Deb Rock (right), nurse manager for La Crosse Outpatient Clinics, and Cynthia Lang (left), telehealth clinical technician, SFT preceptor and CVT preceptor.at the Tomah, WI, VAMC with equipment used to detect age-related macular degeneration. Photo from Sept. 9, 2020 VAntage Point blog.
LOS ANGELES — For many veterans, receiving regular eye care poses a significant challenge even in ordinary years. COVID-19 made it more difficult still. While many veterans with age-related macular degeneration (AMD) missed some appointments and scheduled treatments early in the pandemic, the VA quickly adapted its clinic protocols and outreach to veterans who needed vision care.
As SARS-CoV-2 spread around the world and across the U.S. in the first quarter of 2020, the American Academy of Ophthalmology and its international counterparts issued guidelines recommending the postponement of all non-urgent clinic visits and surgeries as did many governments. In response, some clinics closed down for several months, while others adopted an injection-only approach that kept personal interactions and exposure to a minimum.
Monthly intravitreal anti-VEGF injections are the most common treatment for wet or neovascular age-related macular degeneration (nvAMD), so clinic decisions had a direct impact on AMD patient care and, in many cases, vision. Studies of the effect of early adaptations to the pandemic can continue to provide guidance as the public health emergency continues into its third year.
Maintaining treatment for veterans
Irena Tsui, of the West Los Angeles Veterans Health Administration and the University of California-Los Angeles, and her colleagues studied the impact of the COVID-19 lockdown on intravitreal injections at a VA clinic in Los Angeles County between March 19, 2020, and May 8, 2020, compared to the same period in 2019, with a focus on patient decision-making. During this period, the clinic adopted pre-appointment symptom screening, universal masking, and rigorous disinfection.1
“If there was decreased vision or any new complaint, patients were encouraged to come in,” they said. “In addition, patients with the diagnosis of nvAMD and patients with monocular status were encouraged to come in.” Patients with stable disease and those who received injections for conditions other than AMD were encouraged to reschedule, though they could come in if they preferred.
While patients with AMD represented less than 40% of the total number of patients who came to the injection clinic in 2019, they accounted for 56.5% of those who received injections in 2020. Approximately one-third of the number of patients with other diagnoses came to the clinic in the 2020 period compared to 2019.
In total, the team found that the number of patients that came to the injection clinic in 2020 was less than half the number who came in 2019, 86 vs. 176. Most notably, “the proportion of Hispanic or Latino patients who came to the injection clinic nearly doubled in 2020 compared to 2019 (25.5% vs. 13.1%), but the number of Hispanic or Latino patients barely changed, 23 in 2019 vs. 22 in 2020. The number of White, Black, Asian or Pacific Islander patients who visited the clinic dropped sharply, at least a 50% decline in each group. The rate of nvAMD was similar in both Hispanic and non-Hispanic patients.
“Decision-making during COVID-19 was particularly complex and challenging with multiple factors being weighed and ultimately coming down to the risk of vision loss compared to the risk of contracting or spreading COVID-19 for patients seeking eyecare,” the researchers observed. “Prior studies have reported decreases in injection clinic volumes during local COVID-19 lockdown periods ranging from 3.2% to 98.7%, with most in the 40–60% range.”
The team’s analysis showed that patients with heart conditions, chronic obstructive pulmonary disease or asthma were less likely to come in for injections in 2020, but other medical and psychiatric co-morbidities did not appear to affect veterans decisions. The higher rate of Hispanic or Latino veterans who chose to keep their appointment may reflect a calculation that the treatment would pose “minimal additional increased risk of COVID-19 exposure,” given the higher rate of multi-generational housing and essential worker status in this group seen in studies of COVID-19 hospitalizations in the U.S.
International studies support “injection-only” model
Two recent studies looked at the international impact of COVID-19 lockdowns on patients with AMD and provide support for the approach taken by the VA. One looked at 5,782 eyes with AMD receiving injections before, during and following national lockdowns in Australia, France, Ireland, Italy, the Netherlands, New Zealand, Spain or Switzerland. It found that “eyes with [wet AMD] (n=4649) lost vision in all countries in proportion to the reduced number of injections.” In the countries where patients missed just one injection, visual acuity declined by one letter, while those where two injections were missed saw a decline in acuity of up to four letters, with the exception of New Zealand.2
Further, “vision loss occurred even after [wet AMD] had been prioritized in all the national and international clinical guidelines.” The disruption in injection therapy had extended impacts as well, with 20% of wet AMD patients dropping out of treatment six months post-lockdown. The researchers concluded that “it appears appropriate to prioritize intravitreal therapy for eyes with wet AMD in this scenario,” the researchers concluded.
The second study supported this conclusion, finding that Swiss patients who halted injection therapy during lockdown experienced increased exudative activity and visual and anatomical worsening compared to those who received injections without clinical consultation, imaging or assessment of visual acuity, the “injection-only” approach. The latter group experienced no significant deterioration in vision. While resumption of injection therapy produced some improvement in those who deferred treatment during lockdown, the researchers noted that these patients “showed partially irreversible deterioration of visual function.”3
The authors concluded that “our experience denotes the feasibility of an ‘injection-only’ management plan for implementation in future pandemics.”
- Ashrafzadeh S, Gundlach BS, Tsui I. The Impact of Non-Ophthalmic Factors on Intravitreal Injections During the COVID-19 Lockdown. Clin Ophthalmol. 2021;15:3661-3668 https://doi.org/10.2147/OPTH.S314840
- Zarranz-Ventura J, Nguyen V, Creuzot-Garcher C, et al. International impact of the COVID-19 pandemic lockdown on intravitreal therapy outcomes: Fight Retinal Blindness registry. Retina. 2021 Dec 1. doi: 10.1097/IAE.0000000000003368. Epub ahead of print. PMID: 34907129.
- Montesel A, Gigon A, Giacuzzo C, et al. Treatment deferral during COVID-19 lockdown: functional and anatomical impact on neovascular age-related macular degeneration patients. Retina. 2021 Dec 2. doi: 10.1097/IAE.0000000000003369. Epub ahead of print. PMID: 34907122.
