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The blinding potential of COVID policies

Published:February 19, 2021DOI:https://doi.org/10.1016/j.jcjo.2021.02.001
      Since the emergence of the coronavirus disease 2019 (COVID-19), the pandemic has caused substantial disruption on healthcare service across all specialty disciplines, including ophthalmology. At various points in the pandemic over the course of 2020, many countries and communities had undergone “lock-downs”, limiting patient access to healthcare services due to strict safe-distancing measures and closure of non-essential clinical activities, such as curtailment of clinic office hours and clinic workload, as well as restrictions on elective surgeries. In addition, patient-related factors, such as fear of exposure, may also play a role in cancellation of scheduled appointments, and delaying presentation of acute medical conditions.
      Rhegmatogneous retinal detachment (RRD) is an important cause of acute vision loss, and often classified as a medical emergency.
      • Cheung N
      • Lee SY
      • Wong TY.
      Will the Myopia Epidemic Lead to a Retinal Detachment Epidemic in the Future?.
      RRD is relatively easy to diagnose and has clear standard management pathways typically involving surgery. Thus, it can be used as an index disease to investigate the impact of the COVID-related policies on the ophthalmic service. In this issue of the CJO, Arjmand and colleagues have reported the characteristics of RRD presented at a tertiary health centre amid the initial COVID-19 pandemic period in Canada.
      • Arjmand P
      • Murtaza F
      • Eshtiaghi A
      • Popovic MM
      • Kertes PJ
      • Eng KT.
      Impact of the COVID-19 pandemic on characteristics of retinal detachments: the Canadian experience.
      In this retrospective case-control study, comparisons were made between patients presented with RRD during the 6-month periods before and after the COVID-19 outbreak. The data clearly showed that compared to the patients in the pre-COVID group, patients in the post-COVID group were more likely to present with generally more severe RRD, evident as increased odds of macula-off RRD, more extensive RRD, and worse baseline visual acuity. Interestingly, despite these differences in RRD characteristics, the final visual outcome appeared similar in both groups of the patients. Of note, about half of the RRD cases were treated with pneumatic retinopexy, a practice pattern that may differ to other ophthalmic centres.
      Furthermore, consistent results have been recently reported from the Wills Eye Hospital in the United States.
      • Patel LG
      • Peck T
      • Starr MR
      • et al.
      Clinical Presentation of Rhegmatogenous Retinal Detachment during the COVID-19 Pandemic: A Historical Cohort Study.
      Using two samples from 2018 and 2019 as pre-COVID control groups, their data demonstrated that patients in the post-COVID (2020) group were less likely to present early (20% vs. 37% sought treatment within 1 day) or present with macula-on RRD (24% vs. 50%), more likely to have proliferative vitreoretinopathy (grade C or above; 13% vs. 4.5%), and showed worse visual acuity at baseline (1.00 logMAR [Snellen equivalent 20/200] vs. 0.48 logMAR [Snellen equivalent 20/60]).
      Collectively, these two studies provide good evidence that the COVID-19 pandemic and its related policies likely have caused unintended consequences on the presentation and care of RRD, an acute sight-threatening condition that usually requires urgent surgical intervention. Fortunately, the study by Arjmand and colleagues did not show a difference in the final visual outcome. However, this study used a relatively small sample size with limited follow-up and power to reliably assess such an important functional outcome. In comparison, the final visual acuity reported in their study appeared worse than that of the Primary Retinal Detachment Outcomes Study (Snellen equivalent 20/100 vs. 20/30 to 20/60).
      • Ryan EH
      • Ryan CM
      • Forbes NJ
      • et al.
      Primary Retinal Detachment Outcomes Study Report Number 2: Phakic Retinal Detachment Outcomes.
      Future studies are likely still needed to analyse the long-term anatomical and functional outcomes for patients with RRD during the COVID-19 pandemic. There is a consistent trend of reduced RRD presentations during the COVID period, as evident in the abovementioned studies and others.
      • Wickham L
      • Hay G
      • Hamilton R
      • et al.
      The impact of COVID policies on acute ophthalmology services-experiences from Moorfields Eye Hospital NHS Foundation Trust.
      It is unlikely due to reduced incidence of the disease. Rather, it should serve as a warning signal that current studies could be undercounting delayed presentation of RRD because patients still might not have sought care despite vision loss. Moreover, due to the difference in choice of surgical intervention, the results of the study by Arjmand and colleagues may not be generalizable to other centres where pneumatic retinopexy is less commonly used.
      Despite availability of several effective vaccines, there remain many uncertainties for the outlook of the ongoing COVID pandemic. There will likely be recurrent waves of outbreak, with re-introduction of “lockdowns”, as borders and economies open up. It is therefore important to improve public education on RRD symptoms and encourage patients to seek early care. Additional studies should focus on understanding the exact factors related to delay in care from both the clinical and public health standpoints. Unfortunately, RRD is only one of the many eye diseases that has been impacted on during this pandemic, and the long-term outcomes of other major eye diseases (e.g., glaucoma, age-related macular degeneration, diabetic retinopathy) affected by COVID-19 remain to be determined.

      Declaration of Competing Interest

      None.

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