Changes in the treatment patterns (Table 1)
We identified 258 inpatients with RRD in our study. Among these patients, 79 were admitted during the COVID-19 pandemic, and 179 were admitted during the pre-COVID-19 period.
Compared to the pre-COVID-19 group, fewer patients received SB (27.8%, 41.3%) while more patients received PPV (72.2%, 58.6%, p=0.02). In patients who received SB, fewer patients received subretinal fluid drainage (45.4%,75.7%, p=0.01) in the COVID-19 pandemic group. In patients who received PPV, fewer patients received PPV combined with cataract extraction (7.0%, 21.0%, p=0.02) in the COVID-19 pandemic group. The prevalence of silicone oil (91.2%, 86.7%) or gas (8.8%, 13.3%) tamponade in patients was similar between the two groups (p=0.45).
Table 1 The difference in treatment patterns between the two groups
(n, %)
|
The COVID-19 pandemic group (79)
|
The pre-COVID-19 group (179)
|
P
|
PPV (n, %)
|
57, 72.2%
|
105, 58.6%
|
0.04
|
Combined with SB
|
1, 1.8%
|
0, 0%
|
0.31
|
Combined with PHACO
|
4, 7.0%
|
22, 21.0%
|
0.02
|
Silicone oil tamponade
|
52, 91.2%
|
91, 86.7%
|
0.45
0.79
|
C3F8 tamponade
|
5, 8.8%
|
14, 13.3%
|
SB (n, %)
|
22, 27.8%
|
74, 41.3%
|
0.01
|
Segmental buckle
|
8, 25.8%
|
15, 11.5%
|
0.06
|
Radial buckle
|
1, 3.2%
|
6, 4.6%
|
0.59
|
Combined encircling
|
13, 59.1%
|
53, 71.6%
|
0.62
|
drainage of subretinal fluid
|
10, 45.4%
|
56, 75.7%
|
0.01
|
The impact of patients' presurgery characteristics on the treatment patterns
The patients in the COVID-19 pandemic group had longer median presurgery waiting times than patients in the pre-COVID-19 group (28days, 4days, p<0.001). The rate of RRD-CD (34.2%, 19.6%, p=0.01), pseudophakia (22.8%, 13.4%, p=0.047), and retinal breaks located posterior to the equator (48.1%, 22.9%, p<0.001) were higher in the COVID-19 pandemic group than the pre-COVID-19 group.
The presurgery characteristics of the PPV group and SB group were listed in Table 2. There was a significant difference in age (p<0.001), prevalence of RRD-CD (p<0.001), recurrent RRD (p=0.04), VA less than 0.02 (p<0.001), VA of 0.1–0.5 (p<0.001), VA greater than 0.5 (p=0.01), pseudophakia (p=0.004), location of retinal breaks (p<0.001), macula-off status (p<0.001), and PVR B-C (p<0.001) during the COVID-19 pandemic (p=0.054) between the two groups (Table 2).
Table 2 The patient presurgery characteristics in PPV and SB group
|
PPV (162)
|
SB (96)
|
P
|
Group(COVID)
|
57/105
|
22/74
|
0.054
|
Gender (male/female)
|
100/62
|
60/36
|
1
|
age
|
52.7+13.6
|
39.9+19.9
|
<0.001
|
Presurgery waiting time
|
4[2,8]
|
4[3,12]
|
0.51
|
RRD-CD
|
55/107
|
7/89
|
<0.001
|
Dense VH
|
7/155
|
3/93
|
0.74
|
recurrent
|
19/143
|
4/92
|
0.04
|
Va less than 0.02
|
99/63
|
24/72
|
<0.001
|
Va 0.02-0.1
|
45/117
|
31/65
|
0.48
|
Va 0.1-0.5
|
13/149
|
30/66
|
<0.001
|
Va greater than 0.5
|
5/157
|
11/85
|
0.01
|
pm
|
57/105
|
23/73
|
0.08
|
pseudophakia
|
35/127
|
7/89
|
0.004
|
Retinal break location anterior
|
69/93
|
82/14
|
<0.001
|
posterior
|
67/95
|
12/84
|
<0.001
|
Macular hole
|
2/94
|
26/136
|
0.0003
|
Macular-off
|
15/147
|
33/63
|
<0.001
|
PVR (BC)
|
128/34
|
96/0
|
<0.001
|
Factors related to the choice of PPV in the logistic regression model were older, with the presence of RRD-CD and pseudophakia, retinal breaks located posterior to the equator, a macular hole, and presurgery VA less than 0.02 (AIC=226.14, AUC=0.882) (Figure 1 and Table 3). Those presenting severe PVR, recurrent RRD, or PM during the COVID-19 pandemic were excluded from the model.
Table 3 The factors related to the choice of PPV in the logistic regression model
|
OR
|
CI
|
P
|
RRD-CD
|
2.92
|
1.09-7.89
|
0.03
|
Psedophakia
|
5.00
|
1.81-14.08
|
0.002
|
Break posterior to equator
|
4.87
|
2.11-11.20
|
<0.001
|
Macular hole
|
9.76
|
2.01-47.41
|
0.005
|
Age
|
1.03
|
1.01-1.05
|
0.005
|
Va less than 0.02
|
0.44
|
0.21-0.95
|
0.03
|
Factors related to the choice of SB in the logistic regression model were younger, with the absence of RRD-CD and phakia, retinal breaks located anterior to the equator, and presurgery VA less than 0.02 (AIC=249.69, AUC=0.846) (Figure 2 and Table 4). Those presenting severe PVR, recurrent RRD, or PM during the COVID-19 pandemic were excluded from the model.
Table 4 The presurgery characteristics related to the difference of PPV/SB ratio in the two groups.
|
The COVID-19 pandemic group
|
The pre-COVID-19 group
|
p
|
Age<=40
|
11/11
|
18/42
|
0.08
|
Age>40
|
46/11
|
87/32
|
0.18
|
RRD-CD
|
25/2
|
30/5
|
0.46
|
Retinal break anterior to the equator
|
17/20
|
52/62
|
0.59
|
Retinal break posterior to the equator
|
37/1
|
30/11
|
0.002
|
Macular hole
|
4/0
|
23/1
|
0.85
|
pseudophakia
|
17/1
|
18/6
|
0.10
|
VA <0.02
|
43/5
|
56/19
|
0.03
|
The impact of the surgeon's decision changes on the treatment patterns
We further investigated the difference of procedure choice between the two groups in the presence of specific factors mentioned above that favor PPV or SB. We compared the ratio of PPV/SB between the two groups on each factor enrolled in the logistic regression model (Table4). We showed that the PPV/SB ratio was similar between the two groups in age (p=0.18), RRD-CD(p=0.46), retinal break located anterior to the equator (p=0.59), macular hole (p=0.85), and pseudophakia (p=0.1). The PPV/SB ratio was different between the two groups in patients with retinal break located posterior to the equator (p=0.002) and VA less than 0.02 (p=0.03)
We showed fewer surgeons selected SB in patients with retinal breaks located posterior to the equator in the COVID-19 pandemic (1,11, p=0.002). In those patients, there were more pseudophakic patients in the COVID-19 pandemic group than the pre-COVID-19 group (9/38, 0/41, p<0.001).There was no significant difference between the two groups in age (52.2, 51.9, p=0.66), presurgery waiting times (5.1, 7.1, p=0.16), severe PVR (32/38, 28/41, p=0.11), RRD-CD (21/38, 30/41, p=0.11), PM (11/38, 7/41, p=0.28), or macula-off (35/38, 34/41, p=0.31).
Aside from the impact of pseudophakia on the treatment pattern, there were fewer phakia patients with retinal breaks located posterior to the equator who received SB in the COVID-19 pandemic group than in the pre-COVID-19 group (1/28, 11/30, p=0.01). There were seven patients in the pre-COVID-19 group, and none in the COVID-19 pandemic group received radial buckling.
We also showed fewer patients whose VA was less than 0.02 received SB in the COVID-19 pandemic group than in the pre-COVID-19 group (5/48, 19/75, p=0.03). Those patients whose VA was less than 0.02 had a higher prevalence of retinal breaks located posterior to the equator (31/48, 17/75, p<0.001), and there were shorter presurgery waiting times (4.8, 17.0 months, p=0.008) in the COVID-19 pandemic group than in the pre-COVID-19 group. There was no significant difference between the two groups in age (54.0, 51.4 years, p=0.36), combination of PM (14/48, 27/75, p=0.56), RRD-CD (22/48, 23/75, p=0.13), pseudophakia (11/48, 8/75, p= 0.08), severe of PVR (41/48, 56/75, p=0.23), or macular-off status (41/48, 71/75, p=1.0). Most patients with a retinal break located posterior to the equator in the two groups received PPV (31/31,15/17, p=0.12). The patients with a retinal break located anterior to the equator were chronic RRD patients with PVR C; fewer of them received SB in the COVID-19 pandemic group than in the pre-COVID-19 group (1/9, 9/16, p=0.03).
The impact of the surgeon's decision changes on the adjunctive procedures
We showed fewer patients who received cataract extraction combined with PPV in the COVID-19 pandemic groups (4/57, 22/105, p=0.02). There was no significant difference in patients' presurgery characteristics for those who received combined surgery or those who received PPV in the two groups (Table 5).
Table 5 The presurgery characteristic of patients in the two group underwent combined surgery or PPV
|
Patients underwent combined surgery
|
Patients underwent PPV
|
|
The COVID-19 pandemic group(52)
|
The pre-COVID-19 group(83)
|
p
|
The COVID-19 pandemic group(4)
|
The pre-COVID-19 group(22)
|
p
|
Age
|
53.7
|
52.3
|
0.51
|
44.5
|
52.1
|
0.32
|
Presurgery wait times
|
5.0
|
6.2
|
0.18
|
6.5
|
43.6
|
0.01
|
RRD-CD
|
22
|
22
|
0.09
|
3
|
8
|
0.27
|
PM
|
16
|
32
|
0.46
|
1
|
8
|
1.0
|
PVR B-C
|
47
|
65
|
0.10
|
1
|
14
|
0.27
|
Macular hole
|
1
|
13
|
0.02
|
2
|
10
|
1.0
|
Retinal break anterior to the equator
|
15
|
46
|
0.004
|
1
|
6
|
1.0
|
Retinal break posterior to the equator
|
36
|
24
|
0.001
|
1
|
6
|
1.0
|
We showed fewer patients who received subretinal fluid drainage in SB surgery (10/22, 56/74, p=0.01). In those without subretinal fluid drainage, the rate of PM in the COVID-19 pandemic group was higher than in the pre-COVID-19 group (9/13, 5/28, p=0.003), and the presurgery waiting times were shorter in the COVID-19 pandemic group than in the pre-COVID-19 group (4.2, 15.3 months, p=0.01). There was no significant difference in other presurgery characteristics between the two groups. There was no significant difference in presurgery characteristics in patients who received subretinal fluid drainage between the two groups (Table 6).
Table 6 The presurgery characteristic of patients in the two group underwent subretinal fluid drainage or without subretinal fluid drainage
|
Patients without subretinal fluid drainage
|
Patients underwent subretinal fluid drainage
|
|
The COVID-19 pandemic group(13)
|
The pre-COVID-19 group(28)
|
p
|
The COVID-19 pandemic group(11)
|
The pre-COVID-19 group(46)
|
p
|
Age
|
32
|
35.3
|
0.62
|
48.2
|
42.4
|
0.36
|
Presurgery wait times
|
4.2
|
15.3
|
0.01
|
11.3
|
7.1
|
0.33
|
RRD-CD
|
1
|
0
|
0.31
|
2
|
5
|
0.61
|
PM
|
9
|
5
|
0.003
|
2
|
6
|
0.64
|
Pseudophakia
|
1
|
3
|
1.0
|
0
|
3
|
1.0
|
PVR B-C
|
9
|
20
|
0.40
|
9
|
38
|
1.0
|
Retinal break posterior to the equator
|
2
|
3
|
0.65
|
0
|
8
|
0.33
|
Retinal break anterior to the equator
|
11
|
25
|
0.65
|
11
|
37
|
0.18
|
Macular off
|
10
|
14
|
0.17
|
9
|
31
|
0.48
|
The outcomes of surgery
Compared to patients in the pre-COVID-19 group, the percentage of patients with VA improvement was higher in the COVID-19 group (55.7%, 40.2%, p=0.03).
The overall SSRA rate was similar in the two groups (94.9%, 94.5%, p=1). Also, the SSRA rate of PPV (96.5%, 94.3%, p=0.80) and SB (90.9%, 94.6%, p=0.61) was similar in the two groups.
One out of seven patients with a retinal break located posterior to the equator who received radial buckling and one out of two pseudophakic patients with macular on status in the pre-COVID-19 group failed the SB surgery and required secondary surgery.