The Finnish national guideline for diagnosis, treatment and follow-up of patients with wet age-related macular degeneration

Analysis of prognostic and predictive factors in neovascular age-related macular degeneration Kuopio cohort

PURPOSE

The aim of the study was to explore factors affecting the progression of neovascular age-related macular degeneration (nAMD) and identify predictive factors that can estimate the duration of intravitreal treatments.

METHODS

This retrospective real-world study included 421 nAMD patients treated at the Kuopio University Hospital during years 2007-2021. The collected data included background demographics, treatment history, visual acuity and retinal biomarker analysis. Impact of baseline factors on age at diagnosis, treatment duration, received treatment intensity and visual acuity gains were analysed.

RESULTS

Heavy smoking and high body mass index (BMI) were associated with an earlier onset, while the use of anticoagulation and anti-aggregation medication were associated with a later onset of nAMD. A low number of injections during the first year of treatment and the presence of intraretinal fluid (IRF) at baseline were associated with shorter treatment duration. Interestingly, when IRF only patients were compared to subretinal fluid (SRF) only patients, IRF patients showed higher occurrences of subretinal drusenoid deposits (43.5% vs. 15%, p = 0.04). In addition, when all patients with IRF were compared to SRF only patients, more hyperreflective foci (HRF) and complete RPE and outer retinal atrophy (cRORA; 20.7% vs. 5%, p = 0.02) were observed in patients with IRF.

CONCLUSIONS

Our results reveal that heavy smoking and high BMI are accelerating factors for earlier emergence of nAMD, while the presence of IRF results in a fast-progressing disease. More intriguingly, the link between IRF and appearance of subretinal drusenoid deposits, HRF, and increased retinal atrophy was observed.

Association between Oral Active-Matrix Metalloproteinase-8 Levels and Subretinal Fibrosis among Wet Age-Related Macular Degeneration Patients

PURPOSE

Periodontitis causes low-grade systemic inflammation and has been associated with elevated active-matrix metalloproteinase (aMMP-8) levels, blood-ocular barrier breakdown and a risk of wet age-related macular degeneration. To assess the association between aMMP-8 levels and macular status among patients with wet age-related macular degeneration (AMD).

METHODS

Patients on anti-VEGF treatment for wet AMD were enrolled for oral aMMP-8 rinse test in Mehiläinen Private Hospital, Helsinki, Finland. Macular status was examined from spectral-domain optical coherence tomography (SD-OCT) scans by a medical retina specialist and aMMP-8 levels were analyzed with chairside point-of-care oral rinse (PerioSafe®) test and real-time quantitated by a dentist using the ORALyzer®- reader with a 10 ng/ml cut-off for aMMP-8 activity.

RESULTS

Elevated aMMP-8 levels were found in 10 out of 32 patients. Age, gender, anti-VEGF (bevacizumab or aflibercept) distribution, cumulative number of anti-VEGF injections and treatment interval were comparable between patients with aMMP-8 levels below and above the point-of-care level. Macular status differed in regard to aMMP-8 activity; among patients with aMMP-8 levels below the point-of-care subretinal fibrosis was found in 6 out of 22 eyes, whereas among patients with aMMP-8 levels above the point-of-care subretinal fibrosis was found in 8 out of 10 eyes (p = 0.005). Respectively, the mean thickness of subretinal fibrosis at fovea was 19.5 ± 44.1 and 92.3 ± 78.3 µm (p = 0.018). No differences were found in the presence and in the area of geographic atrophy, or fluid distribution, whereas thicknesses of serous pigment epithelial detachment (65.5 ± 99.5 and 12.9 ± 27.9 µm, p = 0.038) and neuroretina (204.2 ± 57.8 µm and 143.0 ± 43.7 µm, p = 0.006) were greater in the eyes of patients with physiological aMMP-8 levels compared to those with elevated aMMP-8 levels.

CONCLUSION

Elevated aMMP-8 levels may account for subretinal fibrosis formation in wet AMD.

The ideal intravitreal injection setting: office, ambulatory surgery room or operating theatre? A narrative review and international survey

PURPOSE

This study reviews evidence and provides recommendations for the ideal setting of intravitreal injection (IVI) administration of vascular endothelial growth factor (VEGF) inhibitors.

METHODS

A multi-step approach was employed, including content analysis of regulations and guidelines, a systematic literature review, and an international survey assessing perioperative complications and endophthalmitis incidence in relation to injection settings. The literature review searched PubMed and Cochrane databases from 2006 to 2022, focusing on studies reporting correlations between complications and treatment settings. The survey utilized a web-based questionnaire distributed to clinical sites and the international ophthalmic community, with data managed using electronic capture tools.

RESULTS

We reviewed regulations and guidelines from 23 countries across five continents, finding significant variation in IVI administration settings. In most countries, IVI is primarily administered in outpatient clean rooms (96%) or offices (39%), while in others, it is restricted to ambulatory surgery rooms or hospital-based operating theatres (4%). The literature review found that endophthalmitis risk after IVI is generally low (0.01% to 0.26% per procedure), with no significant difference between office-based and operating room settings. The international survey (20 centers, 96,624 anti-VEGF injections) found low overall incidences of severe perioperative systemic adverse events and endophthalmitis, independent of injection settings.

CONCLUSION

No significant differences in perioperative complications were observed among various settings, including operating theatres, ambulatory surgery rooms, offices, hospitals, or extra-hospital environments. Choosing the appropriate clinical setting can optimize patient management, potentially increasing effectiveness, quality, productivity, and capacity.

Visual Outcomes of Anti-VEGF Treatment on Neovascular Age-Related Macular Degeneration: A Real-World Population-Based Cohort Study

Neovascular age-related macular degeneration (nAMD) leads to visual impairment if not treated promptly. Intravitreal anti-VEGF drugs have revolutionized nAMD treatment in the past two decades. We evaluated the visual outcomes of anti-VEGF treatment in nAMD. A real-life population-based cohort study. The data included parameters for age, sex, age at diagnosis, laterality, chronicity, symptoms, visual outcomes, lens status, and history of intravitreal injections. A total of 1088 eyes (827 patients) with nAMD were included. Visual acuity was stable or improved in 984 eyes (90%) after an average of 36 ± 25 months of follow-up. Bevacizumab was the first-line drug in 1083 (99.5%) eyes. Vision improved ≥15 ETDRS letters in 377 (35%), >5 ETDRS letters in 309 (28%), and was stable (±5 ETDRS letters) in 298 (27%) eyes after anti-VEGF treatment. The loss of 5 ≤ 15 ETDRS letters in 44 (4%) eyes and ≥15 ETDRS letters in 60 (6%) eyes was noted. At the diagnosis of nAMD, 110 out of 827 patients (13%) fulfilled the criteria for visual impairment, whereas 179 patients (22%) were visually impaired after the follow-up. Improvement or stabilization in vision was noted in 90% of the anti-VEGF-treated eyes with nAMD. In addition, anti-VEGF agents are crucial in diminishing nAMD-related visual impairment.

Visual impairment due to age-related macular degeneration during 40 years in Finland and the impact of novel therapies

PURPOSE

To evaluate the changes in visual impairment (VI) due to age-related macular degeneration (AMD) during the past 40 years and the impact of novel therapies at population level.

METHODS

In this nationwide register-based study, we assessed the incidence, prevalence, severity, and onset age of VI due to AMD based on the Finnish Register of Visual Impairment data from 1980 to 2019. Our data included 30 016 visually impaired persons with AMD as the main diagnosis for VI. The number of persons treated with intravitreal injections in Finland was obtained from hospital data kept by the Finnish Institute for Health and Welfare.

RESULTS

Between the 1980s and the 2010s, the incidence of reported VI doubled; however, this increase has stagnated in the 2010s. Since 2012, the prevalence of reported VI has decreased. The number of patients treated with intravitreal injections showed a 40-fold increase during 2005-2019. The severity of reported VI has decreased whereas the mean age at the onset of reported VI has increased during the 40 years. The age-adjusted incidence and prevalence of reported VI were significantly higher in females in comparison to males in all decades.

CONCLUSION

Increase in the incidence and prevalence of VI due to AMD in the past decades has stagnated and shifted to older age in the 2010s when therapies for exudative class became commonly available. Furthermore, the prognosis of VI has improved during the past 40 years. These positive trends are likely contributable to improved diagnostic tools, earlier diagnoses, and new therapy options.

Novel Treatments for Age-Related Macular Degeneration: A Review of Clinical Advances in Sustained Drug Delivery Systems

In recent years, the number of patients with ocular diseases is increasing as a consequence of population aging. Among them, one of the most common is the age-related macular degeneration (AMD), a condition that leads to vision loss if it is not treated. AMD is a multifactorial disorder with two advanced forms, dry and neovascular AMD. Currently, although there is no approved therapy that significantly impacts dry AMD progression, several pharmacologic therapies exist for neovascular AMD. Notwithstanding, evidence suggests a suboptimal result in a high number of patients receiving these therapeutic options. Consequently, finding effective strategies is not only a still unmet medical need in dry AMD but also in neovascular AMD. This underlines the need for new drug delivery technologies that can improve the pharmacological action and drug concentration at the target sites. In this regard, sustained drug delivery systems are presented as the most promising therapeutic options in AMD patients. This review summarized the pathogenesis and the current treatment options for AMD, focusing on the emerging ocular sustained drug delivery approaches undergoing clinical trials.

Analyzing subgroups and treatment discontinuation in a Finnish cohort of patients with neovascular AMD

Purpose To study the regional detailed visual outcome and treatment discontinuation of neovascular age-related macular degeneration (nAMD). Methods Clinical records of 110 patients treated for nAMD at the sole referral center in the Helsinki region were analysed retrospectively. The follow-up was up to the fourth year. Results The mean visual acuity (VA) at baseline was 56.3 (SD 16.2) letters. The mean last VA at the first year was 59.7 (20.2), and the corresponding values for the second, third and fourth years were 60.8 (20.6), 60.0 (19.0) and 59.7 (19.3). The mean difference from baseline was +3.39 (SD 14.6), +3.59 (17.6), +0.08 (18.9) and +3.08 (14.3). The number of patients declined each year, with only 51 % of the patients being in treatment until the fourth year. The patients with shorter duration of follow-up tended to have a lower baseline VA, lesser gains and an earlier decline in VA. The VA levels at the last visit were poorer in the shorter follow group. The initial VA response predicted later VA, whereas VA at baseline, age or sex had no effect. However, the effect vanished with a longer time in treatment. Conclusions Long-term VA stabilization was obtained in a regional material. Patients with neovascular AMD consists of cohorts with varying visual outcome and treatment time. Many of the patients benefit from the treatment for some time, however. When comparing real-world results, the outcome of the different follow-up time cohorts should be considered. This calls for new methods for analysing real world nAMD treatment results. Key words: neovascular age-related macular degeneration, anti-VEGF treatment, visual acuity, real-world studies.

A comprehensive model for measuring real-life cost-effectiveness in eyecare: automation in care and evaluation of system (aces-rwm™)

This paper describes a holistic, yet simple and comprehensible, ecosystem model to deal with multiple and complex challenges in eyecare. It aims at producing the best possible wellbeing and eyesight with the available resources. When targeting to improve the real-world cost-effectiveness, what gets done in everyday practice needs be measured routinely, efficiently and unselectively. Collection of all real-world data of all patients will enable evaluation and comparison of eyecare systems and departments between themselves nationally and internationally. The concept advocates a strategy to optimize real-life effectiveness, sustainability and outcomes of the service delivery in ophthalmology. The model consists of three components: (1) resource-governing principles (i.e., to deal with increasing demand and limited resources), (2) real-world monitoring (i.e., to collect structured real-world data utilizing automation and visualization of clinical parameters, health-related quality of life and costs), and (3) digital innovation strategy (i.e., to evaluate and benchmark real-world outcomes and cost-effectiveness). The core value and strength of the model lies in the consensus and collaboration of all Finnish university eye clinics to collect and evaluate the uniformly structured real-world outcomes data. In addition to ophthalmology, the approach is adaptable to any medical discipline to efficiently generate real-world insights and resilience in health systems.

The effects of loading ranibizumab on vision-related quality of life in the treatment of low-risk neovascular age-related macular degeneration

Background:

The loss of central vision plays a major role in the quality of life (QoL). This study evaluates the changes in QoL in the treatment of low-risk neovascular age-related macular degeneration (AMD).

Objectives:

The aim of this study was to evaluate the changes in vision-related QoL in patients receiving intravitreal ranibizumab loading dose for low-risk neovascular AMD.

Design:

A prospective study.

Methods:

Forty-two eyes of 42 patients receiving ranibizumab injections for neovascular AMD were included in this prospective study. The changes in best-corrected visual acuity (BCVA), central macular thickness (CMT) of the patients before the treatment, and 1 month after three loading doses were evaluated. Turkish version of the National Eye Institute 25-Item Vision Function Questionnaire (NEI VFQ-25 TR) was conducted. The changes of QoL scores through the NEI VFQ-25 TR questionnaire were compared with visual acuity (VA) and CMT measurements before the injections and 1 month after the loading dose.

Results:

Forty-two patients (19 females and 23 males) were included in the study, and the mean age was 72.69 ± 7.12 years. After the treatment, a statistically significant improvement in BCVA (0.98 ± 0.44, 0.76 ± 0.42 logMAR, p < 0.001) and a significant decrease in CMT (357.90 ± 71.71, 274.50 ± 58.35 μm, p < 0.001) was observed. The QoL composite score was found to be statistically significantly higher after the treatment (64.27 ± 11.47, 68.56 ± 11.39, p < 0.001). General vision (p < 0.001), ocular pain (p = 0.025), near activities (p < 0.001), distance activities (p = 0.027), vision-specific mental health (p = 0.014), vision-specific role difficulties (p < 0.001), and peripheral vision (p = 0.046) were significantly higher after the treatment.

Conclusion:

NEI VFQ-25 TR is a useful questionnaire for evaluating changes in visual functions and psychosocial characteristics of low-risk neovascular AMD patients before and after the injections.

Epithelial-mesenchymal transition-related serum markers ET-1, IL-8 and TGF-β2 are elevated in a Finnish wet age-related macular degeneration cohort

PURPOSE

It has been hypothesized that epithelial-mesenchymal transition (EMT) may occur in the retinal pigment epithelium of advanced stage age-related macular degeneration (AMD). Various serum and plasma growth factors and inflammatory mediators have been linked to AMD. We were interested in finding out whether systemic levels of EMT-associated markers were altered in the serum of wet AMD patients. Serum biomarkers associated with the various pathological processes of AMD may present an avenue towards identifying and characterizing the birth mechanisms of wet AMD, its progression and severity, paving the way towards the application of precision medicine.

METHODS

We chose to measure the serum levels of known biomarkers of EMT - EGF (epidermal growth factor), ET-1 (endothelin 1), IL-8 (interleukin 8), TGF-β1 and TGF-β2 (transforming growth factor-beta 1 and 2) and VEGF-A (vascular endothelial growth factor A) - using enzyme-linked immunosorbent assays. We measured them from 71 Finnish wet AMD patients who were receiving intravitreal anti-VEGF-A injection treatments, as well as 64 age-adjusted controls.

RESULTS

We found significantly elevated levels of ET-1, IL-8 and TGF-β2 in the serums of wet AMD patients.

CONCLUSIONS

ET-1, IL-8 and TGF-β2 appear to be useful serum biomarkers in understanding active wet AMD. However, we cannot conclude that local retinal EMT-processes could be observed from the corresponding systemic serum biomarkers in patients undergoing anti-VEGF-A treatments.

Autophagy Genes for Wet Age-Related Macular Degeneration in a Finnish Case-Control Study

Age-related macular degeneration is an eye disease that is the main cause of legal blindness in the elderly in developed countries. Despite this, its pathogenesis is not completely known, and many genetic, epigenetic, environmental and lifestyle factors may be involved. Vision loss in age-related macular degeneration (AMD) is usually consequence of the occurrence of its wet (neovascular) form that is targeted in the clinic by anti-VEGF (vascular endothelial growth factor) treatment. The wet form of AMD is associated with the accumulation of cellular waste in the retinal pigment epithelium, which is removed by autophagy and the proteosomal degradation system. In the present work, we searched for the association between genotypes and alleles of single nucleotide polymorphisms (SNPs) of autophagy-related genes and wet AMD occurrence in a cohort of Finnish patients undergoing anti-VEGF therapy and controls. Additionally, the correlation between treatment efficacy and genotypes was investigated. Overall, 225 wet AMD patients and 161 controls were enrolled in this study. Ten SNPs (rs2295080, rs11121704, rs1057079, rs1064261, rs573775, rs11246867, rs3088051, rs10902469, rs73105013, rs10277) in the mTOR (Mechanistic Target of Rapamycin), ATG5 (Autophagy Related 5), ULK1 (Unc-51-Like Autophagy Activating Kinase 1), MAP1LC3A (Microtubule Associated Protein 1 Light Chain 3 α), SQSTM1 (Sequestosome 1) were analyzed with RT-PCR-based genotyping. The genotype/alleles rs2295080-G, rs11121704-C, rs1057079-C and rs73105013-T associated with an increased, whereas rs2295080-TT, rs2295080-T, rs11121704-TT, rs1057079-TT, rs1057079-T, rs573775-AA and rs73105013-C with a decreased occurrence of wet AMD. In addition, the rs2295080-GG, rs2295080-GT, rs1057079-TT, rs11246867-AG, rs3088051-CC and rs10277-CC genotypes were a positively correlated cumulative number of anti-VEGF injections in 2 years. Therefore, variability in autophagy genes may have an impact on the risk of wet AMD occurrence and the efficacy of anti-VEGF treatment.

Effect of cataract surgery on quality of life for patients with severe vision impairment due to age-related macular degeneration

Background

To determine whether patients with severe vision impairment due to advanced age-related macular degeneration (AMD) benefit from bilateral cataract surgery in terms of vision-related quality of life (QoL).

Methods

A prospective interventional single-center study. Ten patients with severe vision impairment due to advanced bilateral AMD were included. The preoperative corrected distance visual acuity (CDVA) was ≥1.0/≥1.0 LogMAR units on Snellen chart and <20/<20 points on Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Patients were not on active treatment for wet AMD as the treatment was expected to have no effect or benefit. The patients were scheduled for immediate sequential bilateral cataract surgery, with target refraction emmetropia (SN60WF, Alcon). Vision-related QoL was measured with National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) preoperatively, at 3 months and 1 year.

Results

The mean age of the patients was 82.5±6.2 years. The mean NEI VFQ-25 overall composite score changed from 44.0±7.1 preoperatively to 54.9±13.7 at 3 months and to 56.9±15.6 at 1 year (P=0.045, Friedman test). During the 1-year follow-up, there was an improvement in the subscale scores indicating difficulty with peripheral vision, mental health symptoms, and role difficulties due to vision (P<0.05 for all, Wilcoxon sign-rank test).

Conclusions

Cataract surgery may improve the vision-related QoL in patients with severe vision impairment due to bilateral advanced AMD.

Correlation between the rate of intravitreal injections, use of aflibercept as a second-line treatment and visual impairment for wet AMD in Finland

PURPOSE

To correlate the rate of intravitreal anti-VEGF injections and the use of aflibercept as a second-line treatment with visual impairment throughout Finland.

METHODS

Information related to anti-VEGF treatment, proportions of bevacizumab and aflibercept and new visual impairments due to wet age-related macular degeneration (AMD) was gathered from 5 university hospitals and 14 central hospital districts between 2015 and 2017 covering 232 568 injections and 1172 visual impairments.

RESULTS

Between 2015 and 2017, the number of annual total anti-VEGF injections increased from 60 412 to 93 589 (+24.5% annual change) and of aflibercept injections from 8299 to 20 833 (+58.7% annual change). The 3-year average for total anti-VEGF injections ranged from 9.6 to 21.1 (median 13.3) per 1000 citizens between hospital districts and for aflibercept injections from 0.8 to 4.0 (median 1.9). According to the primary protocol for wet AMD, during 2015-2017, the number of total anti-VEGF injections increased from 10.9 to 15.2 per 1000 citizens with the pro re nata (PRN) protocol and from 11.3 to 18.9 with the treat-and-extend regimen (TER). The 3-year average of aflibercept injections as a second-line treatment, but not the total number of anti-VEGF or bevacizumab injections, inversely correlated with new onset visual impairments (R = -0.505, P = 0.027) in the hospital districts. The number of visual impairments did not differ between the hospital districts according to the PRN and TER protocols (1.23 ± 0.41 and 1.14 ± 0.67, respectively, per 1000 citizens aged ≥64 years, P = 0.713).

CONCLUSION

These results emphasize that the use of aflibercept injections as a second-line treatment may decrease new onset visual impairments.

The Effect of Blue-Light Filtering Intraocular Lenses on the Development and Progression of Neovascular Age-Related Macular Degeneration

PURPOSE

To assess the effect of blue-light filtering (BLF) intraocular lenses (IOLs) on the prevention of neovascular age-related macular degeneration (nAMD) after cataract surgery.

DESIGN

Cohort study.

PARTICIPANTS

Patients who underwent uneventful cataract surgery between 2007 and 2018 at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland.

METHODS

Subsequent nAMD rates were compared between patients who received BLF IOLs and those who received non-BLF IOLs. Kaplan-Meier and Cox regression analyses for the overall risk of nAMD developing were assessed. Best-corrected visual acuity (BCVA), foveal thickness, treatment interval, and total number of intravitreal injections were secondary outcomes. A separate analysis was performed on patients with pre-existing nAMD to assess the effect of BLF IOLs on nAMD progression. A single eye of each patient was included.

MAIN OUTCOME MEASURE

Neovascular age-related macular degeneration-free survival.

RESULTS

Included were 11 397 eyes of 11 397 patients with a mean age of 75.4 ± 8.3 years (62.5% women). The BLF IOL was used in 5425 eyes (47.6%), and the non-BLF IOL was used in 5972 eyes (52.4%). During follow-up (BLF IOL group, 55.2 ± 34.1 months; non-BLF IOL group, 50.5 ± 30.1 months; P < 0.001), 164 cases of new-onset nAMD were recorded (BLF group, n = 88; non-BLF group, n = 76). The nAMD-free survival was similar between the groups (P = 0.465, log-rank test). In a Cox regression analysis controlling for age, gender, and a documented diagnosis of macular degeneration, the use of a BLF IOL was not predictive of nAMD development (hazard ratio [HR], 1.075; 95% confidence interval [CI], 0.79-1.47; P = 0.652). In nAMD patients, secondary clinical outcomes at 1 year were comparable for BCVA (0.57 ± 0.4 logarithm of the minimum angle of resolution vs. 0.45 ± 0.4 logarithm of the minimum angle of resolution; P = 0.136), foveal thickness (285 ± 109 μm vs. 299 ± 103μm; P = 0.527), number of anti-vascular endothelial growth factor injections (6.5 ± 2.5 vs. 6.2 ± 2.7; P = 0.548), and treatment interval (7.5 ± 2.4 weeks vs. 8.1 ± 2.4 weeks; P = 0.271) for BLF and non-BLF IOLs, respectively. Similarly to patients in whom nAMD developed after the surgery, among patients with nAMD before surgery (BLF, n = 71; non-BLF, n = 74), the clinical outcomes again were comparable (all P > 0.05).

CONCLUSIONS

In a large cohort of patients who underwent cataract surgery, the use of a BLF IOL resulted in no apparent advantage over a non-BLF IOL in the incidence of nAMD or its progression, nor in clinical variables related to nAMD severity.

Comparison of Two Different Treat-and-Extend Protocols with Aflibercept in Wet Age-Related Macular Degeneration: Two-Year Results

INTRODUCTION

To optimize the aflibercept treat-and-extend protocol in wet age-related macular degeneration (wAMD) beyond the 1-year interim report.

METHODS

This 2-year prospective randomized clinical trial included 52 eyes from 52 patients with treatment-naïve wAMD. After the induction phase of three monthly aflibercept injections, patients were randomized 1:1 to two different treat-and-extend protocols. In the treat-and-extend protocol with moderate extensions (T&Em), the treatment interval was extended 1 week at a time up to 12 weeks, and then by 2 weeks up to 16 weeks. In the treat-and-extend protocol with rapid extensions (T&Er), the treatment interval was initially extended to 8 weeks, and then by 2 weeks up to 16 weeks. Main outcome measure was the number of given aflibercept injections.

RESULTS

At the study end point at 2 years, the mean visual gain from the baseline was 7.9 ± 14.5 letters in T&Em, compared to 10.8 ± 16.5 letters in T&Er protocol (P = 0.726). The mean decrease in central subfield macular thickness was 203.0 ± 167.4 µm in T&Em and 192.3 ± 160.2 µm in T&Er protocol (P = 0.822). Treatment interval was 10.3 ± 3.3 weeks in T&Em and 11.7 ± 3.5 in T&Er protocol (P = 0.164) at the end of year 2. The total number of injections in 2 years was 14.1 ± 3.1 in T&Em and 11.6 ± 2.0 in T&Er (P = 0.002), and the number of injections during the second year was 5.4 ± 1.8 and 4.4 ± 1.4, respectively (P = 0.043). A total of 71% of the eyes in both treatment groups had a dry macula at the study end point.

CONCLUSIONS

At 2 years, the anatomical and functional responses between the two treatment groups were similar. However, the number of given aflibercept injections was smaller in the rapid extensions protocol.

TRIAL REGISTRATION

EU Clinical Trials Register Number, 2015-001394-41/FI.

Expression of VEGFA-regulating miRNAs and mortality in wet AMD

MicroRNAs (miRNAs) regulate gene expression; many of them act in the retinal pigment epithelium (RPE), and RPE degeneration is known to be a critical factor in age‐related macular degeneration (AMD). Repeated injections with anti‐VEGFA (vascular endothelial growth factor A) are the only effective therapy in wet AMD. We investigated the correlation between the expression of 18 miRNAs involved in the regulation of the VEGFA gene in serum of 76 wet AMD patients and 70 controls. Efficacy of anti‐VEGFA treatment was evaluated by counting the number of injections delivered up to 12 years. In addition, we compared the relative numbers of deaths in patient with AMD and control groups. We observed a decreased expression of miR‐34‐5p, miR‐126‐3p, miR‐145‐5p and miR‐205‐5p in wet AMD patients as compared with controls. These miRNAs are involved in the regulation of angiogenesis, cytoprotection and protein clearance. No miRNA was significantly correlated with the treatment outcome. Wet AMD patients had greater mortality than controls, and their survival was inversely associated with the number of anti‐VEGFA injections per year. No association was observed between miRNA expression and mortality. Our study emphasizes the need to clarify the role of miRNA regulation in AMD pathogenesis.

Psychometric properties of the National Eye Institute Visual Function Questionnaire (NEI-VFQ 25) in a Norwegian population of patients with neovascular age-related macular degeneration compared to a control population

Background

Although visual acuity and optical coherence tomography (OCT) are most widely used as outcomes in treatment of neovascular age-related Macular Degeneration (nAMD), patient reported outcome measures are increasingly recognized. National Eye Institute Visual Function Questionnaire (NEI-VFQ 25) was developed to capture the perceived visual function. Yet, evidence of psychometric performance in the target population is required. The aim of this study was to examine the psychometric properties of NEI-VFQ 25 in a Norwegian cohort of newly diagnosed nAMD patients followed with a Treat and Extend (T/E) protocol.

Methods

Patients receiving intravitreal anti–vascular endothelial growth factor (anti-VEGF) injection treatment according to a T/E protocol completed a Norwegian translation of NEI-VFQ 25, EuroQoL Health Questionnaire (EQ-5D), and Patient acceptable symptom state (PASS 5) at baseline, 3, 6 and 12 months. In addition, a control population completed the same questionnaires. Visual acuity was assessed with LogMar for best/treated eye. Validity testing comprised face validity by a 0–10 numeric rating scale about relevance of NEI-VFQ 25 as well as regression analyses and correlations between NEI-VFQ 25 and other relevant variables. Reliability was examined with Intraclass Correlation Coefficient (ICC) and Cronbach’s alpha for internal consistency were performed. Responsiveness, discriminatory power and predictive value were also explored.

Results

Number of respondents at baseline, after 3, 6 and 12 months was 197, 186, 176 and 168, respectively. The control population comprised 26 individuals. Face validity of NEI-VFQ 25 had a mean (SD) of 7.8 (1.7) (n = 84). NEI-VFQ was significantly correlated to visual acuity and PASS 5 as well as EQ-5D at baseline. Reliability (ICC) of the overall and sub scores for the patients/controls ranged from 0.49–0.97/0.59–0.97. Cronbach’s alpha was 0.61–0.85. Discriminatory power was confirmed by significant differences of the overall score between controls and patients (P < 0.001). NEI-VFQ 25 indicates responsiveness showing overall score improved significantly (P ≤ 0.001) from baseline to 3 months. NEI-VFQ 25, general health and visual acuity at baseline were the strongest predictors for how patients reported vision after 6 months follow-up.

Conclusion

NEI-VFQ 25 showed acceptable psychometric performance, which supports that the Norwegian version can be used to monitor patients treated for nAMD.

Better visual outcome at 1 year with antivascular endothelial growth factor treatment according to treat-and-extend compared with pro re nata in eyes with neovascular age-related macular degeneration

Purpose

To evaluate treatment outcome at 12 months in eyes with neovascular age‐related macular degeneration (nAMD) treated with antivascular endothelial growth factor (anti‐VEGF) injections according to either pro re nata (PRN)‐ or treat‐and‐extend (TE)‐regimen in one clinical setting in Sweden.

Methods

Data were obtained retrospectively from the Swedish Macula Register, optical coherence tomography‐database and electronic patient charts. The study included 443 eyes; 223 PRN‐ and 220 TE‐treated eyes. Baseline (BL) characteristics and follow‐up data at 6 and 12 months were collected. Statistical regression analysis was performed to evaluate association between treatment strategy and visual outcome at 12 months.

Results

Baseline (BL) characteristics were well balanced between cohorts. Visual acuity at 12 months was higher in TE‐cohort 66.5 (13.1) compared to PRN‐cohort 60.1 (17.6) (p = 0.000). Visual improvement at 12 months was +5.2 (11.8) and +1.2 (12.7) letters Early Treatment Diabetic Retinopathy Study (ETDRS) in TE‐ and PRN‐cohorts, respectively (p = 0.002). Number of administered injections at 12 months was 10.2 (2.1) and 6.3 (2.1) in the two cohorts (p = 0.000). Statistical analysis demonstrated a strong association between TE treatment strategy and improvement in visual acuity at 12 months.

Conclusion

Eyes treated according to TE had better visual outcome at 12 months. The results indicate that treatment according to proactive TE‐regimen is superior to treatment according to PRN‐regimen in clinical routine care of nAMD.

Development and testing of a patient-derived questionnaire for treatment of neovascular age-related macular degeneration: dimensions of importance in treatment of neovascular age-related macular degeneration

PURPOSE

Studies reporting on patient perspectives during treatment of neovascular age-related macular degeneration (nAMD) are limited. Thus, the aim of this study was to develop and test psychometric performance of a patient-derived questionnaire to capture important experiences during intravitreal treatment.

METHODS

Patients (n = 44) with at least 3-month experience of intravitreal injection treatment for nAMD identified the dimensions of priority and also performed a weighting procedure to develop a score for comparison. The questionnaire comprised two versions: one focusing on the relative importance' of the dimensions and one on the experience of the 'management' during treatment. The questionnaire was then tested for psychometric performance in a longitudinal design in newly diagnosed patients at baseline (n = 197), after three (n = 184) and six (n = 150) months of treatment.

RESULTS

Of the 15 included dimensions, the following were most frequently reported: 'receive treatment to preserve vision', 'information', 'waiting time', 'trust' and 'accommodating staff. The psychometric testing showed moderate reliability (intraclass correlation coefficient: 0.65-0.67) for the two versions and high level of face validity (8.3). The dimensions, 'preserving vision', 'early access to treatment', 'pain relief', 'information about the treatment/diagnosis' and 'visual aids' were consistently reported higher in 'importance' than in 'management', at both 3 and 6 months, indicating a potential for improvement in clinical practice for these dimensions.

CONCLUSION

This study provides a brief patient-derived questionnaire, expressed with a score with good psychometric performance that can be used for monitoring during intravitreal injection treatment of nAMD patients.

Improving eye care services with a lean approach

PURPOSE

Effective provision of eye care services in government-financed hospitals is essential to balance the discrepancy between growing demand and limited resources. We aimed to improve efficiency of the treatment protocol for Nd:YAG laser posterior capsulotomy. Predetermined quality targets were a patient-oriented and patient-safe approach and the development of a clinical care process with purposeful use of competences.

METHODS

We utilized a lean process improvement methodology to develop a streamlined Nd:YAG laser posterior capsulotomy treatment protocol. A total of 206 patient visits were evaluated, where the lean-oriented treatment protocol was utilized in 158 of the visits and the conventional (CONV) protocol was followed in 48 of the visits.

RESULTS

All baseline variables were comparable between the study groups. Compared to the CONV protocol, implementation of new operational principles shortened the total reception time per patient from 55:36 ± 30:23; 12-136 min to 44:40 ± 4:49; 37-54 min (mean ± SD; range, p = 0.040). The per hour number of patients and eyes treated in the operation room improved from 4.7 ± 1.6; 2.6-8.4 patients and 5.5 ± 2.0; 3.5-11.3 eyes to 16.3 ± 2.3; 14.3-19.4 patients (p < 0.001) and 18.0 ± 1.6; 16.8-20.4 eyes (p < 0.001). The time spent by the operating physician reduced from 8:19 ± 3:06; 3:57-14:30 min to 3:01 ± 1:00; 1:34-6:38 min in unilateral procedure (p < 0.001) and from 8:45 ± 3:55; 5:52-14:10 min to 4:40 ± 2:03; 2:38-10:14 min in bilateral procedure (p < 0.006). Furthermore, the overall patient satisfaction grade improved from 17.3 ± 1.04; 15-18 points to 17.8 ± 0.61; 15-18 points (p = 0.001).

CONCLUSIONS

The lean approach improved the treatment protocol for Nd:YAG laser posterior capsulotomy with substantial reductions in lead times without compromising patient satisfaction.

Mortality after a cerebrovascular event in age-related macular degeneration patients treated with bevacizumab ocular injections

PURPOSE

To analyse the mortality associated with intravitreal injections of bevacizumab for age-related macular degeneration (AMD) in patients previously diagnosed with stroke or transient ischaemic attack (TIA).

METHODS

We reviewed bevacizumab-treated AMD patients with a diagnosis of stroke or TIA prior to their first bevacizumab injection (n = 948). Those patients, naïve to any anti-vascular endothelial growth factor (anti-VEGF) at the time of stroke/TIA, were then compared to age- and gender-matched patients who had a stroke/TIA at the same time and had never been exposed to anti-VEGF. Survival analysis was performed using adjusted Cox regression. The main outcome measure was survival. Adjusted variables were age, smoking, alcohol abuse, hypertension, diabetes mellitus, obesity, ischaemic heart disease, congestive heart failure and liver cancer.

RESULTS

Age and gender distribution of bevacizumab-treated patients and controls were similar (mean age: 83.4 versus 83.7 years, p = 0.3; 51.7% males versus 52.5% males, p = 0.7). The adjusted mortality in patients who received bevacizumab within 3 months after stroke/TIA was significantly different than in patients non-exposed to bevacizumab (OR = 6.92, 95%, CI 1.88-25.43, p < 0.01). Within 6 months after stroke/TIA, the difference in adjusted mortality showed a strong trend (OR = 2.00, 95%, CI 0.96-4.16, p = 0.064). Within 12 months, it was insignificant (OR = 1.30, 95%, CI 0.75-2.26, p = 0.348).

CONCLUSION

We found increased mortality within three months after a cerebrovascular event in patients treated with bevacizumab for AMD compared to patients for whom there was no record of a prescription to any anti-VEGF agent.

Photodynamic therapy in combination with ranibizumab versus ranibizumab monotherapy for wet age-related macular degeneration: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety between photodynamic therapy (PDT) combined with intravitreal ranibizumab (IVR) and ranibizumab monotherapy in treating wet age-related macular degeneration (AMD).

METHODS

A systematic search was performed in the PubMed, Embase, Web of Science and the Cochrane Library databases through December 31, 2017. The methodological quality of the references was evaluated according to the Cochrane quality assessment. RevMan 5.3 software was used to perform the meta-analysis.

RESULTS

Eight RCTs involving 817 participants were included. Wet AMD eyes in the mono-group achieved better best-corrected vision acuity (BCVA) than the combination group in month 12 (WMD = -0.19, 95% CI = -0.32 to -0.06, P = 0.004, I² = 18%). The proportion of patients gaining more than 15 letters from baseline in the mono-group was larger than that in the combination group (RR = 0.70, 95% CI: 0.56 to 0.87, P = 0.001). However, the number of ranibizumab injections with combination therapy was smaller than that with mono-therapy (MD = -1.13, 95% CI: -2.11 to -0.15, P = 0.02, I² = 85%). No significant differences were observed in the proportions of patients losing more than 15 letters, central retinal thickness (CRT), lesion size of choroidal neovascularization (CNV) and adverse events.

CONCLUSIONS

Combination therapy decreased the number of injections of ranibizumab, although its BCVA improvement was inferior to that of monotherapy over 12 months of follow-up. Given the inherent limitations of the included trials, more studies are needed to further validate and update the findings in this area.

Outcome of anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration in real-life setting

Aims

To evaluate outcome of anti-vascular endothelial growth factor (VEGF) therapy for the treatment of neovascular age-related macular degeneration (nAMD) in the real-life setting and to compare incidence of ocular serious adverse events (SAE) after injections administered by nurses and physicians.

Methods

Retrospective, single-centre study. Medical records of patients receiving anti-VEGF treatment for nAMD between 2008 and 2013 with three-loading-dose regimen were evaluated. Outcome measures were baseline visual acuity (VA), change in VA, number of intravitreal injections, incidence of ocular SAE and patients’ baseline characteristics affecting VA change. In addition, the number of injections per 1000 citizens living in the serving area and per individuals over 65 years old were estimated.

Results

1349 eyes in 1117 patients received a total of 11 562 intravitreal anti-VEGF injections. Twenty-one per cent of patients received treatment for both eyes. The mean baseline Snellen VA was 0.32. The mean change of VA from baseline was +2, +2 and ±0 Early Treatment Diabetic Retinopathy Study letters and the mean numbers of injections were 5.7, 4.7 and 4.9 at years 1, 2 and 3, respectively. There was a negative correlation between baseline VA and change of VA. Incidence of endophthalmitis was 0.086%. No difference in the incidence of ocular SAE was identified between injections given by nurses or by physicians. The number of intravitreal injections per all citizens was 9 per 1000 inhabitants and 45 per 1000 inhabitants over 65 years.

Conclusion

The VA was maintained at the baseline level (±0 letters) with the mean of 15.3 anti-VEGF injections in real-world clinical practice during 3-year follow-up.