Abstract

6-6-2020 was a landmark date for the ophthalmology community, not only because of the normal visual acuity connotation of 6/6 and 20/20, but because it genuinely reflects every ophthalmologist’s dream to bring back perfect vision for every patient. The Covid-19 pandemic had forced ophthalmologists to “refuse to operate” albeit for a short period. This narrative describes how, during a telemedicine call, a surgeon experienced the distress of refusing to operate on a mature cataract. It reveals the trauma caused by the disordered goals of eye care during the pandemic, when elective procedures were abandoned and only emergency services were provided.

The magnitude of cataract blindness is high and there are many challenges to achieving the target of universal eye care despite the vigorous government push and the active efforts of non-governmental organisations (1). “Perfect vision” is what any ophthalmologist worth her salt, genuinely dreams of for her patients. The ophthalmologist’s cup of joy overflows after a successful cataract surgery when the postgraduate student smilingly reports “Patient’s vision is 6/6”. To an eye surgeon, this number has great significance.

On June 6, 2020 — (6-6-2020), the usually bubbly ophthalmology community very quietly observed this unique day as it went viral on the social media, partly because the date matched 6/6 or 20/20 ‒ the connotation for normal visual acuity, and also because it symbolised the goal of every ophthalmologist: “6/6 or 20/20 in every eye, in every patient.” However, on this day, the numbers 6/6 had taken on a new meaning — the minimum “safe distance” when the early pandemic control policies allowed only emergency and not elective surgeries. So, not surprisingly, on this date — 6/6/2020 – a telemedicine call numbed me and my goal, like a frozen globe.

I responded, and the patient said “Doctor, I am Krishnappa speaking” (all names changed). He narrated his story “Six months back, I had visited your hospital for my wife Sharadamma’s eye problem. You had advised cataract surgery at the time. Unfortunately, we had deferred the surgery because our granddaughter had just delivered a baby, and there was no one to take care of the chores at home. Also, her vision was not so bad, you know; she could see till the end of the room and even recognise faces. Now her vision is very poor. She is unable to identify faces. She can only see some light and nothing else. Not only in one eye, but in both. Yesterday, she added salt instead of sugar to my coffee. Doctor, please tell us what to do. Can we come to the hospital for cataract surgery tomorrow?” Well, that was his story. Surely, a salty coffee could not have tasted good.

As I visualised the likely outcome of this unfolding story, I was frozen to the spot. Cataract surgeries had come to a standstill! Vivid images, polyopias crowded my vision… “Covid-19, pandemic, lockdown, quarantine, healthcare workers, personal protective equipment (PPE), aerosol-generating-procedures, RT-PCR, false negatives, surgeon got infected and died”. These were the many keywords going round like floaters in front of my eyes — muscae volitantes, as ophthalmologists would call them. Well, this was my story. My tongue turned bitter (not Covid induced!). Surely, Krishnappa’s salty coffee must have tasted better than this!

I recollected the consensus statement released by the All India Ophthalmological Society (AIOS) and pondered over the collective wisdom shared with us all (2). I had to buy some time before responding to him. I said “Wait, Krishnappa, can you send me a picture of Sharadamma’s eyes on my WhatsApp number?” He did, in the next 20 minutes. And in those 20 long minutes, I found myself operating on my cataractous thoughts — blocking my anxiety with the anaesthetic dose, incising my thoughts with blades and knives, extracting ideas as deftly as I would a cataractous lens, irrigating with a balanced-mind-solution, aspirating my fears, implanting confidence with the ease of an intraocular implant and finally ‒ suturing the right words into the right place ‒ neither too tight, nor too loose, and well placed. I saw myself consolidate into a “single piece”.

And there I was, looking at the picture of Sharadamma’s cataract ‒ what an undergraduate student typically describes as ‘pearly white’ ‒ which meant that the cataract was mature and needed surgery urgently for two reasons: the eye was needlessly blind and leaving it unoperated any longer, could result in complications and permanent loss of vision. I needed some breathing time…a shot of high-flow oxygen. “Please send me clearer and closer pictures of each eye, once again”. I said in a heavy voice. Ten minutes later, the cataract hadn’t changed a bit. And to my big relief, it had not turned ‘milky white’ like the more advanced hyper mature cataract! The next task was deep breathing. No, the next task had to be counselling. But before that, I needed some comforting “No’s” from him. Is the eye red? Is the eye painful? Is the eye watery? These were my questions to remotely assess if the cataract had already developed complications and the answers were a comforting “No”, “No”, and “No”. That meant it was not an emergency.

In an attempt to postpone the elective surgery to a safer time, I needed to hear more of these “No’s”. Is she a diabetic, hypertensive? Any other illness? It was again a triple “No”. This meant she had no co-morbidities and the risk of surgery was not high. I wasn’t happy yet. I was craving for more “No’s”.

And then, something occurred to me that I often teach my ophthalmology students, “Don’t treat a patient only as two ‘eyes’, treat the patient as a ‘whole person’”. With due consideration to the pandemic context, I resumed my enquiry. “Any episodes of fever? Or cough? Or shortness of breath?” I heard the triple ‘No’ again and each ‘No” was a firm ‘No”. I realised by now, that there was only one ‘No’ I wanted to hear. “No for surgery”, at least right now, since none of us was prepared to operate during the initial pandemic. I mustered some courage “See, Krishnappa, Sharadamma is very lucky. Her cataract is mature, but not hypermature, yet. So, it is not an emergency, right? You know about the coronavirus. It has affected so many people and so many have died. Therefore, we have temporarily stopped operating. We are planning to start operations very soon, maybe in two to three weeks’ time, once the pandemic comes under control. And it is very unlikely that Sharadamma’s cataract will develop complications within that period. You can definitely wait. No problem. Once the OT starts functioning, we will call you. And Sharadamma will be one of the first to get operated on. So don’t worry. But remember, in case she develops redness of eyes or watering or pain in the eyes, come immediately and don’t delay. Because, once it gets complicated, vision cannot be guaranteed. Right now, preventing corona infection (read saving life – yours and mine) is more important than vision.” To me, I sounded convincing. There was silence on the other side of the phone. I heard what he did not say:

“Is it not too late, already?”

“Did you not say, don’t wait for the cataract to mature, during the last visit?”

“What happened to the goal of Vision 2020 and preventing anyone from becoming needlessly blind?”

“What will come first: the day of complication or the date of surgery?”

Only time would tell.

Pre-corona, the distress among ophthalmologists was different. We had to deal with the combinations of successful surgeries, but unhappy patients; we call them “6/6-yet-unhappy patients”. Such patients unsettled our sleep. On this day, in the early Covid-19 pandemic, we were hopeful of finding a blind-yet-very-happy (to stay away from possible infection) patient. Letting them remain in the dark, was going to unsettle our waking hours. Our goal had shifted from the acme of the perfect 6/6 vision without any of the minor imperfections such as astigmatism, glare or dryness of the eyes, to serious preoperative concerns of contracting Covid-19 infection or spreading it during the preoperative work-up. Endless unresolved questions came to mind: whether to do lacrimal syringing or not, tonometry or not, phaco surgery or not, aerosol-generation or not, hospitalisation or day care, Covid testing or not, and to operate or not?! We were never warned of such a possibility at any time in our medical education.

That day was a day of intense introspection. I felt a sense of serenity strongly resurfacing in me, displacing and dissipating all my fears. Over the week, fortunately, I gathered courage and started performing the so-far locked-down surgeries, without having to find reasons to defer any more, ever again, during the lockdown.

As with every other healthcare provider, the Covid-19 pandemic had trumped all the customary protocols. The ophthalmology community on this day (6-6-2020) therefore quietly observed this unique day with a distinct lack of enthusiasm.

We were confused about whether tears gave us corona, or corona gave us tears. Hands that typically turned itchy on seeing a cataract, were now busy getting sanitised. We, the eye surgeons, were maintaining a social distance from the 6/6 goal and wearing a mask to hide our helplessness about our duty to care. The goal of the World Health Organization was to eliminate all preventable and curable blindness by the year 2020, as a part of the Vision 2020 Global Initiative.(3). Instead, we were at a standstill — uncomfortably, but surely avoiding surgeries on patients to prevent the spread of infection in a pandemic, albeit temporarily. Our duty to care and self-protection were in conflict. It had taken several years and tons of hard work to achieve the goal of 6/6 for our patients and one little virus had made that goal inaccessible for us. A year down the line, in October 2021, with the pandemic slowly but surely coming under control and our fear descending from Himalayan heights but still hovering over us, the gold standard is gradually returning to normalcy; so also the goals of the then subdued ophthalmologist. We shall overcome this!