## 4 Discussion and Medico-Legal Implications
The surgical activity, compared with that during the equivalent previous year, increased by 14.58% at the SGD, whereas at the UMG, the activity was slightly lower (\(-\)5.56%) (Table 7). During the second wave, the number of cataracts fell again by about 38% and 30% in the SGD and UMG, respectively (Table 7). These fluctuating trends do not agree with the findings described by [PERSON] et al. [34]. In this study, the authors found that the number of cataract surgeries recovered from May 2020, increasing steadily to exceed the monthly average by August 2020. In our case, this trend was a consequence of the enormous increase in COVID-19 patients and the progressive reduction in ICU beds. Indeed, if during the lockdown, southern Italy was less affectedby the pandemic, this scenario was not repeated in the second wave. It could be assumed that this situation led to panic among elderly patients. As reported in several articles, the delay or postponement of cataract surgery has negative impacts on the elderly health (e.g., fractures due to falls, difficulty in driving), thus predisposing them to traffic accidents, depression, and dementia [35, 36, 37]. Concerning corneal surgeries, similar results were observed. Corneal blindness is the third leading cause of blindness in the world [38], and corneal transplantation remains the only technique able to restore tissue transparency [39]. However, apart from a small percentage of cases (i.e., corneal perforation or infection), corneal transplants are, in general, elective surgeries [40]. It is important to note that, as with most solid organ transplants, the risk of transmitting infectious diseases in the recipient or those handling donor tissue must always be taken into account [41, 42]. As a result of these considerations, the corneal surgical activity decreased due to the reorganisation of the national health service and initial uncertainties related to tissue procurement and storage [43, 44]. As reported in a recent Italian overview that analysed data from the Italian Society of Eye Banks (SIBO) during the first quarter of the pandemic, a significant reduction of around 60% was observed [40]. At the UMG, similarly, a significant dramatic fall in total corneal surgeries during the  
Figure 3: The monthly number of surgical procedures performed during the COVID-19-year (blue) compared with pre-COVID-19 year (orange) for the different categories: (**A**) corneal surgery performed at San Giovanni di Dio (SGD); (**B**) corneal surgery performed at University Magna Graccia of Catanzaro (UMG); (**C**) vitreorentinal surgery performed at SGD; (**D**) vitreorentinal surgery performed at (UMG); (**E**) cataract surgery performed at SGD; (**F**) cataract surgery performed at UMG. The dotted orange line in each figure divided the period studied into three phases: lockdown, unlock, and second wave, from left to right, respectively. lockdown period (49%, \(p<0.05\)), followed by a return to normal in the unlock phase, was found (Table 1). Unfortunately, a second decrease of about 32% was observed in the second wave (\(p<0.05\)) (Figure 3B). Finally, analysing the types of corneal transplants performed, our results confirmed the trend reported by [PERSON] et al. (2019), with a reduction of around 30-40%, for both anterior and endothelial keratoplasty; however, in contrast to their results, we observed an increase in PK. Different results were collected at the SGD, but this is due to the fact that, in both years, only emergency surgery was performed, as confirmed by the diseases treated (Table 2). Differentially from the surgical services described above, vitreoretinal surgical service was also affected by the measure for the pandemic containment but, in our case, in the opposite direction. There is poor information regarding the epidemiology of vitreoretinal emergencies during the lockdown ([PERSON] and [PERSON], 2017), but in accordance with the general trend, a downsizing of vitreoretinal procedures was also reported.