The case for continuing elective cataract surgery during the COVID-19 pandemic

Since being declared a pandemic by the World Health Organization on March 11, 2020, the COVID-19 continues to affect an ever-increasing number of people globally, with 976 249 confirmed cases and 50 489 deaths as of April 4, 2020.¹ In Hong Kong, there have been more than 845 confirmed cases and 4 deaths as of April 4, 2020.²

In response to the significantly increased demand on medical resources, many medical organizations have advised their members to withhold all elective surgery during this period, including the American Academy of Ophthalmology.³ We understand the need for this decision, especially regarding procedures requiring general anesthesia, and fully agree that it is necessary for areas facing severe shortages of healthcare workers and personal protective equipment while faced with escalating new infections. However, we propose that in areas where community transmission of new infections is kept low, elective surgeries for eye conditions that cause significant morbidity and disability, and which can be performed under local anesthesia, can be continued or resumed at lower capacity.

This applies particularly to those procedures with a long waiting list, such as with cataract surgery in Hong Kong’s public sector, where the total wait-listed patients were 49 657 (as of December 31, 2019), and the median waiting time to surgery ranged from 7 to 23 months across different hospitals.⁴ Most of these cataract patients are elderly persons with increased risk of hip fractures from falls associated with impaired vision.⁵ We believe that cataract surgery is one of the context-relevant essential services (for Hong Kong and maybe elsewhere) that should not be completely withheld during this pandemic because of its possibly protracted course.⁶

Our ophthalmology department at Grantham Hospital, similar to other ophthalmology centers in Hong Kong, has not discontinued elective cataract surgery (performed at the Day Surgery Center) throughout this period. Because the causative agent for COVID-19, severe acute respiratory syndrome coronavirus 2, is highly contagious with evidence of viral shedding in tears and ocular secretions of affected individuals, additional infection control measures were taken to reduce the possibility of cross infections because the Hospital Authority (administrative body of all public hospitals in Hong Kong) announced activation of emergency response level on January 25, 2020.⁷ These include the following: (1) prescreening several days preoperatively (through phone) and again on the day of surgery at arrival to the Day Surgery Center; (2) the use of personal protective equipment, including compulsory universal face covering with surgical or N95 masks by staff, patients, and visitors within the hospital; and (3) rearrangement of seating (increased spacing between patients) and reducing the number of people in the waiting area (limited to 1 accompanying person per patient).

Patients arriving without surgical masks were provided one, and its use by them extended throughout the cataract surgery (all performed under local anesthesia). In brief, the standardized prescreening procedure involves checking for fever and respiratory symptoms, in addition to history of recent overseas travel and possible contact or exposure to COVID-19 cases. Patients screened as positive had their elective surgery postponed and referred appropriately.

In line with the decrease of nonurgent medical service throughout Hong Kong, our department initially closed 1 operating theater and then 2 operating theaters (of 3 in the Day Surgery Center) from February 11 and 17, 2020, onward, respectively. As expected, the number of cataract operations dropped to 96 for February and 40 for March 2020 (for comparison, we performed a total of 3788 cataract operations in 2019). There were no reported cases of COVID-19 infection among our clinical staff, nor among any patients who underwent cataract surgery, during this period. Although the service was curtailed to minimize patient flow and conserve medical resources for more urgent needs, we believe it is safe, and necessary in some regions, to continue with elective cataract surgery (under local anesthesia) at lower numbers, in view of the likely prolonged period of the current COVID-19 outbreak.