Canadian researchers recently reported significant increases in complications during cataract surgeries performed during the COVID-19 pandemic compared with the pre-pandemic period.¹ First author Nathan Lee-Wing, BS, and MD candidate at the Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Frank Stockl, MD, FRCSC, and James Wiens, MD, FRCSC, both from the Department of Ophthalmology, University of Manitoba, and the Max Rady College of Medicine, University of Manitoba, Winnipeg, reported their results in the Canadian Journal of Ophthalmology.

They cited a recent report on the professional and personal impacts of the COVID-19 pandemic on ophthalmologists.² “During the shutdowns, surgeons experienced prolonged periods of surgical abstinence, which may have affected their complication rates. Previous studies examined the effects of prolonged abstinence from cataract surgery and found increased PCR rates.^3-6” The authors hypothesized that the increased PCR rates were due to attenuation of the physician's surgical skills.

The investigators pointed out the relative lack of data on the effects of prolonged shutdowns such as those that occurred during the pandemic, and because of that they conducted the current retrospective, cross-sectional study to study the complications of cataract surgery during the COVID-19 lockdown. They analyzed the following factors from before the pandemic to during the pandemic: posterior capsular rupture, endophthalmitis, unplanned anterior vitrectomy, return to the operating room within a month of initial surgery, sulcus-positioned intraocular lens (IOL) implant, anterior chamber IOL (AC-IOL) implant, capsular tension ring (CTR) insertion, and the measurement of cumulative dissipated energy (CDE) from phacoemulsification before and during the COVID-19 lockdown.

What complications did the authors attribute to the pandemic?

Lee-Wing and colleagues analyzed the medical records of patients undergoing cataract surgery at two surgical centers from January 2018 to April 2022, specifically, pre-COVID-19 (January 1, 2018, to March 31, 2020, and COVID-19 April 1, 2020, to April 30, 2022. They compared the complication rates during the two time periods for the previously mentioned factors and the rate of return to the operating room within 1 month postoperatively.

The data from 45,559 patients were analyzed. The comparisons between the two time periods were expressed per 100 cataract surgeries.

“The endophthalmitis rates increased from 0.008 to 0.028 (relative risk [RR] 0.27, P = 0.09). The sulcus IOL implant rates increased from 0.61 to 1.00 (RR, 0.61, P < 0.0001). The AC-IOL implant rate increased from 0.53 to 0.68 (RR, 0.78, P = 0.05). The CTR usage rates increased from 0.48 to 0.75 (RR 0.63, P = 0.001). The average CDE increased from 4.6 to 6.7 (P = 0.0030). The PCR rates decreased from 0.49 to 0.38 (RR, 1.3, P = 0.14). The unplanned anterior vitrectomy rates decreased from 0.43 to 0.36 (RR, 1.18, P = 0.35). The rates of return to the operating room remained unchanged at 0.59 and 0.58 (RR, 1.01, P = 0.93),” Dr. Lee-Wing and colleagues reported.

The authors commented on their findings and that multiple factors may have contributed to the increased endophthalmitis rate in the COVID interval.

“First, the postoperative endophthalmitis patients in the COVID interval were on average older and had longer surgeries than those in the pre-COVID interval. Both parameters are known risk factors for endophthalmitis and may have contributed to the increased risk of postoperative endophthalmitis.7 Second, face mask wearing during the postoperative period may have played a role during the COVID period. To our knowledge, there have been no reports of increased postoperative endophthalmitis rates in face mask wearers after cataract surgery. However, an increased incidence of post-vitrectomy endophthalmitis among mask wearers has been previously reported.8Third, the healthcare worker shortage combined with social limitations and isolation during the COVID period may have resulted in elderly patients receiving suboptimal postoperative care and inconsistent instillation of topical medications in the postoperative period,” they said.

References

1. Lee-Wing N, Stockl F, Wiens J. Complication rates in cataract surgery before and during the COVID-19 pandemic. Can J Ophthalmol. 2025;60:193-99.

2. Fathalla Z, Chaudry E, Aminnejad M, et al. Effects of the COVID-19 lockdown on Canadian ophthalmologists: a survey. Can J Ophthalmol. 2023;58:e55-e57.

3. Thomsen ASS, Bach-Holm D, Kjærbo H, et al. Operating room performance improves after proficiency-based virtual reality cataract surgery training. Ophthalmology. 2017;124:524-531.

4. Matarazzo F, Phylactou M, Day AC, et al. Effect of surgical abstinence on the risk for posterior capsule rupture during cataract surgery. J Cataract Refract Surg. 2022;48:173-176.

5. Tzamalis A, Karafotaki K, Karipidi K, et al. The impact of COVID-19 lockdown on cataract surgery: a surgeons’ perspective. Clin Exp Optom. 2021;104:705-710.

6. Theodoraki K, Naderi K, Lam CFJ, et al. Impact of cessation of regular cataract surgery during the COVID pandemic on the rates of posterior capsular rupture and post-operative cystoid macular oedema. Eye. 2023;37:440-445.

7. Cao H, Zhang L, Li L, et al. Risk factors for acute endophthalmitis following cataract surgery: a systematic review and meta-analysis. PLoS One. 2013;8:e71731.

8. Sakamoto T, Terasaki H, Yamashita T, et al. Increased incidence of endophthalmitis after vitrectomy relative to face mask wearing during COVID-19 pandemic. Br J Ophthalmol. 2023;107:1472-1477.