Abstract
Purpose
To investigate the impact of the local alert levels regarding coronavirus disease 2019 (COVID-19) on the clinical patterns of rhegmatogenous retinal detachment (RRD) in Japan.
Study design
Retrospective, single-center, consecutive case series.
Methods
We compared two groups of RRD patients, a COVID-19 pandemic group and a control group. Based on the local alert levels in Nagano, five periods during the COVID-19 pandemic were further analyzed: epidemic 1 (state of emergency), inter-epidemic 1, epidemic 2 (second epidemic duration), inter-epidemic 2, and epidemic 3 (third epidemic duration). Patients’ characteristics, including symptoms’ duration before visiting our hospital, macula status, and retinal detachment (RD) recurrence rate in each period, were compared with those in a control group.
Results
There were 78 patients in the pandemic group and 208 in the control group. The pandemic group had a longer duration of symptoms than the control group (12.0 ± 13.5 days vs. 8.9 ± 14.7 days, P = 0.0045). During the epidemic 1 period, patients had a higher rate of macula-off RRD (71.4% vs. 48.6%) and RD recurrence (28.6% vs. 4.8%) than the control group. This period also demonstrated the highest rates compared to all other periods in the pandemic group.
Conclusion
During the COVID-19 pandemic, RRD patients significantly delayed visiting a surgical facility. They showed a higher rate of macula-off and recurrence compared to the control group during the state of emergency than during other periods of the COVID-19 pandemic, although the difference was not statistically significant due to the small sample size.
Supplementary Information
The online version contains supplementary material available at 10.1007/s10384-023-00980-1.
Keywords: COVID-19, Macula-off, Retrospective cohort study, Rhegmatogenous retinal detachment, State of emergency
Introduction
Coronavirus disease 2019 (COVID-19) was detected in Wuhan, China, in December 2019 [1]. Since then, restrictive measures and lockdowns have significantly affected society and health care management [2, 3]. The World Health Organization declared COVID-19 to be a pandemic on March 11, 2020 [4]. On April 7, 2020, the Japanese government declared a state of emergency for seven prefectures: Tokyo, Kanagawa, Saitama, Chiba, Osaka, Kobe, and Fukuoka [5], while urging all Japanese people to avoid crowded places as well as close-contact situations. The restrictions were imposed upon the entire country on April 16, 2020 [6], including Nagano prefecture with a population of about 2 million people.
Consideration of the spread levels of COVID-19 is essential for health officials and individuals when determining community prevention strategies and individual behavior [7]. In the United States, the Center for Disease Control and Prevention introduced COVID-19 community levels in February 2022 as a standard for individuals, organizations, and communities to help understand the impact of the COVID-19 pandemic [8]. The COVID-19 community levels were determined by three metrics—new COVID-19 admissions per 100,000 population in the past 7 days, the percentage of staffed inpatient beds occupied by COVID-19 patients, and total new COVID-19 cases per 100,000 population in the preceding 7 days [7]. Many communities base their infection control decisions on these standards [8, 9]. In Japan, conversely, there are no country-wide standard COVID-19 community level metrics, and each local authority determines its alert levels based on its own standards. The Nagano government introduced the local COVID-19 alert levels on August 4, 2020 [10]. The alert levels were based on the total number of new COVID-19 cases per 100,000 population in the preceding 7 days [11], as shown in Supplementary Table 1. Notably, alert level 6 is independent of the number of patients and is declared only when the Japanese government designates Nagano as a target area within the state of emergency [11].
Primary rhegmatogenous retinal detachment (RRD) is caused by a retinal break and subsequent fluid inflow and accumulation within the subretinal space. The space extends progressively, involving the fovea in hours to days, depending on several factors such as the status of the lens, site of retinal tears, bullous configuration, axial length, and age [12, 13]. An urgent retinal detachment (RD) repair is recommended as prolonged detachment is associated with poor visual outcomes [12]. Therefore, the Japanese Ophthalmologists Association published a list of ophthalmic emergencies, including RRD, ocular trauma, and endophthalmitis, that require immediate surgery, even during the pandemic [14].
According to previous studies, clinical characteristics of RRD changed during the COVID-19 pandemic [15, 16]. RRD patients had characteristics that indicated a longer RD duration in the early months of the pandemic including an increased ratio of macula-off RD and a prolonged duration of visual impairment [16]. It is also reported that local epidemic waves affected the delay in visits to the clinic [17]. However, reports focusing on the impact of local alert levels on RRD characteristics are scarce. This study assessed the impact of the local COVID-19 alert levels on the baseline, surgical, and postsurgical characteristics of patients with RRD in Nagano in Japan.
Materials and methods
This was a retrospective cohort study of patients who underwent surgery for RRD from March 11, 2017, to March 10, 2021. We reviewed the medical records of all patients who underwent surgery for primary RRD at Shinshu University Hospital in Nagano, Japan, during this period. Patients with the following status were excluded:
A previous history of ophthalmic surgery except for cataract surgery.
Non-rhegmatogenous etiology, including ocular trauma and macular holes.
Eyes with vision loss caused by other diseases, considering the delay in their awareness of impaired vision resulting from RRD.
The second eye in bilateral RRD cases.
This study was approved by the Ethics’ Committee of Shinshu University Hospital (ID number: 5210) and adhered to the tenets of the Declaration of Helsinki. Shinshu University’s website provided participants with an opportunity to opt out of this study.
We retrieved demographic and clinical data, including laterality, lens status, types of surgery, macula status, patient-reported duration of symptoms before presentation to our hospital, the number of detached quadrants of the retina, RD recurrence within 6 months, and the preoperative logarithm of the minimum angle of resolution (logMAR), best-corrected visual acuity (BCVA), and postsurgical logMAR BCVA at 1 month. Based on the proliferative vitreoretinopathy (PVR) classification system published by The Retina Society Terminology Committee in 1983 [18], PVR was divided into Grade A to D. We reviewed Grade C (defined by full-thickness fixed retinal folds) or higher PVR status at the first visit. The details of this system are shown in a previous report [19]. RD onset was determined as the date when the patient first experienced subjective symptoms such as visual field defects and impaired visual acuity. Macular on/off status was evaluated by preoperative B scan of optical coherence tomography in all patients. As previously described, macula-off RRD was defined as detachment involving the fovea [17]. Recurrence of RD was defined as an additional surgical intervention for retinal re-detachment within 6 months postoperatively. We compared these features during the pandemic with those in the control years.
We further divided the COVID-19 pandemic duration (March 11, 2020–March 10, 2021) based on the local alert levels in Nagano to assess the relationship between the alert levels and RRD characteristics. Since the local alert levels were introduced on August 4, 2020, alert levels before August 4 were determined considering the current alert levels. We regarded alert level 1 as an inter-epidemic period and alert level 2 or higher as an epidemic period. The period before the state of emergency (May 11–April 15) was excluded because community-level countermeasures were not fully developed in Nagano. The period after the third epidemic duration (February 17–March 10) was also excluded from the analysis because it did not represent an entire inter-epidemic period before the fourth epidemic. We eventually divided the COVID-19 pandemic as follows: epidemic 1 (April 16–May 14), inter-epidemic 1 (May 15–July 28), epidemic 2 (July 29–September 15), inter-epidemic 2 (September 16–November 13), epidemic 3 (November 14–February 16). The three epidemic durations and corresponding alert levels are shown in Fig. 1. The patient groups in each period were determined based on the date of the patient’s first hospital visit. We compared RRD patients’ demographics and clinical characteristics in each period with those in the control years between March 11, 2017 to March 10, 2020.
Fig. 1.
The number of newly diagnosed COVID-19 patients
Statistical analysis
Continuous variables were represented as mean ± standard deviation and analyzed using the Mann–Whitney U test. The BCVA results were converted to logMAR values. The visual acuity of counting fingers was converted to 2, and that of hand movements was converted to 3, as previously reported [20]. Categorical variables are shown as proportions and analyzed using the chi-square test or Fisher’s exact test. Statistical significance was set at P < 0.05. All statistical analyses were conducted using GraphPad Prism version 9.2.0 (GraphPad Inc).
Results
Influence on baseline characteristics
A total of 208 and 78 patients were eligible for the control and pandemic groups, respectively (69.3 vs. 78 persons on average per year). Baseline characteristics are shown in Table 1. Compared to the control group, the patients in the COVID-19 pandemic group had a significantly longer duration of symptoms (8.9 ± 14.7 days vs. 12.0 ± 13.5 days, P = 0.0045) before presenting to our hospital. There were no statistically significant differences between the groups regarding the ratio of men (64.4% vs. 60.3%, P = 0.58), age (57.8 ± 15.7 years vs. 53.7 ± 17.1 years, P = 0.18), the ratio of right eyes (57.2% vs. 46.2%, P = 0.11), lens status (P = 0.13), and logMAR BCVA at the initial visit (0.54 ± 0.75, 0.50 ± 0.71, P = 0.94). Compared to the control group, the COVID-19 pandemic group had a higher percentage of patients with macula-off RD (48.6% vs. 56.4%, P = 0.28), more extended quadrants of detachment (P = 0.27), presence of PVR grade C or higher at the first visit (5.8% vs. 10.3%, P = 0.19).
Table 1.
Baseline characteristics of subjects in the control and COVID-19 pandemic groups
| Control (n = 208) | Pandemic (n = 78) | P | ||
|---|---|---|---|---|
| Male gender (%) | 134 (64.4) | 47 (60.3) | 0.58a | |
| Age (years), mean ± SD | 57.8 ± 15.7 | 53.7 ± 17.1 | 0.18b | |
| Right laterality (%) | 119 (57.2) | 36 (46.2) | 0.11a | |
| Lens status (%) | ||||
| Phakia | 177 (85.1) | 73 (93.6) | 0.13a | |
| Pseudophakia | 30 (14.4) | 5 (6.4) | ||
| Aphakia | 1 (0.5) | 0 | ||
| Macula status (%) | 0.28a | |||
| Macula-on | 107 (51.4) | 34 (43.6) | ||
| Macula-off | 101 (48.6) | 44 (56.4) | ||
| Duration of symptoms, mean ± SD | 8.9 ± 14.7 | 12.0 ± 13.5 | 0.0045b | |
| Detached quadrants (%) | ||||
| 1 | 53 (25.5) | 15 (19.2) | 0.27a | |
| 2 | 119 (57.2) | 42 (53.9) | ||
| 3 | 29 (13.9) | 18 (23.1) | ||
| 4 | 7 (3.4) | 3 (3.8) | ||
| PVR at first visit (%) | ||||
| PVR | 12 (5.8) | 8 (10.3) | 0.19a | |
| No PVR | 196 (94.2) | 70 (89.7) | ||
| Preoperative logMAR BCVA, mean ± SD | 0.54 ± 0.75 | 0.50 ± 0.71 | 0.94b | |
COVID-19 the coronavirus disease 2019, SD standard deviation, PVR proliferative vitreoretinopathy, logMAR logarithm of the minimum angle of resolution, BCVA best corrected visual acuity
aChi-square test
bMann–Whitney U test
Influence on surgical and postsurgical features
Surgical procedures and postsurgical features are shown in Table 2. There were no statistically significant differences between the groups regarding the rate of PPV (85.1% vs. 76.9%, P = 0.11), recurrence within 6 months (4.8% vs. 9.0%, P = 0.25), and logMAR BCVA at 1 month (0.25 ± 0.44 vs. 0.29 ± 0.40, P = 0.21). There were no statistically significant differences in the RD recurrence rate in the PPV group (5.4% vs. 7.1%, P = 0.74) and the SB group (3.3% vs. 20.0%, P = 0.13).
Table 2.
Surgical and postsurgical features of subjects in the control and COVID-19 pandemic groups
| Control (n = 208) | Pandemic (n = 78) | P | |
|---|---|---|---|
| Types of surgery (%) | |||
| PPV | 177, (85.1) | 60, (76.9) | 0.11a |
| SB | 31, (14.9) | 18, (23.1) | |
| Recurrence within 6 months (%) | |||
| Recurrence | 10, (4.8) | 7, (9.0) | 0.25a |
| No recurrence | 198, (95.2) | 71, (91.0) | |
| logMAR BCVA at one month, mean ± SD | 0.25 ± 0.44 | 0.29 ± 0.40 | 0.21b |
COVID-19 the coronavirus disease 2019, PPV pars plana vitrectomy, SB scleral buckling, logMAR logarithm of the minimum angle of resolution, BCVA best corrected visual acuity, SD standard deviation.
aChi-square test
bMann–Whitney U test
Categorical characteristics of each period
Tables 3 and 4 show the characteristics of categorical variables at baseline, surgical types, and RD recurrence. There were no statistically significant differences between the control group and each period of the pandemic group, except for a higher representation of left eyes in the inter-epidemic 2 period (42.8% vs. 75.0%, P = 0.01). The percentage of macula-off RD was highest in the epidemic 1 period among all periods (48.6% in the control group, 71.4%, 44.4%, 37.5%, 62.5%, and 44.4% in the epidemic 1, inter-epidemic 1, epidemic 2, inter-epidemic 2, and epidemic 3 periods, respectively). The percentage of recurrence of RD within 6 months was highest in the epidemic 1 period among all periods (4.8% in the control group, 28.6%, 11.1%, 0%, 6.2%, and 11.1% in the epidemic 1, inter-epidemic 1, epidemic 2, inter-epidemic 2, and epidemic 3 periods, respectively).
Table 3.
Descriptive statistics for categorical variables of baseline characteristics in each period
| Demographics | Control | Pandemic | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n (eyes) | % | Epidemic 1 (4/16 − 5/14) |
P | Inter-epidemic 1 (5/15 − 7/28) |
P | Epidemic 2 (7/29 − 9/15) |
P | Inter-epidemic 2 (9/16 − 11/13) |
P | Epidemic 3 (11/14 − 2/16) |
P | ||||||
| n (eyes) | % | n (eyes) | % | n (eyes) | % | n (eyes) | % | n (eyes) | % | ||||||||
| Total | 208 | 7 | 18 | 8 | 16 | 18 | |||||||||||
| Sex | |||||||||||||||||
| Female | 74 | 35.6 | 2 | 28.6 | > 0.99 | 7 | 38.9 | 0.80 | 4 | 50.0 | 0.46 | 7 | 43.7 | 0.59 | 9 | 50.0 | 0.30 |
| Male | 134 | 64.4 | 5 | 71.4 | 11 | 61.1 | 4 | 50.0 | 9 | 56.3 | 9 | 50.0 | |||||
| Laterality | |||||||||||||||||
| Left | 89 | 42.8 | 4 | 57.1 | 0.46 | 7 | 38.9 | 0.80 | 4 | 50.0 | 0.72 | 12 | 75.0 | 0.01 | 9 | 50.0 | 0.62 |
| Right | 119 | 57.2 | 3 | 42.9 | 11 | 61.1 | 4 | 50.0 | 4 | 25.0 | 9 | 50.0 | |||||
| Lens status at presentation | |||||||||||||||||
| Phakic | 177 | 85.1 | 6 | 85.7 | 0.98 | 16 | 88.9 | 0.88 | 7 | 87.5 | 0.96 | 16 | 100.0 | 0.25 | 17 | 94.4 | 0.54 |
| Pseudophakic | 30 | 14.4 | 1 | 14.3 | 2 | 11.1 | 1 | 12.5 | 0 | 0.0 | 1 | 5.6 | |||||
| Aphakic | 1 | 0.5 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | |||||
| Macula status at presentation | |||||||||||||||||
| On | 107 | 51.4 | 2 | 28.6 | 0.27 | 10 | 55.6 | 0.80 | 5 | 62.5 | 0.72 | 6 | 37.5 | 0.31 | 10 | 55.6 | 0.80 |
| Off | 101 | 48.6 | 5 | 71.4 | 8 | 44.4 | 3 | 37.5 | 10 | 62.5 | 8 | 44.4 | |||||
| Quadrants detached | |||||||||||||||||
| 1 | 53 | 25.5 | 2 | 28.6 | 0.16 | 5 | 27.8 | 0.94 | 3 | 37.5 | 0.85 | 3 | 18.8 | 0.27 | 2 | 11.1 | 0.48 |
| 2 | 119 | 57.2 | 2 | 28.6 | 10 | 55.6 | 4 | 50.0 | 8 | 50.0 | 11 | 61.1 | |||||
| 3 | 29 | 13.9 | 3 | 42.8 | 2 | 11.0 | 1 | 12.5 | 5 | 31.2 | 4 | 22.2 | |||||
| 4 | 7 | 3.4 | 0 | 0.0 | 1 | 5.6 | 0 | 0.0 | 0 | 0.0 | 1 | 5.6 | |||||
| PVR at presentation | |||||||||||||||||
| PVR | 12 | 5.8 | 0 | 0.0 | > 0.99 | 2 | 11.1 | 0.30 | 0 | 0.0 | > 0.99 | 1 | 6.3 | > 0.99 | 4 | 22.2 | 0.22 |
| No PVR | 196 | 94.2 | 7 | 100.0 | 16 | 88.9 | 8 | 100.0 | 15 | 93.7 | 14 | 77.8 | |||||
PVR proliferative vitreoretinopathy.
Table 4.
Descriptive statistics for categorical variables of surgical procedures and recurrence in each period
| Demographics | Control | Pandemic | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n (eyes) | % | Epidemic 1 (4/16 − 5/14) |
P | Inter-epidemic 1 (5/15 − 7/28) |
P | Epidemic 2 (7/29 − 9/15) |
P | Inter-epidemic 2 (9/16 − 11/13) |
P | Epidemic 3 (11/14 − 2/16) |
P | ||||||
| n (eyes) | % | n (eyes) | % | n (eyes) | % | n (eyes) | % | n (eyes) | % | ||||||||
| Total | 208 | 7 | 18 | 8 | 16 | 18 | |||||||||||
| RD Treatment | |||||||||||||||||
| PPV | 177 | 85.1 | 4 | 57.1 | 0.08 | 12 | 66.7 | 0.08 | 6 | 75.0 | 0.35 | 14 | 87.5 | > 0.99 | 14 | 77.8 | 0.49 |
| SB | 31 | 14.9 | 3 | 42.9 | 6 | 33.3 | 2 | 25.0 | 2 | 12.5 | 4 | 22.2 | |||||
| Recurrence within six months | |||||||||||||||||
| Recurrence | 10 | 4.8 | 2 | 28.6 | 0.05 | 2 | 11.1 | 0.24 | 0 | 0.0 | > 0.99 | 1 | 6.2 | 0.56 | 2 | 11.1 | 0.24 |
| No recurrence | 198 | 95.2 | 5 | 71.4 | 16 | 88.9 | 8 | 100.0 | 15 | 93.8 | 16 | 88.9 | |||||
RD retinal detachment, PPV pars plana vitrectomy, SB scleral buckling.
Continuous characteristics of each period
Tables 5 and 6 show the characteristics of continuous variables at baseline and logMAR BCVA. No significant differences were found between the control and pandemic groups for age and logMAR BCVA at the first visit and 1 month postoperatively. In the epidemic 3 period, there was a significant difference in the duration of symptoms before presenting to our hospital compared with the control period (14.7 ± 14.4 days vs. 8.9 ± 14.7 days, P = 0.01).
Table 5.
Descriptive statistics for baseline continuous variables in each period
| Demographics | Control n (eyes) |
Pandemic | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Epidemic 1 (4/16 − 5/14) |
P | Inter-epidemic 1 (5/15 − 7/28) |
P | Epidemic 2 (7/29 − 9/15) |
P | Inter-epidemic 2 (9/16 − 11/13) |
P | Epidemic 3 (11/14 − 2/16) |
P | ||
| n (eyes) | n (eyes) | n (eyes) | n (eyes) | n (eyes) | |||||||
| Total | 208 | 7 | 18 | 8 | 16 | 18 | |||||
| Age (mean ± SD) | 57.8 ± 15.7 | 44.3 ± 20.2 | 0.08 | 50.4 ± 20.0 | 0.25 | 59.1 ± 13.0 | 0.90 | 58.0 ± 11.4 | 0.97 | 54.9 ± 19.1 | 0.80 |
| Duration of symptoms | 8.9 ± 14.7 | 10.3 ± 10.2 | 0.35 | 11.2 ± 11.3 | 0.34 | 15.6 ± 26.9 | 0.64 | 10.1 ± 9.0 | 0.11 | 14.7 ± 14.4 | 0.01 |
SD standard deviation.
Table 6.
Descriptive statistics for logMAR BCVA in each period
| Demographics | Control | Pandemic | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n (eyes) | Epidemic 1 (4/16 − 5/14) |
P | Inter-epidemic 1 (5/15 − 7/28) |
P | Epidemic 2 (7/29 − 9/15) |
P | Inter-epidemic 2 (9/16 − 11/13) |
P | Epidemic 3 (11/14 − 2/16) |
P | |
| n (eyes) | n (eyes) | n (eyes) | n (eyes) | n (eyes) | |||||||
| Total | 208 | 7 | 18 | 8 | 16 | 18 | |||||
| logMAR BCVA (mean ± SD) | |||||||||||
| At first visit | 0.54 ± 0.75 | 0.30 ± 0.64 | 0.53 | 0.49 ± 0.74 | 0.75 | 0.69 ± 0.96 | 0.85 | 0.66 ± 0.88 | 0.72 | 0.25 ± 0.46 | 0.44 |
| At 1 month | 0.25 ± 0.44 | 0.19 ± 0.35 | 0.84 | 0.19 ± 0.33 | 0.33 | 0.32 ± 0.47 | 0.66 | 0.34 ± 0.46 | 0.45 | 0.25 ± 0.37 | 0.70 |
logMAR logarithm of the minimum angle of resolution, BCVA best corrected visual acuity, SD standard deviation.
Discussion
The COVID-19 pandemic and associated lockdowns or restrictions have considerably impacted patients and healthcare providers worldwide [2]. During the pandemic, behavioral restrictions changed depending on the alert level of the community, which affected medical visits. In our study, the annual RD recurrence rate was 9% during the pandemic but varied from 0 to 28.6% for each period. This suggests that the impact of the pandemic should be evaluated within shorter periods rather than year to year. However, no previous studies have focused on the impact of local alert levels on the characteristics of RRD.
The incidence of RRD increased to 112.5% during the pandemic compared with the control years. Such an increase during the pandemic years was also reported in Canada [15]. This study confirmed a relatively higher number of patients with RRD within the first few months of the pandemic. In contrast, a previous report states that the number of cases declined in urban areas in Japan during the early stages of the pandemic [6]. Given Shinshu University’s rural location, only a few other centers in the surrounding areas can perform RD repair. During the early periods of the COVID-19 pandemic, such core hospitals had to close or postpone surgery to reduce human-to-human viral transmission and divert resources to intensive care units. Thus, our experience of seeing more patients with RRD may be attributed to an increase in referrals from nearby clinics that had previously sent their patients to other facilities.
Our study confirms a significant delay by patients with RRD in presenting to hospitals among the COVID-19 pandemic group, as also reported in previous studies [16, 21]. This delay may have been due to anxiety about exposure to the COVID-19 virus in a healthcare environment. Additionally, in epidemics 2 and 3, patients with RRD exhibited greater delay than in epidemic 1, which may reflect increased anxiety associated with multiple epidemic waves. There had only been a few infected people in Nagano prefecture during the state of emergency. However, during the epidemic 2 and 3 periods, the number of people infected was rising, causing patients with RRD to further delay seeking medical attention.
In our study, the percentage of macula-off RD and extended RD in three or more quadrants was higher during the state of emergency than in other periods, but the difference was not statistically significant. A previous report from the United States shows significantly more patients with macula-off RRD than in a control cohort [16]. The difference in the legal binding force could explain the disparity between this and the previous study. There were no penalties for going out and no public transportation shutdowns during the state of emergency by the Japanese government [22]. Thus, access to a hospital was not denied, and patients could go whenever they wanted. Lockdowns in other countries were more restrictive [23, 24] than in Japan and included fines and public transportation suspension, which may have prevented people from visiting hospitals.
As discussed above, delays in hospital visits were more common in epidemic 2 and 3, although the percentage of macula-off RD was higher in epidemic 1. It is possible that the harsher behavioral restrictions during the state of emergency discouraged patients with mild symptoms not associated with foveal detachment from seeking medical attention and increased the rate of macula-off RD. In addition, the date of onset is a subjective ailment and may not necessarily correlate with the objective retinal condition.
We observed a decrease in the average age of patients with RRD at the beginning of the pandemic. Due to fear of COVID-19 exposure, older patients may have been less likely to be seen in medical facilities. This hypothesis is also supported by a previous article, which states that the proportion of macula-off RD among the elderly was higher in the early pandemic year than in control years [16]. Simultaneously, such a trend was not observed among younger patients [16]. Following the epidemic 2 period, the average age no longer decreased. During the latter months of the pandemic, there may have been widespread anxiety about viral exposure, which eventually outweighed the perception that the risk of COVID-19 morbidity and mortality was lower for younger age groups.
This study indicates that the proportion of scleral buckling (SB) was the highest at the beginning of the pandemic (42.9% in epidemic 1). This observation contradicts a previous report that surgeons encountered more complicated cases and preferred PPV over SB during the COVID-19 pandemic [21]. Although our results may be coincidental given the small sample size, the increased rate of SB might be attributed to a decrease in the average age of patients with RRD visiting our hospital. Compared to SB, PPV has a higher rate of surgery-related complications in young patients with RRD, including cataract formation and PVR [25]. Therefore, SB with silicone sponge is the first-line of treatment for patients under 50 years of age in our practice. This choice could explain the increased SB rate during epidemic 1.
RRD can be triggered and progressed by physical movement of the body and physical activity [26]. Most Japanese citizens avoided going outside during the state of emergency [22]. The proportion of women patients with RRD declined markedly during this period (28.6% in epidemic 1). According to a previous study, urban residents also had a low incidence of RRD among women during the same period [6]. One report suggests differences in behavior among men and women in Japan during the state of emergency [27]. Commuting was not different according to sex; however, for personal reasons women undertook fewer activities, such as shopping, dining, socializing, and entertainment, than men [27]. It might be ascribed to the reduced out-of-home activity that Japanese women had a reduced incidence of RRD. However, the exact reason is unclear, and further research is warranted.
This is the first report showing an increase in RD recurrence under the state of emergency during the COVID-19 pandemic. The RD recurrence rate in the SB group increased from 3.3 to 20.0%, although the difference was not statistically significant due to the small sample size. Several factors are reported as risk factors for the recurrence of RD, including male sex, SB, and the extent of RD in three quadrants or more [28, 29]. All these demonstrate an increase during the state of emergency in this study. Moreover, one report finds that the recurrence group’s average age was lower than that of the nonrecurrence group (45.05 ± 13.42 years) [29], comparable to the epidemic 1 period in our study (44.3 ± 20.2 years). These features might contribute to an increased recurrence rate. RD recurrence is a significant challenge considering the financial and emotional burden faced by vitreoretinal surgeons and patients [29]. During a period of harsh restrictions, the surgical approach tends to be more cautious. On the other hand, this study includes six surgeons with different levels of experience, and it must be noted that this may have affected the RD recurrence rate.
This investigation has several strengths. First, our analysis covered a whole year; hence, it includes the initial months and reflects a more extended transition in characteristics of patients with RRD. Second, in addition to the year-to-year comparison, we also assessed the outcomes in each period of the COVID-19 pandemic, which might be beneficial for understanding the trends on how people react, change, and adapt to local epidemic waves and implemented restrictions.
This study has also several potential limitations. It may be limited in applicability due to geographic location and local activities. Additionally, the incidence of COVID-19 infections and the alert levels of public health measures implemented by local governments varied widely across Japan, making it difficult to generalize our results. Compared to the previous 3 years, a further adjustment is necessary to account for seasonal weather patterns and holidays that can affect RRD analysis. Due to the relatively small sample size during the COVID-19 pandemic, especially the epidemic 1 period, some differences were not statistically significant.
In Japan, this is the first full-year evaluation of the clinical patterns of patients with RRD during the COVID-19 pandemic. We found patients delaying seeking medical care in our hospital during the pandemic. Furthermore, patients with RRD tended to be younger men, more likely to have macula-off RD, three or more quadrants detached, and RD recurrence during the state of emergency than in the lower alert level periods. Due to the limited scope of this study and its small sample size, it would be advantageous to conduct a multicenter study in the future to further elucidate the details of the clinical characteristics of RRD in Japan. COVID-19 is still a worldwide threat; therefore, it is imperative to research clinical patterns of acute ophthalmic diseases, including RRD.
Gray areas indicate epidemic duration. Numbers with dashes are before the alert level system was declared. Numbers without dashes are actual alert levels. The alert level is determined by administrative decisions and does not necessarily correspond to the reference standard for the number of newly diagnosed COVID-19 patients, shown in Supplemental Table 1.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
We would like to thank Editage (www.editage.com) for English language editing.
Conflicts of interest
Y. Chiku, None; T. Hirano, Consulting fees (Novartis, Bayer, ZEISS); K. Hoshiyama, None; Y. Iesato, None; T. Murata, Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events (Novartis, Santen, Bayer, ZEISS).
Footnotes
Corresponding Author: Takao Hirano
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