Intravitreal Anti–Vascular Endothelial Growth Factor Use in France During the Coronavirus Disease 2019 Pandemic

Intravitreal Anti–Vascular Endothelial Growth Factor Use in France During the Coronavirus Disease 2019 Pandemic The coronavirus disease 2019 (COVID-19) pandemic emerged in France in February 2020. On March 17, 2020, a national population lockdown restricted human contacts and travel to a strict minimum until May 11, 2020. Many patients experienced difficulties or fear of accessing health care during lockdown.1 We hypothesized that the COVID-19 pandemic may have modified the dispensing of intravitreal (IVT) anti– vascular endothelial growth factors (anti-VEGF), the main treatment for retinal vascular abnormalities.2 This study quantified changes in the use of IVT anti-VEGF since the pandemic began in France.

The coronavirus disease 2019 (COVID-19) pandemic emerged in France in February 2020. On March 17, 2020, a national population lockdown restricted human contacts and travel to a strict minimum until May 11, 2020. Many patients experienced difficulties or fear of accessing health care during lockdown. 1 We hypothesized that the COVID-19 pandemic may have modified the dispensing of intravitreal (IVT) antivascular endothelial growth factors (anti-VEGF), the main treatment for retinal vascular abnormalities. 2 This study quantified changes in the use of IVT anti-VEGF since the pandemic began in France.
Methods | The study involved beneficiaries of the National Health Insurance scheme (covering about 77% of the French population, or 51.5 million people) using the Système National des Données de Santé (French National Health Data System) of individual anonymized pharmacy claims data. 3,4 The research group has permanent regulatory access to the data from the French National Health Data System (French decree No. 2016-1871of December 26, 2016, on the processing of personal data called National Health Data System and French law articles Art. R. 1461-13 and 14). No informed consent was required because data are anonymized.
The numbers of individuals using aflibercept or ranibizumab were determined by week for the first 23 weeks of 2018, 2019, and 2020. Individuals using bevacizumab were not included; this drug is rarely prescribed and used exclusively in hospitals in France. The study involved the 2 weeks preceding lockdown (March 2 to 15, 2020; weeks 10-11 of the year), 8 weeks of lockdown (March 16 to May 10, 2020; weeks 12-19 of the year), and the first 4 weeks of reopening (May 11 to June 7, 2020; weeks 20-23 of the year). Expected numbers of users per week during these periods of interest were extrapolated from the mean number of users recorded during corresponding weeks in 2018 and 2019. A ratio of 1.16, estimated over weeks 2 to 8 (the mean number of users per week in 2020 divided by the mean number of users per week in 2018 and 2019), was applied to account for the increase in prescriptions between 2018 and 2020. Differences between observed and expected numbers of patients using anti-VEGF were computed each week during periods of interest, overall, and after restrictions to only those using the drugs for the first time (ie, with no reimbursements for IVT anti-VEGF agents during the previous year). All analyses were performed using SAS software, version 9.4 (SAS Institute Inc).

Reopening period
Week 20 Figure). The decrease was particularly marked (−65.3%) for treatment initiations during lockdown. This decrease corresponds to a total of 8169 fewer treatment initiations during the lockdown period. A gradual recovery was observed during reopening (Table).
Discussion | This study shows a relatively marked decrease in IVT anti-VEGF dispensing during lockdown, which was not completely compensated during the first 4 weeks after unlocking. Extrapolation of these data to the entire French population leads to an estimated decrease of 60 000 injections, including 10 500 initiations of IVT anti-VEGF therapy during the 8 weeks of lockdown. These figures must be interpreted relative to the estimated 85 000 IVT anti-VEGF injections per month in France, including 8000 treatment initiations. 1 Limitations include the inability to determine whether these findings are associated with any permanent visual acuity loss. The decrease in IVT anti-VEGF dispensing during the lockdown period could be explained by patients' difficulty accessing an ophthalmology department or the ophthalmologist's decision to postpone injections during the pandemic because of difficulties in disease monitoring, which usually include periodic visual acuity and retina examinations, imaging, or both. Most IVT anti-VEGF therapies, particularly with neovascular age-related macular degeneration, 5,6 should not be delayed, because such delays can lead to permanent visual acuity loss. We believe this situation should continue to be monitored closely, to determine if persistent delays result in longer waiting times to obtain appointments for these treatments. Ideally, the health care system will work on approaches to try to ensure continuity of ophthalmological care in the event of future epidemics.

Ophthalmic Injuries by Less-Lethal Kinetic Weapons During the US George Floyd Protests in Spring 2020
Modern less-lethal weapons, or kinetic impact projectiles (KIPs), may cause ophthalmic morbidity and even mortality 1-3 ; we recently published a detailed description of KIP types and properties. 4 Herein, we highlight devastating consequences of KIPs, investigate the experience of other United States-based academic ophthalmology residency programs, review current law enforcement KIP-use policies, and recommend policy changes that may prevent further injuries.
Method | Exemption from institutional review board review and waiver of consent and Health Insurance Portability and Accountability Act authorization under exempt category 4 (secondary data use for research under 45 CFR 164.501) was obtained from the Colorado Multiple Institutional Review Board; patient data are protected by hospital privacy safeguards. A nonvalidated survey was distributed via email to 115 ophthalmology residency program directors using the database of the Association of University Professors of Ophthalmology from June to July 2020. Programs were queried about the total number and types of injuries seen without details of clinical course or outcomes. Consecutive individuals who sustained ophthalmic injuries during the George Floyd protests in Denver, Colorado, were identified, and clinical course and outcomes were collected.
Projectiles retrieved from local protest sites (>1000 attendees) included rubber baton rounds, foam grenades, and pepper balls. In particular, our institution cared for 6 unique patients who sustained ophthalmic injuries from suspected KIPs. Four (patients 2-5) reported being struck by projectiles fired by law enforcement; 2 could not identify the source (Table). No patients with KIP injuries unassociated with the protests were identified.
Discussion | In addition to our own experience, survey results showed that 20% of other US academic programs also saw patients for ophthalmic injuries that occurred during the George Floyd protests and were suspected to be KIP-related.
Written policies typically forbid firing less-lethal weapons at close range and at vulnerable areas of the body. The Denver Police Department's operational manual confirms: "an officer shall not intentionally deploy the less lethal shotgun projectile…to the head, eyes, throat, neck, breasts of a female, genitalia, or spinal column" or "from a range of less than ten (10) feet." 5 Furthermore, "when any person is struck by the projectile from a less lethal shotgun…immediate evaluation by medical personnel is required." 5 Similar regulations direct officers to aim at the head or neck area "only if deadly force becomes necessary." 6 The trauma seen in Denver, Colorado, and