|Mark P. Breazzano, MD|
An analysis of billing data from 17 large retina centers across the United States has documented a sharp decline in urgent or emergent vitreoretinal surgical procedures during what we now know are the early days of the COVID-19 pandemic.1 Even as vaccines roll out and the country moves toward herd immunity, the effects of the pandemic on retina practices may linger for the foreseeable future, the lead author of the study says.
“I think the study raises important questions; the return to ‘normal’ is probably going to take longer than any of us anticipated,” lead author Mark P. Breazzano, MD, says in an exclusive interview with Retina Specialist Magazine. Dr. Breazzano is an assistant professor at Wilmer Eye Institute of Johns Hopkins University in Baltimore.
Quantifying sharp declines
The study collected billing data on 526,536 procedures from 17 academic and private retina practices across the United States and compared weekly surgical and procedural volumes for March 16 to May 31, 2020—the period when stay-at-home orders were imposed in the states represented in the study—with the corresponding period from 2019.
The study reported these average maximal weekly declines at each institution for the following procedures:
Intravitreal injections (IVI), a 38.6-percent decrease from April 6 to 12, from an average of 437.84 per institution in the corresponding week in 2019 to 273.82 (p=0.002).
Laser/cryotherapy, a 79.6-percent decrease for the same week, from 6.57 procedures per institution to 1.52 (p<0.001).
Retinal detachment repairs, a 59.4-percent decrease April 13 to 19, from 3.45 per institution to 1.55 (p<0.001).
Other vitrectomies, an 84.3- percent decrease for April 6 to 12, from 2.98 procedures on average to 0.75 (p<0.001).
Dr. Breazzano notes that the declines were across the board and didn’t deviate regardless of region or practice setting (academic or private).
Potential role of AAO guidance
As stay-at-home orders were sequentially issued by each state, the American Academy of Ophthalmology released a list of urgent and emergent surgical procedures2 to guide ophthalmologists on prioritizing care during the pandemic. “I believe this guidance was helpful for us in managing these patients because there was considerable uncertainty during this period. The objective was to simultaneously preserve vision and optimize safety from COVID-19 infection,” Dr. Breazzano says of the AAO list.
“I’m not sure what would’ve happened without the recommendation,” he adds. “It is fortunate that we had this guidance up front, and I imagine a more substantial decline may have followed without AAO support.”
Sorting out reasons for declines
Dr. Breazzano notes that IVI declined less than other procedures. Besides the reluctance of patients to come into clinics during the pandemic for fear of COVID-19 infection, another potential factor may have been the stay-at-home orders themselves limiting peoples’ normal movements and activities, thus reducing cases of vitreoretinal traction and the ensuing retinal tears and detachments.
However, it’s unclear whether these patients may present later with late-stage complications from waiting with a retinal detachment, including additional scar tissue from proliferative vitreoretinopathy. Reduced cataract surgery and other elective procedure volumes may have also led to fewer related vitreoretinal complications.
Another explanation for the disparity between IVI and other procedures is the regularity with which IVI patients return to the clinic. They’re connected to the health-care system, Dr. Breazzano says. “But let’s say we have somebody arriving with a retinal detachment referred by another doctor; it may be challenging for them to enter that system,” he says. “New precautionary measures implemented by health systems as a reaction to minimize COVID-19 infection may have also impeded these urgent referrals.”
That may also be a consequence of clinic staff working remotely. “Some of this remote and virtual work might add difficulty in identifying and integrating these patients into the system, and therefore managing the high-
acuity condition,” Dr. Breazzano says.
Lessons going forward
As retina practices emerge from the pandemic, there are lessons that may endure, Dr. Breazzano says.
“I think we’ve learned that certain, simple precautions are quite effective—such as slit lamp shields, wearing masks, and minimizing crowding in the waiting and office spaces with family members and caregivers of patients-—in helping reduce the transmission of pathogens,” he says. He notes that cases of the common cold and seasonal flu declined markedly with mask-wearing and other pandemic-related precautions.
Even with herd immunity on the horizon, ophthalmologists must continue to be vigilant. “We know that ophthalmology has a uniquely higher increased infection risk compared to other physician specialists, and it’s likely bidirectional for our patients, too,”3 Dr. Breazzano says. “We could potentially give it to them in the same way they could give it to us.”
Dr. Breazzano adds, “Ophthalmologists are at higher risk. We know this given our proximity to the face, and the secretions around the face that we’re constantly exposed to, as supported by our data from New York City resident physicians infected early in the pandemic. The first indication of a strong connection between COVID-19 and our specialty was evident by the Chinese ophthalmologist Li Wenliang, the physician who initially sounded alarm bells and ultimately died with COVID-19.
“It’s going to be something that I think that we all as ophthalmologists and retina specialists will carry with us,” he adds. “Given the increased risk for our patients and staff, anything that can be gleaned, including these simple measures, will be important moving forward.” RS
—Richard Mark Kirkner
1. Breazzano MP, Nair AA, Arevalo JF, et al. Frequency of urgent or emergent vitreoretinal surgical procedures in the United States during the COVID-19 pandemic. JAMA Ophthalmol. Published online March 4, 2021. doi:10.1001/jamaophthalmol.2021.0036
2. American Academy of Ophthalmology (2020). List of urgent and emergent ophthalmic procedures. Posted March 27, 2020. https://www.aao.org/headline/list-of-urgent-emergent-ophthalmic-procedures. Accessed March 12, 2021.
3. Breazzano MP, Shen J, Abdelhakim AH, et al; New York City Residency Program Directors COVID-19 Research Group. New York City COVID-19 resident physician exposure during exponential phase of pandemic. J Clin Invest. 2020;130: 4726-4733.
The Food and Drug Administration has approved the Argus 2s Retinal Prosthesis System, a redesigned combination glasses-and- video processing unit initially made for use in combination with the Argus II systems implanted for retinitis pigmentosa. Second Sight Medical Products says it will adapt the Argus 2s to be the external system for the Orion Visual Cortical Prosthesis System currently under development.
Graybug Vision has reported preliminary topline data from the 12-month treatment phase of the Phase IIb ALTISSIMO trial of GB-102, an intravitreal formulation of sunitinib malate, for wet age-related macular degeneration. For patients in the 1-mg arm, the average time to the first rescue treatment was five months. Overall, the 1-mg dose was well-tolerated with no drug-related serious adverse events. Twenty-two patients have completed at least two months of this six-month extension period without the need for further treatment.
A biosimilar of aflibercept recently completed a Phase I trial in South Korea. Alteogen reports that ALT-L9 met safety and efficacy endpoints comparable to those of aflibercept. The company says it intends to pursue a Phase III trial.