Comment on: Impact of reduced elective ophthalmic surgical volume on U.S. hospitals during the early coronavirus disease 2019 pandemic.

Abstract

We read with interest the article by Fliotsos et al.1 They outlined that the COVID-19–related shutdown of elective ophthalmic surgeries affected negatively on hospital income and training opportunities in the United States. As cataract surgery represents the most common ophthalmic surgical procedure and is the core of surgical ophthalmology training, we aimed to assess the impact of theater lockdown on the performance of cataract surgeons of different grade. To this end, we audited cataract operations performed during the first 4 months after theater lockdown in 2020 (May to August 2020, post-lockdown group) to those of the corresponding period in 2019 (May to August 2019, pre-lockdown group) in 2 tertiary ophthalmology centers in the United Kingdom, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, and Royal Victoria Infirmary, Newcastle upon Tyne. The audit was approved by the institutional review board of each center and conformed to the tenets of the Declaration of Helsinki. We compared the 2 groups regarding intraoperative complication rate, particularly posterior capsular rupture (PCR), and baseline clinical characteristics and postoperative corrected distance visual acuity (CDVA). The statistical analyses were performed using STATA 14.0 (Stata Corp), and a P value of less than 0.05 was considered statistically significant. Preoperative and postoperative CDVA were compared by matched-pairs Wilcoxon signed-rank test and the complication rates by χ2 test or Fisher exact test in cases of small numbers. A total of 3649 and 1 732 cataract surgeries were performed in the pre-lockdown and post-lockdown groups, respectively. In the latter, a significantly smaller proportion of surgeries were performed by trainees (1563/3649 vs 642/1732, P < .01). The baseline findings, visual outcomes, and intraoperative complications of the 2 groups are summarized in Table 1. Table 1. - Baseline Characteristics, Visual Outcomes, and Complication Rate in Eyes That Had Cataract Surgery. Variable Pre-lockdown groupa Post-lockdown groupb P value Cataract surgery, n 3 649 1 732 Male sex, % 43 45 .17 Age (y), mean ± SD 75.2 ± 10.1 74.3 ± 10.4 .003 Diabetes, % 20.70 20.90 .87 Surgeon grade (trainee/consultant), % 43/57 37/63 <.01 Preop VA, logMar 0.55 ± 0.5 0.62 ± 0.62 .7 Trainees onlyc 0.52 ± 0.45 0.53 ± 0.55 .016 Ocular copathology, % 40.40 46.00 .007 Follow-up time (d) 42.5 ± 18 45.6 ± 20 .008 Postop CDVA, logMar 0.14 ± 0.27 0.20 ± 0.37 <.01* Trainees onlyc 0.13 ± 0.25 0.21 ± 0.36 <.01* Intraop complications, % Corneal problems 0.52 0.52 .99 Iris problems 0.44 0.23 .24 Zonular dialysis 0.6 0.52 .71 PCR 1.23 1.67 .19 Trainees onlyc 1.47 3.12 .02* PCR/VL 0.71 1.21 .06 Trainees onlyc 1.02 2.34 .03* PCR = posterior capsular rupture; postop = postoperative; preop = preoperative; VA = visual acuity; VL = vitreous loss*Statistically significantaMay to August 2019bMay to August 2020cFisher exact test Despite a similar preoperative CDVA, the postoperative CDVA was significantly worse in the post-lockdown group (P < .01). No statistically significant difference in PCR and PCR with vitreous loss rate was found between the 2 groups; however, the analysis to trainees only showed a higher rate of both and a significantly reduced postoperative CDVA in the post-lockdown group compared with the pre-lockdown group (Table 1), demonstrating, for the first time to our knowledge, an objective effect of pandemic on training. Of interest, this seems to confirm the results of a recent survey investigating the effect of the first lockdown on training, in which approximately half of 504 ophthalmology trainees declared to experience that, after the lockdown, they were no longer able to perform cataract surgery routinely.2 Theater lockdown may compromise trainee surgical performance, resulting in an increase of intraoperative complications. These results highlight the need to implement further strategies to preserve the effectiveness and continuity of surgical training, such as a more intensive use of simulation tools, particularly before the reintroduction to surgery, or the enlargement of the training network through the involvement of more centers to increase the opportunities for trainees to attend surgical sessions. Moreover, trainers may need to supervise trainees when they restart operating after extended periods of inactivity.