Anti-vascular endothelial growth factor treatment regimens preference by choroidal neovascularization patients under COVID-19.

Dear Editor:

Transmitting through close contact, coronavirus disease 2019 (COVID-19) is scaring ophthalmological patients away from clinic attendance.[1] However, timely intravitreal injection of anti-Vascular Endothelial Growth Factor (VEGF) is essential for treating neovascular age-related macular degeneration. Different anti-VEGF injection regimens were long argued on literature for their functional outcomes and practicability of clinic visits;[2] whereas benefits from regimens switching were also evaluated.[3] Under COVID-19, regimen switching was rediscussed with particular concerns on ophthalmology clinic staying time[4] and frequency of clinic visits.[5]

Herein, we report our public acute hospital-based retina clinic observations. As background information, our hospital received active COVID-19 cases for treatment, but there were no operational changes under the 3-month investigative period (1/2/2020-30/4/2020). All patients visiting the hospital were screened by infrared thermometer for fever; fever suspects were all diverted away from the ophthalmology clinic to the hospital's emergency department surveillance ward for further investigations. Besides, patients with travel history from pandemic areas and close contact to COVID-19 infected cases were barred from the ophthalmology unit entrance during the quarantine period. Anti-VEGF were all done inside operation theatre as if before the COVID-19 local outbreak on 24/1/2020; except patients were straightly required to wear facemask inside the hospital area. Active choroidal neovascularization (CNV) patients (defined by new hemorrhage on fundus examination, or presence of fluid on optical coherence tomography) were all on regular monthly or bi-monthly (according to the choice of anti-VEGF) injections. For inactive CNV patients, they were free to choose their injection regimens. All patients paid the anti-VEGF medications themselves, and regimen choices out of a patient's financial concern were excluded from this audit.

A total of 136 anti-VEGF treatment-experienced (with 1–14 injections previously) CNV patients who were financially capable of continuing injection were evaluated. The mean age was 68.3 years old (range 56–92), with male predominance (male-to-female ratio = 2.6:1). At baseline, 59 (43.4%), 26 (19.1%), and 51 (37.5%) patients were having regular, treat-and-extend (T&E,) and pro-re-nata (PRN) injection regimens, respectively. Three active CNV cases were on monthly injections of ranibizumab, and no inactive CNV patients were on the regular injection regime at baseline. About 44.9% of patients switched their regimens under the COVID-19 pandemic, and 28.7% of patients were lost to follow-up, with no mortality or morbidity from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection detected on the territory-wide registry within the month after. Injection-related complications such as subconjunctival hemorrhage, postinjection ocular hypertension, and floaters were reported, with no additional adverse events nor complications arose as a consequence of injection in COVID-19 pandemic era. Strict regulation on facemask wear was believed to be the key. Details of different regimens switching were listed in Fig. 1. Four cases, two each from regular and T&E group, respectively, postponed their entire clinic visit and injection plan for 2 weeks because of acute conjunctivitis, these cases were negative for SARS-CoV-2 eventually. No one was switching to regular monthly injections, nor T&E regimen. T&E regimen patients were most compliance, without any loss to follow-up; whereas the PRN group got the highest loss to follow-up rate. We believe PRN group patients were of poorer treatment motivation on baseline reflected from their PRN choices; while T&E regimen patients were more educational to understand their complicated choices on variable injection intervals. In terms of hospital visit frequency, a total of 61 patients missed together 100 planned hospital visits based on their personal choices on regimen switching. Despite the possibility of irreversible visual loss without timely anti-VEGF intravitreal injection, patients' autonomy was fully respected under the COVID-19 pandemic, when infection of SARS-CoV-2 viruses could be fatal in these vulnerable elderly.

Figure 1

Patient preferences for anti-VEGF treatment regimens for choroidal neovascularization under COVID-19

In conclusion, we observed a change in patients' preference for anti-VEGF treatment regimens under the COVID-19 pandemic. Retina specialists should be aware of such changes with potentially severe consequences; and adapt our injection practice with good patient communication, to minimize COVID-19 infection risk while prioritizing patients' greatest need.

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Conflicts of interest

There are no conflicts of interest.