[Compliance of age related macular degeneration patients undergoing anti-VEGF therapy : Analysis and suggestions for improvement]

Impact of the COVID 19 Pandemic on Treatment of nAMD via a Portal-Based Collaboration

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.

Home Optical Coherence Tomography Monitoring for Neovascular Age-Related Macular Degeneration: Transformative Technology or Cool Toy?

The pending introduction of home-based optical coherence tomography (OCT) in managing neovascular age-related macular degeneration (nAMD) has sparked interesting debates. Advocates assert that home-based OCT will revolutionize care of patients with nAMD, while skeptics question its real-world viability and point out its potential drawbacks. This article delves into the dichotomy, presenting the "pro" argument highlighting the transformative potential of home OCT and the "con" perspective, which scrutinizes the limitations and challenges to adapting the technology to the real-world setting. By exploring both sides of the discourse, we aim to address the promises and complexities surrounding the role of home OCT in the management of nAMD.

Non-adherence and non-persistence to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy: a systematic review and meta-analysis

BACKGROUND

Intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections play a key role in treating a range of macular diseases. The effectiveness of these therapies is dependent on patients' adherence (the extent to which a patient takes their medicines as per agreed recommendations from the healthcare provider) and persistence (continuation of the treatment for the prescribed duration) to their prescribed treatment regimens. The aim of this systematic review was to demonstrate the need for further investigation into the prevalence of, and factors contributing to, patient-led non-adherence and non-persistence, thus facilitating improved clinical outcomes.

METHODS

Systematic searches were conducted in Google Scholar, Web of Science, PubMed, MEDLINE, and the Cochrane Library. Studies in English conducted before February 2023 that reported the level of, and/or barriers to, non-adherence or non-persistence to intravitreal anti-VEGF ocular disease therapy were included. Duplicate papers, literature reviews, expert opinion articles, case studies, and case series were excluded following screening by two independent authors.

RESULTS

Data from a total of 409,215 patients across 52 studies were analysed. Treatment regimens included pro re nata, monthly and treat-and-extend protocols; study durations ranged from 4 months to 8 years. Of the 52 studies, 22 included a breakdown of reasons for patient non-adherence/non-persistence. Patient-led non-adherence varied between 17.5 and 35.0% depending on the definition used. Overall pooled prevalence of patient-led treatment non-persistence was 30.0% (P = 0.000). Reasons for non-adherence/non-persistence included dissatisfaction with treatment results (29.9%), financial burden (19%), older age/comorbidities (15.5%), difficulty booking appointments (8.5%), travel distance/social isolation (7.9%), lack of time (5.8%), satisfaction with the perceived improvement in their condition (4.4%), fear of injection (4.0%), loss of motivation (4.0%), apathy towards eyesight (2.5%), dissatisfaction with facilities 2.3%, and discomfort/pain (0.3%). Three studies found non-adherence rates between 51.6 and 68.8% during the COVID-19 pandemic, in part due to fear of exposure to COVID-19 and difficulties travelling during lockdown.

DISCUSSION

Results suggest high levels of patient-led non-adherence/non-persistence to anti-VEGF therapy, mostly due to dissatisfaction with treatment results, a combination of comorbidities, loss of motivation and the burden of travel. This study provides key information on prevalence and factors contributing to non-adherence/non-persistence in anti-VEGF treatment for macular diseases, aiding identification of at-risk individuals to improve real-world visual outcomes. Improvements in the literature can be achieved by establishing uniform definitions and standard timescales for what constitutes non-adherence/non-persistence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020216205.

Towards a population pharmacokinetic/pharmacodynamic model of anti-VEGF therapy in patients with age-related macular degeneration

PURPOSE

To develop a population pharmacokinetic/pharmacodynamic model (popPKPD) of intravitreal bevacizumab treatment for neovascular age-related macular degeneration (nAMD) patients to learn about the PK/PD relationship and utilise it for dosing regimen decisions on future nAMD patients.

METHODS

The Greater Manchester Avastin for Neovascularisation (GMAN) randomised clinical trial data was retrospectively utilised, and the best-corrected visual acuity (BCVA) and central macular retinal thickness (CRT, measured by optical coherence tomography) were the PD inputs to the model. Using the nonlinear mixed-effects method, the best PKPD structural model was investigated, and the clinical significance of the two different dosing treatment regimens (as-needed versus routine) was evaluated.

RESULTS

A structural model to describe the change of BCVA from the baseline of nAMD patients was successfully obtained based on the turnover PD model concept (drug stimulates the "visual acuity response production"). The popPKPD model and simulation indicate that the routine regimen protocol improves patient visual outcome compared to the as-needed protocol. For the change in CRT, the turnover structural PKPD model was too demanding to fit to the given clinical data.

CONCLUSIONS

This is the first popPKPD attempt in nAMD treatment that shows the potential of this strategy to understand/inform the dosing regimen. Clinical trials with richer PD data will provide the means to build more robust models.

Long-term persistence with aflibercept therapy among treatment-naïve patients with exudative age-related macular degeneration in a universal health care system: a retrospective study

Background

This study  aimed to analyse the persistence rates of treatment-naïve patients with neovascular age-related macular degeneration (nAMD) who received intravitreal aflibercept therapy in a universal health care system.

Methods

In this single-centre retrospective cohort study, we audited data of 918 treatment-naïve patients who received exclusively intravitreal aflibercept therapy for nAMD between September 2015 and May 2021. The primary outcome measures were the rates of treatment nonpersistence (gap in ophthalmological care > 6 months) and long-term nonpersistence (> 12 months).

Results

The rates of nonpersistence and long-term nonpersistence were 12.3% and 3.4% after one year; 22.4% and 9.5% after two years; and 38.3% and 19.3% after five years, respectively. Logistic regression analysis revealed that older age (p = 0.045), male sex (p = 0.039), requirement for caretakers or ambulance (p = 0.001), and low visual acuity of the study eye (p = 0.010) or fellow eye (p = 0.029) were independent risk factors for long-term nonpersistence. Patients aged > 80 and > 85 years (p = 0.013 and p = 0.022, respectively) had more than twice the risk for being nonpersistent to therapy within two years of follow-up compared with younger patients. Male patients (p = 0.033), patients requiring a caretaker (p = 0.038), and patients living > 60 km from the clinic (p = 0.029) had a 2 × higher risk of being persistently nonpersistent to therapy.

Conclusions

Patients with nAMD who were treated with aflibercept had lower nonpersistence rates than those reported in current literature. Multiple independent risk factors were correlated with long-term nonpersistence, early nonpersistence, or complete loss to follow-up. Considering the possible consequences of reduced compliance, further strategies are urgently needed for patients at risk of nonpersistence to therapy.

Können digitale Instrumente wie die Makula-App die AMD-Therapie unterstützen?

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.

Impact of the COVID-19 pandemic's first wave on the care and treatment situation of intravitreal injections in a German metropolitan region

Purpose

This study aims to evaluate the impact of the first coronavirus 2019 (COVID-19) wave in 2020 on patients scheduled for intravitreal injections (IVI) in a German metropolitan region.

Methods

We performed a multicentre prospective survey and retrospective analysis of the records of patients treated with intravitreal injections during the 20-week period from March to July 2020 in all four hospital eye departments in the city of Hamburg using a questionnaire (on treatment adherence, SarsCoV2-related personal, familial and social data) and treatment data.

Results

A total of 1038 patients (2472 IVI, 1231 eyes) and 818 questionnaires were evaluated. Longer duration of therapy, lower visual acuity (VA) of the treated and higher VA of the fellow untreated eye was were associated with a higher probability of visit cancellation. Every additional year of life posed a 2.6% lower risk of noncompliance. A COVID-19 infection in the family environment displayed a 5.5-fold chance of visit cancellation. Patients treated for neovascular age-related macular degeneration (nAMD) had a 36% reduced risk of visit cancellation compared to patients with diabetic macular oedema (DME).

Conclusion

A long preceding treatment period, low VA of the treated eye, high VA of the untreated eye, COVID-19 in the family and DME were identified as risk factors for IVI visit cancellations during the COVID-19 pandemic. Compliance to treatment might be improved in the future by taking these risk factors into account when scheduling patients for IVI during the exceptional circumstances of a pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-021-05521-5.

Importance of Treatment Duration: Unmasking Barriers and Discovering the Reasons for Undertreatment of Anti-VEGF Agents in Neovascular Age-Related Macular Degeneration

Purpose

Since non-adherence (NA) to intravitreal therapy with VEGF drugs is one of the most important modifiable factors compromising treatment outcome of nAMD, the purpose of this study was to investigate the contributing factors and barriers during long-term nAMD treatment.

Methods

Barriers and potential reasons for NA were prospectively measured using the Adherence Barriers Questionnaire Intravitreal Therapy (ABQ-IVT). A random sample of patients receiving intravitreal therapy was drawn based on data for different treatment periods. Three age-sex matched groups included the treatment periods of ≤30 months (group 1), between >30 months and ≤60 months (group 2), and >60 months (group 3). The occurrence of gaps between treatments and/or OCT visits was evaluated.

Results

NA with gaps of >56 days after the scheduled appointment was detected in 39%, 89%, and 100% of patients in group 1, 2, and 3, respectively (groups 1 and 2 vs group 3, p < 0.001). Two or more of such gaps were observed in 6%, 72%, and 94% of patients in group 1, 2, and 3, respectively. The overall ABQ-IVT score showed corresponding differences between the groups: 25.89 ± 7.68 (group 1, 95% CI 22.07–29.71), 34.72 ± 10.32 (group 2, 95% CI: 29.59–38.86), and 33.28 ± 9.04 (group 3, 95% CI 28.78–37.77). Accordingly, the score was inversely correlated with the number of regular follow-up visits in groups 2 and 3 (Pearson correlation coefficient r = −0.65 (p = 0.003) and r = −0.5 (p = 0.034), respectively). Within the groups of longer treatment duration, univariate logistic regression analysis showed higher odds of time commitment and challenge accompanying person to be relevant barriers.

Conclusion

NA is an arising problem with increasing duration of intravitreal therapy. Treatment barriers, detected by the ABQ-IVT, might change or increase during the course of the treatment.

Defining Nonadherence and Nonpersistence to Anti-Vascular Endothelial Growth Factor Therapies in Neovascular Age-Related Macular Degeneration

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.

Acceptability of intravitreal injections in geographic atrophy: protocol for a mixed-methods pilot study

INTRODUCTION

Age-related macular degeneration (AMD) is a common cause of visual impairment, affecting central vision. Geographic atrophy (GA) is an advanced form of the non-neovascular (dry) type of AMD. Late-stage clinical trials suggest that intravitreal injections of novel therapeutics may slow down the rate of GA progression by up to 30% in 1 year, thus allowing people with GA to preserve central vision for a longer period. While intravitreal injections have become an established treatment modality for neovascular (wet) AMD, it is unknown whether patients with (more gradually progressing) GA would accept regular injections that slow down, but do not stop or reverse, vision loss. Therefore, this mixed-methods pilot study will aim to explore whether regular intravitreal injections will be acceptable as treatment for patients with GA, and the factors that may affect treatment acceptability.

METHODS AND ANALYSIS

A mixed-methods survey has been designed in collaboration with a GA patient advisory group. The survey comprises of structured questionnaires, semi-structured interview questions regarding patients' perceptions of intravitreal injections and the burden of treatment, and a task eliciting preferences between different potential treatments. Due to COVID-19 restrictions, this study will be conducted remotely by telephone. Thirty individuals will be recruited from NHS Medical Retina clinics at Central Middlesex Hospital, London. Half of the participants will be naïve to intravitreal injections, while half will have previous experience of intravitreal injections for neovascular (wet) AMD. Qualitative data analysis will be conducted using the Framework Method of analysis to identify key themes from participants' accounts.

ETHICS AND DISSEMINATION

The study received Health Research Authority approval on 23 March 2021 (IRAS Project ID: 287824). Findings will be disseminated through peer-reviewed publications and conference presentations to the medical retina community, as well as through dialogue with patients and macular disease charities.

Nonadherence or Nonpersistence to Intravitreal Injection Therapy for Neovascular Age-Related Macular Degeneration: A Mixed-Methods Systematic Review

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.

[Impact of a more stringent organization of intravitreal injection treatment on the number of treatments and examinations in routine practice]

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.

The patients' view: age-related macular degeneration and its effects - a meta-synthesis

Aim: The aim of this meta-synthesis is to find out what it means for patients with age-related macular degeneration to live with visual impairment, how they cope with the illness and how they experience their medical care, including vascular endothelial growth factor inhibitor therapy.Method: Inclusion criteria: qualitative studies exploring patients' experiences with age-related macular degeneration in their daily lives and with medical care, published in journals in English or German. The included studies were analysed following the rules and principles of grounded theory.Results: For the analysis, twenty-four articles matching the inclusion criteria were identified. Three main analytic themes emerged from the included studies: (i) a life shaped by losses; (ii) the burden of medical treatment; and (iii) coping with vision loss. For patients, visual impairment/vision loss means living with multiple losses in various domains of life. With the introduction of vascular endothelial growth factor inhibitor therapy, patients with neovascular age-related macular degeneration have a good chance of slowing down the disease progression; therapy does, however, also represent a major burden.Conclusion: New strategies need to be conceived to reduce the burden of medical treatment and to improve the dissemination of information about age-related macular degeneration.IMPLICATIONS FOR REHABILITATIONMost of the people with age- related macular degeneration seem to adapt to visual impairment.Medical treatment implies a great physical and psychological burden for patients with neovascular (wet) age- related macular degeneration.The physical and psychological burden needs to be recognized and addressed in the management of patients with neovascular (wet) AMD in medical facilities.More research is needed on how rehabilitation services may support the adaptation process of patients in the different stages of AMD.

Systematic review: non-adherence and non-persistence in intravitreal treatment

Purpose

Intravitreal injection of VEGF inhibitors has become the standard of care for different macular diseases within the last years resulting in improved visual outcomes. Under real-life conditions, however, the necessity for frequent retreatments and reexaminations poses a burden for patients and treatment centers. Non-adherence and non-persistence to intravitreal treatment may lead to inferior clinical outcomes, and knowledge of contributing factors is crucial to improve adherence. This systematic review analyzes current literature for potential factors involved in non-adherence and non-persistence.

Methods

A systematic search was conducted in PubMed and Embase including three different aspects of intravitreal injection therapy: (1) diseases with intravitreal injections as treatment, (2) intravitreal injection, and (3) aspects of therapy adherence or therapy persistence. Data from identified quantitative studies were further extracted and grouped according to WHO criteria (condition, socio-economy, therapy, patient, and health system). The methodological quality of identified studies was graded. Identified qualitative studies (i.e., interviews) were descriptively analyzed and their findings narratively reported.

Results

Twenty-four publications were included. In 16 of those publications, a quantitative data analysis was conducted, analyzing factors associated with non-adherence. Worse visual acuity at baseline and unfavorable development of visual acuity, higher age, and greater distance to the treatment center were associated with non-adherence, while there was inconsistent evidence for an association of comorbidity. In qualitative studies, high follow-up/treatment burden, fear and anxiety, disappointed patient expectations, and lack of motivation to continue treatment were reported as reasons for non-persistence.

Conclusions

Knowledge of potential barriers in IVT treatment may improve adherence and potentially clinical results. Improvements can be achieved particularly in the healthcare complex (organizational improvements) and the “patient” complex by establishing realistic expectations. Recurrent education of the patient may be necessary.

Electronic supplementary material

The online version of this article (10.1007/s00417-020-04798-2) contains supplementary material, which is available to authorized users.

[IVOM quality assurance in Westfalen-Lippe : Structure of quality assurance and results of the pilot study Q-VERA]

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.

Efficacy and Treatment Burden of Intravitreal Aflibercept Versus Intravitreal Ranibizumab Treat-and-Extend Regimens at 2 Years: Network Meta-Analysis Incorporating Individual Patient Data Meta-Regression and Matching-Adjusted Indirect Comparison

Purpose

To compare visual outcomes and treatment burden between intravitreally administered aflibercept (IVT-AFL) and ranibizumab (RBZ) treat-and-extend (T&E) regimens in patients with wet age-related macular degeneration (wAMD) at 2 years.

Methods

A systematic literature review was carried out in Medline, EMBASE, and CENTRAL in October 2018. Matching-adjusted indirect comparison (MAIC) and/or individual patient data meta-regression was used to connect ALTAIR (assessing IVT-AFL T&E) with other studies, adjusting for between-trial differences in baseline visual acuity and age or baseline visual acuity, age, and polypoidal choroidal vasculopathy (PCV) status. Sensitivity analyses were conducted to test the robustness of the results, including direct MAIC between IVT-AFL T&E (ALTAIR) and RBZ T&E (CANTREAT and TREX-AMD trials).

Results

Six randomized controlled trials (RCTs) (ALTAIR, VIEW 1 and 2, CATT, CANTREAT, and TREX) were included in the analysis. IVT-AFL T&E was assessed in one study, ALTAIR (n = 255), while RBZ T&E was assessed in two trials (n = 327). At 2 years, the median difference (95% credibility interval) between IVT-AFL T&E and RBZ T&E regarding the numbers of Early Treatment Diabetic Retinopathy Study (ETDRS) letters gained was not significant (M1: − 2.29 [− 8.10, 3.58]; M2: − 0.55 [− 6.34, 5.29]). IVT-AFL T&E was associated with significantly fewer injections than RBZ-T&E (M1: − 6.12 [− 7.60, − 4.65]; M2: − 5.93 [− 7.42, − 4.45]). Results of the sensitivity analyses were consistent with the main scenarios.

Conclusion

Patients with wAMD receiving an IVT-AFL T&E regimen achieved and maintained improvement in visual acuity with fewer injections over 2 years compared with RBZ T&E. IVT-AFL T&E may therefore serve as the optimal therapy for wAMD, as it was associated with clinical efficacy and minimized treatment burden.

Electronic supplementary material

The online version of this article (10.1007/s12325-020-01298-x) contains supplementary material, which is available to authorized users.

[ANDROMEDA-an investigation of factors influencing the adherence of patients with neovascular age-related macular degeneration using the newly developed patient questionnaire LAF-IVT]

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.

[Reasons for delayed and discontinued therapy in age-related macular degeneration]

BACKGROUND

Critical prerequisites for successful therapy of neovascular age-related macular degeneration (nvAMD) are an early initiation and continuous monitoring; however, delays in starting therapy and non-medically indicated discontinuation of therapy are frequent, which limits therapy efficacy and, thus, visual outcomes.

OBJECTIVE

To identify the reasons for delay in therapy and non-medically indicated termination of therapy.

MATERIAL AND METHODS

Patients who had started a new therapy (starters) and those who independently terminated therapy (dropouts) were interviewed by telephone with a specific, standardized questionnaire. Results were summarized descriptively.

RESULTS

A total of 100 starters and 55 dropouts were interviewed. The mean therapy delay was 22 (±28 SD) days. This was mainly due to the time until the decision to see an ophthalmologist was made. Main reasons for dropping out were: transportation issues (27%), poor general health (25%) and the assumption that there is no benefit from therapy (11%). Of the patients who dropped out 63% would have liked to continue therapy.

CONCLUSION

There is potential for improvement in nvAMD management regarding therapy start as well as therapy maintenance. Sensitizing for initial nvAMD symptoms is important as is reduction of barriers to therapy maintenance, since most therapy dropouts would like to continue the therapy.

[Patient's Knowledge after Informed Consent for Intravitreal Injections]

BACKGROUND

Intravitreal treatment (IVT) is one of the most common ophthalmological procedures. Therapeutic effectiveness is however dependent on patient compliance. Unwanted treatment cessation rates are high though. The authors therefore decided to analyse the patient's knowledge and treatment expectations, as discrepancies are known to negatively affect compliance and thus treatment outcomes.

PATIENTS AND METHODS

The study was designed as an exploratory survey. In total, 100 patients presenting to an outpatient clinic of a tertiary care centre from October to December 2016 were included. A structured, anonymised questionnaire was handed out, consisting mainly of question items with closed code lists as response domains. Solely descriptive analysis of results was performed.

RESULTS

The median age of patients was 73 years. 70% had received more than 3 IVTs in at least one eye. Age-related macula degeneration was the most common underlying cause (52%). 64% expected improvement of visual acuity after IVT. 42% could not name one medication used in their IVT. 55% felt that the information provided during informed consent had been adequate. 69% did not know the post-surgical occurrence of endophthalmitis. Three patients were confident of being able to drive a car directly after IVT.

CONCLUSION

Patient's knowledge of their underlying disease, treatment goals and complications rates exhibited some deficiencies. Standardised patient information sheets could be of significant use and were actively suggested by patients to improve the informed consent process.

Quantitative biometry of zebrafish retinal vasculature using optical coherence tomographic angiography

The zebrafish is a robust model for studying human ophthalmic function and disease because of its fecundity, life-cycle, and similarities between its retinal structure and the human retina. Here, we demonstrate longitudinal in vivo imaging of retinal structure using optical coherence tomography (OCT) and noninvasive retinal vascular perfusion imaging using OCT angiography (OCT-A) in zebrafish. In addition, we present methods for retinal vascular segmentation and biometry to quantify vessel branch length, curvature, and angle. We further motivate retinal vascular biometry as a novel method for noninvasive zebrafish identification and demonstrated 99.9% accuracy for uniquely identifying eyes from a set of 200 longitudinal OCT/OCT-A volumes. The described methods enable the quantitative analysis of the vascular changes in zebrafish models of ophthalmic diseases and may broadly benefit large-scale zebrafish studies.

Effect of anti-VEGF drugs combined with photodynamic therapy in the treatment of age-related macular degeneration

We analyzed the effects of anti-vascular endothelial growth factor (VEGF) drugs combined with photodynamic therapy (PDT) in the treatment of age-related macular degeneration (AMD). Ninety-six cases (192 eyes) of AMD were included in this study and randomly divided into the observation group and control group (n=48 cases per group). The control group was administered the treatment of Lucentis intravitreal injection alone and the observation group was administered Lucentis combined with PDT. The therapeutic effects were compared. The best corrected visual acuity of patients in the two groups increased gradually after treatment. Patients in the observation group had a significantly higher visual acuity when compared to the control group 1 and 6 months post-operation. The differences were statistically significant (P<0.05). The proportion of patients with vision improvement in the observation group was higher than that in the control group from 1 to 6 months; differences were statistically significant (P<0.05). Through detection by color Doppler ultrasound within 6 months after treatment, we observed that the peak systolic velocity and arterial end diastolic velocity of retrobulbar optic nerve bitemporal PCA of the observation group were higher than those of the control group. The values of arterial resistance index and pulsatility index of the observation group were lower than those of control group. The differences were statistically significant (P<0.05). Six months after treatment, the value of central foveal thickness of the observation group was lower than that of the control group, the value of mean sensitivity of visual field parameter 10° and 4° was higher in the observation group than in the control group, and the absolute value of mean defects in the observation group were lower than that of the control group. In summary, the differences were statistically significant (P<0.05). Anti-VEGF drugs combined with PDT can optimize the overall vision of patients with AMD, improve hemodynamic parameters and reduce visual field defects.