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Airody A, Baseler HA, Seymour J, Allgar V, Mukherjee R, Downey L, Dhar-Munshi S, Mahmood S, Balaskas K, Empeslidis T, Hanson RLW, Dorey T, Szczerbicki T, Sivaprasad S, Gale RP. Treatment of age-related macular degeneration with aflibercept using a treat, extend and fixed protocol; A 4-year study of treatment outcomes, durability, safety and quality of life (An extension to the MATE randomised controlled trial). Acta Ophthalmol 2024; 102:e328-e338. [PMID: 37776074 DOI: 10.1111/aos.15774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 07/05/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE Data are limited pertaining to the long-term benefits of aflibercept treatment for neovascular age-related macular degeneration (nAMD). The aim of this study was to provide outcomes, safety, durability and quality-of-life data with aflibercept using a modified treat, extend and fixed regime over 4 years. METHODS Prospective, multicentre, single cohort observational study of treatment-naïve nAMD participants treated with aflibercept as 2-year extension of the MATE-trial that compared early and late Treat-and-Extend for 2 years. Refracted ETDRS best corrected visual acuity (BCVA), central retinal thickness (CRT), treatment interval and adverse events were assessed. Quality-of-life was measured using the Macular Disease Dependent Quality of Life (MacDQoL) and Macular Disease Treatment Satisfaction Questionnaires (MacTSQ). RESULTS Twenty-six of 40 participants completing the MATE-trial were enrolled with 20 completing the total 4-year study. Mean BCVA was 60.7 at Month 0 and 64.8 ETDRS letters at Month 48 while CRT decreased from 423.7 μm to 292.2 μm. Five participants discontinued treatment due to inactivity. The mean number of treatments and visits for the remaining participants was 27 and 30.0, respectively, with treatment intervals extended to 12 weeks in four participants at Month 48. Both AMD-specific QoL and treatment satisfaction remained stable between Months 0 and 48 and mean BCVA significantly correlated with AMD-specific QoL scores at Months 12, 24 and 48. CONCLUSIONS Results suggest that BCVA can be maintained over 48 months when following a treat-extend-and-fix regimen of aflibercept with intervals out to 12 weeks, while maintaining AMD-specific QoL and treatment satisfaction.
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Affiliation(s)
- Archana Airody
- Academic Unit of Ophthalmology, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
- Hull York Medical School, University of York, York, UK
| | - Heidi A Baseler
- Hull York Medical School, University of York, York, UK
- Department of Psychology, University of York, York, UK
| | - Julie Seymour
- Hull York Medical School, University of Hull, Hull, UK
| | - Victoria Allgar
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | | | | | - Sushma Dhar-Munshi
- Kings Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | | | - Konstantinos Balaskas
- University of Manchester, Manchester, UK
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Theo Empeslidis
- Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rachel L W Hanson
- Academic Unit of Ophthalmology, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
- Hull York Medical School, University of York, York, UK
| | - Tracey Dorey
- Academic Unit of Ophthalmology, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Tom Szczerbicki
- Academic Unit of Ophthalmology, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Richard P Gale
- Academic Unit of Ophthalmology, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
- Hull York Medical School, University of York, York, UK
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Airody A, Baseler HA, Seymour J, Allgar V, Mukherjee R, Downey L, Dhar-Munshi S, Mahmood S, Balaskas K, Empeslidis T, Hanson RLW, Dorey T, Szczerbicki T, Sivaprasad S, Gale RP. The MATE trial: a multicentre, mixed-methodology, pilot, randomised controlled trial in neovascular age-related macular degeneration. Pilot Feasibility Stud 2023; 9:63. [PMID: 37081576 PMCID: PMC10116669 DOI: 10.1186/s40814-023-01288-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/30/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND/OBJECTIVES In healthcare research investigating complex interventions, gaps in understanding of processes can be filled by using qualitative methods alongside a quantitative approach. The aim of this mixed-methods pilot trial was to provide feasibility evidence comparing two treatment regimens for neovascular age-related macular degeneration (nAMD) to inform a future large-scale randomised controlled trial (RCT). SUBJECTS/METHODS Forty-four treatment-naïve nAMD patients were followed over 24 months and randomised to one of two treatment regimens: standard care (SC) or treat and extend (T&E). The primary objective evaluated feasibility of the MATE trial via evaluations of screening logs for recruitment rates, nonparticipation and screen fails, whilst qualitative in-depth interviews with key study staff evaluated the recruitment phase and running of the trial. The secondary objective assessed changes in visual acuity and central retinal thickness (CRT) between the two treatment arms. RESULTS The overall recruitment rate was 3.07 participants per month with a 40.8% non-participation rate, 18.51% screen-failure rate and 15% withdrawal/non-completion rate. Key themes in the recruitment phase included human factors, protocol-related issues, recruitment processes and challenges. Both treatment regimens showed a trend towards a visual acuity gain at month 12 which was not maintained at month 24, whilst CRT reduced similarly in both regimens over the same time period. These were achieved with one less treatment following a T&E regimen. CONCLUSION This mixed-methodology, pilot RCT achieved its pre-defined recruitment, nonparticipation and screen failure rates, thus deeming it a success. With some minor protocol amendments, progression to a large-scale RCT will be achievable.
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Affiliation(s)
- Archana Airody
- Academic Unit of Ophthalmology, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, YO31 8HE, UK.
| | - Heidi A Baseler
- Department of Psychology, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Julie Seymour
- Hull York Medical School, University of Hull, Hull, UK
| | - Victoria Allgar
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | | | | | - Sushma Dhar-Munshi
- Kings Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | | | - Konstantinos Balaskas
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Theo Empeslidis
- Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rachel L W Hanson
- Academic Unit of Ophthalmology, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, YO31 8HE, UK
| | - Tracey Dorey
- Research and Development, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Tom Szczerbicki
- Research and Development, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Richard P Gale
- Academic Unit of Ophthalmology, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, YO31 8HE, UK
- Hull York Medical School, University of York, York, UK
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Foss A, Haydock R, Childs M, Duley LM, Empeslidis T, Dhar-Munshi S, Montgomery AA, Ogollah R, Ozolins M, Tesha P, Mitchell E. TANDEM TRIAL: a factorial randomised controlled trial of dose and review schedule of bevacizumab (Avastin) for neovascular macular degeneration in the East Midlands. BMJ Open Ophthalmol 2020; 5:e000588. [PMID: 33344775 PMCID: PMC7725082 DOI: 10.1136/bmjophth-2020-000588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 11/26/2022] Open
Abstract
Objective Neovascular age-related macular degeneration (nAMD) causes damage to the macula and severe vision loss. Bevacizumab is the most cost-effective nAMD treatment. The TANDEM trial was designed to determine whether, in patients with nAMD, low-dose bevacizumab is non-inferior to the standard dose in terms of visual deterioration and whether a bimonthly regimen is non-inferior to monthly, treatment as required, regimens. Methods This was a multicentre, 2×2 factorial, double-masked, non-inferiority randomised trial with patients considered eligible if they met the National Institute for Health and Care Excellence criteria for nAMD treatment with ranibizumab. Participants were randomly assigned to standard (1.25 mg) or low (0.625 mg) dose bevacizumab and either monthly or bimonthly review regimen. The primary outcome was time to vision deterioration, defined as reduction of ≥15 letters (three lines) during the loading phase (visual acuity scores at visits B and C compared with the initial visit A), or ≥6 letters (one line) during the maintenance phase (visual acuity scores at subsequent visits compared with mean vision at visits A–C). Results In total 812 participants (918 eyes) were randomised into the trial. The low dose showed some evidence of being non-inferior to standard dose (HR 1.07; 95% CI 0.80 to 1.42), however, there was no strong evidence of bimonthly review being non-inferior to monthly review (HR 1.45; 95% CI 1.09 to 1.94). There was no difference in visual acuity when assessed at 9 months and no major differences in the frequency of serious adverse events or reactions between the groups. Conclusion The standard dose of bevacizumab can be halved without compromising efficacy. Bimonthly review cannot be considered to be no worse than monthly review.
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Affiliation(s)
- Alexander Foss
- Department of Ophthalmology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rebecca Haydock
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Lelia M Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Theo Empeslidis
- Department of Ophthalmology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sushma Dhar-Munshi
- Department of Ophthalmology, Kings Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, Nottinghamshire, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Reuben Ogollah
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Mara Ozolins
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Paul Tesha
- Department of Ophthalmology, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust, Lincoln, Lincolnshire, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
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Munshi S, Varghese A, Dhar-Munshi S. Computer vision syndrome-A common cause of unexplained visual symptoms in the modern era. Int J Clin Pract 2017; 71. [PMID: 28594459 DOI: 10.1111/ijcp.12962] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/10/2017] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the evidence and available literature on the clinical, pathogenetic, prognostic and therapeutic aspects of Computer vision syndrome. METHODS Information was collected from Medline, Embase & National Library of Medicine over the last 30 years up to March 2016. The bibliographies of relevant articles were searched for additional references. FINDINGS Patients with Computer vision syndrome present to a variety of different specialists, including General Practitioners, Neurologists, Stroke physicians and Ophthalmologists. While the condition is common, there is a poor awareness in the public and among health professionals. INTERPRETATIONS AND IMPLICATIONS Recognising this condition in the clinic or in emergency situations like the TIA clinic is crucial. The implications are potentially huge in view of the extensive and widespread use of computers and visual display units. Greater public awareness of Computer vision syndrome and education of health professionals is vital. Preventive strategies should form part of work place ergonomics routinely. Prompt and correct recognition is important to allow management and avoid unnecessary treatments.
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Affiliation(s)
- Sunil Munshi
- Department of Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ashley Varghese
- Department of Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sushma Dhar-Munshi
- Department of Ophthalmology, Kings Mill Hospital, Sherwood Forest Hospitals NHS Trust, Sutton-In-Ashfield, UK
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Foss AJE, Childs M, Reeves BC, Empeslidis T, Tesha P, Dhar-Munshi S, Mughal S, Culliford L, Rogers CA, Tan W, Montgomery A. Comparing different dosing regimens of bevacizumab in the treatment of neovascular macular degeneration: study protocol for a randomised controlled trial. Trials 2015; 16:85. [PMID: 25873213 PMCID: PMC4376508 DOI: 10.1186/s13063-015-0608-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 02/16/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Bevacizumab (Avastin®) is as effective as ranibizumab (Lucentis®) in the treatment of neovascular age-related macular degeneration (nAMD). However it has two important structural differences. First, it has two active sites instead of one; second, it retains the Fc portion of the antibody which would be expected to confer a significantly longer half-life. These agents have been associated with systemic complications including strokes, so it is desirable to use the smallest effective dose. Furthermore, the standard dosing regimen requires monthly hospital visits, which present a significant challenge both to the hospital services and to the patients (who are elderly). METHODS/DESIGN Patients ≥50 years who are eligible for anti-vascular endothelial growth factor (VEGF) treatment of nAMD in the NHS, who are either newly referred for treatment or have reactivation of nAMD and who have not received treatment to either eye for the previous six months. We have designed a factorial multi-centre masked randomised controlled trial using bevacizumab as the intervention, with patients randomised to one of four arms: to standard or low dose and to monthly or two-monthly patient review. The aim is to recruit sufficient patients (around 1,000) to obtain 304 patients meeting the endpoint over a four-year period. The primary endpoint is time to treatment failure to be analysed using Cox regression. DISCUSSION This randomised control trial will show if half dose and two monthly as required is as effective as full dose and monthly regimes. A two monthly as required regimen of Bevacizumab would significantly reduce both the cost and the service delivery burden for the treatment of nAMD while a reduced dose would be expected to enhance the safety profile of this treatment regime. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number: ISRCTN95654194 , registered on 22 September 2009.
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Affiliation(s)
- Alexander J E Foss
- Department of Ophthalmology, Queen's Medical Centre, Middleton Boulevard, Nottingham, NG7 2UH, England.
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Queen's Medical Centre, C-Floor, South Block, Nottingham, NG7 2UH, England.
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Level 7, Bristol, BS2 8HW, England.
| | - Theo Empeslidis
- Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, England.
| | - Paul Tesha
- Lincoln County Hospital, Greetwell Road, Lincoln, LN2 5QY, England.
| | - Sushma Dhar-Munshi
- Department of Ophthalmology, Kings Mill Hospital, Mansfield Road, Sutton-in-Ashfield, NG17 4JL, England.
| | - Samah Mughal
- Nottingham Clinical Trials Unit, Queen's Medical Centre, C-Floor, South Block, Nottingham, NG7 2UH, England.
| | - Lucy Culliford
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Level 7, Bristol, BS2 8HW, England.
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Level 7, Bristol, BS2 8HW, England.
| | - Wei Tan
- Nottingham Clinical Trials Unit, Queen's Medical Centre, C-Floor, South Block, Nottingham, NG7 2UH, England.
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, Queen's Medical Centre, C-Floor, South Block, Nottingham, NG7 2UH, England.
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Abstract
PURPOSE To report a case of T-cell prolymphocytic leukemia with panuveitis as the primary presenting feature. METHODS Case report. RESULTS A 46-year-old woman presented with pain and blurred vision in the right eye. She was found to have signs of panuveitis with a central exudative retinal detachment. Further investigations revealed that she was suffering from the rare T-cell prolymphocytic leukemia. Both systemic and ocular manifestations of the disease resolved after chemotherapy with Campath-IH antigen and as she went into complete remission. The exudative detachment settled, and visual acuity recovered to 20/20. CONCLUSION This case illustrates that leukemias can present with primarily ocular findings, and the sudden appearance of a serous retinal detachment with inflammatory signs in an otherwise healthy person warrants a thorough systemic screening for an underlying malignancy.
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Affiliation(s)
- S Dhar-Munshi
- Croydon Eye Unit, Mayday University Hospital, Thornton Heath, Surrey, United Kingdom.
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Newsom R, Ayliffe W, Dhar-Munshi S, Kirkham N, Liu C. Management of corneal opacification associated with epibulbar choristomata. Br J Ophthalmol 1999; 83:1404-5. [PMID: 10660312 PMCID: PMC1722915 DOI: 10.1136/bjo.83.12.1403a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Dhar-Munshi S, Ayliffe WH, Jayne D. Branch retinal arteriolar occlusion associated with familial factor V Leiden polymorphism and positive rheumatoid factor. Arch Ophthalmol 1999; 117:971-3. [PMID: 10408469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- S Dhar-Munshi
- Department of Ophthalmology, St George's Hospital, London, England.
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