Determination of Factors Influencing the Health Belief Model (HBM) and Adherence to Intravitreal Anti-vascular Endothelial Growth Factor (VEGF) Among Patients With Diabetic Macular Edema (DME).

Background Diabetic macular edema (DME) is becoming one of the leading causes of blindness worldwide with a significant impact on quality of life. The effectiveness of intravitreal (IVT) anti-vascular endothelial growth factor (VEGF) therapy has been established by clinical trials and has become the treatment of choice in the majority of DME patients in reducing macular edema and improving visual acuity. Frequent drop-out and discontinuation of treatment are major issues. Lack of compliance can lead to worsening outcomes and be a burden to patients and the healthcare system. Purpose The purpose of this study is to assess multiple factors that affect adherence to IVT anti-VEGF treatment among patients with DME, including socioeconomic causes and the Health Belief Model (HBM) domains, in addition to exploring the relationship between them. Methods This cross-sectional study was conducted among DME patients in Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia, from December 2020 to June 2021. We identified eligible patients using a retrospective chart review of clinical findings and optical coherence tomography (OCT) findings. Included subjects were of Malaysian nationality, aged 18 years and above, who were initiated or re-initiated IVT anti-VEGF treatment regime and on follow-up for at least six months from initial injection from January 2019 onwards. A translated and validated self-administered questionnaire was given to the respondents. Data were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). Demographics of the patient were summarized using descriptive statistics, independent sample t-test was used to compare the difference in components of the HBM questionnaire. Linear regression was further used to explore the relationship between patients' demographics and the HBM component. Results A total of 141 patients participated in this study, of whom 56.2% patients were adherent to treatment. The majority were aged 60 years and above (56.7%), male (52.5%), Malay (38.9%), and married (71.6%). There was a significant statistical difference in patients who were adherent to treatment, in terms of life entourage (p=0.004, Fisher Exact test). HBM domains that influenced adherence to treatment included perceived severity, perceived barriers, perceived benefits, cues to action, and self-efficacy (p<0.05, independent sample t-test). Further, multiple logistic regression tests on sociodemographic factors and HBM domains after eliminating confounding factors narrowed down the significant variables to perceived susceptibility (p= 0.023), perceived benefits (p< 0.001), and self-efficacy (p< 0.001). Conclusion Patients' adherence to IVT anti-VEGF is influenced by perceived susceptibility to complications from DME, perceived benefits to the treatment, and self-efficacy.

Reasons for not improving visual acuity of DME patients due to interruption of anti-VEGF therapy during the pandemic and OCT imaging analysis

*AIM: To identify the reasons for not improving visual acuity of patients with diabetic macular edema (DME) and its correlation with optical coherent tomography (OCT) imaging characteristics. They were treated with anti - vascular endothelial growth factor (VEGF) again after an interruption of treatment due to the COVID - 19 pandemic. * METHODS: Retrospective cases study. A total of 31 patients (40 eyes) with DME and treated with anti-VEGF drugs in the Department of Ophthalmology of the First Affiliated Hospital of Xi' an Jiaotong University between December 2019 and July 2020 were selected. All patients had an treatment history of interruption due to COVID-19. Based on the behavioral standard of best corrected visual acuity (BCVA) at 1mo after re - treatment, they were divided into improved visual acuity group (14 eyes) and non-improved visual acuity group (26 eyes). All patients received comprehensive ophthalmic examinations, including BCVA, intraocular pressure, OCT, fundus photography, and fundus fluorescein angiography (FFA). The central retinal thickness (CRT), hyper - reflective retinal dots (HRD), subretinal fluid (SRF), intraretinal fluid (IRF), disorganization of the inner retinal layers (DRIL) and ellipsoid zone disruption (EZD) were quantified by Image J. The correlation between BCVA and CRT, the number of HRD, the diameter of SRF and IRF, and the height of DRIL and EDZ width at 1mo after treatment were analyzed by Spearman correlation. * RESULTS: The proportion of HRD in OCT was significantly higher in the non - improved visual acuity group than that in the improved visual acuity group (chi2 = 5.43, P = 0.0072);There was a positive correlation between the difference of BCVA (LogMAR) and CRT change in DME patients after treatment (rs = 0.406, P = 0.009);There was a positive correlation between BCVA (LogMAR) and EZD width after treatment (rs = 0.358, P = 0.023). There was no correlation between BCVA (LogMAR) after treatment and the number of CRT (rs = - 0. 086, P = 0. 600) and HRD (rs = - 0. 115, P = 0. 482), the diameter and height of SRF (rs = 0.102, P = 0.530;rs = 0.100,P = 0.538) and IRF (rs = 0.134, P = 0. 410;rs = - 0. 014, P = 0. 932), and the width of DRIL (rs = 0.089, P = 0.587). * CONCLUSION(S): The probability of retinal HRD was significantly higher in patients with no visual improvement than that in patients with visual improvement after the re - treatment with anti - VEGF due to the treatment interruption during COVID- 19. EZD width was also closely correlated to the prognosis of visual acuity. As for these patients, HRD manifestations in OCT should be comprehensively considered, taking intravitreal injection of glucocorticoid as an auxiliary strategy if necessary. Copyright © 2022 International Journal of Ophthalmology (c/o Editorial Office). All rights reserved.

Patient Experience With Anti-Vascular Endothelial Growth Factor (VEGF) Therapy in Neovascular Age-Related Macular Degeneration (nAMD) and Diabetic Macular Edema (DME): A Multinational Survey

Objectives: Intravitreal anti-vascular endothelial growth factor (VEGF) therapy is efficacious for neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME). However, the frequent treatment and monitoring required for optimal real-world outcomes can be burdensome to patients and can impact adherence to treatment. This study aimed to understand patient treatment experience with anti-VEGF standard of care. Method(s): A cross-sectional survey was employed comprising de novo questions, patient-reported outcome (PRO) measures and medical chart extraction. Adult patients with nAMD or DME treated with intravitreal anti-VEGF injections for >=12 months were recruited via 38 clinical sites (6 Canada, 6 France, 4 Italy, 7 Spain, 6 United Kingdom, 9 United States). Result(s): Surveys were completed by 391 patients with nAMD and 183 patients with DME. PRO scores indicated that patients across both conditions had relatively high vision-related functioning and were generally satisfied with their current treatment. Mean number of anti-VEGF injections over 12 months across countries ranged from 6.3-9.7 for nAMD and 4.3-8.0 for DME. Nineteen patients with nAMD (19/391;5%) and 27 patients with DME (27/183;15%) missed >=1 injection or examination visit in the past 12 months. Reported barriers were mainly related to treatment (eg, pain and discomfort during/after anti-VEGF injection), clinic (eg, not having someone to accompany them to appointments) and, to a lesser extent, the COVID-19 pandemic. After treatment, the majority recovered in <=1 day;however, 24% (139/574) needed >1 day to recover. Impairment in daily activities due to treatment was reported by 45% (258/574) of patients. Among working patients 62% (41/66) reported productivity impairment from absenteeism. Conclusion(s): Patients reported impairment of daily activities, burden and barriers related to intravitreal anti-VEGF therapy, despite high adherence and treatment satisfaction levels. More durable therapy options, requiring less frequent treatments may be able to reduce treatment-related burden and barriers. Copyright © 2022

Impact of the COVID-19 Pandemic on the Metabolic Control of Diabetic Patients in Diabetic Retinopathy and Its Screening.

(1) Background: Diabetic retinopathy (DR) is a complication of diabetes mellitus (DM), screening programs of which have been affected by the COVID-19 pandemic. The aim of the present study was to determine the impact of the COVID-19 pandemic on the screening of diabetes patients in our healthcare area (HCA). (2) Methods: We carried out a retrospective study of patients with DM who had attended the DR screening program between January 2015 and June 2022. We studied attendance, DM metabolic control and DR incidence. (3) Results: Screening for DR decreased in the first few months of the pandemic. The incidence of mild and moderate DR remained stable throughout the study, and we observed little increase in severe DR, proliferative DR and neovascular glaucoma during 2021 and 2022. (4) Conclusions: The current study shows that during the COVID-19 pandemic, screening program attendance decreased during the year 2020, which then recovered in 2021. Regarding the most severe forms of DR, a slight increase in cases was observed, beginning in the year 2021. Nevertheless, we aimed to improve the telemedicine systems, since the conditions of a significant proportion of the studied patients worsened during the pandemic; these patients are likely those who were already poorly monitored.

Impact of the COVID-19 Pandemic on Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema in Japan.

Anti-vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME) improves visual acuity. However, repeated injections during routine outpatient visits are required to maintain this effect. The recent sudden global outbreak of coronavirus disease 2019 (COVID-19) had a major impact on daily life, including medical care, such as the provision of VEGF therapy. We retrospectively investigated the relationship between the number of anti-VEGF injections for DME and the number of new COVID-19-positive patients at 23 centers in Japan. We also surveyed ophthalmologists regarding the impact of the COVID-19 pandemic on anti-VEGF therapy. In the third and fourth waves of the pandemic, when the number of infected patients increased, the number of injections significantly decreased. In the first, third, and fourth waves, the number of injections increased significantly during the last month of each wave. Approximately 60.9% of ophthalmologists reported that the number of injections decreased after the pandemic. Of the facilities, 52.2% extended the clinic visit intervals; however, there was no significant difference in the actual number of injections given between before and after the pandemic. Although the number of injections temporarily decreased, Japanese ophthalmologists maintained the total annual number of anti-VEGF injections for DME during the pandemic.

Expansion of a teleophthalmology program for diabetic retinopathy screening during the COVID19 pandemic

Purpose : The COVID-19 pandemic prompted efforts to encourage social distancing and minimize non-urgent in-person eye care. Here, we report the outcomes of a teleophthalmology program for diabetic retinopathy screening at an integrated health system in California that was expanded during the pandemic. Methods : We performed a retrospective review of patients who underwent remote retinal imaging as part of a teleophthalmology program for diabetic retinopathy (DR) screening using Current Procedural Terminology (CPT) codes 92227 and 92228 at the University of California, Davis Health system between May 31st , 2019 and June 8th , 2021. Retinal images were captured at primary care locations using a Topcon NW400, Nikon RetinaStation, or Optos Primary fundus cameras, and image grading were performed by trained ophthalmologists or optometrists using a store-and-forward method. Patient records were reviewed to collect demographic, follow-up, and clinical outcomes information. Results : During COVID19 pandemic, the teleophthalmology program screened 570 individuals (mean age 63.2 ± 13.7). There was a significant increase in the number of patients screened per month prior to and following the COVID-19 lock-down in March 2020 (5.0 ± 3.1 patients screened per month prior to and 39.1 ± 34.8 patients per month following, P = 0.0004). Among these, 204 patients received a recommendation for in-person eye care referral, of which 127 received a referral to the UC Davis Eye Center, 85 appointments were scheduled, and 82 patients were followed in person, with a median time of 108 days between screening and in-person follow-up. Follow-up rates were generally lower during the initial months after the pandemic and increased over time. Among the patients who followed in person (mean age 63.9 ± 13.8), 10% of eyes had mild non-proliferative DR (NPDR), 5% had moderate NPDR, 3% had severe NPDR, 2% had PDR, and 4% had diabetic macular edema (DME), with similar proportions before and after the COVID-19 lockdown. Conclusions : Expansion of a teleophthalmology program during the COVID19 pandemic demonstrated improved DR screening rates, increased referrals, and improved follow-up for diabetic eye care at an integrated health system in Northern California.

Patient Experience with Anti-VEGF Intravitreal Injections in Neovascular Agerelated Macular Degeneration and Diabetic Macular Edema: A Multinational Observational Study

Purpose : Anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections are efficacious treatments for neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME), but optimal real-world outcomes require frequent treatment and monitoring that can be burdensome to patients and hinder their ability or willingness to follow their management plan. This study aimed to understand patient treatment experience with anti-VEGF standard of care. Methods : This observational study employed a cross-sectional quantitative survey comprising de novo questions, patient-reported outcome (PRO) measures and medical chart extraction. Adult patients in the USA, UK and Canada with nAMD or DME, and treated with anti-VEGF injections for ≥12 months, were recruited via 21 (9 USA, 6 UK, 6 Canada) clinical sites. Results : Between January and August 2021, 148 (67 USA, 33 UK, 48 Canada) DME and 219 (98 USA, 54 UK, 67 Canada) nAMD patients completed their surveys. While 159 (43%) patients had a study eye visual acuity at most recent reading >70 approxETDRS letters, PRO scores indicated that patients across the two conditions had relatively high visionrelated functioning (NEI-VFQ-25) and were generally satisfied with their current treatment (MacTSQ and RetTSQ). Eighteen DME patients (12%;12% in the US, 27% in the UK, 2% in Canadian samples) and 9 nAMD patients (4%;3% USA, 3% UK, 4% Canada) missed at least 1 injection visit in the past 12 months. Reported barriers were mainly related to treatment, clinic and appointment factors, and the COVID-19 pandemic. Half of the patients reported some level of impairment in their daily activities due to the treatment. Following treatment, the majority recovered within 1 day;however, a sizable portion (24%;21% USA, 31% UK, 22% Canada) needed >1 day to recover. Among the working patients (N = 55), 34 (62%;58% USA, 67% UK, 65% Canada) reported some level of productivity impairment in the form of absenteeism. Conclusions : Despite high adherence and treatment satisfaction levels, patients reported impairment of daily activities, burden, and barriers related to treatment. In general, more DME patients missed at least 1 visit than nAMD patients. More durable treatments with longer intervals could further reduce treatment burden and address the current barriers faced by patients.

Utility of Remote Point-Of-Care Tele-Retinal Imaging for Screening and Diagnosis of Diabetic Retinopathy: A Pilot Study

Purpose : In the COVID-19 era, tele-retinal technologies are rising to the forefront of contactless ophthalmic care. Point-of-care Optical Coherence Tomography (OCT) and fundus photography remotely analyzed by an off-site retina specialist (tele-R) must be validated for screening retinal disorders. This study assesses the feasibility of tele-R as a screening tool for diabetic retinopathy (DR) in an outpatient clinical setting. Methods : A retrospective study was conducted on 16 patients (32 eyes, 28 with DR, and 4 controls) presenting to the retina clinic (RC) of an urban academic medical center. Automated OCT-B and 45 fundus photographs of the posterior pole were taken using a Topcon Maestro 3D OCT-1 unit, and 3D topographical maps of the macula were generated. Images were transmitted to a remote retina specialist (blinded to patient history and demographics) who assessed severity of DR and diabetic macular edema (DME). Primary outcomes included grading of DR and DME with fundus and OCT-B images, respectively, using the International Clinical Diabetic Retinopathy classification scale. The secondary outcome was identifying the severity grade of DME using the 3D macular map. Concordance was tested between diagnoses obtained from tele-R assessment and in-person examination by the retina specialist (gold standard) using Cohen's Kappa statistic (κ). Eyes that could not be assessed were removed from analysis. Results : 30 of 32 eyes with sufficient data for analysis were included. The average age was 57.9 (±11.2) years. 37% of patients were male, 69% were Hispanic, and 94% had Type 2 diabetes. The κ±standard error (SE) for DR severity was 0.738±0.099 (p<0.001), for DME severity was 0.588±0.122 (p<0.001), and for presence of DME was 0.727±0.122 (p<0.001). The retina specialist was able to grade the DME severity in only 10/14 (71%) eyes using the 3D macular map alone, but in 93% (13/14) eyes with OCT-B images. Conclusions : Tele-R is a reliable modality for diagnosis of DR severity;there was substantial agreement on identifying DR severity using tele-R vs in-person examination. There was substantial agreement in discerning DME using tele-R vs in-person while only moderate agreement on determining the severity of DME, which suggests that tele-R may useful in identifying presence of DME but not determining the severity of edema.

Assessing the impact of COVID-19 on visual acuity for diabetic macular edema patients treated with aflibercept in the UK

Purpose : Assessing the impact of COVID-19 on visual acuity (VA) in eyes treated for Diabetic Macular Edema. Methods : Anonymized data from 21 UK centers were extracted from Medisoft for eyes receiving treatment with aflibercept and with VA data in the pre-COVID baseline period (01/10/19 to 30/03/20, N=3,248). Comparisons for period 1 (01/04/20 to 30/09/20, N=2,077)-lockdown following RCOphth Medical Retinal Management Plan, period 2 (01/10/20 to 30/03/21, N=1,850)-intermittent lockdown and period 3 (01/04/21 to 30/09/21, N=1,111;20 centers)-easing of COVID-19 restrictions. VA change was compared for baseline VA, <7 vs. ≥7 injections before period 1 and for eyes losing ≥5 ETDRS letters in period 1. Results : The mean change in VA for eyes with a baseline VA of ≤35 letters, was +4.9, +2.5 and +1.7 letters from baseline to period 1, period 1 to 2 and period 2 to 3, respectively. For baseline VA of 36-55 letters, +0.6, +1.7 and -0.2 letters, from baseline to period 1, period 1 to 2 and period 2 to 3, respectively. For baseline VA of 56-75 letters, +1.9, zero and -0.5 letters, from baseline to period 1, period 1 to 2 and period 2 to 3, respectively. For baseline VA of >75 letters, -4.3, -0.5 and zero letters, from baseline to period 1, period 1 to 2 and period 2 to 3, respectively. For eyes receiving <7 injections before period 1, the mean change in VA was -1.9 letters (N=1,335) from baseline to period 1, +0.5 letters (N=992) from period 1 to 2 and +0.1 letters (N=592) from period 2 to 3. For ≥7 injections before period 1, the mean change in VA was -3.4 letters (N=742) from baseline to period 1, -0.4 letters (N=515) from period 1 to 2 and -1.1 letters (N=303) from period 2 to 3. For eyes losing ≥5 letters before period 1, the mean change in VA when receiving ≥1 injection in period 2 was +3.9 letters (N=283) from period 1 to 2 and -0.1 letters (N=140) from period 2 to 3. For eyes not retreated in period 2, the mean change in VA was -2.9 letters (N=162) from period 1 to 2 and zero letters (N=73) from period 2 to 3. Conclusions : Visual gain between time periods was more likely for lower baseline vision. For eyes with <7 or ≥7 injections before period 1, the mean VA change was a loss in vision in the first period with little change in later periods. For eyes with ≥5 letter loss in period 1, subsequent visual gain was more likely if treatment continued.

Sensitivity of tele-ophthalmic diagnosis of diabetic retinopathy when performed by resident physicians

Purpose : During the Covid-19 era, understanding the benefits and limitations of tele-ophthalmology has become increasingly important. In this study, we aim to assess the accuracy of tele-ophthalmic diagnosis of diabetic retinopathy (DR) and diabetic macular edema (DME) when performed by resident physicians. Methods : Retrospective study on 16 patients (32 eyes;28 DR and 4 controls) who presented to a retina clinic at an academic medical center. Automated OCT-B images with 3D topographic maps and fundus photographs of the posterior pole using a Topcon Maestro 3D OCT-1 unit were taken. Images were transmitted remotely to a resident physician who assessed the severity of the DR and DME on the basis of the fundus photographs and OCT. The same images were transmitted to a retina specialist for grading. Primary outcomes included DR and DME grade as defined by the International Clinical Diabetic Retinopathy classification scale. We then tested the concordance between diagnoses rendered via tele-OCT by the resident compared to the retina attending's remote diagnosis and the gold standard retina specialist's clinical examination using Cohen's Kappa statistic (κ). Results : Agreement between ophthalmology residents and attendings on tele-OCT diagnosis of DR was substantial (78% concordance on presence and 75% on severity), while agreement on identifying and grading edema was moderate (60% concordance on DME presence and 52% concordance on overall DME severity). Detection of DR by residents via tele-retinal imaging is highly sensitive (100% sensitivity), while detection of DME is highly specific (79-95% specificity). Discordance between residents and attendings on DME grading may owe to differences in opinion regarding what constitutes mild edema versus no edema;however, both concordance and predictive accuracy increase when identifying patients with moderate to severe DME. Conclusions : This study provides proof of principle for the sensitivity and specificity for remote diagnosis of DR via tele-OCT fundus and OCT-B images. This technology may be useful in identifying patients at risk of severe vision loss and enable early detection of patients who need referral for prompt treatment. These findings may be particularly relevant to training programs looking to implement tele-retinal diabetic screening or using tele-OCT where prompt access to a retina specialist may not be possible.

The effect of intravitreal dexamethasone implantation on diabetic macular edema refractory to anti-vascular endothelial growth factor treatment

Purpose: To evaluate the efficacy and safety of intravitreal dexamethasone (DEX) implantation for diabetic macular edema (DME) that proved unresponsive to previous anti-vascular endothelial growth factor (VEGF) treatment. Methods: This prospective interventional study recruited 91 patients with refractory DME after previous anti-VEGF treatments in one or both eyes. All patients were followed up for at least 12 months. Best-corrected visual acuity (BCVA), central subfield thickness (CST) and macular volume were measured. Results: Over the 12 months, a mean of 2.1 +/- 0.8 DEX implantations were administered per eye;26 eyes (28.9%) received 1 implantation, 31 (34.4%) received 2, and 34 (36.7%) received 3. BCVA was significantly improved in the first 6 months, from 54.8 to 59.5 letters. Both CST and macular volume decreased significantly after DEX implantation and maintained these improvements for at least 12 months. Subjects who needed the second DEX implantation had a greater number of prior anti-VEGF injections than did those who needed only one implantation (6.0 vs 3.0). Conclusions: Two-thirds of refractory DME required less than two DEX implantations to maintain a dry macula for 12 months. Early switching to intravitreal DEX can be considered as the second-line therapeutic option, especially during the COVID-19 pandemic.

Delayed anti-VEGF injections during the COVID-19 pandemic and changes in visual acuity in patients with three common retinal diseases: A systematic review and meta-analysis.

The COVID-19 pandemic disrupted the regular injections of anti-vascular endothelial growth factor (anti-VEGF) in patients with various retinal diseases globally. It is unclear to what extent delayed anti-VEGF injections have worsened patients' visual acuity. We performed a meta-analysis to assess the impact of delayed anti-VEGF injections on the best-corrected visual acuity (BCVA) in patients with neovascular age-related macular degeneration (nAMD), retinal vein occlusion (RVO), and diabetic macular edema (DME). We searched four computer databases (EMBASE, MEDLINE, Web of Science, Scopus) from inception to January 5, 2022. Data were pooled using the random-effects model. Results were reported by less than 4 months and 4 months or longer for the time period between the first injection during the pandemic and the last pre-pandemic injection. All BCVA measures were converted to the logarithm of the minimum angle of resolution (logMAR) for analyses. Among patients who received injections 4 months or longer apart, the mean difference in BCVA was 0.10 logMAR (or 5 ETDRS letters) (95% confidence interval [CI] 0.06∼0.14) for nAMD patients, 0.01 logMAR (or∼ 1 ETDRS letter) (95% CI -0.25∼0.27) for RVO patients, and 0.03 logMAR (or ∼1 ETDRS letters) (95% CI -0.06∼0.11) for DME patients. These results suggest that patients with nAMD needing scheduled anti-VEGF injections may require priority treatment over those with RVO and DME in the event of disturbed anti-VEGF injections from COVID-19 lockdowns or similar scenarios.

Anatomical and Functional Effects of Oral Administration of Curcuma Longa and Boswellia Serrata Combination in Patients with Treatment-Naïve Diabetic Macular Edema.

Anti-vascular endothelial growth factor nowdays represents the standard of care for diabetic macular edema (DME). Nevertheless, the burden of injections worldwide has created tremendous stress on the healthcare system during the COVID-19 pandemic. The aim of this study was to investigate the effects of the oral administration of Curcuma longa and Boswellia serrata (Retimix®) in patients with non-proliferative diabetic retinopathy (DR) and treatment-naïve DME < 400 µm, managed during the COVID-19 pandemic. In this retrospective study, patients were enrolled and divided into two groups, one undergoing observation (Group A, n 12) and one receiving one sachet a day of Retimix® (Group B, n 49). Best-corrected visual acuity (BCVA) and central macular thickness (CMT) measured by spectral-domain optical coherence tomography were performed at baseline, then at one and six months. A mixed-design ANOVA was calculated to determine whether the change in CMT and BCVA over time differed according to the consumption of Retimix®. The interaction between time and treatment was significant, with F (1.032, 102.168) = 14.416; η2 = 0.127; p < 0.001, indicating that the change in terms of CMT and BCVA over time among groups was significantly different. In conclusion, our results show the efficacy of Curcuma longa and Boswellia serrata in patients with non-proliferative DR and treatment-naïve DME in maintaining baseline CMT and BCVA values over time.

Impact of COVID-19-related lockdown on retinal disorders treated with intravitreal injections.

PURPOSE: To study functional changes in vision and morphological changes on optical coherence tomography (OCT) scans in patients where intravitreal therapy (IVT) with injections has been delayed due to COVID-19 pandemic lockdown. METHODS: Retrospective cross-sectional study included 77 eyes with the diagnosis of exudative age-related macular degeneration (eAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO), regularly receiving IVT with anti-vascular endothelial growth factor (Anti-VEGF) injections or dexamethasone implant and were not able to receive the injections as intended due to lockdown. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), and qualitative morphological features on OCT were analyzed pre- and post-therapy break off. RESULTS: The mean duration of IVT break-off was 57 days. Mean BCVA logarithm of minimum angle of resolution (logMAR) worsened from 0.33 (20/42) to 0.35 (40/44) (P = 0.02) and mean CFT increased from 297.90 µm to 402.16 µm (P < 0.01), from pretherapy break-off to return visit. Worsening of the visual acuity was seen across all the three disease cohorts, significantly more in the eyes with eAMD. CONCLUSION: Marginal decline in the visual acuity and worsening of the OCT features were observed as a result of delay in the IVT injections of DME, eAMD and RVO patients.

PCR61 Burden and Impacts Associated with Caring for Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema Patients: A Multinational Caregiver Survey

Objectives: Optimal real-world outcomes in neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) require frequent and potentially burdensome visits for patients and their caregivers. This study aimed to understand the caregiver perspective on treatment burden, barriers and the impact of caregiving, with a particular focus on the demands of frequent anti-vascular endothelial growth factor (anti-VEGF) intravitreal injection treatment. Methods: Caregivers of adult nAMD/DME patients treated with anti-VEGF injections were enrolled from 21 clinical sites in the USA, UK and Canada. Caregivers completed a cross-sectional survey comprising de novo questions and a self-reported outcome instrument. Results: Overall, 18 DME and 44 nAMD caregivers completed surveys. On average, caregivers provided care 4.3±3.0 days/week, 4.0±4.3 hours/day. Caregivers reported supporting patients on a diverse array of tasks including transportation to doctors' appointments, providing emotional support, and helping with shopping and household chores. Twelve (67%) DME and 30 (68%) nAMD caregivers reported at least one barrier that prevented patients from receiving treatment or attending visits. Barriers were mainly related to the COVID-19 pandemic restrictions, particularly preventing caregivers from accompanying patients to appointments, clinic/appointment factors (distance, difficulty in scheduling appointments, other medical appointments priority, appointment duration), and social/health related factors (caregiver’s availability, care recipient’s reduced mobility/physical limitations). Overall, 13/22 (59%) working caregivers reported an impact on work absenteeism due to helping with treatment appointments. Based on the Caregiver Reaction Assessment scores, caregivers experienced a moderate impact on schedule disruptions, and a milder impact on financial problems, lack of family support, health and self-esteem in relation to their caregiving situation. Conclusions: Caregivers devote significant time to caring for the recipient, with the greatest impact on caregiver schedule disruptions and absenteeism for those working. More durable treatments with longer intervals and fewer appointments may alleviate some of that burden.

Comparison of anatomical and functional outcomes of vitrectomy with internal limiting membrane peeling in recalcitrant diabetic macular edema with and without traction in Indian patients.

PURPOSE: To study and compare the outcomes of pars plana vitrectomy (PPV) with the internal limiting membrane (ILM) peeling in the eyes with recalcitrant diabetic macular edema (DME) with and without vitreomacular traction. METHODS: A comparative prospective interventional study was undertaken in which group 1 included 45 eyes of 45 patients with DME with vitreomacular tractional component and group 2 included 45 eyes of 45 patients with recalcitrant DME without a tractional component. Both groups underwent standard PPV with ILM peeling. All the patients were followed up for a minimum of 6 months. The parameters evaluated were changes in the best-corrected visual acuity (BCVA), central macular thickness (CMT), multifocal electroretinogram (mfERG) parameters, and occurrence of any intraoperative/postoperative surgical complication. RESULTS: The mean CMT improved significantly from 540.6 and 490.2 µm at the baseline to 292.5 and 270.6 µm at 6 months in groups 1 and 2, respectively (P < 0.001). The mean BCVA logMAR improved from 0.78 ± 0.21 to 0.62 ± 0.22 in group 1 and 0.84 ± 0.19 to 0.65 ± 0.21 in group 2 at 6 months follow-up which was not statistically significant. The improvement in the mfERG was seen in group 2 as a significant increase in P1 wave amplitude in ring 2 (2-5°) (P < 0.004) and a significant decrease in P 1 wave implicit time in ring 1 (central 2°) (P < 0.001). None of the eyes suffered from the loss of BCVA or any major surgical complication in either group. CONCLUSION: PPV in recalcitrant DME provides good anatomical outcomes and the results are comparable in DME with and without a tractional component.

The detrimental effects of delayed intravitreal anti-VEGF therapy for treating retinal pathology: lessons from a forced test-case.

PURPOSE: Determine the anatomical consequences of delaying intravitreal injection (IVI) therapy with anti-vascular endothelial growth factor (anti-VEGF) in patients using treat-and-extend (T&E) protocol. METHODS: Retrospective medical record review of consecutive patients receiving intravitreal anti-VEGF therapy using T&E protocol prior to and during the COVID-19 pandemic. RESULTS: The study included 923 eyes of 691patients; 58.8% (543 eyes), 25% (231 eyes), and 16.2% (149 eyes) had nvAMD, DME, and RVO, respectively. Mean (± SD) patient age was 74.5 ± 11.7 years. Overall, 56.3% of cases had a delay in therapy of ≥ 7 days; specifically, 56.2%, 61.5%, and 49.0% of nvAMD, DME, and RVO cases, respectively, had a delay. The median delay in days, among cases ≥ 7 days late was 21 (IQR 7 to 42) days, with 21(IQR 7 to 45), 22.5(IQR 8 to 42), and 14(IQR 7 to 33.5) days of delay among patients with nvAMD, DME, and RVO, respectively. Delaying therapy by ≥ 7 days resulted in increased CST in 47.5%, 58.5%, and 58.9% of nvAMD, DME, and RVO cases, respectively, with a significant correlation between the length of treatment delay and the increase in CST (Spearman's rho: 0.196; p < 0.001). CONCLUSIONS: Delayed IVI treatment in eyes treated with T&E protocol was associated with increased macular thickness with potential consequences with respect to visual outcome.

Therapeutic effect of simultaneous intravitreal dexamethasone and aflibercept on diabetic macular edema.

AIMS: To report the effect of simultaneous intravitreal dexamethasone (DEX) and aflibercept for the treatment of diabetic macular edema (DME). METHODS: This retrospective analysis of an open-label, multicenter, consecutive case series included 102 eyes of 81 patients with DME. Patients were selected into two groups. The control group consisted of 50 eyes treated with aflibercept alone, and the combination group consisted of 52 eyes treated with simultaneous DEX implant and aflibercept injection. The primary endpoints were changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) from baseline to month 6. The secondary endpoint was the interval of retreatment. RESULTS: Baseline BCVA increased and CRT decreased at 6 months in both groups. Pseudophakic eyes in the combination group exhibited significantly greater BCVA improvement compared with phakic eyes (p = 0.031). Fewer intravitreal treatments were required for eyes treated with combination therapy than for those treated with aflibercept alone (1.56 ± 0.54 vs. 4.04 ± 1.26, p < .0001), with a mean retreatment interval of 3.66 ± 0.69 months. CONCLUSIONS: Simultaneous intravitreal DEX and aflibercept achieved non-inferior improvement of visual and anatomic outcomes compared with aflibercept alone for DME, but exhibited a significantly longer treatment interval and superior visual outcome in pseudophakic eyes. This therapeutic approach is considered a valid strategy for treating DME in the era of COVID-19.

[Impact of the SARS-CoV-2 pandemic on diabetic macular edema and prognostic factors]. / Impact de la pandémie du SARS-CoV-2 sur l'œdème maculaire diabétique et facteurs pronostiques.

PURPOSE: To assess functional and anatomical consequences of the delay in intravitreal injections for diabetic macular edema (DME) patients during the corona virus pandemic lockdown in Morocco as well as to evaluate factors associated with disease progression. PATIENTS AND METHODS: This cross-sectional study included DME patients who did not complete their scheduled intravitreal bevacizumab injections during the Lockdown period (March 20, 2020 to May 20, 2020). Data recorded included age, duration of diabetes, number of previous intravitreal injections, best-corrected visual acuity, and central macular thickness before and after the lockdown. RESULTS: One hundred and fifty four eyes of 104 patients were analyzed. 57.8% were male. The mean age was 59.4±9.04 years. The mean duration of delay of intravitreal injections was 57.3±6.7 days. The mean number of intravitreal bevacizumab injections received before the lockdown was 2.29±2.1. Worsening of visual acuity was noted in 44.8% of patients and was associated with a lower number of intravitreal injections performed prior to the lockdown (P=0.001) and with glycemic imbalance (P=0.04). An increase in central macular thickness was noted in 26.6% of patients and was associated with a lower number of intravitreal injections (P=0.038). CONCLUSION: The delay in intravitreal injections during the lockdown had negative effects on visual acuity and central macular thickness in eyes with DME. Prolonged delay in intravitreal anti-VEGF injections in diabetic patients should be avoided.

The Impact of COVID-19 on Diabetic Retinopathy Monitoring and Treatment.

PURPOSE OF REVIEW: Diabetic retinopathy (DR) is one of the leading causes of vision loss worldwide. Although screening and early treatment guidelines for DR have significantly reduced the disease burden, restrictions related to the COVID-19 pandemic have changed real-world practice patterns in the management of DR. This review summarizes evolving guidelines and outcomes of the treatment of DR in the setting of the pandemic. RECENT FINDINGS: Intravitreal injections for DR have decreased significantly globally during the pandemic, ranging from approximately 30 to nearly 100% reduction, compared to corresponding timepoints in 2019. Most studies on functional outcomes show a decrease in visual acuity on delayed follow-up. Changing practice patterns in the management of DR has led to fewer intravitreal injections and overall reduction in visual acuity on follow-up. As COVID variants emerge, it will be necessary to continue evaluating practice guidelines.