BLOG: Pandemic provided opportunity to observe impact of delays in keratoconus care
The temporary shutdown of medical facilities for all but urgent and emergent care at the beginning of the COVID-19 pandemic resulted in delays in care for keratoconus.
It also provided an unusual opportunity to observe how such delays might affect patient outcomes.
At UC Irvine, we temporarily stopped performing nonemergency procedures, including most cross-linking procedures. However, we were later able to get patients with progressive keratoconus rescheduled and, with five doctors on staff who perform cross-linking, were able to catch up relatively quickly. Certainly, there were patients who postponed not only treatments but also diagnostic evaluations due to COVID restrictions or fear of exposure to the virus. Shutdowns in Europe were in some cases more dramatic than in the U.S. and slower to restart, for a variety of factors. At the Royal Liverpool University Hospital in the U.K., the “best case” scenario of a 3- to 4-month delay was recommended for patients with rapidly progressing keratoconus or very thin corneas and longer delays (4+ months) for those with less severe or slower-progressing disease. As a consequence, 46 patients who were waiting to be scheduled for cross-linking at the beginning of the pandemic experienced delays in treatment of 6 months, with about half of the delays deemed to be due to the pandemic guidelines. During that time, the patients experienced statistically significant worsening of keratometric indices and loss of an average of one line of visual acuity. Seventy percent of the patients demonstrated progression according to the ABCD progression criteria, while 39% exhibited progression according to the clinical criteria of 1.5 D or greater increase in maximum keratometry (Kmax) or 20 µm or greater thinning.
The only factors associated with progression in a linear regression model in the U.K. study were higher baseline Kmax and atopy. Although the average age of patients who progressed was lower than those who did not progress, the difference was not statistically significant.
In another study, conducted in the Lombardy region of Italy (one of the areas most dramatically affected by COVID-19 in the early days of the pandemic), ophthalmologists reviewed all charts and conducted telephone triage to prioritize rescheduling by the severity of keratoconus risk, as well as the patient’s risk factors for COVID. Older patients with multiple comorbidities were considered at higher risk for COVID and postponed 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 deemed high priority. By calling in these young, at-risk patients, the department was able to identify progression and accelerate treatment for 50% of its young patients with keratoconus.
It is impossible to predict who will progress rapidly vs. slowly, but we do know that young patients are often at the greatest risk for 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 desire for a student to finish the semester or other scheduling conflicts. Most commonly, delays are related to patients being under- or uninsured or the time required to secure insurance preauthorization. These studies serve as a good reminder to all of us to be cognizant of the risk of delays in care, particularly among young patients who are already known to be progressing and those who have only been treated in one eye for this bilateral disease.
References:
Legrottaglie EF, et al. Eur J Ophthalmol. 2021;doi:10.1177/1120672120960334.
Shah H, et al. Eur J Ophthalmol. 2021;doi:10.1177/11206721211001315.
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