Retinal Detachment and Laser Retinopexy Rates During the COVID-19 Pandemic

Abstract

Purpose:

At the start of March 2020, the COVID-19 pandemic placed an unprecedented burden on the healthcare system. Throughout much of the United States, shelter-in-place orders were imposed to reduce transmission. A consequence of this crisis, risk mitigation orders, and patient fear of exposure may have led to underutilization of emergency services. We aimed to quantify 2 emergent interventions in ophthalmology, specifically acute laser retinopexy procedures and retinal detachment repair, to determine whether these procedures decreased during the start of the pandemic.

Methods:

All retinal detachment surgeries and laser retinopexy procedures were identified using Current Procedural Terminology codes. Rate data during the study period (March 1 through May 31, 2020) was compared to historical data from the year prior (March 2019 through May 2019; epoch 1) as well as the immediate 3 months prior to the study period (December 2019 through February 2020; epoch 2).

Results:

Combined procedures fell by 38.5% (P = .01) and 36.0% (P = .02) when compared to epoch 1 and epoch 2, respectively. The rate of laser retinopexy procedures fell by 45.5% (P = .02) and 33.0% (P = .14) when compared to epoch 1 and epoch 2, respectively. The rate of retinal detachment repair fell by 29.4% (P = .24) and 38.0% (P = .07) when compared to epoch 1 and epoch 2, respectively.

Conclusions:

Procedures fell during the study period, suggesting underutilization of emergent ophthalmology care. It is necessary for ophthalmologists to emphasize the need to seek care for concerning symptoms.

Introduction

On March 11, 2020, the COVID-19 virus outbreak was officially declared a pandemic by the World Health Organization and placed an unprecedented burden on all aspects of society. A national emergency was declared in the United States on March 13, 2020, and throughout most of the country, shelter-in-place orders were implemented in an attempt to reduce transmission and lessen the burden on the health care system. On March 18, 2020, the American Academy of Ophthalmology released guidance on caring for patients during this emerging crisis and recommended ceasing to provide patient care that was not deemed either urgent or emergent. ¹ Additionally, the American Society of Retina Specialists released a list of emergent surgical indications that included repair of acute retinal detachments. ²

Our ophthalmology department, which is within a large academic tertiary center, ceased elective care from March 16, 2020, through May 4, 2020. Although emergency and necessary health care services were fully operational during that time, shelter-in-place orders and patients’ fear of exposure during the emerging pandemic led to underutilization of emergency services. ^{3 -5} A recent Centers for Disease Control and Prevention report has found that emergency department (ED) visits had declined by 42% in the early months of the pandemic, with a 23% and 20% reduction in ED visits for myocardial infarction and stroke, respectively. ⁴ Other reports have similarly demonstrated reduced admission for myocardial infarction and stroke. ^6,7

We examined 2 emergent interventions in ophthalmology, specifically acute laser retinopexy procedures and retinal detachment repair, to determine if a similar decline had occurred at our institution.

Methods

All retinal detachment surgical procedures and laser retinopexy procedures performed at our institution for the treatment of retinal detachment (excluding tractional retinal detachment) and retinal tears were identified using Current Procedural Terminology codes. Our institution is a large academic medical center that includes 12 regional hospitals and 69 primary care centers throughout the Chicagoland area. March 1 through May 31, 2020, was defined as the study period because this timeframe encompassed the start of elective care delay through the end of shelter-in-place orders in Illinois. This period was compared with 2019 data from the same time period (epoch 1) as well as the 3 months immediately prior (December 2019-February 2020) the study period (epoch 2). A Poisson means test was used to determine statistical significance. This study was exempt from institutional review board approval because no patient data were obtained.

Results

Combined retinal detachment repair and laser retinopexy procedures during the study period fell by 38.5% (P = .01) and 36.0% (P = .02) when compared with epoch 1 and epoch 2, respectively (Table 1). Individually, laser retinopexy procedures were performed at a rate of 0.26 per day during the study period, a 45.5% (P = .02) and 33.0% (P = .14) decrease compared with the rate found in epoch 1 and epoch 2, respectively. Retinal detachment repair was performed at a rate of 0.26 per day during the study period, a 29.4% (P = .24) and 38.0% (P = .07) decrease compared with the rate found in epoch 1 and epoch 2, respectively. Figure 1 shows the longitudinal trend with average weekly rates for retinal detachment repair and laser retinopexy procedures from March 2019 through June 2020.

Table 1.

Average Daily Rates (Count/Day) During the Study Period for Laser Retinopexy Procedures, Retinal Detachment Repair, and Combined (Laser Retinopexy + Retinal Detachment) Compared With Epoch 1 and Epoch 2.^a

	Laser retinopexy	Retinal detachment	Combined
Epoch 1 (March 1-May 31, 2019)
Epoch 1 average rate (95% CI)	0.48 (0.3-0.6)	0.37 (0.3-0.5)	0.85 (0.7-1.1)
Study period (March 1-May 31, 2020) average rate (95% CI)	0.26 (0.2-0.4)	0.26 (0.2-0.4)	0.52 (0.4-0.7)
Decrease, %	45.5	29.4	38.5
P	.02b	.24	.01b
Epoch 2 (December 1, 2019-February 29, 2020)
Epoch 2 average rate (95% CI)	0.40 (0.3-0.5)	0.43 (0.3-0.6)	0.82 (0.6-1)
Study period (March 1-May 31, 2020) average rate (95% CI)	0.26 (0.2-0.4)	0.26 (0.2-0.4)	0.52 (0.4-0.7)
Decrease, %	33.0	38.0	36.0
P	.14	.07	.02b

^a A decrease is noted for each comparison (range, 29.4%-45.5% decrease).

^b Statistical significance.

Figure 1.

Four-week rolling average (count/week) for laser retinopexy procedures, retinal detachment repair, and combined (laser retinopexy + retinal detachment).

Conclusions

Overall, combined retinal detachment and laser retinopexy procedures fell significantly during the study period. When analyzing each procedure separately, retinal detachment and laser retinopexy procedures both decreased at a similar rate, although not all comparisons reached statistical significance. This is the first report to note such a decline during the peak of the pandemic and demonstrates the far-reaching health consequences of the COVID-19 pandemic. It is in line with other studies that show similar decreases in noncoronavirus emergency care, suggesting patients could not access or were delaying seeking care during the early pandemic period.

The consequence of this lack of care remains unknown. However, it is conceivable that patients may present with later-stage complications with worse visual outcomes as a result. Future studies are necessary to evaluate the ophthalmologic outcomes of these patients. For instance, a recent report showed an increase in incidence of large submacular hemorrhages among patients with neovascular age-related macular degeneration during the lockdown due to a decrease in utilization of necessary care. ⁸

Retina specialty care in many situations is frontline care for vision-threatening conditions, and it is important for ophthalmologists to emphasize the need for patients to seek care for serious visual symptoms (eg, flashes, floaters, or loss of vision) as well as to present for vital therapy such as intravitreal injections. The American Society of Retina Specialists, in concordance with multiple health agencies, has released guidance on providing safe care for patients during this pandemic, and it is necessary to reassure the public that EDs and physician offices have implemented infection control protocols so that patients may safely seek emergency and necessary care when indicated. ⁹