Measures taken to protect from the COVID-19 pandemic have resulted in fewer intravitreal injections and a reduction in visual acuity upon follow-up for patients with diabetic retinopathy, according to a study published in Current Diabetes Reports. To bring patients back up to speed, the American Academy of Ophthalmology and the Vision Academy Steering Committee, have issued a number of recommendations to modify and improve both monitoring and treatment of diabetic retinopathy. 

The research focused on 3 COVID-19 hotspots in the United States — New York, Boston, and Miami — and was conducted from March 16, 2020 to May 8, 2020. The study shows a decline in intravitreal injections that ranged from 30% to 64%. 

The research identifies patients with diabetic macular edema (DME) as being particularly affected by the pandemic, receiving only 15% of the intravitreal injections administered between March and May 2020. By contrast, 75% of injections were administered to treat age-related macular degeneration.


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Factors contributing to the decline in intravitreal injections included clinic restrictions, closure of private clinics, limited resources, travel restrictions, not enough public transport facilities, and patient concerns, according to the researchers.  

On March 18, 2020, the American Academy of Ophthalmology recommended that all ophthalmologists stop treatment unless considered urgent or emergent care immediately. Thereafter, it issued updated recommendations aimed to lower COVID-19 exposure risks during outpatient clinic visits as well as elective surgeries. These included COVID screening, social distancing in waiting rooms, frequent disinfection, slit lamp shields, and facial coverings.

The clinical volume of intravitreal injections improved during the reopening period of the pandemic. However, the number of intravitreal injections administered did not reach full recovery, the report shows. 

Several institutions have also noted the negative impact of pandemic-induced delayed treatment with regard to visual acuity. For instance, between March 14 to May 4, 2020, a retrospective analysis of patients undergoing intravitreal injections was conducted at the Cole Eye Institute in the United States. The analysis revealed that patients with DME and/or proliferative diabetic retinopathy (PDR) whose appointments were delayed lost 3.48±1.95 ETDRS letters vs patients who attended their scheduled appointment (gained 2.71±1.75 ETDRS letters, P =.0203).

The Vision Academy Steering Committee says in its updated 2021 guidelines that treatment of severe nonproliferative diabetic retinopathy (NPDR) and active PDR should not be delayed due to the risk of vision loss. It also recommends that patients with DME who have significant vision loss should not go more than 4 to 6 months without treatment, and that all DME patients should receive evaluations every 2–3 months.

“Although numerous implementation challenges, such as infrastructure costs and changes in workflow in non-ophthalmic settings, remain, large-scale teleophthalmology programs, when combined with artificial intelligence technologies and at-home monitoring devices, will be beneficial to patients with diabetic retinopathy by improving access to care, particularly in the context of the COVID-19 pandemic,” the researchers explain. 

“More rigorous studies on a population level are needed to fully evaluate the impact of COVID-19 on diabetic retinopathy-related outcomes and whether the associated negative outcomes are permanent.”

Reference

Ahmed I, LIU TYA. The impact of COVID-19 on diabetic retinopathy monitoring and treatment. Curr Diab Rep. Published online September 8, 2021. doi:10.1007/s11892-021-01411-6