Loss to Follow up in Patients with Neovascular Age Related Macular Degeneration treated with Anti-VEGF therapy in the United States in the IRIS® Registry

Factors associated with loss to follow-up in patients with advanced age-related macular degeneration: A telehealth recall initiative

INTRODUCTION

Patients with advanced age-related macular degeneration (AMD) frequently experience loss to follow-up (LTFU), heightening the risk of vision loss from treatment delays. This study aimed to identify factors contributing to LTFU in patients with advanced AMD and assess the effectiveness of telephone-based outreach in reconnecting them with eye care.

METHODS

A custom reporting tool identified patients with advanced AMD who had not returned for eye care between 31 October 2021 and 1 November 2022. Potentially LTFU patients were enrolled in a telephone outreach programme conducted by a telehealth extender to encourage their return for care. Linear regression analysis identified factors associated with being LTFU and likelihood of accepting care post-outreach.

RESULTS

Out of 1269 patients with advanced AMD, 105 (8.3%) did not return for recommended eye care. Patients LTFU were generally older (89.2 ± 8.9 years vs. 87.2 ± 8.5 years, p = 0.02) and lived farther from the clinic (25 ± 43 miles vs. 17 ± 30 miles, p = 0.009). They also had a higher rate of advanced dry AMD (26.7% vs. 18.5%, p = 0.04) and experienced worse vision in both their better-seeing (0.683 logMAR vs. 0.566 logMAR, p = 0.03) and worse-seeing (1.388 logMAR vs. 1.235 logMAR, p = 0.04) eyes. Outreach by a telehealth extender reached 62 patients (59%), 43 through family members or healthcare proxies. Half of the cases where a proxy was contacted revealed that the patient in question had died. Among those contacted directly, one third expressed willingness to resume eye care (20 patients), with 11 scheduling appointments (55%). Despite only two patients returning for in-person eye care through the intervention, the LTFU rate halved to 4.4% by accounting for those patients who no longer needed eye care at the practice.

CONCLUSIONS

There is a substantial risk that older patients with advanced AMD will become LTFU. Targeted telephone outreach can provide a pathway for vulnerable patients to return to care.

Loss to Follow up in Patients with Proliferative Diabetic Retinopathy Treated with Anti-VEGF Therapy and/or Panretinal Photocoagulation in the United States

PURPOSE

To determine the rate of loss to follow up (LTFU) in patients with proliferative diabetic retinopathy (PDR) treated with anti-VEGF therapy and/or panretinal photocoagulation (PRP) in the United States.

DESIGN

Retrospective cohort study using the national IRIS® (Intelligent Research in Sight) Registry data.

SUBJECTS

A total of 73 595 eyes of 56 590 patients with PDR diagnosed between 2013 and 2015 and treated between 2013 and 2018.

METHODS

Multivariable logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

MAIN OUTCOME MEASURES

Loss to follow up was no follow up within 12 months from last treatment.

RESULTS

For patient eyes treated for PDR, 11.7% (95% CI, 11.5-12.0) were LTFU. Among patients with PDR treated with anti-VEGF therapy alone, PRP alone, and anti-VEGF and PRP, the rates of LTFU were 12.3% (95% CI, 11.8-12.7), 12.6% (95% CI, 12.1-13.0), and 10.8% (95% CI, 10.4-11.1), respectively. Risk factors for LTFU include Black or African American race/ethnicity (odds ratio [OR], 1.26; 95% CI, 1.13-1.41; P < 0.001), Hispanic ethnicity (OR, 1.28; 95% CI, 1.16-1.42; P < 0.001), Native American/Alaska Native or Native Hawaiian/Other Pacific Islander race/ethnicity (OR, 2.69; 95% CI, 2.14-3.38; P < 0.001), and unilateral disease (OR, 2.05; CI, 1.88-2.23; P < 0.001). Odds for LTFU were higher with patients with baseline vision of 20/50 to 20/200 (OR, 1.25; 95% CI, 1.15-1.36; P < 0.001) and with vision worse than 20/200 (OR, 1.22; 95% CI, 1.05-1.42; P = 0.01) than for patient eyes with a baseline visual acuity of 20/40 or better. Odds for LTFU were lower for Medicare Fee-for-Service (OR, 0.71; 95% CI, 0.64-0.79; P < 0.001) and Medicare Managed (OR, 0.66; 95% CI, 0.56-0.78; P < 0.001) compared with private insurance. Odds for LTFU were lower for patients treated in the Midwest (OR, 0.72; 95% CI, 0.64-0.81; P < 0.001) and West (OR, 0.83; 95% CI, 0.74-0.94; P = 0.003) compared with in the South region.

CONCLUSIONS

The rate of LTFU is between 10% and 12% among patients with PDR who were treated with anti-VEGF injections and/or PRP. Risk factors include Black or African American race/ethnicity, Hispanic ethnicity, baseline vision worse than 20/40, private insurance, South region, and unilateral disease.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Understanding Loss to Follow-Up in AMD Patients Receiving VEGF Inhibitor Therapy: Associated Factors and Underlying Reasons

BACKGROUND

In patients with wet age-related macular degeneration (AMD), loss to follow-up (LTFU) leads to unplanned interruptions in therapy and the risk of visual loss.

METHODS

This retrospective and prospective case-control cohort study compared AMD patients with (LTFU YES) and without (LTFU NO) LTFU during anti-VEGF treatment over 12 years. LTFU was defined as missing any treatment or monitoring visits, or not scheduling follow-ups for six months.

RESULTS

Significant differences between LTFU NO (n = 298) and LTFU YES (n = 174) groups were age, treatment phase, baseline and final best-corrected visual acuity (BCVA), type of anti-VEGF drug, treatment switch, commuting distance, and escort during commuting. A multivariate logistic regression analysis identified the need for an escort during the commuting and treatment phase as the only significant difference. The four most common reasons for LTFU were general health worsening (21.8%), patient-missed appointments (16.7%), COVID-19-related issues (14.9%), and treatment dissatisfaction (8.6%).

CONCLUSIONS

The factors associated with increased LTFU rates were older age, inactive treatment phase, lower baseline and final BCVA, bevacizumab treatment, monotherapy, longer travelling distance, and commuting with an escort. According to the multivariate logistic regression analysis, only the escort during the commuting and treatment phases was significant. These findings could direct research to explore social support in treatment adherence and highlight the importance of treatment phases in practice.

Emerging Co-Assembled and Sustained Released Natural Medicinal Nanoparticles for Multitarget Therapy of Choroidal Neovascularization

Age-related macular degeneration (AMD) disease has become a worldwide senile disease, and frequent intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) is the mainstream treatment in the clinic, which is associated with sight-threatening complications. Herein, nintedanib, an inhibitor of angiogenesis, and lutein, a potent antioxidant, can co-assemble into nanoparticles through multiple noncovalent interactions. Interestingly, the co-assembled lutein/nintedanib nanoparticles (L/N NPs) exhibit significantly improved stability and achieve long-term sustained release of two drugs for at least two months in mice. Interestingly, in rabbit eyeball with a more complete barrier system, the L/N NPs still successfully distribute in the retina and choroid for a month. In the laser-induced mouse choroidal neovascularization model, the L/N NPs after a minimally invasive subconjunctival administration can successfully inhibit angiogenesis and achieve comparable and even better therapeutic results to that of standard intravitreal injection of anti-VEGF. Therefore, the subconjunctival injection of L/N NPs with long-term sustained drug release behavior represents a promising and innovative strategy for AMD treatment. Such minimally invasive administration together with the ability to effectively inhibit angiogenesis reduce inflammation and counteract oxidative stress and holds great potential for improving patient outcomes and quality of life in those suffering from this debilitating eye condition.

Disparities in Eye Care Utilization Among Refugee and Migrant Populations

Purpose

In this cross-sectional study, we examined refugee/migrant participants' health and eye care utilization compared to controls in San Diego County.

Methods

Data were collected from electronic health records (EHRs) at UCSD Health-affiliated medical centers. Through a manual review of EHRs, eligibility criteria to identify a cohort were developed. A total of 64 refugee/migrant participants and 95 control participants matched based on country of origin, age, and sex were included in the analysis. Demographic characteristics, insurance type, and vision/eye care utilization were compared between the two groups.

Results

A greater proportion of refugee/migrant participants were more likely to be enrolled in government-sponsored insurance programs, predominantly Medicaid when compared to controls (55% vs. 24%, P = < 0.01). When adjusting for age, history of ophthalmic procedure, and surgery, refugee status was associated with fewer encounters with ophthalmologists in a multivariable linear regression model (coefficient = -1.66 [95% confidence interval [CI] = -2.89 to -0.44], P = 0.009).

Conclusions

This study highlights disparities in eye care utilization for refugee/migrant populations. When compared to controls, a larger proportion of refugees/migrants had government-funded insurance, and refugee status was associated with fewer encounters with ophthalmologists. These findings underscore the need for further research on this population to better understand potential healthcare barriers these individuals may encounter.

Translational Relevance

This analysis of EHR data illustrates disparities in eye care experienced by refugees/migrants, highlighting potential gaps in care in a vulnerable population.

Intravitreal Dexamethasone as a Rescue for Anti-Vascular Endothelial Growth Factor Therapy in Neovascular Age-Related Macular Degeneration with Persistent Disease Activity and High Treatment Demand

Purpose: To assess the impact of switching to, or adding, an intravitreal dexamethasone implant (Dex; Ozurdex®) in anti-vascular endothelial growth factor (VEGF) therapy on disease stability and treatment intervals in eyes with neovascular age-related macular degeneration (nAMD) and persistent disease activity and high treatment demand. Methods: This retrospective noncomparative multicenter longitudinal case series included pseudophakic eyes with nAMD and persistent retinal fluid despite regular anti-VEGF therapy (ranibizumab or aflibercept) that received at least 1 intravitreal Dex implant. Visual acuity, central retinal thickness (CRT), and intraocular pressure were recorded before, and after, the addition of Dex to anti-VEGF therapy. Results: Sixteen eyes of 16 patients met the inclusion criteria of persistent fluid despite anti-VEGF therapy, under treatment intervals of ≤7 weeks in 14 instances. Patients were 80.9 ± 7.4 years old and had received 25.5 ± 17.4 anti-VEGF injections before Dex over a period of 36.4 ± 21.9 months before switching. The treatment interval increased from 5.5 ± 3.2 weeks between the last anti-VEGF and first Dex injection to 11.7 ± 7.3 weeks thereafter (P = 0.022). CRT remained stable (385.3 ± 152.1, 383.9 ± 129.7, and 458.3 ± 155.2 μm before switching as well as 12 and 24 months after switching; P = 0.78 and P = 0.36, respectively). An insignificant mean short-term early increase in visual acuity was not sustained over time. Conclusions: The addition of Dex resulted in a relevant and sustained increase in treatment intervals, whereas CRT and visual acuity remained stable in these difficult-to-treat eyes. It may be discussed whether inflammation or other steroid-responsive factors play a significant role in cases of nAMD with nonsatisfactory responses to anti-VEGF.

Shifts in ophthalmic care utilization during the COVID-19 pandemic in the US

BACKGROUND

Healthcare restrictions during the COVID-19 pandemic, particularly in ophthalmology, led to a differential underutilization of care. An analytic approach is needed to characterize pandemic health services usage across many conditions.

METHODS

A common analytical framework identified pandemic care utilization patterns across 261 ophthalmic diagnoses. Using a United States eye care registry, predictions of utilization expected without the pandemic were established for each diagnosis via models trained on pre-pandemic data. Pandemic effects on utilization were estimated by calculating deviations between observed and expected patient volumes from January 2020 to December 2021, with two sub-periods of focus: the hiatus (March-May 2020) and post-hiatus (June 2020-December 2021). Deviation patterns were analyzed using cluster analyses, data visualizations, and hypothesis testing.

RESULTS

Records from 44.62 million patients and 2455 practices show lasting reductions in ophthalmic care utilization, including visits for leading causes of visual impairment (age-related macular degeneration, diabetic retinopathy, cataract, glaucoma). Mean deviations among all diagnoses are 67% below expectation during the hiatus peak, and 13% post-hiatus. Less severe conditions experience greater utilization reductions, with heterogeneities across diagnosis categories and pandemic phases. Intense post-hiatus reductions occur among non-vision-threatening conditions or asymptomatic precursors of vision-threatening diseases. Many conditions with above-average post-hiatus utilization pose a risk for irreversible morbidity, such as emergent pediatric, retinal, or uveitic diseases.

CONCLUSIONS

We derive high-resolution insights on pandemic care utilization in the US from high-dimensional data using an analytical framework that can be applied to study healthcare disruptions in other settings and inform efforts to pinpoint unmet clinical needs.

Evaluation of a self-imaging OCT for remote diagnosis and monitoring of retinal diseases

OBJECTIVES

To evaluate the feasibility and accuracy of a portable, self-imaging optical coherence tomography (OCT) for measuring central subfield thickness (CST) and achieving diagnostic concordance for retinal lesions compared with clinic-based spectral-domain OCT (SD-OCT).

METHODS

This comparative, cross-sectional study was conducted between August 2020 and February 2021. Two groups of adult participants were recruited: (1) a selected cohort of 160 participants with confirmed diagnosis and (2) a consecutive cohort of 315 participants recruited randomly. All participants underwent self-imaging OCT examination, as well as standard OCT examination. CST was automatically calculated for comparisons between the two OCT devices. Diagnostic concordance for retinal lesions and the success rate of self-imaging were assessed within the consecutive cohort.

RESULTS

In the selected cohort, self-imaging OCT images yielded consistent CST with SD-OCT, with a mean difference of 0.1±7.7 µm for normal eyes, 4.9±10.6 µm for macular oedema, -1.3±9.5 µm for choroidal neovascularisation, 5.0±7.8 µm for epiretinal membrane. The self-imaging OCT also demonstrated good repeatability, with a mean test-retest difference in CST of 0.7±3.9 µm and limits of agreement ranging from -6.9 to 8.3 µm. Additionally, within the consecutive cohort, interdevice κ values ranged for detecting various retinal lesions ranged from 0.8 to 1.0, except in the cases of retinal detachment (κ=0.5). All eyes (100%) in the selected cohort and 242 eyes (76.8%) in the consecutive cohort successfully completed self-imaging. Participants spent less time on self-imaging compared with SD-OCT operated by a technician (66.7±20.1 vs 73.3±32.5, p<0.01). A majority of participants (90%) found the self-imaging process 'easy' and 'comfortable'.

CONCLUSIONS AND RELEVANCE

This study demonstrates that our self-imaging OCT and clinical-used SD-OCT are highly consistent not only in measuring the CST but also in identifying most retinal lesions.

Neovascular Age-Related Macular Degeneration in a Predominantly Black Population

BACKGROUND AND OBJECTIVE

We intend to study the characteristics and outcomes of an understudied patient population with neovascular age-related macular degeneration (nAMD).

PATIENTS AND METHODS

This retrospective study evaluated presenting features and outcomes in a predominantly Black patient population with nAMD. A multivariate regression explored baseline characteristics predictive of 1-year vision.

RESULTS

Sixty-three eyes were included. The median (interquartile range) baseline vision was 20/300 (20/80 to counting fingers). Patients' baseline optical coherence tomography findings showed a mean central subfield thickness of 336 µm; 80% (n = 35) and 41% (n = 18) had fluid and central scarring, respectively. The primary predictor for vision at year-one was baseline vision (P = 0.03, 95% CI: 0.04 to 0.91). All of those who gained ≥ 3 lines of vision lacked central scarring at baseline.

CONCLUSION

Further studies are needed to investigate how to improve earlier detection and treatment of nAMD in this patient population. [Ophthalmic Surg Lasers Imaging Retina 2023;54:580-584.].