To the Editor:

We have read with great interest the recent article by Wickham et al. on ‘The impact of COVID policies on acute ophthalmology services—experiences from Moorfields Eye Hospital NHS Foundation Trust’ [1]. During the pandemic, the authors noted a >50% decline in attendances to their Accident & Emergency (A&E) departments and a sharp decline in new referrals for age-related macular degeneration (ARMD) with an almost 25% ‘Did Not Attend’ (DNA) rate by patients already known to the ARMD service [1].

To gain further insight into the impact of COVID-19 on urgent wet ARMD services across the UK, we conducted a self-administered QualtricsXM survey among retinal consultants. Individual survey links were sent to 53 consultants at 46 institutions. We received 18 responses (34% response rate) from hospitals with rapid access wet ARMD services across England and Northern Ireland (Fig. 1). No responses were received from units in Wales or Scotland. Eight units (44.4%) performed optical coherence tomography imaging on fellow eyes during the lockdown period (Fig. 2).

Fig. 1: Demographic information of the respondentsʼ units.
figure 1

Distribution of answers to survey questions.

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Fig. 2: Age-related macular degeneration services before and during the COVID-19 pandemic.
figure 2

Distribution of answers to survey questions.

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Prior to the Covid-19 pandemic the majority (66.7%) of medical retina departments received more than 20 new urgent ARMD referrals per month, while in April and May 2020 most units (83.3%) reported less than 20 monthly referrals (Fig. 2). In addition, an increase in the DNA or cancellation rate of existing ARMD patients was noted by 77.8% of units. Four respondents estimated this rate to be equivalent to 20–30% of their booked appointments, while three consultants reported cancellations and DNAs in the region of more than 100 patients per month. One unit kept their cancellation rate at ~10% by proactively ringing patients to explain their new protocols.

To facilitate the safe continuation of rapid access wet ARMD services, some units cancelled routine monitoring clinics, moved to peripheral sites, put in place physical distancing or one-stop virtual clinics. However, some respondents noted that the need for physical distancing has reduced their capacity, while others reported that some patients declined to attend due to anxiety, shielding or the lack of transport options.

Our results support findings by Wickham et al. [1] by showing a noticeable decline in new ARMD referrals in England and Northern Ireland during the COVID-19 pandemic. This may partially be explained by reduced access to and referrals by community optometrists and General Practitioners [2]. In addition, patients have been less likely to seek medical attention due to fear of contracting COVID-19 or due to government advice on shielding. This change in health-seeking behaviour is reflected in a 56.6% year-on-year reduction in attendance at A&E attendance in England in April 2020 [3].

While our sample size does not allow for generalisation, it is important to recognise that the COVID-19 pandemic has had a marked impact on the provision of wet ARMD care and, subsequently, the visual morbidity of patients in the UK. Further studies are needed to quantify this impact and identify strategies to mitigate service disruptions during future pandemics.