Concomitant Bilateral Intravitreal Injection of Anti-Vascular Endothelial Growth Factor: Experience in Covid-19 Pandemic

Abstract Purpose: To report the concomitant bilateral intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection preference rates of patients before and after the Covid-19 outbreak and to evaluate whether this practice is safe when compared to unilateral injection. Materials and Methods: This is a single-center, retrospective study including consecutive series of 198 eyes of 112 patients received bilateral same-day (concomitant) or unilateral anti-VEGF injections of bevacizumab, ranibizumab, and aflibercept in the operating-room between January 2020 and January 2021. One-year medical record data including preference of bilateral over unilateral injection and adverse events were reviewed with 3-month intervals as before and after Covid-19 pandemic due to the labile Covid-19 outbreak course.Results: A total of 504 injections with 234 concomitant bilateral (%46) were administered to 112 patients. The study group consisted of 58 neovascular age-related macular degeneration (nAMD- 63.7% had bilateral nAMD), 46 diabetic macular edema (DME- 67.3% had bilateral DME) and 8 macular edema complicating retinal vein occlusion (RVO- 25% had bilateral RVO) patients. Of the injections, 156 (31%) were bevacizumab, 144 (29%) were aflibercept, and 204 (40%) were ranibizumab. The mean follow-up time per patient was 7.4 ± 4.3 months (range 4-11 months) and the mean number of injections was 3.6 ± 2.1 (range 2-10). None of the patients experienced serious vision-threatening complications or non-ocular adverse events. 85% of patients whose both eyes involved strongly preferred concomitant bilateral injection during Covid-19 pandemic while it was %35 before Covid-19 (P<0.001). The ratio of the number of concomitant bilateral injections to a total of injections increased from 30% to 57% after Covid-19 (P=0.03). Only 3 patients (2.6%) requested alternating unilateral injections after receiving the second concomitant bilateral injections.Conclusion: Concomitant bilateral injection approach was preferred by the majority of patients and did not increase the adverse event rate when applied under meticulous precautions; This intravitreal injection option may be preferred during still ongoing pandemic to reduce the clinical visits of patients at risk of Covid-19 related mortality due to their comorbidities and age.