Mental health and visual acuity in patients with age-related macular degeneration

A cost-minimization analysis of anti-VEGFs for the treatment of neovascular age-related macular degeneration in the Netherlands

OBJECTIVE

Age-related macular degeneration (AMD) is the main cause of severe vision loss globally. Neovascular AMD (nAMD) is an advanced stage of AMD treated with anti-vascular endothelial growth factors (anti-VEGFs). Although anti-VEGF treatment is effective, the frequent intravitreal injections place a burden on patients, (in)formal caregivers, and clinics. This study assesses the health-economic impact of anti-VEGF agents with lower injection frequency that have the potential to reduce treatment burden and compares it to the standard of care.

METHODS

We developed a cost-minimization model to evaluate the direct medical costs associated with first-line unilateral anti-VEGF treatment across a 3-year time horizon in the Netherlands. The analysis compared aflibercept 8 mg, aflibercept 2 mg, bevacizumab, faricimab, and ranibizumab. Our model adopted a treat-and-extend (T&E) regimen for aflibercept 2 mg, bevacizumab, and ranibizumab. For aflibercept 8 mg, a flexible regimen that was extendable up to 24 weeks was applied, while faricimab followed a flexible regimen that was extendable up to 16 weeks. Additionally, since list prices may vary from net prices, we calculated the break-even price for each anti-VEGF in comparison to bevacizumab, which is the recommended first-line treatment due to its low medication price.

RESULTS

Based on list prices, aflibercept 8 mg led to the lowest treatment costs (€16,251 per patient over a 3-year time horizon), closely followed by bevacizumab (€17,616 per patient over a 3-year time horizon). Ranibizumab led to the highest per-patient costs (€31,746 over a 3-year time horizon). For bevacizumab, most costs were attributable to administration, while for the other anti-VEGFs, most were attributable to medication. Aflibercept 8 mg is cost-saving compared to bevacizumab at their medication prices at the time of writing. Aflibercept 2 mg, faricimab, and ranibizumab should be priced below €488, €591, and €75, respectively. To be cost-equal to bevacizumab with current list prices, anti-VEGFs should be administered with a maximum of 12.7 to 13.8 injections over a 3-year time horizon.

CONCLUSION

According to the injection frequency observed in clinical trials, aflibercept 8 mg would be the anti-VEGF that generates the lowest per-patient healthcare costs for the treatment of nAMD in the Netherlands after a treatment period of three years. Our study indicates that anti-VEGF drugs with a lower injection frequency might provide a cost-saving solution to the increasing burden of anti-VEGF treatment on the healthcare system.

Investigating the Link between Psychological Well-Being and Early-Stage Age-Related Macular Degeneration: A Mendelian Randomization Analysis

PURPOSE

While some studies have started to focus on the link between psychological well-being and age-related macular degeneration (AMD), the relationship remains uncertain. Our research aims to provide new insights into this association, laying a foundation for future interventions and addressing existing knowledge gaps.

METHODS

We utilized the "TwoSampleMR" package in R for a bidirectional Mendelian randomization analysis of psychological well-being (subjective well-being, depression, neuroticism, and Sensitivity to Environmental Stress and Adversity) and early-stage AMD. Causal effects were estimated using the inverse-variance weighted method, and additional methods included weighted median and MR-Egger regression. Sensitivity analyses included Cochran's Q test, MR-Egger intercept analysis, MR-PRESSO, and leave-one-out analysis.

RESULTS

The study found that the population with genetic predisposition to neuroticism had a 39.7% lower risk of early-stage AMD (OR = 0.603, 95% CI = 0.385-0.945, p = 0.027). Conversely, the population with genetic predisposition to subjective well-being had a 3.2% increased risk of early-stage AMD (OR = 1.032, 95% CI = 1.003-1.063, p = 0.029). No significant causal relationships were found from depression or Sensitivity to Environmental Stress and Adversity to early-stage AMD, nor from early-stage AMD to psychological well-being.

CONCLUSION

This study provides preliminary evidence that the relationship between psychological well-being and early-stage AMD may be complex and multifaceted. It suggests that moderate neuroticism levels might reduce early-stage AMD risk through health behaviors, pathophysiological mechanisms, and other factors, while high subjective well-being levels might increase this risk similarly. However, these findings are insufficient for preventive strategies due to a lack of substantial evidence and still require extensive experimental research for further validation.

Systematic dissection of pleiotropic loci and critical regulons in excitatory neurons and microglia relevant to neuropsychiatric and ocular diseases

Advancements in single-cell multimodal techniques have greatly enhanced our understanding of disease-relevant loci identified through genome-wide association studies (GWASs). To investigate the biological connections between the eye and brain, we integrated bulk and single-cell multiomic profiles with GWAS summary statistics for eight neuropsychiatric and five ocular diseases. Our analysis uncovered five latent factors explaining 61.7% of the genetic variance across these 13 diseases, revealing diverse correlational patterns among them. We identified 45 pleiotropic loci with 91 candidate genes that contribute to disease risk. By integrating GWAS and single-cell profiles, we implicated excitatory neurons and microglia as key contributors in the eye-brain connections. Polygenic enrichment analysis further identified 15 pleiotropic regulons in excitatory neurons and 16 in microglia that were linked to comorbid conditions. Functionally, excitatory neuron-specific regulons were involved in axon guidance and synaptic activity, while microglia-specific regulons were associated with immune response and cell activation. In sum, these findings underscore the genetic link between psychiatric disorders and ocular diseases.

Low Vision Rehabilitation Referral Characteristics for Patients with Neovascular Age-Related Macular Degeneration

Background: Despite evidence that low vision rehabilitation (LVR) services can improve visual function in patients with neovascular age-related macular degeneration (nAMD), many patients are not directed to access these resources. This study was conducted to determine factors associated with LVR referral and to assess the visual outcomes from completed evaluations. Methods: The study comprised a retrospective, cross-sectional analysis of patients with nAMD. Referrals for LVR services were extracted from the electronic health record (EHR). The effectiveness of each evaluation was determined by assessing the change in best corrected visual acuity (BCVA) achieved after distance refraction. Costs, quality-adjusted life years (QALYs), and incremental costs per-QALY-gained were calculated based upon the better-seeing eye by using a willingness-to-pay threshold of $50,000/QALY. Results: Out of 560 eligible patients with nAMD, 110 were referred for LVR (19.6%). Referral was more common for individuals who qualified as having low vision, based upon the visual acuity of the better-seeing eye (adjusted odds ratio [aOR], 3.214; 95% confidence interval [CI], 1.920-5.380, p < 0.001), had bilateral nAMD (aOR, 1.592; 95% CI, 1.017-2.492, p = 0.042), or had commercial health insurance compared to those who had Medicare (aOR, 2.887; 95% CI, 1.041-8.009, p = 0.042). Most patients referred completed LVR appointments (86%). More than half of the patients achieved improved BCVA for their better-seeing eye (53%) yielding an average gain of 0.04 QALYs/patient at a cost of $3504/QALY. The estimated net monetary benefit was $1704 per evaluation completed. Conclusions: Most patients with nAMD achieved improvements in visual function after low vision evaluation, yielding improvements in vision-related quality of life at a reasonable cost.

The I-OPTA Questionnaire: A National Assessment of Patients with Neovascular Age-Related Macular Degeneration

INTRODUCTION

Neovascular age-related macular degeneration (nAMD) is the leading cause of irreversible vision loss in developed countries. However, a significant gap persists in understanding this population, exacerbated by their advanced age and visual impairments, which can hinder research participation and access to healthcare. The purpose of this study was to describe the content of the questionnaire and the participating patients with nAMD.

METHODS

The survey includes patients diagnosed with nAMD who had previously received treatment or were currently undergoing intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Participants were recruited using various methods, as reaching out to patients who are no longer receiving treatment poses a particular challenge. A patient and public advisory board assisted throughout the study period.

RESULTS

Of the 713 electronic invitations sent out, 494 (69.3%) patients responded to the questionnaire, with an additional 57 responses obtained through e-mail or telephone interviews. Due to the exclusion of 16 responses, there were a total of 535 valid responses, including 176 from patients previously treated and 359 from those currently undergoing treatment for nAMD. The median age of respondents was 79.9 years (interquartile range [IQR] 75.5-84.7), with 59.8% being women. Among them, 53.2% were married, while 43.1% lived alone.

CONCLUSIONS

Data from the I-OPTA (Identification of Patient-Reported Barriers in Treatment for nAMD) questionnaire allows future exploration of patients who are no longer receiving treatment, patients' knowledge about preventive measures, and the impact of nAMD on visual function and quality of life. Future research, including studies that integrate data from corresponding retinal images and Danish national registers, has the potential to generate invaluable knowledge, providing benefits to both patients and healthcare professionals.

Major sight-threatening eye disorders and mental disorders

The purpose of this study was to: (a) investigate the comorbidities of major sight-threatening eye disorders with mental disorders, (b) investigate the associations and prevalence of reported comorbidities and (c) identify potential influencing factors. A systematic review of the PubMed, Embase, Web of Science and Cochrane Library databases was conducted from inception to 30 December 2023. Studies that presented only laboratory results or used non-representative sampling methods were excluded. Meta-analyses were performed using the inverse variance method with a random-effects model. A total of 67 studies were included in the analysis. The most prevalent comorbidities were diabetic retinopathy (DR) and depression (pooled prevalence of 30%) and DR and anxiety (pooled prevalence of 29%). Significant associations were found between glaucoma and depression (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.21-1.66), glaucoma and anxiety (OR = 2.11, 95% CI = 1.22-3.66), glaucoma and schizophrenia (OR = 1.38, 95% CI = 1.28-1.50), age-related macular degeneration (AMD) and depression (OR = 1.36, 95% CI = 1.18-1.57), and DR and depression (OR = 1.03, 95% CI = 1.01-1.06). Income was identified as a significant contributing factor to the prevalence of comorbidity between glaucoma and depression. Major sight-threatening eye disorders were significantly associated with mental disorders, particularly depression and anxiety. The burden of comorbidity between major sight-threatening eye disorders and mental disorders is not optimistic and may be influenced by income disparities. Healthcare providers are encouraged to assess and manage potential comorbidities to optimize patient outcomes.

[Topical treatment for age-related macular degeneration: Where are we now?]

The therapeutic management of age-related macular degeneration (AMD) is a major public health issue. One of its two late forms, neovascular AMD, is currently treated by intravitreal injections of pharmaceutical active ingredients. Although it is very effective in treating pathologies of the posterior segment of the eye, the intravitreal route is not an ideal option for the long-term management of a chronic disease such as AMD. Indeed, in the literature, some authors even call it a "burden" for the practitioners, the patients and the healthcare system. Thus, consideration should be given to less invasive routes. Among the possible administration routes to reach the posterior segment of the eye, the most suitable for the patient with the least risk of systemic adverse effects is the topical route. Several research teams have attempted to formulate molecules for topical administration in the treatment of atrophic or neovascular AMD. In this review, we emphasize the importance of the pharmaceutical formulation to meet the challenge of targeting the posterior segment of the eye by a topical route.

Identifying geographic atrophy

PURPOSE OF REVIEW

Age-related macular degeneration (AMD) is one of the leading causes of blindness and can progress to geographic atrophy (GA) in late stages of disease. This review article highlights recent literature which assists in the accurate and timely identification of GA, and monitoring of GA progression.

RECENT FINDINGS

Technology for diagnosing and monitoring GA has made significant advances in recent years, particularly regarding the use of optical coherence tomography (OCT). Identification of imaging features which may herald the development of GA or its progression is critical. Deep learning applications for OCT in AMD have shown promising growth over the past several years, but more prospective studies are needed to demonstrate generalizability and clinical utility.

SUMMARY

Identification of GA and of risk factors for GA development or progression is essential when counseling AMD patients and discussing prognosis. With new therapies on the horizon for the treatment of GA, identification of risk factors for the development and progression of GA will become critical in determining the patients who would be appropriate candidates for new targeted therapies.