COVID-19 Lockdowns Drove Fewer Anti-VEGF Injections, Worse Vision in Ophthalmic Patients

Professor Mark Gillies

Lockdowns brought on by the COVID-19 pandemic hindered consistent delivery of anti-VEGF therapy in patients with retina disease, according to a new international study.

In a presentation at the American Academy of Ophthalmology (AAO) 2021 Meeting in New Orleans, Professor Mark Gillies of the Save Sight Institute at University of Sydney, presenting on the Fight Retinal Blindness (FRB) study investigators, shared data highlighting the impact of public COVID-19 response on the overall management of ophthalmic disease.

COVID-19 required a “rapid restructuring” of clinical practices: resources were repurposed to increase patient capacity, and limiting transmission risk was prioritized in clinical environments, Gillies explained.

Additionally, the field focused on reorganizing patient monitoring and treatment protocols, and drug classes such as anti-VEGF therapies were provisioned and prioritized for those with the greatest need. In fact, Gillies shared nationwide data from France showing a 47.1% reduction in filled prescriptions for anti-VEGF therapies in the first 4 weeks of the first pandemic lockdown in 2020, as well as a 65.3% reduction in anti-VEGF treatment initiations.

Gillies and the FRB team sought to interpret the real-world implications of COVID-19 disruption on ophthalmic care, and how such disruptions may vary by diseases and by country.

Their observational assessment of the FRB database included patients receiving anti-VEGF therapy for neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or retinal vein occlusion (RVO), in any of the below 8 countries:

• Australia
• France
• Ireland
• Italy
• Netherlands
• New Zealand
• Spain
• Switzerland

Gillies and colleagues defined a patient’s baseline visit as their last anti-VEGF injection appointment within 3 months prior to the first COVID-19 lockdowns in March 2020. The team assessed data from 6 months prior to and 6 months after lockdown for changes in visual acuity (VA), number of injections and visits, and rates of dropout.

Their population included 5782 eyes from 4708 patients—4649 eyes having nAMD (n = 3797 patients), 654 eyes having DME (n = 440 patients), and 479 eyes having RVO ( n = 471 patients). Patients’ prior-lockdown treatment duration was approximately 2.2 years; 23-30% of patients receiving anti-VEGF were on a 4-6 weekly treatment regimen, and approximately 25% were on a >12 weekly treatment regimen.

Among patients with nAMD, mild-to-moderate mean VA loss following the lockdown was observed in Ireland, Italy, and Spain. All observed countries reported reductions in anti-VEGF injections before and after the COVID-19 lockdowns, with greater reductions observed in Ireland, Italy, New Zealand, and Spain. Patients with DME and RVO received fewer treatment injections than patients with nAMD.

Investigators also reported “noticeably long” treatment intervals for the first injection after the COVID-19 lockdown indicating ≥1 missed injection. Dropouts were severe; each disease cohort reported ≥20% rate of failure to complete 6-month follow-up in care following the lockdown.

All countries’ patients with nAMD reported a mean VA reduction from baseline—anywhere from -0.4 letters to -3.8 post-lockdown. Median injection rates slipped from approximately 4 to 5 prior to lockdowns to 2 to 4 afterward; median treatment intervals extended 1 to 3.5 weeks, depending on the country.

Among patients with DME and RBO, investigators observed greater drop out rates, generally stable or mild VA losses, and decreased anti-VEGF injection frequency across all countries. “This gives us some evidence to suggest we should be prioritizing eyes with neovascular age-related macular degeneration in circumstances such as this,” Gillies said.

The team concluded that COVID-19 and subsequent initial lockdowns were associated with ≥1 missed anti-VEGF injections among European patients with retinal disease; however, services were “quick to return to normal” post-lockdown.

The study, “A Multicountry Analysis of the Effect of COVID-19 on Outcomes of VEGF Inhibitor Therapy,” was presented at AAO 2021.