Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : NC17 - NC20 Full Version

Progression of Diabetic Retinopathy during COVID-19 Pandemic: A Retrospective Study


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/59260.18070
Purban Ganguly, Asif Ayub, Soumyadeep Majumdar, Smiti Rani Srivastava, Jit Bhunia, Asim Kumar Ghosh, Soumyajit Guha

1. Assistant Professor, Department of Ophthalmology, Regional Institute of Ophthalmology, Kolkata, West Bengal, India. 2. Senior Resident, Department of Ophthalmology, Regional Institute of Ophthalmology, Kolkata, West Bengal, India. 3. Assistant Professor, Department of Ophthalmology, Regional Institute of Ophthalmology, Kolkata, West Bengal, India. 4. Associate Professor, Department of Ophthalmology, IPGMER SSKM Hospital, Kolkata, West Bengal, India. 5. Senior Resident, Department of Ophthalmology, Regional Institute of Ophthalmology, Kolkata, West Bengal, India. 6. Director, Professor, Department of Ophthalmology, Regional Institute of Ophthalmology, Kolkata, West Bengal, India. 7. Junior Resident, Department of Ophthalmology, IPGMER SSKM Hospital, Kolkata, West Bengal, India.

Correspondence Address :
Smiti Rani Srivastava,
BH-15, Opposite to Digantika Bus Stop, Salt Lake City, Kolkata-700091, West Bengal, India.
E-mail: drsmiti_srivastava@rediffmail.com

Abstract

Introduction: Emergence and subsequent exponential spread of Coronavirus Disease-2019 (COVID-19) infection during 2020 forced the Government to issue countrywide lockdown from March 2020. Diabetic Retinopathy (DR) is one of the debilitating diseases of the eye which requires regular follow-ups and timely intervention to prevent permanent vision loss. The impact of countrywide lockdown on prevalence and progression of DR needs to be evaluated.

Aim: To assess the effect of COVID-19 pandemic situation on the prevalence and progression of DR and analyse the possible risk factors for progression of DR in the ongoing pandemic period by comparing retrospective data from immediate prepandemic quarter with post lockdown quarter.

Materials and Methods: This retrospective study was conducted in the Department of Opthalmology at Regional Institute of Ophthalmology, Kolkata, West Bengal, India. The study was done during the prepandemic period, from November 2019 to February 2020. In the present study, a cohort of 83 diabetic patients with pre-existing DR was selected from past medical records and compared with post lockdown period during November 2020 to February 2021. Data regarding prevalence of various types of DR, mean Central Macular Thickness (CMT), mean Visual Acuity (VA), proportion of patients requiring >3 doses of monthly anti-Vascular Endothelial Growth Factors (VEGF) and additional laser therapy or vitrectomy, VA improvement and reduction of mean CMT were gathered and compared between those two quarters. The data was analysed using Statistical Package for Social Sciences (SPSS) version 25.0.

Results: The prevalence of moderate Non Proliferative Diabetic Retinopathy (NPDR) (13% vs 25%), severe NPDR (19% vs 8%), Proliferative DR (PDR) (18% vs 7%), Advanced Diabetic Eye Disease (ADED) (4.8% vs 1%) and Diabetic Macular Oedema (DME) (62% vs 28%) increased several folds during post lockdown quarter in comparison to prepandemic quarter. There was a statistically significant difference (p-value <0.05) in baseline mean LogMar Best Corrected Visual Acuity (BCVA) (0.4±0.08 vs 0.9±0.07), mean CMT (386.4±26.8 to 421.8±21.6) positive correlations of some of the possible risk factors for poor visual outcome among the same cohort of patients in the post lockdown period: poor socioeconomic status (35%; Odds Ratio (OR): 3.59, Relative Risk (RR): 2.68), irregular diabetic medication (52%; OR: 3.56, RR: 2.23), residence more than 100 km from the hospital (38%; OR: 3.03, RR: 2.26).

Conclusion: The present study, concludes that, the status of DR stage among study subjects in the post lockdown period has deteriorated when compared with the prepandemic period.

Keywords

Coronavirus disease-2019, Eye disease, Risk factors, Visual outcome

The DR is a chronic disorder of the microvasculature of the retina (1) affecting roughly 93 million patients worldwide (2). Although, the sequelae of untreated DR can be debilitating, repeated studies have shown that, timely treatment can significantly reduce visual loss in patients with DR (3),(4). Despite this, patient compliance with timely follow-up remains a significant barrier to prevent severe vision loss in the diabetic population (3),(4). DR is expected to become an increasingly common cause for morbidity in the developing world, over the coming decades. There has been a well documented rise in the cases of diabetes in the developing world. Prevalence of DR in India is expected to increase three-fold by the 2025 (5),(6). The overall prevalence rates of DR in India, have been seen to vary between 3%-5% in urban populations (7) and approximately 1.1% in rural populations (8). The DR is classified as: very mild NPDR, mild NPDR, moderate NPDR, severe NPDR, ADED and DME, based on internationally accepted Early Treatment Diabetic Retinopathy Study (ETDRS) classification of DR (9).

The advent of Intravitreal Injections (IVIs) of anti-VEGF has revolutionised the management of DR. Studies regarding the efficacy of IVIs of anti-VEGF have shown comparable and potentially superior outcomes to Pan Retinal Photocoagulation (PRP) therapy (10),(11). However, both PRP and IVIs of anti-VEGF require regular patient follow-up to evaluate the response to therapy and the need for further drug intervention to prevent disease progression. As the COVID-19 pandemic emerged and was increasing at an exponential rate during 2020, the Government issued a countrywide lockdown from March, 2020 (order No.40-3/2020-DM-I(A) dated (24.03.2020) (12). This situation affected almost every aspect of the lives up to a great extent. Even after extensive search, similar studies involving DR who compared the progression of disease between the prepandemic period with the post lockdown period, could not be accessed.

Hence, the present study was conducted to assess the effect of COVID-19 pandemic situation on the prevalence and progression of DR patients. The retrospective data from immediate prepandemic quarter regarding prevalence of DR has been compared with post lockdown quarter on a cohort of DR patients. The study has also analysed the possible risk factors for progression of DR in the ongoing pandemic period among the same cohort of study subjects.

Material and Methods

This retrospective study was conducted in the Department of Opthalmology at Regional Institute of Ophthalmology, Kolkata, West Bengal, India. The study was done during the prepandemic period, from November 2019 to February 2020. The study was approved by the Institutional Review Board (IEC no. EC/RIO-62/2021). The data analysis was done after February, 2021. The same cohort of patients was compared for four months in the immediate pre lockdown period and post lockdown period.

Inclusion criteria: Patient’s who were diagnosed with DR during prepandemic quarter.

Exclusion criteria: Patients with co-existing systemic diseases like hypothyroid, hypertension, dyslipidaemia were excluded from the study. Patients who did not turn up in the post lockdown quarter or whose follow-up was not regular or who developed systemic complications related or unrelated to diabetes mellitus were also excluded from the study. Patients with co-existing non diabetic ocular diseases (retinal pathology in addition to DR e.g., co-existent retinal vein occlusion, macular degeneration, etc.,) and the patients, whose complete clinical data and history could not be retrieved from past records in the prepandemic quarter were excluded too.

Study Procedure

In this retrospective study, first a cohort of 83 diabetic patients with pre-existing DR was selected from past medical records who attended the eye clinic during the study quarter of November 2019 to February 2020 (hence, forth referred as prepandemic quarter) after doing simple random sampling. These same cohorts were again examined and treated as and when necessary, between November 2020 to February 2021 (hence, forth referred as post lockdown quarter).

Baseline characteristics e.g., serum Fasting Blood Sugar (FBS)/Postprandial Blood Sugar (PPBS) HbA1c and ocular data including VA; intraocular pressure; presence of DME, Neovascularisation of the Disc (NVD), Neovascularisation Elsewhere (NVE), and Vitreous Haemorrhage (VH); Tractional Retinal Detachment (TRD), Neovascularisation of the Iris (NVI), and Neovascular Glaucoma (NVG) were gathered at the visit during prepandemic quarter and the return visit after ending of lockdown period. VA was recorded using the best available Snellen VA and was converted to the logarithm of the minimum angle of resolution (LogMar) for analysis. These parameters were evaluated by slit lamp biomicroscopic examination augmented with stereoscopic +90 D evaluation of posterior segment of eye ball. Fundus photography and fluorescein angiography were also performed at enrolment and when indicated for confirmation when doubted. In the prepandemic quarter, the clinical data and relevant history was extracted from the hospital records section and from patients’ personal medical records. In the post lockdown quarter, valid informed written consent for inclusion in the study was obtained from every study subject included in the same cohort of 83 patients and were comprehensively examined, investigated and treated {IVI of anti-VEGF/laser/positive predictive value (PPV)} and followed-up for four months.

Statistical Analysis

The data obtained from prepandemic quarter was compared with that of the post lockdown quarter and analysed using SPSS version 25.0. Paired t-test was performed for comparison and correlation of probable risk factors with the outcome was assessed by calculating odds ratio. Statistical significance was set at p-value <0.05.

Results

A cohort of 83 patients with DR, who satisfied the inclusion criteria was included in the study. Progression of DR status during the delayed follow-up period (the patients were advised to follow-up between 4-5 months) is summarised in (Table/Fig 1). The prevalence of different stages of DR was compared between the prepandemic quarter and the post lockdown quarter among the same cohort of patients: prevalence of moderate NPDR (13% vs 25%), severe NPDR (19% vs 8%), PDR (18% vs 7%), ADED (4.8% vs 1%) and DME (62% vs 28%) increased several folds during post lockdown quarter in comparison to prepandemic quarter whereas, prevalence of very mild NPDR (34% vs 19%) and mild NPDR (29% vs 14%) decreased; these differences were statistically significant (p-value <0.05) except ADED group (p-value=0.2, Z-value is -1.4) (Table/Fig 1). There was a statistically significant difference (p-value <0.001) in baseline mean LogMar BCVA (0.4±0.08 vs 0.9±0.07) and mean CMT (386.4±26.8 to 421.8±21.6) between prepandemic quarter and post lockdown quarter (Table/Fig 2).

The post lockdown quarter and prepandemic quarter values of mean FBS (136.4±12.4 vs 121.6±10.6; p<0.001), PPBS (189.3±9.2 vs 176.4±9.8; p<0.001), and HbA1c (7.8±1.2 vs 7.4±1.1; p-value=0.02) were also significantly high (Table/Fig 3).

A total of 46 (55%) out of 83 patients needed more than three doses of monthly IVI of anti-VEGF, when they resumed follow-up after lockdown in comparison to 16 (19%) out of 83 in the prepandemic quarter. The difference was found to be statistically significant (p<0.001). There was significantly greater number of patients who required either additional laser treatment or PPV during post lockdown quarter (42% vs 13%; 22% vs 8%; respectively; p-value=0.04). However, a statistically significant decrease in proportion of patients having BCVA improvement by >0.2 LogMar scale (45% vs 75%) and >10% reduction in mean CMT (39% vs 68%) among patients who received more than three doses of anti-VEGF during post lockdown quarter (n=46) in respect to prepandemic quarter (n=16) (Table/Fig 4). Statistical analyses revealed significant and positive correlations of some of the possible risk factors for poor visual outcome among the same cohort of patients in the post lockdown period: poor socioeconomic status, irregular diabetic medication, residence more than 100 km from the hospital; however, past history of COVID-19 infection and obesity (Body Mass Index (BMI) >30 kg/m2) did not have any positive correlation with the poor visual outcome among the study subjects (Table/Fig 5).

Regarding the change of residence or socioeconomic status, these alterations might have happened because of the pandemic. For the same reason, many of them could not avail public transport to reach hospital and the distance from the hospital became a major factor. During post lockdown check-up, patients specifically mentioned that, they could not avail the medications locally. The regularity of medications was ascertained by checking their physician’s prescriptions, clinical history and blood reports. COVID-19 infection was ascertained based on history checking the treating physician’s prescriptions, discharge certificate and laboratory reports.

Discussion

The present study has shown that, among a cohort of DR patients the prevalence of the stages of DR has worsened significantly when compared between the prepandemic quarter and the post lockdown quarter. Abdelmotaal H et al., conducted a study, among 467 PDR patients as study subjects who received prior PRP and or intravitreal anti-VEGF therapy with an aim to find out the causes for loss of follow-up among the study subjects (13). The authors reported that, the baseline means LogMar BCVA during inclusion of patients who were followed-up was 0.22±0.07 (20/33) and the final mean BCVA was 0.31±0.28 (20/40). In the present study, the mean BCVA deteriorated from 0.4±0.08 to 0.9±0.07. A 9.9% of PDR patients who were followed-up required PPV with respect to the 8% in the present study required PPV. Loss of timely follow-up is an important attribute in deterioration of visual outcome among DR patients. In the present study, the effect of lockdown in pandemic period negatively impacted on the visual outcome the cohort patients. Abdelmotaal H et al., also found positive correlation between loss of follow-up among PDR patients and treatment unaffordability, increasing age, lack of social support and increasing number of IVIs (13). In the present study, too poor visual outcome among the study cohort of DR patients was found to be positively correlated with poorer socioeconomic status, increased distance of residence from hospital and irregular diabetic medication.

Vengadesan N et al., conducted a questionnaire-based study among 500 DR patients with an aim to identify social factors influencing delayed follow-up among study subjects (14). The authors found that, lack of awareness of visual symptoms, inability to find an attendant to accompany and financial liability had significant positive correlation with delayed follow-up among the study subjects. However, the present study was conducted way before the COVID-19 pandemic. The present study has shown that, increased distance of residence from the hospital and poor socioeconomic status had a significant negative impact on the treatment outcome among the study cohort after the lockdown period. In a multicentre retrospective study by Khan R et al., among DR patients in the Indian subcontinent has identified that, lack of awareness among diabetic patients for visual symptoms as a major factor for increased prevalence and poor visual outcome (15). The present study also identified PRP as an effective treatment modality for PDR patients. The lacunae of awareness for retinopathy and visual symptoms among patients that was already pre-existing in the subcontinent has been an additional factor in the lockdown period which has further worsened the visual outcome among the study cohort in the present study.

In an African cross-sectional study by Mtuya C et al., to identify the reasons for poor follow-up among DR patient’s financial factor was highlighted as the principal factor (16). The lockdown period has negatively impacted the global economy in more than one way. The present study also echoes the same findings by showing poorer socioeconomic status as an important factor in poorer visual outcome among DR patients in the post lockdown quarter.

In another retrospective cohort study among PDR patients to analyse the outcome of more than 6 months of loss of follow-up with the visual outcome among the cohort by Obeid A et al., it was shown that, the patients, who received combined therapy with intravitreal anti-VEGF and laser had a better visual outcome than patients, who received only intravitreal injections after more than six months of loss of follow-up (17). The present study has also shown that, in the post lockdown period due to lack of regular follow-up previously during the lockdown period, the visual outcome and reduction of mean CMT was poorer even with three consecutive doses of anti-VEGF injection and additional laser therapy among the study cohort.

Limitation(s)

For risk factor assessment, multivariate analysis was not done. Also, blinding was not done during case selection.

Conclusion

The present study concluded that, prevalence, progression among the DR study subjects in the post lockdown has increased when compared with the prepandemic period. The possible risk factors for such outcome, have been attributed to poorer socioeconomic status, irregular antidiabetic therapy and increased distance of residence from the hospital. The COVID-19 pandemic has negatively impacted in the visual outcome of DR patients which may increase the burden of non preventable blindness in the society. However, the present study needs to be followed-up with a community based prospective analysis to investigate the clinical and social outcome of the COVID-19 pandemic among the DR patients in the subcontinent.

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DOI and Others

DOI: 10.7860/JCDR/2023/59260.18070

Date of Submission: Jul 27, 2022
Date of Peer Review: Sep 19, 2022
Date of Acceptance: Jan 18, 2023
Date of Publishing: Jun 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 30, 2022
• Manual Googling: Dec 15, 2022
• iThenticate Software: Jan 17, 2023 (13%)

ETYMOLOGY: Author Origin

EMENDATIONS: 8

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