Abstract
Purpose
To study the prioritization effects of the of COVID‐19 pandemic on Swedish cataract surgery using a national healthcare registry with high coverage.
Setting
A study from the Swedish National Cataract Register (NCR), involving all patients undergoing cataract surgery in Sweden during 2019–2022 – before, during and after the COVID‐19 pandemic.
Results
With the pandemic outbreak, the number of cataract surgeries fell by 22% in 2020 (15 369 procedures), albeit with large regional differences (−43% to +58%). The numbers recovered in 2021, and in 2022, a new top notation was seen (n = 149 952). On a national level, the patients were younger (−0.46 years, p < 0.001), with a larger proportion of less difficult cases (p < 0.001) and the proportion of males was higher (p < 0.001) during the pandemic, but all these variables also differed substantially between different regions and clinics.
Conclusion
A national registry with high coverage can map the consequences of an event disrupting elective surgery in detail. During the COVID‐19 pandemic, the impact on Swedish cataract surgery varied largely between different regions, clinics, and healthcare providers, leading to inequality in the availability of surgery. These differences likely owed to variations in healthcare policy approaches in different parts of the country. The present study shows that outcomes at one clinic or region cannot be extrapolated to larger regions under these circumstances. It actualizes the need to aim for a healthcare on equal terms, but it also shows a system that delivers care to many despite difficult times.
Keywords: age, cataract, COVID‐19, gender, ocular comorbidity, patient selection, phacoemulsification, visual acuity
1. INTRODUCTION
Sweden is one of few countries with a National Cataract Register (NCR), whose nationwide coverage exceeds 94% (Bro et al., 2023). In the Western world, cataract extraction is the most frequently performed surgical procedure (Spalton & Koch, 2000), and in Sweden, over 130 000 cataract procedures are performed each year. In addition to restoring vision (Gray et al., 2006), cataract surgery has been shown to improve cognitive performance in dementia (Yeo et al., 2024) and to increase the disability‐free life expectancy (Chernew et al., 2016). For these reasons, cataract surgery is generally prioritized as a cost‐effective procedure to improve quality of life (Lansingh et al., 2007). Accordingly, interruptions or major fluctuations in the access to cataract surgery increase the risk of inferior results and postoperative complications (Lundstrom et al., 2011).
In March 2020, the World Health Organization declared COVID‐19 as a global pandemic (WHO, 2020). The COVID‐19 pandemic led to disruptions in the availability of surgical facilities and delays in the scheduling of many types of surgery. While many countries imposed strict lockdown measures to protect their populations, Sweden adopted a different strategy. Instead of mandatory lockdowns, Sweden implemented voluntary restrictions and recommendations, particularly aimed at protecting vulnerable groups. Public spaces, restaurants, schools for children under the age of 16 continued to operate through the pandemic. Sweden did not enforce a quarantine for infected households, but physical distancing and working from home were recommended (Ludvigsson, 2020).
The Swedish approach places great responsibility on the individual in a decentralized healthcare system with public and private sectors. The Swedish healthcare system is divided into three independent levels of government: the national government, the regions, and the municipalities. This multi‐level governance has led to different responses to the pandemic aiming to meet local needs and capacities (Kavaliunas et al., 2020).
Accordingly, different regions in Sweden took different routes in healthcare management during the pandemic, due to different patient demographic and resources. This provides a unique opportunity to assess the effects of these different approaches (Ludvigsson, 2023). The sharpest decline was in rural, sparsely populated regions with less private healthcare, i.e. Värmland (−43%). In the larger regions where private healthcare is available, the decline was smaller and the recovery faster. Our clinical experience and hypothesis were that many non‐essential medical appointments were cancelled, and elective surgery was suspended, leading to a temporary decrease in the number of cataract surgeries performed, but that these effects may have varied due to different approaches in different regions. In this study, we aimed to investigate the various impacts of the COVID‐19 pandemic on cataract surgeries in Sweden using data from the NCR.
2. METHODS
Data were collected from the Swedish NCR, including all cataract surgeries performed in patients over 18 years of age between January 1 2019 and December 31 2022. This observational registry‐based study was approved by the Swedish Ethical Review Authority (DNR 2022–00801‐01) and adhered to the Declaration of Helsinki. The NCR is a nationwide register founded in 1992 and financed by the Swedish municipalities and regions (SKR). Registrations are voluntary, and the data are owned by the participating clinics. The present study is based on data collected perioperatively. Detailed information on the register variables has previously been described (Zetterberg et al. 2020). The high level of coverage together with the regularly validated data offers an opportunity for detailed studies of Swedish cataract surgery.
2.1. Statistical analyses
Pre‐operative best‐corrected visual acuity (BCVA) and age were analysed as continuous variables. BCVAs registered as decimal values in the NCR were converted to Logarithm of the Minimum Angle of Resolution (LogMAR) prior to analysis (Holladay, 1997). The following variables were analysed as categorical variables: the presence of pseudoexfoliations (PEX), ocular comorbidities such as age‐related macular degeneration (AMD), diabetic retinopathy (DRP), glaucoma, cornea guttata, and whether the procedure was done in a private or a public clinic. A variable termed “Difficult case” was defined as patients who had one or more risk factors previously shown to be associated with an increased risk for posterior capsule rupture: age ≥80 years, pre‐operative BCVA <0.1 (decimal), PEX, glaucoma, DRP, cornea guttata and mechanical pupil dilation (Artzen et al., 2009; Segers et al., 2022).
To examine differences in case mix before, during, and after the pandemic, the parameters mechanical pupil dilation, trypan blue staining, capsular tension ring, posterior capsular rupture, and rhexis hooks were used as surrogate markers for small pupil, dense cataract, and zonular instability, respectively.
The number of surgeries performed per region was analysed separately. To stratify pre‐surgical waiting time, patient age was stratified into three groups: <50 years, 50–70 years, and >70 years of age. Unpaired t‐test was used for continuous variables and Chi‐squared test was used for categorical variables, together with ANOVA were used to compare an individual's pre‐ and postoperative values and to compare annual differences compared to baseline. Faulty registrations or data were excluded. IBM SPSS Statistics 26.0 (IBM, Armonk, NY, USA) was used for statistical analyses. For all tests, the level of significance was set to p < 0.05.
3. RESULTS
The study identified 530 747 cataract surgeries performed during the four‐year study period (2019–2022). Of these, 254 cases were excluded, due to age less than 18 years or missing data. In 2020, the number of cataract surgeries in Sweden decreased by 15 369 procedures (22%; p < 0.001). In some regions, the decrease was as high as 43% (Värmland), whereas in other regions an increase could be seen by as much as 58% (Östergötland). By 2021, the numbers recovered to pre‐pandemic levels. In 2022, the number of surgeries reached a new top notation with 149 952 surgeries performed, an increase entirely owing to higher surgical volumes among private healthcare providers (Table 1). Patients who underwent surgery during 2020 were younger compared to 2019, 2021 and 2022 with statistical significance (Table 1). Most clearly, fewer cataract surgeries were performed in the >70 age group in 2020 compared to younger patients (Figure 1).
TABLE 1.
Baseline characteristics.
| 2019 (baseline) | 2020 | 2021 | 2022 | |
|---|---|---|---|---|
| Visual acuity, BCVA, LogMAR | ||||
| Mean (SD) total | 0.41 (0.34) | 0.40 (0.34)* | 0.40 (0.35)* | 0.39 (0.34)* |
| Public | 0.49 (0.40) | 0.48 (0.40)* | 0.48 (0.40)* | 0.48 (0.41)* |
| Private | 0.36 (0.30) | 0.35 (0.30)* | 0.35 (0.35)* | 0.35(0.30)* |
| Age Mean (SD) total | 74.2 (8.8) | 73.7 (8.8)* | 74.4 (8.7)* | 74.6 (9.6)* |
| Public | 74.7 (9.5) | 74.1 (9.5)* | 74.7 (9.4)* | 75.2 (9.3)* |
| Private | 73.9 (8.3) | 73.5 (8.3)* | 74.4 (8.7)* | 74.4 (8.2)* |
| Male sex, n (%) total | 55 412 (42.3) | 50 830 (43.9)* | 57 063 (42.7) | 64 592 (43.1)* |
| Public | 22 169 (43.0) | 19 945 (44.0)* | 21 484 (43.6)* | 21 181 (43.3) |
| Private | 33 243 (42.1) | 30 885 (43.8)* | 35 579 (42.1)* | 43 411 (42.6)* |
| PEX, n (%) total | 12 662 (9.7) | 11 210 (9.7) | 13 066 (9.8) | 13 754 (9.2)* |
| Public | 6 934 (13.2) | 5 846 (13.0) | 6 577 (13.3) | 6 298 (12.8) |
| Private | 5 728 (7.2) | 5 364 (7.6) | 6 489 (7.7)* | 7 456 (7.3) |
| AMD, n (%) total | 17 613 (13.4) | 14 193 (13.1) | 18 090 (13.5) | 20 134 (13.4) |
| Public | 8 058 (15.4) | 6 882 (15.2) | 7 885 (16.0) | 8 340 (17.1)* |
| Private | 9 555 (12.1) | 8 311 (11.8) | 10 205 (12.1) | 11 794 (11.6) |
| Previous vitrectomy, n (%) total | 940 (0.7) | 924 (0.8) | 850 (0.6) | 1 068 (0.7) |
| Public | 830 (1.6) | 741 (1.6) | 622 (1.3)* | 641 (1.3)* |
| Private | 110 (0.01)* | 183 (0.03)* | 228 (0.03)* | 427 (0.04)* |
| Other eye disease, n (%) total | 8 181 (6.2) | 7 159 (6.2) | 7 877 (5.9) | 7 452 (5.0) * |
| Public | 4 953 (9.5) | 4 601 (10.1)* | 4 790 (9.7) | 4 065 (8.3)* |
| Private | 3 155 (4.0) | 2 551 (3.6)* | 3 172 (3.8)* | 3 192 (3.2)* |
| Cornea guttata, n (%) total | 3 741 (2.9) | 3 028 (2.6)* | 3 441 (2.6)* | 4 634 (3.1)* |
| Public | 1 715 (3.3) | 1 365 (3.0) | 1 500 (3.0) | 1 700 (3.5) |
| Private | 2 026 (2.6) | 1 663 (2.4)* | 1 941 (2.3)* | 2 934 (2.8)* |
| Nr of surgeries, n (%) total | 131 128 | 115 759 | 133 649 | 149 952 |
| Public | 52 302 (39.9) | 45 354 (39.2) | 49 235 (36.8) | 48 863 (32.6) |
| Private | 78 827 (60.1) | 70 367 (60.8) | 84 416 (63.2) | 101 089 (67.4) |
Note: Bold numbers = p < 0.05.
Abbreviations: AMD, Age‐related macular degeneration; BCVA, Best‐corrected visual acuity; PEX, Pseudoexfoliation syndrome.
p < 0.001.
FIGURE 1.
The annual number of cataract surgeries in Sweden stratified by age groups <50, 50–70 and >70 years in public and private healthcare.
3.1. Gender
The proportion of male patients undergoing cataract surgery increased in 2020, both in private and public healthcare (p < 0.001). In 2022, the proportion of men undergoing cataract surgery was 42.6% (p < 0.001) in private healthcare providers compared to 43.3% in public healthcare providers.
3.2. Ocular comorbidities
The proportion of AMD patients decreased from 13.4% (n = 17 613) in 2019 to 13.1% (n = 14 193) in 2020 (p = 0.02). Likewise, the proportion of patients with cornea guttata decreased from 2.9% (n = 3741) in 2019 to 2.6% (n = 3028) in 2020 (p < 0.001). We saw no changes in the proportions of cataract patients with glaucoma, diabetes retinopathy, or uveitis during the study period (Table 1).
3.3. Difficult cases
Difficult cases decreased from 45% (n = 58 551) in 2019 to 43% (n = 50 146) in 2020 (p < 0.001). The decrease was seen in both the private and public sectors (Figure 2). In 2021 and 2022, difficult cases were significantly more abundant in both the private and the public healthcare systems compared to 2019 (p < 0.001).
FIGURE 2.
The proportion of difficult cases each year in total and stratified by private or public healthcare provider. Difficult cases were defined as patients with age ≥80 years, pre‐operative best‐corrected visual acuity <0.1 (decimal), pseudoexfoliation syndrome, glaucoma, diabetic retinopathy, cornea guttata and mechanical pupil dilation.
3.4. Healthcare provider
The proportion of patients undergoing surgery by a public healthcare provider decreased each year during our study (Table 1). The number of surgeries performed by public healthcare providers in 2022 was 7% below the number performed in 2019. Conversely, cataract surgery provided by private healthcare increased by 28.2% in 2022 compared to 2019. Patients treated in the private sector were younger, had better visual acuity, and overall had fewer ocular comorbidities (i.e. AMD, PEX, cornea guttata) (Table 1). These findings are also reflected in the proportion of difficult cases (Figure 2).
3.5. Perioperative difficulties
Most parameters indicating perioperative difficulties decreased significantly during 2020, 2021 and 2022 (Table 2). The proportion of posterior capsular rupture remained unchanged during 2020 and increased slightly in 2021 and 2022 (Table 2).
TABLE 2.
Perioperative difficulties.
| 2019 (baseline) | 2020 | 2021 | 2022 | |
|---|---|---|---|---|
| Perioperative difficulties, n (%) total | 9 811 (7.5) | 7 312 (6.3)* | 8 796 (6.6)* | 9 394 (6.3)* |
| Public | 6 616 (12.6) | 4 943 (10.9)* | 5 791 (11.8)* | 5 690 (11.6)* |
| Private | 3 195 (4.1) | 2 369 (3.4)* | 3 195 (3.8)* | 3 704 (3.6)* |
| Posterior capsular rupture, n (%) total | 894 (0.7) | 739 (0.6) | 819 (0.6) | 836 (0.6)* |
| Public | 701 (1.3) | 551 (1.2) | 599 (1.2) | 577 (1.2) |
| Private | 193 (0.2) | 188 (0.3) | 220 (0.3) | 259 (0.3) |
| Capsular tension ring, n (%) total | 3 130 (2.4) | 2 052 (1.8)* | 2 392 (1.8)* | 2 190 (1.5)* |
| Public | 1 582 (3.0) | 1 052 (2.3)* | 1 306 (2.7)* | 1 220 (2.5)* |
| Private | 1 548 (2.0) | 1 000 (1.4)* | 1 086 (1.3)* | 970 (1.0)* |
| Mechanical pupil dilation, n (%) total | 3 194 (2.4) | 2 567 (2.2)* | 3 171 (2.4) | 3 460 (2.3) |
| Public | 2 245 (4.3) | 1 689 (3.7)* | 1 970 (4.0) | 2 072 (4.2) |
| Private | 949 (1.2) | 878 (1.2)* | 1 201 (1.4)* | 1 388 (1.4) |
| Capsule staining, n (%) total | 4 565 (3.5) | 3 409 (2.9)* | 4 134 (3.1)* | 4 710 (3.1)* |
| Public | 3 707 (7.1) | 2 805 (6.2)* | 3 293 (6.7) | 3 226 (6.6) |
| Private | 858 (1.1) | 604 (0.9)* | 841 (1.0) | 1 484 (1.5)* |
| Rhexis hooks, n (%) total | 1 029 (0.8) | 705 (0.6)* | 932 (0.7) | 903 (0.6)* |
| Public | 874 (1.7) | 585 (1.3)* | 787 (1.6) | 767 (1.6) |
| Private | 155 (0.2) | 120 (0.2)* | 145 (0.2) | 136 (0.1)* |
| Number of total surgeries | 131 128 | 115 759 | 133 649 | 149 952 |
| Public | 52 302 (39.9) | 45 354 (39.2) | 49 235 (36.8) | 48 863 (32.6) |
| Private | 78 827 (60.1) | 70 367 (60.8) | 84 416 (63.2) | 101 089 (67.4) |
Note: Bold numbers = <0.05.
p < 0.001.
3.6. Waiting time to cataract surgery
The mean waiting time in the public sector was twice as high (2.9 months) as in the private sector (1.4 months). In addition, the time from preoperative assessment to surgery increased by 6.9% between 2019 and 2020 in the public sector (from 2.9 to 3.13 months), while it remained largely unchanged in the private sector. When analysing the different age groups, the national average waiting time for patients under 50 years of age decreased by 5.3% between 2019 and 2020, but for those over 70 years of age, the waiting time increased by 13.3% (3.0 vs. 3.4 months) over the same period. The group most affected by the increased waiting times were public health patients over the age of 70, who waited an average of 3.4 months to gain access to public healthcare. In comparison, patients under the age of 50 who were treated in private healthcare had an average waiting time of 1.2 months (Table 3). For patients younger than 30 the waiting time was 2.7 months during 2019 and decreased to 2.0 in 2020 only to return back to 2.7 months 2022; however, none of these changes were significant.
TABLE 3.
Waiting time from pre‐operative assessment to cataract surgery.
| Months mean, (SD, range) | 2019 (N = 131 129) baseline | 2020 (N = 115 761) | 2021 (N = 133 651) | 2022 (N = 149 952) |
|---|---|---|---|---|
| National | 2.0, 2.1 (0–30) | 2.1 *, 2.5 (0–29) | 1.8 *, 2.2 (0–30) | 2.0 *, 2.6 (0–87) |
| <50 | 1.9, 1.0 (0–20) | 1.8, 1.0 (0–29) | 1.8, 1.0 (0–29) | 1.9, 1.0 (0–37) |
| 50–70 | 1.8, 1.0 (0–26) | 1.7, 1.0 (0–25) | 1.6, 1.0 (0–30) | 1.8, 1.0 (0–41) |
| >70 | 2.1, 1.0 (0–30) | 2.2, 1.0 (0–29) | 1.84, 1.0 (0–30) | 2.1, 2.2 (0–87) |
| Public | 2.9, 2.0 (0–30) | 3.1 *, 2.0 (0–29) | 2.6 *, 2.0 (0–30) | 3.0, 2.0 (0–45) |
| <50 | 2.6, 2.0 (0–20) | 2.4, 2.0 (0–29) | 2.4, 2.0 (0–29) | 2.6, 2.0 (0–37) |
| 50–70 | 2.6, 2.0 (0–26) | 2.5, 2.0 (0–23) | 2.3, 2.0 (0–30) | 2.6, 2.0 (0–39) |
| >70 | 3.0, 3.0 (0–30) | 3.4, 2.0 (0–29) | 2.7, 2.0 (0–30) | 3.0, 3.0 (0–45) |
| Private | 1.4, 1.0 (0–28) | 1.4 *, 1.0 (0–29) | 1.3 *, 1.0 (0–29) | 1.5 *, 1.0 (0–87) |
| <50 | 1.2, 1.0 (0–17) | 1.2, 1.0 (0–26) | 1.3, 1.0 (0–20) | 1.4, 1.0 (0–18) |
| 50–70 | 1.3, 1.0 (0–26) | 1.2, 1.0 (0–25) | 1.2, 1.0 (0–28) | 1.4, 1.0 (0–41) |
| >70 | 1.4, 1.0 (0–28) | 1.4, 1.0 (0–29) | 1.3, 1.0 (0–29) | 1.6, 1.0 (0–87) |
Note: Excluded patients with waiting time longer than 200 months. Bold numbers = <0.05.
p < 0.001.
3.7. Regional differences
In 2019, 51% (n = 66 842) of all surgeries performed in Sweden were performed in the three largest regions of Skåne, Stockholm and Västra Götaland. In 2020, the number of surgeries performed in these regions decreased by 16% (n = 55 981). In 2021, the numbers were slightly higher than in 2019, and in 2022, the numbers were 21% higher compared to 2019. The largest decreases between 2019 and 2020, −43% and −26%, were recorded in Värmland and Kronoberg, respectively. In contrast, the number of cataract surgeries increased by 58% in Östergötland and 25% in Kalmar in 2020, compared with 2019 (Table S1).
3.8. Travelling to a different region for surgery
The proportion of patients travelling to different regions for healthcare declined from 8% in 2019 to 7.8% in 2020. However, this figure surpassed the 2019 level as early as 2021, reaching 8.3%, and further increased to 9.7% in 2022. Each of these findings was statistically significant compared to the 2019.
4. DISCUSSION
In Sweden, the system with national healthcare registries offers a unique opportunity to analyse the effects of major national or global events detail, since a national registry contains much of the essential data needed for such analyses. We have previously been able to detail the effects of a Swedish national healthcare guarantee on the waiting times for cataract surgery (Hanning & Lundstrom, 1998; Lundstrom et al., 1996), and likewise, the present study offers a unique opportunity to map the national and local effects of the COVID‐19 pandemic.
The pandemic had a significant impact on cataract surgery worldwide, which has been shown in numerous publications (Cetinkaya, 2023; DeYoung et al., 2023; Hulsmans et al., 2023; Lim et al., 2024; Toghi Eshghi et al., 2024). However, studies from others have generally concentrated on average effects on variables such as operation volumes, complications and waiting times, instead of assessing the differences and inequalities within a population (Hulsmans et al., 2023; Toghi Eshghi et al., 2024). Our findings in the present study indicate that the pandemic affected the case mix and patient selection in Sweden significantly, both during the outbreak and in the subsequent year. Accordingly, the number of perioperative difficulties decreased significantly in the first year of the pandemic (2020) due to younger patients and fewer complicated cases. During 2021–2022, the number of peri‐operative difficulties increased again, but it remained below pre‐pandemic levels. Additionally, during 2020, there was a significant decrease in the age of patients undergoing surgery nationwide, and patients older than 70 years had a longer wait time to surgery. There are several possible reasons for the longer waiting time in the oldest part of the population. One could be the voluntary restriction for the elderly during the pandemic to stay at home as much as possible (Ludvigsson, 2020), another could be the reaction of regions where some have introduced age limits for surgery, i.e. only offering surgery to patients under 70. The difference in waiting time when comparing public and private healthcare could also be partly due to Sweden's limited pandemic preparation, which led to a shortage of sterile equipment and staff.
During 2021 and 2022 the age of patients undergoing surgery gradually increased to supersede the values of 2019, likely an effect of an accumulated unmet need for cataract surgery among the elderly during the pandemic. The observed trend towards younger, healthier patients undergoing surgery during the pandemic could initially point to deliberate selection by the healthcare system. A more plausible explanation, however, is that older patients, especially those with multiple ocular and other comorbidities, adhered to national recommendations (Ludvigsson, 2020) to minimize the risk of infection. Consequently, they were more likely not to seek medical care, including elective surgery, during the pandemic. In addition, older people living in rural areas may have perceived the travel required to reach healthcare providers as a risk of infection, which further discouraged them from seeking medical care.
Our registry data show that in Sweden, the number of cataract surgeries decreased by more than 20% from 2019 to 2020. The decline was larger in Sweden than in the US (Vogel et al., 2022), but smaller compared to what has been reported from many other countries during the pandemic (Theodoraki et al., 2023) (Das & Reddy, 2021), likely since Sweden never had a “lockdown” strategy during the pandemic (Andersson & Jonung, 2024). As far as we know Sweden is the only country that did not enforce a lockdown strategy and have a nationwide covering cataract register. The “recovery phase” in Sweden was rapid on the national level; already in 2021, the number of cataract surgeries exceeded pre‐pandemic levels.
While the number of surgeries performed in public healthcare declined by 7% during the study period the private healthcare providers increased the number of surgeries by 22%. Our interpretation is that this is a part of a longer trend in Swedish cataract surgery, rather than an effect by the pandemic (Behndig et al., 2022). Similar patterns have been reported from other countries (Rcopht, 2021).
The proportion of patients that travelled to a different region for cataract surgery decreased slightly during 2020 only to recover 2021 and continue to increase after the pandemic. This trend indicates that many regions were unable to meet the healthcare demands in their population. Additionally, more patients are travelling long distances to gain access to surgery in Sweden. The demographics is skewed in that the older population resides in rural areas to a larger extent, and since part of the recovery was made in larger cities with accessibility to private health care this study shows a large discrepancy in the availability and need for cataract surgery. Our findings show an inequality in Swedish cataract care that further increased during the pandemic to a degree that may have had negative outcomes for elderly patients in public healthcare.
Another inequality revealed by the present study was that the waiting times for cataract surgery in the public sector were generally more than twice as long as those in the private sector. In addition to this, the waiting times during the pandemic increased most for patients >70 years attending public healthcare. A systematic review of 27 studies found that patients who waited >6 months for cataract surgery had less‐than‐expected outcomes (poor vision and poor quality of life) compared to patients who waited <6 weeks (Gray et al., 2006), which underlines the importance of keeping waiting times short. The proportion of men undergoing cataract surgery increased during 2020, despite the fact that men had a higher risk of severe COVID‐19. The differences might be worth examining further in future studies. Two studies assessing complications after cataract surgery during the pandemic found a non‐significant increase in the complication rate in one study, while in the other study saw decreased complications after cataract surgery even after a 2 months of intermission (Hulsmans et al., 2023) (Tzamalis et al., 2021). However, a UK study showed increased rates of posterior capsular rupture, postoperative cystic macular oedema, after the intermission in cataract surgery during their lockdown (Theodoraki et al., 2023). During the duration of this study, we found no significant change in the proportion of patients with a posterior capsular rupture. Our findings show an inequality in Swedish cataract care that further increased during the pandemic to a degree that may have had negative outcomes for elderly patients in public healthcare.
In the high‐volume regions, the number of surgeries decreased significantly more during the pandemic than in the medium‐ and low‐volume regions. This result could be due to other limiting factors before the pandemic such as staff shortages. The different regions in Sweden have a high degree of self‐government in healthcare matters, which likely contributed to the large regional differences seen in for example surgical volumes and waiting times in the present study. In Sweden, private cataract clinics are regulated by municipal governments. Thus, funding is largely based on taxes, sometimes combined with co‐payments for care and medications.
We found significant differences between public and private clinics, with fewer comorbidities and significantly fewer patients aged >70 years in private clinics, a system that leaves the more difficult cases to the public health system. Another interesting finding in this study was the large standard deviation across the country, suggesting that there was a substantial variation in waiting times. Part of the patient selection was interpreted as an effect of the different health policy approaches related to the pandemic and a strive to protect the elderly (Ludvigsson, 2020).
A strength of the current study is a complete set of data from a whole country collected before, during and after a global pandemic. This was possible because of a functioning national register with good coverage and validated data. However, there are inherited limitations with observational register‐based studies. For example, the register was not developed for this specific scientific study, and some variables that would have been interesting to study during the pandemic are not reported to NCR, i.e. amblyopia or previous vitreoretinal surgery. The waiting times in NCR represent the patient's waiting time from planning to surgery at the specific clinic that performed the surgery. Consequently, the waiting time is reset to zero when a patient decides to seek a different clinic. Additionally, the time before preoperative assessment will affect waiting time to surgery as well. Some regions almost closed the ophthalmology clinics altogether, apart from acute conditions. This led to less cataract assessments and an underestimation of the true waiting times for cataract surgery. Furthermore, in some regions the younger patients received care but not the elderly. Type of anaesthesia was not registered at the time of this study. This could introduce bias, as surgery in general anaesthesia is almost exclusively performed in public healthcare facilities, and the waiting time for operations requiring general anaesthesia is likely longer. General anaesthesia is, however, very seldom used in Swedish cataract surgery, and this factor is therefore not likely to affect the outcomes of the present study.
The COVID‐19 pandemic has posed overwhelming challenges to many parts of society and not least to the healthcare systems. This has highlighted potential opportunities for improvement, such as the need to equalize the access to cataract surgery. Our study shows that despite the global pandemic, more than 100 000 patients underwent cataract surgery in Sweden in 2020. This is a significant decrease compared to 2019, which gradually recovered over the course of 2021 and reached an all‐time high in 2022. The system has sufficient repair mechanisms to cope with the accumulated need in the years following. Still, the impact of the COVID‐19 pandemic and the recovery from it was unequally distributed within the country, between different regions, clinics, and healthcare providers, which highlights the need for improvements in the healthcare system to achieve the statutory right to healthcare on equal terms. The COVID‐19 pandemic has had a significant impact on Swedish cataract care, and with this study, the development of the Swedish healthcare system and cataract surgery continues.
Supporting information
Table S1.
Kreku, R. , Behndig, A. & Viberg, A. (2025) Prioritizations in Swedish cataract surgery ‐ when resources are limited—Exemplified by the COVID‐19 pandemic. Acta Ophthalmologica, 103, 61–68. Available from: 10.1111/aos.16749
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Supplementary Materials
Table S1.