1
|
Fevrier H, LaPrise A, Mbagwu M, Leng T, Torres AZ, Borkar DS. Comparison of Methods of Clinical Trial Emulation Utilizing Data From the Comparison of AMD Treatment Trial (CATT) and the IRIS® Registry. OPHTHALMOLOGY SCIENCE 2024; 4:100524. [PMID: 38881608 PMCID: PMC11179401 DOI: 10.1016/j.xops.2024.100524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/16/2024] [Accepted: 03/26/2024] [Indexed: 06/18/2024]
Abstract
Purpose We used exact matching and inverse propensity score weighting (IPSW) using real-world data (RWD) from the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) to emulate the 2 pro re nata (prn) treatment arms from the Comparison of AMD Treatment Trial (CATT) and to compare the outcomes of the RWD arms to the 2 monthly treatment arms from the clinical trial. Design Retrospective cohort study utilizing deidentified electronic health record registry data and patient-level deidentified clinical trial data. Subjects All treatment-naive patient eyes with neovascular age-related macular degeneration treated with ranibizumab or bevacizumab only for 1 year from either the CATT or the IRIS Registry. Methods Patients were identified in the IRIS Registry between October 1, 2015 and December 31, 2019. After all nonimaging-based inclusion and exclusion criteria from the CATT were applied, patient eyes receiving bevacizumab or ranibizumab only on a prn basis were identified as the eligible cohort. Exact matching and ISPW was applied based on age, gender, and baseline visual acuity. Main Outcome Measures Mean change in visual acuity, in approximated ETDRS letters, between baseline and 1 year for the IRIS Registry prn treatment arms generated by exact matching and IPSW. Results We identified 427 eyes treated with ranibizumab prn and 771 eyes treated with bevacizumab prn. Using exact matching, 98% (n = 281) of CATT patient eyes in the bevacizumab monthly treatment arm and 87% (n = 261) of CATT patient eyes in the ranibizumab monthly treatment arm were matched to a patient eye in the IRIS Registry. For the ranibizumab prn treatment arm, patient eyes generated using exact matching gained 1.9 letters and those generated using IPSW gained 2.8 letters (exact matching: 1.9 letters ± 14.0 vs. IPSW: 2.8 letters ± 15.0 letters, P = 0.43). For the bevacizumab prn treatment arm, patient eyes generated using exact matching gained 2.4 letters and those generated using IPSW gained 2.1 letters (exact matching: 2.4 letters ± 15.4 vs. IPSW: 2.1 letters ± 16.0 letters, P = 0.79). Conclusions Both exact matching and IPSW produced similar results in emulating the prn treatment arms of the CATT using IRIS Registry data and patient-level clinical trial data. Similar to prior real-world studies, the clinical outcomes were significantly worse in the IRIS Registry treatment arms compared with the clinical trial. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
| | | | - Michael Mbagwu
- Verana Health, San Francisco, California
- Byers Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, California
| | - Theodore Leng
- Byers Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, California
| | | | - Durga S Borkar
- Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
2
|
Munzar R, Roh S, Ramsey DJ. Factors associated with loss to follow-up in patients with advanced age-related macular degeneration: A telehealth recall initiative. Ophthalmic Physiol Opt 2024; 44:626-633. [PMID: 38425149 DOI: 10.1111/opo.13298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/19/2023] [Accepted: 02/14/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Patients with advanced age-related macular degeneration (AMD) frequently experience loss to follow-up (LTFU), heightening the risk of vision loss from treatment delays. This study aimed to identify factors contributing to LTFU in patients with advanced AMD and assess the effectiveness of telephone-based outreach in reconnecting them with eye care. METHODS A custom reporting tool identified patients with advanced AMD who had not returned for eye care between 31 October 2021 and 1 November 2022. Potentially LTFU patients were enrolled in a telephone outreach programme conducted by a telehealth extender to encourage their return for care. Linear regression analysis identified factors associated with being LTFU and likelihood of accepting care post-outreach. RESULTS Out of 1269 patients with advanced AMD, 105 (8.3%) did not return for recommended eye care. Patients LTFU were generally older (89.2 ± 8.9 years vs. 87.2 ± 8.5 years, p = 0.02) and lived farther from the clinic (25 ± 43 miles vs. 17 ± 30 miles, p = 0.009). They also had a higher rate of advanced dry AMD (26.7% vs. 18.5%, p = 0.04) and experienced worse vision in both their better-seeing (0.683 logMAR vs. 0.566 logMAR, p = 0.03) and worse-seeing (1.388 logMAR vs. 1.235 logMAR, p = 0.04) eyes. Outreach by a telehealth extender reached 62 patients (59%), 43 through family members or healthcare proxies. Half of the cases where a proxy was contacted revealed that the patient in question had died. Among those contacted directly, one third expressed willingness to resume eye care (20 patients), with 11 scheduling appointments (55%). Despite only two patients returning for in-person eye care through the intervention, the LTFU rate halved to 4.4% by accounting for those patients who no longer needed eye care at the practice. CONCLUSIONS There is a substantial risk that older patients with advanced AMD will become LTFU. Targeted telephone outreach can provide a pathway for vulnerable patients to return to care.
Collapse
Affiliation(s)
- Rachel Munzar
- Lahey Department of Surgery, Division of Ophthalmology, UMass Chan Medical School, University of Massachusetts, Burlington, Massachusetts, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Shiyoung Roh
- Lahey Department of Surgery, Division of Ophthalmology, UMass Chan Medical School, University of Massachusetts, Burlington, Massachusetts, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - David J Ramsey
- Lahey Department of Surgery, Division of Ophthalmology, UMass Chan Medical School, University of Massachusetts, Burlington, Massachusetts, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts, USA
- New England College of Optometry, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Basilious A, Smuck B, Duncan J, Malvankar-Mehta MS, Juncal VR, Hooper P, Sheidow TG. Patterns of anti-vascular endothelial growth factor discontinuation in neovascular age-related macular degeneration. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024; 59:e161-e169. [PMID: 36924794 DOI: 10.1016/j.jcjo.2023.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/25/2023] [Accepted: 02/15/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE To report on anti-vascular endothelial growth factor (anti-VEGF) discontinuation in neovascular age-related macular degeneration (nAMD). DESIGN Retrospective cohort study. PARTICIPANTS Treatment-naive nAMD patients initiating anti-VEGF injections between 2015 and 2021. METHODS Demographics, treatment start and end dates, number of injections, treatment length, reason for discontinuation, and baseline and final data (i.e., age, best-corrected visual acuity, and central subfield thickness) were recorded. Statistical analyses using STATA 17.0 assessed differences between baseline and final values and between treatment-discontinuation subgroups. RESULTS A total of 619 eyes of 502 treatment-naive patients (9015 injections) were included (age, 81.6 ± 8.4 years; 64.0% female). Discontinuation rate was 58.3% (361 of 619), with 310 patients discontinuing because of the lack of visual benefit (n = 152), severe comorbidity or death (n = 82), transferred (n = 33), stable off active treatment (n = 19), lack of benefit plus stable off treatment (n = 14), patient decision (n = 6), and ocular comorbidity (n = 4). Among the 309 remaining patients, 51 (16.5%) were lost to follow-up. Discontinuation occurred within the first year in 49.3% (n = 178). Visual acuity was at least maintained in all groups and improved in the following groups: severe comorbidity or death (p < 0.0001), lost to follow-up (p = 0.0003), transferred (p = 0.0004), and stable off treatment (p = 0.0053). The lack of visual benefit group had no improvement in vision regardless of treatment length. Compared with other subgroups, those stable off treatment group was younger (p = 0.0055), had better baseline vision (p = 0.0018), received more injections (p = 0.0437) over a longer time (p = 0.0034), and achieved better final vision (p < 0.0001). CONCLUSION While there was a high discontinuation rate over 7.5 years, most were attributable to disease or treatment factors and nonmodifiable patient factors. Discontinuation frequently occurred within the first year.
Collapse
Affiliation(s)
- Amy Basilious
- From the Ivey Eye Institute, St. Joseph's Health Care, London, ON.
| | - Bobbi Smuck
- From the Ivey Eye Institute, St. Joseph's Health Care, London, ON
| | - Julie Duncan
- From the Ivey Eye Institute, St. Joseph's Health Care, London, ON
| | | | - Verena R Juncal
- From the Ivey Eye Institute, St. Joseph's Health Care, London, ON
| | - Phil Hooper
- From the Ivey Eye Institute, St. Joseph's Health Care, London, ON
| | - Tom G Sheidow
- From the Ivey Eye Institute, St. Joseph's Health Care, London, ON
| |
Collapse
|
4
|
Wykoff CC, Garmo V, Tabano D, Menezes A, Kim E, Fevrier HB, LaPrise A, Leng T. Impact of Anti-VEGF Treatment and Patient Characteristics on Vision Outcomes in Neovascular Age-related Macular Degeneration: Up to 6-Year Analysis of the AAO IRIS® Registry. OPHTHALMOLOGY SCIENCE 2024; 4:100421. [PMID: 38187126 PMCID: PMC10767511 DOI: 10.1016/j.xops.2023.100421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 01/09/2024]
Abstract
Purpose To evaluate anti-VEGF treatment patterns and the influence of patient demographic and clinical characteristics on up to 6-year vision outcomes in neovascular age-related macular degeneration. Design Retrospective, multicenter, noninterventional registry study with up to 6 years of follow-up. Participants A cohort of 254 655 eyes (226 767 patients) with first anti-VEGF injection and at least 2 years of follow-up; 160 423 eyes had visual acuity (VA) data. Methods Anonymized patient data were collected in the United States through the IRIS® Registry (Intelligent Research in Sight). Main Outcome Measures Changes in VA from baseline; frequency of and gaps between intravitreal anti-VEGF injections; treatment discontinuations; switching anti-VEGF agents; and influence of baseline clinical and demographic characteristics on VA. Results After a mean VA increase of 3.0 ETDRS letters at year 1, annual decreases led to a net loss from baseline of 4.6 letters after 6 years. Patients with longer follow-ups had better baseline and follow-up VA. From a mean of 7.2 in year 1 and 5.6 in year 2, mean injections plateaued between 4.2 to 4.6 in years 3 through 6. Treatment was discontinued in 38.8% of eyes and switched in 32.3%. When adjusting for differences at baseline, every additional injection resulted in a 0.68 letter improvement from baseline to year 1; thus, multiple injections in a year have the potential to be clinically meaningful. Older age, male gender, Medicaid insurance, and not being treated by a retina specialist were associated with a higher likelihood of vision loss at year 1. Of the patients, 58.5% lost ≥ 10 letters VA at least once during follow-up, with 14.5% of patients experiencing sustained poor vision after a median of 3.4 years. Conclusions After modest mean VA improvement with intravitreal anti-VEGF injections at year 1, patients netted a loss of VA by year 6. Injection frequency decreased over time, and this was paired with a relatively high rate of discontinuation. Modeling suggested that more frequent injections were associated with better VA. Difficulty with continuous adherence to frequent intravitreal injections may have contributed to undertreatment resulting in less-than-optimal vision outcomes. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Charles C. Wykoff
- Retinal Consultants of Texas, Retina Consultants of America, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
| | | | - David Tabano
- Genentech, Inc., South San Francisco, California
| | | | - Eunice Kim
- Genentech, Inc., South San Francisco, California
| | | | | | - Theodore Leng
- Byers Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, California
| |
Collapse
|
5
|
Kusenda P, Caprnda M, Gabrielova Z, Kukova N, Pavlovic S, Stefanickova J. Understanding Loss to Follow-Up in AMD Patients Receiving VEGF Inhibitor Therapy: Associated Factors and Underlying Reasons. Diagnostics (Basel) 2024; 14:400. [PMID: 38396439 PMCID: PMC10887977 DOI: 10.3390/diagnostics14040400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND In patients with wet age-related macular degeneration (AMD), loss to follow-up (LTFU) leads to unplanned interruptions in therapy and the risk of visual loss. METHODS This retrospective and prospective case-control cohort study compared AMD patients with (LTFU YES) and without (LTFU NO) LTFU during anti-VEGF treatment over 12 years. LTFU was defined as missing any treatment or monitoring visits, or not scheduling follow-ups for six months. RESULTS Significant differences between LTFU NO (n = 298) and LTFU YES (n = 174) groups were age, treatment phase, baseline and final best-corrected visual acuity (BCVA), type of anti-VEGF drug, treatment switch, commuting distance, and escort during commuting. A multivariate logistic regression analysis identified the need for an escort during the commuting and treatment phase as the only significant difference. The four most common reasons for LTFU were general health worsening (21.8%), patient-missed appointments (16.7%), COVID-19-related issues (14.9%), and treatment dissatisfaction (8.6%). CONCLUSIONS The factors associated with increased LTFU rates were older age, inactive treatment phase, lower baseline and final BCVA, bevacizumab treatment, monotherapy, longer travelling distance, and commuting with an escort. According to the multivariate logistic regression analysis, only the escort during the commuting and treatment phases was significant. These findings could direct research to explore social support in treatment adherence and highlight the importance of treatment phases in practice.
Collapse
Affiliation(s)
- Pavol Kusenda
- Department of Ophthalmology, University Hospital—St. Michael’s Hospital, 811 08 Bratislava, Slovakia; (P.K.); (Z.G.)
| | - Martin Caprnda
- First Department of Internal Medicine, Faculty of Medicine, Comenius University, University Hospital Bratislava, 811 07 Bratislava, Slovakia;
| | - Zuzana Gabrielova
- Department of Ophthalmology, University Hospital—St. Michael’s Hospital, 811 08 Bratislava, Slovakia; (P.K.); (Z.G.)
| | | | - Samuel Pavlovic
- Department of Ophthalmology, Faculty Hospital Nitra, 950 01 Nitra, Slovakia;
| | - Jana Stefanickova
- Department of Ophthalmology, Faculty of Medicine, Comenius University, 821 01 Bratislava, Slovakia
- Oftalmocentrum Betliarska Euromedix, 851 07 Bratislava, Slovakia
| |
Collapse
|
6
|
Meer EA, Targ S, Zhang N, Hoggatt KJ, Mehta KM, Brodie F. AGE-RELATED MACULAR DEGENERATION INJECTION FREQUENCY: Effects of Distance Traveled and Travel Support. Retina 2024; 44:230-236. [PMID: 37756667 DOI: 10.1097/iae.0000000000003947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
PURPOSE Although efficacious, intravitreal anti-vascular endothelial growth factor therapy regimens for neovascular age-related macular degeneration can prove difficult for patients to adhere to because of high cost and burden of transportation. METHODS Analysis of electronic health record data from the San Francisco Veterans Administration Medical Center eye clinic (January 1, 2010 to December 31, 2019) was performed, extracting demographic data, anti-vascular endothelial growth factor injection history, and enrollment in the SFVA travel benefit program. Two-tailed P -values were calculated for Poisson regression examining average number of injections per year as the outcome and distance traveled as the primary predictor. Travel benefit was evaluated as a modifying effect on the distance-injection relationship. RESULTS Three hundred and eighteen patients who received intravitreal injection for treatment of neovascular age-related macular degeneration were included in the analysis. Median (interquartile range) distance to clinic was 31.5 miles (7.4-69.4 miles). Driving distance in miles was inversely associated with average number of injections per year. Among all 318 patients, for every additional 100 miles a patient lived from our clinic, the patient received on average 2.5 fewer injections per year ( distance = -0.0025, P < 0.001), but this was not the case for patients with travel benefits ( distance = -0.0011, P = 0.362). CONCLUSION The greater the distance from a patient's eye clinic, the lower the average number of injections per year. However, travel benefits mitigated this relationship, highlighting opportunities for improving patient's adherence through assistance programs.
Collapse
Affiliation(s)
| | - Sonia Targ
- School of Medicine, University of California, San Francisco, California
| | - Ning Zhang
- School of Medicine, University of California, San Francisco, California
- San Francisco VA Health Care System, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California School of Medicina, San Francisco, California; and
| | - Katherine J Hoggatt
- School of Medicine, University of California, San Francisco, California
- San Francisco VA Health Care System, San Francisco, California
| | - Kala M Mehta
- School of Medicine, University of California, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California School of Medicina, San Francisco, California; and
| | - Frank Brodie
- Department of Ophthalmology
- Department of Ophthalmology, San Francisco Veterans Affairs Medical Center, San Francisco, California
| |
Collapse
|
7
|
Cheng BT, Kim AB, Lyon AT, Mirza RG. Disease Awareness Among Patients With Age-Related Macular Degeneration: Patterns and Predictors. JOURNAL OF VITREORETINAL DISEASES 2024; 8:58-66. [PMID: 38223766 PMCID: PMC10786073 DOI: 10.1177/24741264231210078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Purpose: To examine the prevalence and predictors of patient awareness of their disease in adults with age-related macular degeneration (AMD). Methods: This study analyzed 5553 adults 40 years or older in the 2005-2008 National Health and Nutrition Examination Survey who underwent retinal imaging. AMD was determined based on retinal images. Patient awareness of their AMD was assessed by a self-reported AMD diagnosis. Multivariable logistic regression models were constructed to examine the association of patient awareness of their AMD with sociodemographic characteristics and specific AMD lesion types on retinal imaging. Results: AMD was identified in 425 of the adults surveyed (6.5%) (95% confidence interval [CI], 5.5%-7.5%), including 87.7% (95% CI, 82.9%-92.5%) with early AMD and 12.3% (95% CI, 7.5%-17.1%) with late AMD. Among adults with either type of AMD on retinal imaging, 17.5% (95% CI, 13.1%-22.0%) were aware of their disease, which included 11.6% (95% CI, 8.4%-14.9%) with early AMD and 59.2% (95% CI, 43.1%-75.3%) with late AMD (P < .0001). In the same group, those aged 60 years or older (odds ratio [OR], 33.46; 95% CI, 7.67-146.03) and with a best-corrected visual acuity of 20/40 or worse (OR, 4.63; 95% CI, 2.95-7.26) had higher awareness of their AMD diagnosis, whereas Hispanic (OR, 0.28; 95% CI, 0.09-0.88) vs White adults and those who did not speak English at home (OR, 0.05; 95% CI, 0.01-0.41) had lower awareness of their diagnosis. Conclusions: Fewer than 1 in 5 adults with AMD were aware of their personal diagnosis, including fewer than 3 in 5 adults with late AMD. Older adults and those with worse vision were more likely to know they have AMD, whereas Hispanic adults and those who did not speak English at home were less likely. Efforts to increase patients' awareness of their AMD may improve rates of follow-up and prevent vision loss.
Collapse
Affiliation(s)
- Brian T. Cheng
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Wills Eye Hospital, Philadelphia, PA, USA
| | - Anne B. Kim
- Department of Ophthalmology, Rush University Medical College, Chicago, IL, USA
| | - Alice T. Lyon
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rukhsana G. Mirza
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
8
|
Bowe T, Mahmoudzadeh R, Soares RR, Nguyen MK, Hsu J, Kuriyan AE. CHARACTERISTICS OF PARTICIPANTS IN DIABETIC RETINOPATHY CLINICAL RESEARCH CLINICAL TRIALS WHO WERE LOST TO FOLLOW-UP. Retina 2024; 44:111-116. [PMID: 37603443 DOI: 10.1097/iae.0000000000003911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
PURPOSE Our study describes the racial/ethnic composition and the broad health status/severity of disease of the cohorts of Diabetic Retinopathy Clinical Research clinical trials and compares the rates of noncompletion of the trial with the first data report (lost to follow-up). METHODS This study is a retrospective cohort study of participants in Diabetic Retinopathy Clinical Research Retina Network clinical trials who met our inclusion criteria. The primary outcome was the lost to follow-up rates and their associated risk factors. RESULTS Eight clinical trials with 3,492 participants met our inclusion criteria. Participants who were lost to follow-up were more likely to be younger, Hispanic or Black, had Type 1 diabetes mellitus, had worse baseline best-corrected visual acuity, had higher hemoglobin A1c, had higher blood pressure, and had proliferative diabetic retinopathy (PDR) (Diabetic Retinopathy Severity Score >66). CONCLUSION Participants who were lost to follow-up during Diabetic Retinopathy Clinical Research clinical trials tended to be younger, Hispanic or Black, and had worse diabetes and hypertension. This study highlights the importance of ensuring that a representative population is maintained through the end of the study period.
Collapse
Affiliation(s)
- Theodore Bowe
- Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | | | | | | |
Collapse
|
9
|
Willms JO, Mitchell K, Shashtri M, Sundin O, Liu X, Panthagani P, Tran P, Navarro S, Sniegowski C, Shaik AA, Chaudhury T, Reid TW, Bergeson SE. Minocycline and Diacetyl Minocycline Eye Drops Reduce Ocular Neovascularization in Mice. Transl Vis Sci Technol 2023; 12:10. [PMID: 38064336 PMCID: PMC10709801 DOI: 10.1167/tvst.12.12.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 09/24/2023] [Indexed: 12/18/2023] Open
Abstract
Purpose To evaluate the efficacy of minocycline and a novel, modified minocycline analogue that lacks antimicrobial action, diacetyl minocycline (DAM), on choroidal neovascularization (CNV) in mice of both sexes. Methods CNV was induced via laser injury in female and male C57BL/6J mice. Minocycline, DAM, or saline was administered via topical eye drops twice a day for 2 weeks starting the day after laser injury. CNV volume was measured using immunohistochemistry labeling and confocal microscopy. Results Minocycline reduced lesion volume by 79% (P ≤ 0.0004) in female and male mice. DAM reduced lesion volume by 73% (P ≤ 0.001) in female and male mice. There was no significant difference in lesion volume between minocycline and DAM treatment groups or between female and male mice. Conclusions Both minocycline and DAM eye drops significantly reduced laser-induced CNV lesion volume in female and male mice. While oral tetracyclines have been shown to mitigate pathologic neovascularization in both preclinical studies and clinical trials, the present data are the first to suggest that tetracycline derivatives may be effective to reduce pathologic CNV when administered via topical eye drops. However, the action is unrelated to antimicrobial action. Targeted delivery of these medications via eye drops may reduce the potential for systemic side effects. Translational Relevance Topical administration of minocycline and/or DAM via eye drops may represent a novel therapeutic strategy for disorders involving pathologic CNV.
Collapse
Affiliation(s)
- Joshua O. Willms
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kelly Mitchell
- Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Olof Sundin
- Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Xiaobo Liu
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Praneetha Panthagani
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Phat Tran
- Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Stephany Navarro
- Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Colton Sniegowski
- Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Abdul A. Shaik
- Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Tristin Chaudhury
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Ted W. Reid
- Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Susan E. Bergeson
- Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| |
Collapse
|
10
|
Takahashi VKL, Balbino M, Ruppert ADP, de Carvalho LS, Seixas RCS. Lost to follow-up of patients who received intravitreal anti-vascular endothelial growth factor therapy to treat four different retina disorders in an individual center in Brazil. SAGE Open Med 2023; 11:20503121231199655. [PMID: 37808513 PMCID: PMC10559699 DOI: 10.1177/20503121231199655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 08/21/2023] [Indexed: 10/10/2023] Open
Abstract
Objectives To identify risk factors for loss to follow-up in periodic intravitreal anti-vascular endothelial growth factor injections for the treatment patients with diabetic macular edema, subretinal neovascularization, age-related macular degeneration, and retinal vein occlusion in a single eye center in São Paulo, Brazil. Methods This was a retrospective longitudinal study that gathered information from 992 patients who required intravitreal anti-vascular endothelial growth factor drugs over 6 months. The authors included age, eye disease, laterality, monthly income, distance, and payment mode as risk factors. Results Two hundred and seventy patients (29.93%) were lost to follow-up. Multivariate analysis showed age, monthly income, eye involvement, and type of medical assistance independently associated with loss to follow-up. The odds of loss to follow-up were greater among older patients than those less than 50 years (reference), p < 0.001. The odds of loss to follow-up were greater among patients who received unilateral treatment than those who received bilateral injections (p = 0.013). Concerning gross monthly income, there were no differences in the odds of the four salary strata; the data also indicate an absence of difference in the three strata of patients' distance to the clinic. Considering the diagnosis, only age-related macular degeneration showed greater odds of loss to follow-up (p = 0.016). Finally, the data suggest greater odds of loss to follow-up in private patients than in those on a health care plan (p < 0.001). Conclusion Loss to follow-up is paramount because many patients may remain unassisted concerning their eye diseases. Identifying the risk factors is crucial to enforcing measures to increase adherence and the long-term success of the treatment.
Collapse
|
11
|
Jones R, Stratton IM, Scanlon PH, Theodoropoulou S. Disengagement and loss to follow-up in intravitreal injection clinics for neovascular age-related macular degeneration. Eye (Lond) 2023; 37:3186-3190. [PMID: 36914803 PMCID: PMC10564721 DOI: 10.1038/s41433-023-02474-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 01/24/2023] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND/OBJECTIVES Timely assessment and treatment of patients with neovascular AMD (nAMD) are crucial to preservation of vision. Loss to follow up (LTFU) in these patients is a problem but this has not been systematically investigated. SUBJECTS/METHODS A retrospective review of electronic medical records of patients with nAMD first treated with anti-VEGF therapy from 1st Jan 2014 to 31st Dec 2018, was conducted in January 2021. Any patient not seen for more than 12 months was classed as no longer attending. RESULTS Of the 1328 patients who attended between 2014 and 2018, 348 had failed to attend and were eligible for inclusion in this study. Reasons noted for discontinuation of care: discharged by clinician (33.3%), died (20.7%), moved to another unit outside of area (17.5%), stopped attending due to ill-health (13.5%), discharged due to failure to attend (5.6%) and patient choice to no longer attend (4.6%). There were 16 (4.6%) who did not receive any further appointments despite clinician request for follow-up. After 5 years, 50.5% of patients were no longer attending for treatment. Age was a factor in failure to attend, with 7 out of 12 patients aged >100 years no longer being followed up, compared to 1 out of 11 of 50-59 year-olds. CONCLUSIONS When analysing visual outcomes in an AMD service it is important to characterise the patients who are lost to follow up. The outcomes for this group may be avoidably poor and understanding the factors influencing LTFU rate is crucial to addressing shortcomings in a hospital AMD service.
Collapse
Affiliation(s)
- Rebecca Jones
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, GL53 7AN, UK.
| | - Irene M Stratton
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, GL53 7AN, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- University of Southampton, Southampton, UK
| | - Peter H Scanlon
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, GL53 7AN, UK
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
- University of Gloucestershire, Cheltenham, UK
| | - Sofia Theodoropoulou
- Gloucestershire Retinal Research Group, Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, GL53 7AN, UK
| |
Collapse
|
12
|
Andoh JE, Ezekwesili AC, Nwanyanwu K, Elam A. Disparities in Eye Care Access and Utilization: A Narrative Review. Annu Rev Vis Sci 2023; 9:15-37. [PMID: 37254050 DOI: 10.1146/annurev-vision-112122-020934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This narrative review summarizes the literature on factors related to eye care access and utilization in the United States. Using the Healthy People 2030 framework, this review investigates social determinants of health associated with general and follow-up engagement, screenings, diagnostic visits, treatment, technology, and teleophthalmology. We provide hypotheses for these documented eye care disparities, featuring qualitative, patient-centered research. Lastly, we provide recommendations in the hopes of appropriately eliminating these disparities and reimagining eye care.
Collapse
Affiliation(s)
- Joana E Andoh
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Agnes C Ezekwesili
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristen Nwanyanwu
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Angela Elam
- Department of Ophthalmology, WK Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA;
| |
Collapse
|
13
|
Basilious A, Duncan J, Smuck B, Malvankar-Mehta MS, Juncal VR, Hooper P, Sheidow TG. Treatment discontinuation patterns of anti VEGF in retinal vein occlusion. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023:S0008-4182(23)00251-X. [PMID: 37669742 DOI: 10.1016/j.jcjo.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 06/12/2023] [Accepted: 08/15/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVE The purpose of this research is to report on real-world anti-vascular endothelial growth factor (anti-VEGF) treatment patterns in retinal vein occlusions (RVO). DESIGN Retrospective cohort study. PARTICIPANTS Treatment-naive RVO patients initiating anti-VEGF injections between 2015 and 2021. METHODS Medical records available until June 2022 were reviewed. Demographics, diagnosis, number of injections, treatment length, reason for discontinuation, and baseline and final data (e.g., date, age, best-corrected visual acuity [BCVA], and central subfield thickness) were recorded. Statistical analyses performed with STATA 17.0 assessed differences between baseline and final values, branch (BRVO) and central retinal vein occlusion (CRVO), and treatment-discontinuation subgroups. RESULTS A total of 219 treatment-naive eyes were included (70.3 ± 13.2 years of age, 52.5% female), with 99 BRVOs and 120 CRVOs (2482 injections). The discontinuation rate was 76.7% (168 of 219), with 72.7% of patients (77 of 99) with BRVOs and 75.8% of patients (91 of 120) with CRVOs discontinuing injections. Reasons for discontinuation included stable off active therapy (98 eyes), severe comorbidity or death (17 eyes), switched to intraocular steroid (implant or injection) (12 eyes), lack of visual benefit (10 eyes), ocular comorbidity (5 eyes), patient decision (5 eyes), and patient transfer (5 eyes). Among the remaining 67 eyes, 16 (24%) were lost to follow-up. Reasons for discontinuation differed between BRVO and CRVO patients (p = 0.002). Eyes with CRVO presented with worse BCVA (p < 0.0001) and achieved worse final BCVA (p < 0.0001), but both groups experienced improvements (p < 0.0001). Younger age, better baseline BCVA, and a diagnosis of BRVO were independent predictors of better final visual acuity. CONCLUSION Over 7.5 years, treatment was discontinued for three-quarters of RVOs. Stable disease was the most common reason for discontinuation, with nearly half (45%) of all RVOs in the cohort stable off active therapy. Better visual outcomes were achieved in BRVO than in CRVO, although both groups benefited from treatment.
Collapse
Affiliation(s)
- Amy Basilious
- Department of Ophthalmology, Ivey Eye Institute, St. Joseph's Health Care, London, ON..
| | - Julie Duncan
- Department of Ophthalmology, Ivey Eye Institute, St. Joseph's Health Care, London, ON
| | - Bobbi Smuck
- Department of Ophthalmology, Ivey Eye Institute, St. Joseph's Health Care, London, ON
| | | | - Verena R Juncal
- Department of Ophthalmology, Ivey Eye Institute, St. Joseph's Health Care, London, ON
| | - Phil Hooper
- Department of Ophthalmology, Ivey Eye Institute, St. Joseph's Health Care, London, ON
| | - Tom G Sheidow
- Department of Ophthalmology, Ivey Eye Institute, St. Joseph's Health Care, London, ON
| |
Collapse
|
14
|
Zhang C, Friedman S, Mruthyunjaya P, Parikh R. The Biosimilar Paradox: How Anti-Vascular Endothelial Growth Factor Biosimilars Could Increase Patient and Overall Health Care Costs. Ophthalmology 2023; 130:966-972. [PMID: 37116720 DOI: 10.1016/j.ophtha.2023.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/28/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023] Open
Abstract
PURPOSE Anti-vascular endothelial growth factor (VEGF) medications for intraocular use are a major and increasing cost, and biosimilars may be a means of reducing the high cost of many biologic medications. However, a bevacizumab biosimilar, which is currently pending Food and Drug Administration (FDA) approval (bevacizumab-vikg), paradoxically may increase the cost burden of intravitreal anti-VEGF agents, because off-label repackaged drugs may no longer be allowed per the Drug Quality and Security Act (DQSA). We aimed to investigate the potential impact of biosimilars on costs in the United States. DESIGN Cost analysis of anti-VEGF medications. PARTICIPANTS Medicare data from October 2022 and previously published market share data from 2019. METHODS Average sales prices (ASPs) of ranibizumab, aflibercept, and bevacizumab were calculated from Medicare allowable payments. The ASPs of biosimilars were calculated from wholesale acquisition costs from a representative distributor. The cost of an intraocular bevacizumab formulation is modeled at $500/1.25-mg dose and $900/1.25-mg dose. MAIN OUTCOME MEASURES Costs of anti-VEGF drugs to Medicare Part B and patients. RESULTS If an intraocular bevacizumab biosimilar were to be priced at $500, costs to Medicare would increase by $457 million from $3.01 billion to $3.47 billion (15.2% increase). Patient responsibility would increase by $117 million from $768 million to $884 million. Similarly, if intraocular bevacizumab were priced at $900, Medicare costs would increase by $897 million to $3.91 billion (29.8% increase), and patient responsibility would increase by $229 million to $997 million. If bevacizumab were $500/dose, switching all patients currently receiving ranibizumab or aflibercept to respective biosimilars would compensate for only 28.8% of the increased cost. Current prices of ranibizumab and aflibercept biosimilars would have to decrease by an aggregate of 15.7% to $616.80/injection, $1027.97/injection, and $1436.88/injection for ranibizumab 0.3 mg, ranibizumab 0.5 mg, and aflibercept, respectively. CONCLUSIONS An FDA-approved bevacizumab biosimilar for ophthalmic use could increase costs to the health care system and patients, raising concerns for access. This increase would not be offset by ranibizumab and aflibercept biosimilar use at current prices. These data support the need for an exemption of section 503B of the DQSA and continued use of repackaged off-label bevacizumab. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Casey Zhang
- Department of Ophthalmology, Grossman School of Medicine, NYU Langone Health, New York, New York
| | | | | | - Ravi Parikh
- Department of Ophthalmology, Grossman School of Medicine, NYU Langone Health, New York, New York; Manhattan Retina and Eye Consultants, New York, New York.
| |
Collapse
|
15
|
Nguyen AH, Davoudi S, Dong K, Bains A, Ness S, Subramanian ML, Siegel NH, Chen X. Socioeconomic Disparities in Patients Receiving Intravitreal Injections for Age-Related Macular Degeneration Amid the COVID-19 Pandemic. JOURNAL OF VITREORETINAL DISEASES 2023; 7:376-381. [PMID: 37701269 PMCID: PMC10311364 DOI: 10.1177/24741264231173771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Purpose: To determine the effects of socioeconomic factors on visit adherence and the resultant visual outcomes for patients receiving intravitreal injections for neovascular age-related macular degeneration during the COVID-19 pandemic. Methods: In this retrospective case-control study, medical records were reviewed to collect appointment attendance, age, sex, self-reported race/ethnicity, primary language, marital status, insurance, distance from clinic, and Area Deprivation Index (ADI), a measure of socioeconomic disadvantage. Multivariate regression models were created to determine differences in socioeconomic factors between individuals who attended (show group) and those who did not attend (no-show group) appointments. Results: The study enrolled 126 patients in the show group and 115 in the no-show group. On univariate analysis, nonadherence was significantly higher in non-White patients than in White patients (P = .04), urban sites than in suburban sites (P = 1.7 × 10-4), and non-English-speaking patients than in English-speaking patients (P = 4.0 × 10-3). The associations remained significant in multivariate analysis for non-English-speaking patients (P = .03) and urban-site patients (P = .01) after adjusting for age, sex, self-reported race/ethnicity, primary language, marital status, insurance, distance from clinic, site of visit, and ADI. At 6 months and 1 year, a 1-, 2-, and 3-line vision loss was significantly higher in the no-show group than in the show group on univariate and multivariate analysis after adjusting for age, sex, race, lens status, and presence of glaucoma and diabetic retinopathy. Conclusions: Non-English-speaking patients and urban-based patients were less likely to present for intravitreal injection appointments during the initial peak of the COVID-19 pandemic. This disparity translated to worse vision outcomes at 6 months and 1 year.
Collapse
Affiliation(s)
- Anh H. Nguyen
- Boston University School of Medicine, Boston, MA, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston MA, USA
| | - Samaneh Davoudi
- Boston University School of Medicine, Boston, MA, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston MA, USA
| | - Kaylin Dong
- Boston University School of Medicine, Boston, MA, USA
| | - Ashank Bains
- Boston University School of Medicine, Boston, MA, USA
| | - Steven Ness
- Boston University School of Medicine, Boston, MA, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston MA, USA
| | - Manju L. Subramanian
- Boston University School of Medicine, Boston, MA, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston MA, USA
| | - Nicole H. Siegel
- Boston University School of Medicine, Boston, MA, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston MA, USA
| | - Xuejing Chen
- Boston University School of Medicine, Boston, MA, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston MA, USA
| |
Collapse
|
16
|
Yiallouridou C, Acton JH, Banerjee S, Waterman H, Wood A. Pain related to intravitreal injections for age-related macular degeneration: a qualitative study of the perspectives of patients and practitioners. BMJ Open 2023; 13:e069625. [PMID: 37586867 PMCID: PMC10432642 DOI: 10.1136/bmjopen-2022-069625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/01/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES Ocular pain is a commonly reported finding in the intravitreal injection procedure, but post-injection experiences and patient adherence to treatment remain underexplored. We therefore aimed to identify key variations in the intravitreal injection procedure that may influence pain, and to gain insights into the post-injection experience and treatment adherence from the perspective of patients and practitioners. DESIGN Qualitative semistructured interview study using reflexive thematic analysis of transcripts. SETTING Hospital Eye Clinic in Wales, UK. Interviews were conducted between May and September 2019. PARTICIPANTS Purposive sample of patients aged ≥50 years with neovascular age-related macular degeneration and no other retinal pathology who had received at least six intravitreal injections, and practitioners including ophthalmologists, registered nurses and optometrists who performed intravitreal injections at the research site. RESULTS Data saturation was reached with 21 interviews: 14 patients and 7 practitioners. Three main themes were identified from the analysis: fear of losing eyesight and treatment anxiety influence patient adherence to treatment, variability in pain experience during treatment, and post-injection experience and impact on patient recovery. To reassure patients feeling apprehensive about the injections, practitioners promoted safety and trust, and used techniques to manage anxiety. Key variations that may influence pain identified were application of antiseptic or anaesthetic, injecting methods and communication. During injection, patients reported a dull-aching and sharp pain, contrary to practitioners' perspective of feeling a 'pressure'. Patients described prolonged soreness and irritation of up to 36 hours post-injection affecting their sleep and recovery. CONCLUSION Establishing rapport supported patients to recognise the necessity of ongoing treatment to prevent sight loss; however, inadequate pain management led to undesirable outcomes. Practitioners should use pain assessment tools during and immediately after injection and provide ongoing consistent information to help patients manage pain at home.
Collapse
Affiliation(s)
| | - Jennifer H Acton
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
| | - Sanjiv Banerjee
- Ophthalmology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - Ashley Wood
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
| |
Collapse
|
17
|
Yanagi Y, Takahashi K, Iida T, Gomi F, Morii J, Kunikane E, Sakamoto T. Cost-Effectiveness Analysis of Ranibizumab Biosimilar for Neovascular Age-Related Macular Degeneration in Japan. Ophthalmol Ther 2023; 12:2005-2021. [PMID: 37171557 PMCID: PMC10287869 DOI: 10.1007/s40123-023-00715-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/11/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION Neovascular age-related macular degeneration (nAMD) is the world's leading cause of blindness in elderly people. While anti-vascular endothelial growth factor (VEGF) treatments are used as the first option for patients with nAMD, they are generally expensive and need repeated injections. This study aimed to evaluate the cost-effectiveness of anti-VEGF therapies, focusing on the newly launched ranibizumab biosimilar (RBZ BS) in patients with nAMD from a Japanese societal perspective. METHODS A Markov model was developed to simulate the lifetime transitions of a cohort of treatment-naïve patients with nAMD through health states that were based on the involvement of nAMD (single eye vs. both eyes), the treatment status of the patients, and decimal best-corrected visual acuity. The model compared RBZ BS with branded RBZ, aflibercept (AFL), and AFL as loading dose switched to RBZ BS in maintenance in the treat-and-extend (TAE) regimen (RBZ TAE, AFL TAE, and AFL to RBZ BS TAE, respectively), and with branded RBZ in the pro re nata (PRN) regimen, as well as best supportive care (BSC). All processes were validated by five clinical experts. RESULTS When TAE regimens were compared, RBZ BS was dominant (higher quality-adjusted life-years (QALYs) and lower total cost) to AFL TAE and AFL to RBZ TAE. The result was robust regardless of whether the clinical data were taken from the direct head-to-head clinical trial or from indirect treatment comparison. RBZ BS TAE was cost-saving compared to RBZ TAE. RBZ BS TAE was estimated to be dominant to BSC owing to a lower societal cost. Like TAE regimens, RBZ BS was cost-saving compared to RBZ PRN and was dominant to BSC in PRN regimens. CONCLUSION This study suggests that RBZ BS is dominant to other anti-VEGF treatments in patients with nAMD in both TAE and PRN regimens and BSC from a Japanese societal perspective.
Collapse
Affiliation(s)
- Yasuo Yanagi
- Department of Ophthalmology and Microtechnology, Yokohama City University, Kanagawa, Japan.
| | - Kanji Takahashi
- Department of Ophthalmology, Kansai Medical University, Osaka, Japan
| | - Tomohiro Iida
- Department of Ophthalmology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Fumi Gomi
- Department of Ophthalmology, Hyogo Medical University, Hyogo, Japan
| | | | | | - Taiji Sakamoto
- Department of Ophthalmology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| |
Collapse
|
18
|
Alharbi AD, Alotayk NI, Alaboudi AA, Alammar AY, Aldekhail MI, Alharbi MA, Alsamel TA, Aljutayli MA, Aljarbou AM, Aljameeli OM. Prevalence and Visual Consequences of Non-adherent Patients Receiving Anti-vascular Endothelial Growth Factor (VEGF) Injections at King Fahad Specialist Hospital (KFSH), Qassim Region. Cureus 2023; 15:e44340. [PMID: 37779785 PMCID: PMC10538945 DOI: 10.7759/cureus.44340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Anti-vascular endothelial growth factor (VEGF) injection treatment is a widely utilized therapy for various retinal diseases, including diabetic macular edema (DME). Therefore, the importance of compliance and follow-up should be discussed with the patient. There have been no studies conducted in the Qassim region to estimate the prevalence of patients missing their anti-VEGF appointments. To fulfill this need, we conducted this study to evaluate the compliance rate of patients treated with anti-VEGF injections for DME as well as to determine the visual consequences of the delay in anti-VEGF treatment in the Qassim region. METHODOLOGY This observational retrospective cohort study was conducted at King Fahad Specialist Hospital (KFSH) in the Qassim region of Saudi Arabia. We extracted all file numbers of patients who were using intravitreal anti-VEGF injections to treat DME. The data were managed and analyzed using the IBM Statistical Package for the Social Sciences (SPSS) software (IBM Corp., Armonk, NY, USA). RESULTS In the current study, we were able to collect data from 198 patients who received anti-VEGF treatment in the hospital. Among the participants, 57.6% were male, with a mean age of 61.7 years old (standard deviation (SD) = 10.23). Among the patients, we found that the rate of non-adherence to the anti-VEGF injection was 54.5%, and those patients delayed their scheduled doses for more than 56 days. In 47.5% of the patients, delaying or stopping their appointments had no known reason; however, blepharitis was the main reason for delaying or stopping the dose in 27.7% of the patients, followed by endophthalmitis in 18.7% of the patients. There is no significant difference between before and after stopping the treatment, considering visual acuity (VA) or optical coherence tomography (OCT). However, regarding the disease progression, we found that 15 out of the 30 patients had worsened in the OCT after they missed their injections (mean increase in the VA was 6.069 (SD = 97.45), t = -0.278, P = 0.783, and decrease in the OCT was -14.9667 (SD = 133.87, P = 0.454). CONCLUSION There is a high rate of patients who missed their appointments for an anti-VEGF injection. This resulted in the worsening of OCT in half of the 30 patients who were enrolled in the visual consequences study, which had a negative impact on treatment and disease progression.
Collapse
|
19
|
Shahzad H, Mahmood S, McGee S, Hubbard J, Haque S, Paudyal V, Denniston AK, Hill LJ, Jalal Z. Non-adherence and non-persistence to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy: a systematic review and meta-analysis. Syst Rev 2023; 12:92. [PMID: 37269003 DOI: 10.1186/s13643-023-02261-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/26/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections play a key role in treating a range of macular diseases. The effectiveness of these therapies is dependent on patients' adherence (the extent to which a patient takes their medicines as per agreed recommendations from the healthcare provider) and persistence (continuation of the treatment for the prescribed duration) to their prescribed treatment regimens. The aim of this systematic review was to demonstrate the need for further investigation into the prevalence of, and factors contributing to, patient-led non-adherence and non-persistence, thus facilitating improved clinical outcomes. METHODS Systematic searches were conducted in Google Scholar, Web of Science, PubMed, MEDLINE, and the Cochrane Library. Studies in English conducted before February 2023 that reported the level of, and/or barriers to, non-adherence or non-persistence to intravitreal anti-VEGF ocular disease therapy were included. Duplicate papers, literature reviews, expert opinion articles, case studies, and case series were excluded following screening by two independent authors. RESULTS Data from a total of 409,215 patients across 52 studies were analysed. Treatment regimens included pro re nata, monthly and treat-and-extend protocols; study durations ranged from 4 months to 8 years. Of the 52 studies, 22 included a breakdown of reasons for patient non-adherence/non-persistence. Patient-led non-adherence varied between 17.5 and 35.0% depending on the definition used. Overall pooled prevalence of patient-led treatment non-persistence was 30.0% (P = 0.000). Reasons for non-adherence/non-persistence included dissatisfaction with treatment results (29.9%), financial burden (19%), older age/comorbidities (15.5%), difficulty booking appointments (8.5%), travel distance/social isolation (7.9%), lack of time (5.8%), satisfaction with the perceived improvement in their condition (4.4%), fear of injection (4.0%), loss of motivation (4.0%), apathy towards eyesight (2.5%), dissatisfaction with facilities 2.3%, and discomfort/pain (0.3%). Three studies found non-adherence rates between 51.6 and 68.8% during the COVID-19 pandemic, in part due to fear of exposure to COVID-19 and difficulties travelling during lockdown. DISCUSSION Results suggest high levels of patient-led non-adherence/non-persistence to anti-VEGF therapy, mostly due to dissatisfaction with treatment results, a combination of comorbidities, loss of motivation and the burden of travel. This study provides key information on prevalence and factors contributing to non-adherence/non-persistence in anti-VEGF treatment for macular diseases, aiding identification of at-risk individuals to improve real-world visual outcomes. Improvements in the literature can be achieved by establishing uniform definitions and standard timescales for what constitutes non-adherence/non-persistence. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020216205.
Collapse
Affiliation(s)
- Haris Shahzad
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Sajid Mahmood
- Deputy Drugs Controller, Specialized Healthcare and Medical Education Department, Punjab, Lahore, Pakistan
| | - Sean McGee
- School of Biomedical Sciences, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jessica Hubbard
- School of Biomedical Sciences, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sayeed Haque
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alastair K Denniston
- National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- Health Data Research UK, London, UK
| | - Lisa J Hill
- School of Biomedical Sciences, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
20
|
Auger A, Khanna RK, Bonicel P, Pisella PJ, Le Lez ML. [Impact of the French 2020 COVID-19 lockdown on the treatment and follow-up of patients with exudative age-related macular degeneration]. J Fr Ophtalmol 2023:S0181-5512(23)00094-3. [PMID: 37248127 DOI: 10.1016/j.jfo.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/11/2022] [Indexed: 05/31/2023]
Abstract
PURPOSE To assess the impact of the measures taken during the lockdown period from March 17 to May 11, 2020 on the management of patients with exudative age related macular degeneration treated by intravitreal anti-VEGF injections at the University Hospital of Tours. METHODS In this retrospective study, patients were included after analysis of the computerized medical records of patients with age related macular degeneration. Those who were treated for exudative age related macular degeneration who received at least 1 intravitreal injection in the 12 months prior and at least one consultation in the 6 months prior to the lockdown period, were included. The initial and final mean visual acuity were compared with a 5 letter non-inferiority margin. A subgroup analysis was performed according to outcomes. The visual acuities immediately after this period were also recorded. RESULTS In all, 595 eyes of 493 patients were included. The mean initial visual acuity was 59.6 letters, vs. 58.5 for the final visual acuity, i.e. a difference of -1.13 letters with a lower limit of the confidence interval of less than 5. The visual acuity on release from lockdown was comparable to the other 2 measurements. Initial visual acuity and the number of missed treatments were the main factors associated with functional loss. CONCLUSION Patients' visual acuity during the lockdown period was able to be maintained despite the restrictive measures and limitation of care access in France. The most common cause of substantial visual decline was missed intravitreal injections.
Collapse
Affiliation(s)
- A Auger
- Service d'ophtalmologie, hôpital universitaire de Tours, Tours, France.
| | - R K Khanna
- Service d'ophtalmologie, hôpital universitaire de Tours, Tours, France; UMR 1253, iBrain, Tours, Centre-Val de Loire, France
| | - P Bonicel
- Service d'ophtalmologie, centre hospitalier régional d'Orléans, Orléans, France
| | - P-J Pisella
- Service d'ophtalmologie, hôpital universitaire de Tours, Tours, France
| | - M-L Le Lez
- Service d'ophtalmologie, hôpital universitaire de Tours, Tours, France
| |
Collapse
|
21
|
Khurana RN, Li C, Lum F. Loss to Follow up in Patients with Neovascular Age Related Macular Degeneration treated with Anti-VEGF therapy in the United States in the IRIS® Registry. Ophthalmology 2023:S0161-6420(23)00132-X. [PMID: 36858288 DOI: 10.1016/j.ophtha.2023.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE To determine the incidence of loss to follow up (LTFU) and nonpersistence in patients with neovascular age related macular degeneration (AMD) treated with anti-vascular endothelial growth factor (VEGF) injections in the United States. DESIGN Retrospective cohort study using IRIS (Intelligent Research in Sight) Registry data. SUBJECTS 156,327 treatment-naïve neovascular AMD patients who were subsequently treated with anti-VEGF therapy from 2013 to 2015 and followed through 2019. METHODS Multivariable logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) MAIN OUTCOME MEASURES: LTFU was defined as no follow up within 12 months from last intravitreal injection. Nonpersistence was defined as no follow up within 6 months from last intravitreal injection. RESULTS For neovascular AMD, 11.6% (95% CI, 11.4-11.7) of patients were LTFU and 88.4% of patients had a follow up within 12 months. The rate of LTFU is generally higher with increasing age, with odds of LTFU greatest for patients between 81-84 years of age (OR, 2.51; 95% CI, 2.31-2.74; p<0.001) compared with patients 70 years of age and younger. Odds of LTFU for Black or African-American patients (OR, 1.32; 95% CI, 1.08-1.61; p=0.007) were greater than for white patients. Odds of LTFU were higher for patients with Medicaid insurance (OR, 1.27; 95% CI, 1.01-1.60; p=0.04) and lower for patients with Medicare Fee-for-Service insurance (OR, 0.69; 95% CI, 0.64-0.74; p<0.001) compared to patients with Private insurance. 14.3% (95% CI, 14.1-14.4) of patients were nonpersistent and 85.7% of patients had a follow up within 6 months. Odds of nonpersistence were also greatest among patients between 81-84 years of age (OR, 2.13; 95% CI, 1.98-2.29; p<0.001) compared with patients 70 years of age or younger. Odds of nonpersistence for Black or African American patients (OR, 1.38; 95% CI, 1.15-1.65; p<0.001) and Hispanic patients (OR, 1.13; 95% CI, 1.03-1.24; p=0.009) were greater than odds for white patients. CONCLUSIONS Nearly one out of nine neovascular AMD patients treated with anti-VEGF injections are LTFU while one out of seven patients are nonpersistent. Risk factors identified included increasing age, male sex, unilateral involvement, diabetes, Medicaid insurance and race/ethnicity.
Collapse
Affiliation(s)
- Rahul N Khurana
- Northern California Retina Vitreous Associates, Mountain View, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California.
| | - Charles Li
- American Academy of Ophthalmology, San Francisco, California
| | - Flora Lum
- American Academy of Ophthalmology, San Francisco, California
| |
Collapse
|
22
|
Fairbanks AM, Husain D. Controversies and Disparities in the Management of Age-Related Macular Degeneration. Semin Ophthalmol 2023; 38:134-142. [PMID: 36602457 DOI: 10.1080/08820538.2022.2152705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Age-related macular degeneration is a leading cause of blindness in patients aged 50 years and older. Prior to the 21st century, there were no effective treatments for this devastating disease. However, the last 20 years have heralded the development of treatments for both the nonexudative and exudative forms. The invention of AREDS vitamin supplements and anti-VEGF therapies forever changed the treatment of dry and wet age-related macular degeneration, respectively. The rapid adoption and expansion of these vision preserving treatments has created controversy regarding their cost, burden of administration, development, and use of new technologies, genetic considerations, and observed societal disparities. Many of these controversies and disparities persist today and will require further research to resolve.
Collapse
Affiliation(s)
- Aaron M Fairbanks
- Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Deeba Husain
- Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
23
|
Mansour AM, Tripathy K, Parodi MB. A hypothetical therapeutic effect of light peripheral panretinal photocoagulation in neovascular age-related macular degeneration. MEDICAL HYPOTHESIS, DISCOVERY & INNOVATION OPHTHALMOLOGY JOURNAL 2022; 11:137-143. [PMID: 37641639 PMCID: PMC10445313 DOI: 10.51329/mehdiophthal1457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/30/2022] [Indexed: 08/31/2023]
Abstract
Background Vascular endothelial growth factor (VEGF) is a significant modulator of ocular angiogenesis, including that of neovascular age-related macular degeneration (nAMD). Intravitreal injection of anti-VEGF is the benchmark treatment for most retinal vascular diseases, including nAMD, diabetic maculopathy, and macular edema secondary to retinal venous occlusion. Anti-VEGF treatment is a high-frequency, time-consuming, non-cost-effective therapy, especially in countries and regions with limited resources. This treatment is easily restricted, and in practice, maintaining long-term periodic care is challenging for patients. Hypothesis Light peripheral panretinal photocoagulation (PPRP) is applied in a mild form (barely visible mild light gray mark) anterior to the equator so as not to jeopardize the visual field. PPRP lessens the ischemia that causes neovascularization and decreases the metabolic demand in the peripheral retina. PPRP reduces serum angiopoietin-2 and VEGF levels in patients with type 2 diabetes mellitus with proliferative diabetic retinopathy. We propose using light PPRP to suppress VEGF secretion, aiming to attenuate the VEGF drive and halt choroidal neovascular growth in eyes with nAMD. Our regimen is based on two concepts: first, nAMD is a diffuse or generalized disease that affects the posterior segment; and second, PPRP is very effective in regressing diabetic retinopathy. PPRP has reportedly been successful in cases of macular edema (diabetic or following venous occlusion) resistant to VEGF antagonists. Light PPRP may be used as prophylaxis, adjunctive treatment, or monotherapy in nAMD when intravitreal injections of VEGF antagonists are not feasible. Conclusions The established light PPRP therapy could be promising as a one-time, cost-effective therapy or prophylaxis in patients with nAMD or at high risk. This proposed modality could be suitable for patients who have injection phobia or prefer a one-time affordable therapy to the long-term monthly visits to retinologists. Future trials are necessary to verify the safety and efficacy of this proposed treatment modality in selected patients with nAMD.
Collapse
Affiliation(s)
- Ahmad M Mansour
- Department of Ophthalmology, American University of Beirut, Beirut, Lebanon
| | - Koushik Tripathy
- Department of Retina and Uvea, ASG Eye Hospital, Kolkata, West Bengal, India
| | | |
Collapse
|
24
|
Jabir AR, Zaheer HA, Zaheer MA, Zaheer EA, Birdsong R. Detection and Diagnosis of Retinoblastoma: Can Mobile Devices Be the Next Step Toward Early Intervention? Cureus 2022; 14:e30074. [DOI: 10.7759/cureus.30074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
|
25
|
Angermann R, Franchi A, Frede K, Stöckl V, Palme C, Kralinger M, Zehetner C. Long-term persistence with aflibercept therapy among treatment-naïve patients with exudative age-related macular degeneration in a universal health care system: a retrospective study. BMC Ophthalmol 2022; 22:372. [PMID: 36123657 PMCID: PMC9483893 DOI: 10.1186/s12886-022-02593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 09/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background This study aimed to analyse the persistence rates of treatment-naïve patients with neovascular age-related macular degeneration (nAMD) who received intravitreal aflibercept therapy in a universal health care system. Methods In this single-centre retrospective cohort study, we audited data of 918 treatment-naïve patients who received exclusively intravitreal aflibercept therapy for nAMD between September 2015 and May 2021. The primary outcome measures were the rates of treatment nonpersistence (gap in ophthalmological care > 6 months) and long-term nonpersistence (> 12 months). Results The rates of nonpersistence and long-term nonpersistence were 12.3% and 3.4% after one year; 22.4% and 9.5% after two years; and 38.3% and 19.3% after five years, respectively. Logistic regression analysis revealed that older age (p = 0.045), male sex (p = 0.039), requirement for caretakers or ambulance (p = 0.001), and low visual acuity of the study eye (p = 0.010) or fellow eye (p = 0.029) were independent risk factors for long-term nonpersistence. Patients aged > 80 and > 85 years (p = 0.013 and p = 0.022, respectively) had more than twice the risk for being nonpersistent to therapy within two years of follow-up compared with younger patients. Male patients (p = 0.033), patients requiring a caretaker (p = 0.038), and patients living > 60 km from the clinic (p = 0.029) had a 2 × higher risk of being persistently nonpersistent to therapy. Conclusions Patients with nAMD who were treated with aflibercept had lower nonpersistence rates than those reported in current literature. Multiple independent risk factors were correlated with long-term nonpersistence, early nonpersistence, or complete loss to follow-up. Considering the possible consequences of reduced compliance, further strategies are urgently needed for patients at risk of nonpersistence to therapy.
Collapse
Affiliation(s)
- Reinhard Angermann
- Department of Ophthalmology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.,Department of Ophthalmology, Landesklinikum Mistelbach/Gänserndorf, Lichtensteinstraße 67, 2130, Mistelbach, Austria
| | - Alexander Franchi
- Department of Ophthalmology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Katharina Frede
- Department of Ophthalmology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Victoria Stöckl
- Department of Ophthalmology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christoph Palme
- Department of Ophthalmology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Martina Kralinger
- Department of Ophthalmology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Claus Zehetner
- Department of Ophthalmology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| |
Collapse
|
26
|
Nair AA, Finn AP, Sternberg Jr P. Spotlight on Faricimab in the Treatment of Wet Age-Related Macular Degeneration: Design, Development and Place in Therapy. Drug Des Devel Ther 2022; 16:3395-3400. [PMID: 36199631 PMCID: PMC9529225 DOI: 10.2147/dddt.s368963] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Archana A Nair
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Avni P Finn
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paul Sternberg Jr
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, USA
- Correspondence: Paul Sternberg Jr, Chair and G. W. Hale Professor of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, 2311 Pierce Avenue, Nashville, TN, 37232, USA, Email
| |
Collapse
|
27
|
Bui YT, Starr MR, Kung FF, Mejia CA, Bakri SJ. Long-Term Visual Outcomes in Exudative Age-Related Macular Degeneration Patients With Unanticipated Gaps in Therapy. Ophthalmic Surg Lasers Imaging Retina 2022; 53:481-489. [PMID: 36107628 DOI: 10.3928/23258160-20220819-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES This study's objective was to describe long-term visual outcomes of patients with age-related macular degeneration (AMD) treated with intravitreal anti-vascular endothelial growth factor injections who were lost to follow-up and then resumed treatment with anti-vascular endothelial growth factor injections. MATERIALS AND METHODS This was a retrospective cohort study of eyes with at least 7 years of follow-up following the initiation of treatment for wet AMD with and without gaps in therapy. RESULTS The baseline mean logMAR visual acuity was 0.65 ± 0.5 (Snellen acuity 20/89) in eyes with gaps in therapy and 0.53 ± 0.3 (20/68) in eyes without gaps. In the initial 7-year follow-up period, the eyes with gaps in therapy had significantly worse visual acuity (P < .001) and this remained significant when accounting for baseline visual acuity (P < .001). CONCLUSIONS Gaps in intravitreal injection therapy for exudative AMD were negatively associated with visual acuity. Adherence to therapy is important to address in the care of patients with exudative AMD. [Ophthalmic Surg Lasers Imaging Retina 2022;53:481-489.].
Collapse
|
28
|
Abou-Jaoude MM, Crawford J, Kryscio RJ, Moore DB. Accuracy of Ophthalmology Clinic Follow-Up in the Incarcerated Patient Population. JOURNAL OF ACADEMIC OPHTHALMOLOGY 2022. [DOI: 10.1055/s-0042-1758562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
Purpose Incarcerated patients represent a uniquely vulnerable population in the outpatient ophthalmology setting, and the reliability of follow-up in this group is undetermined.
Methods This was a retrospective, observational chart review of consecutive incarcerated patients evaluated at the ophthalmology clinic of a single academic medical center between July 2012 and September 2016. For each encounter the following were recorded: patient age, gender, incarcerated status at the time of encounter (a subset of patients had encounters before/after incarceration), interventions performed, follow-up interval requested, urgency of follow-up, and actual time to subsequent follow-up. Primary outcome measures were no-show rate and timeliness, which was defined as follow-up within 1.5× the requested period.
Results There were 489 patients included during the study period, representing a total of 2,014 clinical encounters. Of the 489 patients, 189 (38.7%) were seen once. Of the remaining 300 patients with more than one encounter, 184 (61.3%) ultimately did not return and only 24 (8%) were always on time for every encounter. Of 1,747 encounters with specific follow-up requested, 1,072 were considered timely (61.3%). Factors significantly associated with subsequent loss to follow-up include whether a procedure was performed (p < 0.0001), urgency of follow-up (p < 0.0001), incarcerated status (p = 0.0408), and whether follow-up was requested (p < 0.0001).
Conclusion Almost two-thirds of incarcerated patients in our population requiring repeat examination were lost to follow-up, particularly those who underwent an intervention or required more urgent follow-up. Patients entering and exiting the penal system were less likely to follow-up while incarcerated. Further work is needed to understand how these gaps compare to those in the general population and to identify means of improving these outcomes.
Collapse
Affiliation(s)
- Michelle M. Abou-Jaoude
- Department of Ophthalmology and Visual Sciences, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jessica Crawford
- Department of Ophthalmology and Visual Sciences, University of Kentucky College of Medicine, Lexington, Kentucky
| | | | - Daniel B. Moore
- Department of Ophthalmology and Visual Sciences, University of Kentucky College of Medicine, Lexington, Kentucky
| |
Collapse
|
29
|
Bakri SJ, Karcher H, Andersen S, Souied EH. Anti-VEGF treatment discontinuation and interval in neovascular age-related macular degeneration in the US. Am J Ophthalmol 2022; 242:189-196. [PMID: 35738393 DOI: 10.1016/j.ajo.2022.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the association between treatment interval and likelihood of anti-vascular endothelial growth factor (anti-VEGF) discontinuation among patients with neovascular age-related macular degeneration (nAMD) in a real-world setting US. DESIGN Retrospective clinical cohort study. METHODS Health insurance claims data from the IBM MarketScan® Commercial and Medicare Supplemental databases were retrospectively reviewed to identify adults with nAMD who received anti-VEGF for the first time between 1 January 2011 and 30 June 2020. The proportion of discontinued patients was analyzed using Kaplan-Meier curves. Cox proportional hazards models were used to examine the association between treatment intervals at 24 months and anti-VEGF discontinuation. RESULTS The analysis included 8,167 patients on continuous, unilateral anti-VEGF treatment for at least 24 months. Baseline demographics and clinical characteristics were well balanced between treatment interval groups. The overall rate of discontinuation from 24 months until 60 months after treatment initiation was 30.4%. At 60 months, patients on shorter treatment intervals were more likely to remain on treatment than those on longer intervals, ranging from 76.8% (4-week interval group) to 60.6% (>12-week interval group) and corresponding to a 28% lower likelihood (HR [SE] 0.72 [0.12], p<0.01) and 55% higher likelihood of discontinuing treatment (HR [SE] 1.55 [0.07], p<0.01), respectively, compared with the 8-week group. CONCLUSIONS nAMD patients on longer anti-VEGF treatment intervals at 24 months had consistently higher discontinuation rates than patients on shorter intervals in the following years. This highlights the need to support and educate patients on long treatment intervals to continue with their treatment.
Collapse
Affiliation(s)
- Sophie J Bakri
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA.
| | | | | | - Eric H Souied
- Department of Ophthalmology, Université Paris-Est Créteil, Paris, France
| |
Collapse
|
30
|
Sood S, Mandell J, Watane A, Friedman S, Parikh R. Cost of Ranibizumab Port Delivery System vs Intravitreal Injections for Patients With Neovascular Age-Related Macular Degeneration. JAMA Ophthalmol 2022; 140:716-723. [PMID: 35708679 DOI: 10.1001/jamaophthalmol.2022.1819] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance The study team investigated costs associated with the ranibizumab port delivery system (PDS) for neovascular age-related macular (nAMD), an alternative to conventional intravitreal anti-vascular endothelial growth factor (VEGF) injections. Objective To investigate costs of intravitreal anti-VEGF injections vs ranibizumab PDS for patients with neovascular AMD (nAMD). Design, Setting, and Participants This cost analysis used trial data and Medicare reimbursement rates and included patients with nAMD who were receiving ranibizumab, aflibercept, bevacizumab injections, or ranibizumab PDS. Main Outcomes and Measures The number of intravitreal ranibizumab, aflibercept, and bevacizumab injections to break even with costs of ranibizumab PDS. Total direct medical costs over 1 year and 5 years for the ranibizumab PDS arm with refills at fixed 6-month intervals compared with monthly or bimonthly injections were calculated using Medicare rates. Scenario and sensitivity analyses accounted for uncertainty and variation. Results The mean (SD) number of ranibizumab, aflibercept, and bevacizumab injections to break even with the cost of ranibizumab PDS with 1 refill was 10.8 (1.3), 9.3 (1.1), and 34.5 (4.2), respectively. Ranibizumab PDS with fixed 6-month refills over 1 year cost $21 016 ($2102). Comparatively, monthly intravitreal ranibizumab cost $1943 (95% CI, -$3047 to $6932; P = .34) more, aflibercept cost $5702 (95% CI, $253-$11 151; P = .04) more, and bevacizumab cost $16 732 (95% CI, -$20 170 to -$13 294, P < .001) less. For bimonthly injections, aflibercept cost $7658 (95% CI, -$11 649.52 to -$3665.61; P = .006) less. Over 5 years, monthly intravitreal ranibizumab projected to cost $25 581 (95% CI, $2275-$48 887; P = .04) more, aflibercept cost $44 374 (95% CI, $18 623-$70 125; P = .008) more, and bevacizumab cost $67 793 (95% CI, -$82 501 to -$53 085; P < .001) less than PDS with fixed refills (mean [SD] cost, $89 218 [$8921]). For bimonthly injections, aflibercept cost $22 422 (95% CI, -$40 287 to -$45,56; P = .03) less. In scenario analyses, ranibizumab PDS with refills as needed offered cost savings compared with real-world intravitreal ranibizumab or aflibercept use at 5 years but not at 1 year. Conclusions and Relevance In this cost analysis, ranibizumab PDS with 1 refill cost more than intravitreal ranibizumab or aflibercept injections if less than or equal to approximately 11 or 10 injections, respectively, are required within the first year. Long term, if less than 4.4 and 3.8 injections are needed per refill, intravitreal ranibizumab and aflibercept is lower cost. Ranibizumab PDS costs more than intravitreal bevacizumab injections throughout scenarios.
Collapse
Affiliation(s)
- Shefali Sood
- New York University School of Medicine, New York
| | - Jordan Mandell
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Arjun Watane
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut
| | | | - Ravi Parikh
- Manhattan Retina and Eye Consultants, New York, New York.,Department of Ophthalmology, New York University School of Medicine, New York
| |
Collapse
|
31
|
Dhingra N, Upasani D, Ghanchi FD. Patterns of treatment discontinuation in patients receiving anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Indian J Ophthalmol 2022; 70:2065-2070. [PMID: 35647983 PMCID: PMC9359266 DOI: 10.4103/ijo.ijo_3066_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: To report the reasons for treatment discontinuation within 5 years in patients receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nAMD). Methods: A retrospective case-notes review of patients commenced on anti-VEGF for nAMD who failed to complete 5 years of follow-up was undertaken. The reasons for treatment discontinuation, baseline age, baseline visual acuity (VA) in Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and the VA change at the last follow-up were recorded. Age-specific all-cause mortality was calculated for deceased patients. Results: Of the 1177 patients, 551 patients (46.8%) failed to complete the 5-year follow-up. The reasons for treatment discontinuation were death (251), early discharge due to stable disease (110), further treatment deemed futile (100), failure to attend (15), ill health (14), patient choice (7), and transfer of care (1). In 53 patients, no reason was documented. The mean baseline age of those who completed the 5-year follow-up (77.4 ± 7.8 years, 95% confidence interval (CI): 76.8–77.9) was significantly lower than those who discontinued the treatment for any reason (82 ± 7.7 years, 95% CI: 81.4–82.6) (P < 0.0001). Survival analysis showed that baseline VA was not a factor in treatment discontinuation; however, visual stability (±5 letters from baseline) was associated with treatment continuation. The age-specific all-cause mortality in deceased patients was lower than that in the general population. Conclusion: At 5 years, only 53% of patients remained in active care, and death was the most common reason for treatment discontinuation. Lower baseline age and VA stability during therapy were associated with treatment continuation.
Collapse
Affiliation(s)
- Narendra Dhingra
- Macula Service, Eye Centre, Mid Yorkshire NHS Trust, Wakefield, WF1 2DG, UK
| | - Deepa Upasani
- Macula Service, Eye Centre, Mid Yorkshire NHS Trust, Wakefield, WF1 2DG, UK
| | - Faruque D Ghanchi
- Bradford Teaching Hospitals, NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, UK
| |
Collapse
|
32
|
The negative impact of COVID-19 pandemic on age-related macular degeneration patients treated with intravitreal bevacizumab injections. Int Ophthalmol 2022; 42:3387-3395. [PMID: 35604624 PMCID: PMC9125960 DOI: 10.1007/s10792-022-02337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 04/18/2022] [Indexed: 11/09/2022]
Abstract
Purpose COVID-19 emerged in the end of 2019 and was declared a worldwide pandemic shortly after. Social distancing and lockdowns resulted in lower compliance in intravitreal injections and office visits. We aimed to assess clinical outcomes among patients who missed these visits compared to those who arrived as planned. Methods Patients who missed or were late to office visits or intravitreal injections were defined as non-adherent and were compared to adherent patients. Our main outcomes were the need for subsequent injections, mean change in best-corrected visual acuity (BCVA), and central macular thickness (CMT). Results This study included 77 patients (24 adherent and 53 non-adherent). The mean BCVA remained stable during the study period for the adherent group (p = 0.159) and worsened in the non-adherent group (p < 0.001). Changes in CMT and maximum thickness were not significant for either group. A higher proportion of patients in the non-adherent group needed subsequent intravitreal injections (49% vs 20%, p = 0.014). Conclusion The findings demonstrate the negative implications of the COVID-19 pandemic and the effect of deferring bevacizumab injections among individuals with age-related macular degeneration. This emphasizes the importance of a scheduled follow-up, also during a pandemic. Supplementary Information The online version contains supplementary material available at 10.1007/s10792-022-02337-y.
Collapse
|
33
|
Increased Distance from Clinic Leads to Higher Loss to Follow-up after Pars Plana Vitrectomy in Diabetic Patients. Retina 2022; 42:1921-1925. [DOI: 10.1097/iae.0000000000003540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Delayed follow-up in patients with neovascular age-related macular degeneration treated under universal health coverage: risk factors and visual outcomes. Retina 2022; 42:1693-1701. [PMID: 35504012 DOI: 10.1097/iae.0000000000003512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report the rate of delayed follow-up visits (DFU), to identify risk factors of DFU and to assess the impact of DFU on outcomes in neovascular age-related macular degeneration (nAMD). PATIENTS AND METHODS This retrospective study included all nAMD patients (n=1291) treated with anti-vascular endothelial growth factor (VEGF) injections between January 2013 and December 2020 in two centers in Quebec, Canada. A DFU was defined as a delay of ≥4 weeks than scheduled. Visual outcomes, especially ≥15 letters loss, were reported. RESULTS A total of 351 patients (27.2%) experienced ≥1 DFU. Odds were greater among older patients (P=0.005), patients treated at the hospital rather than the clinic (P<0.001), and patients with worse initial visual acuity (VA) (P=0.024). A DFU was associated with a mean VA loss of 4.2±13.4 letters (P<0.001), and an increased incidence of intraretinal (IRF) and subretinal fluid (SRF) (P=0.001, P=0.005) at six months despite resumption of injections. Central foveal thickness (CFT) increased after DFU but returned to pre-DFU visit at 6 months. CONCLUSIONS The DFU rate in nAMD patients treated under a universal healthcare system was around 27%. DFU caused significant decreases in VA and increases in IRF and SRF on OCT that did not recover following injections resumption despite normalization of CFT.
Collapse
|
35
|
Douglas VP, Douglas KAA, Vavvas DG, Miller JW, Miller JB. Short- and Long-Term Visual Outcomes in Patients Receiving Intravitreal Injections: The Impact of the Coronavirus 2019 Disease (COVID-19)-Related Lockdown. J Clin Med 2022; 11:jcm11082097. [PMID: 35456189 PMCID: PMC9029849 DOI: 10.3390/jcm11082097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/10/2022] Open
Abstract
Purpose: To investigate the short- and long-term impact of COVID-19—related lockdown on the vision of patients requiring intravitreal injections (IVI) for neovascular Age-related Macular degeneration (nvAMD), diabetic retinopathy (DR), central retinal vein occlusion (CRVO), or branch retinal vein occlusion (BRVO). Methods: This is a retrospective study from the Retina department of three Mass Eye and Ear centers. Charts of patients age of ≥ 18 years with any of the abovementioned diagnoses who had a scheduled appointment anytime between 17 March 2020 until 18 May 2020 (lockdown period in Boston, Massachusetts) were reviewed at baseline (up to 12 weeks before the lockdown), at first available follow-up (=actual f/u) during or after the lockdown period, at 3 months, 6 months, and at last available completed appointment of 2020. Results: A total of 1001 patients met the inclusion criteria. Of those patients, 479 (47.9%) completed their intended f/u appointment, while 522 missed it (canceled and “no show”). The delay in care of those who missed it was 59.15 days [standard deviation (SD) ± 49.6]. In these patients, significant loss of vision was noted at actual f/u [Best corrected visual acuity (BCVA) in LogMAR (Logarithm of the Minimum Angle of Resolution)—mean (±SD)—completed: 0.45 (±0.46), missed: 0.53 (±0.55); p = 0.01], which was more prominent in the DR group [Visual acuity (VA) change in LogMAR—mean (±SD); completed: 0.04 (±0.28), missed: 0.18 (±0.44); p = 0.02] and CRVO [completed: −0.06 (±0.27), missed: 0.11 (±0.35); p = <0.001] groups followed by nvAMD [completed: 0.006 (±0.16), missed: 0.06 (±0.27); p = 0.004] and BRVO [completed: −0.02 (±0.1), missed: 0.03 (±0.14); p = 0.02] ones. Overall, a higher percent of people who missed their intended f/u experienced vision loss of more than 15 letters at last f/u compared to those who completed it [missed vs. completed; 13.4% vs. 7.4% in nvAMD (p = 0.72), 7.8% vs. 6.3% in DR (0.84), 15.5% vs. 9.9% in CRVO (p < 0.001) and 9.6% vs. 2% in BRVO (p = 0.48)]. Conclusions: Delay in care of about 8.45 weeks can lead to loss of vision in patients who receive IVI with DR and CRVO patients being more vulnerable in the short-term, whereas in the long-term, CRVO patients followed by the nvAMD patients demonstrating the least vision recovery. BRVO patients were less likely to be affected by the delay in care. Adherence to treatment is key for maintaining and improving visual outcomes in patients who require IVI.
Collapse
Affiliation(s)
| | | | | | | | - John B. Miller
- Correspondence: ; Tel.: +1-(617)-573-3750; Fax: +1-(617)-573-3698
| |
Collapse
|
36
|
Intravitreal Aflibercept Therapy and Treatment Outcomes of Eyes with Neovascular Age-Related Macular Degeneration in a Real-Life Setting: A Five-Year Follow-Up Investigation. Ophthalmol Ther 2022; 11:559-571. [PMID: 35048330 PMCID: PMC8769092 DOI: 10.1007/s40123-022-00452-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/05/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction We aimed to evaluate visual and anatomical outcomes among eyes with neovascular age-related macular degeneration (nAMD) that were persistent to intravitreal aflibercept therapy compared to those that were nonpersistent to therapy. Methods We audited 648 treatment-naïve eyes of 559 patients regarding visual acuity (VA) given as the logarithm of the minimum angle of resolution (logMAR) and anatomic outcomes at baseline and at each subsequent follow-up visit for up to 5 years. Nonpersistence was defined as a visit-free interval of > 6 months. Results Among the enrolled eyes, 405 were persistent to the therapy and 243 (37%) were nonpersistent, of which 161 (66%) eyes returned for further therapy after a gap of clinical care. In the nonpersistent group, we observed a decline from 0.58 ± 0.35 to 0.92 ± 0.57 logMAR (p = 0.01) after 60 months. Compared with the persistent group, the nonpersistent group had worse visual outcomes at their 33-month (p = 0.03), 42-month (p = 0.01), 51-month (p = 0.001) and 60-month (p = 0.01) visits. Additionally, 5/405 (1.2%) eyes in the persistent group and 8/161 (5.0%) eyes in the nonpersistent group developed an end-stage disease with a subfoveal fibrosis during the observational period (p = 0.013). Conclusion We found that eyes with nAMD that were nonpersistent to intravitreal aflibercept therapy experienced statistically significantly worse VA compared to eyes persistent to therapy within 3 years. Moreover, eyes in the nonpersistent group had a four-fold higher risk of developing a fovea-involving fibrosis. Considering the potential irreversible deterioration with respect to best-corrected VA within nAMD, strategies need to be developed for patients at risk of nonpersistence to therapy.
Collapse
|
37
|
Leung EH, Fan J, Flynn HW, Albini TA. Ocular and Systemic Complications of COVID-19: Impact on Patients and Healthcare. Clin Ophthalmol 2022; 16:1-13. [PMID: 35018092 PMCID: PMC8742614 DOI: 10.2147/opth.s336963] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/23/2021] [Indexed: 12/11/2022] Open
Abstract
There is increasing information available about the effects of the SARS-CoV-2 virus on the systemic and ocular health of patients, as well as the effects of delayed health care. This mini-review summarizes the potential complications and treatments of COVID-19. Systemic findings include respiratory illness, risk of thromboembolic events, and neurologic findings. Some patients may develop persistent symptoms even after the infection resolves. Effective treatment options include glucocorticoids, antivirals, interleukin-6 antagonists, monoclonal antibodies, Janus kinase inhibitors and vaccines. Potential ocular findings of COVID-19 include conjunctivitis, cranial nerve palsies, and microvascular changes in the retina; most symptoms resolved over time. During the lockdown periods, teleophthalmology was utilized to triage non-urgent issues; patients who did present to emergency departments tended to have more severe disease with worse visual prognoses. While transient delays in outpatient ophthalmic care may be tolerated in some patients, others experienced significant vision loss with interruptions in treatments. Resumption of ophthalmic care as soon as possible may help mitigate the effects of delayed care due to the pandemic.
Collapse
Affiliation(s)
| | - Jason Fan
- Bascom Palmer Eye Institute/University of Miami, Miami, FL, USA
| | - Harry W Flynn
- Bascom Palmer Eye Institute/University of Miami, Miami, FL, USA
| | - Thomas A Albini
- Bascom Palmer Eye Institute/University of Miami, Miami, FL, USA
| |
Collapse
|
38
|
Luu KT, Seal J, Green M, Winskill C, Attar M. Effect of Anti-VEGF Therapy on the Disease Progression of Neovascular Age-Related Macular Degeneration: A Systematic Review and Model-Based Meta-Analysis. J Clin Pharmacol 2021; 62:594-608. [PMID: 34783362 PMCID: PMC9305109 DOI: 10.1002/jcph.2002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/11/2021] [Indexed: 11/25/2022]
Abstract
Anti–vascular endothelial growth factor (VEGF) therapy is used to slow the disease progression of neovascular age‐related macular degeneration. Due to the treatment burden of frequent intravitreal injections, anti‐VEGFs are often used on treat and extend protocols rather than the labeled frequency. The current goal of anti‐VEGF drug development is to minimize treatment burden by reducing the number of intravitreal injections. The purpose of this systemic review and model‐based meta‐analysis (MBMA) was to (1) perform modeling to describe the disease progression of neovascular age‐related macular degeneration in the absence of treatment, as well as in the presence of abicipar, aflibercept, brolucizumab, or ranibizumab intervention; (2) and to simulate virtual head‐to‐head comparisons among the drugs with an extended dose schedule of once every 12 weeks (Q12). Data sources were PubMed, internal Allergan data, www.clinicaltrials.gov, and www.clinicaltrialsregister.eu. Eligibility assessment was performed by 2 independent review authors. Randomized, controlled trials that had at least 1 arm with an anti‐VEGF (aflibercept, abicipar, bevacizumab, brolucizumab, pegaptanib, or ranibizumab), a control arm of placebo or anti‐VEGF, a treatment duration of at least 4 months, reported best‐corrected visual acuity data, and at least 20 patients were included. A total of 22 trials, consisting of 55 arms, from across 9500+ subjects and 500+ best‐corrected visual acuity observations were used to develop the model. Consistent with reported data, results from the model showed that abicipar Q12 underperformed ranibizumab (every 4 weeks), aflibercept (every 4 weeks), and brolucizumab (every 8 weeks/Q12) labeled dosing schedules. However, when all drugs were virtually tested using the extended schedule, abicipar outperformed ranibizumab and aflibercept and produced a similar week 52 change from baseline as brolucizumab. Predicted week 52 changes from baseline were 5.92 ± 1.02, 3.04 ± 1.61, 6.61 ± 0.284, and 3.02 ± 2.35 best‐corrected visual acuity letters for abicipar, aflibercept, brolucizumab, and ranibizumab, respectively, using the Q12 schedule. Results demonstrate the feasibility of Q12 dosing with clinically meaningful letter gains for abicipar and brolucizumab. The model developed under this MBMA has utility for exploring different regimens for existing or novel anti‐VEGF agents.
Collapse
|
39
|
Shields CN, Cherkas EG, Mokhashi N, Cai LZ, Pandit RR, Patel SN, Hsu J, Kuriyan AE, Klufas MA, Ho AC. Barriers to Follow-Up Retinal Care During the COVID-19 Pandemic: A Survey Study. Ophthalmic Surg Lasers Imaging Retina 2021; 52:526-533. [PMID: 34661462 DOI: 10.3928/23258160-20210904-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVE To characterize patient-identified barriers to care in those non-compliant with retina appointments during the coronavirus disease 2019 (COVID-19) pandemic. PATIENTS AND METHODS Inclusion criteria included non-compliant patients from March 1, 2020 to May 1, 2020. Ultimately, 1,345 patients were invited to complete a 14-question survey. A retrospective chart review correlated clinical and demographic information. Univariate logistic regression, independent-samples t-test, and Pearson correlation coefficient identified differences among subgroups. RESULTS Of the 1,345 patients, 181 (13.5%) completed the survey. The most significant barriers to care included fear of COVID (76/181; 42.0%), wait times (21/181; 11.6%), and costs (11/181; 6.1%). Patients who got their COVID information from the Centers for Disease Control and Prevention (7.8 ± 2.4) and televised news (8.0 ± 2.0) had higher levels of fear. Finally, patients with diabetic retinopathy and higher Charlson Comorbidity Index scores had greater concerns of COVID (P = .034 and P = .047, respectively). CONCLUSION This survey study suggests fear of COVID-19 is a prominent new barrier to retinal care. Identifying those at risk for loss to follow-up can guide practices as the pandemic continues. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:526-533.].
Collapse
|
40
|
Jacobs B, Palmer N, Shetty T, Dimaras H, Hajrasouliha A, Jusufbegovic D, Corson TW. Patient preferences in retinal drug delivery. Sci Rep 2021; 11:18996. [PMID: 34556761 PMCID: PMC8460733 DOI: 10.1038/s41598-021-98568-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
Retinal vascular diseases (RVDs) are often treated with intravitreally (IVT) injected drugs, with relatively low patient compliance and potential risks. Ongoing research explores alternative RVD treatments, including eye drops and oral tablets. This study surveyed RVD patients treated with IVT injections to establish factors influencing low compliance rates while gauging treatment delivery method preferences. Demographics, perspectives, and treatment preferences were collected via IRB-approved, self-administered survey sent to Glick Eye Institute patients treated via IVT injections. Demographics, diagnoses, and treatments were ascertained from respondents’ medical records. Gender, age, and number of IVT injections received were used as stratifications. Five-level Likert-style scales and t-tests evaluated responses and stratification comparisons. The most common diagnoses in the respondent population (n = 54; response rate = 5%) were age-related macular degeneration, macular edema, and diabetic retinopathy. Respondents had varying levels of education, income, and age. Most (83%) admitted feeling anxious prior to their first IVT injection, but 80% reported willingness to receive IVT injections indefinitely, with a preference for ophthalmologist visits every 1–3 months. Eye drops would be preferred over IVT injections by 76% of respondents, while 65% preferred oral tablets, due to several perceived negative factors of IVT injections and positive factors for eye drops. Stratified groups did not differ in responses to survey questions. RVD patients will accept IVT injections for vision preservation, but alternative delivery methods like eye drops or oral tablets would be preferred. Thus, development of eye drop and oral therapeutics for RVD treatment is further emphasized by these findings.
Collapse
Affiliation(s)
- Brandon Jacobs
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 West Michigan Street, Indianapolis, IN, 46202, USA
| | - Nicholas Palmer
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 West Michigan Street, Indianapolis, IN, 46202, USA
| | - Trupti Shetty
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 West Michigan Street, Indianapolis, IN, 46202, USA.,Neurobiology, Neurodegeneration and Repair Laboratory, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Helen Dimaras
- Hospital for Sick Children, Toronto, ON, Canada.,Department of Ophthalmology and Vision Sciences, and Division of Clinical Public Health, Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Amir Hajrasouliha
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 West Michigan Street, Indianapolis, IN, 46202, USA
| | - Denis Jusufbegovic
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 West Michigan Street, Indianapolis, IN, 46202, USA
| | - Timothy W Corson
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 West Michigan Street, Indianapolis, IN, 46202, USA.
| |
Collapse
|
41
|
Soares RR, Gopal AD, Parikh D, Shields CN, Patel S, Hinkle J, Sharpe J, Ho AC, Regillo CD, Haller J, Yonekawa Y. Geographic Access Disparities of Clinical Trials in Neovascular Age-Related Macular Degeneration in the United States. Am J Ophthalmol 2021; 229:160-168. [PMID: 33848533 DOI: 10.1016/j.ajo.2021.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
To identify geographic and socioeconomic variables predictive of residential proximity to neovascular age-related macular degeneration (nAMD) clinical trial locations. DESIGN Retrospective, cross-sectional study. METHODS Census tract-level data from public datasets and trial-level data from ClinicalTrials.gov were analyzed. We calculated the driving distance (>60 miles) and time (>60 minutes) from the population-weighted US census tract centroid to the nearest clinical trial site. RESULTS We identified 42 trials studying nAMD across 829 unique clinical trial sites in the United States. In a multivariable model, driving distance >60 miles had a significant association with rural location (adjusted odds ratio [aOR] 5.54; 95% confidence interval [CI] 3.86-7.96, P < .0001) and with Midwest (aOR 2.30; 95% CI 1.21-4.38, P = .01) and South (aOR 2.43; 95% CI 1.21-4.91, P = .01) as compared to the Northeast region, and with some college or an associate's degree, as compared to a bachelor's degree (aOR 1.02; 95% CI 1.01-1.04, P = .0007, and aOR 1.05; 95% CI 1.00-1.10, P = .04, respectively). Lower odds of traveling >60 miles to the nearest nAMD trial site were associated with census tracts with a higher percentage of blacks (aOR 0.98; 95% CI 0.97-0.99, P < .0001), Hispanics (aOR 0.97; 95% CI 0.95-0.99, P = .002), and Asians (aOR 0.90; 95% CI 0.88-0.93, P < .0001), as compared to whites, and with a lower percentage of the population <200% of the federal poverty level. Similar predictors were found in time traveled >60 minutes. CONCLUSIONS There are geographic access disparities of clinical trial sites for nAMD in the United States.
Collapse
Affiliation(s)
- Rebecca R Soares
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Anand D Gopal
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Devayu Parikh
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Charlotte N Shields
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Samir Patel
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John Hinkle
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James Sharpe
- Biostatistics Consulting Core, Vickie and Jack Farber Vision Research Center, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Allen C Ho
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Carl D Regillo
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Julia Haller
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yoshihiro Yonekawa
- From Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
42
|
Upasani D, Dhingra N. Ten-year outcome of anti-vascular endothelial growth factor treatment for neovascular age-related macular degeneration. Indian J Ophthalmol 2021; 69:2350-2354. [PMID: 34427220 PMCID: PMC8544087 DOI: 10.4103/ijo.ijo_2868_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Purpose: The aim of this study was to report the 10-year visual outcome in eyes treated with anti-vascular endothelial growth factor (anti-VEGF) agents for neovascular age-related macular degeneration (nAMD) and to assess the impact of switching treatment as part of routine clinical care. Methods: Electronic records of treatment-naïve eyes initiated on intravitreal ranibizumab between January and December 2009 were accessed. The primary outcome measured was the change in visual acuity (VA) in Early Treatment of Diabetic Retinopathy Study letters. The frequency and reasons for treatment discontinuation during each year of follow-up and the impact of switching from ranibizumab to aflibercept were some of the secondary outcomes. Results: Of the 223 eyes (203 patients), 60 eyes completed 10 years of continuous follow-up. After a mean follow-up of 121.4 months, VA declined by 5.6 letters (95% confidence interval [CI] –0.25 to –11.1, P = 0.04). Final VA of ≥70 letters was seen in 20% of eyes and 35% had VA ≤ 35 letters. VA gain of ≥10 letters was seen in 23% and loss of ≥10 letters was seen in 40% of the eyes. Twenty-nine eyes remained on ranibizumab monotherapy and 31 switched to aflibercept. Switched eyes showed a visual decline of 7.1 letters (5.5 letters in monotherapy eyes, P = 0.32) and received a significantly higher number of injections (39.6 ± 9.9 vs. 24.4 ± 13.1, P < 0.0001). Patients discontinuing treatment were older and had lower baseline vision compared to completers. Conclusion: VA declined below the baseline after 10 years of follow-up and switching did not have any effect on the final visual outcome.
Collapse
Affiliation(s)
- Deepa Upasani
- Macula Service, Eye Centre, Mid Yorkshire NHS Trust, Wakefield, United Kingdom
| | - Narendra Dhingra
- Macula Service, Eye Centre, Mid Yorkshire NHS Trust, Wakefield, United Kingdom
| |
Collapse
|
43
|
Discontinuation and loss to follow-up rates in clinical trials of intravitreal anti-vascular endothelial growth factor injections. Graefes Arch Clin Exp Ophthalmol 2021; 260:93-100. [PMID: 34415363 DOI: 10.1007/s00417-021-05246-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/07/2021] [Accepted: 05/12/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Clinical trials are often designed to include homogenous, highly specific patient populations with many resources to reduce patient dropout. Results may not translate to real-world settings. We evaluated discontinuation and loss to follow-up (LTFU) rates in clinical trials of anti-vascular endothelial growth factor (anti-VEGF) injections for diabetic macular edema (DME), age-related macular degeneration (AMD), and retinal vein occlusion (RVO). METHODS Retrospective meta-epidemiological study. The authors queried ClinicalTrials.gov for all completed trials of anti-VEGF injections for DME, AMD, or RVO. Of 658 trials identified, 582 were excluded for being non-interventional, <100 patients, terminating early, or missing study results. The remaining 76 trials of 27,823 patients were analyzed for discontinuation and LTFU rates. RESULTS Mean discontinuation rate was 12.44% (SD 8.12%, range 0-54.12%), with higher rates among control (18.87%) than treatment arms (10.78%, p = .006). Mean LTFU rate was 1.84% (SD 1.78%, range 0-7.76%), with no differences by disease, treatment type, or treatment frequency. CONCLUSION Discontinuation rates of major intravitreal anti-VEGF clinical trials were highly variable, suggesting even trials struggle with overall patient retention. Though trial LTFU rates were low, real-world outcomes may differ due to higher reported LTFU rates, which should be considered when extrapolating trial results to clinical practice.
Collapse
|
44
|
Etiology, Treatment Patterns, and Outcomes for Choroidal Neovascularization in the Pediatric Population: An Intelligent Research in Sight (IRIS®) Registry Study. Ophthalmol Retina 2021; 6:130-138. [PMID: 34091079 DOI: 10.1016/j.oret.2021.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Choroidal neovascularization (CNV) is a rare, but devastating, cause of vision loss in children, with most current publications limited to small case series. Using a large clinical registry allowed us to understand the most common causes of this disease and the visual outcomes. DESIGN Retrospective analysis. PARTICIPANTS Patients younger than 18 years in the Intelligent Research in Sight Registry diagnosed with CNV between 2013 and 2019. METHODS Cases were identified based on International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes for CNV or CNV-related etiology and Current Procedural Terminology treatment codes. MAIN OUTCOME MEASURES Etiology of CNV, treatment patterns, and visual outcomes. RESULTS Two thousand three hundred fifty-three eyes with pediatric CNV were identified. The most common identifiable causes of pediatric CNV were posterior uveitis or inflammatory chorioretinal disease (19.4%), myopia (18.4%), hereditary dystrophy (5.4%), chorioretinal scar (4.2%), choroidal rupture (3.5%), optic nerve drusen (3.2%), osteoma (1.9%), and solar retinopathy (0.2%). In 38.2% of eyes, CNV was idiopathic, and in 5.7% of eyes, multiple causes were coded. One thousand forty-one eyes (44.4%) underwent treatment. The mean age of mean age of patients whose eyes received treatment 13.6 ± 3.5 years compared with 12.4 ± 4.1 years for the untreated group (P < 0.001). In 88.9% of eyes, anti-vascular endothelial growth factor (VEGF) injections were administered, 7.9% of eyes received laser therapy, 0.3% of eyes received photodynamic therapy, and 2.9% of eyes received combination therapy. In the eyes receiving anti-VEGF agents, 68.4% required 3 injections or fewer (P < 0.0001). Eyes undergoing treatment exhibited worse baseline visual acuity (VA) than eyes that did not undergo treatment (0.62 ± 0.50 logarithm of the minimum angle of resolution [logMAR] vs. 0.44 ± 0.50 logMAR; P < 0.0001). Visual acuity in the treatment group improved significantly from 0.62 ± 0.50 logMAR at baseline to 0.39 ± 0.43 logMAR at year 1 (P < 0.0001). Visual acuity in the untreated group improved significantly from 0.44 ± 0.50 logMAR at baseline to 0.34 ± 0.44 logMAR at year 1 (P < 0.001). Treated eyes showed a statistically significant higher odds of exhibiting a 2-line vision improvement or better compared with the untreated group at 12 months regardless of treatment type and after controlling for baseline VA (odds ratio, 2.4; P < 0.0001). CONCLUSIONS CNV is a rare, sight-threatening condition in children, with the most common causes being idiopathic, inflammatory chorioretinal disease, and myopia. Eyes undergoing treatment tended to be in older patients and showed worse baseline VA compared with eyes that did not undergo treatment. Those that were treated experienced significant improvement in vision that was maintained in the long term.
Collapse
|
45
|
Stone LG, Grinton ME, Talks JS. Delayed follow-up of medical retina patients due to COVID-19: impact on disease activity and visual acuity. Graefes Arch Clin Exp Ophthalmol 2021; 259:1773-1780. [PMID: 33977317 PMCID: PMC8112469 DOI: 10.1007/s00417-021-05174-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/12/2021] [Accepted: 03/23/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose The coronavirus pandemic has prompted unprecedented delays to treatment with anti-VEGF intravitreal injections due to the need to reduce hospital attendances and prioritise the patients at highest risk of vision loss. This study aims to quantify the effect of these delays on visual acuity (VA) outcomes and optical coherence tomography (OCT) features for patients receiving treatment for neovascular age-related macular degeneration (nAMD), retinal vein occlusions (RVO) and diabetic macular oedema (DMO) and correlate to the Royal College of Ophthalmologists guidelines (RCOphth). Methods A retrospective data analysis of an electronic medical record was performed on a random sample of eyes receiving anti-VEGF injections for nAMD, RVO or DMO. Data collected included age, sex, reason for injection, number of weeks delay if > 8 weeks from that planned, VA at baseline and follow-up and the OCT features, if delayed. For those eyes not delayed, a visual acuity at 20 weeks was recorded to provide a control group. Results A sample of 981 eyes (858 patients) were analysed. There was a delay in review of 8 weeks or more in 39.6% of patients of which 30.4% had since returned for review (28.4% nAMD, 37.6% RVO and 30.0% DMO). There was no demographic difference identified between the delayed and non-delayed patients; however, the delayed group was significantly more likely to have better vision in their non-treated eye (p = 0.0003). A statistically significant difference was found in the change in VA between the delayed and the not-delayed group for eyes with nAMD (p = 0.001) but not for RVO or DMO. For the delayed group, mean CMT increased by 33 and 100 μm, respectively, for nAMD and RVO and decreased by 7.8 μm for DMO. The VA of 89.7% of DMO eyes returned to baseline, compared to 74.6% and 76.9% of nAMD and RVO eyes. Conclusion The RCOphth guidance to prioritise intravitreal injections for nAMD over DMO appears appropriate in this cohort but not for RVO. Eyes with nAMD experienced the greatest loss of vision with treatment delay, and nAMD and RVO eyes were less likely to return to baseline on restarting treatment.
![]()
Collapse
Affiliation(s)
- Lydia G Stone
- Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.
| | - Michael E Grinton
- Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - James S Talks
- Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.
| |
Collapse
|
46
|
Schwaber EJ, Thompson AC, Smilnak G, Stinnett SS, Whitson HE, Lad EM. Co-Prevalence of Alzheimer's Disease and Age-Related Macular Degeneration Established by Histopathologic Diagnosis. J Alzheimers Dis 2021; 76:207-215. [PMID: 32444545 DOI: 10.3233/jad-200111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous epidemiologic studies have suggested an association between AMD and AD, and several therapeutic agents are being developed based on this principle. However, prior studies have provided conflicting results due in part to their reliance on clinical diagnoses that are not based on gold-standard histopathology. OBJECTIVE To use histopathologic standards for diagnosis in order to determine the co-prevalence of AD among patients with and without AMD. METHODS This is a cross-sectional study of 157 autopsy ocular specimens from patients with and without AMD that were greater than 75 years of age at death. Sarks staging was used to document the severity of AMD, and Braak and Braak staging was used to assess the severity of AD in corresponding brain specimens. The prevalence of AD within different severities of AMD was determined using univariable and multivariable logistic regression. RESULTS 58% of autopsy eyes had AMD. The prevalence of AD was lower in AMD subjects (63%) compared to non-AMD subjects (73%), even when grouped by severity (all p > 0.15). The likelihood of AD was significantly less in AMD subjects, even after adjusting for age and sex in multivariable analysis (OR 0.47, p = 0.049). CONCLUSION Histopathologic diagnoses fail to support an increase in prevalence of AD among subjects with AMD, even when disease severity is considered.
Collapse
Affiliation(s)
- Eric J Schwaber
- Department of Internal Medicine, Griffin Hospital, Derby, CT, USA
| | - Atalie C Thompson
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - Gordon Smilnak
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - Sandra S Stinnett
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - Heather E Whitson
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA.,Department of Medicine, Division of Geriatrics, Duke University Medical Center, Durham, NC, USA
| | - Eleonora M Lad
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
47
|
Moustafa GA, Borkar DS, Eton EA, Koulisis N, Kloek CE. Healthcare disparities contribute to missed follow-up visits after cataract surgery in the USA: results from the perioperative care for intraocular lens study. BMJ Open 2021; 11:e038565. [PMID: 33737416 PMCID: PMC7978071 DOI: 10.1136/bmjopen-2020-038565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To identify factors that contribute to missed cataract surgery follow-up visits, with an emphasis on socioeconomic and demographic factors. METHODS In this retrospective cohort study, patients who underwent cataract extraction by phacoemulsification at Massachusetts Eye and Ear between 1 January and 31 December 2014 were reviewed. Second eye cases, remote and international patients, patients with foreign insurance and combined cataract cases were excluded. RESULTS A total of 1931 cases were reviewed and 1089 cases, corresponding to 3267 scheduled postoperative visits, were included. Of these visits, 157 (4.8%) were missed. Three (0.3%) postoperative day 1, 40 (3.7%) postoperative week 1 and 114 (10.5%) postoperative month 1 visits were missed. Age<30 years (adjusted OR (aOR)=8.2, 95% CI 1.9 to 35.2) and ≥90 years (aOR=5.7, 95% CI 2.0 to 15.6) compared with patients aged 70-79 years, estimated travel time of >2 hours (aOR=3.2, 95% CI 1.4 to 7.4), smokers (aOR=2.7, 95% CI 1.6 to 4.8) and complications identified up to the postoperative visit (aOR=1.4, 95% CI 1.0 to 2.1) predicted a higher rate of missed visits. Ocular comorbidities (aOR=0.7, 95% CI 0.5 to 1.0) and previous visit best-corrected visual acuity (BCVA) of 20/50-20/80 (aOR=0.4, 95% CI 0.3 to 0.7) and 20/90-20/200 (aOR=0.4, 95% CI 0.2 to 0.9), compared with BCVA at the previous visit of 20/40 or better, predicted a lower rate of missed visits. Gender, race/ethnicity, language, education, income, insurance, alcohol use and season of the year were not associated with missed visits. CONCLUSIONS Medical factors and demographic characteristics, including patient age and distance from the hospital, are associated with missed follow-up visits in cataract surgery. Additional studies are needed to identify disparities in cataract postoperative care that are population-specific. This information can contribute to the implementation of policies and interventions for addressing them.
Collapse
Affiliation(s)
- Giannis A Moustafa
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Durga S Borkar
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina, USA
| | - Emily A Eton
- W K Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole Koulisis
- USC Roski Eye Institute, Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolyn E Kloek
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Ophthalmology, University of Oklahoma College of Medicine, Dean McGee Eye Institute, Oklahoma City, Oklahoma, USA
| |
Collapse
|
48
|
Malhotra NA, Greenlee TE, Iyer AI, Conti TF, Chen AX, Singh RP. Racial, Ethnic, and Insurance-Based Disparities Upon Initiation of Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema in the US. Ophthalmology 2021; 128:1438-1447. [PMID: 33716048 DOI: 10.1016/j.ophtha.2021.03.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 01/05/2023] Open
Abstract
PURPOSE This study characterizes the association of risk factors including race, ethnicity, and insurance status with presenting visual acuity (VA) and diabetic retinopathy (DR) severity in patients initiating treatment with anti-vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME). DESIGN Retrospective, cross-sectional study. PARTICIPANTS The Academy Intelligent Research in Sight (IRIS) Registry database was queried for patients who initiated anti-VEGF injection treatment for DME between 2012 and 2020 (n = 203 707). METHODS Multivariate regression analyses were conducted to understand how race, ethnicity, insurance status, and geographic location were associated with baseline features. MAIN OUTCOME MEASURES Visual acuity and DR severity. RESULTS Patients on Medicare and private insurance presented with higher baseline VA compared with patients on Medicaid (median of 2.31 and 4.17 greater Early Treatment Diabetic Retinopathy Scale [ETDRS] letters, respectively P < 0.01). White and non-Hispanic patients presented with better VA compared with their counterparts (median of 0.68 and 2.53 greater ETDRS letters, respectively; P < 0.01). Black and Hispanic patients presented with a worse baseline DR severity compared with White and non-Hispanic patients (odds ratio, 1.23 and 1.71, respectively; P < 0.01). CONCLUSIONS There are ethnic and insurance-based disparities in VA and disease severity upon initiation of anti-VEGF therapy for DME treatment. Public health initiatives could improve timely initiation of treatment.
Collapse
Affiliation(s)
- Nisha A Malhotra
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Tyler E Greenlee
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio; University Hospitals Regional Hospitals Richmond Medical Center, Richmond Heights, Ohio
| | - Amogh I Iyer
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Thais F Conti
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andrew X Chen
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio; Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rishi P Singh
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio; Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
49
|
Greenlee TE, Wang VY, Kang H, Ohlhausen ME, Chen AX, Hom GL, Conti TF, Briskin I, Babiuch AS, Singh RP. CONSEQUENCES OF LAPSES IN TREATMENT WITH VASCULAR ENDOTHELIAL GROWTH FACTOR INHIBITORS IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION IN ROUTINE CLINICAL PRACTICE. Retina 2021; 41:581-587. [PMID: 32658164 DOI: 10.1097/iae.0000000000002888] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Evaluating outcomes in patients receiving intravitreal antivascular endothelial growth factor (VEGF) inhibitors for neovascular age-related macular degeneration whom experience a lapse in treatment. METHODS A retrospective chart review evaluating 3,304 patients ≥18 years who experienced treatment lapses ≥3 months compared with control counterparts. Demographic information, macular thickness as measured by central subfield thickness, and visual acuity were collected at baseline, the first postlapse appointment, and at 3, 6, and 12 months after the lapse for the study group. RESULTS Lapse (n = 241) and control patients (n = 241) had similar baseline visual acuity and central subfield thickness (Early Treatment Diabetic Retinopathy Study: 58.9 ± 20.2 [20/63] vs. 59.2 ± 20.1 [20/63]; central subfield thickness: 252.4 ± 63.2 µm vs. 259.8 ± 66.2 µm, P = 0.21). Analysis revealed that lapse patients experienced a significant increase in central subfield thickness after lapse when compared with controls (279.4 ± 86.9 µm vs. 253.7 ± 65.9 µm, P < 0.01), which normalized on resumption of treatment (259.1 ± 79 µm vs. 246.8 ± 57.6 µm, P = 0.06). Study patients also experienced loss in the visual acuity after lapse when compared with controls (52.9 ± 23.6 Early Treatment Diabetic Retinopathy Study [20/100] vs. 59.9 ± 20.8 [20/63] Early Treatment Diabetic Retinopathy Study, P < 0.01) that did not recover through 12 months of follow-up. CONCLUSION Patients with neovascular age-related macular degeneration who have lapses in care are at risk for poorer outcomes. Although macular thickness normalizes on resumption of treatment, their decline in the visual acuity does not recover.
Collapse
Affiliation(s)
- Tyler E Greenlee
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Victoria Y Wang
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Hannah Kang
- Case Western Reserve University College of Arts and Sciences, Cleveland, Ohio; and
| | - Marc E Ohlhausen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Andrew X Chen
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Grant L Hom
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Thais F Conti
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Isaac Briskin
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Amy S Babiuch
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rishi P Singh
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
50
|
Goyal A, Richards C, Patel V, Syeda S, Guest JM, Freedman RL, Hall LM, Kim C, Sirajeldin A, Rodriguez T, Arsenault SM, Boss JD, Hughes B, Juzych MS. The Vision Detroit Project: Visual Burden, Barriers, and Access to Eye Care in an Urban Setting. Ophthalmic Epidemiol 2021; 29:13-24. [PMID: 33576279 DOI: 10.1080/09286586.2021.1884264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Purpose: Vision loss and blindness are among the top ten disabilities in the United States, yet access and utilization of eye care remains low. Vision Detroit aimed to address eye-care disparities via community-based screenings. By investigating burden of eye disease and barriers to eye-care utilization in an underserved urban community, we may direct efforts to improve access.Methods: Twenty-three screenings were conducted from March 2015-November 2017. Patient information gathered at screenings were demographics, medical and social history, eye exam/referral history, insurance status, primary care physician (PCP) status, and patient-perceived eye-care barriers.Results: Three-hundred-eighty patients were screened, 42% African American and 51% Hispanic. Average age was 53 ± 16.4 years, 70% reported vision problems, 50% reported over two years of vision problems, and average habitual visual acuity in best-seeing eye was 20/37. Eye-care underutilization was reported in 61% of type-2 diabetics. Older age and PCP recommendations/referrals were associated with increased utilization in all patients. Insurance was the most common barrier (53%); of the 55% insured, 31% reported financial barriers. Employed patients were more likely than unemployed to report a time barrier (odds ratio = 1.76, 95% confidence interval 1.03-3.01). Those with high school or less education reported "unaware of need", "unsure where to go", "transportation", and "insurance" as barriers more often.Conclusions: Visual burden was pervasive, yet access was suboptimal. Financial, logistical, and awareness barriers were common. PCP referral and older age were associated with increased utilization. Those less educated reported more barriers, highlighting the need to address fiscal concerns and eye-health education.
Collapse
Affiliation(s)
- Anju Goyal
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA.,Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Collin Richards
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Vaama Patel
- Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sarah Syeda
- Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - John-Michael Guest
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ryan L Freedman
- Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Leo M Hall
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Chaesik Kim
- Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abdala Sirajeldin
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Tannia Rodriguez
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Samantha M Arsenault
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Joseph D Boss
- Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bret Hughes
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA.,Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mark S Juzych
- Department of Ophthalmology, Visual, and Anatomical Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA.,Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| |
Collapse
|