Real-World Experience with Anti-VEGF Injections during COVID-19

Differences in treatment patterns and outcomes offer insights for future care. Cheryl Guttman Krader reports

Decreases in retina care seen in the early days of the COVID-19 lockdown showed considerable variation among countries in the extent and duration of the care interruptions, visual outcomes, and treatment maintenance, a multi-country analysis found.

The study used the observational database of the Fight Retinal Blindness! Registry that contains entries from hundreds of clinicians practicing around the world. It identified patients in Australia, New Zealand, and six European countries (France, Ireland, Italy, the Netherlands, Spain, Switzerland) receiving treatment for neovascular age-related macular oedema (nAMD), retinal vein occlusion (RVO), or diabetic macular oedema (DME) who had a baseline visit within three months of the lockdown in March 2020. The analyses evaluated changes in visual acuity, injection and visit numbers, and dropout rates from six months before the lockdown to six months after the lockdown.

Data from the study included a total of 5,782 eyes of 4,708 patients. A large majority of the study group (80% of both eyes and patients) were receiving treatment for nAMD. Another 11% of patients had DME, and 8% of eyes had RVO. The patients had been treated for an average of 2.2 years prior to the pandemic and received a median of 12 to 14 injections across all three diagnosis subgroups. Approximately 25% of patients were treated every 4 to 6 weeks before the pandemic, and another 25% every 12 weeks for injection.

INJECTION DATA The decrease in injection numbers was greater in countries hit harder by the pandemic in terms of having higher disease prevalence and severity, longer lockdowns with more stringent restrictions, and a greater negative impact on ophthalmic care delivery. Worse visual outcomes correlated with greater reduction in injections, but patients with DME and RVO did better than those with nAMD despite the DME and RVO subgroups experiencing a greater decrease in injection frequency.

The information provides guidance for future adaptations in care delivery, said study director Mark Gillies MD.

“We have all had to restructure our clinical practices because of the COVID-19 pandemic, including repurposing resources to increase capacity and implementing strategies to limit transmission risk in the clinic environment. At the same time, we have had to provide ongoing care with reorganisation of monitoring and treatment protocols, and in many cases, we have had to prioritise people in need,” he commented.

“The findings from this analysis provide some evidence to suggest prioritising anti-VEGF injections for patients with nAMD may be an appropriate response in situations such as occurred with the lockdown resulting from COVID-19.”

Data for all countries showed a reduction in injection numbers six months after the initial lockdown. The change was greatest in Ireland, Italy, Spain, and New Zealand. Analyses considering the indication for treatment showed fewer injections were being given for RVO and DME than for nAMD after the lockdown.

Treatment intervals extended by a median of 1 to 3.5 weeks after the lockdown compared to the pre-pandemic period. The change, which represented approximately one missed injection, was most extreme in Italy, Spain, and France.

Analyses of patient return visits at six months showed a high rate of dropouts across all indications (nAMD 20%, DME 27%, RVO 28%). Furthermore, between 11% and 16% of patients across the three diagnostic subgroups were lost to follow-up, having no without any further visits after the lockdown.

FUNCTIONAL IMPACT Visual acuity remained relatively stable (≤1 letter loss) among patients in Australia across all three diagnostic subgroups. For patients with nAMD, visual acuity was also generally stable among patients in France, New Zealand, and the Netherlands whereas patients in Ireland, Italy, and Spain experienced mild to moderate loss of vision six months after the lockdown. Among patients with nAMD, visual acuity decreased by -0.4 to -3.8 letters across the various countries, Dr Gillies reported.

Despite having higher dropout rates and greater reductions in the number of injections received, patients with DME and RVO generally had stable vision or milder loss than their nAMD counterparts. Again, however, the functional outcomes for patients with DME and RVO varied by country. A mild to moderate loss of vision was seen for patients with DME in Italy and Switzerland. In the RVO subgroup, mild vision loss was seen among patients in Ireland, the Netherlands, Switzerland, and New Zealand.

For more information on the Fight Retinal Blindness! Registry, please visit frbresearch.org.

Professor Gillies presented this study at the American Academy of Ophthalmology 2021 Conference, Retina Subspecialty Day, in New Orleans, Louisiana, USA.

Mark Gillies MD is a Professor of Ophthalmology, Save Sight Institute, University of Sydney, Australia. mark.gillies@sydney.edu.au