Short-Term Outcomes After COVID-19-Related Treatment Interruption Among Patients with Neovascular Age-Related Macular Degeneration Receiving Intravitreal Bevacizumab

Long-term results of the treatment of patients with exudative age-related macular degeneration during the COVID-19 pandemic

PURPOSE

To quantify the long-term impact (24 months) on the visual results and activity of neovascular lesions of COVID-19 confinement in patients with nAMD in our population.

METHODS

A retrospective observational study of patients with nAMD who attended consultation or were treated during the 3 months before confinement was carried out.

RESULTS

144 patients (168 eyes) with nAMD were included, 51 of them (35.42%) came during confinement, and at 24 months the final cohort was 118 patients (133 eyes). The previous VA of 57.99 ± 23.68 letters decreased, clinically relevant and statistically significant, by an average of 6.87 (±16.84) and 7.89 (±19.58) at 12- and 24-months follow-up. This change differs significantly from the two-year vision change observed in the national database of pretreated patients. The median number of injections and consultations is lower in our group at 12 months, compared to the pre-pandemic national database, and tends to equalize at 24 months. We did not find differences in vision when we compared patients who attended consultations during confinement or in treatment intervals greater than 8 weeks (Tq8w).

CONCLUSIONS

The VA of patients with nAMD decreased significantly after confinement, probably due to the lower number of antiangiogenic injections and consultations during the first year, and did not recover during the second year despite the increase in the number of injections and visits close to those reported before confinement.

Mapping vision loss of patients in a glaucoma backlog following the COVID-19 pandemic: a real-world analysis using the Glauc-Strat-Fast risk stratification tool

INTRODUCTION

Glauc-Strat-Fast is a clinical tool recommended by The Royal College of Ophthalmologists to classify glaucoma patients into strata of risk for significant future sight loss and an estimate of resource requirement. The aim of this study was to map the movement of glaucoma patients across stratification boundaries on Glauc-Strat-Fast during the COVID-19 pandemic.

SUBJECTS AND METHODS

Glauc-Strat-Fast was applied to a consecutive sample of 100 primary open angle glaucoma patients in a backlog at Worcestershire Acute Hospitals NHS Trust. Stratification outcomes were compared between clinic visits prior to the COVID-19 pandemic versus the follow-up visit. Patients were stratified twice separately based on their worse eye (i.e., most affected) and better eye (i.e., least affected) according to Glauc-Strat-Fast.

RESULTS

Amount of slippage (difference between target follow-up and actual follow-up) ranged from 2 to 32 months. There was a statistically significant average reduction in visual field mean deviation for better and worse eyes between visits (p = <0.001). At follow-up, no worse eyes were classified as being low risk (green), while 96 were classified as high risk (red). For better eyes, elevation of risk into the highest strata of Glauc-Strat-Fast observed a three-fold increase in patients (19 versus 56) between visits.

DISCUSSION

This retrospective real-world analysis highlights patients' movement into the highest strata on the Glauc-Strat-Fast tool and demonstrates a significant deterioration in visual outcomes during a period of extensive appointment slippage. The findings demonstrate the utility of Glauc-Strat-Fast as a tool for improved patient management.

Barriers to care in neovascular age-related macular degeneration: Current understanding, developments, and future directions

Neovascular age-related macular degeneration is the advanced and irreversible stage of age-related macular degeneration, the leading cause of severe vision loss in older adults. While anti-vascular endothelial growth factor injections have been shown to preserve or improve vision quality in eyes with neovascular age-related macular degeneration, the treatment regimen can be demanding of patients and caregivers, leading to lower rates of adherence. Therefore, it is crucial that disparities and obstacles in neovascular age-related macular degeneration care are identified to improve access to treatment. Review of the current literature revealed 7 major categories of barriers: travel burden, psychological barriers, financial burden and socioeconomic status, treatment regimen, other comorbidities, provider-level barriers, and system-level barriers. We provide an overview of the major barriers to neovascular age-related macular degeneration care that have been reported, as well as gaps in research that need to be investigated further.

Genome-Wide Pleiotropy Study Identifies Association of PDGFB with Age-Related Macular Degeneration and COVID-19 Infection Outcomes

Age-related macular degeneration (AMD) has been implicated as a risk factor for severe consequences from COVID-19. We evaluated the genetic architecture shared between AMD and COVID-19 (critical illness, hospitalization, and infections) using analyses of genetic correlations and pleiotropy (i.e., cross-phenotype meta-analysis) of AMD (n = 33,976) and COVID-19 (n ≥ 1,388,342) and subsequent analyses including expression quantitative trait locus (eQTL), differential gene expression, and Mendelian randomization (MR). We observed a significant genetic correlation between AMD and COVID-19 infection (r_G = 0.10, p = 0.02) and identified novel genome-wide significant associations near PDGFB (best SNP: rs130651; p = 2.4 × 10^-8) in the pleiotropy analysis of the two diseases. The disease-risk allele of rs130651 was significantly associated with increased gene expression levels of PDGFB in multiple tissues (best eQTL p = 1.8 × 10^-11 in whole blood) and immune cells (best eQTL p = 7.1 × 10^-20 in T-cells). PDGFB expression was observed to be higher in AMD cases than AMD controls {fold change (FC) = 1.02; p = 0.067}, as well as in the peak COVID-19 symptom stage (11-20 days after the symptom onset) compared to early/progressive stage (0-10 days) among COVID-19 patients over age 40 (FC = 2.17; p = 0.03) and age 50 (FC = 2.15; p = 0.04). Our MR analysis found that the liability of AMD risk derived from complement system dysfunction {OR (95% CI); hospitalization = 1.02 (1.01-1.03), infection = 1.02 (1.01-1.03) and increased levels of serum cytokine PDGF-BB {β (95% CI); critical illness = 0.07 (0.02-0.11)} are significantly associated with COVID-19 outcomes. Our study demonstrated that the liability of AMD is associated with an increased risk of COVID-19, and PDGFB may be responsible for the severe COVID-19 outcomes among AMD patients.

Long-Term Consequences of COVID-19 Lockdown in Neovascular AMD Patients in Spain: Structural and Functional Outcomes after 1 Year of Standard Follow-Up and Treatment

Consequences of the COVID-19 pandemic on medical care have been extensively analyzed. Specifically, in ophthalmology practice, patients suffering age-related macular degeneration (AMD) represent one of the most affected subgroups. After reporting the acute consequences of treatment suspension in neovascular AMD, we have now evaluated these same 242 patients (270 eyes) to assess if prior functional and anatomical situations can be restored after twelve months of regular follow-up and treatment. We compared data from visits before COVID-19 outbreak and the first visit after lockdown with data obtained in subsequent visits, until one year of follow-up was achieved. For each patient, rate of visual loss per year before COVID-19 pandemic, considered “natural history of treated AMD”, was calculated. This rate of visual loss significantly increased during the lockdown period and now, after twelve months of regular follow-up, is still higher than before COVID outbreak (3.1 vs. 1.6 ETDRS letters/year, p < 0.01). Percentage of OCT images showing active disease is now lower than before the lockdown period (51% vs. 65.3%, p = 0.0017). Although anatomic deterioration, regarding signs of active disease, can be apparently fully restored, our results suggest that functional consequences of temporary anti-VEGF treatment suspension are not entirely reversible after 12 months of treatment, as BCVA remains lower and visual loss rate is still higher than before the COVID-19 pandemic.

Long-term impact of delayed follow-up due to COVID-19 lockdown on patients with neovascular age-related macular degeneration

BACKGROUND

During the first wave of the coronavirus disease 2019 (COVID-19) pandemic in 2020 outpatient care of neovascular age-related macular degeneration (nAMD) patients was severely reduced due to lockdown. Missed visits are known to be detrimental to patients in need of continued anti-vascular endothelial growth factor (VEGF) intravitreal injections (IVIs). The purpose of the study was to assess the effect of a month-long pause of regular visits and anti-VEGF IVIs in nAMD patients.

METHODS

A retrospective study was performed. Patients were treated in a pro re nata ("as needed") scheme. Distance (logMAR) and near (logRAD) visual acuity (VA), optical coherence tomography, delay between planned and actual visit date and the indication for IVI were assessed for 3 continous visits in the 6 months before lockdown (V-3, -2, -1) and the 2 visits after lockdown (V0, V + 1). For analysis of long-term impact, records for visits 1 years before and after lockdown (V-3, V + 2) were gathered.

RESULTS

We included 166 patients (120 female, 46 male) with a median (range) age of 80.88 (59.8-99.36) years. Compared to V-1, distance VA was significantly worse at both V0 (0.27 ± 0.21 vs 0.31 ± 0.23 logMAR, p < 0.001) and V + 1 (0.27 ± 0.21 vs 0.30 ± 0.23 logMAR, p = 0.021). Near VA was significantly worse at both V0 (0.31 ± 0.21 vs 0.34 ± 0.22 logRAD, p = 0.037) and V + 1 (0.31 ± 0.21 vs 0.34 ± 0.22 logRAD, p = 0.02). Visit delay (VD) at V0 was significantly longer than at V + 1 (30.81 ± 20.44 vs 2.02 ± 6.79 days, p < 0.0001). Linear regression analysis showed a significant association between visit delay and a reduction of near VA between V-1 and V + 1 (p = 0.0223). There was a significant loss of distance VA (p = 0.02) in the year after the lockdown period (n = 125) compared to the year before. Loss of reading acuity was not significantly increased (p = 0.3). One year post lockdown, there was no correlation between VA change and visit delay after lockdown (p > 0.05).

CONCLUSIONS

In nAMD patients whose visits and treatment were paused for a month during the first wave of the COVID-19 pandemic, we found a loss of VA immediately after lockdown, which persisted during follow-up despite re-established anti-VEGF treatment. In the short term, length of delay was predictive for loss of reading VA. The comparison of development of VA during the year before and after the lockdown showed a progression of nAMD related VA loss which may have been accelerated by the disruption of regular visits and treatment.

TRIAL REGISTRATION

This article does not report the outcome of a health care intervention. This retrospective study was therefore not registered in a clinical trials database.

Impact of Delayed Intravitreal Anti-Vascular Endothelial Growth Factor (VEGF) Therapy Due to the Coronavirus Disease Pandemic on the Prognosis of Patients with Neovascular Age-Related Macular Degeneration

This study estimated the outcome of delayed intravitreal anti-vascular endothelial growth factor (VEGF) therapy due to the coronavirus (COVID-19) disease pandemic on the prognosis of patients with neovascular age-related macular degeneration (nAMD). This study retrospectively enrolled 57 nAMD patients whose intravitreal anti-VEGF injections were delayed for >2 weeks between February and June 2020. Best-corrected visual acuity (BCVA), central subfield thickness (CST), and anatomical characteristics were evaluated before (baseline), on the day, and at 2, 4, and 6 months after the delayed injection, and risk factors were identified. The average injection interval before and after treatment delay was 3.05 ± 1.45 and 2.41 ± 1.46 months, respectively (p = 0.002). The CST at baseline and on the day of delayed injection was 227.82 ± 62.46 and 267.26 ± 77.74 µm, respectively (p < 0.001). The average BCVA decreased from 0.29 ± 0.29 logMAR (baseline) to 0.38 ± 0.31 logMAR (6 months) (p = 0.001). The maximum subretinal fluid (SRF) height increased from 84.32 ± 89.33 µm (baseline) to 121.38 ± 103.36 µm (6 months) (p = 0.027). A higher baseline maximum SRF height was associated with less SRF height deterioration 6 months later (p < 0.001). Delayed intravitreal anti-VEGF therapy caused by the COVID-19 pandemic has worsened BCVA and residual SRF in nAMD patients after a temporary recovery. The baseline SRF reduce the degree of SRF height deterioration.