Trends in Utilization of Vitreoretinal Services Following the Initial Phase of the 2020 COVID-19 Pandemic.

BACKGROUND: To identify vitreoretinal practice patterns in the months following the initial 2020 national shutdown due to the COVID-19 pandemic in the United States (US). STUDY DESIGN: Retrospective analysis of vitreoretinal practice patterns from multiple retinal centers across the US from January 1, 2018 to December 31, 2020. RESULTS: The lowest utilization of retina care occurred during the week of March 23, 2020, after which utilization returned to pre-pandemic levels by July 2020. Patients with retinal detachments (RDs) presented with worse visual acuity during March, April, and May 2020 compared to the same time periods of 2018 and 2019 (P values < 0.05). However, only comparing eyes that presented in March 2018 to March 2020, was the year 1 vision significantly worse (P = 0.008). CONCLUSION: The COVID-19 pandemic significantly impacted vitreoretinal care. The vision of patients with RDs may not have been affected by the delayed presentation. [Ophthalmic Surg Lasers Imaging Retina 2023;54:15-23.].

Survey of Vitreoretinal Specialists in the United States Regarding Telemedicine During the COVID-19 Pandemic.

Objective: To evaluate the attitudes, beliefs, and practice patterns of vitreoretinal specialists regarding the utilization of telemedicine during the COVID-19 pandemic, and to identify features which may predict future telemedicine use. Methods: An 11-question anonymous survey was completed electronically in July 2020 by vitreoretinal specialists practicing in the United States. Results: The survey response rate was 13.0% (361/2,774). Thirty-five respondents (9.7%) had used telemedicine before March 1, 2020; after March 1, 2020, 170 (47.1%) reported using telemedicine (p < 0.001). Of the 170 respondents who reported telemedicine use, a majority (65.3%;111/170) performed 0-5 patient visits per week. Female retina specialists, younger physicians, and those with prior telemedicine usage were more likely to use telemedicine. Barriers to telemedicine use included concern for misdiagnosis (332/361, 92.0%), inability to obtain optical coherence tomography imaging (330/361, 91.4%), inability to obtain fundus imaging (327/361, 90.6%), lack of access to and/or comfort with the technology (261/361, 72.3%), potential legal liability (229/361, 63.4%), and low reimbursement (227/361, 62.9%). The majority of respondents (225/361; 62.3%) reported that telemedicine without ancillary imaging was not an acceptable way to evaluate patients. However, 59.2% (214/361) would find telemedicine acceptable if remote imaging was available. Conclusions: The pandemic led to a rapid adoption of telemedicine by vitreoretinal specialists. The majority of specialists using telemedicine performed five or fewer visits per week. The availability of remote imaging may increase confidence in clinical outcomes with a subsequent increase in utilization of telemedicine by vitreoretinal specialists.

REGIONAL POPULATION MOBILITY AND OUTPATIENT RETINA VISITS IN THE UNITED STATES DURING THE COVID-19 PANDEMIC.

PURPOSE: To characterize how community mobility patterns across the United States correlate with local changes in retina visits during the pandemic. METHODS: Outpatient retina clinic visits were linked to population mobility by combining multiple public data sets, including the Google Community Mobility Reports and data from the Centers for Disease Control and Infection. Percentage change from baseline in daily-average number of retina visits by county and mobility were measured by county. RESULTS: A total of 2,159,689 patient visits were examined across 332 counties. Daily-average retina visits decreased by 7.0%, 19.0%, 5.0%, and 4.0% from Quarter 1 to 4 of 2020. This decrease was negatively correlated with increased incident of COVID-19 deaths for Quarters 1 to 3 (r = -0.13, r = -0.16, and r = -0.15, respectively, P < 0.001) and increased incident cases for Quarters 1 and 2 (r = -0.18, r = -0.13, respectively, P < 0.001). Daily-average retina visits relative to baseline were significantly lower for metropolitan counties in Quarters 1 and 2, compared with urban and rural (P < 0.001). The decline in retina visits had greatest association with decline in workplace visits in Quarters 1 to 3 (r = 0.27, r = 0.09, r = 0.12, respectively, P < 0.001 for all). CONCLUSION: This study provides insight into how regional mobility patterns may help to explain and predict patient behaviors and retina outpatient visit responses during the COVID-19 pandemic.

ACUTE MACULAR NEURORETINOPATHY AFTER SARS-COV-2 VACCINATION.

PURPOSE: To present the rare case of a patient who developed acute macular neuroretinopathy (AMN) after administration of a single-dose adenovector coronavirus vaccine. METHODS: Retrospective chart review. RESULTS: A 26-year-old woman presented with paracentral scotomas in both eyes that acutely developed 2 days after administration of a single-dose adenovector SARS-CoV-2 vaccine (Johnson & Johnson, New Brunswick, NJ). She had previously received the seasonal influenza immunization without any symptoms and denied having any recent history of viral illnesses. On examination, optical coherence tomography showed parafoveal hyperreflective bands in the outer retina of both eyes without retinal thickening and near-infrared reflectance showed wedge-shaped parafoveal lesions pointing to the fovea, both classic findings in acute macular neuroretinopathy. DISCUSSION: This report highlights the development of acute macular neuroretinopathy after a SARS-CoV-2 vaccination in an otherwise healthy female patient. A single case cannot establish cause and effect, and millions of COVID-19 vaccines have been administered safely at the time of writing. However, this may be a rare association, and clinicians can consider inquiring about recent vaccination history in patients presenting with acute macular neuroretinopathy.

The Influence of Universal Face Mask Use on Endophthalmitis Risk after Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

PURPOSE: Routine use of face masks for patients and physicians during intravitreal anti-vascular endothelial growth factor (VEGF) injections has increased with the emergence of the coronavirus disease 2019 pandemic. This study evaluates the impact of universal face mask use on rates and outcomes of post-injection endophthalmitis (PIE). DESIGN: Retrospective, multicenter, comparative cohort study. PARTICIPANTS: Eyes receiving intravitreal anti-VEGF injections from October 1, 2019, to July 31, 2020, at 12 centers. METHODS: Cases were divided into a "no face mask" group if no face masks were worn by the physician or patient during intravitreal injections or a "universal face mask" group if face masks were worn by the physician, ancillary staff, and patient during intravitreal injections. MAIN OUTCOME MEASURES: Rate of endophthalmitis, microbial spectrum, and visual acuity (VA). RESULTS: Of 505 968 intravitreal injections administered in 110 547 eyes, 85 of 294 514 (0.0289%; 1 in 3464 injections) cases of presumed endophthalmitis occurred in the "no face mask" group, and 45 of 211 454 (0.0213%; 1 in 4699) cases occurred in the "universal face mask" group (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.51-1.18; P = 0.097). In the "no face mask" group, there were 27 cases (0.0092%; 1 in 10 908 injections) of culture-positive endophthalmitis compared with 9 cases (0.004%; 1 in 23 494) in the "universal face mask" group (OR, 0.46; 95% CI, 0.22-0.99; P = 0.041). Three cases of oral flora-associated endophthalmitis occurred in the "no face mask" group (0.001%; 1 in 98 171 injections) compared with 1 (0.0005%; 1 in 211 454) in the "universal face mask" group (P = 0.645). Patients presented a mean (range) 4.9 (1-30) days after the causative injection, and mean logarithm of the minimum angle of resolution (logMAR) VA at endophthalmitis presentation was 2.04 (~20/2200) for "no face mask" group compared with 1.65 (~20/900) for the "universal face mask" group (P = 0.022), although no difference was observed 3 months after treatment (P = 0.764). CONCLUSIONS: In a large, multicenter, retrospective study, physician and patient face mask use during intravitreal anti-VEGF injections did not alter the risk of presumed acute-onset bacterial endophthalmitis, but there was a reduced rate of culture-positive endophthalmitis. Three months after presentation, there was no difference in VA between the groups.

Rationale for American Society of Retina Specialists Best Practice Recommendations for Conducting Vitreoretinal Surgery during the COVID-19 Era.

PURPOSE: To detail the rationale behind recommendations recently published by the American Society of Retina Specialists (ASRS) outlining best practices for safety of vitreoretinal surgeons and staff while performing vitreoretinal surgery during the coronavirus disease (COVID)-19 pandemic. METHODS: The committee for ASRS Best Practices for Retinal Surgery during the COVID-19 Pandemic reviewed existing evidence and information on SARS-CoV-2 transmission, and risk factors during vitreoretinal surgery. Recommendations were based on best available published data, cumulative clinical experiences, and recommendations and policies from other organizations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the strength of recommendations and confidence in the evidence. These serve as interim recommendations which are routinely updated given gaps of knowledge and lack of high-quality data on this evolving subject. RESULTS: Relevant existing literature related to methods of transmission, and ocular manifestations of SARS-CoV-2 are summarized. The data and clinical experiences driving recommendations for pre-operative, intraoperative and post-operative surgical considerations, anesthesia choice, as well as considerations for intravitreal injections are provided. CONCLUSION: Recommendations are provided with the goal of protecting vitreoretinal surgeons and associated personnel from exposure to SARS-CoV-2 during interventional vitreoretinal procedures. This is a rapidly evolving topic with numerous remaining gaps in our current knowledge. As such, recommendations will evolve and the current manuscript is intended to serve as a foundation for continued dialogue on best practices.

Bacterial Dispersion Associated With Various Patient Face Mask Designs During Simulated Intravitreal Injections.

PURPOSE: We sought to investigate bacterial dispersion with patient face mask use during simulated intravitreal injections. DESIGN: Prospective cross-sectional study. METHODS: Fifteen healthy subjects were recruited for this single-center study. Each participant was instructed not to speak for 2 minutes, simulating a "no-talking" policy, while in an ophthalmic examination chair with an blood agar plate secured to the forehead and wearing various face masks (no mask, loose fitting surgical mask, tight-fitting surgical mask without tape, tight-fitting surgical mask with adhesive tape securing the superior portion of the mask, N95 mask, and cloth mask). Each scenario was then repeated while reading a 2-minute script, simulating a talking patient. The primary outcome measures were the number of colony-forming units (CFUs) and microbial species. RESULTS: During the "no-talking" scenario, subjects wearing a tight-fitting surgical mask with tape developed fewer CFUs compared with subjects wearing the same mask without tape (difference 0.93 CFUs [95% confidence interval 0.32-1.55]; P = .003). During the speech scenarios, subjects wearing a tight-fitting surgical mask with tape had significantly fewer CFUs compared with subjects without a face mask (difference 1.07 CFUs; P = .001), subjects with a loose face mask (difference 0.67 CFUs; P = .034), and subjects with a tight face mask without tape (difference 1.13 CFUs; P < .001). There was no difference between those with a tight-fitting surgical mask with tape and an N95 mask in the "no-talking" (P > .99) and "speech" (P = .831) scenarios. No oral flora were isolated in "no-talking" scenarios but were isolated in 8 of 75 (11%) cultures in speech scenarios (P = .02). CONCLUSION: The addition of tape to the superior portion of a patient's face mask reduced bacterial dispersion during simulated intravitreal injections and had no difference in bacterial dispersion compared with wearing N95 masks.

Clinical Presentation of Rhegmatogenous Retinal Detachment during the COVID-19 Pandemic: A Historical Cohort Study.

PURPOSE: To investigate the effect of the coronavirus disease 2019 (COVID-19) pandemic on the clinical presentation of acute, primary rhegmatogenous retinal detachment (RRD). DESIGN: Single-center, consecutive case series with historical controls. PARTICIPANTS: Consecutive patients seeking treatment for primary RRD in a 50-day period during the COVID-19 pandemic (March 9-April 27, 2020) and the corresponding 50-day period during the previous year (March 4-April 22, 2019) in the United States. METHODS: The cohorts were compared to assess demographic variables and clinical presentations. Multivariate logistic regression was used to identify factors predictive of presenting macular attachment status. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients with macula-on RRD at presentation. Secondary outcomes included visual acuity (VA), duration of symptoms before presentation, proportion seeking treatment within 1 day of symptom onset, and presence of primary proliferative vitreoretinopathy (PVR). RESULTS: Eighty-two patients were included in the 2020 cohort compared with 111 patients in the 2019 primary control cohort. Demographic factors were similar between the groups. Significantly fewer patients demonstrated macula-on RRD in the 2020 cohort (20/82 patients [24.4%]) than in the 2019 cohort (55/111 patients [49.5%]; P = 0.001). Patients in the 2020 cohort showed worse median VA at presentation (1.00 logarithm of the minimum angle of resolution [logMAR; Snellen equivalent, 20/200] in 2020 vs. 0.48 logMAR [Snellen equivalent, 20/60] in 2019; P = 0.008), fewer patients sought treatment within 1 day of symptoms (16/80 patients [19.5%] in 2020 vs. 41/106 patients [36.9%] in 2019; P = 0.005), and a greater proportion demonstrated primary PVR (11/82 patients [13.4%] in 2020 vs. 5/111 patients [4.5%] in 2019; P = 0.03). In multivariate analysis, younger age (P = 0.03) and established patient status (P = 0.02) were independent predictors of macula-on status in the 2020 cohort. CONCLUSIONS: Patients with primary RRD during the 2020 COVID-19 pandemic were less likely to have macula-on disease and more likely to delay seeking treatment and to show worse vision and PVR.

Practice Patterns and Responsiveness to Simulated Common Ocular Complaints Among US Ophthalmology Centers During the COVID-19 Pandemic.

IMPORTANCE: The coronavirus disease 2019 (COVID-19) pandemic has drastically changed how comprehensive ophthalmology practices care for patients. OBJECTIVE: To report practice patterns for common ocular complaints during the initial stage of the COVID-19 pandemic among comprehensive ophthalmology practices in the US. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study, 40 private practices and 20 university centers were randomly selected from 4 regions across the US. Data were collected on April 29 and 30, 2020. INTERVENTIONS: Investigators placed telephone calls to each ophthalmology practice office. Responses to 3 clinical scenarios-refraction request, cataract evaluation, and symptoms of a posterior vitreous detachment-were compared regionally and between private and university centers. MAIN OUTCOMES AND MEASURES: The primary measure was time to next appointment for each of the 3 scenarios. Secondary measures included use of telemedicine and advertisement of COVID-19 precautions. RESULTS: Of the 40 private practices, 2 (5%) were closed, 24 (60%) were only seeing urgent patients, and 14 (35%) remained open to all patients. Of the 20 university centers, 2 (10%) were closed, 17 (85%) were only seeing urgent patients, and 1 (5%) remained open to all patients. There were no differences for any telemedicine metric. University centers were more likely than private practices to mention preparations to limit the spread of COVID-19 (17 of 20 [85%] vs 14 of 40 [35%]; mean difference, 0.41; 95% CI, 0.26-0.65; P < .001). Private practices had a faster next available appointment for cataract evaluations than university centers, with a mean (SD) time to visit of 22.1 (27.0) days vs 75.5 (46.1) days (mean difference, 53.4; 95% CI, 23.1-83.7; P < .001). Private practices were also more likely than university centers to be available to see patients with flashes and floaters (30 of 40 [75%] vs 8 of 20 [40%]; mean difference, 0.42; 95% CI, 0.22-0.79; P = .01). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of investigator telephone calls to ophthalmology practice offices, there were uniform recommendations for the 3 routine ophthalmic complaints. Private practices had shorter times to next available appointment for cataract extraction and were more likely to evaluate posterior vitreous detachment symptoms. As there has not been a study examining these practice patterns before the COVID-19 pandemic, the relevance of these findings on public health is yet to be determined.

Ophthalmology conferences in the coronavirus disease 2019 era.

PURPOSE OF REVIEW: To discuss key considerations involved in adapting an in-person ophthalmology conference to a virtual medium. RECENT FINDINGS: In 2020, several ophthalmological societies have held or are planning to hold virtual conferences in lieu of their previously scheduled in-person ophthalmology conference because of the coronavirus disease 2019 pandemic. The strategic meeting components attempted to be retained in these transitions include educational information disseminating, academic discussion with colleagues, sponsorships, and networking. Live-streamed components of a virtual conference may be entirely real time or may include a combination of both prerecorded and live-streamed components. A virtual meeting may offer either a single live-streamed program or several concurrent live-streamed programs from which attendees can choose. The availability of on-demand content, mechanisms for audience participation, avenues for industry interaction and contribution, registration costs, and continuing medical education credit availability vary between virtual meeting formats. SUMMARY: Transition of an in-person ophthalmology conference to a virtual format with retention of the inherent value associated with the meeting is possible and the experiences of societies executing this adaptation can be helpful for others entering this space. There are numerous considerations regarding meeting format and logistics to contemplate in light of each meeting's specific audience and objectives.

Real-world vitreoretinal practice patterns during the 2020 COVID-19 pandemic: a nationwide, aggregated health record analysis.

PURPOSE OF REVIEW: The COVID-19 pandemic has posed an unprecedented challenge to the healthcare community. To reduce disease transmission, national regulatory agencies temporarily recommended curtailment of all nonurgent office visits and elective surgeries in March 2020, including vitreoretinal outpatient care in the USA. The effect of these guidelines on utilization of vitreoretinal care has not been explored to date. RECENT FINDINGS: Retinal outpatient visits, new patient visits, intravitreal antivascular endothelial growth factor injections and in-office multimodal retinal imaging has seen a significant decline in utilization in the early phase of the pandemic. Intravitreal injections were performed at a comparatively higher rate than office visits. Utilization appeared to steadily increase in April 2020. Telemedicine visits, enabled by new national legislation for all areas of medicine, have been adopted to a modest degree by the retina community. SUMMARY: In-office retinal care declined in response to the COVID-19 pandemic and national regulatory guidelines limiting nonurgent care. These trends in practice patterns and care utilization may be of interest to vitreoretinal providers and all ophthalmologists at large.

Ocular trauma during COVID-19 stay-at-home orders: a comparative cohort study.

PURPOSE OF REVIEW: The aim of this study was to report characteristics of patients presenting with serious ocular injuries during the COVID-19 stay-at-home orders. RECENT FINDINGS: Of 1058 patients presenting for emergency evaluation during the stay-at-home order, 62 (5.9%) patients [mean (SD) age, 41.1 (19.2) years; 19 (31%) women; 31 (50%) white] presented with severe ocular trauma. The daily mean (SD) number of patients who presented for emergency evaluation decreased from 49.0 (9) to 36.4 (6) during the quarantine (P < 0.001). Patients presenting during the stay-at-home order were less likely to have health insurance [odds ratio (OR), 0.33; 95% confidence interval (95% CI), 0.13-0.90, P = 0.024], more likely to have a delayed presentation (difference, 22.7 h, 95% CI, 5.8-39.5, P < 0.001, more likely to travel farther to seek emergency care (difference, 10.4 miles, 95% CI, 2.6-18.2, P < 0.001) and more likely to have an injury occur at home (OR, 22.8; 95% CI, 9.6-54.2, P < 0.001). Of injuries occurring at home, there was a significant increase in injuries arising from home improvement projects during the stay-at-home order (28 vs. 0%, P = 0.02). SUMMARY: During the COVID-19 pandemic, patients with ocular trauma were more likely to have injuries sustained at home and have additional barriers to care. These changes underscore a need for targeted interventions to optimize emergent eye care during a pandemic.