The Impact of COVID-19 on Diabetic Retinopathy Monitoring and Treatment

Two-Year Follow-Up Study of Patients with Neovascular Age-Related Macular Degeneration Undergoing Anti-VEGF Treatment during the COVID-19 Pandemic

BACKGROUND

regular intravitreal anti-vascular endothelial growth factor (VEGF) treatment is crucial for patients with neovascular age-related macular degeneration (nAMD), and delayed treatment can exacerbate disease progression.

METHODS

we compared the outcomes of on-time versus delayed intravitreal anti-VEGF treatment for patients with nAMD. This study was conducted during the coronavirus disease 2019 (COVID-19) pandemic with a 2-year follow-up period. The best-corrected visual acuity (BCVA) and anatomical findings were evaluated before the pandemic, during the pandemic, and at 6-, 12-, 18-, and 24-months post-pandemic.

RESULTS

The delayed and on-time groups comprised 54 and 72 patients, respectively. After the pandemic, the injection interval increased by 0.65 ± 1.51 months (p = 0.003), with 22.2% of the patients in the delayed group switching to the treat-and-extended regimen (p < 0.001). The delayed group showed greater mean BCVA deterioration (p = 0.027) and central subfield thickness (p = 0.037) at 6 months and worse maximum subretinal fluid height (p = 0.022) at 18 months than the on-time group. No difference was observed between the groups in the second year.

CONCLUSION

the negative effects of delaying anti-VEGF treatment because of the COVID-19 pandemic can be ameliorated by changing the treatment regimen and shortening treatment intervals.

Risk Stratification for Diabetic Retinopathy Screening Order Using Deep Learning: A Multicenter Prospective Study

Purpose

Real-world evaluation of a deep learning model that prioritizes patients based on risk of progression to moderate or worse (MOD+) diabetic retinopathy (DR).

Methods

This nonrandomized, single-arm, prospective, interventional study included patients attending DR screening at four centers across Thailand from September 2019 to January 2020, with mild or no DR. Fundus photographs were input into the model, and patients were scheduled for their subsequent screening from September 2020 to January 2021 in order of predicted risk. Evaluation focused on model sensitivity, defined as correctly ranking patients that developed MOD+ within the first 50% of subsequent screens.

Results

We analyzed 1,757 patients, of which 52 (3.0%) developed MOD+. Using the model-proposed order, the model's sensitivity was 90.4%. Both the model-proposed order and mild/no DR plus HbA1c had significantly higher sensitivity than the random order (P < 0.001). Excluding one major (rural) site that had practical implementation challenges, the remaining sites included 567 patients and 15 (2.6%) developed MOD+. Here, the model-proposed order achieved 86.7% versus 73.3% for the ranking that used DR grade and hemoglobin A1c.

Conclusions

The model can help prioritize follow-up visits for the largest subgroups of DR patients (those with no or mild DR). Further research is needed to evaluate the impact on clinical management and outcomes.

Translational Relevance

Deep learning demonstrated potential for risk stratification in DR screening. However, real-world practicalities must be resolved to fully realize the benefit.

Advances and Perspectives in Relation to the Molecular Basis of Diabetic Retinopathy-A Review

Diabetes mellitus (DM) is a growing problem nowadays, and diabetic retinopathy (DR) is its predominant complication. Currently, DR diagnosis primarily relies on fundoscopic examination; however, novel biomarkers may facilitate that process and make it widely available. In this current review, we delve into the intricate roles of various factors and mechanisms in DR development, progression, prediction, and their association with therapeutic approaches linked to the underlying pathogenic pathways. Specifically, we focus on advanced glycation end products, vascular endothelial growth factor (VEGF), asymmetric dimethylarginine, endothelin-1, and the epigenetic regulation mediated by microRNAs (miRNAs) in the context of DR.

Examining Global Crises: Extracting Insights From the COVID-19 Pandemic and Natural Disasters to Develop a Robust Emergency Diabetic Retinopathy Strategy for Puerto Rico

In this critical analysis, we investigate the profound impact of natural disasters and pandemics on the care and adherence to treating diabetic retinopathy, a severe complication of diabetes requiring continuous monitoring and treatment to prevent vision loss. Our study also sheds light on the social and economic context of Puerto Rico, emphasizing recent emergency events that have exacerbated existing public health challenges. Through a comprehensive review of relevant literature from PubMed, Google Scholar, and the George Washington University Himmelfarb Health Sciences Library database, we identified 31 pertinent articles out of 45 evaluated, focusing on the effects of these crises on healthcare delivery, diabetic retinopathy screening, and treatment. The evidence strongly indicates that during such emergencies, barriers to healthcare escalate, leading to significant treatment delays and a reduction in diabetic retinopathy screening and diagnosis, ultimately resulting in deteriorated visual outcomes. Thus, our review underscores the urgent need for the development of effective emergency plans tailored specifically to diabetic retinopathy, particularly in Puerto Rico, where diabetes prevalence and its complications are notably higher. Such plans should not only incorporate established emergency measures but also harness emerging technological advances in the field of ophthalmology to ensure optimal preparedness for future pandemics and natural disasters.

Impact of the COVID-19 Pandemic on Mental Health among Patients with Chronic Ocular Conditions

The COVID-19 pandemic had significant impacts on the mental and visual health of patients. This cross-sectional, survey-based, multicentric study evaluates the state of mental and visual health among patients with chronic ocular diseases such as glaucoma, neovascular age-related macular degeneration, diabetic retinopathy, or chronic uveitis during the lockdown period of the COVID-19 pandemic. Mental health was assessed using three questionnaires: the Patient Health Questionnaire-9 (PHQ-9), the Impact of Event Scale-Revised (IES-R), and the National Eye Institute Visual Function Questionnaire-25 (VFQ-25). A total of 145 patients completed the questionnaires. The PHQ-9 showed that most respondents (n = 89, 61%) had none or minimal depressive symptoms, while 31 (21%) had mild depressive symptoms, 19 (13%) had moderate depressive symptoms, 5 (3%) had moderately severe depressive symptoms, and 1 (1%) had severe depressive symptoms. Regarding stress surrounding the pandemic, the median IES-R showed mild distress in 16 (11%), moderate distress in 7 (5%), and severe distress in 4 (3%). The COVID-19 pandemic lockdowns had a negative impact on patients' mental health with close to 20% of the patients reporting at least moderately depressive symptoms and 19% reporting at least mildly distressful symptoms.

Intravitreal Injection Planning during COVID-19 Pandemic: A Retrospective Study of Two Tertiary University Centers in Italy

The COVID-19 pandemic has hampered the optimum management of retinal diseases. This study examined the impact of the pandemic on the intravitreal-injection practice in two academic centers in Italy along with the related medico-legal implications. A retrospective analysis of electronic medical records from 16 March 2020 to 14 March 2021 at the ophthalmological departments of University of Cagliari (SGD) and University Magna Græcia of Catanzaro (UMG) was conducted. The data collected between 16 March 2020 and 14 June 2020 (lockdown), 15 June 2020 and 13 September 2020 (unlock), and 14 September 2020 and 14 March 2021 (second wave) were compared with those of the same period of the previous year. Weekly data on the administered drug and the number and type of treated disease were collected and analyzed. During the lockdown, a drop of 59% at SGD (p < 0.00001) and 77% at UMG (p < 0.00001) in intravitreal injections was found. In the first year of the pandemic, the reduction in injections was approximately of 27% (p < 0.0008) and 38% (p < 0.0001) at SGD and UMG, respectively. The COVID-19-related containment measures and the health resources redistribution have led to a delay in the treatment of chronic diseases of the retina, prioritizing the undeferrable ones. The lack of management guidelines has conceived relevant ethical and medico-legal issues that need to be considered in future measures planning.

Identification of miRNA-mRNA Regulatory Networks Associated with Diabetic Retinopathy using Bioinformatics Analysis

INTRODUCTION

Diabetic retinopathy (DR) is a major complication of diabetes and a leading cause of visual loss. This study aimed to explore biomarkers for DR that may provide additional reference to DR pathogenesis and development.

METHODS

The differentially expressed genes (DEGs) between the DR and control samples in the GSE53257 dataset were identified. Logistics analyses were performed to identify DR-associated miRNAs and genes, and correlation analysis was performed to determine the correlation between them in GSE160306.

RESULTS

A total of 114 DEGs in DR were identified in GSE53257. Three genes, including ATP5A1 (down), DAUFV2 (down), and OXA1L (down), were differentially expressed between DR and control samples in GSE160306. Univariate logistics analysis identified that ATP5A1 (OR=0.007, p = 1.40E-02), NDUFV2 (OR = 0.003, p = 6.40E-03), and OXA1L (OR = 0.093, p = 3.08E-02) were DR-associated genes. ATP5A1 and OXA1L were regulated by multiple miRNAs, of which hsa-let- 7b-5p (OR = 26.071, p = 4.40E-03) and hsa-miR-31-5p (OR = 4.188, p = 5.09E-02) were related to DR. ATP5A1 and OXA1L were closely correlated with each other in DR.

CONCLUSION

The hsa-miR-31-5p-ATP5A1 and hsa-let-7b-5p-OXA1L axes might play novel and important roles in the pathogenesis and development of DR.

Impact of COVID-19 on the Delivery of Eye Care to Uninsured Diabetic Patients at a Student-Run Free Clinic: A Comprehensive Evaluation of Eye Clinic Performance

Background

Diabetic retinopathy is the leading cause of blindness among working-age adults in the United States and requires timely screening and management. This study evaluates the impact of the coronavirus disease 2019 (COVID-19) pandemic on diabetic retinopathy screening (DRS) for uninsured, predominantly Latino patients at the University of California San Diego Student-Run Free Clinic Project (SRFCP).

Methods

A retrospective chart review was conducted of all living diabetic patients at SRFCP who were seen in 2019 (n=196), 2020 (n=183), and 2021 (n=178). Ophthalmology clinic referrals, scheduled patient visits, and visit outcomes were analyzed longitudinally to determine the impact of the pandemic on screening patterns.

Results

The study population was 92.1% Latino, 69.5% female, with a mean age of 58.7 years. The distribution of patients seen (p<0.001), referred (p=0.012), and scheduled (p<0.001) in 2020 and 2021 significantly differed from 2019. In 2019, 50.5% of 196 patients eligible for DRS were referred, 49.5% were scheduled, and 45.4% were seen. In 2020, 41.5% of 183 eligible patients were referred, but only 20.2% were scheduled and 11.4% were seen. In 2021, there was a rebound: 63.5% of 178 patients were referred, 56.2% scheduled and 46.1% seen. No shows and cancellations represented 12.4% and 6.2% of the 97 encounters scheduled in 2019, but were markedly higher (10.8% and 40.5% respectively) for the 37 encounters scheduled in 2020.

Conclusions

The COVID-19 pandemic significantly impacted the delivery of eye care at SRFCP. The need for annual DRS exceeded the capacity of the ophthalmology clinic in all years studied, but the difference was especially pronounced with more stringent COVID-19 restrictions in 2020. SRFCP patients could benefit from telemedicine DRS programs to improve screening capacity.

Impact of the COVID-19 Pandemic on the Metabolic Control of Diabetic Patients in Diabetic Retinopathy and Its Screening

(1) Background: Diabetic retinopathy (DR) is a complication of diabetes mellitus (DM), screening programs of which have been affected by the COVID-19 pandemic. The aim of the present study was to determine the impact of the COVID-19 pandemic on the screening of diabetes patients in our healthcare area (HCA). (2) Methods: We carried out a retrospective study of patients with DM who had attended the DR screening program between January 2015 and June 2022. We studied attendance, DM metabolic control and DR incidence. (3) Results: Screening for DR decreased in the first few months of the pandemic. The incidence of mild and moderate DR remained stable throughout the study, and we observed little increase in severe DR, proliferative DR and neovascular glaucoma during 2021 and 2022. (4) Conclusions: The current study shows that during the COVID-19 pandemic, screening program attendance decreased during the year 2020, which then recovered in 2021. Regarding the most severe forms of DR, a slight increase in cases was observed, beginning in the year 2021. Nevertheless, we aimed to improve the telemedicine systems, since the conditions of a significant proportion of the studied patients worsened during the pandemic; these patients are likely those who were already poorly monitored.

Telehealth Encourages Patients with Diabetes in Racial and Ethnic Minority Groups to Return for in-Person Ophthalmic Care During the COVID-19 Pandemic

Purpose

The COVID-19 pandemic had a disproportionate impact on patients from racial and/or ethnic minority groups, causing many to delay healthcare. This study evaluates the role telehealth visits played in helping patients with diabetes mellitus (DM) return for subsequent, in-person eye examinations after the outbreak of COVID-19.

Methods

This retrospective, cross-sectional study analyzed 8147 patients with DM who had completed an outpatient ophthalmology and/or optometry visit in 2019 and who were due for return evaluation after the outbreak of COVID-19 in 2020. Factors associated with return for subsequent, in-person eye examination were assessed.

Results

The mean age of patients was 68.8 (±13.0) years, and 42% were women. 7.4% of patients identified as Asian; 2.9% as Black; 3.4% as Hispanic or Latin American; 0.92%, as more than one race; 1.78%, as other races; and 80.7% as White. Patients from racial and/or ethnic minority groups completed fewer in-person eye examinations after the outbreak of COVID-19 compared with White patients (35.6% versus 44.5%, χ²=36.172, P<0.001). However, both groups accessed telehealth services at a similar rate during this period (21.1% versus 21.9%, χ²=0.417, P=0.518). Importantly, patients who received telehealth services returned for subsequent, in-person eye examinations at substantially higher rates, regardless of race (51.0% and 46.6%, respectively, χ²=1.840, P=0.175). This offset the otherwise lower rate of return experienced by patients from racial and/or ethnic minority groups compared with White patients among the group of patients who did not receive any telehealth services (32.7% versus 42.7%, χ²=36.582, P<0.001). The impact of telehealth on the likelihood of in-person return remained significant after taking into account age, gender, race, language, residence, severity of diabetic retinopathy (DR), and vision in a multivariate model.

Conclusion

Telehealth initiatives benefited patients from racial and/or ethnic minority groups by reducing disparities in access to eye care experienced during the COVID-19 pandemic.

Living Without a Diagnosis: A Patient's Perspective on Diabetic Macular Ischemia

Diabetic macular ischemia (DMI) is a common complication of diabetic retinopathy (DR) that can result in progressive and irreversible vision loss. DMI is associated with damage in the vessels that supply blood to the retina and the enlargement of the foveal avascular zone. Currently, there are no approved treatments specifically for DMI. Furthermore, there is limited published information about the prognosis, prevalence or outcomes of DMI, and there is no consensus regarding diagnostic criteria. It is vital to ensure that there is sufficient, accessible and accurate information available to support patients, caregivers and physicians. To lay the foundation for more research into DMI and its impact on patients, we (a patient with DMI and an expert ophthalmologist) have worked together to interweave our personal perspectives and clinical experiences with a review of currently available literature on DMI. The development of a set of confirmed diagnostic criteria for DMI would assist both patients and physicians, allowing patients to access validated information about their condition and supporting the development of clinical trials for treatments of DMI. Training for physicians must continue to emphasise the importance of treating a patient holistically, rather than only treating their symptoms. Most importantly, developing trust and a healthy rapport between a patient and their physician is important in managing health anxiety and ensuring adherence to beneficial treatments or lifestyle adjustments; physicians must cultivate an open and flexible management approach with their patients. Finally, holistic educational programmes for patients, physicians and the general public around DMI and how it can affect daily functioning would facilitate general understanding and disease awareness.

Diabetic macular ischemia (DMI) is a common problem for patients with diabetic retinopathy that can lead to sight loss. There is very little information available about DMI, particularly from a patient’s point of view. To address the lack of information about DMI, we (a person with DMI and her eye doctor) have worked together to examine what it is like to live with DMI. It is important to provide clear and accessible information about diseases to patients and carers. The lack of information about DMI may be upsetting for some people, and should be addressed with more research. Developing of a set of confirmed signs and symptoms for the diagnosis of DMI would allow people to be more confident in the information that they receive about their disease, and support the development of treatments for DMI. The support of others is central to the wellbeing of people with vision loss. Although people with vision loss may also lose independence, care from loved ones can help to improve quality of life. Most importantly, developing trust between a patient and their doctor is central to managing people’s fears about their eyesight, and making sure that they follow helpful advice. Doctors must use an open and flexible approach with their patients, providing information in an honest and understandable way.

Cardiovascular Risk Stratification in Diabetic Retinopathy via Atherosclerotic Pathway in COVID-19/non-COVID-19 Frameworks using Artificial Intelligence Paradigm: A Narrative Review

Diabetes is one of the main causes of the rising cases of blindness in adults. This microvascular complication of diabetes is termed diabetic retinopathy (DR) and is associated with an expanding risk of cardiovascular events in diabetes patients. DR, in its various forms, is seen to be a powerful indicator of atherosclerosis. Further, the macrovascular complication of diabetes leads to coronary artery disease (CAD). Thus, the timely identification of cardiovascular disease (CVD) complications in DR patients is of utmost importance. Since CAD risk assessment is expensive for low-income countries, it is important to look for surrogate biomarkers for risk stratification of CVD in DR patients. Due to the common genetic makeup between the coronary and carotid arteries, low-cost, high-resolution imaging such as carotid B-mode ultrasound (US) can be used for arterial tissue characterization and risk stratification in DR patients. The advent of artificial intelligence (AI) techniques has facilitated the handling of large cohorts in a big data framework to identify atherosclerotic plaque features in arterial ultrasound. This enables timely CVD risk assessment and risk stratification of patients with DR. Thus, this review focuses on understanding the pathophysiology of DR, retinal and CAD imaging, the role of surrogate markers for CVD, and finally, the CVD risk stratification of DR patients. The review shows a step-by-step cyclic activity of how diabetes and atherosclerotic disease cause DR, leading to the worsening of CVD. We propose a solution to how AI can help in the identification of CVD risk. Lastly, we analyze the role of DR/CVD in the COVID-19 framework.

Management of acute proliferative diabetic retinopathy related complications during the first COVID-19 wave

Background

Routine hospital eye services (HES) across the National health service (NHS), and diabetic eye screening (DES) in Scotland were paused during the COVID-19 lockdown in March 2020. Alternate pathways for managing acute ophthalmic pathology were devised in NHS Grampian covering the North-East of Scotland. Emergency eye treatment centres (EETC) manned by community optometrists were set up to treat and triage referrals to HES.

Methods

Retrospective study analysing consecutive patients referred to a tertiary eye centre (Aberdeen Royal Infirmary) with proliferative diabetic retinopathy (PDR) related complications between March and August 2020. General demographical data, diabetic history, visual acuity, ocular complication, type of management, time to follow-up, and any appointment cancellations were extracted for analysis.

Results

Fifty two eyes of 46 patients with PDR related complications were identified. HES appointment had been delayed or cancelled in 22 patients (48%) due to COVID-19. Mean age was 54.5 years (±15.1), 21 (46%) were female, 21 (46%) had type 1 diabetes; mean HbA1c was 78 mmol/l (±18.7). Vision ranged from 6/6 to perception of light. 36 (78%) patients had unilateral vitreous haemorrhage (VH), 6 (13%) bilateral, 2 (4%) tractional retinal detachments and 3 (6.5%) had neovascular glaucoma.

Of 48 acute PDR presentations, 18 (38%) were given anti-VEGF within 72 h and two (4%) had PRP the same day. 16 (33%) were rebooked into the laser clinic, 13 (27%) referred for urgent surgical review, and 17 (35%) advised observation and review in clinic. After a median follow-up of 6 months, 12 eyes (23%) of 11 patients progressed to have vitrectomy.

Conclusion

Despite lockdown, hospital appointment cancellations and recommended footfall reduction limiting capacity due to COVID-19, patients reaching out with PDR complications were promptly referred to HES and appropriate treatments carried out with COVID-19 precautions as recommended.

What is the impact of microvascular complications of diabetes on severe COVID-19?

Evidence suggests severe coronavirus disease-19 (COVID-19) infection is characterised by pulmonary and systemic microvasculature dysfunction, specifically, acute endothelial injury, hypercoagulation and increased capillary permeability. Diabetes, which is also characterised by vascular injury in itself, confers an increased risk of adverse COVID-19 outcomes. It has been suggested that pre-existing endothelial dysfunction and microvascular disease in diabetes will exacerbate the vascular insults associated with COVID-19 and thus lead to increased severity of COVID-19 infection. In this article, we evaluate the current evidence exploring the impact of microvascular complications, in the form of diabetic retinopathy and nephropathy, in individuals with COVID-19 and diabetes. Future insights gained from exploring the microvascular injury patterns and clinical outcomes may come to influence care delivery algorithms for either of these conditions.

Effect of COVID-19 Pandemic on Presentation of Patients With Diabetic Retinopathy in a Multitier Ophthalmology Network in India

OBJECTIVE

This study aimed to describe the demographics and clinical profile of patients with diabetic retinopathy (DR) presenting during the novel coronavirus disease 2019 (COVID-19) lockdown and unlock phases in India.

METHODS

This hospital-based cross-sectional study included patients presenting from March 25, 2019, to March 31, 2021. All patients who presented with DR were included as cases. The data were collected using an electronic medical record system.

RESULTS

In total, 88,012 patients diagnosed with retinal diseases were presented to the network and included for analysis. There were 21,271 (24%) DR patients during the study period and the majority were men (71%) from the urban area (45%). An increasing number of patients with proliferative DR (56%), sight-threatening DR (79%), need for vitreoretinal procedures (31%), and intravitreal injections (19%) were seen during the lockdown (phase one-four). There was a significant increase in the number of patients with blindness in pre-lockdown (20%), lockdown (32%), and post-lockdown (26%). Patterns of sight-threatening DR and blindness were similar in both fresh and follow-up patients.

CONCLUSION

The presentation of DR patients in hospital is evolving because of the COVID-19 pandemic. The footfalls of patients during the unlock (phase 1-10) regained to two-thirds of the pre-COVID-19 level. There was an increase in patients with sight-threatening DR and the need for vitreoretinal surgery and intravitreal injections during the lockdown (phase 1-4).