The Impact of COVID-19 on Intravitreal Injection Compliance

Treatment patterns and visual acuity change of AMD patients, before, during and after the COVID-19 pandemic lockdowns: A large cohort

PURPOSE

To evaluate the impact of the changes in treatment patterns before, during and after the COVID-19 pandemic on best-corrected visual acuity (BCVA) in previously treated neovascular age-related macular degeneration (nAMD) patients.

METHODS

A multi-centre, retrospective, observational study of consecutive nAMD patients during 2019-2021. Data collected included demographics, BCVA, dates of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections and clinic visits.

RESULTS

A total of 1652 eyes of 1652 nAMD patients were included, out of which 850 eyes were assessed in 2019 (pre-COVID-19), 630 eyes were assessed in 2020 (COVID-19) and 974 eyes were assessed in 2021 (post-COVID-19). During the COVID-19 period, the mean number of anti-VEGF injections was significantly lower than the corresponding pre-COVID-19 and post-COVID-19 periods (5.55 compared to 6.13 and 6.60, respectively p < 0.01). A constant lower ratio of injections per patient/month was observed during COVID-19 compared to previous and following years, with a notable decline during March-April, reaching a ratio of 0.4 in 2020 versus 0.65 in 2019 and 0.62 in 2021 (p < 0.01). Baseline BCVA (0.825, p < 0.001), number of injections (-0.007, p < 0.001), gender (-0.027, p = 0.037) and age (0.004, p < 0.001) were shown to be significant predictors of final BCVA.

CONCLUSION

During the COVID-19 period, patients were treated with significantly less intravitreal anti-VEGF injection compared to the previous year with compensation in the following year. These changes in treatment patterns did not have a significant impact on BCVA outcomes. Age, gender, baseline BCVA and number of injections are predictors of final visual outcomes.

Intravitreal Injection Rates for Neovascular Age-Related Macular Degeneration in Australia During the 2020 COVID-19 Lockdowns

PURPOSE

We investigate the impact of COVID-19 and lockdowns on anti-vascular endothelial growth factor (anti-VEGF) treatment for neovascular age-related macular degeneration (AMD) in Victoria (Australian state with highest burden of COVID-19 in 2020) and Australia, by examining anti-VEGF prescriptions supplied for AMD treatment between 2018 and 2020.

METHODS

We performed a retrospective, population-based analysis of aflibercept and ranibizumab prescriptions supplied for the treatment of AMD in Victoria and Australia between 1 January 2018 and 31 December 2020, as recorded by the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS, the Australian Government program subsidising medication costs for Australian residents and veterans. Poisson models and univariate regression were used to descriptively examine trends in monthly anti-VEGF prescription rates with time and changes in monthly prescription rates (prescription rate ratios [RR]).

RESULTS

In 2020, anti-VEGF AMD prescription rates in Victoria decreased by 18% during the nationwide lockdown between March and May (RR 0.82, 95% CI: 0.80-0.85, p < .001), and by 24% during the Victorian-specific lockdown between July and October (RR 0.76, 95% CI: 0.73-0.78, p < .001). In Australia, prescription rates tended to decrease between January and October 2020, reducing by 25% (RR 0.75, 95% CI: 0.74-0.77, p < .001) between these months, including between March and April (RR 0.94, 95% CI: 0.92-0.95, p < .001) but not April and May (RR 1.10, 95% CI: 1.09-1.12, p < .001).

CONCLUSION

In 2020, anti-VEGF prescriptions for AMD treatment decreased modestly in Victoria during both lockdowns and in Australia during the year. Decreases may represent reduced treatment because of COVID-19, including public health orders, patients' self-limiting care, and ophthalmologists treating-and-extending to maximum intervals.

Impact of Coronavirus Disease 2019 on Intravitreal Antivascular Endothelial Growth Factor Injection Rates in Nigerians

Aim

To quantify the impact of coronavirus disease 2019 (COVID-19) on the rate of intravitreal antivascular endothelial growth factor (VEGF) injections (IVI) in eye hospitals in Nigeria.

Materials and Methods

A retrospective, observational, comparative study. The IVIs given 12 months before (pre-COVID) and 12 months after the first announcement of the COVID-19 lockdown (COVID) in Nigeria in four hospitals were used as the sample for this study. All eyes were treatment naïve. We determined the total number of all anti-VEGF injections, the number given for each indication, and the number of each type of the three anti-VEGFs given. A comparison of the presenting vision in IVI eyes between the two eras and the visual outcome of the IVI treatment was made. Data were analyzed using the SPSS version 22 to determine statistical significance.

Results

Male/female ratio, pre-COVID 63.4%/36.6% and COVID 58.6%/41.4% (P = 0.123). Age, pre-COVID 61.3 (SD 12.9) 9-95 years and COVID 57.5 (SD 16.4) 0.15-95 years. There was a 15.3% (81 eyes) reduction in the number of eyes between pre-COVID and COVID eras (528 and 447 eyes, respectively). Likewise, the number of IVIs reduced by 26% (221 IVIs) from 850 pre-COVID to 629 COVID, P = 0.005. A comparison of the proportion of eyes in the four clinic locations between the two eras was not statistically significant (P = 0.148). The commonest indication was proliferative diabetic retinopathy in both eras, 208 versus 178 eyes (323 versus 226 IVIs). Bevacizumab, Ranibizumab, and Aflibercept were given in the following proportions 60.2%, 22.3%, and 17.4% (pre-COVID) versus 60.2%, 31.5%, and 8.3% (COVID), P = 0.000. Presenting visual acuity was >6/60 in 67.4% of eyes (pre-COVID) versus 59.4% of eyes (COVID), P = 0.039. Vision improved in 51.3% of eyes (pre-COVID) versus 47.7% (COVID); there was no significant difference in visual outcome comparing both eras, P = 0.972.

Conclusion

COVID-19 significantly reduced the number of eyes and IVIs. Eyes had worse presenting visual acuity during the COVID era; however, treatment outcome was comparable between COVID and pre-COVID eras.

Patient adherence to therapy after switch to aflibercept from bevacizumab or ranibizumab for treatment-refractory neovascular age-related macular degeneration

PURPOSE

Clinical trials have demonstrated that switching patients from intravitreal bevacizumab (IVB) or ranibizumab (IVR) to aflibercept (IVA) for treatment-refractory neovascular age-related macular degeneration (nAMD) can decrease the injection frequency. This study evaluated whether there was a difference in the rate of injections or nonadherent events after switching therapies.

METHODS

The study comprised a retrospective, cross-sectional analysis of patients treated for nAMD from 2010 to 2018 who received ≥3 intravitreal injections of IVB/IVR prior to switching to IVA because of treatment-refractory nAMD. The treatment index, outcomes, and adherence to treatment were compared between both treatment regimens.

RESULTS

Sixty-two patients (67 eyes) met inclusion criteria. There was no change in the treatment index (0.65 versus 0.66, P = 0.650) or the number of nonadherent events (33 versus 36, P = 0.760) after the switch from IVB/IVR to IVA. Central macular thickness (CMT) increased 7.7%±13.8% in eyes that had a nonadherent event (283±69 µm to 304±75 µm after resuming care, P = 0.039). There was no short-term impact on visual acuity (VA) for this subset of eyes (0.387±0.202 LogMAR versus 0.365±0.156 LogMAR, P = 0.636). Patients who had nonadherent events ended the study with similar VA compared with patients who had no treatment lapses (0.370±0.616 LogMAR versus 0.337±0.638 LogMAR, P = 0.843).

CONCLUSION

Switching from IVB/ IVR to IVA for treatment-refractory nAMD in a real-world setting does not reduce the treatment index or increase adherence to treatment. Although there were short-term anatomical effects resulting from missed treatments, VA remained stable.

Anatomical and Functional Outcomes with Prompt versus Delayed Initiation of Anti-VEGF in Exudative Age-Related Macular Degeneration

PURPOSE

To investigate the correlation between time from diagnosis of treatment-naïve exudative age-related macular degeneration (AMD) to the introduction of anti-VEGF treatment and anatomical and functional outcomes.

DESIGN

Retrospective cohort study.

METHODS

Included were treatment-naïve exudative AMD patients who presented to a single tertiary medical center between 2012 and 2018. All patients were treated within the first 30 days of their diagnosis with three monthly intravitreal injections of bevacizumab. Patients were divided into three groups: group 1 (prompt anti-VEGF) were injected with bevacizumab within ten days, group 2 (intermediate anti-VEGF) within 11-20 days, and group 3 (delayed anti-VEGF) within 21-30 days from diagnosis. Baseline characteristics and clinical outcomes were compared up to two years from treatment.

RESULTS

146 eyes of 146 patients were included. Sixty-eight patients were in the prompt anti-VEGF group, 31 in the intermediate anti-VEGF group, and 47 in the delayed anti-VEGF group. Following the induction phase of three intravitreal bevacizumab injections, the mean central subfield macular thickness (328.0 ± 115.4 µm vs. 364.6 ± 127.2 µm vs. 337.7 ± 150.1 µm, p = 0.432) and the best-corrected visual acuity (0.47 ± 0.38 vs. 0.59 ± 0.48 vs. 0.47 ± 0.44 logMAR units, p = 0.458) were comparable between the prompt, intermediate and delayed anti-VEGF groups. Anatomical and functional outcomes, treatment burden, number of relapses and eyes with second-line anti-VEGF therapy were comparable between the groups at both 1-year and 2-year timepoints.

CONCLUSIONS

Our real-world evidence data emphasize that even if anti-VEGF induction cannot be initiated promptly within ten days from diagnosis of naïve exudative AMD, the visual and anatomical prognosis of the patients may not worsen if the treatment is started within one month of diagnosis.

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.

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.

Reasons for Delayed Anti-VEGF Treatment During COVID-19 Lockdown and Clinical Impact in Neovascular Age-Related Macular Degeneration

INTRODUCTION

Timely anti-vascular endothelial growth factor (VEGF) treatment is crucial for visual function in neovascular age-related macular degeneration (nAMD). The aim of this study was to assess the reasons for anti-VEGF treatment delay during the COVID-19 lockdown and its clinical impact in patients with nAMD.

METHODS

A retrospective, observational, multicentre study in patients with nAMD treated with anti-VEGF therapy was performed in 16 centres nationwide. Data were retrieved from the FRB Spain registry, patient medical records and administrative databases. Patients were divided into two groups based on whether they received or missed intravitreal injections during the COVID-19 lockdown.

RESULTS

A total of 302 eyes from 245 patients were included (timely treated group [TTG] 126 eyes; delayed treatment group [DTG] 176 eyes). Visual acuity (VA; ETDRS letters) decreased from baseline to post-lockdown visit in the DTG (mean [standard deviation] 59.1 (20.8) vs. 57.1 (19.7); p = 0.020) and was maintained in the TTG (64.2 [16.5] vs. 63.6 [17.5]; p = 0.806). VA worsened by an average of - 2.0 letters in the DTG and by - 0.6 in the TTG (p = 0.016). A higher proportion of visits were cancelled due to hospital overload in the TTG (76.5%) than in the DTG (47%), and a higher proportion of patients missed visits in the DTG (53%) than in the TTG (23.5%, p = 0.021), with fear of COVID-19 infection being the main reason for missed visits (60%/50%).

CONCLUSIONS

Treatment delays were caused by both hospital saturation and patients' decision; the latter being mainly driven by fear of COVID-19 infection. These delays had a detrimental effect on the visual outcomes in nAMD patients.

[Impact of the French 2020 COVID-19 lockdown on the treatment and follow-up of patients with exudative age-related macular degeneration]

PURPOSE

To assess the impact of the measures taken during the lockdown period from March 17 to May 11, 2020 on the management of patients with exudative age related macular degeneration treated by intravitreal anti-VEGF injections at the University Hospital of Tours.

METHODS

In this retrospective study, patients were included after analysis of the computerized medical records of patients with age related macular degeneration. Those who were treated for exudative age related macular degeneration who received at least 1 intravitreal injection in the 12 months prior and at least one consultation in the 6 months prior to the lockdown period, were included. The initial and final mean visual acuity were compared with a 5 letter non-inferiority margin. A subgroup analysis was performed according to outcomes. The visual acuities immediately after this period were also recorded.

RESULTS

In all, 595 eyes of 493 patients were included. The mean initial visual acuity was 59.6 letters, vs. 58.5 for the final visual acuity, i.e. a difference of -1.13 letters with a lower limit of the confidence interval of less than 5. The visual acuity on release from lockdown was comparable to the other 2 measurements. Initial visual acuity and the number of missed treatments were the main factors associated with functional loss.

CONCLUSION

Patients' visual acuity during the lockdown period was able to be maintained despite the restrictive measures and limitation of care access in France. The most common cause of substantial visual decline was missed intravitreal injections.

Delivery Systems in Ocular Retinopathies: The Promising Future of Intravitreal Hydrogels as Sustained-Release Scaffolds

Slow-release delivery systems are needed to ensure long-term sustained treatments for retinal diseases such as age-related macular degeneration and diabetic retinopathy, which are currently treated with anti-angiogenic agents that require frequent intraocular injections. These can cause serious co-morbidities for the patients and are far from providing the adequate drug/protein release rates and required pharmacokinetics to sustain prolonged efficacy. This review focuses on the use of hydrogels, particularly on temperature-responsive hydrogels as delivery vehicles for the intravitreal injection of retinal therapies, their advantages and disadvantages for intraocular administration, and the current advances in their use to treat retinal diseases.

Pseudophakia as a surprising protective factor in neovascular age-related macular degeneration

PURPOSE

To assess the impact of lens status on macular function among patients treated for neovascular age-related macular degeneration (nvAMD) in whom scheduled intravitreal injections were delayed.

METHODS

We reviewed demographic and clinical data as well as macular optical coherence tomographic images of 34 patients (48 eyes) who did not follow their injection schedule during the first wave of COVID-19 in Israel. Functional worsening was defined as a loss of at least 0.1 in decimal best-corrected visual acuity (BCVA). Morphological worsening was defined as new or increased subretinal/intraretinal fluid or a new hemorrhage. OCT indices of quality were used as a measure for cataract density and progression.

RESULTS

Pseudophakia was associated with a better functional outcome than phakic status: there was a loss of 0.06±0.12 vs. 0.15±0.10 decimal BCVA in the pseudophakic and phakic eyes, respectively (P=.001). A similar trend was observed for morphological changes over the same period: there was an increase in macular thickness of 9±26% vs.12±40%, respectively (P=0.79). During the first wave of COVID-19, the index of OCT quality remained stable for phakic eyes (26±3.6 before the first wave of COVID-19, 26±2.9 afterward; P=1) and pseudophakic eyes (30±2.4 before the first wave of COVID-19, 30±2.6 afterward; P=1).

CONCLUSION

Pseudophakic eyes with nvAMD that missed their scheduled intravitreal injections experienced fewer morphological and functional complications than phakic eyes with nvAMD.

Effect of the COVID-19 Pandemic on Surgical Outcomes for Rhegmatogenous Retinal Detachments

We reviewed the medical records of 438 eyes in 431 patients who had undergone surgeries for rhegmatogenous retinal detachments (RRD) or proliferative vitreoretinopathy (PVR ≥ Grade C) to determine whether the COVID-19 pandemic had affected outcomes. The patients were divided into 203 eyes in Group A that had undergone surgery from April to September 2020, during the pandemic, and 235 eyes in Group B that had undergone surgery from April to September 2019, before the pandemic. The pre- and postoperative visual acuity, macular detachment, type of retinal breaks, size of the RRD, and surgical outcomes were compared. The number of eyes in Group A was fewer by 14%. The incidence of men (p = 0.005) and PVR (p = 0.004) was significantly higher in Group A. Additionally, the patients in Group A were significantly younger than in Group B (p = 0.04). The differences in the preoperative and final visual acuity, incidence of macular detachment, posterior vitreous detachment, types of retinal breaks, and size of the RRD between the two groups were not significant. The initial reattachment rate was significantly lower at 92.6% in Group A than 98.3% in Group B (p = 0.004). The COVID-19 pandemic affected the surgical outcomes for RRD with higher incidences of men and PVR, younger aged patients and lower initial reattachment rates even though the final surgical outcomes were comparable.

COVID-19 Pandemic Lockdowns Impact on Visual Acuity of Diabetic Macular Edema: A Large cohort

INTRODUCTION

Evaluating the impact of unplanned treatment gap, secondary to COVID-19 pandemic lockdowns, on visual acuity in previously treated diabetic macular edema (DME) patients.

METHODS

A multi-center, retrospective, study of DME patients, previously treated with anti-VEGF injections who were followed-up during COVID-19 pandemic (2020) comparing to pre COVID-19 period (2019) Results: A total of 634 DME patients with a mean age of 68.4 years met the inclusion criteria, 385 were assessed in 2019 (pre COVID-19) and 239 patients assessed in 2020 (COVID-19). Baseline BCVA among patients in 2019 and 2020 was 0.52±0.44, 0.45±0.43 (LogMAR, respectively). There was no significant difference between the years 2020 and 2019 in baseline BCVA (p=0.07). Mean number of anti-VEGF injections was significantly lower (5 Vs 6, p<0.01), with a major lower ratio of injections per patient in the COVID-19 first lockdown period (March-June 2020) in the COVID-19 group. Baseline BCVA (p<0.01) was the only significant predictor of final BCVA. Number of injections, age, gender and the year weren't found as a predictor of final BCVA.

CONCLUSIONS

In a large cohort of DME patients, an unplanned delay in treatment with anti- VEGF injections for 2-3 months due to COVID-19 pandemic lockdown, had no significance impact on visual acuity. For most patients, returning to routine treatment regimen was sufficient for BCVA maintaining.

The negative impact of COVID-19 pandemic on age-related macular degeneration patients treated with intravitreal bevacizumab injections

Purpose

COVID-19 emerged in the end of 2019 and was declared a worldwide pandemic shortly after. Social distancing and lockdowns resulted in lower compliance in intravitreal injections and office visits. We aimed to assess clinical outcomes among patients who missed these visits compared to those who arrived as planned.

Methods

Patients who missed or were late to office visits or intravitreal injections were defined as non-adherent and were compared to adherent patients. Our main outcomes were the need for subsequent injections, mean change in best-corrected visual acuity (BCVA), and central macular thickness (CMT).

Results

This study included 77 patients (24 adherent and 53 non-adherent). The mean BCVA remained stable during the study period for the adherent group (p = 0.159) and worsened in the non-adherent group (p < 0.001). Changes in CMT and maximum thickness were not significant for either group. A higher proportion of patients in the non-adherent group needed subsequent intravitreal injections (49% vs 20%, p = 0.014).

Conclusion

The findings demonstrate the negative implications of the COVID-19 pandemic and the effect of deferring bevacizumab injections among individuals with age-related macular degeneration. This emphasizes the importance of a scheduled follow-up, also during a pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10792-022-02337-y.

The Reorganization of a Psychiatric Unit During COVID-19: A Reflection for Psychiatric Hospital Design

OBJECTIVE

The COVID-19 pandemic has impacted healthcare systems worldwide. Although this disease has primarily impacted general medicine intensive care units, other areas of healthcare including psychiatry were modified in response to corona measures to decrease the transmission of the disease. Reflecting on the modifications to the environment provides an opportunity to design psychiatric environments for future pandemics or other demands for healthcare.

BACKGROUND

The therapeutic environment of psychiatric wards was modified in Friesland, the Netherlands, in response to COVID-19. During this time, an interdisciplinary team met consistently to contribute to the preliminary design of a new psychiatric hospital.

METHODS

During the first 18 months of the pandemic, clinical reflections were made to describe the impact of COVID-19 on the psychiatric care environment. Architects have created a preliminary design of a new psychiatric hospital based on these reflections, monthly collaborative design discussions based on virtual mock-ups and evidence-based design based on theoretical concepts and research.

RESULTS AND CONCLUSIONS

This theoretical and reflective study describes how an inpatient psychiatric environment was restructured to manage infection during COVID-19. The therapeutic environment of the psychiatric ward and patient care changed drastically during COVID-19. The number of patients accessing care decreased, patient autonomy was restricted, and the function of designated behavioral support spaces changed to manage the risk of infection. However, these challenging times have provided an opportunity to reflect on theories and consider the design of new hospital environments that can be adapted in response to future pandemics or be restructured for different care functions.

INTERNATIONAL IMPACT OF THE COVID-19 PANDEMIC LOCKDOWN ON INTRAVITREAL THERAPY OUTCOMES: Fight Retinal Blindness Registry

PURPOSE

To evaluate the impact of the COVID-19 pandemic lockdowns on the outcomes of eyes treated for neovascular age-related macular degeneration, diabetic macular edema, and retinal vein occlusion in eight countries.

METHODS

A multicenter international database study of 5,782 eyes (4,708 patients) receiving intravitreal antivascular endothelial growth factor injections before, during, and after national lockdowns. The baseline visit was defined as the last visit within 3 months before lockdown, and prelockdown and postlockdown periods were defined as 6 months before and after the lockdown date.

RESULTS

Eyes with neovascular age-related macular degeneration (n = 4,649) lost vision in all countries in proportion to the reduced number of injections. The mean visual acuity change postlockdown ranged from -0.4 to -3.8 logarithm of the minimum angle of resolution letters, and the median number of injections/visits decreased from 4-5/4-7 to 2-4/2-4 postlockdown. The diabetic macular edema (n = 654) and retinal vein occlusion (n = 479) eyes' mean visual acuity change ranged from -2.8 to +1.7 letters and -1.6 to +0.1 letters, and the median number of injections/visits decreased from 2.5-5/4-6 to 1-3/2-4 and from 3-5.5/4-5 to 1-3.5/2-3.5, respectively. The 6-month dropout rates postlockdown were 20% for neovascular age-related macular degeneration, 27% for diabetic macular edema, and 28% for retinal vein occlusion.

CONCLUSION

This international study provides estimates of the impact of COVID-19 pandemic lockdown on intravitreal therapy and suggests that prioritizing neovascular age-related macular degeneration eyes seems appropriate.

COVID-19 Pandemic Lockdowns Impact on Visual Acuity of Neovascular AMD Patients: A Large cohort

PURPOSE

Evaluating the impact of delayed care, secondary to COVID-19 pandemic lockdowns, on visual acuity in previously treated neovascular AMD (nAMD) patients.

METHODS

A multi-center, retrospective, study of nAMD patients previously treated with anti-VEGF injections who were followed-up during 2019 (pre COVID-19) and compared to nAMD patients during 2020 (COVID-19).

RESULTS

A total of 1,192 nAMD patients with a mean age of 81.5 years met the inclusion criteria. Of these, 850 patients were assessed in 2019 (pre COVID-19) and 630 patients assessed in 2020 (COVID-19). 308 patients were assessed through both 2019-2020 and thus were included in both cohorts. There was no significant difference between the years 2020 and 2019 in terms of baseline and change in BCVA (p=0.342, p=0.911 respectively). Mean number of anti-VEGF injections was significantly lower (5.55 Vs 6.13, p<0.01), with constant lower ratio of injections per patient in the COVID-19 period. Baseline BCVA (0.859, p<0.01), number of injections (-0.006, p=0.01) and age (0.003, p<0.01) were predictors of final BCVA.

CONCLUSIONS

In nAMD patients, delayed care secondary to COVID-19 pandemic lockdowns has no statistically significant impact on BCVA. Baseline BCVA, older age and lower number of yearly anti VEGF injections are predictors for decrease BCVA.

Fluocinolone acetonide implant in diabetic macular edema: International experts' panel consensus guidelines and treatment algorithm

Center-involving diabetic macular edema (DME) is a leading cause of vision impairment in working-age adults. While its management is particularly challenging in a poorly compliant population, continuous innovation and the advent of new molecules have improved its outcome. The control of glycemia and of systemic aggravating factors remain essential to slow down progression of disease complications including DME. The indications for macular laser photocoagulation has progressively been phased out as a standard of care and replaced by local intraocular anti-VEGFs biologics and glucocorticoids (GCs). Intravitreal GCs in controlled-release drug delivery systems have allowed to reduce injection frequency and treatment burden. The non biodegradable Fluocinolone Acetonide (FAc) implant allows a long-lasting stabilization of both functional and anatomic improvements. However, adequate patient selection and monitoring through regular follow-up are essential for optimal results. Based on their experience and the latest literature, the aim of the present review is to provide international expert panel consensus on the place of the FAc implant in the treatment algorithm of DME, as well as its safety profile and how to manage it.

Telemedicine for the Diagnosis and Management of Age-Related Macular Degeneration: A Review

Use of ophthalmic telemedicine for patients with age-related macular degeneration (AMD) has shown remarkable advances over recent years. The recent COVID pandemic accelerated this transition since in-person evaluation of elderly patients at high risk for advanced AMD and severe vision loss were also at higher risk for complications from COVID infection. To date, ophthalmic telemedicine has been successfully used in remote retinal consultation by general ophthalmologists for AMD management, hybrid testing visits with both in-office testing and remote evaluation, as well as early successes in home-based remote monitoring of patients with high-risk AMD. We therefore review the current literature and evidence base related to ophthalmic telemedicine for AMD.

Effects of delay in anti-vascular endothelial growth factor intravitreal injections for neovascular age-related macular degeneration

Purpose

To assess the impact of COVID-19-related delay in intravitreal injection timing on macular structure and visual acuity (VA) among patients treated for neovascular age-related macular degeneration (nvAMD).

Methods

We reviewed demographic and clinical data and macular ocular computerized tomographic images of 34 patients (48 eyes, group A) who did not follow their injection schedule during the first wave of COVID-19 and compared them to 46 patients (71 eyes, group B) who did. Functional worsening was defined as a loss of at least 0.1 in decimal VA. Anatomic worsening was defined as new or increased subretinal/intraretinal fluids or new hemorrhage.

Results

The planned mean ± standard deviation intervals between the intravitreal injections were 5.7 ± 2.7 weeks for group A and 5.5 ± 2.4 weeks for group B (P = 0.60). The actual intervals were 13.6 ± 6.8 (7.9 ± 5.2 weeks’ delay) and 5.3 ± 2.4 weeks (no delay), respectively (P < 0.001). The best corrected visual acuity worsened in 23 group A eyes (47.9%) and in 6 group B eyes (8.5%) (odds ratio [OR] 9.97, P < 0.001). Anatomic features indicative of nvAMD worsening were detected in 31 group A eyes (64.6%) and in 16 group B eyes (22.5%) (OR 5.73, P < 0.001). A new macular hemorrhage was observed in 4 group A eyes (8.3%) and in no group B eyes (P = 0.09).

Conclusion

Delay in timely retinal care during the COVID-19 restrictions period resulted in short-term negative outcomes, including macular bleeding, in nvAMD patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-021-05505-5.

Impact of the COVID-19 pandemic's first wave on the care and treatment situation of intravitreal injections in a German metropolitan region

Purpose

This study aims to evaluate the impact of the first coronavirus 2019 (COVID-19) wave in 2020 on patients scheduled for intravitreal injections (IVI) in a German metropolitan region.

Methods

We performed a multicentre prospective survey and retrospective analysis of the records of patients treated with intravitreal injections during the 20-week period from March to July 2020 in all four hospital eye departments in the city of Hamburg using a questionnaire (on treatment adherence, SarsCoV2-related personal, familial and social data) and treatment data.

Results

A total of 1038 patients (2472 IVI, 1231 eyes) and 818 questionnaires were evaluated. Longer duration of therapy, lower visual acuity (VA) of the treated and higher VA of the fellow untreated eye was were associated with a higher probability of visit cancellation. Every additional year of life posed a 2.6% lower risk of noncompliance. A COVID-19 infection in the family environment displayed a 5.5-fold chance of visit cancellation. Patients treated for neovascular age-related macular degeneration (nAMD) had a 36% reduced risk of visit cancellation compared to patients with diabetic macular oedema (DME).

Conclusion

A long preceding treatment period, low VA of the treated eye, high VA of the untreated eye, COVID-19 in the family and DME were identified as risk factors for IVI visit cancellations during the COVID-19 pandemic. Compliance to treatment might be improved in the future by taking these risk factors into account when scheduling patients for IVI during the exceptional circumstances of a pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-021-05521-5.

The detrimental effects of delayed intravitreal anti-VEGF therapy for treating retinal pathology: lessons from a forced test-case

Purpose

Determine the anatomical consequences of delaying intravitreal injection (IVI) therapy with anti-vascular endothelial growth factor (anti-VEGF) in patients using treat-and-extend (T&E) protocol.

Methods

Retrospective medical record review of consecutive patients receiving intravitreal anti-VEGF therapy using T&E protocol prior to and during the COVID-19 pandemic.

Results

The study included 923 eyes of 691patients; 58.8% (543 eyes), 25% (231 eyes), and 16.2% (149 eyes) had nvAMD, DME, and RVO, respectively. Mean (± SD) patient age was 74.5 ± 11.7 years. Overall, 56.3% of cases had a delay in therapy of ≥ 7 days; specifically, 56.2%, 61.5%, and 49.0% of nvAMD, DME, and RVO cases, respectively, had a delay. The median delay in days, among cases ≥ 7 days late was 21 (IQR 7 to 42) days, with 21(IQR 7 to 45), 22.5(IQR 8 to 42), and 14(IQR 7 to 33.5) days of delay among patients with nvAMD, DME, and RVO, respectively. Delaying therapy by ≥ 7 days resulted in increased CST in 47.5%, 58.5%, and 58.9% of nvAMD, DME, and RVO cases, respectively, with a significant correlation between the length of treatment delay and the increase in CST (Spearman’s rho: 0.196; p < 0.001).

Conclusions

Delayed IVI treatment in eyes treated with T&E protocol was associated with increased macular thickness with potential consequences with respect to visual outcome.

Treat-and-Extend Regimens for the Management of Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy: Consensus and Recommendations From the Asia-Pacific Vitreo-retina Society

PURPOSE

Review and provide consensus recommendations on use of treat-and-extend (T&E) regimens for neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV) management with relevance for clinicians in the Asia-Pacific region.

METHODS

A systematic search of MEDLINE, EMBASE, and Cochrane databases, and abstract databases of the Asia-Pacific Vitreo-retina Society, European Society of Retina Specialists, American Academy of Ophthalmology, and Controversies in Ophthalmology: Asia-Australia congresses, was conducted to assess evidence for T&E regimens in nAMD. Only studies with ≥100 study eyes were included. An expert panel reviewed the results and key factors potentially influencing the use of T&E regimens in nAMD and PCV, and subsequently formed consensus recommendations for their application in the Asia-Pacific region.

RESULTS

Twenty-seven studies were included. Studies demonstrated that T&E regimens with aflibercept, ranibizumab, or bevacizumab in nAMD, and with aflibercept in PCV, were efficacious and safe. The recommendation for T&E is, after ≥3 consecutive monthly loading doses, treatment intervals can be extended by 2 to 4 weeks up to 12 to 16 weeks. When disease activity recurs, the recommendation is to reinject and shorten intervals by 2 to 4 weeks until fluid resolution, after which treatment intervals can again be extended. Intraretinal fluid should be treated until resolved; however, persistent minimal subretinal fluid after consecutive treatments may be tolerated with treatment intervals maintained or extended if the clinical condition is stable.

CONCLUSIONS

T&E regimens are efficacious and safe for nAMD and PCV, can reduce the number of visits, and minimize the overall burden for clinicians and patients.

Safety Outcomes of Brolucizumab in Neovascular Age-Related Macular Degeneration: Results From the IRIS Registry and Komodo Healthcare Map

Importance

Limited data exist on the real-world safety outcomes of patients with neovascular age-related macular degeneration treated with brolucizumab (Beovu).

Objective

To determine the real-world incidence of intraocular inflammation (IOI), including retinal vasculitis (RV) and/or retinal vascular occlusion (RO), for patients with neovascular age-related macular degeneration who underwent brolucizumab treatment. Additionally, potential risk factors associated with these adverse events were evaluated.

Design, Setting, and Participants

This cohort study included patients with neovascular age-related macular degeneration in the Intelligent Research in Sight (IRIS) Registry and Komodo Healthcare Map. Patients initiating and receiving 1 or more brolucizumab injections from October 8, 2019, to June 5, 2020, with up to 6 months of follow-up were included.

Intervention

Brolucizumab injections.

Main Outcome and Measures

Incidence of IOI (including RV) and/or RO and RV and/or RO and risk stratification for the identified risk factors.

Results

Of 10 654 and 11 161 included eyes (from the IRIS Registry and Komodo Health database, respectively), the median follow-up times were 97 and 95 days. Most eyes switched from another anti-vascular endothelial growth factor agent (9686 of 10 654 [90.9%] and 10 487 of 11 161 [94.0%], respectively), most commonly aflibercept (7160 of 9686 [73.9%] and 7156 of 10 487 [68.2%]), and most were from women (6105 of 10 654 [57.3%] and 6452 of 11 161 [57.8%]). The overall incidence of IOI and/or RO was 2.4% (255 of 10 654 eyes) and 2.4% (268 of 11 161 eyes) for the IRIS and Komodo groups, respectively, and RV and/or RO, 0.6% (59 of 10 654 eyes and 63 of 11 161 eyes), respectively. Patients with a history of IOI and/or RO in the 12 months before brolucizumab initiation had an increased observed risk rate (8.7% [95% CI, 6.0%-11.4%] and 10.6% [95% CI, 7.5%-13.7%]) for an IOI and/or RO event in the 6 months following the first brolucizumab treatment compared with patients without prior IOI and/or RO (2.0% in both data sets). There was an increased estimated incidence rate in women (2.9% [95% CI, 2.5%-3.3%] and 3.0% [95% CI, 2.6%-3.4%]) compared with men (1.3% [95% CI, 1.0%-1.7%] and 1.4% [95% CI, 1.0%-1.7%]), but this risk was not as large as that of a prior IOI and/or RO. Similar findings were observed for patients with RV and/or RO events.

Conclusions and Relevance

The incidence rate of IOI and/or RO was approximately 2.4%. Patient eyes with IOI and/or RO in the 12 months prior to first brolucizumab injection had the highest observed risk rate for IOI and/or RO in the early months after the first brolucizumab treatment. However, given study limitations, the identified risk factors cannot be used as predictors of IOI and/or RO events, and causality with brolucizumab cannot be assessed.

The effect of COVID-19 pandemic on the attendance and clinical outcomes of patients with ophthalmic disease: A mini-review

The outbreak of COVID-19 was followed by a rapid spread leading to its declaration as a pandemic in a short time. The transmission through aerosols and direct contact with infected individuals forced the application of strict safety protocols and rearrangements in the activities of different healthcare systems around the world. Ophthalmology healthcare workers are highly exposed to viral infection and therefore adjustments were made to ensure the safety of patients and health providers by performing only urgent treatments. The suspension and delay in regular follow-up visits and the lower number of patients recorded during the lockdown period due to restrictions and patient anxiety led to severe consequences in the clinical and anatomical outcome affecting the overall prognosis. The current review aims to summarize the effect of the lockdown policies in the number and profile of patients that attended the ophthalmology clinics from different countries and analyze the effect of the pandemic in terms of vision and patient functionality. The effects of the pandemic included a reduction in the number of appointments, cancellations of non-emergency conditions and delays of surgical interventions. These had a negative effect in terms of visual outcomes.

Patient preferences in retinal drug delivery

Retinal vascular diseases (RVDs) are often treated with intravitreally (IVT) injected drugs, with relatively low patient compliance and potential risks. Ongoing research explores alternative RVD treatments, including eye drops and oral tablets. This study surveyed RVD patients treated with IVT injections to establish factors influencing low compliance rates while gauging treatment delivery method preferences. Demographics, perspectives, and treatment preferences were collected via IRB-approved, self-administered survey sent to Glick Eye Institute patients treated via IVT injections. Demographics, diagnoses, and treatments were ascertained from respondents’ medical records. Gender, age, and number of IVT injections received were used as stratifications. Five-level Likert-style scales and t-tests evaluated responses and stratification comparisons. The most common diagnoses in the respondent population (n = 54; response rate = 5%) were age-related macular degeneration, macular edema, and diabetic retinopathy. Respondents had varying levels of education, income, and age. Most (83%) admitted feeling anxious prior to their first IVT injection, but 80% reported willingness to receive IVT injections indefinitely, with a preference for ophthalmologist visits every 1–3 months. Eye drops would be preferred over IVT injections by 76% of respondents, while 65% preferred oral tablets, due to several perceived negative factors of IVT injections and positive factors for eye drops. Stratified groups did not differ in responses to survey questions. RVD patients will accept IVT injections for vision preservation, but alternative delivery methods like eye drops or oral tablets would be preferred. Thus, development of eye drop and oral therapeutics for RVD treatment is further emphasized by these findings.

[Impact of the SARS-CoV-2 pandemic on diabetic macular edema and prognostic factors]

But

Décrire le retentissement sur l’acuité visuelle et l’épaisseur centromaculaire après arrêt des injections intravitréennes d’anti-VEGF chez les patients diabétiques marocains au cours de la pandémie du Coronavirus. Et étudier les facteurs pouvant être associés à l’aggravation.

Matériel et méthodes

Cette étude transversale monocentrique a inclus les patients programmés pour injections intravitréennes de Bevacizumab au cours de la période du confinement (20 mars 2020–20 mai 2020) et qui n’en ont pas bénéficié. Ont été recueillis : l’âge, le sexe, l’ancienneté du diabète, le nombre d’injections reçues avant le confinement, l’acuité visuelle en pré-confinement et post-confinement ainsi que l’épaisseur centromaculaire pré-confinement et post-confinement.

Résultats

Cent cinquante quatre yeux de 104 patients ont été analysés. 57,8 % étaient des hommes avec une moyenne d’âge de 59,4 ± 9,04 ans. La durée moyenne d’arrêt des injections intravitréennes est de 57,3 ± 6,7 jours. Le nombre moyen d’injections intravitréennes de Bevacizumab reçues avant le confinement a été estimé à 2,29 ± 2,1. L’aggravation de l’acuité visuelle a été notée chez 44,8 % de nos patients. Les facteurs associés à l’aggravation fonctionnelle sont le faible nombre d’injections intravitréennes de Bevacizumab reçues avant le confinement (p = 0,001) ainsi que le déséquilibre diabétique (p = 0,04). L’aggravation structurelle a été constatée chez 26,6 % des patients et elle était associée au faible nombre d’injections réalisées avant le confinement (p = 0,038).

Conclusion

Le report des injections intravitréennes au cours du confinement a eu des effets négatifs sur l’acuité visuelle et l’épaisseur centromaculaire des yeux avec OMD. Un report prolongé des injections intravitréennes d’anti-VEGF chez les patients diabétiques doit être évité.

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

PURPOSE OF REVIEW

Diabetic retinopathy (DR) is one of the leading causes of vision loss worldwide. Although screening and early treatment guidelines for DR have significantly reduced the disease burden, restrictions related to the COVID-19 pandemic have changed real-world practice patterns in the management of DR. This review summarizes evolving guidelines and outcomes of the treatment of DR in the setting of the pandemic.

RECENT FINDINGS

Intravitreal injections for DR have decreased significantly globally during the pandemic, ranging from approximately 30 to nearly 100% reduction, compared to corresponding timepoints in 2019. Most studies on functional outcomes show a decrease in visual acuity on delayed follow-up. Changing practice patterns in the management of DR has led to fewer intravitreal injections and overall reduction in visual acuity on follow-up. As COVID variants emerge, it will be necessary to continue evaluating practice guidelines.

The Impact of Non-Ophthalmic Factors on Intravitreal Injections During the COVID-19 Lockdown

Purpose

Early on in the COVID-19 pandemic, it was difficult to know what factors would affect patient and physician decision-making regarding ophthalmic care utilization. The purpose of this study is to investigate the effect of non-ophthalmic factors on patient decision-making to receive intravitreal injections during the COVID-19 lockdown.

Patients and Methods

Data on patients who had intravitreal injection appointments at a tertiary care Veterans Health Administration clinic during a seven-week period (March 19, 2020-May 8, 2020) of the COVID-19 outbreak in Los Angeles County were collected and compared to patients who had intravitreal injection appointments during the same time period in 2019. Demographic characteristics, injection diagnoses, visual acuities, body mass indices, co-morbidities, and psychiatric conditions of patients and clinic volumes were tabulated and compared between the two time periods.

Results

There were 86 patients in the injection clinic in 2020 compared to 176 patients in 2019. The mean age and gender of patients in the injection clinic did not differ between 2019 and 2020. Compared to 2019, the number of patients who identified as Hispanic or Latino remained nearly the same, but the number of patients who identified as White, Black, or Asian or Pacific Islander decreased by nearly half. In 2020, a greater proportion of patients came to the injection clinic for neovascular age-related macular degeneration (56.5% vs 39.3%, p=0.017), but a decreased proportion of patients diagnosed with a heart condition (OR 0.57, 95% CI 0.33, 0.96), chronic obstructive pulmonary disease (OR 0.43, 95% CI 0.21, 0.91), or asthma (OR 0.09, 95% CI 0.01, 0.70) came to the injection clinic.

Conclusion

The COVID-19 pandemic was associated with behavioral changes in eyecare utilization influenced by race and systemic co-morbidities. These data can be used to design and implement strategies to address disparities in essential ophthalmic care among vulnerable populations.

Impact on Visual Acuity in Neovascular Age Related Macular Degeneration (nAMD) in Europe Due to COVID-19 Pandemic Lockdown

This is a retrospective, multicenter study of consecutive patients with nAMD scheduled for a visit and/or a treatment with an intravitreal injection (IVI) during the 3 months before lockdown in the Ophthalmology Departments of six centers of Europe.The study was conducted on 546 patients, of which 55.13% were females, almost 100% of the patients were White/Caucasian race, and 71.53% of the patients presented a type 1 macular neovascularization (NVM). A total of 62.82% of patients (343 patients) that were on scheduled clinic visits and/or intravitreal injection treatment during the 3 months before the quarantine did not attend either to visit or for treatment during the lockdown. The mean number of injections during the lockdown was significantly reduced. This was followed by a significant reduction in the mean best-corrected visual acuity (BCVA) between the 3 months before the lockdown (mean BCVA of 60.68 ± 19.77 letters) and 6 months after lockdown (mean BCVA of 56.98 ± 22.59 letters). Patients with better BCVA before the lockdown and the ones showing neovascular activity were more likely to attend their scheduled visits and/or IVI treatments. The COVID-19 pandemic and the lockdown have led to a decrease in the number of IVI treatments in patients with nAMD, evidencing a significant vision loss at 6 months.

Economic Impact of COVID-19 Lockdown on Italian NHS: Focus on Diabetes Mellitus

Background

In Italy, the adoption of a total lockdown has generated almost total suspension of outpatient visits except for emergencies. Even after lockdown, the pandemic fear created additional barriers to access the health services. The aim of our study is to evaluate the economic impact of the lockdown for COVID-19 on public health in Italy, focusing on its effects on diabetic population.

Materials and Methods

We analyzed the impact of the lockdown on excess mortality and morbidity in the Italian diabetic population during 2020. The analysis was divided into several steps: a quantification of specialist visit reduction, the calculation of excess mortality in the diabetic population, the economic evaluation of the slowdown in the use of innovative diabetic therapies. Furthermore, the impact of the lockdown on the reduction of procedures and follow-up visits in diabetic population was evaluated. The overall impact of the pandemic and lockdown effects on costs and quality of life was then calculated.

Results

During 2020, a drop of 28% in patient access has been observed. Diabetic patients recorded a twice higher mortality value compared to general population (20.4% vs 10.2%). The analysis of market data revealed a slowdown in consumption of new antidiabetic therapies (−14%, 27% vs 41%). We estimated an expense of €26.6 million for NHS and a loss of 257 utilities in diabetic population due to the missed benefits related to slowdown in innovative antidiabetic drugs use and non-optimal follow-up and control of diabetes complications. In simulation scenarios, we also estimated an overall expenditure ranging from €38.7 to 94.0 million and a loss of 294–836 utilities.

Conclusion

Diabetic population paid a high tribute to pandemic and lockdown, both in terms of number of deaths and burden of diabetic complications, together with an overall deterioration of quality of life.

Assessment of Patients' Confidence Regarding a New Triage Concept in a Medical Retina Clinic during the First COVID-19 Outbreak

BACKGROUND

During the first COVID-19 pandemic outbreak, a new triage concept had to be implemented for patients with retinal diseases having a scheduled appointment at the medical retina clinic. In this study, we aimed to assess patients' confidence in this triage concept and patients' satisfaction regarding the received treatment during the outbreak.

METHODS

This retrospective study included all patients with a diagnosed retinal disease, triaged into three priority groups based on their condition's urgency during lockdown. After restrictions were eased, a subset of previously triaged patients was interviewed to assess their confidence in the triage and their satisfaction regarding the received treatment during the pandemic.

RESULTS

In total, 743 patients were triaged during the lockdown. Over 80% received an urgent appointment (priority 1). Among all priority 1 patients, over 84% attended their appointment and 77% received an intravitreal injection (IVI), while 7% cancelled their appointment due to COVID-19. In post-lockdown interviews of 254 patients, 90% trusted the emergency regimen and received treatment.

CONCLUSIONS

Our triage seemed to be useful in optimizing access to treatment for patients with retinal diseases. An excellent rating of patients' confidence in the triage and satisfaction regarding the received treatment during the first COVID-19 outbreak could be achieved.

Ophthalmic Outpatient and Inpatient Care Under Pandemic Conditions: Hygiene, Triage and New Challenges

BACKGROUND

The progression of the COVID-19 pandemic has caused significant changes in the environment for outpatient and inpatient care in ophthalmology, with limitations on access to medical care but also new observations and challenges. We now describe major developments in recent months and provide an outlook on the expected consequences.

METHODS

PubMed literature search, clinical survey.

RESULTS

To date, the course of the COVID-19 pandemic has been characterised by several new but overall rare ocular manifestations, the ophthalmological shared management of COVID-19 patients on intensive care units, and a significant decrease in case numbers, associated with an increase in case severity and relative proportion of emergencies, as a result of delayed presentation of patients and reduced treatment adherence. With the introduction of hygiene measures and infection control procedures, ophthalmic patient care was maintained - including emergencies and urgent treatments. Due to the extensive postponement of elective surgeries, scarce therapeutic and health care professional resources, and the prioritisation of critically ill patients from other specialties, there is a reasonable likelihood that urgent treatments will be delayed as infection rates rise.

CONCLUSION

Outpatient and inpatient care in ophthalmology during the COVID-19 pandemic is primarily accompanied by additional organisational or medical challenges and a decline in case volume. Although to date emergency and urgent ophthalmic treatments have been maintained, long-term persistence of pandemic conditions will require additional strategies to provide continuation of ophthalmic care at the required level.

Effect of COVID-19-Associated Lockdown on Patients With Diabetic Retinopathy

Purpose To evaluate the effect of the coronavirus disease 2019 (COVID-19)-related lockdown in the management of patients with diabetic retinopathy (DR), including diabetic macular edema (DME), in a tertiary reference center in Greece. Methods In this retrospective study, we first compared the number of patients who were diagnosed with DR or DME in our clinic during the period of the lockdown and during the same period of the previous year. In addition, we included consecutive patients with DR or DME, who were followed up and treated regularly in our clinic and their appointments deferred due to lockdown, so as to compare the visual acuity, fundoscopy, and optical coherence tomography (OCT) findings prior to and post lockdown. Results During the lockdown period, there was a statistically significant decrease in patients with DR and DME as compared to the same period in the previous year. Regarding patients with previously diagnosed DME, there was a statistically significant worsening in their visual acuity and central retinal thickness after lockdown as compared to the last visit before lockdown (p<0.001 for both comparisons). Concerning patients diagnosed with DR and without DME before lockdown, 30% of patients with severe non-proliferative diabetic retinopathy (NDPR) and 8.3% of patients with quiescent proliferative DR (PDR) progressed to active PDR while four out of 107 patients (3.7%) developed DME during the lockdown. Multivariate regression analysis revealed that only the time interval between the last visit before lockdown and the first visit after the lockdown was associated with the best-corrected visual acuity (BCVA) change (p=0.017). Conclusions The COVID-19-related lockdown was related to the postponement in patient care, which resulted in significantly worse visual acuity outcomes in patients with DR.

The effect of COVID-19 pandemic restrictions on neovascular AMD patients treated with treat-and-extend protocol

Purpose

To investigate the adherence rate of neovascular age-related macular degeneration (nAMD) patients in treat-and-extend (TAE) protocol to their anti-vascular endothelial growth factor (anti-VEGF) intravitreal injection (IVI) appointments and to evaluate the functional and anatomical outcomes of the patients who attended and did not attend their IVI appointments during the coronavirus disease 2019 (COVID-19) restriction period (RP).

Methods

The patients with nAMD having IVI appointments between March 16 and June 1, 2020 (RP in Turkey) were included in this retrospective study. For adherence analysis, the patients who attended (Group 1, n = 44) and who did not attend (Group 2, n = 60) their IVI appointment visits during the RP (V_RP) were evaluated according to their last visit before the RP (V₀). For outcome analysis, the patients who attend V_RP and have follow-up (Group 1a, 46 eyes) and who did not attend V_RP but later attended for follow-up (Group 2a, 33 eyes) were evaluated for functional (best-corrected visual acuity, BCVA [logMAR]) and anatomical (optical coherence tomography [OCT] disease activity) outcomes at the first visit after RP (V₁) and last visit within six months after RP (V₂). Patients received a complete ophthalmologic evaluation with anti-VEGF (Aflibercept) IVI administration at all visits.

Results

The adherence rate of the patients to V_RP was 42.3% (44/104). The patients in Group 1 were significantly younger (mean ± SD years, 71.0 ± 8.1 vs. 74.7 ± 8.0, p = 0.024), had better median [IQR] BCVA at their first presentation (0.30 [0.54] vs. 0.61 [1.08], p = 0.023) and V₀ (0.40 [0.48] vs. 0.52 [0.70], p = 0.031), and had less hypertension (36.4% vs. 58.3%, p = 0.044) than Group 2. The mean ± SD delay of planned IVI at V_RP in Group 2a was 13.9 ± 6.2 weeks. Disease activity in OCT was significantly higher in Group 2a than Group 1a at V₁ (60.6% vs. 32.6%, p = 0.025). In Group 2a, the median (IQR) BCVA was significantly worse at V₁ (0.70 [0.58]) and V₂ (0.70 [0.59]) than V₀ (0.52 [0.40], p = 0.047 and p = 0.035, respectively).

Conclusions

More than half of the scheduled nAMD patients in TAE protocol missed their IVI visits during the RP, which resulted in a delay of their treatments. The delay of IVI treatment in those patients resulted in an increase in OCT disease activity and a decrease in BCVA.

Short term visual and structural outcomes of anti-vascular endothelial growth factor (anti-VEGF) treatment delay during the first COVID-19 wave: A pilot study

Regularly scheduled intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections are essential to maintaining and/or improving many ocular conditions including: neovascular age-related macular degeneration (nAMD), diabetic retinopathy, and retinal vein occlusions with macular edema (RVO). This study aims to assess the effect of unintended delays in anti-VEGF treatment during the first wave of the COVID-19 pandemic. This retrospective case series identified patients receiving regularly scheduled anti-VEGF intravitreal injections based on current procedural terminology (CPT) code at two practices in Minnesota. Diagnoses were limited to nAMD, diabetic macular edema (DME), proliferative diabetic retinopathy, and RVO. Patients were divided into two groups based on whether they maintained or delayed their follow-up visit by more than two weeks beyond the recommended treatment interval during the COVID-19 lockdown. The 'COVID-19 lockdown' was defined as the period after March, 28th, 2020, when a lockdown was declared in Minnesota. We then compared the visual acuity and structural changes to the retina using ocular coherence tomography (OCT) to assess whether delayed treatment resulted in worse visual outcomes. A total of 167 eyes from 117 patients met criteria for inclusion in this study. In the delayed group, the average BCVA at the pre- and post-lockdown visits were 0.614 and 0.715 (logMAR) respectively (p = 0.007). Central subfield thickness (CST) increased from 341 to 447 in the DME delayed group (p = 0.03) while the CST increased from 301 to 314 (p = 0.4) in the nAMD delayed group. The results of this pilot study suggests that treatment delays may have a negative impact on the visual and anatomic outcomes of patients with nAMD and DME. Future studies with larger sample sizes are required for further investigation.

Short-Term Effects of COVID-19-Related Deferral of Intravitreal Injection Visits

PURPOSE

To determine secondary effects of the mandated COVID-19 pandemic closure period for elective treatment on non-elective, injection-based retina care and outcomes.

PATIENTS AND METHODS

In this cross-sectional, retrospective analysis of a single-provider outpatient clinic across multiple satellites, consecutive patients returning for intravitreal injections (IVIs) of anti-vascular endothelial growth factor or corticosteroids were identified as "delayed" or "undelayed" during a six-week study interval during the COVID-19 pandemic that closely following a mandated period of prohibited elective encounters. A "delayed" encounter was defined as having a follow-up interval exceeding 33% of the recommended cycle. Patients seen for IVIs during the corresponding six-week interval a year previously were identified for study as pre-COVID-19 controls. Main outcome measures included best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) assessment based on findings of intraretinal or subretinal fluid consistent with new or recurrent neovascular events.

RESULTS

The study included 183 eyes of 144 patients who underwent IVI-based care from June 18, 2020, through August 7, 2020, compared to 193 eyes of 154 patients injected during the corresponding interval 1 year before. There were 62 eyes of 46 patients seen in the study period later than scheduled (among 144 patients of 183 eyes in total), which represented a larger proportion of delayed patients compared to the previous year (31.9% vs. 14.9%, p<0.0005). Considering the patterns from the control group, the attributed delay due to COVID-19 was 15.0% of patients. The delayed return eyes had a greater decline in BCVA (3 letters), higher rates of worsened OCT results (48%), and prompted reduction in previously prescribed injection intervals (p<0.02).

CONCLUSION

The unintended consequence of delayed care of patients on established care regimens should be anticipated, and mitigate strategies considered if similar restrictions are mandated in the future.