Coronavirus is still an inescapable fact of life for many of us depending on where we live. Take the Media MICE team, for example: Your correspondent lives in Central Europe where disruption is minimal, whereas other members of the team live in parts of Southeast Asia where full lockdowns are in effect. The impact on ophthalmology is similarly diffuse.
Medical practices and clinicians in different countries have adopted a myriad number of practices to continue operating during the coronavirus pandemic. In some countries telemedicine has become more common and effective, whereas in others, ophthalmology remains shuttered to one degree or another. Of particular note is how clinicians are continuing to carry out anti-vascular endothelial growth factor (anti-VEGF) treatment.
Anti-VEGF treatment is used to block vascular endothelial growth factor (VEGF) and it represents one of the most exciting developments in ophthalmology. The conditions treated by anti-VEGF, which include wet age-related macular degeneration (nAMD), macular edema and diabetic retinopathy (DR), are some of the most commonly encountered retinal diseases. This ensures that anti-VEGF has broad importance to the ophthalmology sector.
Anti-VEGF treatment is administered via intravitreal injections — and in 2016 alone, approximately 2.6 million injections were provided.1 Use of anti-VEGF injections has steadily increased and a number of drugs are available. These include ranibizumab (Lucentis, Genentech), aflibercept (Eylea, Bayer) and bevacizumab (Avastin, Genentech).
As anti-VEGF is an injection-focused treatment, utilizing it in a telemedicine environment has proven difficult. It requires trained medical personnel to be carried out effectively. In the coronavirus era, continuing anti-VEGF treatment with social distancing requirements has become a pressing issue.
Which diseases to treat and which to monitor?
It is particularly pressing in two cases, DR and nAMD. Untreated nAMD may cause fibrosis or scarring which can in turn lead to permanent visual loss, thus making continuing treatment highly important. On the other hand, as one of the main comorbidity factors of coronavirus is diabetes, it is worth considering limiting the amount of time DR patients spend in clinics.2
This is why the authors of the study Proposed Strategies for Intravitreal Injections During the COVID-19 Pandemic3 examined how to safely continue injection treatment. Comprising a group of primarily Indian doctors, the researchers sought to find new fundamental best practices. According to researcher Dr. Ashish Sharma, telemedicine is not a panacea.
“Telemedicine is important where the prevalence of COVID-19 is high and it works for routine ophthalmic complaints such as itching, irritation, watering, etc. However, it won’t work for specialties such as retina where timely treatment is the key,” Dr. Sharma said.
Dr. Sharma’s team recognized the limits of telemedicine and concluded that clinicians should implement three iniativiates to continue injection treatment. The first is an abbreviated clinical routine where patients should arrive alone; the reception process should be brief; and regular evaluations with fundus photography, optical coherence tomography, and formal detailed vision testing should be avoided. Dilation examination could also be avoided.3
Learn the best practices from different regions
The second recommendation is patient selection, where patients should be separated into categories based on their conditions. For patients with cystoid macular edema for example, treatment and screening can continue with telemedicine or limited injections. Conversely, patients with nAMD should be given priority for injections.
The final recommendation is protection which calls for high personal standards, including slit-lamp shields for patients when required, while stating that complete personal protective equipment may not be warranted when managing asymptomatic patients. Also, the study recommends that quick intravitreal injections with minimal staff interaction can be performed in a dedicated outpatient injection room, a common practice in Western countries, but not in countries such as India.4
For Dr. Sharma, these recommendations represent a considerable opportunity to assist patients and prevent vision loss. As they are broad in approach they can be applied in most countries and clinics. Ultimately, they also empower ophthalmologists to rely on clinical judgment rather than first-level evidence.
“I don’t think that anyone would have an answer to how long the coronavirus pandemic will last at this point. Realistically, it would take at least a year to get things back on track,” Dr. Sharma said.
“With the suggestions put forth here, we believe that we are equipped to do just that in the COVID-19 era,” he added.
1. Bakri SJ, Thorne JE, Ho AC, et al. Safety and efficacy of anti-vascular endothelial growth factor therapies for neovascular age-related macular degeneration. Ophthalmology. 2019;126(1):55-63.
2. 4. Guan W, Ni Z, Hu Y, et al. China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-1720.
3. Sharma A, Kumar N, Parachuri N, et al. Proposed Strategies for Intravitreal Injections During the COVID-19 Pandemic. Retina Today. Accessed September 6, 2020.
4. Narayanan R. Guidelines for intravitreal injections. The Official Newsletter of Vitreo-Retinal Society—India. 2018;7-10.