RESEARCH ARTICLES

OFTALMOLOGI : Jurnal Kesehatan Mata Indonesia, 30 Apr 2023 | https://doi.org/10.11594/ojkmihttps://doi.org/10.11594/ojkmi.v5i1.49
Year : 2023 | Volume: 5 | Issue: 2 | Pages : 1

MANAGEMENT OF IRREGULAR ASTIGMATISM AFTER CORNEAL ULCER WITH RGP CONTACT LENS IN PATIENTS WITH HIGH MYOPIA

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Introduction: The spread of Coronavirus disease (COVID-19) in Indonesia has had a significant impact on health services, including ophthalmology. The increased risk of viral transmission during ophthalmological examinations and procedures prompted for change in protocol and number of services. This study aimed to describe the changes in pediatric ophthalmology and strabismus division patient visits at a national eye center in Indonesia before and during the Coronavirus disease (COVID-19) pandemic.

Methods: This was a cross-sectional descriptive study using secondary data including number of pediatric ophthalmology and strabismus patients’ visits, International Classification of Diseases (ICD-10) code diagnosis, and procedures from outpatient clinic and emergency department (ED) in the time period before (January 2019-March 2020) and during (April 2020-December 2020) the COVID-19 pandemic, associated with the start of COVID-19 restriction measures. Data was presented in the form of tables and graphs.

Results: During the COVID-19 pandemic, overall patient visits to the Pediatric Ophthalmology-Strabismus division decreased by 47.83% (from 2,171.7 patients/month to 1,132.9 patients/month), and number of procedures were reduced by 74.9% (from 154.53 to 79.7 procedures per month).

Conclusion: The number of patient visits to Pediatric Ophthalmology and Strabismus division at a national eye center in Indonesia had decreased during the COVID-19 pandemic, both at outpatient clinic and ED visits. All cases had decreased except retinopathy of prematurity screening. The number of operative procedures also experienced a decrease in this COVID-19 pandemic situation.

Introduction

The spread of Coronavirus disease (COVID-19) in Indonesia has had a significant impact on health services, including ophthalmology. Increased viral transmission risk during close-contact ophthalmic practice examinations and procedures prompted for change in the service system, as issued by American Academy of Ophthalmology (AAO) COVID-19 practice guidelines.1,2 

            To suppress viral transmission, implementation of large-scale social restrictions was imposed in Indonesia, starting in April 2020. Concurrent decreases in the number of ophthalmic visits and surgeries may cause significant risk of visual acuity and ophthalmic condition deterioration.1–3 This study aimed to describe changes in pediatric ophthalmology and strabismus division patient visits before and during the COVID-19 pandemic at a national eye center in Indonesia.

Materials and Methods

This study was a descriptive study with a cross-sectional observational design conducted at Cicendo Eye Hospital, a national eye center in Indonesia. The data used was secondary data retrieved from the information and technology (IT) division for pediatric ophthalmology and strabismus patients for the year 2019 and 2020, which consisted of data on the number of visits and diagnosis of pediatric ophthalmology and strabismus (PO-S) patients in settings of outpatient clinic and Emergency Department (ED).  Diagnostic data used the International Classification of Disease-10 (ICD-10) codes in 2020. Data on the number and types of procedures conducted from the pediatric ophthalmology and strabismus division were also recorded in this study.

       Data was categorized according to pandemic conditions, namely before (January 2019-March 2020) and during (April 2020-December 2020) the COVID-19 pandemic. April 2020 was the beginning of large-scale social restriction implementations related to COVID-19 in the West Java region, Indonesia, hence we set March-April as the limit. Data was processed manually using Microsoft Excel and presented in the form of tables and graphs.

Results

There was an overall total of 42,771 pediatric ophthalmology-strabismus patient visits in 2019 and 2020 combined from PO-S outpatient clinics and ED. Total visits were 26,618 in 2019 and 16,153 in 2020. March-April 2020 was the cut-off point between before and during the COVID-19 pandemic related to social restriction measures. The average number of visits of all pediatric ophthalmology and strabismus patients before the pandemic was 2,171.7 patients/month. When compared to the condition after the start of the COVID-19 pandemic, this number showed drastic reduction by 47.83% to 1,132.9 patients/month. Figure 1 shows overall changes in the number of patients visits to pediatric ophthalmology and strabismus division. The lowest total visits were in April 2020 at 409 patients, a decrease of 72.02% compared to the previous month.           

Figure 2 illustrates the number of patient visits at PO-S outpatient clinics compared to ED. A 75.17% decrease in the number of visits occurred in PO-S clinics in April 2020, from 1,361 patients in March 2020 to 338 patients in April 2020. Visits at ED in April 2020 only decreased by 29.70% from 101 patients in March 2020 to 71 patients in April 2020.

Table 1 presents data of the most cases by diagnosis in outpatient clinic settings based on ICD-10 code in 2020. Before the pandemic, service for the highest number of cases was found in patients with the ICD-10 diagnosis code Z.09, for post-treatment and post-surgery examinations with an average of 838.13 cases/month, which diminished by 44.86% during the pandemic to 462.11 cases/month. Diagnoses that declined most were in cases of stenosis and tear duct insufficiency (H04.5), conjunctivitis (H.10) and visual cortex disorders (H47.6). There was one diagnosis that did not decrease during the pandemic, on the contrary increased by 21.35% from an average of 7.6 cases/month to 9.22 cases/month, which was retinopathy of prematurity (ROP). Before the pandemic, retinopathy of prematurity ranked as the 18th highest diagnostic case average per month, yet during the pandemic increased to 11th.

The total number of procedures was 1,826 in 2019, and 1,209 in 2020. The average number of procedures before the pandemic was 154.53 procedures per month. This number declined 74.9% to 79.7 procedures per month during the pandemic. Of the ten most frequent procedures, strabismus surgery had the largest decrease, which was about 67.95%. Procedures indicated for trauma such as eyelid suturing increased by 50.79% per month, for cases of corneal and/or scleral rupture there was a decrease by 25.68%. The average comparison of the number of procedures before and during the pandemic is shown in Table 2.

       Figure 3 shows the trend of procedures in the Pediatric Ophthalmology and Strabismus division each month in 2019 and 2020. Compared to February 2020, the number of procedures decreased by 64.95% in March 2020 to 75 procedures and further declined 90.67% in April 2020 to seven procedures. An increase was first observed in May 2020 by 214.29% to 22 procedures and continued to increase in the following month to 64 procedures (190.91% when compared to the previous month).

Discussion

The AAO recommendation on March 18, 2020 calling on ophthalmologists to limit routine checkups, surgical procedures, and inpatient measures only for urgent and emergent eye conditions, has been implemented worldwide including in Indonesia. Our institute has implemented restrictions on the number of non-emergency patient visits in outpatient clinics and elective surgeries in order to minimize viral transmission of COVID-19, also enacting a work from home (WFH) system for a number of employees which are all in line with decisions from the central and regional Indonesian government related to large-scale social restrictions and AAO recommendations. Emergency services remain open without restrictions. The restriction of patient visits is reflected in this study, which found reduced visits by 75.17% from March 2020 to April 2020. Services at ED decreased by 29.70% from March 2020 to April 2020. This decline may also be influenced by the government's appeal to stay at home. Similarly, the Megan et al study in the United Kingdom showed that there was a decrease in the number of pediatric ophthalmology clinic patients visits by 87.2% at the first peak of the pandemic.3,4

       Overall, ED visits decreased by 19.10% during the COVID-19 pandemic. Conversely, Jade et al's study examined changes in ED visits when compared to the year before the pandemic, visits were reduced by 32%, or reduced by 18 patients per day, but the study referred to ED eye services, not limited to pediatric ophthalmology services. Whilst Meghan et al's study at Johns Hopkins stated that visits to the pediatric ophthalmology division showed a significant decrease in the number of visits with p<0.001.5–7

       Changes in the number of cases based on ICD-10 diagnosis code showed a large difference, both on visits at PO-S outpatient clinics and at ED before and during the COVID-19 pandemic in Indonesia. Most cases decreased in number, but there was one case that increased by 21.35% from 7.60 cases/month to 9.22 cases/month, which is retinopathy of prematurity. During the pandemic, we stopped ROP screening in a central hospital that was separate from our clinics for administrative reasons and to reduce viral transmission. Our findings of an increased number of ROP screening patients may be related to this.

The Iason et al study at Boston Children's Hospital showed that screening examinations in premature infants (<31 weeks) increased from 82 infants in 2019 to 97 in 2020 in hospitalized infants, while retinopathy of prematurity screening in hospitalized infants decreased from 280 to 228 cases in 2019 and 2020. Patient examinations in clinics, both premature infant screening examination and retinopathy of prematurity examination decreased in number. The number of screened infants was reduced from 70 to 38 patients, as well as retinopathy of prematurity examined infants reduced from 113 to 53 patients. Furthermore, The Katotch et al study in India also showed a decrease in the number of infants screened both at clinic visits (396 and 87, p = 0.001), as well as in patients hospitalized in the Neonatal Intensive Care Unit (NICU) (241 and 169, p = 0.001) in the pre-COVID-19 time period (January 1 – March 23, 2020) and during the COVID-19 pandemic (March 24-May 31, 2020).8,9

       The most frequent procedure in the PO-S division in our study was examination under anesthesia (EUA) with or without retinal imaging. Abhisek explained that EUA is indicated for patients who are uncooperative and have a low pain threshold. Examples of cases indicative of EUA are congenital glaucoma, congenital cataracts, microphthalmia, megalocornea, and retinoblastoma. Abhisek also mentioned that although EUA is favored to examine non-emergency cases, these cases are extremely time-sensitive and can affect patients’ visual prognosis if delayed.10,11

       The AAO issued another recommendation on April 17, 2020 to consider re-opening ophthalmic practices, however this must be adjusted to the conditions of their respective regions, government decisions, applicable institutional policies, test availability, and the individual willingness of ophthalmologists. Delayed examination in pediatric ophthalmology patients can lead to potential worsening of ocular condition with risk of permanent vision loss such as cataracts, uveitis, and amblyopia. It is imperative that a health institution implement a strict patient examination protocol to minimize the possibility of virus transmission in order to ensure safety of patients and medical personnel. The use of personal protection equipment (PPE) including masks and eye protection, prohibiting patients from speaking during close-contact slit lamp examination, installing plastic protectors on slit lamps, frequent disinfection, maintaining distance in patient waiting rooms, reducing staff numbers, and administrative controls by identifying visitors with COVID-19 are measures that can be applied in preventing transmission of the virus. 4,5,12–14

       There are several limitations to our study, including the brief study period, had it included data from 2021 the study may provide a broader picture of data and hence give an overview of the latest pediatric ophthalmology patient visits. Also, in the diagnosis of patient cases, this study used ICD-10 codes from 2020, whereas ICD-10 codes from 2021 have a more diverse patient case directory and can potentially describe patient cases in more detail. Additionally, this study used a descriptive research design, therefore further analytical research is needed.

Conclusion

   The number of patient visits to Pediatric Ophthalmology and Strabismus division at a national eye center in Indonesia had decreased during the COVID-19 pandemic, both in outpatient visits and ED visits. All cases showed a decrease in number, except cases of retinopathy of prematurity that had increased. The number of procedures of the PO-S division also experienced a decrease in this COVID-19 pandemic situation. Ophthalmologists should be aware of this possibility in the event of future lockdown or social restriction situations. Further analytical research is required in order to obtain a better detailed picture of the situation.

Author Contributions

All the authors attest that they meet the current ICMJE criteria for authorship. Feti Karfiati Memed conceptualized the study, collected, analyzed, interperted the data, drafted and reviewed the manuscript. Annisa Rahayu conceptualized the study, collected, analyzed, interperted the data, drafted the manuscript. Sesy Caesarya analyzed, interperted the data, and provided critical revisions to the manuscript. Primawita Oktarima analyzed, interperted the data, and provided critical revisions to the manuscript. Irawati Irfani provided critical revisions and reviewed the manuscript. Mayasari Wahyu Kuntorini provided critical revisions and reviewed the manuscript. Amanda Widayanti interpreted the data, drafted, revised and reviewed the manuscript. All the authors read and approved the final manuscript.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

References

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Keywords: COVID-19 pandemic, Pediatric ophthalmology and strabismus practice

Citation: *, ( 2023), MANAGEMENT OF IRREGULAR ASTIGMATISM AFTER CORNEAL ULCER WITH RGP CONTACT LENS IN PATIENTS WITH HIGH MYOPIA. OFTALMOLOGI : Jurnal Kesehatan Mata Indonesia, 5(2): 1

Received: 08/01/2023; Accepted: 08/30/2023;
Published: 30/04/2023

Edited by:

Ms.RATNA NOVIANTA , Ariesanti Tri Handayani ,

Reviewed by:

Elsa Gustianty, -, -, ID

Ine Renata Musa, -, -, ID

*Correspondence: Ms.RATNA NOVIANTA, Ratnanoviantari20@gmail.com