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Fenner BJ, Ting DSW, Tan ACS, Teo K, Chan CM, Mathur R, Yeo IYS, Wong TY, Wong EYM, Cheung CMG. Real-World Treatment Outcomes of Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy in Asians. Ophthalmol Retina 2019; 4:403-414. [PMID: 31953109 DOI: 10.1016/j.oret.2019.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/06/2019] [Accepted: 10/28/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the 12-month outcomes of treatment-naïve eyes with choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) after initiation of intravitreal anti-vascular endothelial growth factor (VEGF) monotherapy or combination therapy with verteporfin photodynamic therapy (PDT). DESIGN A 12-month single-center, retrospective, comparative, nonrandomized cohort study. PARTICIPANTS Patients with AMD or PCV who initiated intravitreal anti-VEGF therapy during 2015. METHODS Demographics, visual outcomes, OCT, and treatment data were collected at baseline and months 1, 3, 6, and 12 after treatment initiation. Multivariate analysis was performed to identify baseline features predictive of visual maintenance and improvement after 12 months of treatment. MAIN OUTCOME MEASURES Primary end point was visual acuity (VA) change from baseline to month 12. Secondary end points were treatment exposure and change in central subfield thickness on OCT. RESULTS A total of 364 patients (165 AMD and 199 PCV) were included. Baseline vision was 41 and 43 logarithm of the minimum angle of resolution (logMAR) letters for AMD and PCV patients, respectively. Patients with AMD and PCV received 5.5 and 5.3 injections (5.0 monotherapy vs. 5.6 combination therapy; mean, 1.2 PDT sessions), respectively. Patients with AMD gained 4.7 logMAR letters after 12 months (P = 0.002), whereas PCV patients gained 6.6 logMAR letters (P = 0.001) and 10.8 logMAR letters (P < 0.001) for monotherapy and combination therapy, respectively. Only patients with presenting VA of fewer than 35 letters (Snellen equivalent, 6/60) achieved significant visual improvement (10.4 letters for AMD, 17.1 letters for PCV with monotherapy, and 35.5 letters for PCV with combination therapy). Predictors of VA gain included number of intravitreal injections (AMD and PCV adjusted odds ratio, 12.1 [P = 0.001] and 12.5 [P = 0.004] for ≥7 injections, respectively) and baseline VA of 20 logMAR letters or fewer (adjusted odds ratio, 3.8 and 10.6 for AMD and PCV, respectively). Age, gender, race, use of PDT or focal laser therapy, and central subfield thickness were not predictive of significant visual gain at 12 months. CONCLUSIONS In Asian patients, treatment of AMD with anti-VEGF therapy yielded 12-month visual outcomes comparable with those of other real-world studies from Western populations but poorer than those of controlled trials. In contrast, for PCV eyes, anti-VEGF monotherapy and combination therapy with PDT yielded comparable outcomes as those of controlled clinical trials.
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Affiliation(s)
- Beau J Fenner
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore
| | - Daniel S W Ting
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Anna C S Tan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Kelvin Teo
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Choi Mun Chan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Ranjana Mathur
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Ian Y S Yeo
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Tien Y Wong
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Edmund Y M Wong
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Chui Ming Gemmy Cheung
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore.
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Kim JH, Chang YS, Kim JW, Kim CG, Lee DW. Long-term incidence and timing of reactivation in patients with type 3 neovascularization after initial treatment. Graefes Arch Clin Exp Ophthalmol 2019; 257:1183-1189. [PMID: 30931489 DOI: 10.1007/s00417-019-04306-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 02/12/2019] [Accepted: 03/21/2019] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The purpose of the present study was to evaluate the long-term incidence and timing of reactivation in patients with type 3 neovascularization who were treated with three monthly anti-vascular endothelial growth factor (VEGF) injections. METHODS A total of 179 patients (179 eyes) diagnosed with type 3 neovascularization with dry macula after three monthly anti-VEGF loading injections were included in this retrospective study. After the initial treatment, patients were followed up without further injection until the first reactivation. The incidence and timing of the first reactivation after the initial treatment were recorded, and factors predictive of early reactivation (≤ 6 months after the third anti-VEGF injection) were investigated. RESULTS During a mean follow-up of 37.5 ± 18.8 months, the first reactivation was noted in 145 patients (81.0%) at a mean of 6.6 ± 4.1 months after the third injection. In 94 eyes (64.8%), reactivation was noted 2-6 months after the third injection, while in 37 eyes (25.5%) it was noted 7-12 months after the third injection. In the remaining 14 eyes (9.7%), the reactivation was noted after this period. The incidence of early reactivation was higher in women (P = 0.014) and patients with thicker choroid (P = 0.026). CONCLUSIONS In patients with type 3 neovascularization, almost all reactivation was noted within 15 months of the third anti-VEGF injection, suggesting the need for close follow-up and detailed examination during this period. Female patients with thick choroid should be monitored more frequently during this early period.
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Affiliation(s)
- Jae Hui Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, #156 Youngdeungpo-dong 4ga, Youngdeungpo-gu, Seoul, 150-034, South Korea.
| | - Young Suk Chang
- Department of Ophthalmology, Konyang University College of Medicine, Daejeon, South Korea
| | - Jong Woo Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, #156 Youngdeungpo-dong 4ga, Youngdeungpo-gu, Seoul, 150-034, South Korea
| | - Chul Gu Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, #156 Youngdeungpo-dong 4ga, Youngdeungpo-gu, Seoul, 150-034, South Korea
| | - Dong Won Lee
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, #156 Youngdeungpo-dong 4ga, Youngdeungpo-gu, Seoul, 150-034, South Korea
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Elshout M, Webers CA, van der Reis MI, Schouten JS. A systematic review on the quality, validity and usefulness of current cost-effectiveness studies for treatments of neovascular age-related macular degeneration. Acta Ophthalmol 2018; 96:770-778. [PMID: 29862641 DOI: 10.1111/aos.13824] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 04/13/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Ophthalmologists increasingly depend on new drugs to advance their treatment options. These options are limited by restraints on reimbursements for new and expensive drugs. These restraints are put in place through health policy decisions based on cost-effectiveness analyses (CEA). Cost-effectiveness analyses need to be valid and of good quality to support correct decisions to create new treatment opportunities. In this study, we report the quality, validity and usefulness of CEAs for therapies for nAMD. METHODS A systematic review in PubMed, EMBASE and Cochrane was performed to include CEAs. Quality and validity assessment was based on current general quality criteria and on elements that are specific to the field of ophthalmology. RESULTS Forty-eight CEAs were included in the review. Forty-four CEAs did not meet four basic model quality and validity criteria specific to CEAs in the field of ophthalmology (both eyes analysed instead of one; a time horizon extending beyond 4 years; extrapolating VA and treatment intervals beyond trial data realistically; and including the costs of low-vision). Four CEAs aligned with the quality and validity criteria. In two of these CEAs bevacizumab as-needed (PRN) was more cost-effective than bevacizumab monthly; aflibercept (VIEW); or ranibizumab monthly or PRN. In two CEAs, ranibizumab (PRN or treat and extent) was dominant over aflibercept. In two other CEAs, aflibercept was either more cost-effective or dominant over ranibizumab monthly or PRN. CONCLUSION Two of the CEAs of sufficient quality and validity show that bevacizumab PRN is the most cost-effective treatment. Comparing ranibizumab and aflibercept, either treatment can be more cost-effective depending on the assumptions used for drug prices and treatment frequencies. The majority of the published CEAs are of insufficient quality and validity. They wrongly inform decision-makers at the cost of opportunities for ophthalmologists to treat patients. As such, they may negatively influence overall patient outcomes and societal costs. For future ophthalmic treatments, CEAs need to be improved and only published when they are of sufficient quality and validity.
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Affiliation(s)
- Mari Elshout
- Maastricht University Medical Center; University Eye Clinic Maastricht; Maastricht The Netherlands
| | - Carroll A.B. Webers
- Maastricht University Medical Center; University Eye Clinic Maastricht; Maastricht The Netherlands
| | - Margriet I. van der Reis
- Maastricht University Medical Center; University Eye Clinic Maastricht; Maastricht The Netherlands
| | - Jan S.A.G. Schouten
- Maastricht University Medical Center; University Eye Clinic Maastricht; Maastricht The Netherlands
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Patel S. Medicare Spending on Anti–Vascular Endothelial Growth Factor Medications. ACTA ACUST UNITED AC 2018; 2:785-791. [DOI: 10.1016/j.oret.2017.12.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 11/30/2017] [Accepted: 12/12/2017] [Indexed: 01/01/2023]
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Real JP, Luna JD, Palma SD. The reactivation time in the treatment of AMD: a forgotten key parameter? Graefes Arch Clin Exp Ophthalmol 2018; 256:1079-1087. [PMID: 29675724 DOI: 10.1007/s00417-018-3974-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE Summarize and compare the available evidence on the reactivation times in patients with age-related macular degeneration treated with Ranibizumab (RNB). METHOD Systematic review of studies that reported the reactivation time of patients (direct method) or the number of injections received in a certain period of follow-up (indirect method). RESULTS Only 18 of 89 selected studies reported the average reactivation time of patients in a manifest form, without the need of any calculation. The average calculated, weighted reactivation time was 101.8 days with the direct method and 99.8 days in the indirect method (84 studies included). With both methods, it was found that the average reactivation time of the RCTs was between 2 and 3 weeks less than the average time identified in the observational studies. These differences are also reflected in the clinical results, there being a correlation between the number of doses received and the change in BCVA. The analysis of 11 comparative studies showed a difference in reactivation times between patients treated with RNB or Bevacizumab (BVZ). CONCLUSION There are few direct studies of reactivation time, but calculation from the PRN dose number turns out to be a good approximation for retrospective study of the variable. The use of the PRN, with criteria not based on optical coherence tomography scans, delays the application of doses between 2 or 3 weeks, and patients suffer loss of clinical benefits. RNB enables patients to receive less injections than BVZ throughout treatment.
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Affiliation(s)
- J P Real
- Unidad de Investigación y Desarrollo en Tecnología Farmacéutica (UNITEFA), CONICET and Departamento de Ciencias Farmacéuticas, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Ciudad Universitaria, 5000, Córdoba, Argentina
| | - J D Luna
- Vitreo-Retinal Department, Centro Privado de Ojos Romagosa SA - Fundación VER, Deán Funes 429/432, Córdoba, Argentina
| | - S D Palma
- Unidad de Investigación y Desarrollo en Tecnología Farmacéutica (UNITEFA), CONICET and Departamento de Ciencias Farmacéuticas, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Ciudad Universitaria, 5000, Córdoba, Argentina.
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Windsor MA, Sun SJ, Frick KD, Swanson EA, Rosenfeld PJ, Huang D. Estimating Public and Patient Savings From Basic Research-A Study of Optical Coherence Tomography in Managing Antiangiogenic Therapy. Am J Ophthalmol 2018; 185:115-122. [PMID: 29224686 DOI: 10.1016/j.ajo.2017.09.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 01/21/2023]
Abstract
PURPOSE To compare patient and Medicare savings from the use of optical coherence tomography (OCT) in guiding therapy for neovascular age-related macular degeneration (nvAMD) to the research investments made in developing OCT by the National Institutes of Health (NIH) and the National Science Foundation (NSF). DESIGN Observational cohort study. METHODS Main outcome measures were spending by Medicare as tracked by Current Procedural Terminology codes on intravitreal injections (67028), retinal OCT imaging (92134), and anti-vascular endothelial growth factor (anti-VEGF) treatment-specific J-codes (J0178, J2778, J9035, J3490, and J3590). These claims were identified from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services among fee-for-service (FFS) Medicare beneficiaries from 2012 to 2015; 2008 claims were acquired from the 100% FFS Part B Medicare Claims File. OCT research costs were determined by searching for grants awarded by NIH and NSF from inception to 2015. All costs and savings were discounted by 3% annually and adjusted for inflation to 2015 dollars. RESULTS From 2008 to 2015, the United States government and nvAMD patients have accrued an estimated savings of $9.0 billion and $2.2 billion, respectively, from the use of OCT to guide personalized anti-VEGF treatment. The $9.0 billion represents a 21-fold return on government investment into developing the technology through NIH and NSF grants. CONCLUSIONS Although an overall cost-benefit ratio of government-sponsored research is difficult to estimate because the benefit may be diffuse and delayed, the investment in OCT over 2 decades has been recouped many times over in just a few years through better personalized therapy.
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SOCIETAL COSTS ASSOCIATED WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION IN THE UNITED STATES. Retina 2016; 36:285-98. [PMID: 26428606 DOI: 10.1097/iae.0000000000000717] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to use a cross-sectional prevalence-based health care economic survey to ascertain the annual, incremental, societal ophthalmic costs associated with neovascular age-related macular degeneration. METHODS Consecutive patients (n = 200) with neovascular age-related macular degeneration were studied. A Control Cohort included patients with good (20/20-20/25) vision, while Study Cohort vision levels included Subcohort 1: 20/30 to 20/50, Subcohort 2: 20/60 to 20/100, Subcohort 3: 20/200 to 20/400, and Subcohort 4: 20/800 to no light perception. An interviewer-administered, standardized, written survey assessed 1) direct ophthalmic medical, 2) direct nonophthalmic medical, 3) direct nonmedical, and 4) indirect medical costs accrued due solely to neovascular age-related macular degeneration. RESULTS The mean annual societal cost for the Control Cohort was $6,116 and for the Study Cohort averaged $39,910 (P < 0.001). Study Subcohort 1 costs averaged $20,339, while Subcohort 4 costs averaged $82,984. Direct ophthalmic medical costs comprised 17.9% of Study Cohort societal ophthalmic costs, versus 74.1% of Control Cohort societal ophthalmic costs (P < 0.001) and 10.4% of 20/800 to no light perception subcohort costs. Direct nonmedical costs, primarily caregiver, comprised 67.1% of Study Cohort societal ophthalmic costs, versus 21.3% ($1,302/$6,116) of Control Cohort costs (P < 0.001) and 74.1% of 20/800 to no light perception subcohort costs. CONCLUSION Total societal ophthalmic costs associated with neovascular age-related macular degeneration dramatically increase as vision in the better-seeing eye decreases.
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Kawczyk-Krupka A, Bugaj A, Potempa M, Wasilewska K, Latos W, Sieroń A. Vascular-targeted photodynamic therapy in the treatment of neovascular age-related macular degeneration: Clinical perspectives. Photodiagnosis Photodyn Ther 2015; 12:161-75. [DOI: 10.1016/j.pdpdt.2015.03.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 03/09/2015] [Accepted: 03/10/2015] [Indexed: 01/23/2023]
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Dakin HA, Wordsworth S, Rogers CA, Abangma G, Raftery J, Harding SP, Lotery AJ, Downes SM, Chakravarthy U, Reeves BC. Cost-effectiveness of ranibizumab and bevacizumab for age-related macular degeneration: 2-year findings from the IVAN randomised trial. BMJ Open 2014; 4:e005094. [PMID: 25079928 PMCID: PMC4120317 DOI: 10.1136/bmjopen-2014-005094] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assess the incremental cost and cost-effectiveness of continuous and discontinuous regimens of bevacizumab (Avastin) and ranibizumab (Lucentis) for neovascular age-related macular degeneration (nAMD) from a UK National Health Service (NHS) perspective. DESIGN A within-trial cost-utility analysis with a 2-year time horizon, based on a multicentre factorial, non-inferiority randomised controlled trial. SETTING 23 hospital ophthalmology clinics. PARTICIPANTS 610 patients aged ≥50 years with untreated nAMD in the study eye. INTERVENTIONS 0.5 mg ranibizumab or 1.25 mg bevacizumab given continuously (monthly) or discontinuously (as-needed) for 2 years. MAIN OUTCOME MEASURES Quality-adjusted life-years (QALYs). RESULTS Total 2-year costs ranged from £3002/patient ($4700; 95% CI £2601 to £3403) for discontinuous bevacizumab to £18 590/patient ($29 106; 95% CI £18 258 to £18 922) for continuous ranibizumab. Ranibizumab was significantly more costly than bevacizumab for both continuous (+£14 989/patient ($23 468); 95% CI £14 522 to £15 456; p<0.001) and discontinuous treatment (+£8498 ($13 305); 95% CI £7700 to £9295; p<0.001), with negligible difference in QALYs. Continuous ranibizumab would only be cost-effective compared with continuous bevacizumab if the NHS were willing to pay £3.5 million ($5.5 million) per additional QALY gained. Patients receiving continuous bevacizumab accrued higher total costs (+£599 ($938); 95% CI £91 to £1107; p=0.021) than those receiving discontinuous bevacizumab, but also accrued non-significantly more QALYs (+0.020; 95% CI -0.032 to 0.071; p=0.452). Continuous bevacizumab therefore cost £30 220 ($47 316) per QALY gained versus discontinuous bevacizumab. However, bootstrapping demonstrated that if the NHS is willing to pay £20 000/QALY gained, there is a 37% chance that continuous bevacizumab is cost-effective versus discontinuous bevacizumab. CONCLUSIONS Ranibizumab is not cost-effective compared with bevacizumab, being substantially more costly and producing little or no QALY gain. Discontinuous bevacizumab is likely to be the most cost-effective of the four treatment strategies evaluated in this UK trial, although there is a 37% chance that continuous bevacizumab is cost-effective. TRIAL REGISTRATION NUMBER ISRCTN92166560.
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Affiliation(s)
- Helen A Dakin
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - James Raftery
- Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Andrew J Lotery
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Susan M Downes
- Oxford Eye Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Usha Chakravarthy
- Centre for Experimental Medicine, The Queen's University of Belfast, Belfast, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Lemos-Reis R, Moreira-Gonçalves N, Melo AB, Carneiro AM, Falcão-Reis FM. Immediate effect of intravitreal injection of bevacizumab on intraocular pressure. Clin Ophthalmol 2014; 8:1383-8. [PMID: 25092962 PMCID: PMC4114901 DOI: 10.2147/opth.s64721] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Purpose To investigate the immediate effect of intravitreal injection of bevacizumab on intraocular pressure (IOP). Methods This was a prospective and nonrandomized study. A total of 291 eyes with macular edema or active choroidal neovascularization were submitted to a single 1.25 mg (0.05 mL) bevacizumab intravitreal injection. Intraocular pressure was measured with an Icare® tonometer immediately before and after injection in a seated position. The presence of subconjunctival reflux was recorded. The fellow eye served as the control. Results Mean preoperative IOP was 18.0±5.9 mmHg in the treated eye versus 16.9±6.0 mmHg in the fellow eye. Mean postoperative IOP was 42.1±14.5 mmHg in the treated eye versus 17.5±6.0 mmHg in the fellow eye. The IOP variation was statistically significant in both cases and controls (P<0.001 and P=0.003, respectively), and this increase was higher in cases than in controls (P<0.001). Postoperative IOPs higher than 50 mmHg were achieved in 32.0% of the eyes. Subconjunctival reflux was present in 21.3% and determined a lower IOP rise (P<0.001). Tested variables (glaucoma, phakic status, and sex) did not have a statistically significant effect on IOP rise or subconjunctival reflux. Conclusion IOP increases with intravitreal bevacizumab injection, reaching 50 mmHg or more in about one third of patients. A higher IOP is expected if no subconjunctival reflux occurs. The baseline IOP does not influence the incidence of subconjunctival reflux. The clinical relevance of these facts has yet to be clarified.
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Affiliation(s)
| | | | - António B Melo
- Department of Ophthalmology of Hospital de São João, Porto, Portugal
| | - Angela M Carneiro
- Department of Ophthalmology of Hospital de São João, Porto, Portugal ; Department of Sense Organs, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Fernando M Falcão-Reis
- Department of Ophthalmology of Hospital de São João, Porto, Portugal ; Department of Sense Organs, Faculty of Medicine, University of Porto, Porto, Portugal
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Ranibizumab versus Bevacizumab for Neovascular Age-related Macular Degeneration: Results from the GEFAL Noninferiority Randomized Trial. Ophthalmology 2013; 120:2300-9. [PMID: 23916488 DOI: 10.1016/j.ophtha.2013.06.020] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 05/31/2013] [Accepted: 06/06/2013] [Indexed: 11/22/2022] Open
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Uğurlu N, Aşık MD, Yülek F, Neselioglu S, Cagil N. Oxidative Stress and Anti-oxidative Defence in Patients with Age-related Macular Degeneration. Curr Eye Res 2013; 38:497-502. [DOI: 10.3109/02713683.2013.774023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cionni DA, Lewis SA, Petersen MR, Foster RE, Riemann CD, Sisk RA, Hutchins RK, Miller DM. Analysis of Outcomes for Intravitreal Bevacizumab in the Treatment of Choroidal Neovascularization Secondary to Ocular Histoplasmosis. Ophthalmology 2012; 119:327-32. [DOI: 10.1016/j.ophtha.2011.08.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 07/24/2011] [Accepted: 08/19/2011] [Indexed: 11/30/2022] Open
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Day S, Acquah K, Lee PP, Mruthyunjaya P, Sloan FA. Medicare costs for neovascular age-related macular degeneration, 1994-2007. Am J Ophthalmol 2011; 152:1014-20. [PMID: 21843875 DOI: 10.1016/j.ajo.2011.05.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 05/07/2011] [Accepted: 05/10/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE To assess changes in Medicare payments for neovascular age-related macular degeneration (AMD) since introduction of anti-vascular endothelial growth factor (VEGF) therapies. DESIGN Retrospective, longitudinal cohort study. METHODS Using the Medicare 5% sample, beneficiaries with new diagnoses of neovascular AMD in 1994 (N = 2497), 2000 (N = 3927), and 2006 (N = 6041) were identified using International Classification of Diseases (ICD-9-CM). The total first-year health care and eye care costs were calculated for each beneficiary. Propensity score matching was used to match individuals in the 2000 and 2006 cohorts with the 1994 cohort on age, sex, race, Charlson Comorbidity Index, and low vision/blindness. RESULTS The number of beneficiaries newly diagnosed with neovascular AMD more than doubled between the 1994 and 2006 cohorts. Overall yearly Part B payments per beneficiary increased significantly from $3567 for the 1994 to $5991 for the 2006 cohort (P < .01) in constant 2008 dollars. Payments for eye care alone doubled from $1504 for the 1994 cohort to $3263 for the 2006 cohort (P < .01). Most of the increase in payments for eye care in 2006 reflected payments for anti-VEGF injections, which were $1609 over 1 year. Mean annual numbers of visits and imaging studies also increased significantly between the 1994 and 2006 cohort. Results were similar in the matched sample. CONCLUSIONS The introduction of anti-VEGF intravitreal injections has offered remarkable clinical benefits for patients with neovascular AMD, but these benefits have come at the cost of an increased financial burden of providing care for these patients.
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Smiddy WE. Economic considerations of macular edema therapies. Ophthalmology 2011; 118:1827-33. [PMID: 21507488 DOI: 10.1016/j.ophtha.2010.12.034] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 12/16/2010] [Accepted: 12/30/2010] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To relate costs and treatment benefits for diabetic macular edema (DME), branch retinal vein occlusion (BRVO), and central retinal vein occlusion (CRVO). DESIGN A model of resource use, outcomes, and cost-effectiveness and utility. PARTICIPANTS None. METHODS Results from published clinical trials (index studies) of laser, intravitreal corticosteroids, intravitreal anti-vascular endothelial growth factor (VEGF) agents, and vitrectomy trials were used to ascertain visual benefit and clinical protocols. Calculations followed from the costs of 1 year of treatment for each treatment modality and the visual benefits as ascertained. MAIN OUTCOME MEASURES Visual acuity (VA) saved, cost of therapy, cost per line saved, cost per line-year saved, and costs per quality-adjusted life years (QALYs). RESULTS The lines saved for DME (0.26-2.02), BRVO (0.74-4.92), and CRVO (1.2-3.75) yielded calculations of costs/line of saved VA for DME ($1329-$11,609), BRVO ($494-$13,039), and CRVO ($704-$7611); costs/line-year for DME ($60-$561), BRVO ($25-$754), and CRVO ($45-$473); and costs/QALY ($824 to $25,566). CONCLUSIONS Relative costs and benefits should be considered in perspective when applying and developing treatment strategies.
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Affiliation(s)
- William E Smiddy
- Bascom Palmer Eye Institute, PO Box 016880, Miami, FL 33101-6880, USA.
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Subfoveal retinal and choroidal thickness after verteporfin photodynamic therapy for polypoidal choroidal vasculopathy. Am J Ophthalmol 2011; 151:594-603.e1. [PMID: 21295766 DOI: 10.1016/j.ajo.2010.10.030] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/20/2010] [Accepted: 10/20/2010] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the morphologic retinal and choroidal changes after verteporfin photodynamic therapy (PDT) with and without ranibizumab for polypoidal choroidal vasculopathy using spectral-domain optical coherence tomography. DESIGN Retrospective, comparative series. METHODS The enhanced depth imaging optical coherence tomography technique was used in this retrospective, comparative series to measure the subfoveal retinal and choroidal thicknesses before and after treatment. RESULTS Twenty-seven eyes with polypoidal choroidal vasculopathy were examined retrospectively. Sixteen eyes were treated with PDT monotherapy (PDT group). Eleven eyes were treated with PDT after intravitreal ranibizumab injection (ranibizumab plus PDT group). The polypoidal lesions regressed in all cases at 3 months. The mean retinal thickness, including the retinal detachment, increased from 401 ± 157 μm before treatment to 506 ± 182 μm 2 days after PDT (P<.001) and decreased to 365 ± 116 μm by 1 week after treatment (P=.03) and 265 ± 127 μm by 6 months after treatment (P<.001). The mean choroidal thickness increased from 269 ± 107 μm before treatment to 336 ± 96 μm 2 days after PDT treatment (P < .001 compared with baseline) and decreased to 262 ± 96 μm by 1 week after treatment (P=.24) and 229 ± 104 μm by 6 months (P<.001). Although the choroidal thickness showed a similar trend with both therapies, the retinal thickness in the ranibizumab plus PDT group remained thinner than that in the PDT group until 6 months after treatment. CONCLUSIONS PDT was associated with decreased retinal and choroidal thicknesses. Combination therapy reduced the transient exudation after PDT in some cases, and monthly intravitreal ranibizumab injections maintained retinal thinning and seemed to improve vision better than PDT monotherapy.
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Mitchell P, Annemans L, White R, Gallagher M, Thomas S. Cost effectiveness of treatments for wet age-related macular degeneration. PHARMACOECONOMICS 2011; 29:107-131. [PMID: 21244102 DOI: 10.2165/11585520-000000000-00000] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Age-related macular degeneration (AMD) is a leading cause of blindness in people aged ≥50 years. Wet AMD in particular has a major impact on patient quality of life and imposes substantial burdens on healthcare systems. This systematic review examined the cost-effectiveness data for current therapeutic options for wet AMD. PubMed and EMBASE databases were searched for all articles reporting original cost-effectiveness analyses of wet AMD treatments. The Centre for Reviews and Dissemination and Cochrane Library databases were searched for all wet AMD health technology assessments (HTAs). Overall, 44 publications were evaluated in full and included in this review. A broad range of cost-effectiveness analyses were identified for the most commonly used therapies for wet AMD (pegaptanib, ranibizumab and photodynamic therapy [PDT] with verteporfin). Three studies evaluated the cost effectiveness of bevacizumab in wet AMD. A small number of analyses of other treatments, such as laser photocoagulation and antioxidant vitamins, were also found. Ranibizumab was consistently shown to be cost effective for wet AMD in comparison with all the approved wet AMD therapies (four of the five studies identified showed ranibizumab was cost effective vs usual care, PDT or pegaptanib); however, there was considerable variation in the methodology for cost-effectiveness modelling between studies. Findings from the HTAs supported those from the PubMed and EMBASE searches; of the seven HTAs that included ranibizumab, six (including HTAs for Australia, Canada and the UK) concluded that ranibizumab was cost effective for the treatment of wet AMD; most compared ranibizumab with PDT and/or pegaptanib. By contrast, HTAs at best generally recommended pegaptanib or PDT for restricted use in subsets of patients with wet AMD. In the literature analyses, pegaptanib was found to be cost effective versus usual/best supportive care (including PDT) or no treatment in one of five studies; the other four studies found pegaptanib was of borderline cost effectiveness depending on the stage of disease and time horizon. PDT was shown to be cost effective versus usual/best supportive care or no treatment in five of nine studies; two studies showed that PDT was of borderline cost effectiveness depending on baseline visual acuity, and two showed that PDT was not cost effective. We identified no robust studies that properly evaluated the cost effectiveness of bevacizumab in wet AMD.
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Affiliation(s)
- Paul Mitchell
- Discipline of Ophthalmology, University of Sydney, Westmead Hospital, Hawkesbury Road, Westmead, New South Wales, Australia.
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Keane PA, Sadda SR. Predicting visual outcomes for macular disease using optical coherence tomography. Saudi J Ophthalmol 2011; 25:145-58. [PMID: 23960916 DOI: 10.1016/j.sjopt.2011.01.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 01/21/2011] [Indexed: 12/31/2022] Open
Abstract
In recent years, the management of macular disease has undergone radical changes, in part because of new therapeutic approaches, but also due to the introduction of a new imaging modality - optical coherence tomography (OCT). The application of OCT imaging has clarified many aspects of chorioretinal disease pathophysiology and elucidated many hitherto unrecognized disease characteristics. From an early stage in its development, OCT has also been revolutionary in attempting to extract clinically useful measurements from image data in an automated fashion. As a result, OCT-derived measurements of retinal thickness have been rapidly embraced in clinical and research settings. However, as knowledge of OCT image analysis has developed, it has become increasingly clear that even accurate measurements of retinal thickness may fail to predict visual outcomes for many diseases. As a result, the focus of much current clinical imaging research is on the identification of other OCT-derived anatomic biomarkers predictive of visual outcomes - such biomarkers could serve as surrogate endpoints in clinical trials and provide prognostic information in clinical practice. In this review, we begin by highlighting the importance of accurate visual function assessment and describing the fundamentals of OCT image evaluation, before describing the current state-of-the-art with regard to predicting visual outcomes, for a variety of macular diseases, using OCT.
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Key Words
- AMD, age-related macular degeneration
- Age-related macular degeneration
- BRVO, branch retinal vein occlusion
- CME, cystoid macular edema
- CNV, choroidal neovascularization
- CRVO, central retinal vein occlusion
- CSC, central serous chorioretinopathy
- Central serous chorioretinopathy
- Contrast sensitivity
- DME, diabetic macular edema
- Diabetic macular edema
- ELM, external limiting membrane
- ERM, epiretinal membrane
- ETDRS, Early Treatment Diabetic Retinopathy Study
- GA, geographic atrophy
- Geographic atrophy
- IS–OS, inner segment–outer segment
- MPS, Macular Photocoagulation Study
- Microperimetry
- OCT, optical coherence tomography
- Optical coherence tomography
- PED, pigment epithelium detachment
- RPE, retinal pigment epithelium
- Surrogate endpoints
- Visual acuity
- logMAR, logarithm of the minimum angle of resolution
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Affiliation(s)
- Pearse A Keane
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, United Kingdom
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Inflammatory mediators and angiogenic factors in choroidal neovascularization: pathogenetic interactions and therapeutic implications. Mediators Inflamm 2010; 2010. [PMID: 20871825 PMCID: PMC2943126 DOI: 10.1155/2010/546826] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 07/02/2010] [Indexed: 01/22/2023] Open
Abstract
Choroidal neovascularization (CNV) is a common and severe complication in heterogeneous diseases affecting the posterior segment of the eye, the most frequent being represented by age-related macular degeneration. Although the term may suggest just a vascular pathological condition, CNV is more properly definable as an aberrant tissue invasion of endothelial and inflammatory cells, in which both angiogenesis and inflammation are involved. Experimental and clinical evidences show that vascular endothelial growth factor is a key signal in promoting angiogenesis. However, many other molecules, distinctive of the inflammatory response, act as neovascular activators in CNV. These include fibroblast growth factor, transforming growth factor, tumor necrosis factor, interleukins, and complement. This paper reviews the role of inflammatory mediators and angiogenic factors in the development of CNV, proposing pathogenetic assumptions of mutual interaction. As an extension of this concept, new therapeutic approaches geared to have an effect on both the vascular and the extravascular components of CNV are discussed.
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Okubo A, Arimura N, Abematsu N, Sakamoto T. Predictable signs of benign course of polypoidal choroidal vasculopathy: based upon the long-term observation of non-treated eyes. Acta Ophthalmol 2010; 88:e107-14. [PMID: 20337601 DOI: 10.1111/j.1755-3768.2009.01850.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To find predictable signs of benign polypoidal choroidal vasculopathy (PCV). METHODS Medical records of 13 eyes from 12 patients who were followed up for 5 years or longer without treatment among 258 consecutive patients with PCV were reviewed retrospectively. The main outcomes measured were best corrected visual acuity (BCVA) and fundus findings during the follow-up period. RESULTS The average age at presentation was 68 years, and the average follow-up period after diagnosis was 80 months (range, 62-119 months). The initial mean logarithmic value of the minimal angle of resolution (logMAR) BCVA was 0.28 +/- 0.26, and the final mean logMAR BCVA was 0.62 +/- 0.72. The difference in the logMAR BCVA values between the two points was not statistically significant (p > 0.05). The trend of change from baseline at 2-year follow-up was consistent with those at 5-year follow-up in nine eyes. Fundus findings at the initial examination were classified into two patterns: (i) reddish-orange nodules and detachment of the retinal pigment epithelium with/without detachment of the neurosensory retina (nine eyes); (ii) reddish-orange nodules alone, or nodules and small subretinal haemorrhage (four eyes). In the eyes with the first pattern, clinical course and visual prognosis were variable. An absence of hard exudates could be a sign to maintain a benign clinical course or stable vision with this pattern. The eyes with the second pattern took a benign clinical course with stable vision. CONCLUSIONS There is certainly a group of PCV eyes with a benign prognosis. Considering the huge cost and risk of current therapies, the initial ocular findings could be deciding factors that determine the necessity for further treatment.
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Affiliation(s)
- Akiko Okubo
- Department of Ophthalmology, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan.
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June CH, Blazar BR, Riley JL. Engineering lymphocyte subsets: tools, trials and tribulations. Nat Rev Immunol 2009; 9:704-16. [PMID: 19859065 DOI: 10.1038/nri2635] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cell-based therapies with various lymphocyte subsets hold promise for the treatment of several diseases, including cancer and disease resulting from inflammation and infection. The ability to genetically engineer lymphocyte subsets has the potential to improve the natural immune response and correct impaired immunity. In this Review we focus on the lymphocyte subsets that have been modified genetically or by other means for therapeutic benefit, on the technologies used to engineer lymphocytes and on the latest progress and hurdles in translating these technologies to the clinic.
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Affiliation(s)
- Carl H June
- Department of Pathology and Laboratory Medicine and Abramson Family Cancer Research Institute, University of Pennsylvania, Philadelphia, PA 19104, USA.
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