September 15, 2022
2 minute read
Sumit “Sam” Garg, MD, is associate professor of ophthalmology, vice president of clinical ophthalmology, and medical director of the Gavin Herbert Eye Institute at the University of California – Irvine.
Disclosures: Garg reports that he is an advisor for the National Keratoconus Foundation and a consultant for Glaukos.
The temporary closure of medical facilities for all but emergency and emergent care at the start of the COVID-19 pandemic led to delays in keratoconus care.
It also provided an unusual opportunity to observe how such delays might affect patient outcomes.
At UC Irvine, we have temporarily stopped performing elective procedures, including most cross-linking procedures. However, we were then able to reschedule patients with progressive keratoconus, and with five physicians on staff doing cross-linking, we were able to catch up relatively quickly. Certainly, there have been patients who have postponed not only treatments but also diagnostic evaluations due to COVID restrictions or fear of being exposed to the virus. Shutdowns in Europe were in some cases more dramatic than in the United States and slower to restart, for various factors. At the Royal Liverpool University Hospital in the UK, a “best case” delay of 3-4 months has been recommended for patients with rapidly progressing keratoconus or very thin corneas and longer delays (more than 4 months) for those with less severe keratoconus. or a slower progressing disease. As a result, 46 patients who were waiting to be scheduled for cross-linking at the start of the pandemic experienced treatment delays of 6 months, with about half of the delays considered to be due to pandemic guidelines. During this time, the patients experienced a statistically significant worsening of the keratometric indices and a loss of an average of one line of visual acuity. Seventy percent of patients progressed according to the ABCD progression criteria, while 39% progressed according to the clinical criteria of an increase of 1.5 D or more in maximum keratometry (Kmax) or d thinning of 20 µm or more.
The only factors associated with progression in a linear regression model in the UK study were higher baseline Kmax and atopy. Although the average age of patients who progressed was lower than that of those who did not progress, the difference was not statistically significant.
In another study, conducted in the Lombardy region of Italy (one of the regions hardest hit by COVID-19 at the start of the pandemic), ophthalmologists reviewed all records and conducted telephone triage to prioritize treatment. deferral based on severity of keratoconus risk, as well as patient risk factors for COVID. Older patients with multiple comorbidities were considered to be at higher risk for COVID and deferred when possible. Young patients with progressive keratoconus who had not yet undergone cross-linking or whose second eye was affected after cross-linking on the first eye were considered high priority. By bringing in these at-risk young patients, the service was able to identify progression and expedite treatment for 50% of its young keratoconus patients.
It is impossible to predict who will progress quickly or slowly, but we know that young patients are often most at risk of rapid progression. The pandemic was an unusual situation, but delays in care are not uncommon, even in routine practice. They may be due to a student’s desire to complete the semester or other scheduling conflicts. Most often, delays are related to patients being underinsured or uninsured, or the time required to obtain pre-approval for insurance. These studies remind us all to be aware of the risk of delayed treatment, especially in young patients who are already known to be progressing and in those who have only been treated in one eye for this disease. bilateral.
Legrottaglie EF, et al. Eur J Ophthalmol. 2021;doi:10.1177/1120672120960334.
Shah H, et al. Eur J Ophthalmol. 2021;doi:10.1177/11206721211001315.