Table 1.
Guidance for anti-VEGF intravitreal injections in retinal disease patients according to local COVID-19 epidemic pressure [1]
| Low epidemic pressure situationsa | |
| General considerations | |
| • Regularly monitor medical/healthcare staff for signs and symptoms of infection | |
| • Provide staff with regular training on use of PPE and other safety practices | |
| • Consistently implement and follow personal, facility, and instrument hygiene/disinfection rules | |
| Prioritizing patients according to medical need | |
| • Discuss treatment prioritization with the patient, taking into account the legal/regulatory environment, status of the epidemic, and the capacity to reschedule postponed procedures | |
|
• If necessary, prioritize treatment visits over monitoring visits o Inform patients on how to self-monitor their vision/implement the use of home monitoring technologies, if possible | |
| • Defer appointments of COVID-19-positive/suspect patients, except for cases requiring emergency intervention to prevent imminent danger of severe vision loss | |
|
• Prior to the appointment, inform patients about the safety and hygiene measures in place • Provide a “Dear Patient” letter that reiterates the importance of attending appointments and offers advice on what to do should they be unable to attend [8] | |
| • Provide patient support via an emergency contact number manned by a senior ophthalmologist | |
| Reducing exposure during the patient visit | |
|
• Ensure wearing of face masks at all times (patients and staff) [9–11] o An N95 or FFP2 mask is preferred or a surgical mask where these are not available | |
| • Ensure good ventilation in all rooms [12] | |
| • Limit exposure in waiting rooms by use of masks, 1m or 2 m physical distancing, spacing out appointments, allowing only one accompanying adult if necessary, and promoting queuing outside the waiting room | |
| Reducing exposure during the patient examination | |
| • Wear PPE for patients who are COVID-19-positive/suspect, or for all patients, as directed by local authorities | |
| • Keep examinations as brief as possible and consider implementing physical distancing measures between patients and staff | |
| • Thoroughly disinfect hands and equipment, including keyboards, between patients | |
| • Affix large plastic/plexiglass shields to slit lamps and OCT | |
| • To reduce risk of contamination, tape the upper edges of the face mask during intravitreal injection procedures | |
| • For COVID-19-positive/suspect patients, emergency surgery/intervention should take place in a facility with appropriate safety measures and PPE in place | |
| High epidemic pressure situationsb, in addition to the above recommendations | |
| Prioritizing patients according to medical need | |
|
• Pre-screen patients by phone to identify symptomatic/suspected COVID-19-positive patients (or relatives/caregivers) • Prioritize and maintain treatment schedules in patients with nAMD (particularly if they are in the first 2 years of treatment), new patients with significant vision loss, neovascular glaucoma, and monocular or quasi-monocular patients (only one eye > 20/40) | |
| • Consider postponement of appointments for non-monocular patients, except patients with significant vision loss from recent DME, proliferative diabetic retinopathy, acute-phase RVO, and ischemic RVO who should not be postponed | |
| • Avoid prolonged treatment postponement (> 4–6 months) and reassess the situation regularly (within 2–3 months) | |
| • Patients with DME and BRVO who already had their treatment postponed > 6 months during the initial wave of the COVID-19 pandemic should have their treatment maintained | |
| Reducing exposure during the patient examination | |
| • Limit the use of OCT examinations and special instruments unless they are critical to decision-making | |
| Treatment regimen considerations | |
| • Avoid treatment regimens and regimen changes that require frequent monitoring to adjust dosing intervals | |
| • Avoid switching treatment regimen unless there is a clear lack of response | |
| • Avoid changing treatment intervals in patients with nAMD who are responding to a fixed-dose regimen | |
|
• Consider reverting to the last effective treatment interval and use this for fixed dosing in patients with AMD receiving variable-interval treatment regimens o Reassure patients that fixed-dose anti-VEGF regimens are an effective way of delivering treatment [7, 13, 14] | |
| • Maintain the loading phase schedule and select longer-acting therapies for new patients | |
| • Only consider reimplantation of a dexamethasone implant in patients with DME/RVO if they are responding well and have a history of normal intraocular pressure under such treatment | |
| • Consider panretinal photocoagulation instead of intravitreal anti-VEGF for patients with severe PDR | |
| Extreme epidemic pressure situationsc, in addition to all the above recommendations | |
| Prioritizing patients according to medical need | |
| • Postpone non-urgent appointments where there is capacity to reschedule within ≤ 4–6 months | |
| • Prioritize and maintain treatment schedules in patients with nAMD (particularly if they are in the first 2 years of treatment), new patients with significant vision loss, neovascular glaucoma, and monocular or quasi-monocular patients (only one eye > 20/40) | |
| • Consider referral to a non-hospital-based clinic or ambulatory surgical center | |
|
• Consider using telemedicine consultations for patient triaging and to monitor those whose in-person appointments have been postponed o It may be acceptable in the short term (≤ 4–6 months) to monitor the disease on function only | |
| • Consider offering home care for patients unable to attend in-person appointments (e.g., under lockdown) | |
| Reducing exposure during the patient examination | |
|
• Avoid thorough visual acuity testing of every patient o A simple self-performed test such as a near-reading chart may be sufficient to flag an important visual change requiring further investigation |
aRt significantly < 1 without herd immunity through mass vaccination; some physical distancing measures are likely to be implemented. These recommendations are also valid in situations with a higher alert level
bRt ~ 1 and/or many clusters of COVID-19-positive people are present in the community but there is no strain on hospital resources. These recommendations are also valid in situations with a higher alert level
cRt significantly > 1 and hospital resources are under significant pressure; lockdown measures may be in place. These recommendations are only valid in this alert level
AMD age-related macular degeneration, BRVO branch retinal vein occlusion, DME diabetic macular edema, nAMD neovascular age-related macular degeneration, OCT optical coherence tomography, PDR proliferative diabetic retinopathy, PPE personal protective equipment, RVO retinal vein occlusion, VEGF vascular endothelial growth factor