In this questionnaire study, we investigated patients’ attitude, fears and subjective barriers in regard to receiving care for urgent ophthalmologic diseases in a tertiary center in Germany. We included patients with an acute need for treatment as an inpatient, regardless of whether surgery was indicated or not. This has to be considered when comparing the numbers from this setting to other studies reporting on emergency department visits (8, 9) or ophthalmic surgical care (10).
Due to changes in the institutional guidelines, which allowed elective surgery again after April 20th, we divided our study group into two subgroups around April 20th .
Generally, the majority of the included patients did not report significant difficulties reaching either their referral ophthalmologist or the hospital. Only eight of the included 93 patients stated, that the pandemic led to a significant delay from their decision to visit an ophthalmologist to the actual examination. During the course of the pandemic, however, a significantly higher ratio of patients utilized our institutions emergency unit directly without a referral by their ophthalmologist. In this group also patients had a higher likelihood of a subjective deterioration of symptoms. This might reflect difficulties in scheduling timely appointments with their referral ophthalmologist.
Other studies reported a sub-average utilization of emergency departments not only in ophthalmology (8, 9), but also in other areas like dentistry (11) or general emergency units (12). Patients’ attitudes or subjective barriers have not been reported, though.
Retinal disorders were the most common cause for referral, with more than 60% of the cases. Within this group, retinal detachments were the most common singular cause with 41.9%, followed by retinal vessel disorders (12.9%). Comparable figures for retinal detachments have been reported from a tertiary center in the USA (10). Corneal disorders and neuro-ophthalmologic diseases followed with 14.0% and 10.8%, respectively. While these numbers were not compared to pre-pandemic times in our study, they reflect the orientation of the tertiary center with a focus on the treatment of vitreoretinal disease.
A group from the UK found evidence for more progressed retinal detachments (characterized by a higher rate of macula-off situations and PVR) during the pandemic compared to pre pandemic levels (13). In the presented study, patients did not report a delayed treatment, as reported above. Severity of RD in our collective was not assessed. As indicated above, however, a significantly higher percentage of patients in our study group indicated that their symptoms deteriorated during the course of the pandemic (39.5% before vs. 60% after April 20th, p < 0.05). We could not assess severity of RD within our study group.
Similar trends have been reported in other surgical areas. For example, a group from Scotland presented evidence for more progressed cases of appendicitis in a district general hospital, defined as a higher severity and the increased need for surgery (14). A group from Italy, where COVID-19 hit exceptionally hard in early 2020, reported that in up to 40% of non-traumatic emergency cases treatment was unusually delayed (15). Another group from Italy reported about a delay in treatment in 12 children with acute diseases, resulting in the need of intensive care in 6 patients and death in 4 of these patients (16). The reasons for the reported delays cannot be entirely elucidated. Contributing factors may be associated with different complexes, such as the patients’ attitudes (e.g. fear of infection), institutional guidelines (e.g. limited access to emergency units, general physicians), or governmental regulations (lockdown).
In our study, at least every fourth patient was afraid of COVID-19, and 30% of patients were concerned that they had a higher likelihood of infection at the treatment center. There was no difference in regard to the two subgroups before and after April 20th. Patients with systemic comorbidity or preexisting health conditions tended to be more afraid of an infection and were more likely to expect problems in the follow-up care. Compared to a study investigating a representative sample of US adults, which reported an average of nearly 7 in a scale of 10 for fear (17), the patients in our study appeared less concerned. This may correlate with the time of survey, as well as with the extent of the pandemic in Germany and the USA. Figures were generally lower in Germany compared to the US during the first wave of the pandemic. Additionally, the patients in our study had an urgent medical ophthalmologic disease, which may also change the perception of personal risk, compared to a randomly selected study group.
In this study, higher age was negatively correlated with fear of infection itself and the risk for infection in the hospital. Similar findings were reported in an online survey of residents of Hong Kong (18), where out of the sociodemographic factors investigated, only younger age was statistically significantly correlated with a higher concern of becoming infected in a multivariate analysis. This study, however, did not find an association of a lower perceived personal risk with less careful behaviour (e.g. hand-washing, avoidance of public gatherings) in the older patients. A national survey in the US done in March 2020 also reported a generally more optimistic outlook and better mental health in older patients, except the perceived infection-fatality risk (19). Still, protection of high-risk groups, such as patients aged 65 or older, should be protected, and the health care providers should establish protocols minimizing contacts of patients at risk, either with health care providers or other patients (3, 20, 21).
The presented study has some limitations which have to be considered. Patient recruitment was in part performed retrospectively, and due to the design of the study especially patients in the pre April 20th subgroup were interviewed via telephone.
Some patients eligible for the study did not sign informed consent and could not be included.
Of note, institutional or national guidelines in which patients should be treated as inpatients may differ and could hinder comparability of the provided numbers with other countries or health systems. Patients who did not visit their ophthalmologist or referred to our emergency unit at all could not be included.