The COVID-19 pandemic has dramatically changed the landscape of medical practices across the country. At the beginning of the pandemic, most subspecialties considerably altered practice patterns, only managing acute or emergent patients to avoid unnecessary exposure between patients and health care workers.^1,2 At the height of the pandemic in March and April 2020, ophthalmology, in particular, saw the greatest decrease in outpatient visits among all medical specialties compared to the same time period in the prior year.³ This is in part due to many common ophthalmologic conditions that can safely have delays in management without permanent vision loss (eg, cataracts). Vitreoretinal specialists, on the other hand, manage conditions that can potentially lead to permanent vision loss if management is delayed. Retinal tears, retinal detachments, and endophthalmitis are emergent conditions. Other conditions require timely intravitreal anti-VEGF or steroid injections, such as neovascular age-related macular degeneration (AMD), diabetic macular edema, and retinal vein occlusion. Delaying the care for these patients may result in permanent vision loss.⁴ Despite the blinding nature of these conditions, vitreoretinal specialists still saw a significant reduction in surgical volume during the COVID-19 pandemic (Figure 1).

After the American Academy of Ophthalmology (AAO) issued a statement on March 18, 2020, urging all ophthalmologists only to provide emergent care, retinal physicians, along with other ophthalmologists, radically adjusted their daily schedules to provide safe and efficient care to selected patients to limit the potential spread of COVID-19, but also to conserve personal protective equipment. Many retinal conditions are associated with aging, which places many patients who require retina care in higher risk categories for morbidity and mortality associated with COVID-19. Retinal physicians employed several strategies to try to limit the number of patients and the amount of time patients spent in clinic, including limiting testing and imaging for patients, identifying patients who could be extended further between injections, triaging new patient referrals, and incorporating telehealth and hybrid telehealth strategies.

IMPACT ON RETINA PRACTICE

Some studies have tried to quantify the impact of COVID-19 on retina practices. A study by Xu et al used the Vestrum database, a large-scale national retina practice database, to analyze the usage of retinal care during the pandemic. Specifically, they evaluated changes in office visits, intravitreal injection volume, and use of telemedicine care for vitreoretinal specialists during the pandemic compared to the same time periods from 2018 and 2019.⁵ Comparing the 10 weeks of the pandemic to the first 10 weeks of 2020, the study found a significant reduction in the number of injections, return office visits, new patient visits, and number of optical coherence tomography (OCT) and fluorescein angiography images performed. All 4 of these metrics were also significantly reduced during the same time period in 2019. There were also no differences in the geographic distribution of these metrics across the country or COVID-19 incidence. The authors then devised a ratio of intravitreal anti-VEGF injections to office visits (IAI-OV). This metric served as a surrogate for how vitreoretinal practices were managing and prioritizing injection patients who required continued treatment during the pandemic. The study found a significant increase in the IAI-OV ratio during the first 10 weeks of the pandemic compared to the first 10 weeks of 2020, as well as when compared to the same time periods of 2019 and 2018.

As one would expect, the study also found an increase in the utilization of telemedicine visits during the first 10 weeks of the pandemic. Interestingly, though, the mean number of telemedicine visits across this national database, which housed over 1.6 million unique patients, there were only 64±57 telemedicine visits performed per week during the first 10 weeks of the pandemic. As other studies have shown, vitreoretinal practices and surgeons may be reluctant to use telemedicine^6-9 but also because examination of the retina exam cannot be done without a direct patient-physician encounter.

In a presentation during the 2020 virtual AAO Annual Meeting, Schwartz et al presented the IRIS Registry’s data regarding office visits as well as intravitreal injection use during the pandemic.¹⁰ The study delineated that at the peak of 2020 pre-COVID, there were more than 191,000 daily ophthalmology visits captured within the IRIS database, and this number was reduced to 28,000 visits during the peak of COVID, a reduction of more than 85%. All types of ophthalmic care were greatly reduced, but the authors also presented a figure highlighting that retina visits were impacted to a lesser degree than the rest of ophthalmology. Comparing the ratio of retina visits to the rest of ophthalmology subspecialties in the IRIS database, retina visits comprised approximately 20% of all eye visits before the pandemic. During the pandemic, however, approximately 38.5% of all eye visits were retina related. It was not until week 12 of the pandemic that this ratio returned to prepandemic levels. The database also highlighted that the Northeast was disproportionally seeing fewer patients than the rest of the country during April and May 2020, and even slightly extending into June 2020.

IMPACT ON INTRAVITREAL INJECTIONS

Examining the intravitreal injection data specifically, the authors only examined patients receiving monthly injections in the same eye during the 5 months leading up to the pandemic and then analyzed the injection pattern during the pandemic. In the 12 weeks pre-COVID, the mean number of injections per week was 122,785 compared to 99,695 per week during the first 12 weeks of the pandemic. In the 12 weeks leading up to the pandemic, there were 39,819 patients receiving monthly injections and met the inclusion criteria. Of these patients, 19,353 (48.6%) continued to receive monthly treatment during the first 12 weeks of the COVID-19 pandemic and 35,506 (89.2%) received at least 1 injection. This left 4,324 (10.8%) of patients who did not receive any injections during the first 12 weeks of the pandemic. Analyzing the visual acuity, prepandemic, the cohort had a mean Snellen acuity of ~20/50, which was maintained in the monthly cohort as well as the cohort that received at least 1 injection, both of which had mean acuities of ~20/50. Interestingly, the cohort that did not receive an injection had a mean acuity of ~20/60 when they returned to the office. The authors concluded that patients’ vision was not adversely affected by the response of retina specialists in managing injection patients during the pandemic.

IMPACT ON URGENT PROCEDURES

A recent paper from Breazzano et al examined the rates of urgent or emergent vitreoretinal procedures (injections, lasers, retinal detachment repair, and other vitrectomies) during the early part of the COVID-19 pandemic using CPT billing data from 17 practices across the country.⁹ The authors compared the frequency of each of those 4 metrics to the same time period from 2019, analyzing over 525,000 CPT codes, the majority of which (91.8%) were injection codes. They found a significant reduction in each metric from March 16, 2020 through May 31, 2020, except for injection volume, which began to increase early in May 2020 and was no longer significantly reduced compared to 2020.

The authors did subanalyses by region and found similar results across the country as well as by whether the practice was tax-exempt (academic) vs non-tax-exempt (private) and again found similar reductions across each metric regardless of practice type. The authors concluded that further studies are warranted to understand the implications of these reduced urgent procedures during the recovery phase following the height of the COVID-19 pandemic as well as to assess how long this decrease will last.

CONCLUSION

It is clearly evident that numerous studies examining vitreoretinal practices during COVID-19 have shown a great reduction in many metrics of patient and imaging volume. Clearly, many reductions in care are driven in part by physicians as evidenced by the large increase in the IAI-OV ratio presented in the study by Xu et al and the maintenance of injection patients presented by Schwartz and colleagues. However, there are likely many other factors affecting patient volume during the COVID-19 pandemic. Many patients simply did not and still do not want to go to a physician’s office unless it is absolutely necessary. Unfortunately, sometimes patients wait too long before presenting for ophthalmic care, leading to increased disease severity at presentation and insurmountable visual acuity loss.¹¹

Despite these delays in care and decrease in volume, it does appear that patients maintained good visual acuity while under the care of vitreoretinal specialists as evidenced in the presentation by Schwartz et al and that volumes appear to be approaching prepandemic levels. The impact of the COVID-19 pandemic on clinical volumes is still present and will continue in the future, but retina volume appears to be increasing and approaching prepandemic levels (Figure 1). Vitreoretinal specialists need to continue to be vigilant about utilizing strategies to provide care for patients to preserve and improve vision for patients while mitigating risk of spread of COVID-19 among patients, caregivers, and staff, and conserve personal protective equipment. RP

REFERENCES

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2. American College of Surgeons. COVID-19: recommendations for management of elective surgical procedures. March 13, 2020. Accessed April 13, 2021. https://www.facs.org/covid-19/clinical-guidance/elective-surgery
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