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Rothaus K, Kintzinger K, Heimes-Bussmann B, Faatz H, Lommatzsch AP. Impact of the COVID 19 Pandemic on Treatment of nAMD via a Portal-Based Collaboration. Klin Monbl Augenheilkd 2022. [PMID: 35926516 DOI: 10.1055/a-1806-2474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Under the influence of the COVID 19 pandemic and the lockdown in Germany, there were significantly fewer consultations in almost all medical disciplines. Especially given the need for consistent treatment and follow-up of nAMD patients, this can have far-reaching consequences for visual function, especially in elderly patients. METHODS In a retrospective analysis of nAMD patients, the number of visits (IVI or follow-up), OCTs or IVIs performed and the mean worst visual acuity for the period before and after the first COVID 19-associated lockdown were compared in a portal-based collaboration of 50 eye care practices. Patients were treated according to the pro re nata (PRN) regimen that included intravitreal injection of VEGF inhibitors based on activity criteria in the OCT follow-up. RESULTS A total of 34,660 visits from 55 months were included in the analysis. Before lockdown (16 March 2020), an average of 81.8% ± 2.1% of patients were regularly checked or treated (every 4 to 5 weeks). With the onset of lockdown, the proportion of patients receiving optimum treatment dropped to 64.0%. Initially, the proportion of OCT follow-ups decreased from 48.4% to 30.9% and, with a delay, the proportion of injections decreased from 57.5% to 45.8%. This was also reflected in the number of OCT follow-ups: 15.5 before, 11.4 during and 17.2 after lockdown (p < 0.001). In 29% of cases, an individual worsening of visual acuity by more than 0.1 logMAR after the end of the lockdown compared to before the lockdown could be observed. On average, mean visual acuity decreased significantly by 0.054 logMAR (p < 10-11). This significant impairment was not reversed again during the remaining observation period, although the number of visits, OCT examinations and IVIs in the following 12 months were at the pre-lockdown level. CONCLUSIONS The pandemic-related lockdown resulted in unintended treatment breaks in nAMD patients receiving IVI therapy. The decrease in visits as well as in IVIs caused a loss of visual function in the observed cohort. The consistent treatment regimen of nAMD patients was resumed shortly after the lockdown with an immediate normalization of the number of OCT examinations and IVIs. However, a permanent loss of visual function was observed, and this did not improve within a year after the lockdown. This finding highlights the importance of better case management, leading to improved patient adherence in the event of further waves of COVID or other pandemics.
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Affiliation(s)
- Kai Rothaus
- Retinologie, Augenzentrum am St. Franziskus-Hospital, Münster, Deutschland
| | | | | | - Henrik Faatz
- Retinologie, Augenzentrum am St. Franziskus-Hospital, Münster, Deutschland
| | - Albrecht Peter Lommatzsch
- Retinologie, Augenzentrum am St. Franziskus-Hospital, Münster, Deutschland
- Universitätsaugenklinik, Universität Duisburg-Essen, Duisburg, Deutschland
- Achim Wessing Institut für Ophthalmologische Diagnostik, Universität Duisburg-Essen, Duisburg, Deutschland
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2
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Thier A, Breuning M, Wolfram C, Zeitz O, Holmberg C. Emotional and physical experiences of people with neovascular age-related macular degeneration during the injection process in Germany: a qualitative study. BMJ Open 2022; 12:e058266. [PMID: 35705348 PMCID: PMC9204446 DOI: 10.1136/bmjopen-2021-058266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 05/20/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In order to better understand the continued barriers to the provision of vascular endothelial inhibitor therapy, this study aims to investigate patients' experiences with neovascular age-related macular degeneration (nvAMD) in Germany during the injection process and how they deal with it. DESIGN AND PARTICIPANTS This analysis is part of the qualitative arm of a wider mixed-methods study. We recruited participants all over Germany via ophthalmologists, eye clinics, general practitioners, care bases and support groups between June 2018 and December 2020 and selected a subsample of study participants with nvAMD who were either undergoing or had previously undergone vascular endothelial growth factor inhibitor therapy. We conducted narrative, semistructured, face-to-face interviews at the participants' homes, which were audio-recorded. The interviews were thematically analysed. RESULTS Twenty-two participants were included in this analysis. Experiencing neovascular macular degeneration was dominated by the injection experience. Study participants perceived the treatment with vascular endothelial inhibitor injections as uncomfortable, and they described undergoing varying levels of anxiety during the whole injection process. After some years of receiving multiple injections, the pain and not experiencing any positive effects made participants with significant vision loss want to discontinue therapy. Furthermore, they narrated negative injection experiences in association with their interactions with medical staff and doctors. CONCLUSION Although time in the medical setting is limited, efficient and good doctor-patient relationships seem crucial for satisfying care experiences. A respectful and humane relationship may be one key to achieving treatment adherence.
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Affiliation(s)
- Anne Thier
- Institute of Social Medicine and Epidemiology, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Martina Breuning
- Self-Help Research Comprehensive Cancer Center Freiburg - CCCF Medical Center -, University of Freiburg, Freiburg im Breisgau, Baden-Württemberg, Germany
| | - Christian Wolfram
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Oliver Zeitz
- Department of Ophthalmology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Christine Holmberg
- Institute of Social Medicine and Epidemiology, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Potsdam, Germany
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3
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Tripp A, Brink S, Lemmen KD, Mussinghoff P, Pauleikhoff D. Können digitale Instrumente wie die Makula-App die AMD-Therapie unterstützen? Klin Monbl Augenheilkd 2022; 239:793-798. [DOI: 10.1055/a-1711-4306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Hintergrund Eine lang andauernde und kontinuierliche Anti-VEGF-Therapie ist bei der neovaskulären altersabhängigen Makuladegeneration (nAMD) der therapeutische „Goldstandard“, um
individuell das bestmögliche Sehvermögen zu erhalten. Das Management der Erkrankung bedeutet für Betroffene und Angehörige eine große Herausforderung. Dabei bleiben Real-Life-Ergebnisse von
Patienten unter der Anti-VEGF-Therapie (IVOM-Therapie) oft hinter denen aus randomisierten klinischen Studien zurück. Das Ziel der vorliegenden Studie war es, zu untersuchen, ob digitale
Instrumente, wie die vom AMD-Netz entwickelte Makula-App 1.0, dies unterstützen können.
Patienten und Methoden Die Ergebnisse einer in die Makula-App 1.0 integrierten Nutzerbefragung (n = 110) sowie einer zusätzlichen direkten Befragung zum Thema „Digitales
Terminmanagement in der IVOM-Therapie“ von Augenärzten (n = 54) und Patienten (n = 60) werden bez. Nutzung und Akzeptanz der Makula-App analysiert.
Ergebnisse Die Befragungen ergaben, dass 79% der Nutzer den Informationen der Makula-App 1.0 vertrauen, 71% finden die App sowie das Terminmanagement hilfreich für den Alltag und 80%
der Nutzer würden die App weiterempfehlen. 52% der Augenärzte und 65% der Patienten sehen einen deutlichen Nutzen zukünftiger digitaler Tools für die Patientenadhärenz. Eine digitale
Terminmanagementfunktion bewerten auch 82% der Ärzte als wichtig.
Schlussfolgerungen Dem Einsatz der Makula-App 1.0 besonders beim Terminmanagement, aber auch als Informationstool, standen die Nutzer mehrheitlich positiv gegenüber, ebenso wie
möglichen Weiterentwicklungen. Auch Augenärzte sehen in digitalen Tools wie der Makula-App 1.0 ein wichtiges Instrument zur Verbesserung des Terminmanagements und der Patientenadhärenz.
Diese positiven Einschätzungen unterstützen die Sinnhaftigkeit der Entwicklung einer interaktiven Plattform Makula-App 2.0, die einen direkten Austausch zwischen Patienten und Augenarzt
ermöglichen kann.
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4
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Claessens D, Ichhpujani P, Singh RB. MacuFix® versus Amsler grid for metamorphopsia categorization for macular diseases. Int Ophthalmol 2021; 42:229-238. [PMID: 34420124 PMCID: PMC8380298 DOI: 10.1007/s10792-021-02017-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/13/2021] [Indexed: 12/04/2022]
Abstract
Purpose Macular diseases often lead to metamorphopsia, which is traditionally tested using the Amsler grid. This study evaluates a novel method for assessing metamorphopsia, based on the software AMD-A Metamorphopsia Detector, application MacuFix®. Methods In this observational study, the usability of a new smartphone-based testing method to assess metamorphopsia was evaluated in 45 patients experiencing metamorphopsia in at least one eye using the questionnaire “System Usability Score (SUS).” Additionally, the diagnostic adherence of self-monitoring with the Amsler grid was compared to self-monitoring with the novel software MacuFix®. Results The average score of the SUS questionnaire in this study was 76.7 ± 15.5, corresponding to the “good” score on the grading scale. The average interval between two home administered tests was significantly shorter (6 days) when the application was used as compared to using the Amsler grid (19 days). The odds ratio of the frequency of patients using the application to the patients using the home test was 4.
Conclusion MacuFix® application can help in effective home monitoring of macular function as high user satisfaction and increased testing frequency was observed in its use in patients with macular diseases.
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Affiliation(s)
- Daniela Claessens
- Augenheilkunde Lindenthal, Dürener Str. 251, 50931, Cologne, Germany.
| | - Parul Ichhpujani
- Department of Ophthalmology, Government Medical College & Hospital, Chandigarh, India
| | - Rohan Bir Singh
- Department of Ophthalmology, Massachusetts and Ear and Ear, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
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5
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Okada M, Wong TY, Mitchell P, Eldem B, Talks SJ, Aslam T, Daien V, Rodriguez FJ, Gale R, Barratt J, Finger RP, Loewenstein A. Defining Nonadherence and Nonpersistence to Anti-Vascular Endothelial Growth Factor Therapies in Neovascular Age-Related Macular Degeneration. JAMA Ophthalmol 2021; 139:769-776. [PMID: 34081099 DOI: 10.1001/jamaophthalmol.2021.1660] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Importance Poor adherence or persistence to treatment can be a barrier to optimizing clinical practice (real-world) outcomes to intravitreal injection therapy in patients with neovascular age-related macular degeneration (nAMD). Currently, there is a lack of consensus on the definition and classification of adherence specific to this context. Objective To describe the development and validation of terminology on patient nonadherence and nonpersistence to anti-vascular endothelial growth factor therapy. Design, Setting, and Participants Following a systematic review of currently used terminology in the literature, a subcommittee panel of retinal experts developed a set of definitions and classification for validation. Definitions were restricted to use in patients with nAMD requiring intravitreal anti-vascular endothelial growth factor therapy. Validation by the full nAMD Barometer Leadership Coalition was established using a modified Delphi approach, with predetermined mean scores of 7.5 or more signifying consensus. Subsequent endorsement of the definitions was provided from a second set of retinal experts, with more than 50% members agreeing or strongly agreeing with all definitions. Main Outcomes and Measures Development of consensus definitions for the terms adherence and persistence and a classification system for the factors associated with treatment nonadherence or nonpersistence in patients with nAMD. Results Nonadherence was defined as missing 2 or more treatment or monitoring visits over a period of 12 months, with a visit considered missed if it exceeded more than 2 weeks from the recommended date. Nonpersistence was defined by nonattendance or an appointment not scheduled within the last 6 months. The additional terms planned discontinuation and transfer of care were also established. Reasons for treatment nonadherence and nonpersistence were classified into 6 dimensions: (1) patient associated, (2) condition associated, (3) therapy associated, (4) health system and health care team associated, (5) social/economic, and (6) other, with subcategories specific to treatment for nAMD. Conclusions and Relevance This classification system provides a framework for assessing treatment nonadherence and nonpersistence over time and across different health settings in the treatment of nAMD with current intravitreal anti-vascular endothelial growth factor treatments. This may have additional importance, given the potential association of the coronavirus pandemic on adherence to treatment in patients with nAMD.
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Affiliation(s)
- Mali Okada
- Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Paul Mitchell
- Westmead Institute for Medical Research, University of Sydney, Sydney, Australia
| | - Bora Eldem
- Department of Ophthalmology, Hacettepe University, Ankara, Turkey
| | - S James Talks
- The Newcastle upon Tyne Hospitals NHS Foundation, Newcastle upon Tyne, United Kingdom
| | - Tariq Aslam
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, United Kingdom
| | - Vincent Daien
- Montpellier University Hospital, Montpellier, France
| | - Francisco J Rodriguez
- Fundación Oftalmologica Nacional, Universidad del Rosario School of Medicine, Bogotá, Colombia
| | - Richard Gale
- Department of Ophthalmology, York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Jane Barratt
- International Federation on Ageing, Toronto, Ontario, Canada
| | - Robert P Finger
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Anat Loewenstein
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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6
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Lommatzsch A, Eter N, Ehlken C, Lanzl I, Kaymak H, Schuster AK, Ziemssen F. [Adherence to anti-VEGF treatment-Considerations and practical recommendations]. Ophthalmologe 2021; 118:801-809. [PMID: 33270147 PMCID: PMC8342348 DOI: 10.1007/s00347-020-01273-5] [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] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Numerous studies have identified a lack of treatment adherence as an important factor that often conflicts with the necessary number of anti-VEGF injections and therefore a better functional result. OBJECTIVE This article discusses approaches and possible measures to reduce the risk of late and infrequent intravitreal injections leading to the major issue of undertreatment. MATERIAL AND METHOD In the course of an expert dialogue, relevant parameters of treatment adherence and variables were identified. Meaningful processes were structured and assigned to organizational areas. RESULTS The compilation of meaningful measures enables practitioners to optimize their own implementation in different areas. Regular monitoring measures can identify the extent of treatment interruption and discontinuation. For specific indicators (treatments per time interval, longest pause interval, minimum coverage per unit time, delay) an effect on the development of visual function was demonstrated. Organizational measures, training of teams and referring physicians, redundant and iterative information transfer to patients have been proven in the experience of experts. The firm integration of these processes into the structures is facilitated by working with checklists. CONCLUSION An optimization of the processes is possible to improve the adherence and the functional results; however, interventional studies showing how adherence and persistence can be increased in the German treatment setting are still lacking.
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Affiliation(s)
| | - Nicole Eter
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Münster, Deutschland
| | - Christoph Ehlken
- Klinik für Ophthalmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Ines Lanzl
- Chiemsee Augen Tagesklinik, Prien, Deutschland
| | - Hakan Kaymak
- Makula-Netzhaut-Zentrum, Düsseldorf-Oberkassel, Deutschland
| | | | - Focke Ziemssen
- Department für Augenheilkunde Tübingen, Universitäts-Augenklinik, Elfriede-Aulhorn-Str. 7, 72076, Tübingen, Deutschland.
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7
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Pfau M, Sahu S, Rupnow RA, Romond K, Millet D, Holz FG, Schmitz-Valckenberg S, Fleckenstein M, Lim JI, de Sisternes L, Leng T, Rubin DL, Hallak JA. Probabilistic Forecasting of Anti-VEGF Treatment Frequency in Neovascular Age-Related Macular Degeneration. Transl Vis Sci Technol 2021; 10:30. [PMID: 34185055 PMCID: PMC8254013 DOI: 10.1167/tvst.10.7.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Purpose To probabilistically forecast needed anti-vascular endothelial growth factor (anti-VEGF) treatment frequency using volumetric spectral domain-optical coherence tomography (SD-OCT) biomarkers in neovascular age-related macular degeneration from real-world settings. Methods SD-OCT volume scans were segmented with a custom deep-learning-based analysis pipeline. Retinal thickness and reflectivity values were extracted for the central and the four inner Early Treatment Diabetic Retinopathy Study (ETDRS) subfields for six retinal layers (inner retina, outer nuclear layer, inner segments [IS], outer segments [OS], retinal pigment epithelium-drusen complex [RPEDC] and the choroid). Machine-learning models were probed to predict the anti-VEGF treatment frequency within the next 12 months. Probabilistic forecasting was performed using natural gradient boosting (NGBoost), which outputs a full probability distribution. The mean absolute error (MAE) between the predicted versus actual anti-VEGF treatment frequency was the primary outcome measure. Results In a total of 138 visits of 99 eyes with neovascular AMD (96 patients) from two clinical centers, the prediction of future anti-VEGF treatment frequency was observed with an accuracy (MAE [95% confidence interval]) of 2.60 injections/year [2.25-2.96] (R2 = 0.390) using random forest regression and 2.66 injections/year [2.31-3.01] (R2 = 0.094) using NGBoost, respectively. Prediction intervals were well calibrated and reflected the true uncertainty of NGBoost-based predictions. Standard deviation of RPEDC-thickness in the central ETDRS-subfield constituted an important predictor across models. Conclusions The proposed, fully automated pipeline enables probabilistic forecasting of future anti-VEGF treatment frequency in real-world settings. Translational Relevance Prediction of a probability distribution allows the physician to inspect the underlying uncertainty. Predictive uncertainty estimates are essential to highlight cases where human-inspection and/or reversion to a fallback alternative is warranted.
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Affiliation(s)
- Maximilian Pfau
- Department of Biomedical Data Science, Stanford University, Palo Alto, CA, USA.,Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Soumya Sahu
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA.,Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Rawan Allozi Rupnow
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA.,Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Kathleen Romond
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Desiree Millet
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | | | - Jennifer I Lim
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Theodore Leng
- Byers Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Daniel L Rubin
- Department of Biomedical Data Science, Stanford University, Palo Alto, CA, USA
| | - Joelle A Hallak
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
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8
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Faatz H, Gunnemann ML, Rothaus K, Book M, Gutfleisch M, Lommatzsch A, Pauleikhoff D. [Influence of CNV vascular morphology in exudative age-related macular degeneration on development of visual acuity and need for anti-VEGF therapy after 1 year]. Ophthalmologe 2021; 118:154-161. [PMID: 32601817 DOI: 10.1007/s00347-020-01136-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this pilot study was to investigate vascular morphological characteristics of choroidal neovascularization (CNV) at the time of the initial diagnosis of exudative age-related macular degeneration (nAMD), which enable a prognosis for the development of visual acuity and the necessity for treatment in the first year. METHODS In 57 patients with the initial diagnosis of nAMD, CNV was detected by optical coherence tomography angiography (OCT-A) and an automated quantitative vessel analysis was performed with respect to area, total vessel length, flow value and average vessel caliber of the CNV. After 12 months patients were divided into 2 groups based on visual acuity (visual loss vs. visual gain) and necessity of anti-VEGF therapy (<7 intravitreal injections, IVOM vs. ≥7 IVOM). RESULTS The mean CNV area was 0.95 mm2 ± 1.07 mm2 (group visual loss 1.56 mm2 ± 1.54 mm2; group visual gain 0.65 mm2 ± 0.53 mm2; p = 0.002/<7 IVOM 1.05 mm2 ± 1.40 mm2; ≥7 IVOM 0.98 mm2 ± 0.94 mm2, p = 0.60). The average total vessel length of the CNV was 9.84 mm ± 11.35 mm (visual loss 16.00 mm ± 16.58 mm; visual gain 6.74 mm ± 5.42 mm; p < 0.003/<7 IVOM 11.21 mm ± 15.10; ≥7 IVOM 9.90 mm ± 9.68 mm; p = 0.68). The mean flow value of the CNV was 0.40 ± 0.06 (visual loss 0.37 ± 0.04; visual gain 0.41 ± 0.07; p = 0.004/<7 IVOM 0.42 ± 0.08; ≥7 IVOM 0.38 ± 0.06; p = 0.02). The average vessel caliber was 28.86 µm ± 2.93 µm (visual loss 28.39 µm ± 2.97 mm; visual gain 29.32 µm ± 3.05 µm; p = 0.24/<7 IVOM 30.26 µm ± 3.49 µm; ≥7 IVOM 28.23 µm ± 2.25 µm; p = 0.02). CONCLUSION The results show that a mathematical quantification of the CNV in nAMD is possible using OCT‑A. This analysis confirmed again that the size of the CNV (area and total vessel length) is decisive for the prognosis of visual acuity. It also shows that a larger flow value as a sign of a well-differentiated CNV is associated with a better functional prognosis. The number of IVOMs required, however, depends primarily on the composition of the CNV (flow value and vascular caliber). More precise imaging and larger examination cohorts could possibly reveal further relevant biomarkers.
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Affiliation(s)
- Henrik Faatz
- Augenzentrum am St. Franziskus Hospital Münster, Münster, Deutschland.
| | | | - Kai Rothaus
- Augenzentrum am St. Franziskus Hospital Münster, Münster, Deutschland
| | - Marius Book
- Augenzentrum am St. Franziskus Hospital Münster, Münster, Deutschland
| | | | - Albrecht Lommatzsch
- Augenzentrum am St. Franziskus Hospital Münster, Münster, Deutschland.,Klinik für Augenheilkunde, Universitätsklinikum Essen, Essen, Deutschland.,Achim Wessing Institut für Bildgebung in der Ophthalmologie am Universitätsklinikum Duisburg-Essen, Essen, Deutschland
| | - Daniel Pauleikhoff
- Augenzentrum am St. Franziskus Hospital Münster, Münster, Deutschland.,Klinik für Augenheilkunde, Universitätsklinikum Essen, Essen, Deutschland.,Achim Wessing Institut für Bildgebung in der Ophthalmologie am Universitätsklinikum Duisburg-Essen, Essen, Deutschland
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9
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Okada M, Mitchell P, Finger RP, Eldem B, Talks SJ, Hirst C, Paladini L, Barratt J, Wong TY, Loewenstein A. Nonadherence or Nonpersistence to Intravitreal Injection Therapy for Neovascular Age-Related Macular Degeneration: A Mixed-Methods Systematic Review. Ophthalmology 2021; 128:234-247. [PMID: 32763265 PMCID: PMC7403101 DOI: 10.1016/j.ophtha.2020.07.060] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 07/21/2020] [Accepted: 07/27/2020] [Indexed: 11/09/2022] Open
Abstract
TOPIC Systematic review of risk factors for nonadherence and nonpersistence to intravitreal anti-vascular endothelial growth factor (VEGF) injection therapy for neovascular age-related macular degeneration (nAMD). CLINICAL RELEVANCE Lack of adherence (nonadherence) or undertreatment (nonpersistence) with respect to evidence from clinical trials remains a significant barrier to optimizing real-world outcomes for patients with nAMD. Contributing factors and strategies to address this are poorly understood. METHODS Studies that reported factors for nonadherence and nonpersistence to anti-VEGF therapy as well as studies examining strategies to improve this were included. Trial eligibility and data extraction were conducted according to Cochrane review methods. Risk of bias was assessed using the Mixed Method Assessment Tool and certainty of evidence evaluated according to the GRADE Confidence in the Evidence from Reviews of Qualitative Research tool. Data were collated descriptively. RESULTS Of the 1284 abstract results screened, 124 articles were assessed in full and 37 studies met the inclusion criteria. Definitions of nonadherence and nonpersistence varied or were not reported. Nonpersistence occurred early, with up to 50% of patients stopping treatment by 24 months. High rates of nonadherence were similarly reported, occurring in 32% to 95% of patients. Certainty of this finding was downgraded to a moderate level because of the heterogeneity in definitions used across studies. Multiple factors determine nonadherence and nonpersistence, including at the condition, therapy, patient, social/economic, and health systems/healthcare team levels. Moderate quality evidence points to lower baseline vision and poorer response to treatment as condition-related variables. The effects of other factors were of lower certainty, predominantly due to small numbers and potential biases in retrospective assessment. Although many factors are not modifiable (e.g., patient comorbidity), other factors are potentially correctable (e.g., lack of transport or mismatched patient expectations). Evidence on strategies to improve adherence and persistence is limited, but where available, these have proven effective. CONCLUSIONS Awareness of factors related to poor patient adherence and persistence in nAMD could help identify at-risk populations and improve real-world outcomes. Further work is required to develop uniform definitions and establish high-quality evidence on interventions that can be easily implemented.
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Affiliation(s)
- Mali Okada
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia.
| | - Paul Mitchell
- Department of Ophthalmology, University of Sydney, Sydney, Australia
| | | | - Bora Eldem
- Department of Ophthalmology, Hacettepe University, Ankara, Turkey
| | - S. James Talks
- The Newcastle upon Tyne Hospitals NHS Foundation, Newcastle upon Tyne, United Kingdom
| | | | | | - Jane Barratt
- International Federation on Ageing, Toronto, Canada
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore,Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Anat Loewenstein
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Glück S, Brandlhuber U, Gerbutavicius R, Kortüm GF, Kortüm I, Navarrete Orozco R, Rakitin M, Strodtbeck M, Kortüm K. [Impact of a more stringent organization of intravitreal injection treatment on the number of treatments and examinations in routine practice]. Ophthalmologe 2020; 118:1134-1139. [PMID: 33252769 DOI: 10.1007/s00347-020-01267-3] [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: 08/18/2020] [Revised: 10/31/2020] [Accepted: 11/08/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Results from recent studies show that less intravitreal injections are often performed in everyday practice than in controlled trials, which subsequently leads to worse treatment success. In this study we analyzed the introduction of a more stringent organization of treatment using workflow optimization and new IT systems and analyzed the effect on treatment continuity. MATERIAL AND METHODS In the second quarter of 2019 a new medical practice management software and a software for automated injection planning were implemented. There was also a change of the treatment regimen from pro re nata (PRN) to treat and extend (T&E ). We analyzed the results of the patients regarding the frequency of injections and treatment controls three quarters before (Q3/2018-Q1/2019) and three quarters after the change (Q2/2019-Q4/2019). Treatment-naive and pretreated patients were analyzed. RESULTS In group 1 (Q3/2018-Q1/2019) the average number of injections per quarter was 1.74 (SD = 0.4). Eyes of patients from group 2 (Q2/2019-Q4/2019) received on average 2.17 (SD = 0.3) injections. The number of check-ups per quarter was 1.71 (SD = 0.3) before the introduction, and thereafter 2.16 (SD = 0.3). There was a significant increase in the number of OCTs from 1.18 (SD = 0.2) to 1.98 (SD = 0.3). The visual acuity was stable in both groups. CONCLUSION We were able to show that the introduction of the medical practice management software and the change of the regimen from PRN to T&E can achieve numbers of injections, check-ups and OCT similar to those in studies. A standardized procedure facilitates efficient treatment planning and enables a better patient management.
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Affiliation(s)
- S Glück
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland.
| | - U Brandlhuber
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland
| | - R Gerbutavicius
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland
| | - G-F Kortüm
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland
| | - I Kortüm
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland
| | - R Navarrete Orozco
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland
| | - M Rakitin
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland
| | - M Strodtbeck
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland
| | - K Kortüm
- Augenarztpraxis Dres. Kortüm, Solitudestr. 24, 71638, Ludwigsburg, Deutschland.,Augenklinik, Universität München, München, Deutschland
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11
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Mintz J, Labiste C, DiCaro MV, McElroy E, Alizadeh R, Xu K. Teleophthalmology for age-related macular degeneration during the COVID-19 pandemic and beyond. J Telemed Telecare 2020; 28:670-679. [PMID: 32990152 PMCID: PMC9444820 DOI: 10.1177/1357633x20960636] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION COVID-19 has disrupted how ophthalmic practice is conducted worldwide. One patient population that may suffer from poor outcomes during the pandemic are those with age-related macular degeneration (AMD). Many practices are performing some form of teleophthalmology services for their patients, and guidance is needed on how to maintain continuity of care amongst patients with AMD using teleophthalmology. METHODS A literature search was conducted, ending 1 August 2020, to identify AMD outcomes and telecare management strategies that could be used during the COVID-19 pandemic. RESULTS 237 total articles were retrieved, 56 of which were included for analysis. Four American Academy of Ophthalmology and Center for Disease Control web resources were also included. DISCUSSION Risk-stratification models have been developed that let providers readily screen existing patients for their future risk of neovascular AMD (nAMD). When used with at-home monitoring devices to detect nAMD, providers may be able to determine who should be contacted via teleophthalmology for screening. Telemedicine triage can be used for new complaints of vision loss to determine who should be referred to a retinal specialist for management of suspected nAMD. To increase access and provider flexibility, smartphone fundus photography images sent to a centralized teleophthalmology service can aid in the detection of nAMD. Considerations should also be made for COVID-19 transmission, and teleophthalmology can be used to screen patients for the presence of COVID-19 prior to in-person office visits. Teleophthalmology has additional utility in connecting with nursing home, rural, and socioeconomically disadvantaged patients in the post-pandemic period.
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Affiliation(s)
- Joel Mintz
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida, USA
| | - Chase Labiste
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida, USA
| | - Michael V DiCaro
- College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Evan McElroy
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida, USA
| | - Reza Alizadeh
- Department of Ophthalmology, University of Arizona, Tucson, Arizona, USA
| | - Kunyong Xu
- Department of Ophthalmology, University of Arizona, Tucson, Arizona, USA
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12
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Stasch-Bouws J, Eller-Woywod SM, Schmickler S, Inderfurth J, Hoffmann P, Ohlmeyer C, Kammering B, Pauleikhoff D. [IVOM quality assurance in Westfalen-Lippe : Structure of quality assurance and results of the pilot study Q-VERA]. Ophthalmologe 2020; 117:336-342. [PMID: 31912271 DOI: 10.1007/s00347-019-01030-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The KVWL-QS assists ophthalmologists in the transfer for good clinical praxis into real life. In addition the QS-commission initiated a pilotstudy "Qualitäts-Versorgung bei AMD" (Q‑VERA) in order to test new instruments for improvements. It was analized, if Reading Center (RC) based controls in combination with specific case-management modules can improve the results of IVOM treatment. PATIENTS AND METHODS In 5 treatment centers 878 consecutive patients with newly diagnosed AMD (Neu-Patienten) were included, who were treated with the IVAN-scheme. Initial FA and OCT images were transferred electronically to the RC. Also 781 retreatment patients (mean 20.7 IVOM before) with retreatment due to lesion activity were observed. RESULTS In 5% of the 878 newly treated patients a discrepancy between RC and treatment center was recorded. In this group the 481 patients, who finished up to the analysis date the 12-month follow-up, the visual function (increase in BCVA) and SD-OCT (reduction in central retinal thickness) results were comparable with large prospective cohorts. This was achieved with 6.5 injections and 10.6 visits over 12 months. In the group of 781 patients with repeated injections the number of injections over 12 months was 7.7 and the number of visits 11.6. CONCLUSION Quality assessment can improve the efficacy of IVOM therapy for AMD patients in real life. In addition to existing structures, electronical exchange by a RC assisted evaluation can further improve the quality by reducing the number of unnecessary treatment visits. The case-management with adherence control, re-call-system and specific information for patients and relatives can specifically increase the long-term adherence and thus the success of the therapy.
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Affiliation(s)
| | - S M Eller-Woywod
- Augenärztliche Gemeinschaftspraxis Gütersloh, Gütersloh, Deutschland
| | | | | | - P Hoffmann
- Augen- & Laserklinik Castrop-Rauxel, Castrop-Rauxel, Deutschland
| | - C Ohlmeyer
- Augenzentrum am St. Franziskus-Hospital Münster, Hohenzollernring 74, 48155, Münster, Deutschland
| | - B Kammering
- Kassenärztliche Vereinigung Westfalen Lippe, Dortmund, Deutschland
| | - D Pauleikhoff
- AMD-Netz e. V., Münster, Deutschland. .,Augenzentrum am St. Franziskus-Hospital Münster, Hohenzollernring 74, 48155, Münster, Deutschland. .,Universitätsaugenklinik, Universität Duisburg-Essen, Essen, Deutschland.
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13
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Bucher F, Mussinghoff P, Kühn T, Stahl A, Böhringer D. [Technical aspects of quality assurance for intravitreal injections (IVI)]. Ophthalmologe 2020; 117:307-312. [PMID: 31912270 DOI: 10.1007/s00347-019-01029-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Successful quality assurance in intravitreal injection (IVI) of medications requires a complex information technology infrastructure. The main challenges are data availability independent of location, standardization of clinical data, integration of extensive and currently non-standardized image documentation from coherence tomography and compliance with data protection regulations. OBJECTIVE In this article the technical implementation and data protection principles are reviewed. MATERIAL AND METHODS Essential aspects in the implementation of quality assurance in the field of IVI are discussed in a systematic approach. RESULTS In the field of network architectures web-based applications supplemented by local virtual private networks (VPN) and/or other software instances have recently replaced the previously commonly used physical data medium exchange. The standardization of the data, e.g. by converting the visual acuity into logMAR, plays an important role in the collection of treatment data. Multiple non-standardized data formats in optical coherence tomography complicate the general quality assurance structure and comparability of data. CONCLUSION International standards will probably facilitate this in the near future. Until then individual solutions have to be found on site.
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Affiliation(s)
- F Bucher
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Killianstr. 5, 79106, Freiburg, Deutschland
| | - P Mussinghoff
- Augenzentrum am St. Franziskus-Hospital Münster, Münster, Deutschland
| | - T Kühn
- ContraCare GmbH, Fürth, Nürnberg, Deutschland
| | - A Stahl
- Klinik und Poliklinik für Augenheilkunde, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - D Böhringer
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Killianstr. 5, 79106, Freiburg, Deutschland.
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14
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[ANDROMEDA-an investigation of factors influencing the adherence of patients with neovascular age-related macular degeneration using the newly developed patient questionnaire LAF-IVT]. Ophthalmologe 2019; 117:765-774. [PMID: 31720846 DOI: 10.1007/s00347-019-01005-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Lack of adherence to treatment is a widespread problem in the anti-VEGF (Vascular Endothelial Growth Factor) treatment of patients with neovascular age-related macular degeneration (nAMD). In contrast to the extent of the lack of treatment adherence, there is so far insufficient evidence for elucidating the causes of nonadherence. The ANDROMEDA study was initiated to investigate the influencing factors on the adherence of nAMD patients to treatment. The focus of the study was on patient reported endpoints, as the perceptions and experiences of the patients are of enormous importance for the investigation of the various aspects of adherence to treatment. OBJECTIVE This publication presents the design of the ANDROMEDA study as well as the development of a new patient questionnaire for the assessment of barriers to treatment within the design of the study. MATERIAL AND METHODS This prospective noninterventional observational study to assess the compliance of patients with nAMD and anti-VEGF treatment was started at the end of January 2019. It is planned to include 1000 patients in 120 study centers throughout Germany with an observational period of 24 months. Patient interviews on general and vision-related quality of life, treatment satisfaction and possible barriers to treatment will be conducted at the beginning and after 4, 12 and 24 months. All patient visits will be documented by the study centers as part of the clinical routine. To date, there has been no suitable instrument for recording patient-related circumstances and potential barriers to anti-VEGF treatment. Therefore, a specific patient questionnaire for longitudinal assessment of adherence factors to intravitreal (anti-VEGF) therapy (LAF-IVT) was developed as part of the study concept. The questionnaire, developed by an expert panel, was tested via qualitative interviews for its cognitive characteristics ahead of its use. RESULTS The results of the study are expected in early 2023. The cognitive examination of the LAF-IVT confirmed the feasibility of the new questionnaire. The practicability and significance of the new instrument can be assessed after completion of the quantitative data collection. CONCLUSION The symptoms, barriers, burdens and quality of life effects experienced by patients influence the adherence to treatment and thus the outcome. A better understanding of the patient's views and experiences is the basis for long-term optimization of care.
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15
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Thiele S, Nadal J, Pfau M, Saßmannshausen M, von der Emde L, Fleckenstein M, Holz FG, Schmid M, Schmitz-Valckenberg S. Prognostic Value of Retinal Layers in Comparison with Other Risk Factors for Conversion of Intermediate Age-related Macular Degeneration. Ophthalmol Retina 2019; 4:31-40. [PMID: 31649003 DOI: 10.1016/j.oret.2019.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/01/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To analyze longitudinal thickness changes of retinal layers in comparison with established risk factors in eyes with age-related macular degeneration (AMD) with regard to their prognostic value for conversion into advanced AMD stages. DESIGN Prospective, longitudinal natural history study. PARTICIPANTS Ninety-one eyes of 91 patients with AMD (73.3±7.3 years; 62 female patients [50.4%]) of the Molecular Diagnostic of Age-related Macular Degeneration (MODIAMD) study without exudative or nonexudative late-stage AMD in the study eye at baseline. METHODS At each annual follow-up visit, all subjects underwent ophthalmic examination with assessment of best-corrected visual acuity (BCVA) and retinal imaging, including spectral-domain OCT (SD-OCT), over a study period of 6 years. PURPOSE To analyze longitudinal thickness changes of retinal layers in comparison with established risk factors in eyes with age-related macular degeneration (AMD) with regard to their prognostic value for conversion into advanced AMD stages. MAIN OUTCOME MEASURES Qualitative structural AMD features and SD-OCT-based quantitative thickness changes of different retinal layers, such as the retinal pigment epithelium-drusen complex (RPEDC), were assessed by multimodal imaging. Their prognostic relevance regarding disease conversion was determined using Cox regression (cloglog link function). RESULTS In the multivariable analysis, the presence of focal hyperpigmentation, almost reaching statistical significance, showed the strongest effect regarding the development of nonexudative late-stage AMD (hazard ratio [HR], 5.88; 95% confidence interval [CI], 0.69-50.2; P = 0.052) followed by the presence of refractile drusen (HR, 4.82; 95% CI, 1.33-17.44; P = 0.0164). A thickening of the RPEDC was the only assessed retinal layer that exhibited a significant effect on the development of nonexudative advanced AMD (HR, 1.03; 95% CI, 1.0-1.07; P = 0.0393), whereas no association was observable for the other retinal layers. Neither qualitative nor quantitative markers were significant predictors for the development of exudative late-stage AMD (P > 0.05). CONCLUSIONS The results indicate that the development of both exudative and nonexudative AMD is associated with distinct prognostic features. However, compared with the assessment of qualitative AMD features, the quantification of retinal layers on average across the central retina had less prognostic impact. Further studies are needed to identify and validate robust biomarkers in early AMD stages.
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Affiliation(s)
- Sarah Thiele
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Jennifer Nadal
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | | | | | | | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Germany
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16
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Heinemann M, Welker SG, Li JQ, Wintergerst MWM, Turski GN, Turski CA, Holz FG, Finger RP. Awareness of Age-Related Macular Degeneration in Community-Dwelling Elderly Persons in Germany. Ophthalmic Epidemiol 2019; 26:238-243. [PMID: 30917716 DOI: 10.1080/09286586.2019.1597898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Due to current demographic trends age-related macular degeneration (AMD) is becoming more prevalent. When disease progresses to late-stage neovascular AMD, rapid initiation of treatment is required to achieve optimal outcomes. However, many affected individuals may be unaware of their disease impeding and delaying care seeking. Therefore, in an exploratory study we assessed whether elderly persons living independently in the community were aware of their AMD. Methods: Participants were recruited in eleven seniors' community centers. Participants underwent a standardized interview followed by non-mydriatic fundus photography of the macula and the optic disc in both eyes (Canon CR-2AF, Canon, New York, USA). The images were graded by an ophthalmologist and the data were analyzed descriptively. Results: A total of 281 participants (73.9 ± 8.1 years; 71.9% women) underwent bilateral fundus photography. The fundus photographs of 208 participants (74%; 73.6 ± 7.0 years; 73.1% women) could be graded. In a third (32.2%, n = 67) no pathological changes were detected. AMD was present in 24.5% of the examined subjects (n = 51). Half of the cases had early (47.1%), followed by intermediate (41.2%) and late (11.7%) AMD. Only one third (n = 16, 31.4%) were aware of their disease. Conclusions: A quarter of community dwelling elderly had AMD but only a third of these were aware of being affected with AMD. This confirms previous studies demonstrating low awareness for age-related eye diseases in the community. Considering the increase in population aging, awareness campaigns for AMD are needed.
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Affiliation(s)
- M Heinemann
- a Department for Ophthalmology , University of Bonn , Bonn , Germany
| | - S G Welker
- a Department for Ophthalmology , University of Bonn , Bonn , Germany
| | - J Q Li
- a Department for Ophthalmology , University of Bonn , Bonn , Germany
| | - M W M Wintergerst
- a Department for Ophthalmology , University of Bonn , Bonn , Germany
| | - G N Turski
- a Department for Ophthalmology , University of Bonn , Bonn , Germany
| | - C A Turski
- a Department for Ophthalmology , University of Bonn , Bonn , Germany
| | - F G Holz
- a Department for Ophthalmology , University of Bonn , Bonn , Germany
| | - Robert P Finger
- a Department for Ophthalmology , University of Bonn , Bonn , Germany
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