key: cord-0818647-7gjgu3z6 authors: Romano, Francesco; Monteduro, Davide; Airaldi, Matteo; Zicarelli, Federico; Parrulli, Salvatore; Cozzi, Mariano; Staurenghi, Giovanni title: Increased Number of Submacular Hemorrhages As a Consequence of COVID-19 Lockdown date: 2020-06-25 journal: Ophthalmology. Retina DOI: 10.1016/j.oret.2020.06.027 sha: d4cdbfc8559b4c864134dea93a15a783b23ef07c doc_id: 818647 cord_uid: 7gjgu3z6 Abstract During early months of Covid-19, significant nonattendance to scheduled appointments was noticed in our tertiary center for nAMD. This resulted in an increased rate of sub-macular hemorrhages in April 2020 compared to two control periods. During early months of Covid-19, significant nonattendance to scheduled appointments was noticed in our 28 tertiary center for nAMD. This resulted in an increased rate of sub-macular hemorrhages in April 2020 29 compared to two control periods. The implementation of national lockdown (starting March 8, 2020) and social containment measures have 58 undoubtedly generated anxiety in the local population, resulting in significant nonattendance to scheduled 59 office visits. 4 After the initial efforts to cope with this unexpected public health emergency, our clinicians are 60 starting to weigh in on the impact of this pandemic on clinical practice. Aim of this study is to report the attendance rates to the service of Medical Retina and the incidence of large 62 SMH in an Italian tertiary center for nAMD during the early months of COVID-19 pandemic. The occurrence of SMH secondary to choroidal neovascular membrane was collected from clinical records and 68 confirmed by means of multimodal imaging, including color fundus photography, optical coherence 69 tomography and fundus autofluorescence. Only nAMD patients already undergoing pro-re-nata anti-VEGF 70 treatment with SMH of at least one disc-diameter within the macular region were included. 2 Patients with 71 previous history of large SMH were excluded from the study. Patients affected by bilateral nAMD are routinely 72 treated with an interval of at least 14 days due to Italian Health Authorities' regulations. The attendance rate to the clinic and the incidence rate of SMHs from the same months of the previous year 74 (March-April 2019) were analyzed as controls. Since the majority of our patients were switched to bevacizumab from September 2019 for economic reasons, an additional control bimester (October 1 to November 30, 2019) 76 was considered to avoid biases related to drug selection. The attendance rates were calculated in relation to the scheduled office visits and intravitreal treatments. Student's T test was used to explore the differences among the weekly attendances in distinct time periods. The incidence rate of SMH was instead obtained measuring the number of SMH cases occurring per-month 80 among scheduled nAMD patients. Poisson regression analysis was used to assess the ratio between the 81 incidence rates (IRR) of large SMH among the different study periods. 92 treatments in the previous month (p=0.035). In April 2020, the interval between the appearance of large SMH 101 and the last intravitreal anti-VEGF injection was significantly longer than the usual interval between two 102 intravitreal anti-VEGF injections for this subset of patients (3.6±0.8 vs. 1.9±0.5 months; p=0.01). Complete demographic data and rates are reported in Table 1 . Figure 2 shows the weekly attendance to 104 scheduled appointments and SMH incidence during the three analyzed periods (available at 105 http://www.aaojournal.org). This report reveals that a meaningful decrease in the attendance rate to our clinic was followed by an ominous 107 increment of large sub-macular hemorrhages during the early months of Covid-19 pandemic. Several real-world studies have reported that poor adherence to treatment or to strict follow-up can be 109 responsible for worse visual outcomes in nAMD. 5,6 110 We hypothesize that nonattendance to scheduled appointments after the implementation of national 111 lockdown might have partially contributed to the significant increase in the occurrence of large SMH. While this 112 might be a plausible explanation, we acknowledge that a selection bias may exist as patients with SMH are 113 more prone to refer to our attention due to the sudden worsening of central vision. However, the higher 114 number of total hemorrhages in April 2020 and the elevated rate of nonattendance to office visits among SMH 115 cases seem to support our hypothesis. In conclusion, our findings confirm that Covid-19 pandemic is leaving the medical community with indirect 117 consequences to address. This seems particularly true for nAMD, where regular follow-up visits and intravitreal 118 treatments are essential to maintain good vision and prevent serious complications. It is likely that Legend: n, number; SD, standard deviation. 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