Effects of COVID-19 pandemic on glaucoma appointment scheduling in a tertiary hospital in London, UK.

PURPOSE: To investigate the impact of the delay in patient appointments caused by the COVID-19 pandemic and the triage system on the glaucomatous disease of patients in a London tertiary hospital. METHODS: Observational retrospective study that randomly selected 200 glaucoma patients with more than 3 months of unintended delay for their post-COVID visit and other inclusion and exclusion criteria. Demographic information, clinical data, number of drugs, best-corrected visual acuity (BCVA), intraocular pressure (IOP), visual field (VF) mean deviation (MD), and global peripapillary retinal nerve fibre layer (pRNFL) thickness were obtained from the pre- and post-COVID visit. At the post-COVID visit, the clinical outcomes subjective clinical concern and change of treatment or need for surgery were also annotated. The variables were stratified by glaucoma severity (according to the MD into early, moderate and advanced) and by delay time (more and less than 12 months) and analysed using SPSS. RESULTS: We included 121 eyes (from 71 patients). The median patient age was 74 years (interquartile range -IQR- 15), 54% were males and 52% Caucasians. Different glaucoma types and all glaucoma severities were included. When data was stratified for glaucoma severity, at the pre-COVID visit, significant differences in BCVA, CCT and IOP were observed and there were significantly higher values in the early glaucoma group. The median follow-up delay was 11 months (IQR 8), did not differ between the glaucoma severity groups and did not correlate to the glaucoma severity. At the post-COVID visit, significant differences in BCVA, IOP, and Global pRNFL thickness were observed between the glaucoma severity groups, as lower BCVA and higher IOP and pRNFL thickness were observed in the early glaucoma group. At the post-COVID visit there was cause for concern in 40 eyes: 5 were followed more closely, 22 had a change of treatment and 13 were booked for surgery (3 for cataract and 10 for glaucoma surgery). However, the number of eyes with causes for concern were similar between the glaucoma severity groups and there was no correlation between these clinical outcomes and the delay of the post-COVID visit. The number of topical hypotensive medications increased significantly after the post-COVID visit, higher number of medications were observed in the advanced glaucoma group. When differences of IOP, MD and pRNFL thickness between the pre and post-COVID visit, only the MD difference was significantly different between the glaucoma severity groups because it was higher in the severe group. When data was stratified for delay longer or shorter than 12 months, no differences were observed between the groups except at the pre-COVID visit, when the numbers of patients with MD deviation >-6 dB had longer delay time. When differences in IOP, MD and RNFL thickness were calculated, only the pRNFL thickness showed significant differences between the delay groups, because it was higher in the longer delay group. Finally, when paired analysis of the variables at the pre- and post-COVID visits, stratified by glaucoma severity and delay were conducted, although there were no significant differences in IOP in any group, the BCVA decreased significantly in the overall group and in the longer delay groups, the number of hypotensive drugs increased significantly overall and in the moderate and advanced glaucoma, the MD of the VF worsened significantly in the overall group and in the early glaucoma and longer delay groups and the pRNFL thickness decreased significantly in all groups. CONCLUSIONS: We document that delayed care impacts negatively on the glaucomatous disease of our patients because at the post-COVID visit there were reasons for clinical concern in a third of eyes that resulted in change of treatment or surgery. However, these clinical consequences were not related to IOP, glaucoma severity or delay time and reflect that the triage methods implemented worked adequately. The most sensitive parameter to indicate progression in our sample was the pRNFL thickness.

What has COVID taught us about glaucoma management?

Since the spread of coronavirus pandemic caused by the SARS‐CoV‐2 virus, several measures were implemented worldwide to try to stop the pandemic and minimize its impact on healthcare.Ophthalmologists are one of the most exposed specialists to airborne particles due to their close proximity to patients' faces during the examination.Therefore during the pandemic, all non‐essential procedures and appointments were cancelled or postponed, and new approaches to virtual clinics were explored.This presentation will discuss the impact of Covid related delayed care in patients with glaucoma and how the implementation of virtual and diagnostic clinics had on reducing long waiting list and streamlining patient's care .

Delayed follow‐up of glaucoma patients due to COVID‐19 pandemic – impact on disease progression

PurposeTo determine the impact of delayed follow‐up on the disease course in patients with glaucoma.MethodsA retrospective case series of 224 glaucoma patients. Data analysis from the hospital electronic medical record was performed on patients attending the glaucoma clinic between April and May 2021 at Charing Cross Hospital, London, United Kingdom, after easing of the national lockdown due to COVID‐19 pandemic. The main outcome measures included increased intraocular pressure (IOP), worsening of visual field (VF) defect, thinning of retinal nerve fibre layer (RNFL) and the posterior pole using spectral domain Optical Coherence Tomography (OCT).ResultsNotes from 224 patients were analysed. Among them, 24 patients were identified to develop a progression of glaucoma. Majority of patients (10, 42%) had open angle glaucoma, 6 (25%) had normal tension glaucoma, 5 (21%) were glaucoma suspects, 2 (8%) had narrow angle glaucoma and 1 (4%) had angle closure glaucoma. The mean IOP (±SD) pre‐lockdown was 15.4 ± 3.8 mmHg and post‐lockdown was 16.7 ± 5.4 mmHg (p < 0.05). The average RNFL thickness pre‐lockdown was 79.7 ± 15.7 µm and post‐lockdown was 78.8 ± 15.6 µm (p > 0.05). Of the 24 patients who developed progression, 16 had an increase in IOP (mean ∆ IOP was 3.8 ± 1.8 mmHg;p < 0.05), 19 patients had a clinically significant RNFL thinning (mean ∆ was 3.3 ± 1.4 µm;p < 0.05) and 9 patients had worsening of VF. The average timing between pre‐ and post‐lockdown visit was 15.1 months (SD ± 7.6).ConclusionsThese results confirm that a proportion of patients developed glaucoma progression during the COVID Lockdown which could be attributed to delayed follow‐up. Further analyses of these data will be needed to confirm how the results of this study could help to guide future decisions making and guidance on prioritising and managing glaucoma patients if disruption to standard of care occurs.

The iVAN Project: an innovative solution to meet the challenges in trial recruitment during a global pandemic

PurposeCOVID‐19 has greatly affected the number of patients willing and able to attend hospital, with research activity also greatly impacted. Imperial College Ophthalmology Research Group (ICORG) have observed clinical backlogs and a 77% decrease in trial patient recruitment. As a first of its kind, this project aims to combat clinic waiting lists and patient confidence in trial involvement through creating a safe, flexible and decentralised healthcare environment with iVAN, a mobile research unit.MethodsA survey of outpatients was performed exploring attitudes towards visiting hospital for clinical and research reasons amidst a pandemic. A vehicle was equipped with state‐of‐the‐art clinical research facilities in a COVID‐safe environment. A multi‐stage approach was taken in order to achieve relevant driving and roadworthiness certification, multi‐disciplinary involvement and healthcare network planning in order to ensure the smooth progression of the project. A pilot period of clinical visits was carried out and evaluated in close vicinity to the hospital.ResultsOf the 53 patients surveyed, 60% percent of patients were not willing to take part in clinical trials with others having concerns related to travel and being in the hospital. The final layout of the vehicle includes imaging devices, a visual field analyser, IT equipment and space for staff to see patients. Social distancing and infection control have been ensured to provide a pleasant and safe working environment. A pilot period is underway assessing staff and patient satisfaction along with capacity and trial data runs, with future plans involving satellite clinics in the community.ConclusionsFlexible and innovative service provision continues to be required to minimise morbidity attributable to the pandemic. The iVan has the facilities to bring decentralised, specialist ophthalmic care into local communities in a COVID‐safe manner, whilst being a useful tool to engage future research participants.