Management of Neovascular Age-Related Macular Degeneration during the COVID-19 Pandemic

Using a Smartphone-Based Chatbot for Postoperative Care After Intravitreal Injection During the COVID-19 Pandemic: Retrospective Cohort Study

BACKGROUND

During the COVID-19 pandemic period, it was difficult to carry out regular and scheduled follow-up of patients in the outpatient department, especially during lockdown periods. However, early detection of initial infection or other serious conditions is vital for patients after ocular surgery, such as intravitreal injection (IVI) for age-related macular degeneration (AMD).

OBJECTIVE

We evaluated the use of a smartphone-based postoperative care chatbot system (PCCS) with an instant bidirectional feedback system for patients to self-report postoperative symptoms and signs.

METHODS

During the COVID-19 level 3 epidemic alert in July 2021 in Taiwan, the PCCS alerted the patients to report and grade 6 ocular symptoms and signs associated with ocular inflammation or retinal detachment. Patients used the PCCS for 7 days post surgery to assess their symptoms and signs each day after receiving an alert. Data were automatically collected using a cloud computer system, including symptom grades and messages sent to medical staff for further medical assistance. A user satisfaction questionnaire was administered to the patients on the seventh day post surgery.

RESULTS

In total, 185 patients participated in this study. There were 26 (3.03%) reports of symptom grade deterioration (including increased blurred vision, eye swelling, nausea, and floaters or flashes) from 12 (6.5%) patients. We found no difference in the gender of patients who received an early medical consultation. One case of endophthalmitis was reported, wherein an improvement was observed after prompt administration of IVI antibiotics twice. Overall, 87% (n=185) of patients were satisfied or very satisfied with communicating their symptoms instantly through the app; they were willing to use it again and believed that it could improve the quality of care. Seven of the 185 (3.8%) patients had an earlier medical consultation and 1 (0.5%) had endophthalmitis.

CONCLUSIONS

The chatbot system, designed for self-reporting postoperative symptoms and providing instant bidirectional feedback on smartphones, could be beneficial for enhancing the quality of care in early medical consultations without gender differences among patients with AMD receiving IVI, and achieved satisfactory responses from patients.

Impact of the COVID 19 Pandemic on Treatment of nAMD via a Portal-Based Collaboration

BACKGROUND

Under the influence of the COVID 19 pandemic and the lockdown in Germany, there were significantly fewer consultations in almost all medical disciplines. Especially given the need for consistent treatment and follow-up of nAMD patients, this can have far-reaching consequences for visual function, especially in elderly patients.

METHODS

In a retrospective analysis of nAMD patients, the number of visits (IVI or follow-up), OCTs or IVIs performed and the mean worst visual acuity for the period before and after the first COVID 19-associated lockdown were compared in a portal-based collaboration of 50 eye care practices. Patients were treated according to the pro re nata (PRN) regimen that included intravitreal injection of VEGF inhibitors based on activity criteria in the OCT follow-up.

RESULTS

A total of 34,660 visits from 55 months were included in the analysis. Before lockdown (16 March 2020), an average of 81.8% ± 2.1% of patients were regularly checked or treated (every 4 to 5 weeks). With the onset of lockdown, the proportion of patients receiving optimum treatment dropped to 64.0%. Initially, the proportion of OCT follow-ups decreased from 48.4% to 30.9% and, with a delay, the proportion of injections decreased from 57.5% to 45.8%. This was also reflected in the number of OCT follow-ups: 15.5 before, 11.4 during and 17.2 after lockdown (p < 0.001). In 29% of cases, an individual worsening of visual acuity by more than 0.1 logMAR after the end of the lockdown compared to before the lockdown could be observed. On average, mean visual acuity decreased significantly by 0.054 logMAR (p < 10-11). This significant impairment was not reversed again during the remaining observation period, although the number of visits, OCT examinations and IVIs in the following 12 months were at the pre-lockdown level.

CONCLUSIONS

The pandemic-related lockdown resulted in unintended treatment breaks in nAMD patients receiving IVI therapy. The decrease in visits as well as in IVIs caused a loss of visual function in the observed cohort. The consistent treatment regimen of nAMD patients was resumed shortly after the lockdown with an immediate normalization of the number of OCT examinations and IVIs. However, a permanent loss of visual function was observed, and this did not improve within a year after the lockdown. This finding highlights the importance of better case management, leading to improved patient adherence in the event of further waves of COVID or other pandemics.

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.

Telehealth improves follow-up and monitoring of age-related macular degeneration during the COVID-19 pandemic

PURPOSE

To prevent vision loss, it is important to monitor patients with age-related macular degeneration (AMD) for the development of choroidal neovascularization. The coronavirus disease 2019 (COVID-19) pandemic caused many patients to miss or delay visits. To offset those gaps in care, providers utilized telehealth (TH) to evaluate patients for symptoms of disease progression and provide health education on the importance of continuous monitoring.

METHODS

This study evaluates the impact of TH encounters on the rate of return for recommended in-person examinations for 1103 patients with non-neovascular (dry) AMD seen in an outpatient ophthalmology clinic in 2019 and due for return evaluation after the outbreak of COVID-19 in 2020. Logistic regression analysis was used to identify demographic, clinical, and sociomedical factors associated with TH utilization and in-person return.

RESULTS

422 patients (38%) utilized TH during the study period. Patients who completed a TH encounter were more likely to return for an in-person examination as compared with those who did not receive TH (OR: 1.8, CI 95%: 1.4-2.3, P < 0.001). Completing a TH visit was associated with the detection of new wet AMD (OR: 3.3, 95% CI 1.04-10.6, P = 0.043), as well as with an earlier return for those patients who were found to have disease progression (62 ± 54 days vs. 100 ± 57 days, P = 0.049).

CONCLUSION

Completing a TH visit increased the rate at which patients with dry AMD returned for recommended in-person eye examinations. In many cases, this permitted the earlier detection of wet AMD, which is linked with achieving better outcomes.

IMPACT study: Impact of adherence to anti-VEGF intravitreal injections for macular disease during COVID 19-related confinement in France

PURPOSE

The aim of this study was to evaluate the impact of adherence to French coronavirus disease 2019 (COVID 19)-related guidelines for intravitreal injection (IVI) practice on the visual outcomes of patients treated with anti-vascular endothelial growth factor (VEGF) agents for macular diseases during the first lockdown period.

METHODS

Observational multicentre study including all patients from 18 centres with an IVI initially planned during the lockdown. Visual acuity (VA, ETDRS) was recorded at 1 and 4 months after lockdown. French COVID 19-related guidelines recommended maintaining IVI practice. We defined three groups of patients: A, adherent to guidelines; NA+, non-adherent with delayed IVIs; and NA-, non-adherent without IVIs performed during the lockdown. Risk factors for non-adherence and visual loss were studied.

RESULTS

A total of 3020 eyes of 3020 patients, aged 77.8 ± 11.6 years, 59.8% women, were included. 59.3% were non-adherent(46.7% NA+, 12.6% NA-). A smaller decrease in VA at 4 months was observed in the A group than the NA+ and NA- group (-0.2 ± 6.7, -0.3 ± 6.9 and -1.5 ± 6.9, respectively [p < 0.001]). Factors associated with non-adherence were in multivariable analysis, older age, hospital practice, low-density population areas, high viral incidence areas, longer intervals between injection and treat and extent protocol. Factors associated with visual loss at 4 months in multivariable analysis were, being in the NA- group, older age, T&E and fixed regimens.

CONCLUSION

Strict adherence to guidelines was associated with better visual outcome, although most of our patients did not attend as planned. Identification of patients at risk could help in the future in case of a new pandemic lockdown.

The importance of monitoring wet age-related macular degeneration patients during Coronavirus disease 19 pandemic: A retrospective study of assessment of functional and structural outcomes

Objectives

Intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections are the gold standard treatment for wet age-related macular degeneration (wet AMD). Coronavirus disease 2019 (COVID-19) has led to the cancellation of many scheduled intravitreal anti-VEGF injection visits. We compared the functional and structural visual outcomes of wet AMD patients who did not adhere to their planned intervals (group 1) with those who did (group 2).

Methods

Wet AMD patients of Swiss Visio Montchoisi and RétinElysée were included. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) changes between their first visit after the end of the first national lockdown in Switzerland (27 April 2020, first post-lockdown visit) and their last visit before the beginning of the first national lockdown in Switzerland (13 March 2020, last pre-lockdown visit) were assessed. The BCVA outcome was defined as unfavorable when there was a loss of ≥ 5 ETDRS letters in the first post-lockdown visit compared to the BCVA at last pre-lockdown visit. The OCT outcome was defined as unfavorable when there was an increase in at least one of the parameters, intraretinal fluid (IRF), subretinal fluid (SRF), or pigment epithelial detachment (PED), at the first post-lockdown visit compared to the last pre-lockdown visit.

Main results

Group 1 (89 patients, 109 eyes) had a 13.41% greater rate of unfavorable BCVA outcomes and a 38.27% greater rate of unfavorable OCT outcomes than group 2 (96 patients, 122 eyes) (P = 0.04, P < 0.0001, respectively). Multivariate analysis showed that the more the patients deviated from their programmed injections and the higher the BCVA pre-lockdown, the higher the rate of unfavorable BCVA outcomes (P = 0.03 and P = 0.02, respectively). OCT outcomes were not a predictive factor for an unfavorable BCVA outcome.

Conclusions

The cancellation of many intravitreal anti-VEGF injection appointments resulted in worse functional and structural outcomes in wet AMD patients. The COVID-19 pandemic led many patients to refrain from their routine intravitreal anti-VEGF injection appointments, allowing us to analyze the role of designated intervals in the treatment of wet AMD. During any future lockdown due to COVID-19 or similar circumstances, continuity of care for wet AMD patients should be maintained.

Challenges of personal protective equipment use among ophthalmologists during the COVID-19 pandemic: A multicenter international study

PURPOSE

To explore the possible challenges and difficulties of using Personal Protective Equipment (PPE) in ophthalmic practice during the Coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This is a multicenter, international survey among practicing ophthalmologists across different countries. The survey was conducted from September 9th to October 24th, 2020. It included a total of 23 questions that navigated through the currently adopted recommendations in different clinical situations. The survey also assessed the convenience of using various PPE in ophthalmic practice and addressed the clarity of the examination field while using various PPE during clinical or surgical procedures.

RESULTS

One hundred and seventy-two ophthalmologists completed the survey (101 from Egypt, 50 from the USA, and 21 from four other countries). The analysis of the responses showed that most ophthalmologists use face masks without significant problems during their examinations, while face shields followed by protective goggles were the most inconvenient PPE in the current ophthalmic practice. Moreover, most of the participants (133, 77.3%) noticed an increase in their examination time when using PPE. Furthermore, a considerable percentage of the respondents (70, 40.7%) stopped using one or more of the PPE due to inconvenience or discomfort.

CONCLUSIONS

Due to the unique nature of the ophthalmic examination, certain PPE are not ophthalmologist-friendly. Innovative PPE should be tailored for prompt, more convenient, and clearer ophthalmological practice.

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.

Intravitreal Injections during the COVID-19 Outbreak in Northern Italy: An Innovative Approach for a High Quality and Safe Treatment

BACKGROUND

Intravitreal injection (IVI) is a standard procedure performed in ophthalmology to treat several conditions, and is performed in different settings across countries. The Italian guidelines recommend this intervention is performed in an operating room to minimize the risk of infections, while in other countries, including Canada, USA and the UK, IVIs are performed in the ophthalmologist's office. The 2020 COVID-19 outbreak caused a dramatic modification in outpatient care. Consequently, non-urgent surgical activities, like IVIs, were subjected to a drastic reduction.

METHODS

We conducted observational study which investigated the outcomes of IVIs performed in an ophthalmologist's office using a mobile laminar flow unit, the Operio mobile (Toul Meditech, Operio®) versus an operating room setting.

RESULTS

Use of the Operio mobile allowed the safety performance of 3838 IVIs during COVID-19 and significantly reduced the waiting time of the first visit. This results in a faster intervention without affecting the technical IVI procedure that remained unchanged comparing the two settings. Specifically, we observed a 26% reduction in operation costs for each IVI performed in the office, which can be translated to a higher impact when considering the total number of IVIs performed over one year.

CONCLUSION

The use of the Operio mobile in an ophthalmologist's office provides flexibility to perform IVIs, assuring patient safety, reducing healthcare personnel employment times, and the waiting lists for the patients, increasing the number of surgeries and improving the cost-effectiveness of the procedure.

Additive value of a face-to-face visit to virtual remote decision in patients with neovascular age-related macular degeneration

INTRODUCTION

The increasing high prevalence of neovascular age-related macular degeneration (nvAMD) in the aging population combined with the need for frequent monitoring and treatment for many years, especially in the COVID19 era, raises the need to establish an effective, reliable and safe follow up and treatment model. This study evaluates the difference in treatment decisions comparing between the gold standard face-to-face clinical examination and virtual evaluation approach based only on visual acuity (VA) and optical coherence tomography (OCT) scans without clinical fundoscopic examination in neovascular age-related macular degeneration patients.

METHODS

Single center retrospective cohort study who compared an original 'face-to-face' visit treatment decision regarding the need for anti-vascular endothelial growth factor (anti-VEGF) drug, interval, and treatment regimen based on routine VA, spectral domain -OCT imaging and dilated fundus examination (DFE) to two 'virtual' treatment decisions based on evaluation of OCT scans and previous medical records before and after revealing VA data on the same nvAMD patients eyes.

RESULTS

169 eyes of 114 patients were included in the study. 49 patients (43%) suffered from bilateral nvAMD and had both eyes included in the study. Agreement between the "face-to-face visit treatment decision" and "virtual treatment decision" was noted in 74.6% and 71.6% eyes before and after revealing the patient's visual acuity in the study visit, respectively.

CONCLUSIONS

Virtual evaluation results in similar treatment decisions for nvAMD patients compared to standard face-to-face clinical examination.

OUTCOMES IN PATIENTS RESUMING INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOLLOWING TREATMENT DELAY DURING THE CORONAVIRUS-19 PANDEMIC

PURPOSE

To evaluate the outcomes of delay in care secondary to the coronavirus pandemic in patients requiring intravitreal anti-vascular endothelial growth factor therapy.

METHODS

A retrospective review was performed, and subjects were divided into two groups: 1) a study group of patients who experienced a treatment delay of ≥6 weeks from the intended follow-up during the coronavirus pandemic and resumed treatment with ≥2 anti-vascular endothelial growth factor injections over 6 months following treatment delay, and 2) a control group of patients who received regular care throughout the coronavirus pandemic.

RESULTS

Totally, 234 subjects were analyzed. The mean treatment delay from the intended follow-up in the study group was 11.8 (±4.0) weeks. Visual acuity and central macular thickness worsened from baseline to 6 months after resuming anti-vascular endothelial growth factor therapy in the study group (P < 0.0001 and P = 0.001, respectively). Visual acuity and central macular thickness were better in the control group compared with the study group at the end of the 6-month study period (P < 0.0001 for both).

CONCLUSION

Treatment delay in subjects undergoing anti-vascular endothelial growth factor therapy for retina disease during the coronavirus pandemic had worse visual and anatomical outcomes despite reinitiating treatment over 6 months compared with a control group, suggesting irreversibility and permanence of outcomes.

Modifications of intravitreal injections in response to the COVID-19 pandemic

The Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented disruption to the normal operation of the healthcare system. On a worldwide scale, hospitals suspended nonurgent surgeries and outpatient visits to downsize clinical loadings to redistribute manpower to counteract the pandemic's impact. So far, there is no evidence-based guideline defining a clear line between urgent and nonurgent indications of intravitreal injections (IVI). Herein, we aimed to summarize IVI algorithm modifications and discuss the patient prioritization according to medical needs in the hostile environment in the COVID crisis. Assessing current literature, we found that neovascular age-related macular degeneration is considered the utmost priority among conditions that require IVI. Other conditions assigned with a high priority include monocular or quasi-monocular patients (only one eye > 20/40), neovascular glaucoma, and new patients with significant vision loss. Although patients with central retinal vein occlusion and proliferative diabetic retinopathy are not advised to delay treatments, we found no consistent evidence that correlated with a worse outcome. Diabetic macular edema and branch retinal vein occlusion patients undertaking treatment delay should be regularly followed up every 2 to 3 months. Serving as the principle of management behind the algorithm modifications, the reduction of both patient visit and IVI therapy counts should be reckoned together with the risk of permanent visual loss and COVID infection.

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.

Prospective, Longitudinal Pilot Study

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

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.

The COVID-19 Pandemic Has Had Negative Effects on Baseline Clinical Presentation and Outcomes of Patients with Newly Diagnosed Treatment-Naïve Exudative AMD

PURPOSE

To investigate whether the coronavirus disease 2019 (COVID-19) pandemic-associated postponement in care had effects on the baseline clinical presentation of patients with newly diagnosed treatment-naïve exudative neovascular age-related macular degeneration (AMD).

METHODS

We included the first 50 consecutive patients referred within the COVID-19 pandemic with a diagnosis of treatment-naïve exudative neovascular AMD. Two groups of fifty consecutive patients with newly diagnosed neovascular exudative AMD presenting in 2018 and 2019 (control periods) were also included for comparisons.

RESULTS

Baseline visual acuity was statistically worse in patients referred during the COVID-19 pandemic period (0.87 ± 0.51 logarithm of the minimum angle of resolution (LogMAR)) as compared with both the "2019" (0.67 ± 0.48 LogMAR, p = 0.001) and "2018" (0.69 ± 0.54 LogMAR, p = 0.012) control periods. Data on the visual function after a loading dose of anti-vascular endothelial growth factor (VEGF) was available in a subset of patients (43 subjects in 2020, 45 in 2019 and 46 in 2018, respectively). Mean ± SD best corrected visual acuity (BCVA) at the 1-month follow-up visit after the third anti-VEGF injection was still worse in patients referred during the COVID-19 pandemic (0.82 ± 0.66 LogMAR) as compared with both the "2019" (0.60 ± 0.45 LogMAR, p = 0.021) and "2018" (0.55 ± 0.53 LogMAR, p = 0.001) control periods. On structural optical coherence tomography (OCT), the maximum subretinal hyperreflective material (SHRM) height and width were significantly greater in the COVID-19 pandemic patients.

CONCLUSIONS

We demonstrated that patients with newly diagnosed treatment-naïve exudative neovascular AMD referred during the COVID-19 pandemic had worse clinical characteristics at presentation and short-term visual outcomes.

Delayed Intravitreal Anti-VEGF Therapy for Patients During the COVID-19 Lockdown: An Ethical Endeavor

PURPOSE

To assess the impact of Jordanian's Corona Virus Disease (COVID-19) lockdown on visual acuity and macular thickness in patients with macular edema receiving intravitreal injections, and to assess the ethical endeavor of lockdown among serious sight threatening conditions.

PATIENTS AND METHODS

This retrospective observational study included patients planned for intravitreal injections who did not complete the planned course before the lockdown (ie, before 20th of March 2020). Data included demographics, indication for the intravitreal injection, corrected distance visual acuity (CDVA), and central macular thickness on Optical Coherence Tomography (OCT) before and after the lockdown.

RESULTS

One-hundred and sixty-six eyes of 125 patients were studied, 68 (54.4%) patients were males, and the mean (± standard deviation, SD) age was 64.79 (±9.41) years. Mean (±SD) duration of delay in the planned injection was 60.97 (±24.35) days. The change in visual acuity was statistically significant for patients with diabetic macular edema (p= 0.045 improvement), patients with central retinal vein thrombosis (CRVO) (p= 0.05 deterioration), and patients with age-related macular degeneration (AMD) (p= 0.005 deterioration). Of interest, delay of more than 2 months and the previous need for 3 or more injections were significant poor prognostic factors for visual outcome for patients with diabetic macular edema (p=0.027 and 0.045).

CONCLUSION

The impact of delay in the scheduled intravitreal injections resulted in variable outcomes depending on the indication. Triaging the urgency of patients should be based on the indication to support the equity principle of bioethics, where those in need are prioritized against others, depending on potential adverse outcome.

Effects of the COVID-19 pandemic on neovascular age-related macular degeneration and response to delayed Anti-VEGF treatment

Objectives

To investigate the effects of the COVID-19 pandemic on the treatment course of neovascular age-related macular degeneration (nAMD) patients who received anti-VEGF injection therapy with real-life data.

Methods

This retrospective study consisted of 116 eyes of 106 patients. Ophthalmic examination, assessment of best-corrected visual acuity (BCVA), optical coherence tomography (OCT) findings and data of last two visits before restrictions (V-2 and V-1) and the first visit (V0) after the release of national lockdown and subsequent visits (V1 and Vlast) were recorded. The lockdown period was determined by the time interval between March 11 and June 1, 2020.

Main results

The injection interval before V-1 was significantly longer than the interval after V0 (2.56 ± 0.9 vs. 2.14 ± 0.8 months, P = 0.02). While the median central macular thickness (CMT) was significantly increased at V0 compared to V-1 [274(132–711) vs. 238(136–628), P < 0.001], the median CMT was significantly lower at V1 compared to V0 [256 (136–591) vs. 274(132–711), P = 0.003]. The median BCVA was 0.67(0.1–1.1) logMAR at V-1 and significantly worsened to 0.78 (0.1–1.2) logMAR at V0 (P = 0.003). Although the median BCVA improved to 0.69 logMAR (0.1–1.2) at Vlast, the difference did not reach statistical significance compared to V0 (P = 0.08).

Conclusion

Treatment delay due to the COVID-19 pandemic cause progression of nAMD and visual impairment. To plan more frequent anti-VEGF treatments and visits may be an appropriate approach until the disease stabilizes. However, it should be kept in mind that despite the improvement in OCT findings, the desired success in VA could not be achieved in the short term.

Hybrid Telehealth Medical Retina Clinic Due to Provider Exposure and Quarantine During COVID-19 Pandemic

Objective

To present our hybrid telehealth medical retina clinic service with intravitreal injections (IVI) treatment as a safe alternative to in-person visits and examination during COVID-19 pandemic disease.

Methods

Due to exposure to a COVID-19 positive retina fellow, our retina service, in quarantine, evaluated patients’ medical files and retinal scans using a telemedicine approach. A different protocol for patients coming for IVI during the COVID-19 pandemic was established for IVI administration.

Results

During the 14-day quarantine period (between March 18th and March 31st 2020), the hybrid telehealth medical retina clinic performed 523 IVI to 394 patients with a mean age ± SD 70.96 ± 14.4 years. IVI were administered for neovascular age-related macular degeneration in 50.5% of the cases (199 patients), diabetic macular edema in 21.3% (84 patients), retinal vein occlusion in 17.5% (69 patients), and 10.7% for other retinal pathologies (42 patients). No ocular or systemic complications were observed.

Conclusion

During disasters and pandemics, IVI can be provided safely using a hybrid telehealth medical retina clinic approach but only in the appropriate patient and health care system.

Short-term outcomes of patients with neovascular exudative AMD: the effect of COVID-19 pandemic

PURPOSE

To estimate the impact of delayed care during the coronavirus disease 2019 (COVID-19) pandemic on the outcomes of patients with neovascular age-related macular degeneration (AMD).

METHODS

Consecutive patients with diagnosis of neovascular AMD were consecutively enrolled between March 9, 2020, and June 12, 2020, (during and immediately after the Italian COVID-19 quarantine). During the inclusion (or pandemic) visit (V₀), patients received a complete ophthalmologic evaluation, including optical coherence tomography (OCT). Best-corrected visual acuity (BCVA) and OCT findings from the two preceding visits (V_-1 and V_-2) were compared with data at V₀.

RESULTS

One-hundred patients (112 eyes) were enrolled in this study. The time interval between following visits was 110.7 ± 37.5 days within V₀ and V_-1 and 80.8 ± 39.7 days within V_-1 and V_-2, respectively (P < 0.0001). BCVA was statistically worse at the V₀ visit as compared with the immediately preceding (V_-1) visit (0.50 ± 0.43 LogMAR and 0.45 ± 0.38 LogMAR at the V₀ and V_-1 visits, respectively; P = 0.046). On structural OCT, 91 out of 112 (81.2%) neovascular AMD eyes displayed the evidence of exudative disease activity at the V₀ visit, while 77 (68.7%) eyes exhibited signs of exudation at the V_-1 visit (P = 0.022). No differences in terms of BCVA and OCT findings were detected between the V_-1 and V_-2 visits. In multiple regression analysis, the difference in BCVA between V₀ and V_-1 visits was significantly associated with the interval time within these two visits (P = 0.026).

CONCLUSION

The COVID-19 pandemic-related postponement in patient care proved to be significantly associated with worse short-term outcomes in these patients.

Clinical Experience in the Administration of Intravitreal Injection Therapy at a Tertiary University Hospital in Jordan During the COVID-19 Lockdown

PURPOSE

To describe the clinical experience with the delivery of intravitreal injection therapy to patients with various indications at a tertiary university hospital during the COVID-19 lockdown in Jordan.

METHODS

This is a retrospective observational study of patients who received intravitreal injections between April 12th and May 9th, 2020, a period during the national COVID-19 lockdown (March 16th to June 6th, 2020). Special medical and logistic arrangements, priority and visual risk assessment and strict infection control precautions were implemented. Demographics, diagnosis, intravitreal injection history, medical history, ophthalmic examinations and optical coherence tomography data were collected and analyzed.

RESULTS

Intravitreal injections were successfully administered to 132 patients with diabetic retinopathy, age-related macular degeneration and retinal vein occlusion. All logistic and transmission control measures were followed by the medical staff and patients with no incidents. No new exposures or COVID-19 positive cases were traced to our location or time of therapy. No complications related to the injections were recorded. The mean period of delay due to the lockdown from the original scheduled appointment was six weeks. Mean visual acuity significantly decreased from 20/55 before the lockdown to 20/70 after the lockdown, and mean central macular thickness significantly increased from 329 to 370 μ.

CONCLUSION

The administration of intravitreal injection therapy during the COVID-19 lockdown under special safety precautions was feasible and successful. Resumption of the essential therapies and medical services during periods of pandemic restrictions while adhering to strict transmission control measures is encouraged.