The True Effect of Lapses in Care

In the retina world, time matters. Certain conditions, such as retinal detachment (RD), acute symptomatic retinal breaks, and neovascular glaucoma, require urgent care, but even chronic conditions, such as wet age-related macular degeneration (AMD) and diabetic macular edema (DME), call for early intervention and consistent follow-up to ensure positive visual outcomes.

During the ongoing COVID-19 pandemic, lapses in medical care due to government-mandated shutdowns, overly crowded health care facilities, loss of health insurance or income, and patient fear have led to poorer patient outcomes, particularly for those with retinal pathology. This article details the ramifications of the COVID-19 shutdown on our retina patients.

THE DAILY DEMAND

Our retina clinic is always bustling. On any given day we have up to four physicians, both MDs and ODs, seeing an average of 50 to 60 patients—each. Throughout the day the schedule grows as outside providers refer patients for urgent evaluation for conditions such as macula-on RDs, hemorrhagic posterior vitreous detachments with possible breaks, and post-cataract surgery endophthalmitis.

The urgent referrals are squeezed between our more routine patients, those with wet AMD, DME, or macular edema associated with retinal vein occlusion (RVO) who require anti-VEGF injections every 1 to 2 months to maintain their vision. Patients with nonproliferative diabetic retinopathy (DR) without macular edema, dry AMD, peripheral retina degenerations, and choroidal nevi are scheduled every 3 to 6 months for monitoring.

SHUTDOWN

In the spring of 2020, our usual hustle and bustle came to a screeching halt as COVID-19 swept through the United States. Although our patient care was deemed essential and we never shut our doors, many patients chose to stay home to avoid potential exposure to the virus. A survey of retina specialists in Retina Today showed that patient volume dropped to as low as 40% of the pre-pandemic volume during May and June of 2020.¹

Surprisingly, even the constant influx of emergent referrals slowed considerably. Routine care through our referring ODs and MDs had stopped, and patients weren’t identifying emergent conditions on their own. Even if patients were experiencing visual symptoms, many weren’t coming in, assuming it was something they could address after the pandemic had ended.

THE AFTEREFFECTS

Although the patient load has returned to normal, the effects of this lapse in care continue to reverberate through our practice more than a year later.

Patients with wet AMD were perhaps hit the hardest. Early intervention with anti-VEGF therapy leads to better visual outcomes in those who convert from dry to wet AMD, and entering visual acuity is a significant factor in a patient’s visual prognosis. A patient who presents with VA of 20/40 at conversion is more likely to maintain that legal driving vision than a patient who presents with initial VA of 20/200.² Patients with wet AMD are also highly reliant on routine, even monthly, injections to maintain their visual acuity.² Unfortunately, this patient population is also older, and was more likely to delay care for fear of COVID-19.

Stone et al found that, during the COVID-19 pandemic, those being treated with anti-VEGF injections for wet AMD experienced the greatest loss of vision compared to patients with DME and macular edema from RVO; they were also the least likely to have their vision return to normal once treatment was reinstated.³ This is due to the aggressive nature of choroidal neovascularization in AMD and the formation of subretinal scarring. Greenlee et al showed that after lapses in anti-VEGF treatment for wet AMD, macular thickness can be restored to normal with resumed treatment, but visual acuity loss is often permanent due to submacular scarring (Figure 1).⁴

Our patients with diabetes faced numerous challenges as well. This patient population tends to be younger than the wet AMD population, with many still in the workforce, which may be why DR is the leading cause of blindness in the working-age population.⁵ Recent conversations with my own patient base suggest loss of work and loss of health insurance has been a significant hurdle for these patients during the pandemic. Numerous patients have reported that their delays in care have been due to financial strain. A survey by the American Diabetes Association (ADA) found that 12% of patients with diabetes surveyed experienced insurance disruption during the pandemic.⁶

Another crucial factor for patients with diabetes is fear, as they are at a higher risk of severe complications of COVID-19. Unfortunately, this has stopped many patients from keeping their retina and routine ocular health appointments and delayed their systemic care. The ADA survey reported that 43% of patients with diabetes delayed routine medical care during the pandemic, and 50% of those did so out of fear of COVID-19.⁶

We are still seeing patients with DR who haven’t been seen for more than a year due to pandemic-related reasons. Many are in poorer systemic health than they were before the pandemic, and they have been without follow-up for far too long, putting them at increased risk for sight-threatening complications such as macular edema, macular ischemia, tractional RD, vitreous hemorrhage, and neovascular glaucoma (Figure 2).

EMBRACE TECHNOLOGY THAT LETS YOU ADAPT TO THE TIMES

As the pandemic continues, the question remains: How can we positively influence our patients’ retina health during this time? For my patients with intermediate-stage AMD, I recommend the ForeseeHome Monitoring Program (Notal Vision), which uses the concept of hyperacuity to detect metamorphopsias consistent with conversion to wet AMD. The at-home monitoring system alerts the physician when conversion is detected, providing elderly patients with a safe means of monitoring between office visits.⁷

Longer acting anti-VEGF agents such as brolucizumab-dbll (Beovu, Novartis), approved for exudative AMD and in clinical trials for DME, may decrease the burden of follow-up. In addition, new delivery systems such as the anti-VEGF port delivery system (ranibizumab injection 100 mg/mL; Susvimo, Genentech), recently approved for exudative AMD, may be considered to give patients longer follow-up times.

Such technology is just one way we can adjust to the needs of our patients during this ongoing health crisis.

REACHING THROUGH THE BARRIER

Fear of COVID-19 is real, but risk of vision loss without care is also a crucial consideration, and we must strive to stress the importance of follow-up care, both ocular and systemic, to our patients. We must remain accessible to and open with our patients and provide them with a safe environment in which to seek care. Educating patients to recognize signs or symptoms that require emergent care is also crucial. With all of this put together, we have a better chance of preserving vision.