Abstract
Purpose:
During the coronavirus disease 2019 (COVID-19) pandemic, private practice, inpatient consult services, and academic residency programs in ophthalmology saw a decrease in patient encounters. This study elucidates how community hospital ophthalmology consult (OC) services were affected during the pandemic. We aim to determine whether there was a change in resident OC volume in a community-based ophthalmology program consult service during the COVID-19 pandemic. Secondary objectives included analyzing the change in the types of diagnoses and the number of patients seen for diabetic retinopathy over the same time.
Methods:
A retrospective cross-sectional study was conducted reviewing the electronic health record (EHR) charts from OCs for the period 2017–2021. Records were categorized by referral source and the nature of OCs (trauma, acute, or chronic); OCs were further grouped by year and weak of referral. An intermonth analysis of weekly OC counts in each category was performed for the average number of consults in February–April 2017–2019 and for February–April 2020. A one-tailed t-test was performed. All t-tests assumed equal variances.
Results:
Weekly OCs in 2020 revealed no statistically significant differences in overall cases or in acute or chronic cases when the volume before the COVID-19 pandemic was compared to the volume after the onset of the pandemic. However, a statistically significant increase in the average weekly trauma cases was noted when 2020 (an average of 2.7 cases per week) was compared to the weekly average for the same weeks of years 2017– 2019 (0.4; P = 0.016). This statistically significant increase in trauma in 2020 disappeared when comparing weeks 11–17 in 2020 (2.2 cases per week) and the average of 2017–2019 (1.1).
Conclusion:
This report outlines no significant change in OCs before and after the onset of the pandemic compared to three previous years. There was, however, an increase in trauma consults during the pandemic and an increase in the number (though not the proportion) of diabetic retinopathy (DR+) patients seen by residents. This report uniquely describes no significant changes in the resident volume of patients seen during the COVID-19 global pandemic.
Keywords: Community health, COVID-19, ophthalmology, resident education
On March 10, 2020, the US State of Michigan Department of Health and Human Services identified the first two presumptive cases of the severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2 (coronavirus disease 2019 [COVID-19]),[1] in the state. Subsequently, on March 23, 2020, the Governor of Michigan signed a “shelter-in-place” Executive Order suspending activities not necessary to sustain or protect life, to prevent overwhelming the health-care system.[1] During this time, the American Academy of Ophthalmology (AAO) released a statement recommending that all ophthalmologists provide only urgent and emergent eye care for their patients.[2]
Studies have shown that the effect of similar orders in and outside of the USA reduced overall ophthalmological patient encounters (inpatient and outpatient) by 46.9%–97.14%.[3-6] Though most of these studies aggregate data for the entire private practice or tertiary care center, one study showed a decline in inpatient services of 53.5% during a 7-week lockdown in Germany.[7] Other studies show large declines in overall trauma while also revealing resurgences or increases in specific types of ocular trauma, including home- and exercise-related injuries and open globe injuries.[8-12]
Ophthalmological residency education during this time in the USA and the state of Michigan saw a major shift to online didactics, decreases in patient volumes, and even temporary deployment of residents to cover nonophthalmological specialties in hard-hit hospitals.[13-15] It is likely that the AAO's recommendations are against providing anything but urgent or emergent care,[2] and the decline in patient encounters and surgical procedures due to hospital restrictions, patient reluctance to seek treatment, and other factors reduced the number of patient consultations and surgical procedures performed by residents. However, no such reports of the impacts of these factors in ophthalmology residency education in the USA exist in the literature to date, except a single study. This study assessed cases in a residency consult service for both inpatient and emergency room services, which found an overall decline in ophthalmological consults (OCs), but did not specify whether one or both settings saw a decline.[16]
This study analyzes the overall number of OCs, number of trauma cases, number of procedures performed, and changes in the most common ophthalmological diagnoses from both the emergency department (ED) and the inpatient hospital setting, both immediately before and immediately following the start of the COVID-19 pandemic. We also assess changes in residency education by defining education as the number of OCs emanating from these impacts.
This study looks at the differences in OCs across four community hospitals (hospitals A, B, C, and D) in the suburban areas of a greater metropolitan area in the USA. The four community hospitals served by the ophthalmology residency program (ORP) are different in their size and location. The largest hospital, Hospital A, included in the study is a 632-bed, level-2 trauma facility, housing three residency programs (Diagnostic Radiology, Internal Medicine, and Obstetrics/Gynecology) affiliated with a local state university. In 2021, this hospital had 24,996 discharges and 69,079 emergency visits. Hospital B has a 148-bed facility that is home to the ORP as well as a physical medicine and rehabilitation residency. In 2021, Hospital B had 7177 discharges and 32,319 ED visits. Hospital C is a 193-bed, level-2 trauma center with nine affiliated residency programs affiliated with a local college of osteopathic medicine; in 2021, it had 10,513 discharges and 34,479 ED visits. Hospital D is a 99-bed, level-3 trauma center with 5965 discharges and 46,789 ED visits in 2021. All four community hospitals serve the local metropolitan area and southeast part of the state.
Methods
This was a retrospective analysis of the dataset of all OCs by the resident service of four local hospitals from January 1, 2017 to May 31, 2021. Records from the Epic electronic health record (EHR) were retrieved and reviewed by the physician authors. This study received approval from the affiliated Institutional Review Board on July 20, 2021.
The following relevant variables were extracted from the EHR: date and location (inpatient ward or ED) of each OC, nature of injury, surgical procedure performed (if any), diagnosis (es), patient gender, patient race, patient ethnicity, and patient date of birth. Inclusion criterion was as follows: all adults (age 18 years or older) seen for an OC at one of the four hospital sites. Exclusion criteria included patients under 18 years old and patients not seen by a resident for an OC. Records were categorized by the nature of ophthalmologic diagnosis as trauma (13.9% of all cases during the time period), acute (61.9%), or chronic (24.2%). The number of cases in each step of the data extraction process is shown in Fig. 1.
Figure 1.
Original figure. Breakdown of all cases during within the analysis period. The number of cases that were referred from the emergency department and inpatient services were further classified into case type (acute, chronic, trauma). N = number of patient encounters.
Changes before and after COVID-19 shelter-in-place order
An intermonth analysis of weekly OC counts in each category was performed for the average number of OCs in February–April 2017–2019, and for February–April 2020, by comparing weeks 6–11 (following the “state of emergency” issued by the governor on March 10 and before the shelter-in-place order for the state, issued on March 24, 2020^1) to weeks 12–17 using a Student's t-test (March 16, 2020 is the midpoint of February–April 2020). Since we expected a decrease in OCs, a one-tailed t-test was performed. All t-tests assumed equal variances. A similar review of consults was conducted comparing the 52 weeks before the start of the pandemic in the USA (March 15, 2019–March 14, 2020) and the first 52 weeks of the health crisis (March 15, 2020–March 14, 2021) as a whole, not just the impact of the shelter-in-place order.
Changes in ophthalmological diagnoses pre– and post–COVID-19
Primary, secondary, and tertiary diagnoses for all OCs were explored for the period from January 1, 2017 to May 31, 2021. A comparison of the top five primary, secondary, and tertiary diagnoses for each year from 2017 to 2020 was performed, and the number of each diagnosis recorded during the year was noted.
Changes in the number of patients seen for diabetic retinopathy during the COVID-19 pandemic
Counts for patients to the ophthalmology service receiving the diagnosis of diabetic – no retinopathy (DR−), diabetic retinopathy (DR+), and proliferative diabetic retinopathy (PDR) were noted for the average number of OCs in 2017–2019 and for 2020. A Chi-square analysis for the proportion of DR−, DR+, and PDR patients as a proportion of all patients was performed.
Results
Changes before and after COVID-19 shelter-in-place order
Comparing the weekly average OCs from 2017 to 2019 to the weekly OCs in 2020–2021 revealed no statistically significant differences in the overall cases, or in acute or chronic cases in either weeks 6–11 or 12–17 [see Tables 1 and 2]. There was a statistically significant increase in the average weekly trauma cases on comparing the entire two periods (0.4/week, 2017–2019 vs. 2.7/week, 2020; P = 0.016), which was not significant (2.2 cases/week vs. 1.1 cases/week) when comparing only weeks 11–17 in 2020 to the entire 2017–2019 period.
Table 1.
Weekly ophthalmology consults by category, 2017–2021
| Consult week | Total | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
||||||||||||||
| 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | ||||
| 2017 | Condition | A | 11 | 7 | 8 | 4 | 5 | 10 | 8 | 4 | 3 | 12 | 6 | 7 | 85 |
| C | 3 | 4 | 2 | 2 | 1 | 0 | 7 | 3 | 1 | 3 | 3 | 2 | 31 | ||
| T | 1 | 0 | 1 | 0 | 0 | 0 | 2 | 2 | 5 | 2 | 0 | 2 | 15 | ||
| 2017 Total | 15 | 11 | 11 | 6 | 6 | 10 | 17 | 9 | 9 | 17 | 9 | 11 | 131 | ||
| 2018 | Condition | A | 10 | 8 | 4 | 16 | 14 | 6 | 8 | 11 | 13 | 18 | 13 | 11 | 132 |
| C | 3 | 4 | 4 | 4 | 6 | 6 | 4 | 3 | 1 | 6 | 3 | 8 | 52 | ||
| T | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 0 | 0 | 3 | 0 | 10 | ||
| 2018 Total | 14 | 13 | 9 | 20 | 21 | 13 | 13 | 15 | 14 | 24 | 19 | 19 | 194 | ||
| 2019 | Condition | A | 14 | 10 | 14 | 12 | 12 | 15 | 17 | 16 | 12 | 25 | 14 | 15 | 176 |
| C | 7 | 5 | 8 | 2 | 3 | 8 | 2 | 3 | 3 | 5 | 5 | 6 | 57 | ||
| T | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | ||
| 2019 Total | 21 | 15 | 22 | 14 | 15 | 23 | 19 | 19 | 15 | 30 | 20 | 21 | 234 | ||
| 2020 | Condition | A | 8 | 12 | 7 | 12 | 12 | 7 | 0 | 22 | 13 | 8 | 8 | 9 | 118 |
| C | 4 | 5 | 0 | 5 | 4 | 3 | 0 | 8 | 3 | 2 | 3 | 2 | 39 | ||
| T | 4 | 2 | 0 | 3 | 3 | 4 | 0 | 5 | 1 | 1 | 2 | 1 | 26 | ||
| 2020 Total | 16 | 19 | 7 | 20 | 19 | 14 | 0 | 35 | 17 | 11 | 13 | 12 | 183 | ||
| 2021 | Condition | A | 10 | 8 | 21 | 21 | 9 | 11 | 12 | 15 | 13 | 16 | 19 | 12 | 167 |
| C | 3 | 4 | 4 | 7 | 2 | 3 | 6 | 3 | 6 | 0 | 1 | 1 | 40 | ||
| T | 5 | 4 | 6 | 9 | 2 | 5 | 3 | 6 | 7 | 2 | 4 | 5 | 58 | ||
| 2021 Total | 18 | 16 | 31 | 37 | 13 | 19 | 21 | 24 | 26 | 18 | 24 | 18 | 265 | ||
| Total all years | Condition | A | 53 | 45 | 54 | 65 | 52 | 49 | 45 | 68 | 54 | 79 | 60 | 54 | 678 |
| C | 20 | 22 | 18 | 20 | 16 | 20 | 19 | 20 | 14 | 16 | 15 | 19 | 219 | ||
| T | 11 | 7 | 8 | 12 | 6 | 10 | 6 | 14 | 13 | 5 | 10 | 8 | 110 | ||
| All years total | 84 | 74 | 80 | 97 | 74 | 79 | 70 | 102 | 81 | 100 | 85 | 81 | 1007 | ||
Original data. Classification of consult includes acute, chronic, and trauma. A=acute, C=chronic, T=trauma
Table 2.
Average weekly OCs 2017–2019 compared to weekly OCs in 2020, before and after the shelter-in-place order
| All cases | 2017–2019 | 2020 | Probability of difference in means (Student’s t-test, one-tailed) | ||
|---|---|---|---|---|---|
|
|
|
||||
| Mean | SD | Mean | SD | ||
| Cases (before): | 14.4 | 1.4 | 15.8 | 4.9 | P=0.250 |
| Cases (after): | 16.7 | 3.8 | 14.7 | 11.5 | P=0.347 |
|
| |||||
| Acute cases | Mean | SD | Mean | SD | |
|
| |||||
| Cases (before): | 10.0 | 1.3 | 9.7 | 2.6 | P=0.391 |
| Cases (after): | 11.8 | 3.3 | 10.0 | 7.2 | P=0.292 |
|
| |||||
| Trauma cases | Mean | SD | Mean | SD | |
|
| |||||
| Cases (before): | 0.4 | 0.3 | 2.7 | 1.5 | P=0.017* |
| Cases (after): | 1.1 | 0.4 | 1.7 | 1.8 | P=0.212 |
|
| |||||
| Chronic cases | Mean | SD | Mean | SD | |
|
| |||||
| Cases (before): | 4.0 | 0.8 | 3.5 | 1.9 | P=0.281 |
| Cases (after): | 3.8 | 1.3 | 3.0 | 2.7 | P=0.269 |
Original data. *Significant at the P=0.05 level. OC=ophthalmology consult, SD=standard deviation
As an extra step, a brief review of OCs exactly 1 year before and after March 14, 2020 was conducted, outside of the shelter-in-place order. The weekly averages (standard deviations) and minimum and maximum cases for the 52-week period immediately before and immediately following the shelter-in-place order are provided in Table 3. A comparison of weekly cases in each category for the 52-week period before and after the shelter-in-place order revealed no statistically significant difference in the number of consults (trauma, acute, or chronic) seen during those time periods (F = 0.927, P = 0.336).
Table 3.
OC averages by category
| Case type | Mean (SD) | Min. | Max. | |
|---|---|---|---|---|
| 52-week pre-COVID weekly OC average | Acute | 13.92 (6.30) | 2 | 40 |
| Chronic | 4.13 (3.11) | 0 | 18 | |
| Trauma | 2.44 (1.93) | 0 | 8 | |
| 52-week post-COVID weekly OC average | Acute | 12.27 (5.18) | 2 | 28 |
| Chronic | 5.06 (3.62) | 0 | 16 | |
| Trauma | 3.9 (2.25) | 0 | 9 |
COVID=coronavirus disease, OC=ophthalmology consult, SD=standard deviation
Changes in ophthalmological diagnoses pre– and post–COVID-19
Table 4 shows the top five diagnoses encountered by the residents each year, along with the number of times each diagnosis was recorded during that year.
Table 4.
Top ophthalmological diagnoses by the number of consults and year, 2017–2020
| Rank | 2017 | 2018 | ||||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Primary | Secondary | Tertiary | Primary | Secondary | Tertiary | |
| 1. | Subjective blurry vision (69) | Nuclear sclerotic cataract (160) | Nuclear sclerotic cataract (118) | Subjective blurry vision (73) | Nuclear sclerotic cataract (78) | Nuclear sclerotic cataract (92) |
| 2. | Orbital fracture (57) | Pseudophakia (56) | Pseudophakia (50) | Subjective visual disturbance (58) | Dry eye syndrome (46) | Pseudophakia (47) |
| 3. | Corneal abrasion (28) | Dry eye syndrome (36) | Dry eye syndrome (19) | Orbital fracture (57) | Pseudophakia (33) | Dry eye syndrome (30) |
| 4. | Herpes zoster ophthalmicus (21) | Subconjunctival hemorrhage (33) | Diabetes without retinopathy (17) | Corneal abrasion (28) | Diabetes without retinopathy (33) | Subconjunctival hemorrhage (17) |
| 5. | Preseptal cellulitis (21) | Diabetic retinopathy (27) | Refractive error (13) | Conjunctivitis (25) | Diabetic retinopathy (29) | Diabetes without retinopathy (15) |
|
| ||||||
| Rank | 2019 | 2020 | ||||
|
|
|
|||||
| Primary | Secondary | Tertiary | Primary | Secondary | Tertiary | |
|
| ||||||
| 1. | Subjective blurry vision (91) | Nuclear sclerotic cataract (114) | Nuclear sclerotic cataract (164) | Subjective blurry vision (106) | Diabetes without retinopathy (72) | Nuclear sclerotic cataracts (105) |
| 2. | Subjective visual disturbance (90) | Dry eye syndrome (82) | Pseudophakia (83) | Orbital fracture (86) | Dry eye syndrome (63) | Pseudophakia (58) |
| 3. | Orbital fracture (66) | Diabetic retinopathy (52) | Dry eye syndrome (36) | Subjective visual disturbance (57) | Pseudophakia (51) | Glaucoma (28) |
| 4. | Corneal abrasion (38) | Diabetes without retinopathy (48) | Diabetes without retinopathy (30) | Corneal abrasion (42) | Diabetic retinopathy (43) | Dry eye syndrome (21) |
| 5. | Subconjunctival hemorrhage (32) | Subconjunctival hemorrhage (43) | Diabetic retinopathy (23) | Herpes zoster ophthalmicus (29) | Subconjunctival hemorrhage (40) | Diabetic retinopathy (18) |
Table 5.
Analysis of DR cases 2017–2021
| DR cases | ||||
|---|---|---|---|---|
|
| ||||
| − | + | PDR | ||
| Consult year | 2017–2019 | 55 | 57 | 28 |
| 2021 | 90** | 59 | 44* | |
| Total | 4078 | 250 | 4328 | |
Original data used. (−) Cases with no diabetic retinopathy. (+) Cases with diabetic retinopathy. *Statistically significant at P=0.05. **Statistically significant at P=0.001. DR=diabetic retinopathy, PDR=proliferative diabetic retinopathy
Changes in the number of patients seen for diabetic retinopathy during the COVID-19 pandemic
Computing average OCs from 2017 to 2019 revealed that the average of total OCs from 2017 to 2019 was 942, compared to 1032 total OCs in 2020, despite the pandemic. All patient types increased from the average of 2017–2019 to 2020: DR − increased from 55 to 90, DR + increased from 57 to 59, and PDR increased from 28 to 44. The increase in OCs for DR − cases was statistically significant (χ̄2= 10.192, P = 0.001) as was the increase in PDR cases (χ2 = 3.397, P = 0.047).
Discussion
On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a worldwide pandemic.[17] Over the proceeding days, the state closed all schools, banned large gatherings, and by the 23rd of March 2020, a stay-at-home order was issued by the governor, eventually extending it to June 1, 2020.[17] Although nonessential workers were now permitted to leave their homes, there were still heavy restrictions in place, including gatherings <10 people, mask mandates, and to work from home if possible. By October, more businesses were reopening, but it was not until after the first vaccines became available in December 2020 and January 2021 that restrictions were beginning to be lifted.[17]
Despite these restrictions and the stay-at-home order, our ORP found no significant change in the number of OCs before and after the onset of the pandemic compared to three previous years. Nor did we discover a statistically significant increase or decrease in the entire first year of the pandemic when compared to the previous year. This resulted in nearly no change in care to the patients served by the residency. In addition, different from other published research discussing ophthalmological residency volume during the pandemic, this ORP did not see any significant decrease in patients or cases during the COVID-19 pandemic and its associated changes in behavior, such as lockdowns or delaying care.[16,18,19]
Changes in the ORP revealed an increase in trauma during the pandemic and an increase in the number (though not the proportion) of DR + patients seen by residents. The exact cause for the increase in trauma cases during the initial stages of the pandemic has yet to be determined. With greater isolation, one would expect a decrease in accidental trauma-related incidences. Perhaps a future review of the specific trauma cases may be warranted to possibly reveal an underlying pattern. These changes may indicate that, during the pandemic, the ORP continued its growth in patient volume, leading to a direct increase in cases seen. The quality of training with respect to the volume of patient exposure appears to not have been affected during the pandemic. Continuing data analysis is needed as the pandemic status of COVID-19 has yet to be lifted by the WHO at the time of this report.
Before this analysis and to our knowledge, only one reported residency program has analyzed the COVID-19 pandemic's impact on the volume of the residents’ consultation service.[16] Other studies have shown a decline in volume for private practice or residency clinic visits; another study surveyed resident and attending perceptions of volume and educational changes.[13,14,18,19] This then, to our knowledge, is the first report of changes in OC volumes from both the inpatient department and the ED and the only study finding no significant changes in OCs for a residency program's consult service during the COVID-19 pandemic.
An important limitation of this review is that the number of active COVID-19 cases during the review period of this study were not contrasted with our OCs. It is possible that higher or lower infectious cases could have altered some results. Further investigation into this specific clinical question may be warranted, but was out of the scope of this analysis. Other limitations include the small sample size of four community-based hospitals in a single state of a single ophthalmology residency.
Further research is needed to determine the reasons for this ORP's incongruency compared to the national decline in OCs during the COVID-19 pandemic, and whether smaller, community-based ophthalmology residency training programs may enjoy some educational advantages over traditional academic health center programs during public health emergencies such as the COVID-19 pandemic.
Conclusion
This report highlights that there were no notable differences in OCs before and after the pandemic, when compared to the three preceding years. However, there was an observed rise in trauma consults during the pandemic, as well as an increase in the overall number (though not proportion) of patients with diabetic retinopathy (DR+) seen by residents. Interestingly, this report specifically notes that there were no significant alterations in the volume of patients attended to by residents throughout the global COVID-19 pandemic.
Financial support and sponsorship
Research funding was provided by Beaumont Hospital – Taylor.
Conflicts of interest
There are no conflicts of interest.
References
- 1.Whitmer GG. Executive Order 2020-21: Temporary requirement to suspend activities that are not necessary to sustain or protect life. Accessed March, 16, 2023. https://www.michigan.gov/whitmer/news/state-orders-and-directives/2020/03/23/executive-order-2020-21.
- 2.American Academy of Ophthalmology. Recommendations for urgent and nonurgent patient care. [[Last accessed on 2023 Mar 16]]. Available from: https://www.aao.org/headline/new-recommendations-urgent-nonurgent-patient-care .
- 3.Sethi K, Levine ES, Roh S, Marx JL, Ramsey DJ. Modeling the impact of COVID-19 on retina clinic performance. BMC Ophthalmol. 2021;21:206. doi: 10.1186/s12886-021-01955-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Agarwal R, Sharma N, Patil A, Thakur H, Saxena R, Kumar A. Impact of COVID-19 pandemic, national lockdown, and unlocking on an apex tertiary care ophthalmic institute. Indian J Ophthalmol. 2020;68:2391–5. doi: 10.4103/ijo.IJO_2366_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Berkenstock MK, Liberman P, McDonnell PJ, Chaon BC. Changes in patient visits and diagnoses in a large academic center during the COVID-19 pandemic. BMC Ophthalmol. 2021;21:139. doi: 10.1186/s12886-021-01886-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Poyser A, Deol SS, Osman L, Kuht HJ, Sivagnanasithiyar T, Manrique R, et al. Impact of COVID-19 pandemic and lockdown on eye emergencies. Eur J Ophthalmol. 2020;31:2894–900. doi: 10.1177/1120672120974944. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Schuh A, Kassumeh S, Schmelter V, Demberg L, Siedlecki J, Anschütz A, et al. Effects of the first COVID-19 lockdown on ophthalmological patient care. Klin Monbl Augenheilkd. 2021;238:1220–8. doi: 10.1055/a-1529-6726. [DOI] [PubMed] [Google Scholar]
- 8.Agrawal D, Parchand S, Agrawal D, Chatterjee S, Gangwe A, Mishra M, et al. Impact of COVID-19 pandemic and national lockdown on ocular trauma at a tertiary eye care institute. Indian J Ophthalmol. 2021;69:709–13. doi: 10.4103/ijo.IJO_3200_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Al-khersan H, Lazzarini TA, Kunkler AL, Laura DM, Fan KC, Zhang L, et al. Ocular trauma secondary to exercise resistance bands during the COVID-19 pandemic. Am J Emerg Med. 2021;42:217–20. doi: 10.1016/j.ajem.2020.11.054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Bapaye MM, Nair AG, Mangulkar PP, Bapaye CM, Bapaye MM. Resurgence of “bow and arrow” related ocular trauma: Collateral damage arising from COVID-19 lockdown in India? Indian J Ophthalmol. 2020;68:1222–3. doi: 10.4103/ijo.IJO_901_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Wu C, Patel SN, Jenkins TL, Obeid A, Ho AC, Yonekawa Y. Ocular trauma during COVID-19 stay-at-home orders: A comparative cohort study. Curr Opin Ophthalmol. 2020;31:423–6. doi: 10.1097/ICU.0000000000000687. [DOI] [PubMed] [Google Scholar]
- 12.Stedman EN, Jefferis JM, Tan JH. Ocular trauma during the covid-19 lockdown. Ophthalmic Epidemiol. 2021;28:458–60. doi: 10.1080/09286586.2021.1875012. [DOI] [PubMed] [Google Scholar]
- 13.Kumar A, Agarwal D. Commentary: Restructuring residency training in ophthalmology during COVID-19 era: Challenges and opportunities. Indian J Ophthalmol. 2020;68:1005–6. doi: 10.4103/ijo.IJO_1462_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Mishra D, Nair AG, Gandhi RA, Gogate PJ, Mathur S, Bhushan P, et al. The impact of COVID-19 related lockdown on ophthalmology training programs in India-Outcomes of a survey. Indian J Ophthalmol. 2020;68:999–1004. doi: 10.4103/ijo.IJO_1067_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Mishra K, Boland MV, Woreta FA. Incorporating a virtual curriculum into ophthalmology education in the coronavirus disease-2019 era. Curr Opin Ophthalmol. 2020;31:380–5. doi: 10.1097/ICU.0000000000000681. [DOI] [PubMed] [Google Scholar]
- 16.Tingley J, Tauber J, Thuma T, Moon JY, Barmettler A. Impact of the COVID-19 pandemic on quantity and characteristics of ophthalmology consults. Telemed J E Health. 2022;28:1547–51. doi: 10.1089/tmj.2021.0512. [DOI] [PubMed] [Google Scholar]
- 17.Michigan COVID-19 timeline: University of Michigan School of Public Medicine. 2022. [[Last accessed on 2023 Mar 16]]. Available from: https://covidmapping.org/timeline.html .
- 18.Silva N, Laiginhas R, Meireles A, Barbosa Breda J. Impact of the COVID-19 Pandemic on ophthalmology residency training in Portugal. Acta Med Port. 2020;33:640–8. doi: 10.20344/amp.14341. [DOI] [PubMed] [Google Scholar]
- 19.Alahmadi AS, Alhatlan HM, Bin Helayel H, Khandekar R, Al Habash A, Al-Shahwan S. Residents’perceived impact of COVID-19 on Saudi Ophthalmology Training Programs-A survey. Clin Ophthalmol. 2020;14:3755–61. doi: 10.2147/OPTH.S283073. [DOI] [PMC free article] [PubMed] [Google Scholar]