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ORIGINAL ARTICLE

Challenges and impact of COVID-19 lockdown on Indian

optometry practice: A survey-based study
Siddharth K Karthikeyan a , Pooja Nandagopal b , Vivek Suganthan R b,∗ , Anush Nayak a

a
Department of Optometry, Netha Jyothi college of Optometry, Udupi, Karnataka, India
b
Department of Optometry, Manipal College of Health Professional, Manipal Academy of Higher Education, Manipal, Karnataka,
India

Received 4 July 2020; accepted 20 October 2020

KEYWORDS Abstract
COVID-19; Purpose: The Indian government announced a nationwide lockdown as a preventive measure to
Optometry practice; control the prevailing COVID-19 pandemic. This survey was developed and conducted to assess
Tele-optometry; the impact of lockdown on Indian optometry practice.
Business continuity; Methods: A survey questionnaire was designed and circulated across the optometrists practicing
Online education in India through multiple social media platforms. All the data were extracted and only valid
response were analyzed and reported.
Results: A total of 691 optometrists participated in the survey. Most of the participants (22.25%)
were in private practice followed by academics (14.89%). Among the valid responses collected,
it was found that 43.37% of the respondents were consulting patients during the lockdown.
Of these, 27.17% of optometrists were examining infectious cases and 48.68% were exam-
ining all the patients who came for consultation. Approximately 50.94% of the participated
optometrist had begun telephonic/e-mail/video consultations. In addition, 64.48% reported
that optometrists were at an equal risk of clinching COVID-19 on comparison with other domains
during patient examination. Nearly 30.44% respondents felt that optometrists would face chal-
lenges in approaching the patient post COVID-19 considering the close working distance.
Conclusion: A proportion of optometrist have switched to some form of teleconsultation in
order to aid patients during this prevailing pandemic. Regulatory bodies should issue appropri-
ate guidelines regarding the safe optometry practice for the betterment of both patient and
practitioners during face-to-face consultation.
© 2020 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

∗ Corresponding author at: Department of Optometry, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal

576104, Karnataka, India.

E-mail address: [email protected] (V.S. R).
https://doi.org/10.1016/j.optom.2020.10.006
1888-4296/© 2020 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: S. K Karthikeyan, P. Nandagopal, V.S. R et al., Challenges and
impact of COVID-19 lockdown on Indian optometry practice: A survey-based study, Journal of Optometry,
https://doi.org/10.1016/j.optom.2020.10.006
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Introduction The survey questionnaire (Google form) was struc-

tured and finalized after a group discussion with four
Toward the end of 2019, a cluster of people presented with optometrists. The structured questionnaire was circulated
signs related to pneumonia in the Wuhan a city in China, among optometrists practicing in India through social
which was later identified to be novel coronavirus disease medias, namely WhatsApp, Telegram, and Facebook. The
2019 (COVID-19).1,2 After initial diagnosis of this novel dis- survey responses were collected from April 24, 2020, to April
ease, there was an alarming increase in the rate of COVID-19 29, 2020. A reminder was sent every 2 days via social media
cases in China, and by early 2020 WHO (World Health Organi- platforms. In the online survey, respondents could not alter
zation) declared this COVID-19 outburst as a pandemic. The responses after submitting the questionnaire.
first case of COVID-19 in India was noted in Kerala on 30th The survey consisted of a 15-item questionnaire
January 2020. (Appendix Table 1) focusing on different optometry prac-
COVID-19 manifests flulike ailment with fatigue, sore tices, mode of education, and patient care in India during
throat, fever, cough, dyspnoea, occasional diarrhea and the COVID-19 lockdown. A team of five optometrist piloted
vomiting.3 Literature suggests that old age and the pres- the questionnaire initially to check the clarity and to assess
ence of comorbidities could result in poor prognosis of the the time required to complete the survey.12 Minor cor-
condition. In older age group and immune-compromised rections to the questionnaire were made based on their
individuals, the condition is found to deteriorate to acute feedback. The estimated time to completion of this ques-
respiratory distress syndrome and multi-organ failure, lead- tionnaire was approximately 2---3 min. At the beginning of
ing to death.3---5 the survey, a written statement indicated that the partici-
WHO had notified that the transmission could primarily pation is voluntary and their response to the survey implies
occur through contacts, droplets, and fomites.4,5 Consider- their consent for participation. The statement also men-
ing this, many countries including India have announced a tioned that the questionnaire was to be completed only by
complete lockdown as a preventive measure to constrain the the optometrist practicing in India.
spread.2,3 Indian government imposed a nation-wide lock- As the optometry profession in India is not regulated,13
down of all non-essential services for 21 days from 25th to filter out the responses from practitioners who had
March 2020, and on 14th April 2020, the lockdown got completed short-term courses, one item in the ques-
extended further for 19 days till 3rd May 2020. General tionnaire requested the responder to fill their highest
guidelines proposed by the national and international orga- educational qualification in optometry. Further to filter
nizations might not be directly applicable to India and to responses from undergraduate and diploma students, an
eye-care professionals in particular. In addition, few guide- option ‘‘Diploma/Bachelors student’’ was added. One item
lines released by health ministries of different states, lead in the questionnaire requested the responder to provide
to confusion and panic among eye-care practitioners.6---8 information about their previous participation in the survey
As a result of the pandemic, many hospitals and clinics to avoid multiple response from the same responder.14
pulled themselves off from offering service. The closure of
outpatient departments has decreased the accessibility to Sample size
health care.3,6
Optometrists are primary eye-care professionals who
The sample size calculated15 was 593, considering approxi-
delivers patient care and dispense optical devices such
mately 49,000 Indian optometrists13 and 4% margin of error
as spectacles, contact lens, and low-vision devices. Many
with 95% confidence interval.
optometrists across India have closed their practice for
non-essential services during the lockdown. Owing to the
prevailing pandemic, optometrists have been challenged Data analysis
with issues pertaining to patient care, manufacturing and
dispensing optical devices, maintaining business stability, The analysis was conducted and graphs were generated using
and control of infection.9 This survey aimed at assessing the GraphPad Prism (version 6.04 for Windows; GraphPad Soft-
impact of COVID-19 lockdown on optometry education and ware, La Jolla, CA). The proportion of each response was
care of sick, highlighting the modes of teaching and patient calculated. The Checklist for Reporting Results of Internet
consultation. E-Surveys (CHERRIES) guidelines were used to prepare the
survey16 (Table 1).

Methods Results

A cross-sectional online survey questionnaire was adminis- Survey response was received from 691 optometrists. Of
tered in accordance with the Declaration of Helsinki.10 The which, data from only 611 were valid and were included
aim of this survey was to evaluate the optometrist practice for the analysis. Data were excluded from 11 undergrad-
pattern and patient care during the COVID-19 lockdown. As uate/diploma students, 1 optometrist practicing outside
this study aimed to collect only the perception and the ser- India, 14 technicians with short-term courses, 33 respon-
vice by the optometrists, ethics approval was not obtained. dents who had reported to have responded the survey
The information collected did not include personal infor- before, and 21 respondents with logical contradictions (e.g.,
mation and was anonymized, which was similar to surveys those who answered that they were not practicing any kind
carried out by Nilesh et al.11 and Nair et al.3 of teleconsultation had also responded that they are charg-

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Table 1 Summary of the methodology followed in the Table 2 Summary of the demographics of the optometrists
survey. involved in the survey.
Sr no. Description Survey report Characteristics No. of No. of
responses responses
1 Survey development Literature review
(n) (%)
followed by a
discussion between Gender (n = 611)
four optometrist to Male 298 48.77
finalize items of the Female 313 51.23
questionnaire Primary place of practice (n = 611)
2 Number and nature of 15 mix of open- and Academics 91 14.89
items in the close-ended questions Private practice 136 22.25
questionnaire Corporate 59 9.65
3 Reliability Not determined Optical retail 71 11.62
4 Mode of survey Internet-based Optometrist pursuing PG 8 1.30
5 Survey period April 24, 2020, to Research 31 5.07
April 29, 2020 Private hospital 52 8.51
6 Sample frame Open survey: Open Charitable hospital 80 13.09
for all optometrists Govt. hospital 80 13.09
across India Unemployed 3 0.49
7 Target population Optometrist Qualification (n = 611)
practicing in India Diploma 90 14.72
8 Recruitment process Open invitation over B. Optom. 345 56.46
social media, namely M. Optom. 144 23.57
Facebook, WhatsApp, M.Phil. 9 1.42
and Telegram, in a Fellowship 11 1.80
target group with two Ph.D. 6 0.99
reminder messages PGDO 6 0.99
9 Participation Voluntary PG, postgraduate.
participation
10 Survey administration Sequential questions
administered using ing for teleconsultation). Among the included respondents,
Google forms 51.23% were female and 48.77% were male. The character-
11 Informed consent E-consent istics of the respondents are mentioned in Table 2.
12 Incentives None
13 Randomization of No such mechanism Academic practice
items or employed
questionnaires Of the respondents who nominated to be primarily involved
14 Use of adoptive Yes in academics, research, and higher education, 62.30% were
questions involved in online teaching. Modes used for online teaching
15 Number of screens 6 are shown in Fig. 1.
16 Review step Review with back Respondents involved in taking online classes were asked
button; no alteration about the expenses involved in taking online classes com-
possible once the pared to normal offline teaching. However, 59.26% said that
response is submitted online teaching was less expensive, 7.41% felt it to be more
17 Preventing multiple No such mechanism expensive, and 33.33% reported to be equally expensive.
entries from single employed The results of five-point Likert scale accessing comfort,
respondent, e.g., satisfaction, successfulness, the response of students, and
cookies used their preference in continuing online classes are shown in
18 Data capturing Automatic conversion Fig. 2.
into a spreadsheet
19 Data analysis Descriptive statistics
Clinical practice
qualitative thematic
analysis of
open-ended questions
Of the total optometrists responded, 43.37% were involved
20 Software used for GraphPad Prism
in consulting patients during the lockdown either in hospi-
statistical analysis (version 6.04 for
tals or through teleconsultation. Fig. 3 shows the number
Windows, GraphPad
of optometrists engaged in consultation from their primary
Software, La Jolla,
mode/place of practice.
CA,
Optometrists who were currently involved in consulting
www.graphpad.com)
patients were asked to mention the type of patient or the
conditions they were consulting. Infections were the most

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Fig. 1 Number of optometrists involved in online teaching, their opinion about the expense, and the type of online platform
used.

Fig. 2 Opinion about teaching in the grade scale of 1 (low) to

5 (high).

Fig. 3 Number of optometrists who responded that they were

commonly consulted by 27.17%, followed by red eye seen seeing patients during the COVID-19 lockdown.
by 26.79%, and emergency cases by 18.87% optometrists.
Furthermore, 48.68% optometrists reported that they were
consulting all patients coming to them (Fig. 4). said that they were favorably considering the prospec-
The respondents were questioned for their exploration tive idea of starting such initiative, whereas 30.19% of the
and initiation on other avenues for attending patients such clinicians reported to have no plans in starting any such
as teleconsultation. For such initiatives, 50.94% responded consultations. Among those who were involved in telecon-
positively (Fig. 5). In contrast, 18.87% of the clinicians sultation, 85.19% did not charge any professional fees from

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who participated in the study were questioned for their per-

ceptions of the risk of contracting COVID-19 while examining
patients. About 22.59% felt that risk of contracting COVID-19
is high for optometrists; 12.93% and 64.48% felt to have
lower and equal risk, respectively.
The last part of the survey focused on accessing
optometrists’ opinion on challenges they will be facing dur-
ing their practice post-COVID-19 lockdowns (Table 3).

Discussion

Our survey revealed that a greater part of the optome-

Fig. 4 Ocular conditions seen by optometrist during the try practice was hampered during the pandemic. During
COVID-19 lockdown. pandemic, although optometrists may be available, the
unavailability of other support personnel may cause opera-
patients; 11.11% reported that were charging the consulta- tional and logistical challenges for continuing a health-care
tion as they normally charge for an physical consultation; facility. It was noted that 43.37% of the optometrists were
and 3.7% collected less professional charges than that for involved in consulting the patients.
an in-person consultation. Interestingly, none of the respon- Optometrists were selective in consulting patient. Infec-
dents reported charging higher consultation fee than usual. tious conditions, redness, and emergencies were the most
commonly consulted cases. Interestingly, 48.68% of respon-
dents involved in consulting stated that they were consulting
Lockdown: challenges and current scenario all patients those who came seeking consultation.
As there are no given guidelines to optometric practice
It was found that 75.94% optometrists were involved in in India during the lockdown,6 the usage of personal protec-
attending online seminars and webinars. All the optometrists tive equipment and precautionary methods followed during

Fig. 5 Number of optometrists practicing teleconsultation during the COVID-19 lockdown.

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procedures and social distancing. Health-care setting pro-

Table 3 Table showing the potential challenges for
vides an favorable environment for virus to spread from
optometrist during COVID-19 lockdown.
person to person or from lifeless objects in shared areas
Challenges post No. of responses (%) such as waiting hall and examination rooms.9 Measures
COVID-19 lockdown to forestall the infection include social distancing, use
Difficulty in dispensing 121 (19.80)
of protective equipment, and hygiene/infection control
spectacles/contact
procedures.7
lenses
Typical COVID-19 virus can survive for up to 72 h.24 San-
Reduction in buying 122 (19.97)
itizing work place and other areas where patients might
capacity of the
touch (e.g., door handle) is an effective way to forestall the
patient
spread of infectious agents.9 Frequent hand washing with
Challenges in 186 (30.44)
alcohol-based sanitizers after patient contact effectively
approaching the
reduces the spread of any infectious material.25
patient consider
A simple mnemonic ‘‘MASKS’’ strategy, developed by
contact procedures
Hogg and Houston,26 can be used as a necessary precau-
and social distancing
tion for outpatient setting: ‘‘M----masks for patients with
(e.g., GAT, direct
cough and fever and providers examining those patients;
ophthalmoscope,
A----alcohol gel for sanitation (for patients as well as office
etc.)
staff); S----seating of potentially infectious individuals apart
Difficulties in 42 (6.87)
from others (recommended distance at least 1 m); and
administration of
K----kleening (disinfecting) hard surfaces; S----signs to guide
clin-
patients and staff (e.g., to promote handwashing)’’. The
ics/hospitals/institutions/organizations
estimated implementation cost such methods in a typi-
Reduction in patient 77 (12.60)
cal clinical setting that attends 30 patients/day is $2 per
flow in the clin-
day.
ics/hospital/optical
outlet
Teleconsultation
Have no idea 15 (2.45)
GAT, Goldmann applanation tonometer. It was interesting to know that almost 50.94% of respon-
dents were involved in providing patient care through
examining the patient is questionable. Considering closer teleconsultation. Teleconsultation can be used as an effec-
working distance while examining patients, optometrists tive means for providing patient care by avoiding in-clinic
found themselves to be at equal or high risk of getting direct contact. Teleconsultation can be performed through
infected by COVID-19, which in accordance with the results different means that include telephone consultations, mon-
of the survey shown by Nair et al.3 itoring with mobile phone-based applications, and remote
Optometry is the first face of interaction concerning eye consultations with specialists by electronic data transfer.9,27
care; and eye clinic is an environment with high-risk for both However, advanced technology is not the only mode of
the examiner and the patient, and the eye-care practitioner improving teleconsultation; revamp in history taking through
need to understand the risk factors associated with it. the use of validated questionnaires or adapting patient-
Ocular infection cases were the most common condi- reported outcome measures may enhance patient care.27
tion that was being examined by 72 (27.17%) optometrists. There are a few other vision-related applications that show
The ocular implications of the severe acute respiratory syn- promising outcomes, for example, for the assessment of
drome coronavirus 2 (SARS-CoV-2) are clearly established contrast sensitivity,28 manifest and latent deviations,29 and
and the literature reports ocular surfaces are more prone visual field screening.30---32 At the same time, the major-
for SARS-CoV-2 invasion.17---19 ity remain unvalidated for clinical use.33 The potential
It is also reported in the literatures that, patients with for estimating visual acuity and refractive error utiliz-
no conjunctivitis tested positive for SARD-CoV-2 nucleic ing handheld electronic gadgets is growing in the area of
acid in conjunctival sac swabs.20 Virus can enter respira- research.31 A study on web-based refraction in adult pop-
tory track through nasolacrimal ducts via tears droplets.20 ulation (aged 18---40 years) showed good agreement with
Though the reported studies suggested ocular transmission a customary subjective refraction.27,34,35 For several years,
low risk,21,22 it is also known that one-third of the COVID-19 teleconsultation in eye care has demonstrated to be a use-
positive patients had ocular implications such as chemo- ful, valid, and cost-effective method in managing the eye
sis, epiphora, and conjunctival hyperemia, and it is possible diseases.9,36---38 In the setting of social distancing, sending
to transmit via eyes.23 To reduce infection post lockdown, clinical data electronically to an eye care specialist for
prevention at the level of primary eye care is vital. online consultation could reduce the need for patients to
visit another public gathering place (e.g., hospitals and
clinics) and in turn may forestall patients’ exposure to
Prevention at primary eye care setting contagious individuals.9 In addition to validated and well-
researched tools, usability, medico-legal implications, and
In this survey, 30.44% respondents mentioned that there practitioner opinions are likely to influence the usage of
are challenges on approaching a patient considering contact teleconsultation.

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Business interruption and recovery practice in the future. Other reasonable changes include,
employee and environmental protection measures to fore-
Among the respondents, 22.25% were having their own inde- stall disease transmission.46 In future some new proof will
pendent practice, which was similar to practice during develop, changing the prevention and treatment modalities
normal days.11 Among the private practitioners, 46.32% were for COVID-19. From the perspective of eye-care practition-
under total lockdown, which could create economic damage ers, it is challenging to put on restrictions in the workplace.
on a small business due to absence of staff, interrupted util- But for the eye-care practitioners to return to serving society
ities, or consumer fear. A study has shown that two-thirds of optimally and securely, the regulatory bodies should provide
businesses will file bankruptcy within a year, if they do not some clear guidelines in order to resume patient care with-
resume the business within two weeks after a disaster.39 out trading off wellbeing of both the practitioners and their
The aftereffect of business by acute natural disasters patients.
includes problems such as customer accessibility, absence
of employee, and shipping delays, which tender to busi- Author contribution
ness losses and impede recovery. On chance if particular
regions are set apart as zones of higher danger, difficulties to SKK --- Involved in study conception and design, data acqui-
recuperation become magnified.40 Providers of services and sition, drafting, critical revising and final approval of the
goods whose markets are restricted to a local level (e.g., manuscript.
optometrists) are more helpless against delays in long-term PN - Involved in study design, data acquisition, data anal-
recuperation after a disaster.9,41 ysis, drafting and critically revising the manuscript.
Providers of services or goods must be prepared for dis- VSR - Involved in study design, data acquisition, data
ruption in the typical progression of trade. Businesses that analysis, drafting and critically revising the manuscript.
prepare for emergencies beforehand in general endure and AN - Involved in study design, data acquisition and draft-
resume typical activities in a superior way than those that ing the manuscript.
don’t.9,41 The study by Hom et al.9 summarized 10 business
planning methods, namely the preparation of getting orga-
nized, risk assessment, employee health, employee policies, Source(s) of support
supply and service interruptions, pandemic and manage-
ment plan, prepare to fill vacancies, plans for business Nil.
continuity, inform/education of employees, and informing
other stakeholders. Presentation at a meeting

Academic practice Nil.

Among the optometrists with academic and research back- Conflicting interest
ground, 62.30% were found to be involved in taking the
class online using various modes. The results suggest that The authors have no conflicts of interest to declare.
a higher number of educators have quickly adopted online
classes, suggesting the need for development of devoted
online modules explicit to characterized territories of com- Acknowledgement
petency alongside definite arranging of blended learning
exercises.42 Though literature suggests that there is a sig- We would like to thank Mr. Kumaran, General Secretary,
nificant increase in scoring lower grades among students Optometric Association of Tamil Nanbargal (OATN) and
compared to face-to-face classes, motivating and continu- Karthikeyan K, Chairman, Tamil Nadu Government Optom-
ous interaction with the students during online classes may etry professionals Association and Vice President, National
improve grades.43---45 Ophthalmic Association for helping us in circulating the
The lockdown, which was a first in India, brought many questionnaire with the optometrist in national and state
ambiguities in both personal and professional fronts for associations.
most health-care practitioners. The rapidly-evolving sce-
nario made it challenging to have a detailed survey on Appendix A. Supplementary data
practice, usage of personal protective equipment, and
adherence to guidelines. Thus, the duration for the survey Supplementary material related to this arti-
completion was kept short. cle can be found, in the online version, at
doi:https://doi.org/10.1016/j.optom.2020.10.006.
Conclusion
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