Temporal association of vitreous hemorrhage and hypertension after COVID-19 mRNA vaccines.

Vitreous hemorrhage as common eye presentation and hypertension as common systemic presentation are difficult to designate whether they are coincidental or causal in terms of adverse events of COVID-19 vaccinations. Temporal association of hypertension and vitreous hemorrhage was noted in a patient repeatedly after the second and third COVID-19 vaccinations.

COVID-19 impact on delayed clinical visits in diabetic retinopathy patients

Purpose : The COVID-19 pandemic created an unprecedented setback for diabetic retinopathy (DR) patients receiving routine anti-vascular endothelial growth factor (VEGF) injections. In this retrospective clinical study, we assessed visual and anatomical outcomes of “late follow-up” appointments cancelled or rescheduled during an 11-week quarantine period from March 15th- June 1st, 2020, due to the urgency to limit non-emergent clinical visits. This study tested the hypothesis that strict frequency of treatment is a requisite for successful therapy. Methods : To meet “late follow-up” requirements, all study patients had appointments scheduled within the quarantine period that were delayed past their previous physician recommended interval, beyond June 1st, 2020. Of the 7042 delayed patients, 5137 returned for examination. 2764 were injection patients, of which 616 were delayed beyond the quarantine period. These 616 patients were subsequently categorized by diagnosis. We then analyzed the electronic medical record (EMR) for 300 eyes with treatment-requiring diabetic retinopathy to establish baseline anatomical and visual status prior to the delayed clinical visit. The EMR of the follow-up appointment was subsequently viewed for comparison. Best-corrected visual acuity (BCVA) and retinal examination findings were recorded from both visits. All eyes received at least 1 anti-VEGF injection prior to March 15th, 2020. Results : 300 eyes were delayed beyond their previously scheduled interval an average of 14.04 weeks. Upon return, 37 eyes (12.3%) had improved BCVA, 169 (56.3%) remained stable, and 94 (31.4%) had worsened. Of the 300 eyes, there was an average of 2.2 lines lost (p=0.03). 29 delayed eyes (9.7%) returned with improved macular edema, 121 (40.3%) remained stable, and 143 (47.7%) had worsened upon examination. Due to vitreous hemorrhage, edema progression in 7 eyes (2.3%) was unknown. 290 eyes (96.7%) remained with non-proliferative DR, while 10 (3.3%) progressed to proliferative DR. 23 (7.6%) returned with new or worsened vitreous hemorrhages. No patients developed a retinal tear or detachment during this period. Conclusions : COVID-19 had a severe impact on routine clinical visits. Prolonged frequency of anti-VEGF treatment for DR is associated with increased risk for BCVA decline and negative anatomical outcomes. Effective therapy requires strict compliance with intravitreal injections and routine clinical appointments.

Telemedicine Assisted Postoperative Care Following Microincision Vitrectomy Surgery

Purpose : Microincision vitrectomy surgery (MIVS) studies have shown low complication rates. In the setting of the COVID-19 pandemic and rural satellite clinics, we investigated the role of telemedicine as an alternative to postoperative visit (POV) regimens after uncomplicated MIVS. Methods : This IRB approved, prospective single-site, and single-surgeon study included patients without any history of glaucoma, ocular trauma, or severe systemic or ocular disease who underwent uncomplicated MIVS for any indication between January-August 2021. Prophylactic topical pressure-lowering drops were prescribed if POV intraocular pressure (IOP) was ≥22 mmHg. POVs included the same day after surgery, week(s) 1, 2, 8, and 12. Patients were randomly assigned (1:1) into two arms: telemedicine (TM) or In-person (IP). Weeks 1 and 8 POV utilized protocol-based and questionnaire guided undilated exams performed by an ophthalmology fellow that were conducted either TM or IP, according to arm assignment. Any patients with concerning symptoms identified at these visits were scheduled for dilated exams with the surgeon. All patients underwent dilated exams performed by the surgeon on the same day after surgery, weeks 2 and 12. Primary endpoint was mean best corrected visual acuity (BCVA). Secondary endpoints included changes in intraocular pressure (IOP), retinal nerve fiber layer thickness, and number of additional visits. Statistical analysis included Mann Whitney U and chi-square tests. Results : Fifty-two eyes from 50 patients (33 female, 17 male;p-value=0.02) with mean ages of 68.4±6.8 years underwent 55 total surgeries with 25 or 27G MIVS platforms. Forty-seven patients have completed all POVs. Mean preop BCVA logMAR was 0.53±0.55 and 0.40±0.45, and at 12 weeks, they were 0.39±0.45 and 0.26±0.33 for the TM and IP groups, respectively. No significant between-group differences were found for primary or secondary outcomes. All cases of abnormal IOP resolved by the following POV with pressure lowering drops. Concerning symptoms were identified in five patients requiring additional visits, revealing two cases of worsening macular edema (1 TM and 1 IP) and one case each of cataract progression (TM), vitreous hemorrhage (IP), and macular hole recurrence (TM). No complications presented at the TM or IP visits. Conclusions : Telemedicine-assisted POV regimens may be a safe and convenient alternative for patients undergoing uncomplicated MIVS.

Use of Resident Tele-Ophthalmic Diagnosis to Aid in Management of VisionCompromising Retinal Pathology

Purpose : In recent years, innovations in tele-ophthalmology have shown promise in providing quality ophthalmic care to patients in low-access settings and high-risk environments such as the COVID-19 pandemic. Emergency departments and urgent centers may benefit from tele-ophthalmology applications;the tele-images can be sent to the covering ophthalmologist or, to another ED for evaluation of images prior to transferring the patient. In this study, we aimed to assess the ability of resident physicians to identify features of posterior-pole retinal pathology using teleophthalmology. Methods : Retrospective study on 16 patients (32 eyes;30 with retinal pathology and 2 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 attempted to identify retina pathology using fundus photography and OCT. The same images were consequently evaluated by a retina specialist for grading. We then tested the concordance between diagnoses rendered via tele-OCT by the resident physician and the gold standard clinical examination (performed by the retina specialist) using Cohen's Kappa statistic (κ). Results : An overall average of 79.9% concordance for 69 potential findings was obtained between the retina attending's diagnosis with clinical examination and the resident physician's diagnosis using tele-OCT/fundus images based on Cohen's Kappa statistic (κ). The concordance was lower in eyes with vitreous hemorrhage most likely due to the inferior quality fundus and OCT-B images. The resident exam also identified the presence of any macular pathology in all 30 eyes with macular pathology and correctly identified the controls, indicating 100% sensitivity for identifying abnormal findings using tele OCT/fundus images. Conclusions : This study verifies the utility of resident screening of tele-OCT fundus and OCT-B images to identify retinal pathology. Tele-ophthalmology likely has a useful role in triaging retinal pathology whose outcomes could be affected by timely intervention. Many unnecessary emergency transfers may be avoided if the on-call ophthalmology residents are able to review the fundus and OCT images before hand.

COVID-era influence on follow-up trends and the impact on retinovascular disease progression

Purpose : COVID changed follow-up logistics starting 3/2020 in South Texas (STX). The incidence of proliferative retinovascular (RV) events in the emergent setting increased after shut down in STX. We investigate patterns of follow-up behavior in patients with and without proliferative complications of RV diseases. Methods : We used CPT and ICD-10 codes in date range 1/2018 to 4/2021 to include patients diagnosed with diabetic retinopathy (DR) and retinal vein/artery occlusions (RVO/RAO) and analyzed them as two groups: anti-VEGF ± panretinal photocoagulation (PRP) (nonvitrectomy group) vs vitrectomies. We compared before and after COVID-era: appointment intervals and lapses, rate of progression in EDTRS staging for patients with DR. Results : At initial encounter, 2/133/125 patients of 1503 had mild/moderate/severe DR. 40/5 patients had RVO/RAO. There were 429/1074 patients in the vitrectomy/nonvitrectomy group. Vitrectomy group had 123 non-clearing vitreous hemorrhages, 72 tractional retinal detachments, and 189 unclassified proliferative retinovascular complications. Prior to COVID, visit interval was 28.4 ± 43.2 vs 30.8 ± 47.8 days in the vitrectomy vs nonvitrectomy group (p=0.61). After COVID, the interval duration for the vitrectomy group increased to 39.8 ± 76.5 days with no increase in the nonvitrectomy group (p<0.001). Time to diagnosis of EDTRS-staged progression after COVID increased by an average of 21.5 days in the vitrectomy group and by 26.7 days in the nonvitrectomy group. After COVID restrictions, missed appointments in the vitrectomy vs nonvitrectomy group changed from 24.5% to 30.8% vs 28.1% to 33.4%. Across all encounters, the vitrectomy versus nonvitrectomy group had 19.1% vs 21.9% cancellation rate (6.08 vs 5.85 appointments/patient) and 7.81% vs 8.39% no show rate (3.09 vs 2.97 appointments/patient). Overall, patients with DR who experienced EDTRS-staged progression missed 21.2% of appointments (6.8 per patient for those with missed appointments). Conclusions : Patients who required vitrectomy versus those able to be managed in clinic missed appointments in the same proportion and quantity before COVID and increased appointment lapses similarly after COVID restrictions, but interval duration and variability was significantly higher in patients that eventually suffer a complication severe enough to necessitate vitrectomy.

A Cross-Sectional Study on the Effect of the COVID-19 Pandemic on Ocular Health at a Tertiary Care Department of Ophthalmology

Purpose : The COVID-19 pandemic caused disruptions in ophthalmic care, and may have negatively impacted some patients more than others. We performed a retrospective, cross-sectional study at our large, tertiary care ophthalmology referral center in the Midwest region of the United States in an attempt to identify patients at risk for worsening ocular health during the COVID-19 shutdowns. Methods : We completed retrospective Electronic Health Record data extraction of demographic and clinical outpatient encounter-level data for all patients examined in our department from March-May 2019, August-October 2019, March-May 2020 (peak COVID), and August-October 2020 (COVID recovery). Changes in mean logMAR visual acuity (logMAR VA), mean intraocular pressure (IOP), and mean number of procedures per encounter were tested and stratified by age (<18, 18-64, and 65+ years-old), and compared based on associated billing codes. Results : During peak COVID, there was a 73% decrease in the number of outpatient clinical encounters compared to the control time period in 2019 (6,976 vs. 26,068), and mean patient age was significantly lower during peak COVID (mean age 53.4, 95% CI 52.8- 54.0) compared with the other time periods. Documented best-corrected logMAR VA of the right and left eyes worsened for pediatric, adult, and elderly patient age groups;IOP of the right and left eyes worsened when evaluating all patients together;and the mean number of procedures performed per encounter increased by 74% comparing early 2019 to peak COVID months. The billing diagnoses associated with the worst ocular health outcomes during the COVID-related shutdowns include patients with anophthalmia of the fellow eye;infectious keratitis;open, chronic angle closure, and secondary causes of glaucoma;ocular inflammatory disorders;optic neuritis and ischemic optic neuropathies;and vitreoretinal disorders related to diabetes, macular degeneration, and vitreous or retinal hemorrhages. Conclusions : Patients seen during the COVID-19 pandemic were younger, had worsened logMAR VA, increased IOP, and underwent more procedures compared to the COVID-recovery and 2019 control months. Numerous billing diagnoses were associated with worse measures ocular health. Patients with these ocular disorders may need prioritization during future periods of reduced access ophthalmic care.

Retinal vasoocclusive spectrum following COVID-19.

The coagulation abnormalities and thromboembolic complications of coronavirus 2 (SARS-CoV-2) are now a well-established fact. The hypercoagulable state, the tendency for thromboembolism, and a cytokine surge state have been the exclusive reasons for multiorgan failure and other morbidities that have been regularly reported in COVID-19 patients. Ocular involvement in patients with active disease and those who have recovered is uncommon but not rare. We report a case series of four patients with CRVO, BRVO, CRAO, and vitreous hemorrhage in patients with proven COVID-19 infection and no other systemic ailments. The case series also tries to correlate the elevated D-dimer values, which signify a plausible prothrombotic state with the vaso-occlusive phenomenon in the retina leading to significant visual morbidity.