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

Abstract

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.

Key words

COVID 19 - nAMD - IVOM - health services research

Publikationsverlauf

Eingereicht: 08. Februar 2022

Angenommen: 22. März 2022

Artikel online veröffentlicht:
04. August 2022

• References/Literatur

• 1 Heimes B, Gunnemann F, Ziegler M. et al. [Compliance of age related macular degeneration patients undergoing anti-VEGF therapy: Analysis and suggestions for improvement]. Ophthalmologe 2016; 113: 925-932 DOI: 10.1007/s00347-016-0275-z.
• 2 Ehlken C, Ziemssen F, Eter N. et al. Systematic review: non-adherence and non-persistence in intravitreal treatment. Graefes Arch Clin Exp Ophthalmol 2020; 258: 2077-2090 DOI: 10.1007/s00417-020-04798-2.
• 3 Lommatzsch A, Eter N, Ehlken C. et al. [Adherence to anti-VEGF treatment-Considerations and practical recommendations]. Ophthalmologe 2021; 118: 801-809 DOI: 10.1007/s00347-020-01273-5.
• 4 Wintergerst MWM, Bouws J, Loss J. et al. Pro re nata anti-VEGF treatment results for neovascular age-related macular degeneration in routine clinical treatment: comparison of single with triple injections. Ophthalmologe 2018; 115: 1035-1041 DOI: 10.1007/s00347-017-0610-z.
• 5 Stemplewitz B, Luethy J, Eddy MT. et al. Impact of the COVID-19 pandemicʼs first wave on the care and treatment situation of intravitreal injections in a German metropolitan region. Graefes Arch Clin Exp Ophthalmol 2022; DOI: 10.1007/s00417-021-05521-5.
• 6 Borrelli E, Grosso D, Vella G. et al. Short-term outcomes of patients with neovascular exudative AMD: the effect of COVID-19 pandemic. Graefes Arch Clin Exp Ophthalmol 2020; 258: 2621-2628 DOI: 10.1007/s00417-020-04955-7.
• 7 Corradetti G, Corvi F, Nguyen TV. et al. Management of Neovascular Age-Related Macular Degeneration during the COVID-19 Pandemic. Ophthalmol Retina 2020; 4: 757-759 DOI: 10.1016/j.oret.2020.05.015.
• 8 Parravano M, Borrelli E, Costanzo E. et al. Protect Healthcare Workers and Patients from COVID-19: The Experience of Two Tertiary Ophthalmology Care Referral Centers in Italy. Ophthalmol Ther 2020; 9: 231-234 DOI: 10.1007/s40123-020-00251-z.
• 9 Shmueli O, Chowers I, Levy J. Current safety preferences for intravitreal injection during COVID-19 pandemic. Eye (Lond) 2020; 34: 1165-1167 DOI: 10.1038/s41433-020-0925-x.
• 10 Deutsche Ophthalmologische Gesellschaft (DOG), Retinologische Gesellschaft e.V. (RG), Berufsverband der Augenärzte Deutschlands e. V. (BVA). [Statement of the German Ophthalmological Society (DOG), the Retinological Society (RG) and the Professional Association of German Ophthalmologists (BVA) on anti-VEGF treatment in neovascular age-related macular degeneration: Status February 2020]. Ophthalmologe 2020; 117: 746-754 DOI: 10.1007/s00347-020-01117-2.
• 11 Molenberghs G, Thijs H, Jansen I. et al. Analyzing incomplete longitudinal clinical trial data. Biostatistics 2004; 5: 445-464 DOI: 10.1093/biostatistics/5.3.445.
• 12 Kuhlen R, Schmithausen D, Winklmair C. et al. The Effects of the COVID-19 Pandemic and Lockdown on Routine Hospital Care for Other Illnesses. Dtsch Arztebl Int 2020; 117: 488-489 DOI: 10.3238/arztebl.2020.0488.
• 13 Böhringer D, Gruber M, Reinhard T. Ophthalmological Interventions Not Covered. Dtsch Arztebl Int 2021; 118: 68 DOI: 10.3238/arztebl.m2021.0040.
• 14 Arruabarrena C, Toro MD, Onen M. et al. Impact on Visual Acuity in Neovascular Age Related Macular Degeneration (nAMD) in Europe Due to COVID-19 Pandemic Lockdown. J Clin Med 2021; 10: 3281 DOI: 10.3390/jcm10153281.
• 15 Denys P, Miere A, Colantuono D. et al. Intravitreal injections during COVID-19 outbreak: Protective measures, total duration of care and perceived quality of care in a tertiary retina center. Eur J Ophthalmol 2022; 32: 372-376.: DOI: 10.1177/11206721211003488.
• 16 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; DOI: 10.1097/IAE.0000000000003369.
• 17 Borrelli E, Grosso D, Vella G. et al. Impact of COVID-19 on outpatient visits and intravitreal treatments in a referral retina unit: letʼs be ready for a plausible “rebound effect”. Graefes Arch Clin Exp Ophthalmol 2020; 258: 2655-2660 DOI: 10.1007/s00417-020-04858-7.
• 18 Stattin M, Ahmed D, Graf A. et al. The Effect of Treatment Discontinuation During the COVID-19 Pandemic on Visual Acuity in Exudative Neovascular Age-Related Macular Degeneration: 1-Year Results. Ophthalmol Ther 2021; 10: 935-945 DOI: 10.1007/s40123-021-00381-y.