Purpose There is an urgent need to address how to best provide ophthalmic care for patients with retinal disease receiving intravitreal injections with anti-vascular endothelial growth factor agents during the ongoing global COVID-19 pandemic. This article provides guidance for ophthalmologists on how to deliver the best possible care for patients while minimizing the risk of infection. Methods The Vision Academy's Steering Committee of international retinal disease experts convened to discuss key considerations for managing patients with retinal disease during the COVID-19 pandemic. After reviewing the existing literature on the issue, members put forward recommendations that were systematically refined and voted on to develop this guidance. Results The considerations focus on the implementation of steps to minimize the exposure of patients and healthcare staff to COVID-19. These include the use of personal protective equipment, adherence to scrupulous hygiene and disinfection protocols, pre-screening to identify symptomatic patients, and reducing the number of people in waiting rooms. Other important measures include triaging of patients to identify those at the greatest risk of irreversible vision loss and prioritization of treatment visits over monitoring visits where possible. In order to limit patient exposure, ophthalmologists should refrain from using treatment regimens that require frequent monitoring. Conclusion Management of patients with retinal disease receiving intravitreal injections during the COVID-19 pandemic will require adjustment to regular clinical practice to minimize the risk of exposure of patients and healthcare staff, and to prioritize those with the greatest medical need. The safety of patients and healthcare staff should be of paramount importance in all decision-making.

Aims: To evaluate diabetic retinopathy (DR) screening with a portable handheld smartphone-based retinal camera and telemedicine in an urban primary health care setting; to evaluate the learning curve for image acquisition, performed by healthcare personnel without previous experience on retinal imaging. Methods: Prospective study that enrolled patients with type 2 diabetes mellitus (T2DM) followed at a primary healthcare unit in São Paulo, Brazil. After a brief training in image acquisition, there was further continuous feedback during the remote image reading process. Each patient underwent two fundus and one anterior ocular segment images per eye, after mydriasis. Patients were classi ed according need of referral. Results: A total of 627 adult individuals with T2DM underwent retinal evaluation. The population was composed by 63.2% female individuals, age median of 66 years-old, diabetes duration 10.7 ± 8.2 years and A1c 7.7 ± 1.9% (61 + 20.8 mmol/mol). The most prevalent associated comorbidities were arterial hypertension (80.3%) and dyslipidemia (50.2%). Referral decision was possible in 81.2% patients. Most patients had absent or non-referable DR; the main ocular media opacity detected was cataract. After the 7 th day of image acquisition, the daily rate of patients whose images allowed clinical decision was maintained above 80%. A higher A1c was associated with referable DR. Conclusion: A low-cost DR screening strategy with a handheld device and telemedicine is feasible and has the potential to increase coverage of DR screening in underserved areas; the possibility of mobile units is relevant for DR screening in the context of Covid-19 pandemic.

The purpose of this study was to investigate the early alterations of retinal function, assessed with electrophysiology, in newly onset type 2 diabetes patients without vascular retinopathy. Seventeen patients with newly diagnosed type 2 diabetes (duration 7±3 months), without any vascular retinopathy in fundus photographs, were examined with full-field electroretinogram (ERG) and multifocal ERG (mfERG). The results were compared with those of age-matched subjects without diabetes. In the dark-adapted full-field ERG, the a-wave and the 30-Hz flicker implicit times were delayed in diabetes patients compared to controls, P=0.001 and P=0.020. In the first-order kernel of the mfERG, the first positive wave, P1, was delayed in all areas measured. The electrophysiological examinations demonstrate early alterations of retinal function characterised by a delayed a-wave implicit time in the dark-adapted full-field ERG, representing the rod signalling, and alterations in the multifocal ERG reflecting cone and/or postreceptoral function.

Aims  To study the occurrence of heart disease and death in Type 1 diabetic patients and evaluate whether presence of microangiopathy, i.e. nephropathy and retinopathy, was associated with the outcome. Methods  A 12‐year observation study of 462 Type 1 diabetic patients without a previous history of heart disease at baseline who were treated under routine care in a hospital out‐patient clinic. Results  A total of 85 patients developed signs of heart disease, i.e. myocardial infarction (n = 41), angina (n = 23), and heart failure (n = 17) and 56 patients died. The mortality for patients without signs of heart disease during the observation period was 7.6% compared with 51% in patients with myocardial infarction (P < 0.001), 26% in patients with angina (P < 0.01) and 65% in patients with heart failure (P < 0.001). The relative risk for death was 9.0 (P < 0.001) and 2.5 (P < 0.05) times higher in patients with macroalbuminuria and microalbuminuria, respectively. The risk for cardiovascular death was 18.3 times (P < 0.001) higher in patients with macroalbuminuria compared with patients with normoalbuminuria. In patients with sight‐threatening retinopathy, the relative risk for death was 7.0 times higher (P < 0.01) and the risk for coronary heart disease events 4.4 times higher (P < 0.05) compared with patients with no retinopathy. However, when retinopathy was adjusted for presence of macroalbuminuria, this association disappeared. Conclusion  This study shows a high incidence of heart disease in patients with Type 1 diabetes. The worse prognosis was seen in patients with sight‐threatening retinopathy and macroalbuminuria and microalbuminuria at baseline. Macroalbuminuria and microalbuminuria were independently associated with a high risk for heart disease and death while the association with sight‐threatening retinopathy only occurred in the presence of nephropathy.

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