COVID-19 Impacted Anti-VEGF Treatment Patterns, But Not Visual Acuity Outcomes


Patients were treated with fewer anti-VEGF injections in 2020 compared to the previous year, but these changes did not significantly impact BCVA outcomes.

Gilad Rabina, MD | Image Credit: LinkedIn

Gilad Rabina, MD

Credit: LinkedIn

Ophthalmic treatment patterns during the COVID-19 pandemic showed significantly fewer intravitreal anti-vascular endothelial growth factor (VEGF) injections compared to the previous year, with compensation occurring the following year, according to new research.1

However, despite these varying changes in treatment patterns during the pandemic, the analysis including more than 1500 eyes revealed no significant impact on best-corrected visual acuity (BCVA) outcomes.

“A single postponement of intravitreal anti-VEGF injection therapy may be tolerable if subsequently returning to a routine treatment regimen, with no significant impact on the BCVA outcomes,” wrote the investigative team, led by Gilad Rabina, MD, department of ophthalmology, Tel Aviv Sourasky Medical Center.

Optimal results for anti-VEGF treatment have been observed in clinical trials utilizing a monthly fixed-dose regimen, but there is a resulting burden placed on both the patient and clinician. Real-world practice often employs validated, but less frequent regimens, including pro re nata (PRN) and treat-and-extend, as a compromise.

The onset of the COVID-19 pandemic impacted patient care globally. In ophthalmology, reduced injections and a lack of regular clinical assessments have previously been linked to worse outcomes in nAMD treatment. Declines in outpatient volume during the pandemic could have a significant, lasting impact on patient outcomes.2

In this analysis, Rabina and colleagues examined the impact of changes in treatment patterns before, during, and after the COVID-19 pandemic on BCVA in eyes with nAMD, to determine if the change in injection frequency correlated to visual function. The retrospective, multicenter, observational study included consecutive patients with nAMD examined by retina specialists in the investigative team’s clinic between January 2019 and December 2021.1

Patients included for each group year were required to have treatment and follow-up for a prior 12-month period receiving either monthly fixed-dosing, PRN, or treat-and-extend regimen. The analysis collected data on demographics, slit-lamp examination, BCVA, type and dates of anti-VEGF injections, and clinic visits. BCVA was assessed in the first quarter and last quarter of each study year.

Overall, a total of 1652 eyes of 1652 patients with nAMD were treated with an anti-VEGF injection and included in the analysis. Regarding the study period, 850 eyes were assessed in 2019 (pre-COVID-19), 630 eyes were assessed in 2020 (COVID-19), and 974 eyes were assessed in 2021 (post-COVID-19).

During the COVID-19 period, the mean amount of anti-VEGF injections was significantly lower than the pre-COVID-19 and post-COVID-19 periods (5.55 versus 6.13 and 6.60, respectively; P <.01).

For each individual study period, a significant decrease in Q1 and Q4 BCVA was observed by investigators: in the pre-COVID-19 period, BCVA decreased from 0.62 logMAR to 0.65 logMAR (P <.01); in the COVID-19 period, BCVA decreased from 0.59 logMAR to 0.63 logMAR (P = .003); in the post-COVID-19 period, BCVA decreased from 0.66 to 0.70 logMAR (P = .005).

The analysis revealed baseline BCVA (0.825; P <.001), number of injections (-0.007; P <.001), gender (-0.027; P = .037), and age (0.004; P <.001) were each significant predictors of the final quarter’s BCVA. However, the period of injection was not considered a predictor for final BCVA.

Based on these analyses, Rabina and colleagues suggest a specific individual may suffer from visual loss, but a single delay would not harm BCVA outcomes if patients return to a regular treatment interval.

“Thus, this study demonstrates that a single delay of up to 4 months in previously treated nAMD patients would not harm BCVA outcomes in a large group of patients, especially if they subsequently compensate by simply returning to a routine treatment regimen, as observed in the post-COVID-19 group,” investigators wrote.


  1. Barequet D, Shor R, Segal O, et al. Treatment patterns and visual acuity change of AMD patients, before, during and after the COVID-19 pandemic lockdowns: A large cohort [published online ahead of print, 2023 Sep 12]. Acta Ophthalmol. 2023;10.1111/aos.15756. doi:10.1111/aos.15756
  2. Arruabarrena, C., Toro, M.D., Onen, M., Malyugin, B.E., Rejdak, R., Tognetto, D. et al. (2021) Impact on visual acuity in neovascular age related macular degeneration (nAMD) in Europe due to COVID-19 pandemic lockdown. J Clin Med10, 3281.
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