REPORT: Working Group on Medical Retina (WG-MR) of the Netherlands Ophthalmological Society (NOG)
Advice and step-by-step plan for ophthalmologists by the Working Group on Medical Retina (WG-MR) of the Netherlands Ophthalmological Society (NOG) with regard to Intravitreal Injections (IVIs) in the context of reduction of care activities due to COVID-19.
The basic starting point of the WG-MR is that IVIs are not an elective treatment. If the IVI is postponed, the patient runs a variable (based on the degree of indication) risk of permanent vision loss. If fewer IVIs are given, there is by definition a higher risk of vision loss.
Step 1: Organizational suggestions for IVIs as included in the NOG newsletter of March 18, 2020:
- Call the patients the day before the injection and ask about complaints related to a respiratory infection (sore throat, cough, fever, vomiting). If this is the case, then postpone the IVI for 2 weeks, provided the patient is free of complaints for 48 hours.
- Depending on your situation, plan no more than 20 IVIs per half-day so that fewer patients are in the preparation areas.
- If possible, let accompanying person wait outside the outpatient clinic.
- Apply additional hand hygiene and touch as few patients as possible.
- Have the patients change themselves as much as possible. When help is needed for the patient, apply hand hygiene after this.
- In general: control push buttons with elbows and not with your hands.
- Clean the door handles with alcohol every hour. Prevent patients from grasping the door handles by opening the doors as a caregiver.
- If possible, replace the chairs with ones without a backrest.
- remove all magazines, coffee cups, etc. from the waiting room, given the survival time of the virus on cardboard. This also applies to leaflets; are sometimes read and then put back on the shelve.
Step 2: Advice from the WG MR of 19 March – Possibilities to reduce the number of IVIs and care contacts without harm to the patient
This depends on diagnosis and indication grade:
– AMD patients will in most cases eventually experience vision loss from delay of IVIs or extension of intervals.
– There is some room to reduce the nr of IVIs in an initial treat and extend process, by extending the interval with larger steps.
– Patients on ‘maintenance’ treatment by IVIs every 3 months are also suitable for postponement, but with self-monitoring.
– CNV in myopia: for patients under 50-55 years it is sufficient to give 2 injections, followed by self-monitoring, with the exception of recurrent cases who need long term repeated injections. Less injections is not possible.
– CNV in PXE: usually aggressive clinical course, ‘maintenance’ treatment every 8-10 weeks is strongly recommended.
– Nearly all RVO patients have an optimal interval at which the edema just does not recur. With a longer interval, the edema usually returns sharply with eventual permanent vision loss. This group also does not lend itself to fewer injections.
– In this group, there is some room in an initial treat and extend process, by extending the interval with larger steps.
– DME patients are treated intensively in the first 1.5 years. This group lends itself to slightly reduce the frequency of injections throughout the treatment process, but this depends on the individual situation, and stopping or prolonged delay of IVIs is not possible.
– Across the board, the number of IVIs may be decreased by up to 5-10% without harming patients. In a treat and extend schedule, the number of OCTs and vision measurements can be reduced, by continuing treatment with the last appropriate treatment interval used without measurements.
Step 3-Update March 25: further reduction of contamination risk
To reduce the risk of patients and their environment from becoming infected with Covid-19 while traveling, and by minimizing the risk of contacts with healthcare personnel, it is recommended that:
– if possible, send each patient who is scheduled for an injection a letter with the request to contact the clinic in advance for a fever, cough and / or cold, and include a visual acuity self-test and an Amsler card with the letter for self monitoring.
-let patients come by taxi individually for the IVI. There is currently contact with the health insurers to realize an integral reimbursement of individual taxi costs for IVIs.
-screen patients for signs of infection before entering the clinic.
-minimize contact with caregivers and therefore omit OCT and vision measurement where appropriate, allowing patients to be treated at the last proven effective interval. In the case of active treat and extend, the OCT may be required to extend the interval.
-It is also advisable to call patients who are calling off or who do not show up by an ophthalmologist, so that risk of loss of vision can be appropriately discussed and a shared decision can be made on postponing the IVI if neccessary.
-In case of postponement of the IVI due to a curfew from the care or nursing home, it is best to contact the management of the institute in question.
Step 4-Update March 25: What to do in case of capacity limitation
4a-In case of capacity problems, we recommend moving the IVIs to ZBCs/Private clinics, of which the large chains have already indicated that they can temporarily take over IVIs, if diagnosis, VEGF inhibitor and a series of injections at the desired interval are indicated.
4b-If, despite all these possibilities, a reduction of IVIs is required by triage, maintenance treatments, long-standing IVI pathways to the worst eye and IVIs in DME patients after the first year of treatment may be the first to be delayed.