New normal - Tenets with Cataract Surgery Every Ophthalmologist Should Know during COVID-19 pandemic

Dr. Jatinder Singh Bhalla
Dr. Satender Kumar Singh
Dr. Amit Mehtani, MBBS, MS,DNB (OPHTHAL)
Published Online: April 1st, 2021 | Read Time: 21 minutes, 51 seconds


Cataract is the second most common cause of preventable blindness worldwide and the most common cause of preventable blindness in India, affecting nearly 65.2 million worldwide [1-5]. To control the number, a high cataract surgery rate (CSR) is required. Sudden lockdown due to the current pandemic led to the cessation of elective cataract surgery [6,7], causing a sharp decline in the required CSR. In India as per the National Programme for Control of Blindness (NPCB) data 2018-19, the desired CSR was 947866 which could not be achieved [7]. As the unlock process has started, resumption of elective cataract surgeries is being initiated with precautionary measures. In this article, we have tried to summarize the current guidelines for elective cataract surgery.

Preferred practice for cataract surgery:

1. General measures:

The Govt. of India (GOI), Ministry of Health and Family Welfare (MoHFW) have advised certain preventive measures to avoid transmission (mask, hand hygiene, and social distancing) [6], and it must be followed everywhere. As the SARS COV-2 virus has a high rate of transmission and cross infection [7], some more precautions should be taken:

  • Appointment based practice to prevent overcrowding in the waiting area.
  • Well-trained and minimum staff for managing the OPD and Operating Room
  • Regular infrared thermal screening of both employees and patients
  • Questionnaire-based patient screening for symptoms of SARS CoV-2.
  • Open door practice
  • Full safety gear/standard PPE (Mask, gloves, eye gear, face shield, disposable gown, breath shield)
  • Regular cleaning of all surfaces like tabletops, door handles etc. with 1% sodium hypochlorite solution.
  • Use of the Arogya Setu app (if possible).

2. Patient Selection:

Sudden lockdown led to the postponement of planned cataract surgery and relinquished screening of new patients. As we are in midst of the pandemic and with the “unlock” announced, it is mandatory to prepare ourselves for resuming normal practice. Prioritization of patients based on ocular triage should be done and pre-evaluated patients prior to lockdown need to be telephonically contacted and planned for surgery. Also, new patients coming to the OPD should be screened and evaluated. Those having medical issues along with cataracts should be thoroughly assessed and planned only after clearance from concerned specialties. Eyes with mature, hypermature, lens-induced glaucoma, pediatric cataract and other ocular co-morbidity in which cataract precludes further treatment should be given priority.

Table 1: Criteria for patient selection for cataract surgery (proposed by RCOphth) [16]

Criteria A

The patient has significant visual symptoms confirmed to be due to cataract

Visual symptoms due to cataracts are impairing the patient’s activities of daily living, and it is anticipated that this will be improved by surgery

Criteria B

Cataract surgery is needed to facilitate the management of ocular comorbidity, including but not limited to screening or treatment of diabetic retinopathy; glaucoma monitoring; treatment of angle-closure glaucoma

Criteria C

The patient indicates a willingness to have cataract surgery following a discussion including:

How the cataract affects the persons’ vision and quality of life

Whether one or both eyes are affected

Consequences of not undergoing surgery for ocular health, quality of life and other reasons such as continuing to meet legal driving standards

3. Screening:

Various studies [8-15] have reported the presence of the virus in the ocular secretions of affected individuals. Hence it is important to take all necessary precautions. Social distancing should be practiced during the consultation and history taking [7]. Wearing of triple-layer surgical mask/N95 mask by the doctor and patient is deemed necessary, as by merely wearing a mask, the risk of transmission itself is highly reduced [17]. Handing over documents should be avoided [7], instead if possible, old documents should be shared over by email, WhatsApp, or Telegram.

4. Pre-op evaluation:

  • Visual acuity testing: Avoid using occluder, patient should use their hand to cover the eye not being examined. Testing should be done from the smallest possible letter over the vision drum to finish the test as fast as possible [7].
  • Intraocular Tension: To be measured only if signs of raised IOP are present, the patient is on any kind of steroids, is known case of glaucoma, or planned for cataract surgery. To record the IOP Goldman applanation tonometer, Schiotz tonometer or Tonopen. The tip should be cleaned with 70% isopropyl alcohol between cases and with 1% Sodium hypochlorite at the beginning and end of OPD day. Non-contact tonometer (NCT) should be avoided as it is an aerosol-generating procedure [7].
  • Lacrimal Sac: The patency of the lacrimal sac can be assessed by ROPLAS method by wearing examination gloves or using fluorescein dye . In suspected cases of nasolacrimal duct blockage, cataract surgery should be postponed. Syringing should be avoided as it is an aerosol generating procedure. [7]
  • Slit-lamp Examination: Breath shield should be present to prevent transmission through aerosolized respiratory droplets. Single person policy should be considered to prevent the transmission to other HCW’s. Slit lamp should be cleaned with 70% isopropyl alcohol before examining another patient [18].
  • Fundus evaluation: Retina of all patients undergoing cataract surgery must be examined, preferably using an Indirect ophthalmoscope or 90 D or 78 D lens and use of direct ophthalmoscopes should be avoided [7].
  • Biometry [7]: Ultrasound Biometry- The tip of the probe should be cleaned with alcohol swab after every case and sufficient time to dry up should be given. In case of use of immersion scan, cleaning of the Prager shell along with the probe should be done with clean fluid. Whereas Optical biometry, is the preferable method for measuring the eye. The main instrument panel should be cleaned using a soft, lint‑free cloth dampened with 70% Isopropyl alcohol. All necessary cleaning should be followed as per manufacturer’s guidelines of each machine to avoid inadvertent damage by the cleaning solutions. Breath shields should be incorporate between the technician and the patient to prevent direct contact with the aerosols generated. The joystick, locking screw for the instrument base, head rest, chin rest, handlebar which the patient holds, keyboard and touch display should be cleaned with isopropyl alcohol 70% after every test.
  • Keratometry: Any keratometer can be used. The breath shield can be customized and placed as a barrier. The joystick, locking screw for the instrument base, head rest, chin rest, handlebar should be cleaned using alcohol swab after examining each patient [7].

5. Counseling:

All the necessary information regarding surgery should be communicated either on the first visit for new cases or telephonically for pre-listed cases. Instructions for surgery‑day should be explained. Important information must be shared by phone, e-mail, or WhatsApp. Special COVID-19 consents can be added to the preoperative protocol [19].

6.Choice of Surgery:

The choice of surgery is primarily resource and surgeon dependent. Even-though phacoemulsification is the most preferred technique and considered as the gold standard [20] for cataract extraction, Manual Small Incision Cataract Surgery (MSICS) is equally practiced in a large part of the country. The debate on which technique is better has been going on for long and various studies have quoted the benefits over each other. The much-debated concern is the transmission of the virus through aerosol generated during cataract surgery. Although the presence of the virus in aqueous has not yet been confirmed by any authority, also the chances of transmission through aerosol in cataract surgery is exceptionally low [17]. According to AAO and AIOS, the aqueous is replaced by the viscoelastic initially and later by balanced salt solution (BSS) hence the aerosol generated is of the BSS and/ or viscoelastic [7,17]. The role of povidone-iodine 5% prior to surgery has also shown active response against the SARS CoV-2 virus [7,17]. Another source for aerosol generation is through wound/incision, which can be minimized by regular wetting of the ocular surface and incision site by viscoelastic [21].

Table 2: Techniques for preventing aerosol generation in different surgical techniques.

Phacoemulsification [21]

Method to minimize aerosol generation

  • Avoid using jet stream of BSS for wetting of cornea, instead remove the cannula before wetting is one technique.
  • Viscoelastic is proven to better than BSS.
  • Regular use of viscoelastic at the wound site.
  • Changing the size of the incision from 2.7 mm to 2.2 mm has reported low to no aerosol generation.
  • Replacing the aqueous with viscoelastic initially and the by BSS
  • Put viscoelastic before hydrating the wound.

Manual Small Incision Cataract Surgery (MSICS)

  • Minimal cautery to obtain a blood-free surgical field [7].
  • Avoid using jet stream for wetting of cornea.
  • Use viscoelastic at different steps for avoiding repeated wetting with BSS. [7].
  • Detach the syringe from the cannula and empty it in the pouch and avoid spilling on the floor.
  • Put viscoelastic before hydrating the wound

7. Role of pre-operative testing for SARS CoV-2:

ICMR reports state that more than 80% of those who were tested positive were asymptomatic and with limitations in the availability of diagnostic tests, it is prudent to assume that all patients are potential COVID-19 positive patients. Thus, it is necessary to take additional precautions during cataract surgery and perioperative period. But the mandatory pre-operative testing for SARS CoV-2 for elective cataract surgery is still undecided [6,17].

8. Operating room (OR) safety measures: [22,23]

  • Well trained and minimum staff to assist the surgery
  • Surgery to be done by well-trained surgeons to fasten the process.
  • Disinfection of the OT should be done after each case as per guidelines by CDC.
  • The most important factor is to ensure that the virus laden airborne particles shouldn’t escape the room occupied by patient and simultaneously maintain a low concentration of viral load inside the OR in order to control the spread of infections and also to protect HCW’s.
  • As all pre-existing OR’s are recirculatory type positive pressure OR’s, it is important to convert them into a non-recirculatory type, negative pressure OT (>5 Pa), with the recommended temperature of 24 to 30° C and relative humidity of 40 to 70%.
    • This can be achieved by blocking off the return air vents in the OR. Air Handling Unit (AHU) must be a dedicated one for every OR and must have the provision of receiving adequate outdoor air supply. Additionally, an independent exhaust blower shall be provided to extract the room air and exhaust out into the atmosphere, after suitable “exhaust air treatment” by high-efficiency particulate air (HEPA) filtration. If not possible, then chemical disinfection (1% hypochlorite) or Ultraviolet (UV) irradiation or heating at 75° C can also be done.
    • Places where availability of AHU is not possible, the option to have stand-alone room air-conditioners (Split AC of 2 tons each) can be considered as they re-circulate air within a single occupied zone. Recirculation of cool air by room air conditioners must be accompanied by outdoor air intake through exhaust by natural exfiltration. Fresh air intake through a fan filter (or a HEPA filter) unit will prevent outdoor dust entry and exhaust fans should be kept operational.


9. Intra-op safety tips:

It is important to take precautions and ensure complete safety while operating.

  • Patient to wear a surgical mask (mask with respirators are not to be used) [17].
  • The operating surgeon must wear an N 95 mask.
  • Eye gear should be worn.
  • Sterile double gloves should be worn and changed after every case.
  • Use of standard PPE kit.
  • Proper care must be taken to avoid any cut or needle prick during any procedure as the chance of infection through wound may be high.
  • Ensure proper draping to prevent respiratory droplet infection.
  • Use of 10% povidone Iodine for extraocular use and 5% for ophthalmic use pre and post-surgery.
  • Although the chances of getting infected through aerosol generation during cataract surgery remain unclear, a new method of preventing aerosol spread is by creating a barrier using surgical drape [24].

10. Post-operative Care:

Patients following cataract surgery should not be called frequently to the clinic/hospital to prevent infection. They should be seen on the first post-op day and the rest of the follow-up should be done through telemedicine at 14th and 30th post-op day. They should be counseled about alarming signs for which they should consult on an emergency basis.


Unlike novel coronavirus, cataracts may not systemically jeopardize the patient’s condition, but it surely does make one helpless and dependent by making them visually handicapped and also affects the health-related quality of life. The current pandemic may have slowed down our progress in fight against preventable blindness, but with careful and alert actions we can learn to live and survive the pandemic and continue to provide a safe and high-quality ophthalmic care and deflate the global burden of preventable blindness due to cataract. At the same time, the safety of ourselves and the surgical team should be paramount in our scheme of things so that we tide over this period of crisis by staying safe healthy, and alive. This is possible by being resilient, adaptable, and willing to learn from each other’s experiences.


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Dr. Jatinder Singh Bhalla
Head, Department of Ophthalmology , DDU Hospital, New Delhi
DR JS Bhalla, MS, DNB, MNAMS is an aluminus of Maulana Azad Medical College, New Delhi, and presently working as HOD , DDU Hospital New Delhi with a teaching experience of 25 years . Has a special interest in Cataract and Glaucoma with publications in peer reviewed national/ international journals. He is currently on Editorial Board of Indian journal of Ophthalmology, Delhi Journal of Ophth. & DOS times; Reviewer of Asia Pacific Journal of Ophth. & JCOR (Journal of Maharashtra Ophth. Society), evaluator of Instruction courses, free papers, thesis & Videos at AIOC. Delivered keynote lectures & conducted Instruction Course at annual AIOC. He is also presently a member Scientific Committee AIOS & Treasurer DOS . He has been awarded IIRSI Gold Medal (2019), Felicitated 5 times by National Eye Bank, AIIMS (2014 2019) Dr. RN Sabharwal gold medal by DOS in 2017,2018 ,Distinguished Resource Teaching award by DOS (2017- 2019), DMA Appreciation award (2016), Delhi Govt State award (2015 ) . He also has been awarded AC Agarwal trophy by DOS in 2018 , Best paper Award by ISCKRS in 2016 , Ophthaquest in 2017 & 2018 & DOS in 2019 .
Dr. Satender Kumar Singh
Senior Resident, Department of Ophthalmology, DDU Hospital
Dr. Satender Kumar Singh is working as senior resident in the department of Ophthlmology. He has several publication and has won several best paper awards in various ophthalmology conferences -Ramesh Krishna Award for Best Poster in P G category on in 39th M P State Conference, Dr Kumud V Joshi Award for Best Paper In P.G Category in 41st M.P State Ophthalmic Society Conference and 1st prize in P G Quiz conducted in 41st M P State Ophthalmic Society conference
Dr. Amit Mehtani, MBBS, MS,DNB (OPHTHAL)
Consultant , Department of Ophthalmology, DDU Hospital
Dr. Amit Mehtani is a Consultant Ophthalmologist at DDU hospital, a district level multi speciality hospital in New delhi under the aegis of Delhi government. His field of interest is cataract surgery , astigmatism , paediatric ophthalmology, medical retina and imaging of eye. He is actively involved in teaching post graduate students and has presentations in state and national forums.
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