Changes in the interaction of ophthalmologists and ophthalmic industry during and after COVID-19 lockdown: A perspective.

Dear Editor:

Ophthalmology has a complex relationship with pharmaceutical companies and instrument manufacturers, referred to as the ophthalmic industry (OI). These companies provide medications and intraocular implants for the patients, instruments, and surgical consumables for the doctors and maintenance services to the ophthalmic practices. The country-wide movement restrictions or 'lockdown' to combat the ongoing corona virus disease (COVID)-19 pandemic, brought the production in many large and small-scale industries to a halt. Economics is a game of supply and demands, and both got skewed variably by COVID-19. The OI faced the same supplier problems as other industries, while the demand for pharmaceutical products fell when eye hospitals were catering only to emergency ocular conditions. During the lockdown, the mismatch in supply and demand was not very huge. However, as the lockdown eases and society resumes its regular work, this mismatch may become significant.

During the lockdown, the import of raw materials and active pharmaceutical agents (APIs) from other countries was restricted, affecting the Micro, Small and Medium Enterprises (MSMEs) more than the large manufacturing units, as they usually buy limited stocks of raw material at a time. Large-scale migration of contractual workers to their native places has significantly depleted their working labour-force. Therefore, manufacturing was reduced to as low as 20-30% of the pre-lockdown capacity.[1] Last-mile delivery to the pharmacies and patients was also affected due to widespread disruption of internal transport, packaging, courier and logistic services during the lockdown.[2] Essential drugs such as antibiotics, steroids, and anti-glaucoma medications, required for emergency conditions like conjunctivitis, uveitis, keratitis, endophthalmitis and glaucoma, which were in demand even during the lockdown were also hit by low production and delivery, disrupting whatever basic ophthalmology practice was happening during lockdown.

Research and development, a major chunk of investment for the OI earlier, may see cuts with the incoming economic recession. Focus has shifted from development of non-COVID-19 newer molecules towards developing innovative and low cost PPE (Personal Protective Equipment) and COVID-19-specific therapeutics.[3] Cancellation of numerous ophthalmology conferences and workshops during this time, which were opportunities for the OI to launch their latest products and innovations and reach the distributors, have already taken a severe setback this year. Unable to reach their clients physically, the OI representatives are now trying hard to keep in touch with ophthalmologists via text messages, phone calls and online webinars to remind them of their products.

Unnecessary stock-piling created artificial shortage, as in the case of hydroxychloroquine (HCQ), where a widely available cheap anti-malarial drug was mass-hoarded because the Indian Council of Medical Research (ICMR) recommended it as chemoprophylaxis for COVID-19 contacts and their health care workers.[4] Patients suffering from rheumatoid arthritis some of whom had ocular manifestations too and malaria, who actually required it were left with no recourse.[5] Similarly, panic buying of masks, gloves and sanitizers caused their scarcity and consequent increase in their prices. Despite efforts by the government, the N95 masks which earlier costed INR 150 are now being sold at not less than INR 400.[6]

Elective surgeries which constituted the bulk of surgical volumes have reduced and will take time to recover. During the lockdown, the rates of cataract surgeries fell by nearly 95%.[7] Hence, ophthalmic devices such as intraocular lens implants, which are often acquired on credit or 'bundled' with other expensive equipment from the OI, are not getting utilised as expected. Many hospitals may not be in a position to pay the annual maintenance charges (AMCs) for the various machines and instruments (amounting to lakhs of rupees) in the current scenario. Costing of PPE and extra sanitation are adding to their financial burden.

Ophthalmologists need financially compassionate OI partners right now. The OI can offer to waiver or defer the AMCs and other consumables bought on credit, by either extending the AMC contracts by at least 3 months, or allowing installed payments till profits recover.[8] The OI has shown its generous side by pledging to donate funds, medical equipment, PPE, testing kits and therapeutics to government agencies and non-profit organisations, towards fighting this disease all over the world.[9] It is notable that most of the support to Indian ophthalmologists has come from Indian OI as compared to from it's international counterparts. This should make us think about discarding our love for “brands” and supporting our Indian companies, now more than ever, to boost our own economy. The OI also needs to start procuring indigenous APIs and reduce their dependence on imported raw materials. The ophthalmologists can guide them regarding the products or quality that needs to be improved upon, and try to make the Indian pharmaceutical industry self-sufficient, in line with the Government's 'Aatm-Nirbhar' initiative. We are already the second largest producer of PPE within 2 months, after the Government started promoting indigenous manufacturing.[10] Liquor factories producing sanitizers, automobile manufacturers producing face shields and low-cost ventilators and cottage industries producing reusable PPE and masks are just few examples of our industry's resourcefulness and 'jugaad*', in fighting this pandemic.[1112]

The OI need to ensure steady supply of the essential medications required for basic ophthalmology practice. They can provide a list of contacts available locally, nationally and internationally to facilitate a smooth transition from lockdown. Until manufacturing regains full functioning, some alternative sources can be provided to continue patient care. The OI executives can communicate within their network of practicing ophthalmologists to help redistribute essential medicines as per the demand and availability of the limited drugs within the market. For example, if a particular district has surplus of medicines (either due to shutdown of hospitals or by manufacturing surplus of it within the district), and another district has lack of those medicines (if there is more ophthalmic requirement or if the drug is not manufactured within its boundaries), then the OI can collaborate within those districts to divert the excessive supply from one to the other. The OI can partner with common online delivery services to deliver its products to the patients. Doctors can ensure their uninterrupted and cost-friendly supply of PPE by directly collaborating with the OI, bypassing the 'expensive' middlemen.

Ophthalmologists should be aware of spurious companies which promise cheaper products without quality. They should stick with their preferred trusted OI partners whilst thinking about financial deals.

Together ophthalmologists and OI can work for the society at large in promoting and fostering quality ophthalmic care.

*Jugaad (noun) – A flexible approach to problem-solving that uses limited resources in an innovative way.

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Conflicts of interest

There are no conflicts of interest.