoing major operating procedures was 705 from March to August 2020 in comparison to the year 2019 in which 1588 patients underwent major surgery in the same duration [Graph 2].

The OPD procedures were also compared with consecutive periods in 2019 from March to August. The different procedures such as refraction, tonometry, perimetry, and optical coherence tomography (OCT) were compared. The patients who underwent refraction are depicted in [Graph 3], noncontact tonometry is shown in [Graph 4], perimetry is shown in [Graph 5], and OCT is shown in [Graph 6]. These observations were made from March to August 2020. The period of lockdown and unlockdown depicted in [Table 7] and worldwide , national and regional profile of corona cases depicted in [Table 8]. If we look at the number of cases across the world and in India, it was observed that cases were doubling every month. The doubling rate is high in the beginning due to lesser number of cases but subsequently decreased as the volume of cases soared up.

Table 7: Phases of lockdown and unlockdown

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Table 8: Profile of corona cases

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  Discussion Top

There were lockdown and containment measures across different countries around the world. Similarly, in India, complete lockdown was imposed initially for 3 weeks from 25th March to 14th April, the ophthalmic services were limited to urgent consultations and emergency surgeries suc as phacomorphic glaucoma and open globe injury repair. This phase was marked by anxiety and fear among people as there was a ban on people from stepping out of their house and prohibition of all social, political, cultural, and religious activities. Strict administrative execution of lockdown and curfews leads to the reduction in the number of patients visiting the hospital and accounted for a drastic dip in the number of patients visiting OPD and OT procedures [Graphs 1-6] in the months of March and April 2020. The total number of patients undergoing refraction in the month of April 2020 was 239 in comparison to 4482 in April 2019, thereby showing a 95% reduction. Similarly, the total number of patients undergoing OCT in the month of April 2020 was 28 in comparison to 445 in April 2019, thereby showing a 92% reduction in these services. The number of patients undergoing operating procedures in the month of April 2020 was 24 in comparison to 252 in April 2019, thereby showing a 90% reduction in operating procedures.

People initially refused to accept the external reality, because it was too threatening which is the denial phase of psychosocial behavior. In this phase, there is a resolution of emotional conflict and reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant aspects of external reality. Most people believed that this pandemic was happening too far from them and they will not be affected so they resented restrictions of their routine activities and hence, there was a violation of lockdown in beginning. Although there was a limited spread of diseases during the first lockdown, it could not be contained so the lockdown was further extended from 14th April to 3rd May for another 3 weeks with conditional relaxation after 20th April. The COVID-affected areas were classified as red, orange, and green zones depending upon the number of positive cases. Red zones have a substantial number of positive cases, orange zones have a limited number of cases, and green zones have no CoV-positive cases. There were incidences of blaming certain groups and communities for the spread of disease. This was another mechanism adopted by society, an effort to reduce stress by attributing it to others, which is called projection in psychosocial defense.[3],[4]

The 3rd and 4th phases of lockdown (4th May–17th May and fourth Phase 18th May–31st May) were marked by easing of restrictions with normal movement in green zones and demarcation of containment and buffer zones.[5] There were incidences of violence against healthcare workers and law implementing agencies. This explained the displacement as psychosocial defense in which people shifted aggressive impulses to a more acceptable or less threatening target; redirecting emotion to a safer outlet to avoid dealing directly with what is frightening or threatening.[3],[4] The phases of lockdown gave the time to the authority to prepare the hospitals and develop the quarantine centers. The standard guidelines were laid down. Procurement of kits, masks, and disposals was ensured. There was hardly any production of indigenous personal protection kits in the beginning of epidemic, but this interval provided increased industrial production of N95, testing kits, and personal protective equipment.

The lockdown phase was followed by unlock phase 1.0 (June 1–June 30, 2020) permitting shopping malls, hotels, and restaurants to open and lockdown restrictions imposed in containment zones only, thereby increasing the movement of people and the risk of spread of virus also increased. These phases of unlockdown were marked by acceptance and suppression as psychosocial defense behavior. This was depicted in this study by a gradual rise in the number of patients coming to eye OPD. The acceptance at the level of society was seen where people were ready to move out of fear despite an increase in the number of cases. Individuals and people were consciously not paying attention to such thoughts and emotions, to cope with the present reality; making it possible to access distressing emotions while accepting them is called suppression.[3],[4] While 2nd unlocking phase was easing of restrictions on industries and services sectors and later phases of unlock down eased night curfews and permitting inter and intra-state travel and other recreational activities. In these phases of unlockdown, though the people were afraid, they had overcome the anxiety and fear after the initial phase of denial to a certain extent. They had partially accepted and were learning to live with it, despite the increasing number of corona-positive cases. This explains the gradual increase in OPDs and OTs.

The standard protocols for patients coming to the hospital had to be followed in which the screening at the entrance gate was done. A suspect was sent to the triage area before being taken up for admission. The SOPs for OPD, OT, and ward staffs were issued to prevent the transmission of CoV in medical, paramedical staff, and patients. It has been stressed by international health organizations such as the American Academy of Ophthalmology that ophthalmologists and eye health-care providers must wear face and eye shields while examining high-risk patients with a history of international travel or travel from corona hot spots area, and history of fever and breathing difficulties.[6] These eye care providers have to examine the patients with close proximity and various studies have revealed the presence of ACE 2 receptors in conjunctiva and cornea as an entry point of virus and CoV has been isolated from tears and conjunctival discharge of CoV-infected patients.[7],[8]

There were a number of patients who were not getting adequate treatment or consultation during the restriction period. This is bound to increase the prevalence of visually disabled and blind individuals. We should be ready to handle the expected surge of patients with visually threatening situations in post-COVID-19-era.

  Conclusion Top

The SARS-CoV-2 global pandemic has caused a radical transformation in the lives of people. Due precautions should be taken by ophthalmologists and eye care providers as they are slightly at high risk of acquiring infection. The psychosocial impact of this pandemic is deep and is likely to be deeper as the restrictions and fear persist longer. There is a possibility that these disorders will lead to increased incidence anxiety, depression, suicide, and crimes, which must be addressed at mass levels along with pandemic control measures. As per the WHO, this global pandemic is likely to stay longer, these precautions should be followed during and after unlocking phase as slowly and steadily we would be getting back to elective patients.

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Conflicts of interest

There are no conflicts of interest.

  References Top

CDC. 2019 Novel Coronavirus, Wuhan, China January 26, 2020.  Back to cited text no. 1
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.  Back to cited text no. 2
[PUBMED]  [Full text]  
Cramer P. Protecting the Self. New York; Guilford Publications The Guilford Press; 2006. p. 17.  Back to cited text no. 3
Vaillant G. Ego mechanisms of defense and personality psychopathology (PDF). J Abnorm Psychol 1994;103:44-50.  Back to cited text no. 4
Schueller E, Klein E , Lin G, Tseng K, Balasubramanian R, Kapoor G. COVID-19 India. Potential impact of the lockdown and other long term policies Centre for disease Dyanamics, Economics and Policy Review; 19 April 2020.  Back to cited text no. 5
American Academy of Ophthalmology. Important Coronavirus Updates for Ophthalmologists. Available from: https://www.aao.org/headline/alert-important-coronavirus-context. [Last accessed on 2020 Apr 16].  Back to cited text no. 6
Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor recognition by the novel coronavirus from Wuhan: An analysis based on decade-long structural studies of SARS coronavirus. J Virol 2020;94:e00127-20.  Back to cited text no. 7
Sun Y, Pan X, Liu L, Ni RX. Expression of SARS coronavirus S protein functional receptor ACE2 in human and rabbit cornea and conjunctiva. Rec Adv Ophthalmol 2004;24:332-6.  Back to cited text no. 8


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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