Anat Loewenstein, MD, MHA

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The worldwide challenges of healthcare accessibility have been accentuated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Social distancing and population lockdowns combined with restrictions, such as the requirement for reduced time during patient visitation and decreased physical proximity within clinical settings, have created additional barriers to patient assessments.

To meet the rapidly evolving needs of patients within a pandemic setting, retinal specialists have had to innovate and look to evolving technologies and practices. It is important to examine and qualitatively assess perceptions of the digital health transformation as well as barriers to adoption and early implementation of digital services. The feedback can be used to improve patient outcomes and, ultimately, provide interventions that are accessible to both patients and clinicians.

To meet the need for data on perceptions, a global survey to explore alternative modalities of retinal care utilised during the pandemic was distributed to retinal specialists between 31 March and 12 April 2020. The survey consisted of 44 questions that explored the impact of SARS-CoV-2 across three major domains: digital teleophthalmology, home monitoring and decentralised patient care.

A total of 214 retinal specialists completed the survey. Respondents were predominantly from Western Europe (n = 152, 71%) but also included clinicians from Eastern Europe, United States, North Africa, the Middle East and South America. All participants had medical retinal expertise with a significant majority (56%) having over 15 years of experience in ophthalmology.

Prior to the pandemic, rates of utilisation of teleophthalmology, home monitoring and decentralised patient care were low: 22%, 30% and 19%, respectively (see 

). During the SARS-CoV-2 pandemic, healthcare services increased their utilisation of teleophthalmology (49%, 

 < 0.001) and home monitoring services (42%, 

Minor changes were observed for methods of decentralised patient care, such as intravitreal injections occurring outside of a medical setting and patient screening. This is despite the ongoing need for increased provision of these type of interventions.

Reimbursement was the major factor that influenced the uptake of teleophthalmology services during the Covid-19 pandemic (odds ratio 9.62, 95% confidence interval: 2.42–38.16). However, home monitoring and decentralised care did not demonstrate the same increased uptake with the increased availability of reimbursement infrastructure.

During the pandemic, retinal specialists felt that teleophthalmology would be best utilised for the purposes of triage (75%), consultation (75%) and follow-up (71%), as well as therapy instruction (70%). However, the survey showed that only 50% felt that teleophthalmology would sustainably change the way they deliver retinal care in the future, with 22% saying that it would not change their practice and 27% being unsure (see 

This study found a significant increase in the implementation of home monitoring services during the SARS-CoV-2 pandemic, with 42% (n = 90) of the investigated institutions increasing their efforts for the purpose of home monitoring (

< 0.001). Despite the previously questioned external validity of the Amsler grid,

 it remained the most commonly-used visual functional test (n = 150, 70%); however, novel alternatives, such as smartphone-based (n = 40, 19%) and hardware-based (n = 16, 8%) assessmentsgained popularity (see 

Our study was the first to assess attitudes towards the transformative effects of the Covid-19 pandemic on the delivery of retinal care. Attitudes shifted toward acceptance and increased utilisation of teleophthalmology and home monitoring services during the pandemic. This may be the result of increased familiarity with and availability of structures for teleophthalmology and home monitoring that existed prior to the pandemic.

Utilisation of decentralised care did not significantly change. Poor uptake of decentralised care initiatives may be the result of a complex interplay of regulatory and procedural barriers coupled with significant retinal specialist discomfort with decentralised care initiatives: 31% were “not at all comfortable” and 28% were “uncomfortable” with patient care in non-medical settings prior to the pandemic.

Covid-19 has had a significant impact on the way that retinal specialists interact with their patients. Utilisation of teleophthalmology and home monitoring have increased since the onset of the pandemic, as has the positive attitude towards these interventions. However, despite its poor uptake, the response to decentralised care should be critically evaluated as it could still provide an important avenue for increasing retinal healthcare accessibility to marginalised patients at risk of visual deterioration.

Further research is needed to analyse these attitudes. Stratifying by generation may be useful to advance our understanding of clinician perspectives and the evolving nature of the field.

In addition, further studies assessing the attitudes of retinal specialists in other geographical locations may provide unique perspectives from healthcare services with different structures and challenges, which may differ from the results of this study, which represented a predominantly European perspective on digital retinal healthcare. Ultimately, long-term prospective studies may be useful in determining the effectiveness of newly implemented digital services on overall patient outcomes.

In conclusion, digital healthcare will continue to provide new avenues for improving patient outcomes. The short-term changes that have been implemented recently will sow the seed for sustainable improvement, and it is up to retinal specialists and policymakers to create the foundations for the digital age of ophthalmology from now on.

Dr Rosenblatt is an ophthalmologist and vitreo-retina surgeon from the Tel-Aviv Medical Center, Tel Aviv, Israel, and currently on his second fellowship at the Royal Victorian eye and ear hospital in Melbourne, Australia. Dr Faes is a Swiss medical retina and uveitis fellow at Moorfields Eye Hospital in London, United Kingdom. Prof. Loewenstein is chair of ophthalmology at Tel-Aviv Medical Center and vice dean of the Faculty of Medicine and Sidney Fox chair of ophthalmology at Tel Aviv University, Tel Aviv, Israel.

The authors have no financial disclosures relevant to the article.

Faes L, Bodmer NS, Bachmann LM, et al. Diagnostic accuracy of the Amsler grid and the preferential hyperacuity perimetry in the screening of patients with age-related macular degeneration: systematic review and meta-analysis. 

Articles

A global survey of retinal experts assessed their perceptions of evolving clinical practice in the Covid-19 era, focusing on digital teleophthalmology, home monitoring and decentralised patient care.

Assessing barriers to retinal care during a pandemic

 Hello. My name is Anat Loewenstein. I am the chair of the Department of Ophthalmology at the Tel Aviv Medical Center and vice dean of the Sackler Faculty of Medicine at Tel Aviv University in Tel Aviv, Israel.

The rationale in targeting both Ang-2 [angiopoietin‐2] and VEGF [vascular endothelial growth factor] in the management of neovascular macular degeneration and diabetic macular edema results from the fact that both Ang-2 and VEGF are implicated in the pathogenesis of these diseases. We know that Ang-2 levels are increased in retinal diseases as compared to control, specifically very much so in diabetic retinal disease. Elevated Ang-2 levels lead to vascular leakage and neovascularization by sensitizing blood vessels to the effect of VEGF-A. Elevated levels of Ang-2 cause displacement of Ang-1 on type 2, inhibiting type 2 activation. This increases Ang-2 expression, which primes the blood vessels for angiogenesis and sensitizes them to cytokines, such as VEGF-A. And we all know that elevated VEGF-A levels cause vascular leakage and promote neovascularization.

The YOSEMITE and RHINE were randomized, double-masked, multicenter studies that were designed to evaluate the efficacy and safety of faricimab vs aflibercept. Following a loading dose, patients received treatment either q8 [every 8 weeks] for aflibercept as per the label, or in 1 of 2 regimens for faricimab. The first regimen was [every 8] weeks and the second was according to a personalized treatment interval [PTI] in which patients received treatment according to their disease activity. The results of the YOSEMITE and RHINE studies showed that faricimab met the primary end point, demonstrating advantages in durability potential in anatomy vs aflibercept. The best corrected visual acuity gains from baseline with faricimab dosed every 8 weeks, or up to every 16 weeks, were noninferior to aflibercept dosed per the label every 8 weeks. There were better anatomical outcomes with faricimab vs aflibercept. This was seen when you looked at the change in central subfield thickness favoring faricimab, showing absence of diabetic macular edema in more patients, and showing absence of intraretinal fluid in more patients. Dosing up to every 16 weeks in the PTI dosing arm showed a durability of [every 16 weeks] in more than 50% of the patients. More than 70% of the patients achieved a durability of more than 12 weeks.

The results for YOSEMITE and RHINE showed extended durability for faricimab, meaning that patients with diabetic macular edema can potentially be treated less often with this new drug. The ability to treat patients less often has a tremendous impact on their quality of life and on the ability of the patient, physician, and the system to provide the exact treatment the patient needs by the way of having less burden and, as a result, increased compliance. The studies showed that even though there was a longer interval possible between treatments, the results are noninferior to the results with the comparator.

The design of the TENAYA and LUCERNE studies was recently presented at the Angiogenesis, Exudation, and Degeneration 2021 virtual symposium. TENAYA and LUCERNE were randomized, double-masked, multicenter studies that were designed to evaluate the efficacy and safety of faricimab vs aflibercept. Patients were randomized equally to either aflibercept given as per the global label of every 8 weeks following the loading dose, which was given after 3 months, or the faricimab up to [every 16] weeks, after 4 monthly doses in length. Patients in the faricimab arm were assessed for activity, and the drug was given according to disease activity. This allowed for evaluation of the possibility to lengthen the time interval between doses according to the activity of the disease in the particular patient.

The results of the TENAYA and LUCERNE studies were presented at the Angiogenesis 2021 meeting and showed that these double-blind, randomized trials met the primary end point, with faricimab demonstrating the ability to be extended over 12 weeks in 80% of the patients in the first year. Regarding visual acuity, the results showed noninferiority of faricimab with extended interval between doses as compared to aflibercept given bimonthly, [every 8] weeks. In addition, the studies showed durability of up to 16 weeks in 45% of the patients and the ability to extend the dosing to more than 12 weeks in almost 80% of the patients. The results of these studies showed meaningful reduction in central subfield thickness with faricimab given up to 16 weeks, which was comparable to aflibercept given every 8 weeks. Regarding safety, faricimab was well tolerated, with intraocular inflammation rates being only about 2% in the faricimab arms.

The results of the TENAYA and LUCERNE studies have significant implications for the treatment of our patients with neovascular macular degeneration. We know from all of the previous trials that in order to manage neovascular macular degeneration, we need to see the patients very often and to treat them with at least 8 injections yearly for the visual acuity to stay stable following the initial increase in visual acuity. Now, we finally have the ability to lengthen the interval between doses, thus allowing the patients decreased burden and improved quality of life. In these elderly patients, it is crucial to lower their need to get injections by way of having a drug that has a longer duration. This has the potential to increase their compliance, to enable the system and the physician to cope with the burden, as well as the patient and their caregiver, and thus improve the final outcome.

Videos

Anat Loewenstein, MD, MHA, explores dual Ang-2/VEGF-A inhibition in the management of diabetic macular edema and exudative age-related macular degeneration. 

Ang-2/VEGF-A Inhibition Synergistic Effect in DME and AMD 

 In the Angiogenesis, Exudation, and Degeneration 2021 virtual symposium, the role of Home OCT was presented in the treatment of patients with neovascular macular degeneration. It has been shown that elderly patients with neovascular macular degeneration are able to self-image on the Home OCT device and produce high grade images that are mounted to a cloud and interpreted by artificial intelligence, with alerts sent to the patient and the physician if re-treatment is needed. This technology allows for the patient to be treated in a timely manner when fluid accumulates, avoid noninjection visits, quantify the volume of fluid at all times, and see individualized treatment responses to various drug therapies.

The Angiogenesis, Exudation, and Degeneration 2021 virtual symposium showed very exciting data about new treatments for non-neovascular macular degeneration; for example, geographic atrophy. The meeting emphasized all of the new treatments combating complement dysfunction in these patients. Viral-mounted therapies that are given subretinally, intravitreally, or suprachoroidally provide us with the potential to treat this unmet need of management of geographic atrophy.

For the past decade, we have had excellent treatment options for our patients with neovascular macular degeneration and diabetic macular edema. Still, these treatments are not ideal. They do initially provide us with good visual acuity for our patients. However, to get to these good visual acuity results, patients need to be monitored in the clinic very frequently and get frequent injections. Since this is not feasible in the long term on a large scale, many patients are undertreated, not monitored enough, and therefore have poorer outcomes compared to the people in the trials. Nowadays, we’re starting to have the means for the patient to receive fewer injections by way of treatments that have a longer duration, dual function, and the ability to monitor the patients without them coming to the clinic for noninjection visits. This holds a lot of promise that we will soon be able to treat our patients in a more effective manner. We will be able to mostly have them only come in for injection visits, with longer intervals between injections than what we have nowadays. As a result, I expect that the compliance of the patient and the ability of the system to accommodate this huge number of patients will increase, and therefore the final visual acuity outcomes will be significantly better.

Angiogenesis, Exudation, and Degeneration 2021 Virtual Symposium highlights and thoughts on current treatments options for DME and exudative AMD are discussed. 

Author | Anat Loewenstein, MD, MHA

Articles

Assessing barriers to retinal care during a pandemic

Ang-2/VEGF-A Inhibition Synergistic Effect in DME and AMD

Angiogenesis 2021 Virtual Symposium Takeaways & Final Thoughts