COVID-19 Pandemic Linked to Significant Decrease in Number of Intravitreal Injections

The COVID-19 pandemic significantly decreased the number of intravitreal injections (IVIs) for retinal disorders, compared to rates reported pre-COVID, according to epidemiologic patterns found in new research.¹

Decrease rates in IVIs were found to be significantly higher among patients with age-related macular degeneration (AMD), who were older than patients from other subgroups, and may have resulted in greater loss of vision.

“Considering the fact that very early in the beginning of the pandemic, it was revealed that older age is a major risk factor for the severity of COVID-19 disease, it can be hypothesized that the concerns about COVID-19 infection had its greatest effect on AMD patients compared to the younger groups of patients with other IVI-indications,” wrote the investigative team, led by Mohammad Zarei, MD, from Farebi Eye Hospital in Tehran, Iran. “It is also noteworthy that older people are probably more dependent on their family members for seeking health care services, and this may further compromise the chance for receiving IVIs.”

IVIs are considered an elective medical measure in the majority of cases, suggesting both the amount and referral of patients receiving injections may have been influenced by the pandemic. Using data from their center, Zaeri and colleagues aimed to evaluate the epidemiologic impact of COVID-19 on IVI procedures regarding changes in IVI numbers, indications, and referral patterns of patients. The retrospective comparative cohort study retrieved data on patients receiving IVIs between February 2019 - February 2021, covering the 12 months before and after the beginning of the COVID-19 pandemic.

Patients were categorized into 5 groups according to the diagnostic code: diabetic macular edema (DME), choroidal neovascularization (CNV)/age-related macular degeneration (AMD), retinal venous occlusion (RVO), retinopathy of prematurity (ROP), and miscellaneous indications. The IVIs of either bevacizumab or triamcinolone acetonide or both together were performed following a defined protocol in a modified operating room setting. Primary outcomes for the study included the change in the total number of injections and the change in various IVIs indications; secondary outcomes consisted of the change in the referral pattern of patients.

A total number of 40,600 OR visits were recorded during the study period, including 25,590 (n = 34,508 injections) in pre-COVID and 15,010 (n = 19,879 injections) in COVID periods. Compared to the pre-COVID period, data showed a 37.6% decrease in the number of patients receiving IVI in the COVID period (10518 injections vs. 6569 injections). The analysis revealed a parallel decrease in the number of OR visits (25,590 vs. 15,010; 41.4%) and injections (34,508 vs. 19,879; 42.4%).

There was no correlation observed between the number of reported national confirmed cases of COVID-related deaths and IVI numbers (P = .71 and P = .45, respectively). The most prevalent indication in both periods was DME-related OR visits; 68.6% (n = 17,542) and 69.2% (n = 10,386) in pre-COVID and COVID, respectively. Patients in the AMD group had a significantly higher decrease in OR visit rate compared to the DME and RVO groups (P <.001).

Additionally, parallel to the change in the number of injections, a similar pattern in the number of patients receiving IVIs was reported. Patients with AMD had the highest decrease in the IVI rate (46.3%), which was significantly higher than decrease in other indications (P <.001). Meanwhile, the number of patients with ROP showed no decrease after COVID-19.

“Finding a comprehensive explanation for this poor correlation pattern needs more in‑depth studies on the behavior and dynamism of health systems and individual persons in reaction to an epidemiologic crisis,” investigators wrote. “However, factors like lack of reliable COVID-related statistics, poor agility, and slow reaction of health system to crises, or lack of reliable information and guideline, especially in the early months of the pandemic, may be considered.”

References

1. Mirghorbani M, Riazi-Esfahani H, Bazvand F, Bahar MM, Yaseri M, Zarei M. Impact of Coronavirus Disease 2019 Pandemic on the Epidemiology of Intravitreal Injections. J Curr Ophthalmol. 2023;34(4):442-447. Published 2023 Apr 29. doi:10.4103/joco.joco_253_22Zarei
2. M, Roohipoor R, Mahmoudzadeh R, Yaseri M, Riazi-Esfahani H. Epidemiology of intravitreal injections in Iran: Indications and referral patterns in a tertiary hospital. Clin Ophthalmol. 2020;14:1201–6.