key: cord-0839087-585xbqtf authors: Mundae, Rusdeep; Velez, Adrian; Sodhi, Guneet S.; Belin, Peter J.; Kohler, James M.; Ryan, Edwin H.; Tang, Peter H. title: Trends in the clinical presentation of primary rhegmatogenous retinal detachments during the first year of the COVID-19 pandemic date: 2021-11-19 journal: Am J Ophthalmol DOI: 10.1016/j.ajo.2021.11.017 sha: 78932700c8e419b10c52a7fb47a03fa64e476081 doc_id: 839087 cord_uid: 585xbqtf Purpose To evaluate the effect of one full year of the coronavirus disease 2019 (COVID-19) pandemic on clinical presentation of acute, primary rhegmatogenous retinal detachment (RRD). Design Single-center, retrospective observational cohort study. Methods Patients were divided into two cohorts; consecutive patients treated for primary RRD during the COVID-19 pandemic (March 9, 2020 to March 7, 2021; pandemic cohort) and patients treated during the corresponding time in previous year (March 11, 2019 to March 8, 2020; control cohort). Main outcome measures Proportion of patients presenting with macula-involving (mac-off) or macula-sparring (mac-on) RRD. Results 952 patients in the pandemic cohort and 872 patients in the control cohort were included. Demographic factors were similar. Compared to the control cohort, significantly greater number of pandemic cohort patients presented with mac-off RRDs ([60.92%] pandemic, [48.17%] control, P = 0.0001) and primary proliferative vitreoretinopathy (PVR; [15.53%] pandemic, [6.9%] control, P = 0.0001). Pandemic cohort patients (10.81%) had significantly higher rates of lost to follow-up compared to control cohort (4.43%; P = 0.0001). Patients new to our clinic demonstrated significant increase in mac-off RRDs in the pandemic cohort (65.35%) compared to control cohort (50.40%; P = 0.0001). Pandemic cohort patients showed worse median final best-corrected visual acuity (BCVA; 0.30 logarithm of the minimum angle of resolution [logMAR]) compared to control cohort (0.18 logMAR; P = 0.0001). Conclusions Patients with primary RRD during the first year of the COVID-19 pandemic were more likely to have mac-off disease, present with primary PVR, be lost to follow-up, and have worse final BCVA outcomes. Coronavirus disease 2019 (COVID- 19) was initially identified in Wuhan, China in December of 2019 1 and was declared a global pandemic by the World Health Organization (WHO) on March 11, 2020. 2 The American Academy of Ophthalmology (AAO) responded by issuing a statement one week later recommending all American ophthalmologists to immediately cease providing non-urgent care. 3 Subsequently on March 27, 2020, the AAO published a list of urgent and emergent ophthalmic surgeries that should continue unabated, including the repair of retinal detachment (RD). 4 Despite this guidance, studies have shown that fewer patients with ophthalmic emergencies sought care during the initial months of the pandemic. 5, 6 This is also reflected outside of ophthalmology by a decline in overall emergency department visits 7 and critical procedures performed. 8, 9 Possible explanations include challenges posed by stay-at-home measures, socioeconomic hardship, and general anxiety brought about by the pandemic. Primary rhegmatogenous retinal detachment (RRD) is an ophthalmic emergency and results from a full-thickness retinal break secondary to vitreous traction, were liquified vitreous fluid flows through the break and accumulates within the subretinal space. 10, 11 If subretinal fluid (SRF) spares the macula (mac-on), the main goal of surgical timing is to preempt macular involvement (mac-off) as a detachment of the fovea confers a worse visual prognosis. 10 Progression to mac-off RRD can occur within hours to days, depending on various factors such as pseudophakia, site of retinal break(s), degree of vitreous liquefaction, bullous configuration, axial length, and age. 10, 11 Duration of foveal detachment and better best-corrected visual acuity (BCVA) at the initial examination have been shown to correlate with improved post-surgical outcomes. 11 Recent studies have demonstrated that clinical trends for patients presenting with primary RRDs have changed during the COVID-19 pandemic. Patel et al. found that early in the pandemic a greater proportion of patients with primary RRDs delayed seeking medical care, had worse initial BCVA, and presented more commonly with significant clinical characteristics such as foveal detachment and primary proliferative vitreoretinopathy (PVR). 12 Arjmand et al. also reported a higher rate of worse clinical presentations but showed that final BCVA and anatomic outcomes remained the same. 13 Demographic, preoperative, operative, and follow-up data were collected from a review of the electronic medical record. Race was self-identified with categories of "Caucasian", "Black", "Asian", "Native American", "Hispanic", "Decline to Specify", or "Other". Median household income was used as a quantitative surrogate for socioeconomic status tabulated from the American Communities Survey 2017 of median income by the patient's home zip code. Patients were considered "established" if they had been previously seen by the practice within a 3-year period before diagnosis of primary RRD; otherwise, they were considered "new". The distance from the patient's home zip code to the clinic of initial visit was used as a quantitative surrogate for healthcare access and was calculated based on the shortest route (miles) mapped using Google Maps software (Alphabet, Inc., Mountain View, CA). The time between initial diagnosis and surgery was recorded as well. Initial Snellen BCVA was obtained from the visit where the patient was diagnosed by our clinic. Final Snellen BCVA was determined at the longest post-operative visit; however, those with a follow-up course less than 3-months were excluded from analysis. The primary outcome was the proportion of patients demonstrating mac-on RRD, as opposed to mac-off RRD (defined as the presence of subretinal fluid involving or within 1 optic disc diameter from the fovea) on preoperative clinical evaluation. Secondary outcomes include initial and final BCVA, proportion of patients with symptom duration of 1 day or less, mean duration of RRD symptoms (vision loss, flashes, floaters, or visual field defect), time to surgical repair, and the presence of grade C or higher primary proliferative vitreoretinopathy (PVR). The historical control group from 2019 was used as a comparator for all primary and secondary outcomes. Statistical analysis was performed on JMP software (SAS Institute, Cary, NC). Snellen BCVA was converted to logarithm of the minimum angle of resolution (logMAR) units for quantitative analysis, with logMAR values for BCVA of "light perception", "hand motion", and "counting fingers" assigned values of 2.7, 2.3, and 1.8, respectively. 15 Comparison of categorical variables between two cohorts was completed using a 2-tailed Fisher exact test. Continuous quantitative variables including age, median household income, travel distance, duration of symptoms, time to surgery, and logMAR BCVA were found to be non-normal using the Shapiro-Wilk test. The Median test, utilizing median rank scores, was used for comparisons involving travel distance and logMAR BCVA. All other non-normal distributions were compared using the Mann-Whitney U test. A P-value of less than 0.05 was considered statistically significant. Querying the billing data for CPT codes 67110 (repair of RD using pneumatic retinopexy respectively. After excluding patients without a primary rhegmatogenous etiology, a total of 952 and 872 patients were assigned to the pandemic and control cohorts, respectively. Various baseline characteristics described in Table 1 were found to be similar between the two cohorts. There was an increase in the total number of patients with primary RRDs that underwent surgical repair in the pandemic cohort compared to the control cohort over 1 year (Table 1) 16 Both cohorts showed similar numbers of PR and SB/PPV procedures performed; however, we observed a significant increase in primary SB and complex RD procedures in the pandemic cohort (Table 1) . Mac-off RRDs in the pandemic cohort was significantly greater than the control cohort (Table 1 ). The greatest decline in the pandemic cohort occurred during week 4, and the greatest increase occurred during week 51 (February 22 to 28, 2021) ( Figure 1 , C). While mac-off RRDs increased significantly (P = 0.0001) in the pandemic cohort for all quarters compared to the control cohort, the greatest increase was observed in Q4 (Figure 1, D) . The presence of primary PVR in RRD was significantly greater compared to the control cohort (Table 1) . Each quarter of the year exhibited a significant increase in the presentation of primary PVR in the pandemic cohort compared to the control cohort, with the greatest observed in Q2 (Figure 1, D) . Postoperative follow-up data were collected for all patients in the study who underwent surgical repair of primary RRD. When examining the duration of follow-up, approximately 21.10% and 14.98% of patients did not present for a 3-month or later appointment in the pandemic and control cohorts, respectively. Further analysis revealed that a similar number of patients in the pandemic and control cohorts were referred back to their primary eyecare provider prior to the 3-month timepoint for continued follow-up cares (PRN; Figure 2 , A). Thus, the total amount of patients who failed to present for follow-up appointments at 3-months and further (lost to follow-up) significantly increased in the pandemic cohort compared to the control cohort. Established vs. new patients A patient was deemed "established" if he or she was examined in the clinic within 3 years prior to the diagnosis of a primary RRD. Under these criteria, the pandemic cohort had a statistically greater proportion of established patients compared to the control cohort (Table 1) . New patients were found to have significantly more mac-off RRD's in the pandemic cohort compared to the control cohort; however, this did not differ significantly when comparing established patients (Figure 2, B) . Using a cut-off age of 50 years, we analyzed the differences in primary RRD presentation between younger (age ≤ 50 years) and older (age > 50 years) patients within the pandemic and control cohorts. While more patients of both age subgroups were found to have mac-off RRDs in the pandemic cohort compared to the control cohort over the entire year, there was a significantly larger increase in the older subgroup (Figure 2 , C). When the 1-year data were divided quarterly, analysis revealed a significantly lower proportion of mac-off RRDs observed during Q1 of the pandemic in the younger subgroup but increases in each subsequent quarter thereafter. In contrast, the older subgroup consistently demonstrated significantly greater proportions of macoff RRD in each quarter throughout the pandemic. For the entire year, initial presenting BCVA for the pandemic cohort was significantly worse compared to the control cohort; however, there was no significant difference observed in patients with mac-off disease between the pandemic and control cohorts (Figure 3 ). There was also no significant difference in initial BCVA observed in patients new to the clinic between pandemic and control cohorts. The final BCVA for the pandemic cohort was significantly worse compared to the control cohort. When focusing on mac-off RRD patients, final BCVA for the pandemic cohort was significantly worse compared to the control cohort. Finally, new patients in the pandemic cohort demonstrated significantly worse final BCVA compared to those in the control cohort. After excluding 11 traveling patients with addresses of more than 700 miles from our clinics (2 from Arizona, 2 from Florida, 1 from Ohio, 1 from Oklahoma, 2 from Pennsylvania, 2 from Texas, and 1 from Wyoming), geographic analysis showed that there was no significant difference in distance traveled between the pandemic cohort and the control cohort (Figure 4, A) . When we aggregated patients from both cohorts, we found that patients with mac-off RRDs traveled significantly further than patients with mac-on RRDs (Figure 4, B) . There was no significant difference observed in distance traveled by patients with mac-off RRDs between the pandemic and cohorts (Figure 4, C) . We also found that new patients traveled significantly farther distances to our clinics for care compared to established patients when aggregating both cohorts (Figure 4, D) ; however, there was no significant difference in travel distance by new patients between the pandemic and control cohorts (Figure 4 , E). While previous studies on the effects of the COVID-19 pandemic clinical trends in emergent ophthalmic diseases have often focused on the initial months, we examined the first full year to evaluate long-term patterns. Similar to reports from Europe 17-20 and North America 12, 14, 21 , we experienced a significant decline in patients presenting with primary RRDs during the first few months; however, this quickly recovered to and even exceeded that which was seen in the previous year. Our data supports findings by Arjmand et al. that there was no significant decline in primary RRD presentation during the first 6 months of the pandemic. 13 Possible explanations include increased referrals to our practice as a result of reduced capacity by and/or closures of primary eye clinics as well as patient hesitation toward seeking care at hospital emergency departments due to fear of potential COVID-19 exposure. We hypothesize that two events during the year may have had the greatest clinical impact on observed RRD trends in our study population: 1) the initial declaration of the global pandemic by the WHO (occurring in Q1) and 2) the exponential surge of laboratory-confirmed COVID-19 cases that Minnesota experienced from November to December of 2020 (occurring in Q3). RRD patients in Q1 may have delayed seeking care due to the novel nature of the virus and to our lack of understanding about its transmissibility at that time. With the statewide COVID-19 case surge in Q3, RRD patients may have delayed care due to a heightened sense of anxiety about potential viral exposure in a medical setting. These patients appear to have eventually presented for care and were captured in the Q2 and Q4 data, explaining the significant increase in both quarters for mac-off RRDs. Unfortunately, final BCVA outcomes may have suffered as a result. The proportion of older (age > 50 years) patients presenting with mac-off RRD was consistently increased across all quarters of the pandemic year (Figure 1, H) ; however, this was not observed in younger (age ≤ 50 years) patients during Q1 (Figure 1, G) . Our findings support Patel et al. who reported no significant decline in the proportion of younger patients presenting with mac-on RRDs during the first 50 days of the pandemic. 12 Interestingly, the proportion of younger patients presenting with mac-off RRD significantly increased for Q2 through Q4 in a similar trend as older patients. A possible explanation is the general anxiety about viral exposure in the later months of the pandemic eventually outweighed earlier perceptions of lower risk of COVID-19 morbidity and mortality in the younger age groups. The presence of primary PVR is a poor prognostic factor associated with delayed presentation. 22 Even though this was significantly increased in all quarters of the pandemic year, we noted the greatest increase in Q2 (Figure 1, D) . It is possible that Q2 is not only capturing patients who developed an RRD during Q1 and chose to delay care, but also patients who It is possible that PRN patients could have been lost to follow-up with their local eye care provider after being referred back from our clinic; however, we do not have access to these outside clinical data. The increase in mac-off RRDs during the pandemic was most noticeable in patients who were new to our clinic (Figure 1, F) , similar to results from Patel et al. 12 A likely explanation is that new patients may have lacked an awareness of clinical RD symptoms or failed to comprehend the importance of early treatment. 23 While the incidence of PVR and mac-off RRDs were higher during the pandemic, we found no statistically significant difference in patient-perceived duration of RD symptoms between the two cohorts (Table 1) . We believe this is due to the unreliability of patient-reported duration of RRD symptoms, as we observed no linear correlation between duration of symptoms and severity of disease for our current study. It is well known that determining RRD duration is difficult due to high variance of patient-reported symptoms 25 , which can be mitigated by incorporating specific questions during the history intake. 26, 27 Unfortunately, these measures were not a part of our routine clinical practice during the duration of this study. Numerous studies within ophthalmology and other fields of medicine have shown that the distance a patient travels for care can be a quantifiable marker for access to care. [28] [29] [30] [31] In our study, we did not observe a significant impact by the pandemic on travel distance for our patients. Although overall patients in the pandemic cohort as well as those who were new to our clinic were trending towards further distances traveled, these measures did not obtain statistical significance. When looking at all patients in this study, regardless of whether they were in the pandemic or control cohort, we found that patients with mac-off RRDs and those who were new to our clinic traveled significantly further for care. This indicates broader disparities in access to healthcare that predates the pandemic. Further studies are essential to investigate this important topic. There were several important limitations to our study. Due to its retrospective nature, there was inherent bias towards patient selection and loss to follow-up. Since the majority of our patient population is Caucasian with a median household income higher than the national median, this limits the applicability of our results across various racial and socioeconomic groups. Our geographical area and local market prominence may additionally limit the broader applicability of this study. Furthermore, the incidence of COVID-19 infections and the varying severity of public health measures taken by local governments varied greatly across the United States, limiting extrapolation of our data to other regions. Timing of surgery after the RRD was diagnosed did not differ between the two cohorts, indicating our clinic was successful in maintaining access to the operating room during the pandemic. Since we chose the corresponding time from the previous year for comparison, innate variations in RRD presentation due to factors such as seasonal weather patterns and holidays should be controlled for. To our knowledge, this study is the first to investigate changes in the clinical trends for primary RRD presentation over the first full year of the COVID-19 pandemic. It also contributes to national trends observed during the pandemic by commenting on the geographical trends seen in the Upper Midwest region in a large retina-only practice. We found that a significant number of our patients experienced a delay in obtaining care either due to anxieties about the pandemic or to difficulties in navigating a healthcare landscape beset by reduced capacity and financial hardships. 32, 33 The unfortunate end-result was increased mac-off disease and primary PVR, both of which contributed to worsened visual outcomes. With the declining numbers of COVID-19 Schlenker A, Tadrous C, Ching G, et al. Retrospective analysis of ophthalmology referrals during the COVID-19 pandemic compared to prepandemic. Can J Ophthalmol 2021;S0008-4182:00083-1. Peter Tang is an associate at VitreoRetinal Surgery, PLLC and an Adjunct Assistant Professor in the Department of Ophthalmology & Visual Neurosciences at the University of Minnesota. He completed a BA from the University of Pennsylvania as well as a combined MD/PhD program from the Medical University of South Carolina. He underwent Ophthalmology residency training at the University of Minnesota followed by a fellowship in Vitreoretinal Surgery and Ocular Oncology at the Byers Eye Institute at Stanford University. Rusdeep Mundae is an ophthalmology resident at the University of Minnesota. He obtained his BS in Neuroscience from University of California, Los Angeles (UCLA) and his MD from Saint Louis University School of Medicine. He completed his preliminary year in internal medicine at Rush University Medical Center. He has interests in retinal imaging, machine learning/AI, and ophthalmic technology and innovation. Precis (35 words) The first year of the COVID-19 pandemic has brought about significant changes in the clinical trends of rhegmatogenous retinal detachment presentation. 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Lessons learned from the management of COVID-19 in Quebec (Canada) Quarterly analysis of macoff RRDs (black bars) and presence of primary proliferative vitreoretinopathy (PVR; gray bars) in the pandemic cohort expressed as a percentage of the control cohort (D) showed significant increases (P = 0.0001) for all quarters Younger patients demonstrated a significant decrease (P = 0.0018) in the percentage of mac-off RRDs in the pandemic cohort (black bar) compared to the control cohort (gray bar) in the first quarter (Q1); however, this trend reversed for the remainder of the year (C, top). In contrast, the percentage of older patients in the pandemic cohort with mac-off RRDs was significantly greater Distribution of logMAR BCVA by cohort. Box-and-whisker plot illustrates distribution of logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) between pandemic and control cohorts from initial and final clinical visits The box depicts the interquartile range, the line within the box depicts the median, and the bars above and below the box depict maximum and minimum range, respectively. When considering all patients presenting with primary RRDs (A), the pandemic cohort showed both significantly worse (P = 0.0486) initial BCVA (median = 0.54 logMAR; Snellen equivalent, 20/70) compared to the control cohort (median = 0.40 logMAR; Snellen equivalent, 20/50) as well as significantly worse (P = 0.0001) final BCVA (median = 0.30 logMAR; Snellen equivalent, 20/40) compared to the control cohort (median = 0.18 logMAR; Snellen equivalent, 20/30). Patients presenting with mac-off RRDs during the pandemic (B) did not exhibit a significant difference There was no significant difference (P = 0.1569) observed in initial BCVA of new patients between the pandemic and control cohorts (C); however, new patients in the pandemic cohort demonstrated a significantly worse