Author: Joel Luethy
Co-authors: Marc Schargus, Birthe Stemplewitz
Evaluation of the impact of the first coronavirus 19 (COVID-19) wave in 2020 on patients scheduled for intravitreal injections (IVI) in a German metropolitan region (Hamburg). IVI are by far the most frequently performed medical procedure in Germany (approximately 1.5 million injections per year) and account for up to 54% of all intraocular surgeries.
The most common indications of IVI are neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME), and macular oedema caused by retinal vein occlusion (RVO). All of which if left untreated, can lead to profound and irreversible visual impairment
Multicenter prospective survey and retrospective analysis during from March to July 2020 in all four hospital eye departments in the city of Hamburg. These are as follows: Departments of Ophthalmology of Asklepios Hospital Nord-Heidberg, Asklepios Hospital Barmbek, Asklepios Hospital Altona, and University Medical Center Hamburg-Eppendorf.
We performed a multicenter prospective survey and retrospective analysis of the records of patients treated with intravitreal injections during the 20 weeks period from March to July 2020 using a specially designed questionnaire and treatment data. Inclusion criteria included written informed consent, at least one intravitreal injection in the study period between March 15th and July 31st, 2020, and an indication for intravitreal injections according to current German guidelines. Patient data like treatment diagnosis, number of previously received intravitreal injections and treatment period per eye, as well as every IVI with date and substance within our study period, were obtained from patient records of each hospital. In addition, patients were asked to complete a custom made questionnaire to gain further information about COIVD-19-related healthcare issues. The questionnaire consisted of 28 questions on two pages and was divided in three sections: infectious status regarding COVID-19, ophthalmological treatment during COVID-19 and 3) home, and medical care situation. Questionnaires were filled out in collaboration with a research assistant either in person during a treatment appointment or via telephone.
1038 patients (2472 IVI, 1231 eyes) and 818 completed questionnaires were evaluated. 459 (56%) were female and the mean age was 77 +- 10 years. 67% had injections because of AMD, 15% because of DME, 15% because of macula oedema due to RVO, and 3% because of other choroidal neovascularisations.
Longer duration of IVI therapy (p<0.001), lower visual acuity (VA) of the treated (p<0.001), and higher VA of the fellow untreated eye (p<0.001) were associated with a higher probability of visit cancellation. Higher age was associated with a lower probability of cancellation (p<0.001). Every additional year of life posed a 2.6 % lower risk of non-compliance. A COVID-19 infection in the family environment displayed a 5.5-fold chance of visit cancellation (p<0.001). Patients treated for nAMD had a 36 % reduced risk of visit cancellation (p=0.016) compared to patients with DME. Patients treated because of DME cancelled their appointments more often (p = 0.033).
The diagnosis of RVO (p=0.688), bilateral IVI (p=0.541) and gender (p=0.630) showed no statistical significance regarding visit cancellation. Due to the small number of manifest COVID-19 (n=4) among our cohort, no statistical impact could be detected.
Our study shows that the eye hospitals in the city area of Hamburg were able to maintain and continue IVI therapy despite the tightened situation with restricted capacities and under difficult general conditions. Nevertheless, cancellation of visits by the patients was a major issue.
A long preceding treatment period, low VA of the treated eye, high VA of the untreated eye, COVID-19 in the family and DME were identified as risk factors for IVI visit cancellations during the COVID-19 pandemic.
Compliance to treatment might be improved in the future by taking these newly described risk factors into account when scheduling patients and especially patients at risk for IVI during the exceptional circumstances of a pandemic.
This study was partly funded by Novartis Pharma GmbH, Germany