Attitudes to cataract surgery during the COVID-19 pandemic: a patient survey.

We applaud Shih et al. [1] initiatives in ensuring continuity of clinical care for ophthalmology patients at the University of Hong Kong during the current COVID-19 pandemic. Taking into account the available guidance on infection control measures, their efforts to ensure that both patients and clinical staff remain safe in clinical settings is to be commended. However, in addition to the substantial impact of COVID-19 on healthcare in general [2], one of the consequences of lockdown measures in the United Kingdom and elsewhere has been a significant reduction in elective surgery, including cataract surgery (CS). CS is the commonest elective surgery in the National Health Service (NHS) with good post-operative and quality of life (QOL) improvements [3, 4]. There is no published evidence regarding attitudes and concerns of patients awaiting elective surgery during the current pandemic. The median age of CS patients in the UK is 76.3 years [3], placing them in a vulnerable COVID-19 age group. The selection of patients for CS, with consideration of their concerns and expectations, is important for direct patient care and wider healthcare planning. To address this, we undertook a questionnaire survey to explore patient attitudes and concerns towards undergoing CS during this pandemic.

The survey was approved by our institution’s audit and quality improvement project team. Data collection adhered to the tenets of the Declaration of Helsinki and UK Data Protection Act. The patient sample included all patients on the CS waiting list (n = 376) at our institution. Patients were contacted by telephone from 20th May to 5th June 2020. Informed verbal consent was obtained, and an anonymized seven-question survey completed for each patient. A 5-point Likert scale was used for each question, and each question was analysed independently. Data were analysed using SPSS Version 26.0 (IBM Corp, Armonk, NY, USA). Mann–Whitney and Spearman Rank Correlation tests were used to compare non-parametric data.

Two attempts were made to contact each patient. The survey was completed by 207 (55%). Patient demographics and responses are displayed in Table 1. 64.8% of patients strongly agreed/agreed that their eyesight was reducing their QOL. 70% were prepared to attend hospital for CS within one month. 27.6% preferred to wait until there were no more cases of COVID-19 or a vaccine developed, even if this was over 6 months. 30.9% responded that they would not attend as the person accompanying them on the day of surgery was worried about COVID-19. 47.3% and 37.2% were concerned about contagion in the hospital or on their journey to/from hospital, respectively. 26.6% were more positive towards immediate sequential bilateral cataract surgery (ISBCS), which might help surgical throughput [5]. There was a positive correlation between worsening QOL and willingness to attend (r = 0.236, p = 0.001). Patients were less likely to attend if they were worried about contagion in hospital (r = −0.487, p = 0.000) or on their journey (r = −0.413, p = 0.000), or if the accompanying person was concerned (r = −0.458, p = 0.000). There were no differences in responses between genders, first or second eye CS patients, and under-70 and over-70 age groups. There were no differences between responders/non-responders in terms of age, gender or first or second eye surgery.

Table 1

Patient demographics and responses to questionnaire survey.

Patient demographics	n (%)
Survey responses	207
Males:Females	87:120
Age range (years)	41–94
Mean age (years)	69.6
Waiting for 1st Eye: 2nd Eye	105:102
1. My eyesight is significantly interfering with my quality of life.
Strongly agree	62 (30.0%)
Agree	72 (34.8%)
Neutral	15 (7.2%)
Disagree	34 (16.4%)
Strongly disagree	24 (11.6%)
2. I am happy to come in within the next month for my cataract surgery
Strongly agree	93 (44.9%)
Agree	52 (25.1%)
Neutral	6 (2.9%)
Disagree	25 (12.1%)
Strongly disagree	31 (15.0%)
3. I wish to come in for my cataract surgery until there are no more cases of Coronavirus in the UK and/or there is a vaccine for Coronavirus, even if this takes 6 months or next year.
Strongly agree	26 (12.6%)
Agree	31 (15.0%)
Neutral	16 (7.7%)
Disagree	55 (26.6%)
Strongly disagree	79 (38.2%)
4. I cannot come in for cataract surgery as my family member/carer/friend who has to accompany me on the day is worried about Coronavirus.
Strongly agree	23 (11.1%)
Agree	41 (19.8%)
Neutral	33 (15.9%)
Disagree	54 (26.1%)
Strongly disagree	56 (27.1%)
5. I am worried about contracting Coronavirus at the hospital when having my cataract surgery.
Strongly agree	45 (21.7%)
Agree	53 (25.6%)
Neutral	21 (10.1%)
Disagree	33 (15.9%)
Strongly disagree	55 (26.6%)
6. On the day of cataract surgery, I am worried about catching Coronavirus on my journey to and from hospital.
Strongly agree	34 (16.4%)
Agree	43 (20.8%)
Neutral	13 (6.3%)
Disagree	46 (22.2%)
Strongly disagree	71 (34.3%)
7. My attitude to the idea of having cataract surgery for both of my eyes in the same sitting has changed during the pandemic.
Strongly agree	25 (12.1%)
Agree	30 (14.5%)
Neutral	77 (37.2%)
Disagree	36 (17.4%)
Strongly disagree	39 (18.8%)

At a time when UK lockdown measures are only starting to be eased, with substantial new daily case numbers and the highest reported numbers of deaths in Europe [2], 70% of our patients, many of whom are age vulnerable, are willing to attend for elective CS. Indeed 64.8%, whose surgery has been delayed, feel that their QOL has deteriorated due to worsening eyesight, reflecting the indirect effects on morbidity of measures required to prevent COVID-19. This coupled with the likely substantial numbers of individuals in the community with visually-significant cataract, undiagnosed because of the lockdown measures and now requiring CS, suggests that the recommencement of an adjusted, safe, elective CS service with sufficient case numbers to meet demand and prevent excessive future CS waiting times is imperative. It is, however, of note that almost half of our patients and 30% of their relatives/carers/friends are concerned about the risks of contracting COVID-19 at the hospital and/or during their journey and they will require reassurance that all possible precautions and protocols are being undertaken to prevent contagion.