Digital Technology for AMD Management in the Post-COVID-19 New Normal

Update on coronavirus disease 2019: Ophthalmic Manifestations and Adverse Reactions to Vaccination

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 was one of the most devastating public health issues in recent decades. The ophthalmology community is as concerned about the COVID-19 pandemic as the global public health community is, as COVID-19 was recognized to affect multiple organs in the human body, including the eyes, early in the course of the outbreak. Ophthalmic manifestations of COVID-19 are highly variable and could range from mild ocular surface abnormalities to potentially sight and life-threatening orbital and neuro-ophthalmic diseases. Furthermore, ophthalmic manifestations may also be the presenting or the only findings in COVID-19 infections. Meanwhile, global vaccination campaigns to attain herd immunity in different populations are the major strategy to mitigate the pandemic. As novel vaccinations against COVID-19 emerged, so were reports on adverse ophthalmic reactions potentially related to such. As the world enters a post-pandemic state where COVID-19 continues to exist and evolve as an endemic globally, the ophthalmology community ought to be aware of and keep abreast of the latest knowledge of ophthalmic associations with COVID-19 and its vaccinations. This review is a summary of the latest literature on the ophthalmic manifestations of COVID-19 and the adverse ophthalmic reactions related to its vaccinations.

Patient Perspective on the Monitoring of Their Wet Age-Related Macular Degeneration during Coronavirus Disease 2019: A Retrospective Study

Background and Objectives: The purpose was to provide the patients’ perspective on the monitoring of their wet age-related macular degeneration (wet AMD) during coronavirus disease 2019 (COVID-19) and the importance of telemedicine. Materials and Methods: Wet AMD patients that underwent intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in two Swiss ophthalmology clinics, completed two questionnaires after the first confinement due to COVID-19 in Switzerland. The first evaluated their views concerning their adherence to scheduled injections during the confinement, and the application of telemedicine in the future. The second, adapted from the National Eye Institute Visual Function Questionnaire-25, assessed their opinions on visual function change during confinement. Results: From a total of 130 patients, 8.5% responded they did not respect their assigned schedule (group 1) while 91.5% responded they did (group 2). A total of 78.7% of group 2 considered treatment reception as more relevant compared to the risk of COVID-19 contraction. During the pre-lockdown period, group 2 patients required more help from others than group 1 patients (p = 0.02). In the possibility of another lockdown, 36.3% of group 1 and 8.7% of group 2 would choose telemedicine to monitor their wet AMD (p = 0.02), 54.5% and 86.9% would rather visit the clinic (p = 0.02), while 9.0% and 4.3% would cancel their appointment, respectively. It was found that 70% of group 1 and 33.6% of group 2 would prefer to use the telemedicine services than visiting a telemedicine centre (p = 0.04). Conclusions: During circumstances similar to the COVID-19 confinement, most patients would prefer to visit the clinic. Group 1 would prefer wet AMD monitoring via telemedicine at a higher rate than group 2.

Digital Transformation in Healthcare: Technology Acceptance and Its Applications

Technological innovation has become an integral aspect of our daily life, such as wearable and information technology, virtual reality and the Internet of Things which have contributed to transforming healthcare business and operations. Patients will now have a broader range and more mindful healthcare choices and experience a new era of healthcare with a patient-centric culture. Digital transformation determines personal and institutional health care. This paper aims to analyse the changes taking place in the field of healthcare due to digital transformation. For this purpose, a systematic bibliographic review is performed, utilising Scopus, Science Direct and PubMed databases from 2008 to 2021. Our methodology is based on the approach by Wester and Watson, which classify the related articles based on a concept-centric method and an ad hoc classification system which identify the categories used to describe areas of literature. The search was made during August 2022 and identified 5847 papers, of which 321 fulfilled the inclusion criteria for further process. Finally, by removing and adding additional studies, we ended with 287 articles grouped into five themes: information technology in health, the educational impact of e-health, the acceptance of e-health, telemedicine and security issues.

Predicting the immediate impact of national lockdown on neovascular age-related macular degeneration and associated visual morbidity: an INSIGHT Health Data Research Hub for Eye Health report

OBJECTIVE

Predicting the impact of neovascular age-related macular degeneration (nAMD) service disruption on visual outcomes following national lockdown in the UK to contain SARS-CoV-2.

METHODS AND ANALYSIS

This retrospective cohort study includes deidentified data from 2229 UK patients from the INSIGHT Health Data Research digital hub. We forecasted the number of treatment-naïve nAMD patients requiring anti-vascular endothelial growth factor (anti-VEGF) initiation during UK lockdown (16 March 2020 through 31 July 2020) at Moorfields Eye Hospital (MEH) and University Hospitals Birmingham (UHB). Best-measured visual acuity (VA) changes without anti-VEGF therapy were predicted using post hoc analysis of Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD trial sham-control arm data (n=238).

RESULTS

At our centres, 376 patients were predicted to require anti-VEGF initiation during lockdown (MEH: 325; UHB: 51). Without treatment, mean VA was projected to decline after 12 months. The proportion of eyes in the MEH cohort predicted to maintain the key positive visual outcome of ≥70 ETDRS letters (Snellen equivalent 6/12) fell from 25.5% at baseline to 5.8% at 12 months (UHB: 9.8%-7.8%). Similarly, eyes with VA <25 ETDRS letters (6/96) were predicted to increase from 4.3% to 14.2% at MEH (UHB: 5.9%-7.8%) after 12 months without treatment.

CONCLUSIONS

Here, we demonstrate how combining data from a recently founded national digital health data repository with historical industry-funded clinical trial data can enhance predictive modelling in nAMD. The demonstrated detrimental effects of prolonged treatment delay should incentivise healthcare providers to support nAMD patients accessing care in safe environments.

TRIAL REGISTRATION NUMBER

NCT00056836.

Digital Advancements in Retinal Models of Care in the Post-COVID-19 Lockdown Era

The coronavirus disease-2019 (COVID-19) pandemic introduced unique barriers to retinal care including limited access to imaging modalities, ophthalmic clinicians, and direct medical interventions. These unprecedented barriers were met with the robust implementation of digital advances to aid in monitoring and efficiency of retinal care while taking into the account of public safety. Many of these innovations have been successful in maintaining efficiency and patient satisfaction and are likely to stay to help preserve vision in the future. In this article we highlight these advances implemented during the pandemic including telescreening triage, virtual retinal imaging clinics, at-home optical coherence tomography, mobile phone self-monitoring, and virtual reality monitoring technology. We also discuss advancing innovations including Internet of Things and Blockchain technology that will be critical for further implementation and security of these digital advancements.

The COVID-19 Pandemic and Ophthalmic Care: A Qualitative Study of Patients with Neovascular Age-Related Macular Degeneration (nAMD)

Concerns have been expressed about the relationship between reduced levels of health care utilisation and the COVID-19 pandemic. This study aimed to elicit and explore the views of patients with neovascular age-related macular degeneration (nAMD) regarding the COVID-19 pandemic and their ophthalmic care. Semi-structured telephone interviews were conducted with thirty-five patients with nAMD taking part in a larger diagnostic accuracy study of home-monitoring tests. Participants were recruited using maximum variation sampling to capture a range of key characteristics including age, gender and time since initial treatment. Transcribed interview data were analysed using a deductive and inductive thematic approach. Three themes emerged from the analysis: i. access to eye clinic care. ii. COVID-19-mitigating factors and care delivery and iii. social and personal circumstances. Participants reported anxieties about cancelled or delayed appointments, limited communication from clinic-based services about appointments, and the impact of this on their ongoing care. Despite these concerns, there was apprehension about attending appointments due to infection risk and a perception that nAMD patients are a ‘high risk’ group. Views of those who attended clinics during the study period were, however, positive, with social distancing and infection control measures providing reassurance. These findings contribute to our understanding about experiences of patients with nAMD during the COVID-19 pandemic and may have potential implications for future planning of care services in similar circumstances. Innovative approaches may be required to address issues related to access to care, including concerns about delayed or cancelled appointments.

Personalized treatment supported by automated quantitative fluid analysis in active neovascular age-related macular degeneration (nAMD)-a phase III, prospective, multicentre, randomized study: design and methods

INTRODUCTION

In neovascular age-related macular degeneration (nAMD) the exact amount of fluid and its location on optical coherence tomography (OCT) have been defined as crucial biomarkers for disease activity and therapeutic decisions. Yet in the absence of quantitative evaluation tools, real-world care outcomes are disappointing. Artificial intelligence (AI) offers a practical option for clinicians to enhance point-of-care management by analysing OCT volumes in a short time. In this protocol we present the prospective implementation of an AI-algorithm providing automated real-time fluid quantifications in a clinical real-world setting.

METHODS

This is a prospective, multicentre, randomized (1:1) and double masked phase III clinical trial. Two-hundred-ninety patients with active nAMD will be randomized between a study arm using AI-supported fluid quantifications and another arm using conventional qualitative assessments, i.e. state-of-the-art disease management. The primary outcome is defined as the mean number of injections over 1 year. Change in BCVA is defined as a secondary outcome.

DISCUSSION

Automated measurement of fluid volumes in all retinal compartments such as intraretinal fluid (IRF), and subretinal fluid (SRF) will serve as an objective tool for clinical investigators on which to base retreatment decisions. Compared to qualitative fluid assessment, retreatment decisions will be plausible and less prone to error or large variability. The underlying hypothesis is that fluid should be treated, while residual persistent or stable amounts of fluid may not benefit from further therapy. Reducing injection numbers without diminishing the visual benefit will increase overall patient safety and relieve the burden for healthcare providers.

TRIAL-REGISTRATION

EudraCT-Number: 2019-003133-42.

Associations between the COVID-19 Pandemic and Hospital Infrastructure Adaptation and Planning—A Scoping Review

The SARS-CoV-2 pandemic has put unprecedented pressure on the hospital sector around the world. It has shown the importance of preparing and planning in the future for an outbreak that overwhelms every aspect of a hospital on a rapidly expanding scale. We conducted a scoping review to identify, map, and systemize existing knowledge about the relationships between COVID-19 and hospital infrastructure adaptation and capacity planning worldwide. We searched the Web of Science, Scopus, and PubMed and hand-searched gray papers published in English between December 2019 and December 2021. A total of 106 papers were included: 102 empirical studies and four technical reports. Empirical studies entailed five reviews, 40 studies focusing on hospital infrastructure adaptation and planning during the pandemics, and 57 studies on modeling the hospital capacity needed, measured mostly by the number of beds. The majority of studies were conducted in high-income countries and published within the first year of the pandemic. The strategies adopted by hospitals can be classified into short-term (repurposing medical and non-medical buildings, remote adjustments, and establishment of de novo structures) and long-term (architectural and engineering modifications, hospital networks, and digital approaches). More research is needed, focusing on specific strategies and the quality assessment of the evidence.

A Systematic Literature Review and Bibliometric Analysis of Ophthalmology and COVID-19 Research

This review is proposed to summarize the updates on COVID-19 and ophthalmology along with the bibliometric features of articles that have been published since the beginning of the COVID-19 outbreak. The databases, including PubMed, Scopus, and Web of Science, were searched using "Coronavirus," "COVID-19," "SARS-CoV-2," "pandemic," "ophthalmology," "ophthalmic," and "eye" keywords. All published articles except commentaries, errata, and corrigenda up to April 2021 were included. Titles and abstracts were screened, and ophthalmology-focused articles were collected. The bibliographic information of the articles, such as the name and country of the first author, type of study, date of publication, language, and journal name, were extracted. Included studies were assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. After systematic searching, 2,669 distinct articles were screened by title/abstract, and 1,174 ophthalmology-focused articles were selected to be reviewed. Ophthalmology-focused publications accounted for less than 0.5 percent of the total COVID-19-related articles. Most of the articles were published in the Indian Journal of Ophthalmology, and the main publication type was "original article." Almost 88% of the publications were in English. There was a decline in the publication rate during the initial months of 2021 compared with the middle and last months of 2020. Most of the publications were affiliated with the United States of America. However, Singapore and the United Kingdom were the countries with the highest number of publications after population adjustment. Furthermore, a comprehensive review on major topics including SARS-CoV-2 ocular tropism, ophthalmic manifestations, ocular complications due to COVID-19 treatment strategies, the pandemic effect on ophthalmology care and operations, myopia progression during the pandemic, and telemedicine was conducted.

Development and Clinical Validation of Semi-Supervised Generative Adversarial Networks for Detection of Retinal Disorders in Optical Coherence Tomography Images Using Small Dataset

PURPOSE

To develop and test semi-supervised generative adversarial networks (GANs) that detect retinal disorders on optical coherence tomography (OCT) images using a small-labeled dataset.

METHODS

From a public database, we randomly chose a small supervised dataset with 400 OCT images (100 choroidal neovascularization, 100 diabetic macular edema, 100 drusen, and 100 normal) and assigned all other OCT images to unsupervised dataset (107,912 images without labeling). We adopted a semi-supervised GAN and a supervised deep learning (DL) model for automatically detecting retinal disorders from OCT images. The performance of the 2 models was compared in 3 testing datasets with different OCT devices. The evaluation metrics included accuracy, sensitivity, specificity, and the area under the receiver operating characteristic curves.

RESULTS

The local validation dataset included 1000 images with 250 from each category. The independent clinical dataset included 366 OCT images using Cirrus OCT Shanghai Shibei Hospital and 511 OCT images using RTVue OCT from Xinhua Hospital respectively. The semi-supervised GANs classifier achieved better accuracy than supervised DL model (0.91 vs 0.86 for local cell validation dataset, 0.91 vs 0.86 in the Shanghai Shibei Hospital testing dataset, and 0.93 vs 0.92 in Xinhua Hospital testing dataset). For detecting urgent referrals (choroidal neo-vascularization and diabetic macular edema) from nonurgent referrals (drusen and normal) on OCT images, the semi-supervised GANs classifier also achieved better area under the receiver operating characteristic curves than supervised DL model (0.99 vs 0.97, 0.97 vs 0.96, and 0.99 vs 0.99, respectively).

CONCLUSIONS

A semi-supervised GAN can achieve better performance than that of a supervised DL model when the labeled dataset is limited. The current study offers utility to various research and clinical studies using DL with relatively small datasets. Semi-supervised GANs can detect retinal disorders from OCT images using relatively small dataset.

COVID-19 and Retinal Degenerative Diseases: Promising link “Kaempferol”

Coronavirus disease (COVID-19) outbreak has caused unprecedented global disruption since 2020. Approximately 238 million people are affected worldwide where the elderly succumb to mortality. Post-COVID syndrome and its side effects have popped up with several health hazards, such as macular degeneration and vision loss. It thus necessitates better medical care and management of our dietary practices. Natural flavonoids have been included in traditional medicine and have also been used safely against COVID-19 and several other diseases. Kaempferol is an essential flavonoid that has been demonstrated to influence several vital cellular signaling pathways involved in apoptosis, angiogenesis, inflammation, and autophagy. In this review, we emphasize the plausible regulatory effects of Kaempferol on hallmarks of COVID-19 and macular degeneration.

Drop in well-being of ARMD patients under treatment with anti-VEGF injections during the COVID-19 pandemic

Purpose

Patients with age-related macular degeneration (ARMD) are required to follow a treatment protocol that requires regular follow-ups. The COVID-19 pandemic has created an additional burden for patients with ARMD under treatment with anti-vascular endothelial growth factor (anti-VEGF) injections, since patients face a congestion of the health system and closing of the outpatient services. This study examines the impact of the uncertainty regarding patients’ treatment on their sense of well-being.

Methods

This is a longitudinal cohort study of eighty patients who were followed during the year following the outbreak of the COVID pandemic. Patients reported their sense of well-being with the WHO-5 questionnaire and their perception and fears for the impact of the pandemic on their ongoing ARMD treatment.

Results

There was a significant drop in mental well-being during the pandemic that paralleled the self-reported impact of the pandemic on ARMD treatment. Patients who reported a higher impact of COVID-19 on their treatment had experienced a higher drop in mental wellbeing compared to those who hadn’t, with female gender being an additional risk factor. Objective measurements of visual acuity did not factor in the drop of sense of well-being.

Conclusions

The high initial level of uncertainty regarding ARMD patients’ long-term course was further exacerbated when exposed to additional uncertainties during the pandemic regarding their standard of care. Planning ahead for continuation of services and close contact with patients during similar health emergencies is of paramount importance.

Quantitative assessment of retinal fluid in neovascular age-related macular degeneration under anti-VEGF therapy

The retinal world has been revolutionized by optical coherence tomography (OCT) and anti-vascular endothelial growth factor (VEGF) therapy. The numbers of intravitreal injections are on a constant rise and management in neovascular age-related macular degeneration (nAMD) is mainly driven by the qualitative assessment of macular fluid as detected on OCT scans. The presence of macular fluid, particularly subretinal fluid (SRF) and intraretinal fluid (IRF), has been used to trigger re-treatments in clinical trials and the real world. However, large discrepancies can be found between the evaluations of different readers or experts and especially small amounts of macular fluid might be missed during this process. Pixel-wise detection of macular fluid uses an entire OCT volume to calculate exact volumes of retinal fluid. While manual annotations of such pixel-wise fluid detection are unfeasible in a clinical setting, artificial intelligence (AI) is able to overcome this hurdle by providing real-time results of macular fluid in different retinal compartments. Quantitative fluid assessments have been used for various post hoc analyses of randomized controlled trials, providing novel insights into anti-VEGF treatment regimens. Nonetheless, the application of AI-algorithms in a prospective patient care setting is still limited. In this review, we discuss the use of quantitative fluid assessment in nAMD during anti-VEGF therapy and provide an outlook to novel forms of patient care with the support of AI quantifications.

Orthoptic service survey in the UK and Ireland during the interim recovery period (summer 2020) of the COVID-19 pandemic

COVID-19 extended through 2020 with impact on all hospital services. The purpose of this study was to determine the extent of orthoptic service provision during the initial recovery period from July to September 2020 in the UK, Ireland and Channel Islands. We conducted a prospective survey-based cross-sectional study using an online survey aiming for coverage of orthoptic departments across the UK, Ireland and Channel Islands. The survey sought to gather data on orthoptic practice during the COVID-19 pandemic period between the first and second waves in the UK. Questions included within the survey asked about the impact on services paused or reduced during the pandemic, the reinstatement of services, backlog of appointments, changes to arrangement and conduct of appointments, changes to working practice, impact to lives of orthoptists, and access by orthoptists to professional support and guidelines. We circulated the online survey through the British and Irish Orthoptic Society that reaches over 95% of UK and Irish orthoptic services and through social media and orthoptic research networks. This survey was open from July 1^st to September 30^th 2020 and achieved a response rate from orthoptic departments of 85%. A high rate (92%) of teleconsultations continued with 50% of departments using a proforma to guide the teleconsultation and with added use of risk assessment for patient appointments. To enable reopening of clinics, multiple changes were made for patient and staff flow through clinic areas. Reduced clinical capacity was confirmed by 76.5% of departments. Appointments averaged 15-20 minutes and there was routine use of PPE and cleaning and adoption of staggered appointments with added evening/weekend clinics. There was increased use of information resources/leaflets for patients and dependence on professional and health care guidance documents. The average backlog for patient appointments had increased to 26 weeks. The initial UK and Irish recovery phase in summer 2020 allowed a glimpse at adjustments needed to reopen orthoptic clinics for in-person appointments. Teleconsultation remained in frequent use but with greater risk assessment and triage to identify those requiring in-person appointments.