Full Report : COVID-19 pandemic -related Harms in Uveitis.

Dr S Mansfield Smith MBChB MRCP(UK), Dr NJ Ghadiri FRCP FHEA, Dr SM Sharma, Mr TR Burke MD FRCOph MRCPI

Telemedicine into uveitis practice was rapidly introduced during the COVID-19 Pandemic and large cohorts of patients were rapidly triaged to telephone clinics to enable social distancing measures  This study enquired whether the pandemic-enforced reduction in face-to-face appointments resulted in harm to uveitis patients.

Objectives:

• Report the number of uveitis patients in the UK who came to harm during COVID 19 pandemic
• Identifying the COVID-19 pandemic- related cause of harm e.g. patient factors, social factors, service delivery factors.
• Characterize the severity of systemic and ocular harm.

Methods:

Specialist centers involved in the care of uveitis patients were invited to take part in this study. Five U.K specialist uveitis centres collected anonymized data over a 7-month period from January 2021-July 2021. This included the January ‘lockdown'. Data was collected using Redcap tool.

Table 1 Causes of Harm

We used the RCOPhth framework for categorizing the level of harm ¹  as follows: catastrophic, major, moderate and minor . We excluded expected complications of planned treatment, disease progression which would have occurred despite adequate care, and development of a new disease.

Results:

14 cases of harm were reported in uveitis patients.  Harm was identified in 11/14 cases during face-to-face encounters compared to 3/14 during telephone consultations. 4 uveitis patients experienced major harm, 6 moderate harm, 4 minor harm. Causes of harm were related to service delivery n=7, patient factors n=2, social factors n=1, and in 2 cases,  a combination of service delivery and patient factors, patient and social factor (n=1), service delivery and social factors( n=1).

Delayed care was identified in 10 patients ( average 4 months; range 2 weeks- 12 months) In 3 patients who experienced major harm there was at least a 4-month delay in review.

In the free text comments section , mental health issues  and in particular, anxiety related to COVID were highlighted by the reporting clinician. One clinician was concerned the wrong patients were being triaged to telephone clinics.

Figure 1 showing anatomic classification of Uveitis patients who experienced harm.

Table 2

Clinicians' comments about remote consultations

Table 3

 Conclusions:

This study provides a valuable insight into the causes of harm to uveitis patients during the COVID-19 pandemic.  From analyzing all submissions when deciding on the setting for a review for patients on long term treatment during a pandemic or similar event, clinical factors including the need to change treatment, history of steroid response, patient vulnerability and time from last face to face review must be considered.

 Findings from this study indicate the importance of safety- netting when managing uveitis patients in the COVID 19 pandemic. From comments made by clinicians it is important that the assessing clinician considers screening for psychosocial distress during virtual or telephone clinics to better support this group of patients. Our results  indicate that complex and vulnerable patients should be  triaged to be reviewed face to face wherever possible in the setting of a pandemic or when a service is proposing to incorporate remote consultations as part of service delivery.

 Reference 1. Categories of Harm derived from the provisional Royal College of Ophthalmology Guidance on categorizing Harm in 2020. This has since been updated. Current guidance available from: https://www.rcophth.ac.uk/wp-content/uploads/2022/01/Measuring-levels-of-harm-in-an-ophthlamic-setting-.pdf

21^st February 2023

ADVICE ON COVID-19 VACCINATION FOR PATIENTS WITH UVEITIS ON IMMUNOSUPPRESSION TREATMENT

Uveitis patient may be on tablets or injections to treat the inflammation in their eyes. These have the effect of reducing the effectiveness of their immune system to fight off infection. This means that they are at increased risk of severe COVID-19 and prolonged symptoms, or long COVID. Vaccination reduces the risk of severe COVID-19.

Why and how to have COVID vaccination

All patients on immunosuppression medication should have a COVID-19 vaccine, whatever their treatment regimen or underlying diagnosis. The benefits of the COVID-19 vaccination outweigh the risks, and by having the vaccine they reduce the risk of developing severe complications from COVID-19 infection. People on immunosuppression should have had three primary vaccinations and a booster after 3 months or more. If you have not had 4 or more doses of COVID vaccination you can book additional doses on the NHS website. You may need to take a clinic letter or prescription record with you to show you are taking immunosuppression.

Vaccination in people on immunosuppression

The body's response to vaccination is less in people taking immunosuppression treatments. This is why they are recommended to have a third primary vaccine dose, and a booster three months later. There is still a protective response from COVID vaccination, and a reduced response does not change the fact that the benefits outweigh the risks. Studies that have looked at this have looked at measures of immune response in the blood rather than the actual effectiveness of COVID vaccination in people taking immunosuppressants compared to other people. The best way to measure the immune response to vaccines in the blood is also not agreed by everyone studying this.

One study of 250 adults taking methotrexate (up to 25mg/week) for rheumatological conditions found that suspending methotrexate for two weeks after the third primary or booster vaccination resulted in a better response to the vaccine (VROOM study). There is a small risk of disease flare from suspending methotrexate for 2 weekly doses and this approach should be discussed with your uveitis doctor.

Given that vaccine responses are reduced in people taking immunosuppression they may want to take additional precautions such as wearing a mask in public/crowded places and hand washing regularly. This is especially true when there are upsurges COVID locally.

Steroid treatment and Vaccination

Steroids by mouth are usually given as prednisolone tablets. Taking 10mg or more of prednisolone a day counts as taking immunosuppression medication, so the same advice as above applies. Also if you have had prednisolone at a dose of 20mg or more for 10 days, steroids by intravenous infusion (methylprednisolone or hydrocortisone), or a steroid injection round the eye (also called orbital floor or sub-tenons triamcinolone) in the last month the advice is the same. If it is possible to delay high dose steroid treatment or injection round the eye till two weeks after vaccination, that is preferable for vaccine response, but in active uveitis there may be a risk to sight in doing that.

If you are taking less than 10mg of prednisolone then you do not need a third primary dose of COVID vaccine but it is advised to have had your two primary doses and at least one booster. There are no studies on steroid injections or implants directly in to the eye (called Ozurdex, Iluvien) but it is likely that the dose of steroid in the rest of the body is low enough that no special measures have to be taken with regard to COVID and vaccination.

Children and young people

All children and young people over five are eligible for COVID vaccination. Children aged 5-11 receive the paediatric and adolescent dose (10 micrograms) of Pfizer BioNTech. Those five and over with severe immunosuppression in proximity to their first or second dose of the vaccine are eligible for a third primary vaccine, ideally at least eight weeks after their last dose.