Evolving Treatment Paradigm in the Management of Diabetic Macular Edema in the Era of COVID-19

Abstract

Intravitreal therapy is widely recognized as a major milestone in ophthalmology being one of the most commonly performed ocular procedures (He et al., 2018). The spread of coronavirus disease (COVID-19) still represents an important public health problem worldwide (Ferrara et al., 2020; Wang et al., 2020). This novel virus infection, is causing a significant downsizing of non-urgent treatments provided for ocular disorders (Tognetto et al., 2020; ToroM. D. et al., 2020, ToroM. et al., 2020), including intravitreal therapy (Elfalah et al., 2021). Since diabetic retinopathy (DR) still remains the leading cause of blindness among working-age adults (Ting et al., 2016), ophthalmologists should be aware of the potential negative effects of COVID-19 restrictions in the management of diabetic patients in the next months. The global COVID-19 pandemic led many governments from different nations to adopt protective and strict measures to reduce its spread. In these unprecedented circumstances, many healthcare systems are overwhelmed and under stress. In this scenario, there is an urgent need to support ophthalmologists who are treating patients with intravitreal injections in decision-making protocols. In order to provide continuity of care, and to reduce the risk of contamination, series of protection measures have been proposed (Iovino et al., 2020a; Borrelli et al., 2020; Korobelnik et al., 2020). Nevertheless, many patients cannot receive a prompt therapy due to all public health restriction measures. During COVID-19 outbreak Carnevali et al. proposed treatment priority levels to treat the most urgent patients, although a drop of 91.7% of the injections performed compared to the same period of 2019 was registered (Carnevali et al., 2020). Diabetic patients are considered at high risk for COVID-19 complications and should not be exposed to avoidable risks, including the injections procedure itself. However, continuation of care, where possible, is important to avoid irreversible vision loss. For non-monocular patients with diabetic macular edema (DME), postponement (>4–6 months) of appointments has been proposed (Korobelnik et al., 2020). As recently reported, postponing treatment in patients with good visual acuity does not affect the prognosis at 1 year, regardless of whether the DMEwas treated or not (Busch et al., 2019). Conversely, in patients with more advanced DR and worse visual acuity, a delay in treatments could cause irreversible visual loss (Ting et al., 2016; Elfalah et al., 2021). Anti-vascular endothelial growth factor (VEGF) injections represent generally a first-line therapy for several retinal disorders including DME (Heier et al., 2012; Reibaldi et al., 2014; Schmidt-Erfurth et al., 2017; Plyukhova et al., 2020), but monthly injections are needed at least during the loading dose (Schmidt-Erfurth et al., 2017). Of note, intravitreal dexamethasone (DEX) implant 0.7 mg (Ozurdex®, Allergan, Inc. Irvine, CA, United States) is considered a valid alternative for both refractory to anti-VEGF treatment eyes and treatment naïve ones (Iglicki et al., 2019; Iovino et al., Edited by: Mario Damiano Toro, Medical University of Lublin, Poland