A total of 326 patients were recruited into the study, 200 (200/326, 61.3%) patients from Singapore and 126 (126/326, 38.7%) patients from New Delhi, India. The mean age of patients was 58.2 years (median age of 61 years, SD ± 17.9), with 169 (51.8%) patients being female. The youngest patient was 11 years old and the oldest patient was 93 years old. In terms of laterality, 169 (51.8%) patients had unilateral disease while 146 (44.8%) had bilateral disease, the remaining 11 (3.4%) were unknown. The survey inquired into the number of patients who had experienced cancellations or postponement of appointments. A total of 286 patients (286/326, 88%) of patients responded to this question. We found that a large proportion of patients (151/286, 52.8%) had appointments cancelled during the lockdown period; these appointments included outpatient reviews, surgeries, intravitreal injections and laser procedures. Some patients had more than one such appointment cancelled, resulting in a total of 186 reported cancellations amongst the 151 patients who responded. Cancellation of outpatient consultations (128/186, 68.8%) was the most common, followed by surgeries (19/186, 10.2%), intravitreal injections (25/186, 13.4%) and laser procedures (8/186, 4.3%), the rest were not specified (6/186, 3.2%). Most patients were on at least one eye drop medication (134/326, 41.1%), followed by no eye drop medications (122/326, 37.4%), two eye drop medications (47/326, 14.4%) and lastly three or more eye drop medications (23/326, 7.1%). Follow-up frequency was also recorded and found that the majority of patients recruited (175/326, 53.6%) were required to visit the eye clinic at a frequency shorter than 6-monthly, while patients who required annual follow-up or longer were less likely to be present during the initial reopening phase of outpatient services (55/326, 16.9%) and hence fewer such patients were recruited. Cataract (56/326 17.1%), diabetic retinopathy (34/326, 10.4%) and glaucoma (25/326, 7.7%) were amongst the most common eye conditions. Table 1 describes the demographics of the patients, their follow-up status and treatment received. Table 2 describes the ophthalmic conditions faced by the patients from both centres. Patients from each centre demonstrated distinct responses to the survey and hence results will be reported and compared in the sections below. Survey responses could be broadly classified into four main themes of patients’ perceptions: (1) impact on eye care, (2) access to care, (3) risk of transmission of COVID-19 and (4) non-contact telehealth strategies. Table 3 captures all patients’ responses to the questionnaire. Figure 1 describes the combined responses of patients from both Singapore and India. Figure 2 describes the responses of patients from Singapore while Fig. 3 describes the responses of patients from India.
A total of 200 patients were recruited from the Singaporean centre. The majority of patients were female (126/200, 63.0%). The mean age was 65.7 years (SD ± 13.7 years) and the median age was 67 years old. The youngest patient was 19 years old and the oldest was 93 years old. In terms of laterality, 103 (103/200, 51.5%) patients have unilateral disease while 91 (91/200, 45.5%) had bilateral disease and 6 (6/200, 3.0%) were unknown. A total of 126 patients were recruited from the centre in New Delhi, India. The majority of patients were male (81/126, 64.3%). The mean age was 46.3 years (SD ± 17.4 years) and the median age was 50 years old. Similar in proportion to the Singaporean patients, approximately half (66/126, 52.4%) had unilateral disease while 55 (55/126, 43.7%) had bilateral disease and 5 (5/126, 4.0%) were unknown. In comparison, there were more female patients recruited from the Singaporean centre compared to the Indian centre (63.0% vs 35.7% female). The patients from the Singaporean centre were also older compared to those from the Indian centre (mean age of 65.7 vs 46.3 years).
Baseline Visit Frequency and Medication Burden
A total of 91 (91/200, 45.5%) patients from the Singaporean centre required follow-up frequency shorter than 6 months. This contrasts with patients from the Indian centre who required more frequent follow-ups, with two-thirds (84/126, 66.7%) of patients requiring visits shorter than 6-monthly, out of which 36 (36/126, 28.6%) patients had a visit frequency of at least once a month. Half (100/200, 50.0%) of patients from Singapore were not on any long-term eye drop medications while the other half were on at least one eye drop medication (100/200, 50.0%). As for the Indian centre, most patients were on at least one eye drop medication (104/126, 82.5%) and only a handful were not on any medications (22/126, 17.5%) (Table 1).
The two most common eye conditions experienced by patients from the Singaporean centre were cataract (46/200, 23.0%) in the pre- or postoperative stage and glaucoma (or glaucoma suspect) (25/200, 12.5%) (Table 2). As for patients from the Indian centre, the most common eye condition was diabetic retinopathy (26/126, 20.6%), followed by uveitis or ocular inflammatory conditions (11/126, 8.7%). The proportion of retinal and macular conditions seemed to be much higher in patients from the Indian centre (36/126, 28.6%) compared to those from Singapore (14/200, 7.0%) during the study period. More patients from the Singaporean centre presented to the clinic for routine screenings such as plaquenil toxicity, diabetic eye screening, glaucoma suspect screenings and routine eye check-ups. This contrasts with the Indian centre where such visits were absent.
Perceptions on Impact on Eye Care
Patients from India and Singapore had differing perspectives about the impact the pandemic had on their eye health. When asked if COVID-19 had negatively impacted their eye disease, 13.5% (12.5% agree, 1% strongly agree) of patients from the Singaporean centre agreed, whereas a large majority of 61.9% (46.8% agree, 15.1% strongly agree) of patients from the Indian centre agreed. Amongst the patients from Singapore, most felt that their eye conditions were stable (68.5%, 65% agree, 3.5% strongly agree), while only about a third (32.6%, 27% agree, 5.6% strongly agree) of patients from India felt their eye condition was stable.
Patients were also asked about the psychological impact of their eye disease during lockdown, e.g. if they were more distressed by their eye condition compared to regular days, or if it was the most important issue or least of their worries. The majority of patients from India were more distressed as compared to regular days (58.7%, 37.3% agree, 21.4% strongly agree), where 50% (27.8% agree 22.2% strongly agree) felt that their eye disease was the most important issue they faced during the lockdown and 47.6% (34.1% disagree, 13.5% strongly disagree) disagreed that their eye condition was the least of their worries. On the contrary, for patients in Singapore, only 19.5% (17% agree and 2.5% agree) felt more distressed, 31.5% (24.5% agree, 7% strongly agree) felt that their eye condition was the most important issue and 38% (36.5% agree and 1.5% strongly agree) agreed that their eye condition was the least of their worries.
Perceptions on Access to Care
There was a significant difference between patients from each centre in terms of access to care and medications. The majority of patients from the Indian centre were affected such that 70.8% (48.4% agree, 22.2% strongly agree) agreed that they were unable to access the appropriate care for their eye condition, in contrast to only 21.5% (20.5% agree, 1.0% strongly agree) of patients from the Singaporean centre. Similarly, 42.0% (35.7% agree, 6.3% strongly agree) of patients from India were unable to obtain medications, in contrast to only 7% (6.0% agree, 1.0% strongly agree) of patients from Singapore. In addition, patients from India felt more strongly that their eye care centre could have done more for their eye disease during the lockdown, with 50.8% (38.9% agree, 11.9% strongly agree) agreeing, compared to 29% (27.5% agree, 1.5% strongly agree) of patients from Singapore. When asked about reasons for treatment being affected during the lockdown, 72 patients from the Indian centre responded. The most cited reason is the lack of transport (76.4%, 55/72), unavailability of the hospital or healthcare staff (43.1%, 31/126), travel restrictions (6.9%, 5/72) and financial constraints (1.4% 1/72) (Fig. 4).
Perceptions on Risk of Transmission
Risk of exposure to COVID-19 was more of a deterrent to visit eye care centres for patients in India than it was for patients in Singapore. Two-thirds of patients from the Indian centre (66.6%, 45.2% agree, 21.4% strongly agree) were afraid of being infected with COVID-19 if they were to visit the clinic or hospital. As for the Singaporean centre, only 35% (25.5% agree, 9.5% strongly agree) agreed.
Perceptions on Non-contact Telehealth Strategies
Most patients found that the medication delivery service was a convenient way to obtain medications, with 61.1% (50.0% agree, 11.1% strongly agree) of patients from India and 58% (44.5% agree, 13.5% strongly agree) of patients from Singapore who agree. Patients from the Indian centre were more receptive to teleconsultation and non-contact healthcare strategies such that the majority (61.9%, 50.0% agree, 11.9% strongly agree) of patients felt that being able to contact their doctor during the lockdown via teleconsultation could help with their eye condition. On the other hand, more patients from the Singaporean centre disagreed (43.0%, 41.0% disagree, 2.0% strongly disagree) with teleconsultation services than those who agreed (31.0%, 29.5% agree, 1.5% strongly agree).