1
|
Ryan B, Jones M, Anderson P, Reynolds R, Nicholls REM, Cullen K, Davies M, North R, Molik B, Wallace C. Hospital to community in Wales: What is the value of optometrists playing a greater role in managing neovascular AMD and glaucoma in primary care? Ophthalmic Physiol Opt 2024. [PMID: 39387705 DOI: 10.1111/opo.13397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 09/06/2024] [Accepted: 09/17/2024] [Indexed: 10/15/2024]
Abstract
PURPOSE To evaluate the value of enhanced optometric services for managing neovascular age-related macular degeneration (nAMD) and glaucoma in primary care optometry services, instead of hospital eye services (HES). METHODS Seven enhanced optometric service pathways in primary care in Wales were assessed with a mixed-methods approach: three for nAMD and four for glaucoma. The methods were a patient-related experience measure (PREM), a Realist Review and Evaluation involving both patients and staff, a discrete event simulation model estimating the economic impact of the pathways and a workforce survey of optometrists to gauge capability and capacity. RESULTS Patient-related experience measure responses (802) indicated that primary care experience was comparable to that of HES. Utilising enhanced optometric services in primary care resulted in reduced wait times compared with HES, with suspected nAMD shortened to 4-5 days and glaucoma monitoring to 5 days. Waiting lists were dramatically reduced with primary care-based services to just three people waiting for nAMD and five for glaucoma, compared with 216 and 5691 people, respectively, in HES. Consultant ophthalmologist time was reduced from 57% to 15%-16% for nAMD services and from 48% to 22%-23% for glaucoma services. Integrating enhanced optometric services into primary care incurred a similar cost. The workforce survey confirms that optometrists possess the skills and qualifications and are willing to deliver these enhanced optometric services. The Realist Review and Evaluation revealed that clear patient communication, effective coordination and strong interprofessional communication between optometrists and ophthalmologists along with a shared electronic record are crucial to the success of this change. CONCLUSION Providing enhanced optometric services in primary care for nAMD and glaucoma brings substantial benefits for the UK National Health Service and patients, including reduced waiting times, waiting lists and released HES capacity. The success of this transition hinges on clear patient communication, administrative co-ordination and effective interprofessional communication.
Collapse
Affiliation(s)
- Barbara Ryan
- Aneurin Bevan University Health Board, Newport, UK
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
| | - Mari Jones
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Pippa Anderson
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
- Division of Population Medicine, PRIME Centre Wales PRIME, Cardiff University School of Medicine, Cardiff, UK
| | - Rhiannon Reynolds
- Aneurin Bevan University Health Board, Newport, UK
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
| | - Rebecca E M Nicholls
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Katherine Cullen
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Mark Davies
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Rachel North
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
- Division of Population Medicine, PRIME Centre Wales PRIME, Cardiff University School of Medicine, Cardiff, UK
| | | | - Carolyn Wallace
- Division of Population Medicine, PRIME Centre Wales PRIME, Cardiff University School of Medicine, Cardiff, UK
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| |
Collapse
|
2
|
Estarreja J, Mendes P, Silva C, Camacho P, Mateus V. Off-Label Use of Bevacizumab in Patients Diagnosed with Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis. Pharmaceuticals (Basel) 2024; 17:1000. [PMID: 39204105 PMCID: PMC11357420 DOI: 10.3390/ph17081000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/18/2024] [Accepted: 07/26/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the leading cause of vision loss in elderly people. Current pharmacological treatment in vascular AMD includes anti-VEGF agents, such as ranibizumab and aflibercept. Additionally, the off-label use of bevacizumab has been shown to be effective and has a lower cost, making it an interesting pharmacological approach; however, there is no consensus about its use. Therefore, this systematic review and meta-analysis aims to evaluate the efficacy, safety, and efficiency of bevacizumab in AMD patients. METHODS This review only focused on randomized controlled clinical trials published in 2010 in the MEDLINE database that compared the effect of bevacizumab with ranibizumab. The risk of bias in each included study was assessed using the CASP Randomised Clinical Trials checklist. RESULTS Twelve studies were included for qualitative synthesis, and nine of them were considered for meta-analysis. Bevacizumab-treated patients showed a significantly reduced neovascularization in a longer spectrum of time; however, they had a higher incidence of endophthalmitis than those treated with ranibizumab. Regarding efficiency, the mean number of administrations was reduced in the treatment with bevacizumab in comparison to ranibizumab. CONCLUSIONS Clinical evidence demonstrates that bevacizumab has efficacy and safety profiles comparable with ranibizumab; however, it is relatively more efficient.
Collapse
Affiliation(s)
- João Estarreja
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
| | - Priscila Mendes
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
| | - Carina Silva
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
- Centro de Estatística e Aplicações, Universidade de Lisboa, 1749-016 Lisbon, Portugal
| | - Pedro Camacho
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
| | - Vanessa Mateus
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Av. Professor Gama Pinto, 1649-003 Lisbon, Portugal
| |
Collapse
|
3
|
Jackson TL, Desai R, Wafa HA, Wang Y, Peacock J, Peto T, Chakravarthy U, Dakin H, Wordsworth S, Lewis C, Clinch P, Ramazzotto L, Neffendorf JE, Lee CN, O'Sullivan JM, Reeves BC. Stereotactic radiotherapy for neovascular age-related macular degeneration (STAR): a pivotal, randomised, double-masked, sham-controlled device trial. Lancet 2024; 404:44-54. [PMID: 38876132 DOI: 10.1016/s0140-6736(24)00687-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/19/2024] [Accepted: 04/03/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Neovascular age-related macular degeneration (nAMD) is a leading cause of blindness. The first-line therapy is anti-vascular endothelial growth factor (anti-VEGF) agents delivered by intravitreal injection. Ionising radiation mitigates key pathogenic processes underlying nAMD, and therefore has therapeutic potential. STAR aimed to assess whether stereotactic radiotherapy (SRT) reduces the number of anti-VEGF injections required, without sacrificing visual acuity. METHODS This pivotal, randomised, double-masked, sham-controlled trial enrolled participants with pretreated chronic active nAMD from 30 UK hospitals. Participants were randomly allocated in a 2:1 ratio to 16-Gray (Gy) SRT delivered using a robotically controlled device or sham SRT, stratified by treatment centre. Eligible participants were aged 50 years or older and had chronic active nAMD, with at least three previous anti-VEGF injections, including at least one in the last 4 months. Participants and all trial and image reading centre staff were masked to treatment allocation, except one unmasked statistician. The primary outcome was the number of intravitreal ranibizumab injections required over 2 years, tested for superiority (fewer injections). The main secondary outcome was Early Treatment Diabetic Retinopathy Study visual acuity at two years, tested for non-inferiority (five-letter margin). The primary analysis used the intention-to-treat principle, and safety was analysed per-protocol on participants with available data. The study is registered with ClinicalTrials.gov (NCT02243878) and is closed for recruitment. FINDINGS 411 participants enrolled between Jan 1, 2015, and Dec 27, 2019, and 274 were randomly allocated to the 16-Gy SRT group and 137 to the sham SRT group. 240 (58%) of all participants were female, and 171 (42%) of all participants were male. 241 participants in the 16-Gy SRT group and 118 participants in the sham group were included in the final analysis, and 409 patients were treated and formed the safety population, of whom two patients allocated to sham treatment erroneously received 16-Gy SRT. The SRT group received a mean of 10·7 injections (SD 6·3) over 2 years versus 13·3 injections (5·8) with sham, a reduction of 2·9 injections after adjusting for treatment centre (95% CI -4·2 to -1·6, p<0·0001). The SRT group best-corrected visual acuity change was non-inferior to sham (adjusted mean letter loss difference between groups, -1·7 letters [95% CI -4·2 to 0·8]). Adverse event rates were similar across groups, but reading centre-detected microvascular abnormalities occurred in 77 SRT-treated eyes (35%) and 13 (12%) sham-treated eyes. Overall, eyes with microvascular abnormalities tended to have better best-corrected visual acuity than those without. Fewer ranibizumab injections offset the cost of SRT, saving a mean of £565 per participant (95% CI -332 to 1483). INTERPRETATION SRT can reduce ranibizumab treatment burden without compromising vision. FUNDING Medical Research Council and National Institute for Health and Care Research Efficacy and Mechanism Evaluation Programme.
Collapse
Affiliation(s)
- Timothy L Jackson
- King's Ophthalmology Research Unit (KORU), Department of Ophthalmology, King's College Hospital, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Riti Desai
- King's Ophthalmology Research Unit (KORU), Department of Ophthalmology, King's College Hospital, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Hatem A Wafa
- Department of Population Health Sciences, King's College London, London, UK
| | - Yanzhong Wang
- Department of Population Health Sciences, King's College London, London, UK
| | - Janet Peacock
- Department of Population Health Sciences, King's College London, London, UK; Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, NH, USA
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK; Network of Ophthalmic Reading Centres UK: London (Moorfields), Liverpool, and Belfast Ophthalmic Reading Centres, UK
| | | | - Helen Dakin
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Cornelius Lewis
- Medical Engineering and Physics, King's College Hospital, London, UK
| | - Patricia Clinch
- Medical Engineering and Physics, King's College Hospital, London, UK
| | - Lisa Ramazzotto
- King's Ophthalmology Research Unit (KORU), Department of Ophthalmology, King's College Hospital, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - James E Neffendorf
- King's Ophthalmology Research Unit (KORU), Department of Ophthalmology, King's College Hospital, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Chan Ning Lee
- King's Ophthalmology Research Unit (KORU), Department of Ophthalmology, King's College Hospital, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Joe M O'Sullivan
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | | |
Collapse
|
4
|
Hogg RE, Wickens R, O'Connor S, Gidman E, Ward E, Treanor C, Peto T, Burton B, Knox P, Lotery AJ, Sivaprasad S, Donnelly M, Rogers CA, Reeves BC. Home-monitoring for neovascular age-related macular degeneration in older adults within the UK: the MONARCH diagnostic accuracy study. Health Technol Assess 2024; 28:1-136. [PMID: 39023220 PMCID: PMC11261425 DOI: 10.3310/cyra9912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
Abstract
Background Most neovascular age-related macular degeneration treatments involve long-term follow-up of disease activity. Home monitoring would reduce the burden on patients and those they depend on for transport, and release clinic appointments for other patients. The study aimed to evaluate three home-monitoring tests for patients to use to detect active neovascular age-related macular degeneration compared with diagnosing active neovascular age-related macular degeneration by hospital follow-up. Objectives There were five objectives: Estimate the accuracy of three home-monitoring tests to detect active neovascular age-related macular degeneration. Determine the acceptability of home monitoring to patients and carers and adherence to home monitoring. Explore whether inequalities exist in recruitment, participants' ability to self-test and their adherence to weekly testing during follow-up. Provide pilot data about the accuracy of home monitoring to detect conversion to neovascular age-related macular degeneration in fellow eyes of patients with unilateral neovascular age-related macular degeneration. Describe challenges experienced when implementing home-monitoring tests. Design Diagnostic test accuracy cohort study, stratified by time since starting treatment. Setting Six United Kingdom Hospital Eye Service macular clinics (Belfast, Liverpool, Moorfields, James Paget, Southampton, Gloucester). Participants Patients with at least one study eye being monitored by hospital follow-up. Reference standard Detection of active neovascular age-related macular degeneration by an ophthalmologist at hospital follow-up. Index tests KeepSight Journal: paper-based near-vision tests presented as word puzzles. MyVisionTrack®: electronic test, viewed on a tablet device. MultiBit: electronic test, viewed on a tablet device. Participants provided test scores weekly. Raw scores between hospital follow-ups were summarised as averages. Results Two hundred and ninety-seven patients (mean age 74.9 years) took part. At least one hospital follow-up was available for 317 study eyes, including 9 second eyes that became eligible during follow-up, in 261 participants (1549 complete visits). Median testing frequency was three times/month. Estimated areas under receiver operating curves were < 0.6 for all index tests, and only KeepSight Journal summary score was significantly associated with the lesion activity (odds ratio = 3.48, 95% confidence interval 1.09 to 11.13, p = 0.036). Older age and worse deprivation for home address were associated with lower participation (χ2 = 50.5 and 24.3, respectively, p < 0.001) but not ability or adherence to self-testing. Areas under receiver operating curves appeared higher for conversion of fellow eyes to neovascular age-related macular degeneration (0.85 for KeepSight Journal) but were estimated with less precision. Almost half of participants called a study helpline, most often due to inability to test electronically. Limitations Pre-specified sample size not met; participants' difficulties using the devices; electronic tests not always available. Conclusions No index test provided adequate test accuracy to identify lesion diagnosed as active in follow-up clinics. If used to detect conversion, patients would still need to be monitored at hospital. Associations of older age and worse deprivation with study participation highlight the potential for inequities with such interventions. Provision of reliable electronic testing was challenging. Future work Future studies evaluating similar technologies should consider: Independent monitoring with clear stopping rules based on test performance. Deployment of apps on patients' own devices since providing devices did not reduce inequalities in participation and complicated home testing. Alternative methods to summarise multiple scores over the period preceding a follow-up. Trial registration This trial is registered as ISRCTN79058224. Funding This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/97/02) and is published in full in Health Technology Assessment; Vol. 28, No. 32. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Ruth E Hogg
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Robin Wickens
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sean O'Connor
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Eleanor Gidman
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Elizabeth Ward
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Charlene Treanor
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Ben Burton
- James Paget University Hospitals NHS Trust, Great Yarmouth, UK
| | - Paul Knox
- University of Liverpool, Liverpool, UK
| | - Andrew J Lotery
- Department of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Michael Donnelly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Chris A Rogers
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | |
Collapse
|
5
|
Pauleikhoff D, Gunnemann ML, Ziegler M, Heimes-Bussmann B, Bormann E, Bachmeier I, Yu S, Garcia Armendariz B, Pauleikhoff L. Morphological changes of macular neovascularization during long-term anti-VEGF-therapy in neovascular age-related macular degeneration. PLoS One 2023; 18:e0288861. [PMID: 38134207 PMCID: PMC10745158 DOI: 10.1371/journal.pone.0288861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
PURPOSE To analyze the morphological changes of macular neovascularization (MNV) in exudative neovascular age-related macular degeneration under long-term intravitreal anti-vascular endothelial growth factor (VEGF) therapy in a retrospective cohort study. METHODS AND PATIENTS We evaluated 143 nAMD eyes of 94 patients (31 male, 63 female; initial age 55-97 y, mean age 75.9 ± 7.5 y), who started anti-VEGF therapy (IVAN pro re nata (PRN) protocol) between 2009-2018 and received ongoing therapy until the last recorded visit (mean follow-up 5.3 ± 2.9 y, range 1-14 y). The mean total number of injections was 33.3 ± 19.8 with 7.0 ± 2.3 injections/year. MNV size and, if present, associated complete retinal pigment epithelium (RPE) and outer retina atrophy (cRORA) size were measured on optical coherence tomography (OCT) volume scans at the initial visit and for each year of follow-up. MNV and cRORA were identified on B-scans and their respective borders were manually transposed onto the en-face near infrared image and measured in mm2. RESULTS MNV enlarged through follow-up, with a mean growth rate of 1.24 mm2 / year. The mean growth in MNV size was independent of initial MNV size, age, gender, MNV subtypes or number of injections per year. Nevertheless, a great interindividual variation in size and growth was observed. cRORA developed in association with increasing MNV size and its incidence increased linearly over follow-up. cRORA lesions also showed continuous growth by a rate of 1.22 mm2 / year. CONCLUSIONS Despite frequent long-term anti-VEGF therapy, we observed ongoing MNV growth. This is consistent with the concept that the development of MNV may be a physiological biological repair mechanism to preserve RPE and photoreceptor function, provided hyperpermeability and fluid exudation are controlled. Whether recurring low VEGF levels or other factors are responsible for MNV growth remains controversial.
Collapse
Affiliation(s)
- Daniel Pauleikhoff
- Dep. of Ophthalmology, St. Franziskus Hospital Muenster, Münster, Germany
| | | | - Martin Ziegler
- Dep. of Ophthalmology, St. Franziskus Hospital Muenster, Münster, Germany
| | | | - Eike Bormann
- Institute of Biostatistics and Clinical Research, University Muenster, Münster, Germany
| | - Isabel Bachmeier
- F. Hoffmann-La Roche Ltd., Pharma Research and Early Development, Basel, Switzerland
| | - Siqing Yu
- F. Hoffmann-La Roche Ltd., Pharma Research and Early Development, Basel, Switzerland
| | | | - Laurenz Pauleikhoff
- Dep. of Ophthalmology, Faculty of Medicine, University of Hamburg, Hamburg, Germany
| |
Collapse
|
6
|
Wright DM, Chakravarthy U, Das R, Graham KW, Naskas TT, Perais J, Kee F, Peto T, Hogg RE. Identifying the severity of diabetic retinopathy by visual function measures using both traditional statistical methods and interpretable machine learning: a cross-sectional study. Diabetologia 2023; 66:2250-2260. [PMID: 37725107 PMCID: PMC10627908 DOI: 10.1007/s00125-023-06005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/14/2023] [Indexed: 09/21/2023]
Abstract
AIMS/HYPOTHESIS To determine the extent to which diabetic retinopathy severity stage may be classified using machine learning (ML) and commonly used clinical measures of visual function together with age and sex. METHODS We measured the visual function of 1901 eyes from 1032 participants in the Northern Ireland Sensory Ageing Study, deriving 12 variables from nine visual function tests. Missing values were imputed using chained equations. Participants were divided into four groups using clinical measures and grading of ophthalmic images: no diabetes mellitus (no DM), diabetes but no diabetic retinopathy (DM no DR), diabetic retinopathy without diabetic macular oedema (DR no DMO) and diabetic retinopathy with DMO (DR with DMO). Ensemble ML models were fitted to classify group membership for three tasks, distinguishing (A) the DM no DR group from the no DM group; (B) the DR no DMO group from the DM no DR group; and (C) the DR with DMO group from the DR no DMO group. More conventional multiple logistic regression models were also fitted for comparison. An interpretable ML technique was used to rank the contribution of visual function variables to predictions and to disentangle associations between diabetic eye disease and visual function from artefacts of the data collection process. RESULTS The performance of the ensemble ML models was good across all three classification tasks, with accuracies of 0.92, 1.00 and 0.84, respectively, for tasks A-C, substantially exceeding the accuracies for logistic regression (0.84, 0.61 and 0.80, respectively). Reading index was highly ranked for tasks A and B, whereas near visual acuity and Moorfields chart acuity were important for task C. Microperimetry variables ranked highly for all three tasks, but this was partly due to a data artefact (a large proportion of missing values). CONCLUSIONS/INTERPRETATION Ensemble ML models predicted status of diabetic eye disease with high accuracy using just age, sex and measures of visual function. Interpretable ML methods enabled us to identify profiles of visual function associated with different stages of diabetic eye disease, and to disentangle associations from artefacts of the data collection process. Together, these two techniques have great potential for developing prediction models using untidy real-world clinical data.
Collapse
Affiliation(s)
- David M Wright
- Centre for Public Health, Queen's University Belfast, Belfast, UK.
| | | | - Radha Das
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Katie W Graham
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Timos T Naskas
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Jennifer Perais
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Ruth E Hogg
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| |
Collapse
|
7
|
Hunter AML, Anderson RS, Redmond T, Garway-Heath DF, Mulholland PJ. Investigating the Spatiotemporal Summation of Perimetric Stimuli in Dry Age-Related Macular Degeneration. Transl Vis Sci Technol 2023; 12:37. [PMID: 38019498 PMCID: PMC10691387 DOI: 10.1167/tvst.12.11.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/26/2023] [Indexed: 11/30/2023] Open
Abstract
Purpose To measure achromatic spatial, temporal, and spatiotemporal summation in dry age-related macular degeneration (AMD) compared to healthy controls under conditions of photopic gaze-contingent perimetry. Methods Twenty participants with dry AMD (mean age, 74.6 years) and 20 healthy controls (mean age, 67.8 years) performed custom, gaze-contingent perimetry tests. An area-modulation test generated localized estimates of Ricco's area (RA) at 2.5° and 5° eccentricities along the 0°, 90°, 180°, and 270° meridians. Contrast thresholds were measured at the same test locations for stimuli of six durations (3.7-190.4 ms) with a Goldmann III stimulus (GIII, 0.43°) and RA-scaled stimuli. The upper limit (critical duration) of complete temporal summation (using the GIII stimulus) and spatiotemporal summation (using the RA stimuli) was estimated using iterative two-phase regression analysis. Results Median (interquartile range [IQR]) RA estimates were significantly larger in AMD participants (2.5°: 0.21 [0.09-0.41] deg2; 5°: 0.32 [0.15-0.65 deg2]) compared to healthy controls (2.5°: 0.08 [0.05-0.13] deg2; 5°: 0.15 [0.08-0.22] deg2) at all test locations (all P < 0.05). No significant difference in median critical duration was found in AMD participants with the GIII stimulus (19.6 [9.9-30.4] ms) and RA-scaled stimuli (22.9 [13.9-40.3] ms) compared to healthy controls (GIII: 17.0 [11.3-24.0] ms; RA-scaled: 22.4 [14.3-33.1] ms) at all test locations (all P > 0.05). Conclusions Spatial summation is altered in dry AMD, without commensurate changes in temporal summation. Translational Relevance The sensitivity of perimetry to AMD may be improved by utilizing stimuli that probe alterations in spatial summation in the disease.
Collapse
Affiliation(s)
- Aoife M. L. Hunter
- Centre for Optometry and Vision Science, Biomedical Sciences Research Institute, Ulster University, Coleraine, UK
| | - Roger S. Anderson
- Centre for Optometry and Vision Science, Biomedical Sciences Research Institute, Ulster University, Coleraine, UK
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Tony Redmond
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
| | - David F. Garway-Heath
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Pádraig J. Mulholland
- Centre for Optometry and Vision Science, Biomedical Sciences Research Institute, Ulster University, Coleraine, UK
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
| |
Collapse
|
8
|
Bachmeier I, Armendariz BG, Yu S, Jäger RJ, Ebneter A, Glittenberg C, Pauleikhoff D, Sadda SR, Chakravarthy U, Fauser S. Fibrosis in neovascular age-related macular degeneration: A review of definitions based on clinical imaging. Surv Ophthalmol 2023; 68:835-848. [PMID: 37023894 DOI: 10.1016/j.survophthal.2023.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
Despite the success of antiangiogenic therapy in controlling exudation in neovascular age-related macular degeneration (nAMD), the involvement of the outer retina in fibrosis results in gradual vision loss over time. The development of drugs that prevent or ameliorate fibrosis in nAMD requires that it is accurately detected and quantified with reliable endpoints and identification of robust biomarkers. Achievement of such an aim is currently challenging due to the lack of a consensus definition of fibrosis in nAMD. As a first step towards the establishment of a clear definition of fibrosis, we provide an extensive overview of the imaging modalities and criteria used to characterize fibrosis in nAMD. We observed variety in the selection of individual and combinations of imaging modalities, and criteria for detection. We also observed heterogeneity in classification systems and severity scales for fibrosis. The most commonly used imaging modalities were color fundus photography, fluorescein angiography and optical coherence tomography (OCT). A multimodal approach was frequently utilized. Our review suggests that OCT offers a more detailed, objective and sensitive characterization than color fundus photography/fluorescein angiography. Thus, we recommend it as a primary modality for fibrosis evaluation. This review provides a basis for future discussions to reach a consensus definition using standardized terms based on a detailed characterization of fibrosis, its presence and evolution, and taking into consideration impact on visual function. Achieving this goal is of paramount importance for the development of antifibrotic therapies.
Collapse
Affiliation(s)
- Isabel Bachmeier
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland.
| | - Beatriz G Armendariz
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Siqing Yu
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Ralf J Jäger
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | - Andreas Ebneter
- Department of Ophthalmology, Cantonal Hospital St. Gallen, University of Bern, Switzerland
| | - Carl Glittenberg
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| | | | - SriniVas R Sadda
- Doheny Eye Institute, University of California-Los Angeles, Pasadena, 91103 CA, USA
| | - Usha Chakravarthy
- Queens University of Belfast, Institute of Clinical Science Block A, Belfast, UK
| | - Sascha Fauser
- Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland
| |
Collapse
|
9
|
Wei W, Anantharanjit R, Patel RP, Cordeiro MF. Detection of macular atrophy in age-related macular degeneration aided by artificial intelligence. Expert Rev Mol Diagn 2023:1-10. [PMID: 37144908 DOI: 10.1080/14737159.2023.2208751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Age-related macular degeneration (AMD) is a leading cause of irreversible visual impairment worldwide. The endpoint of AMD, both in its dry or wet form, is macular atrophy (MA) which is characterized by the permanent loss of the RPE and overlying photoreceptors either in dry AMD or in wet AMD. A recognized unmet need in AMD is the early detection of MA development. AREAS COVERED Artificial Intelligence (AI) has demonstrated great impact in detection of retinal diseases, especially with its robust ability to analyze big data afforded by ophthalmic imaging modalities, such as color fundus photography (CFP), fundus autofluorescence (FAF), near-infrared reflectance (NIR), and optical coherence tomography (OCT). Among these, OCT has been shown to have great promise in identifying early MA using the new criteria in 2018. EXPERT OPINION There are few studies in which AI-OCT methods have been used to identify MA; however, results are very promising when compared to other imaging modalities. In this paper, we review the development and advances of ophthalmic imaging modalities and their combination with AI technology to detect MA in AMD. In addition, we emphasize the application of AI-OCT as an objective, cost-effective tool for the early detection and monitoring of the progression of MA in AMD.
Collapse
Affiliation(s)
- Wei Wei
- Department of Ophthalmology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
- Department of Surgery & Cancer, Imperial College London, London, UK
- Imperial College Ophthalmology Research Group (ICORG), Imperial College Ophthalmology Research Group, London, UK
| | - Rajeevan Anantharanjit
- Imperial College Ophthalmology Research Group (ICORG), Imperial College Ophthalmology Research Group, London, UK
- Western Eye Hospital, Imperial College Healthcare NHS trust, London, UK
| | - Radhika Pooja Patel
- Imperial College Ophthalmology Research Group (ICORG), Imperial College Ophthalmology Research Group, London, UK
- Western Eye Hospital, Imperial College Healthcare NHS trust, London, UK
| | - Maria Francesca Cordeiro
- Department of Surgery & Cancer, Imperial College London, London, UK
- Imperial College Ophthalmology Research Group (ICORG), Imperial College Ophthalmology Research Group, London, UK
- Western Eye Hospital, Imperial College Healthcare NHS trust, London, UK
| |
Collapse
|
10
|
Kawai K, Miyata M, Ooto S, Tamura H, Ueda-Arakawa N, Takahashi A, Uji A, Muraoka Y, Miyake M, Yamashiro K, Tsujikawa A. Macular atrophy at 5 years after photodynamic therapy for polypoidal choroidal vasculopathy. Eye (Lond) 2023; 37:1067-1072. [PMID: 35422494 PMCID: PMC10102034 DOI: 10.1038/s41433-022-02067-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 03/23/2022] [Accepted: 04/04/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To investigate predictors for macular atrophy (MA) involving the fovea after photodynamic therapy (PDT) followed by pro re nata (PRN) treatment for polypoidal choroidal vasculopathy (PCV). METHODS This prospective observational study analysed treatment-naïve eyes with symptomatic PCV without MA at baseline which were followed up for 5 years. All eyes were initially treated with PDT, followed by a PRN regimen of anti-vascular endothelial growth factor (VEGF) therapy and/or PDT. We assigned eyes with and eyes without development of MA involving the fovea 5 years after the initial treatment into MA and non-MA groups, respectively. Baseline parameters and the number of treatments were compared between the two groups. RESULTS Seventy-two eyes of 69 consecutive patients were included, and 29 eyes of 29 patients were analysed. Twelve (41%) and 17 (59%) eyes were assigned into the MA and non-MA groups, respectively. There were significant differences in subfoveal choroidal thickness (226.2 ± 47.8 μm vs. 278.8 ± 68.1 μm, P = 0.03) and number of anti-VEGF injections (13.7 ± 9.6 vs. 5.4 ± 5.6, P = 0.007) between the MA and non-MA groups, but not in the number of PDT sessions (P = 0.71). Best-corrected visual acuity at 5 years in the MA group was lower than in the non-MA group (P = 0.048). CONCLUSION Our long-term observation suggests that a thin subfoveal choroid at baseline and many followed anti-VEGF injections in a PRN regimen increase the risk for development of MA involving the fovea 5 years after PDT.
Collapse
Affiliation(s)
- Kentaro Kawai
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Manabu Miyata
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Sotaro Ooto
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Tamura
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Naoko Ueda-Arakawa
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ayako Takahashi
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihito Uji
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuki Muraoka
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahiro Miyake
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Yamashiro
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Ophthalmology, Otsu Red Cross Hospital, Otsu, Japan
| | - Akitaka Tsujikawa
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| |
Collapse
|
11
|
Bae SS, Koenigstein D, Weaver T, Merkur A, Albiani D, Pakzad-Vaezi K, Kirker A. Incidence of ocular hypertension after anti-VEGF injections: examining the effect of drug filtration and silicone-free syringes. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023; 58:66-72. [PMID: 34331870 DOI: 10.1016/j.jcjo.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/25/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine the difference in incidence of ocular hypertension (OHT) following the introduction of filtered anti-vascular endothelial growth factor (anti-VEGF) medication in silicone-free syringes. DESIGN Retrospective cohort study. METHODS A retrospective review of consecutive treatment-naive patients receiving intravitreal anti-VEGF injections in a group practice was performed. Data from the cohort receiving nonfiltered anti-VEGF in insulin syringes (IS group) was collected from June 2015. Data from the cohort receiving filtered anti-VEGF in silicone-free syringes (SFS group) was collected from June 2019. Follow up data were collected at 1 year. Exclusion criteria included prior anti-VEGF treatment, known glaucoma or diagnosis of glaucoma suspect before anti-VEGF treatment, neovascular glaucoma, steroid use, or vitrectomy during follow-up. Primary outcome was the cumulative incidence of intraocular pressure (IOP) > 21 mmHg and IOP ≥ 30 mm Hg at any follow-up visit. The use of IOP lowering therapy was also recorded. RESULTS The mean age (71 ± 13 years), mean number of injections (9.6 ± 2.7), and median follow-up time (392 ± 57 days) were similar between groups. The incidence of IOP ≥ 21 mm Hg was 34% (34/100) in the IS group and 15% (15/100) in the SFS group (p = 0.025). The incidence of IOP ≥ 30 mm Hg was 8% (8/100) in the IS group and 0% (0/100) in the SFS group (p =0.004). The incidence of IOP-lowering therapy was 13% in the IS group and 0% in the SFS group (p =0.0002). CONCLUSION The incidence of OHT and treatment with IOP-lowering therapy significantly decreased after the introduction of filtered anti-VEGF medication and silicone-free syringes.
Collapse
Affiliation(s)
- Steven S Bae
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Dvir Koenigstein
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Travers Weaver
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Andrew Merkur
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - David Albiani
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Kaivon Pakzad-Vaezi
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Andrew Kirker
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC..
| |
Collapse
|
12
|
Claessens JLJ, Wanten JC, Bauer NJC, Nuijts RMMA, Findl O, Huemer J, Imhof SM, Wisse RPL. Remote follow-up after cataract surgery (CORE-RCT): study protocol of a randomized controlled trial. BMC Ophthalmol 2023; 23:41. [PMID: 36717799 PMCID: PMC9885558 DOI: 10.1186/s12886-023-02779-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/10/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Cataract surgery has become one of the most performed surgical procedures worldwide. Postoperative management consists of routine clinical examinations to assess post-operative visual function and detect possible adverse events. Due to the low incidence of complications, the majority of clinic visits after cataract surgery are uneventful. Nonetheless, valuable time and hospital resources are consumed. We hypothesize that remote post-operative follow-up involving teleconsultations and self-assessments of visual function and health status, could be a valid alternative to face-to-face clinical examinations in selected patient groups. The practice of remote follow-up after cataract surgery has not yet been evaluated. The aim of this study is to investigate the validity, safety and cost-effectiveness of remote cataract surgery follow-up, and to report on the patients' experiences with remotely self-assessing visual function. METHODS This study is a multicenter, open-label, randomized controlled trial. Patients planned for cataract surgery on both eyes, without ocular comorbidities, are eligible for participation. Participants will be allocated (1:1) into one of the two study groups: 'telemonitoring' or 'usual care'. Participants in the 'telemonitoring' group will perform in-home assessments after cataract surgery (remote web-based eye exams and digital questionnaires on their own devices). Participants in the 'usual care' group will have regular post-operative consultations, according to the study site's regular practice. Outcome measures include accuracy of the web-based eye exam for assessing visual acuity and refraction, patient-reported outcome measures (visual function and quality of life), adverse events, and cost aspects. DISCUSSION Investigating remote follow-up after cataract surgery fits the current trends of digitization of health care. We believe that remote self-care can be a promising avenue to comply with the increasing demands of cataract care. This randomized controlled trial provides scientific evidence on this unmet need and delivers the desired insights on (cost)effectiveness of remote follow-up after cataract surgery. TRIAL REGISTRATION ClinicalTrials.gov: NCT04809402. Date of registration: March 22, 2021.
Collapse
Affiliation(s)
- Janneau L J Claessens
- Department of Ophthalmology, University Medical Center Utrecht, Postbus 85500, Huispostnummer E03.136, Utrecht, 3508 GA, the Netherlands.
| | - Joukje C Wanten
- University Eye Clinic Maastricht, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Noël J C Bauer
- University Eye Clinic Maastricht, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Rudy M M A Nuijts
- University Eye Clinic Maastricht, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Oliver Findl
- Vienna Institute for Research in Ocular Surgery, a Karl Landsteiner Institute, Hanusch Hospital, Vienna, Austria
| | - Josef Huemer
- Vienna Institute for Research in Ocular Surgery, a Karl Landsteiner Institute, Hanusch Hospital, Vienna, Austria
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Saskia M Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Postbus 85500, Huispostnummer E03.136, Utrecht, 3508 GA, the Netherlands
| | - Robert P L Wisse
- Department of Ophthalmology, University Medical Center Utrecht, Postbus 85500, Huispostnummer E03.136, Utrecht, 3508 GA, the Netherlands
| |
Collapse
|
13
|
Gan G, Michel M, Max A, Sujet-Perone N, Zevering Y, Vermion JC, Zaidi M, Savenkoff B, Perone JM. Membranoproliferative glomerulonephritis after intravitreal vascular growth factor inhibitor injections: A case report and review of the literature. Br J Clin Pharmacol 2023; 89:401-409. [PMID: 36208427 DOI: 10.1111/bcp.15558] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/28/2022] [Accepted: 09/22/2022] [Indexed: 12/01/2022] Open
Abstract
Systemic administration of agents that inhibit vascular endothelial growth factor (VEGF) and therefore vascular proliferation is often used to treat various cancers. However, these agents are associated with a number of side effects, including proteinuria and renal injury. Intravitreal injection of anti-VEGF agents has become the cornerstone of macular disease treatment. Since these agents cross the blood-retina barrier and enter the circulation, systemic side effects have been reported. We report the novel case of a 57-year-old patient who presented with macular oedema secondary to central retinal vein occlusion, underwent three monthly loading-dose injections with the anti-VEGF agent ranibizumab, and 2 weeks after the second injection presented with biopsy-verified membranoproliferative glomerulonephritis. Twelve weeks after presenting with renal failure and 10 weeks after his last anti-VEGF injection, the patient demonstrated spontaneous recovery of his kidney function. The patient had a history that promoted renal fragility, including hypertension, liver transplantation 6 years earlier for alcohol-related cirrhosis and new-onset diabetes mellitus after transplant. Our literature review and case suggest that although adverse renal events after intravitreal anti-VEGF injections are very rare, ophthalmologists and nephrologists should be aware of this risk.
Collapse
Affiliation(s)
- Grace Gan
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France
| | - Mathis Michel
- Department of Nephrology, Mercy Hospital, Metz-Thionville Regional Hospital Center, Metz, France
| | - Antoine Max
- Cypath Metz, Cytopathology Laboratory, Metz, France
| | - Nicolas Sujet-Perone
- Department of Nephrology, Robert Debré Hospital, Reims University Hospital Center, Reims, France
| | - Yinka Zevering
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France
| | - Jean-Charles Vermion
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France
| | - Mohamed Zaidi
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France
| | - Benjamin Savenkoff
- Department of Nephrology, Mercy Hospital, Metz-Thionville Regional Hospital Center, Metz, France
| | - Jean-Marc Perone
- Department of Ophthalmology, Metz-Thionville Regional Hospital Center, Mercy Hospital, Metz, France
| |
Collapse
|
14
|
Peto T, Evans RN, Reeves BC, Harding S, Madhusudhan S, Lotery A, Downes S, Balaskas K, Bailey CC, Foss A, Ghanchi F, Yang Y, Phillips D, Rogers CA, Muldrew A, Hamill B, Chakravarthy U. Long-term Retinal Morphology and Functional Associations in Treated Neovascular Age-Related Macular Degeneration: Findings from the Inhibition of VEGF in Age-Related Choroidal Neovascularisation Trial. Ophthalmol Retina 2022; 6:664-675. [PMID: 35314388 DOI: 10.1016/j.oret.2022.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE To describe the frequency of long-term morphologic features and their relationships with visual function in participants who exited the Inhibition of VEGF in Age-Related Choroidal Neovascularisation (IVAN; ISRCTN92166560) trial. DESIGN Multicenter cohort study up to 7 years after enrollment. PARTICIPANTS Patients enrolled in the IVAN trial, excluding participants who died or withdrew during the trial. METHODS Multimodal fundus images, best-corrected visual acuity (BCVA), and low-luminance visual acuity (LLVA) were obtained for a subset of 199 participants who attended a research visit. Clinical sites (n = 20) also provided all visual acuity and clinical information from usual care records for 532 participants and submitted the most recent color, OCT, and other fundus images for 468 participants to a reading center. MAIN OUTCOME MEASURES Assessed the following from the most recent images: intralesional macular atrophy (ILMA) within the footprint of the neovascular lesion; hyperreflective material (HRM); intraretinal fluid (IRF); subretinal fluid (SRF); pigment epithelial detachment (PED); and disorganized retinal outer layers (DROLs). Cross-sectional relationships between morphologic features and BCVA/LLVA were estimated. RESULTS Intralesional macular atrophy was present in 31.8% of the study eyes at IVAN exit (mean follow-up, 1.96 years) and 89.5% at the most recent imaging visit (mean follow-up, 6.18 years). Hyperreflective material, IRF, SRF, PED, and DROLs were present in 78.8%, 47.7%, 7.6%, 94.5%, and 55% of the study eyes, respectively. In the subset with complete imaging data, in eyes without DROL, the BCVA was worst in the thinnest outer fovea tertile (thinnest minus middle and thickest tertiles, -19.7 and -19.5 letters, respectively), whereas in eyes with DROL, the BCVA was worst in the thickest (thinnest and middle tertiles minus thickest, 12.5 and 12.2, respectively). Regression models showed that the presence of ILMA and HRM was independently associated with BCVA (22 letters worse [95% confidence interval {CI}, -11.2 to -32.8; P < 0.001] and 9.8 letters worse [95% CI, -0.1 to -19.4; P = 0.047], respectively). Subretinal fluid and foveal PED were associated with better BCVA (5.9 letters [95% CI, -7.9 to 19.7; P = 0.399] and 6.4 letters [95% CI, -1.1 to 14.0; P = 0.094], respectively). The model with LLVA was similar. A sensitivity analysis involving the entire eligible cohort yielded similar estimates. CONCLUSIONS Macular atrophy and HRM were common after 7 years of follow-up and strongly associated with visual outcomes.
Collapse
Affiliation(s)
- Tunde Peto
- Queen's University of Belfast, Royal Victoria Hospital, Belfast, Ireland
| | - Rebecca N Evans
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Barnaby C Reeves
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Simon Harding
- Department of Eye and Vision Science, University of Liverpool and St Paul's Eye Unit, Liverpool University Hospitals National Health Service Foundation Trust, Members of Liverpool Health Partners, Liverpool, United Kingdom
| | - Savita Madhusudhan
- Department of Eye and Vision Science, University of Liverpool and St Paul's Eye Unit, Liverpool University Hospitals National Health Service Foundation Trust, Members of Liverpool Health Partners, Liverpool, United Kingdom
| | - Andrew Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Susan Downes
- University Hospitals National Health Service Trust, Oxford, United Kingdom
| | - Konstantinos Balaskas
- Moorfields Eye Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Clare C Bailey
- Department of Ophthalmology, University Hospitals Bristol National Health Service Foundation Trust, Bristol, United Kingdom
| | - Alexander Foss
- Department of Ophthalmology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Faruque Ghanchi
- Department of Ophthalmology, Bradford Royal Infirmary, Bradford, West Yorkshire, United Kingdom
| | - Yit Yang
- Department of Ophthalmology, New Cross Hospital, The Royal Wolverhampton National Health Service Trust, Wolverhampton, United Kingdom
| | - Dawn Phillips
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Chris A Rogers
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Alyson Muldrew
- Queen's University of Belfast, Royal Victoria Hospital, Belfast, Ireland
| | - Barbra Hamill
- Queen's University of Belfast, Royal Victoria Hospital, Belfast, Ireland
| | - Usha Chakravarthy
- Queen's University of Belfast, Royal Victoria Hospital, Belfast, Ireland.
| |
Collapse
|
15
|
Calles-Monar PS, Sanabria MR, Alonso-Tarancon AM, Coco-Martin RM, Mayo-Iscar A. Modifiable Determinants of Satisfaction with Intravitreal Treatment in Patients with Neovascular Age-Related Macular Degeneration. Drugs Aging 2022; 39:355-366. [PMID: 35486357 DOI: 10.1007/s40266-022-00937-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The success of intravitreal treatment for neovascular age-related macular degeneration (nAMD) depends on maximal adherence to treatment, which in turn requires patient satisfaction. OBJECTIVE The aim of this study was to assess the factors associated with nAMD patient satisfaction to implement actions to improve treatment experiences and increase adherence. DESIGN This was a prospective, observational, analytical, cross-sectional study. SUBJECTS Our study included 100 consecutive nAMD patients under intravitreal treatment for at least 1 year. METHODS Patients completed the Macular Disease Treatment Satisfaction Questionnaire (MacTSQ) and the EuroQol Visual Analog Scale (EQ VAS). A logistic regression was estimated to model the low values of the satisfaction score (MacTSQ < 50). RESULTS The mean age of patients was 82.1 ± 7.8 years and 62% were female. Males (p = 0.002) and patients who improved their visual acuity (p = 0.004) were more satisfied, while patients who received a higher number of injections (p = 0.036) and treatment in both eyes (p = 0.001) were less satisfied. Higher health-related quality of life was related to higher satisfaction. The sensitivity and specificity of the predictive model were 75.8% and 76.1%, respectively. Factors independently associated with low satisfaction were female sex (odds ratio [OR] 6.84), going to the clinic alone (OR 8.51), longer duration of treatment (OR 0.62), receiving treatment in both eyes (OR 3.54), and suffering a decline in visual acuity (OR 3.30). The questionnaire revealed patients' needs for more information and injection points closer to their homes. CONCLUSIONS Well-defined areas for improvement were identified, i.e. to improve the information offered to each patient, to incorporate new long-acting drugs, and to establish locations for injection services in peripheral areas.
Collapse
Affiliation(s)
- Paola S Calles-Monar
- Ophthalmology Department, San Telmo Hospital, Palencia University Hospital Complex, 34004, Palencia, Spain.
| | - María R Sanabria
- Ophthalmology Department, San Telmo Hospital, Palencia University Hospital Complex, 34004, Palencia, Spain
| | - Ana M Alonso-Tarancon
- Ophthalmology Department, San Telmo Hospital, Palencia University Hospital Complex, 34004, Palencia, Spain
| | - Rosa M Coco-Martin
- Institute of Applied Ophthalmobiology, University of Valladolid, Valladolid, Spain.,OFTARED Health Research Thematic Network, Carlos III Health Institute, Madrid, Spain
| | - Agustín Mayo-Iscar
- Department of Statistics and O.R. & IMUVA, University of Valladolid, Valladolid, Spain
| |
Collapse
|
16
|
Quality-adjusted life years in macular oedema due to age-related macular degeneration, diabetes and central retinal vein occlusion: the impact of anti-VEGF agents in a tertiary centre in Greece. Int Ophthalmol 2022; 42:2673-2684. [PMID: 35416615 DOI: 10.1007/s10792-022-02256-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 03/12/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME), and macular oedema due to central retinal vein occlusion (CRVO) are leading causes of vision loss, currently managed with anti-vascular endothelial growth factor injections (anti-VEGF). The aim of this study was to calculate QALYs in patients with nAMD, DME, and CRVO treated with anti-VEGF agents (QALYs+) in a Greek tertiary hospital setting and compare them to theoretical QALYs that the patients would have without treatment (QALYs-). MATERIAL AND METHODS The study included 143 treatment-naive patients with macular oedema due to nAMD (n = 79), DME (n = 57), and CRVO (n = 7), who received anti-VEGF injections as monotherapy according to the Treat-and-Extend (T&E) protocol. The anti-VEGF agents were ranibizumab and aflibercept in equivalent fractions. QALYs where calculated by the formula QALY = Utility Value × Time, where "Time" refers to the follow-up period of the study. For QALYs-, we assumed that visual acuity remained unchanged during this period. RESULTS Mean follow-up time was 1.3 ± 1.2 years in the nAMD group, 1 ± 1.3 years in the DME group, and 0.5 ± 1 years in the CRVO group. There was no statistically significant difference between QALYs- and QALYs+ in all three ocular pathologies for the study period (p > 0.05 for each of the three statistical tests performed). DISCUSSION/CONCLUSION Possible explanations for the lack of significant difference between QALYs - and QALYs + in nAMD, DME, and CRVO groups, may be the short time horizon used in this analysis, the inclusion of data from the better-seeing eye (BSE) and the specific socio-economic, geographical and health care characteristics of this rural Greek area.
Collapse
|
17
|
MEHTA ALEXANDER, STEEL DAVIDH, MULDREW ALYSON, PETO TUNDE, REEVES BARNABYC, EVANS REBECCA, CHAKRAVARTHY USHA. Associations and Outcomes of Patients with Submacular Hemorrhage Secondary to Age-related Macular Degeneration in the IVAN Trial. Am J Ophthalmol 2022; 236:89-98. [PMID: 34626573 DOI: 10.1016/j.ajo.2021.09.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE To compare demographics, visual acuity (VA) and retinal morphology between those with, and without baseline submacular hemorrhage (SMH) for patients enrolled in the Inhibit VEGF in Age-related Choroidal Neovascularization trial (IVAN). DESIGN Secondary analyses of a randomized, controlled trial of image and clinical data. METHODS Setting; The IVAN trial collected data in 23 UK hospitals. Study population; IVAN study eyes (with untreated neovascular age-related macular degeneration at randomization) with at least 12 months of follow-up and adequate imaging. Intervention; Study eyes were randomly assigned between monthly ranibizumab, as-needed ranibizumab, monthly bevacizumab, or as-needed bevacizumab. Imaging at baseline was graded independently for the presence, type, position, and extent of SMH. Main outcome measures; The main outcome measures were VA (primary outcome), subretinal fibrosis, atrophic scarring, and retinal thickness outcomes at 12 and 24 months RESULTS: Of 605 IVAN trial participants, 535 were included in this analysis. Patients with SMH at baseline (286 [53%]) were older (P = .010) and affected eyes were more likely to have intraretinal fluid present (P = .038). The VA was significantly worse in those with baseline SMH at month 0 (P < .001; estimate of difference 6 letters; 95% CIs, 4-8 letters), but the difference decreased and was not significant at month 12 or 24. No significant association was found between baseline SMH and subretinal fibrosis, atrophic scarring, or central retinal thickness. CONCLUSIONS The presence of SMH at baseline was associated with age, intraretinal fluid, and decreased baseline VA. By month 12, VA was no longer significantly different in those who presented with SMH at baseline.
Collapse
|
18
|
Banister K, Cook JA, Scotland G, Azuara-Blanco A, Goulão B, Heimann H, Hernández R, Hogg R, Kennedy C, Sivaprasad S, Ramsay C, Chakravarthy U. Non-invasive testing for early detection of neovascular macular degeneration in unaffected second eyes of older adults: EDNA diagnostic accuracy study. Health Technol Assess 2022; 26:1-142. [PMID: 35119357 DOI: 10.3310/vlfl1739] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Neovascular age-related macular degeneration is a leading cause of sight loss, and early detection and treatment is important. For patients with neovascular age-related macular degeneration in one eye, it is usual practice to monitor the unaffected eye. The test used to diagnose neovascular age-related macular degeneration, fundus fluorescein angiography, is an invasive test. Non-invasive tests are available, but their diagnostic accuracy is unclear. OBJECTIVES The primary objective was to determine the diagnostic monitoring performance of tests for neovascular age-related macular degeneration in the second eye of patients with unilateral neovascular age-related macular degeneration. The secondary objectives were the cost-effectiveness of tests and to identify predictive factors of developing neovascular age-related macular degeneration. DESIGN This was a multicentre, prospective, cohort, comparative diagnostic accuracy study in a monitoring setting for up to 3 years. A Cox regression risk prediction model and a Markov microsimulation model comparing cost-effectiveness of the index tests over 25 years were used. SETTING This took place in hospital eye services. PARTICIPANTS Participants were adults (aged 50-95 years) with newly diagnosed (within the previous 6 weeks) neovascular age-related macular degeneration in one eye and an unaffected second (study) eye who were attending for treatment injections in the first eye and who had a study eye baseline visual acuity of ≥ 68 Early Treatment Diabetic Retinopathy Study letters. INTERVENTIONS The index tests were Amsler chart (completed by participants), fundus clinical examination, optical coherence tomography, self-reported vision assessment (completed by participants) and visual acuity. The reference standard was fundus fluorescein angiography. MAIN OUTCOME MEASURES The main outcome measures were sensitivity and specificity; the performance of the risk predictor model; and costs and quality-adjusted life-years. RESULTS In total, 552 out of 578 patients who consented from 24 NHS hospitals (n = 16 ineligible; n = 10 withdrew consent) took part. The mean age of the patients was 77.4 years (standard deviation 7.7 years) and 57.2% were female. For the primary analysis, 464 patients underwent follow-up fundus fluorescein angiography and 120 developed neovascular age-related macular degeneration on fundus fluorescein angiography. The diagnostic accuracy [sensitivity (%) (95% confidence interval); specificity (%) (95% confidence interval)] was as follows: optical coherence tomography 91.7 (85.2 to 95.6); 87.8 (83.8 to 90.9)], fundus clinical examination [53.8 (44.8 to 62.5); 97.6 (95.3 to 98.9)], Amsler [33.7 (25.1 to 43.5); 81.4 (76.4 to 85.5)], visual acuity [30.0 (22.5 to 38.7); 66.3 (61.0 to 71.1)] and self-reported vision [4.2 (1.6 to 9.8); 97.0 (94.6 to 98.5)]. Optical coherence tomography had the highest sensitivity across all secondary analyses. The final prediction model for neovascular age-related macular degeneration in the non-affected eye included smoking status, family history of neovascular age-related macular degeneration, the presence of nodular drusen with or without reticular pseudodrusen, and the presence of pigmentary abnormalities [c-statistic 0.66 (95% confidence interval 0.62 to 0.71)]. Optical coherence tomography monitoring generated the greatest quality-adjusted life-years gained per patient (optical coherence tomography, 5.830; fundus clinical examination, 5.787; Amsler chart, 5.736, self-reported vision, 5.630; and visual acuity, 5.600) for the lowest health-care and social care costs (optical coherence tomography, £19,406; fundus clinical examination, £19,649; Amsler chart, £19,751; self-reported vision, £20,198; and visual acuity, £20,444) over the lifetime of the simulated cohort. Optical coherence tomography dominated the other tests or had an incremental cost-effectiveness ratio below the accepted cost-effectiveness thresholds (£20,000) across the scenarios explored. LIMITATIONS The diagnostic performance may be different in an unselected population without any history of neovascular age-related macular degeneration; the prediction model did not include genetic profile data, which might have improved the discriminatory performance. CONCLUSIONS Optical coherence tomography was the most accurate in diagnosing conversion to neovascular age-related macular degeneration in the fellow eye of patients with unilateral neovascular age-related macular degeneration. Economic modelling suggests that optical coherence tomography monitoring is cost-effective and leads to earlier diagnosis of and treatment for neovascular age-related macular degeneration in the second eye of patients being treated for neovascular age-related macular degeneration in their first eye. FUTURE WORK Future works should investigate the role of home monitoring, improved risk prediction models and impact on long-term visual outcomes. STUDY REGISTRATION This study was registered as ISRCTN48855678. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 8. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Katie Banister
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jonathan A Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Beatriz Goulão
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Heinrich Heimann
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Ruth Hogg
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sobha Sivaprasad
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | |
Collapse
|
19
|
Eshtiaghi A, Issa M, Popovic MM, Muni RH, Kertes PJ. GEOGRAPHIC ATROPHY INCIDENCE AND PROGRESSION AFTER INTRAVITREAL INJECTIONS OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS FOR AGE-RELATED MACULAR DEGENERATION: A Meta-Analysis. Retina 2021; 41:2424-2435. [PMID: 34101693 DOI: 10.1097/iae.0000000000003207] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Geographic atrophy (GA) is a complication of advanced neovascular age-related macular degeneration that can lead to permanent vision loss. We sought to estimate the incidence and progression of GA after intravitreal injections of antivascular endothelial growth factor agents in eyes with neovascular age-related macular degeneration. METHODS Ovid MEDLINE, EMBASE, and Cochrane CENTRAL were searched from inception to May 2020. Included studies reported on the progression or development of GA in eyes with neovascular age-related macular degeneration after antivascular endothelial growth factor therapy. RESULTS Thirty-one articles and 4,609 study eyes (4,501 patients) were included. Eyes received a mean of 17.7 injections over 35.2 months. The prevalence of GA at baseline was 9.7%. The pooled incidence of GA was 30.5% at the end of follow-up. There was a positive, moderate linear correlation between the mean total number of injections and GA incidence at the final follow-up (R2 = 0.30; P = 0.01). Monthly treatment was associated with a significantly higher risk for GA development relative to pro re nata (relative risk = 1.40, 95% confidence interval = [1.21-1.61], P < 0.001). Risk factors for GA development included GA in the fellow eye, retinal angiomatous proliferation, drusen, and reticular pseudodrusen. CONCLUSION We found an association between the frequency and number of treatments with antivascular endothelial growth factor agents and the development of GA in neovascular age-related macular degeneration. Future studies should clarify risk factors, population characteristics, and relative contributions of treatment and disease progression on GA development in this context.
Collapse
Affiliation(s)
- Arshia Eshtiaghi
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mariam Issa
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marko M Popovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Rajeev H Muni
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Ophthalmology, St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada; and
| | - Peter J Kertes
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- John and Liz Tory Eye Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
20
|
Foss A, Rotsos T, Empeslidis T, Chong V. The Development of Macular Atrophy in Patients with Wet Age-Related Macular Degeneration Receiving Anti-VEGF Treatment. Ophthalmologica 2021; 245:204-217. [PMID: 34695835 DOI: 10.1159/000520171] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022]
Abstract
Age-related macular degeneration (AMD) is a leading cause of blindness. Late AMD can be classified into exudative (commonly known as wet AMD [wAMD]) or dry AMD, both of which may progress to macular atrophy (MA). MA causes irreversible vision loss and currently has no approved pharmacological treatment. The standard of care for wAMD is treatment with anti-vascular endothelial growth factors (VEGF). However, recent evidence suggests that anti-VEGF treatment may play a role in the development of MA. Therefore, it is important to identify risk factors for the development of MA in patients with wAMD. For example, excessive blockade of VEGF through intense use of anti-VEGF agents may accelerate the development of MA. Patients with type III macular neovascularisation (retinal angiomatous proliferation) have a particularly high risk of MA. These patients are characterised as having a pre-existing thin choroid (age-related choroidopathy), suggesting that the choroidal circulation is unable to respond to increased VEGF expression. Evidence suggests that subretinal fluid (possibly indicative of residual VEGF activity) may play a protective role. Patients receiving anti-VEGF agents must be assessed for overall risk of MA and there is an unmet medical need to prevent the development of MA without undertreating wAMD.
Collapse
Affiliation(s)
- Alexander Foss
- University of Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom
| | - Tryfon Rotsos
- Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - Theo Empeslidis
- Boehringer Ingelheim International GmbH, Ingelheim Am Rhein, Germany
| | - Victor Chong
- Boehringer Ingelheim International GmbH, Ingelheim Am Rhein, Germany
| |
Collapse
|
21
|
Phan LT, Broadhead GK, Hong TH, Chang AA. Predictors of Visual Acuity After Treatment of Neovascular Age-Related Macular Degeneration - Current Perspectives. Clin Ophthalmol 2021; 15:3351-3367. [PMID: 34408393 PMCID: PMC8364912 DOI: 10.2147/opth.s205147] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 12/30/2022] Open
Abstract
Visual acuity is a key outcome measure in the treatment of neovascular age-related macular degeneration (nAMD) using anti-vascular endothelial growth factor agents. Large variations in visual responses between individuals within clinical trials and real-world studies may relate to underlying differences in patient and treatment factors. Most notably, a better baseline visual acuity, younger age and smaller choroidal neovascularization lesion size have been strongly associated with achieving better visual outcomes. In addition, there is emerging evidence for other roles including genetic factors and anatomical variables such as fluid status. Apart from patient-related factors, treatments that favor a higher number of injections tend to provide better visual outcomes. Overall, the identification of predictive factors does not currently play an essential role in the clinical management of patients with nAMD. However, they have allowed for the understanding that early detection, timely management and close monitoring of the disease are required to achieve optimal visual outcomes. Further investigation into predictive factors alongside the development of novel therapeutic agents may one day provide a means to accurately predict patient outcomes. Treatment regimens that offer flexible dosing patterns such as the treat-and-extend strategy currently provide a degree of personalization during treatment.
Collapse
Affiliation(s)
- Long T Phan
- Sydney Retina, Sydney, New South Wales, Australia.,Discipline of Orthoptics, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Geoffrey K Broadhead
- Sydney Retina, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Andrew A Chang
- Sydney Retina, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
22
|
Kaiser PK, Wykoff CC, Singh RP, Khanani AM, Do DV, Patel H, Patel N. RETINAL FLUID AND THICKNESS AS MEASURES OF DISEASE ACTIVITY IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION. Retina 2021; 41:1579-1586. [PMID: 33949342 PMCID: PMC8297539 DOI: 10.1097/iae.0000000000003194] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE Retinal fluid and thickness are important anatomical features of disease activity in neovascular age-related macular degeneration, as evidenced by clinical trials that have used these features for inclusion criteria, retreatment criteria, and outcome measures of the efficacy of intravitreal injections of anti-vascular endothelial growth factor agents. METHODS A literature review of anatomical measures of disease activity was conducted. RESULTS Treatment goals for neovascular age-related macular degeneration include improving/maintaining vision by drying the retina, and several analyses have evaluated the relationship between visual function and anatomy. The change in retinal thickness has been found to correlate with the change in the visual acuity, and variation in retinal thickness may predict visual acuity outcomes. In addition, specific fluid compartments may have different prognostic values. For example, the presence of intraretinal fluid has been associated with poorer visual acuity, whereas the presence of subretinal fluid has been associated with better visual acuity. Retinal fluid and thickness are important for selecting dosing interval durations in clinical trials and clinical practice. CONCLUSION Retinal thickness and retinal fluid are common anatomical measures of disease activity in neovascular age-related macular degeneration. Further research is required to fully elucidate the relationship between anatomical features and visual outcomes in neovascular age-related macular degeneration.
Collapse
Affiliation(s)
- Peter K. Kaiser
- Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Charles C. Wykoff
- Retina Consultants of Texas, Retina Consultants of America, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas;
| | - Rishi P. Singh
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Arshad M. Khanani
- Sierra Eye Associates, Reno, Nevada
- University of Nevada, Reno School of Medicine, Reno, Nevada
| | - Diana V. Do
- Byers Eye Institute, Stanford University, Palo Alto, California; and
| | - Hersh Patel
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | - Nikhil Patel
- Novartis Pharmaceuticals, East Hanover, New Jersey
| |
Collapse
|
23
|
Pfau M, Sahu S, Rupnow RA, Romond K, Millet D, Holz FG, Schmitz-Valckenberg S, Fleckenstein M, Lim JI, de Sisternes L, Leng T, Rubin DL, Hallak JA. Probabilistic Forecasting of Anti-VEGF Treatment Frequency in Neovascular Age-Related Macular Degeneration. Transl Vis Sci Technol 2021; 10:30. [PMID: 34185055 PMCID: PMC8254013 DOI: 10.1167/tvst.10.7.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Purpose To probabilistically forecast needed anti-vascular endothelial growth factor (anti-VEGF) treatment frequency using volumetric spectral domain-optical coherence tomography (SD-OCT) biomarkers in neovascular age-related macular degeneration from real-world settings. Methods SD-OCT volume scans were segmented with a custom deep-learning-based analysis pipeline. Retinal thickness and reflectivity values were extracted for the central and the four inner Early Treatment Diabetic Retinopathy Study (ETDRS) subfields for six retinal layers (inner retina, outer nuclear layer, inner segments [IS], outer segments [OS], retinal pigment epithelium-drusen complex [RPEDC] and the choroid). Machine-learning models were probed to predict the anti-VEGF treatment frequency within the next 12 months. Probabilistic forecasting was performed using natural gradient boosting (NGBoost), which outputs a full probability distribution. The mean absolute error (MAE) between the predicted versus actual anti-VEGF treatment frequency was the primary outcome measure. Results In a total of 138 visits of 99 eyes with neovascular AMD (96 patients) from two clinical centers, the prediction of future anti-VEGF treatment frequency was observed with an accuracy (MAE [95% confidence interval]) of 2.60 injections/year [2.25-2.96] (R2 = 0.390) using random forest regression and 2.66 injections/year [2.31-3.01] (R2 = 0.094) using NGBoost, respectively. Prediction intervals were well calibrated and reflected the true uncertainty of NGBoost-based predictions. Standard deviation of RPEDC-thickness in the central ETDRS-subfield constituted an important predictor across models. Conclusions The proposed, fully automated pipeline enables probabilistic forecasting of future anti-VEGF treatment frequency in real-world settings. Translational Relevance Prediction of a probability distribution allows the physician to inspect the underlying uncertainty. Predictive uncertainty estimates are essential to highlight cases where human-inspection and/or reversion to a fallback alternative is warranted.
Collapse
Affiliation(s)
- Maximilian Pfau
- Department of Biomedical Data Science, Stanford University, Palo Alto, CA, USA.,Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Soumya Sahu
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA.,Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Rawan Allozi Rupnow
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA.,Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Kathleen Romond
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Desiree Millet
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | | | - Jennifer I Lim
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Theodore Leng
- Byers Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Daniel L Rubin
- Department of Biomedical Data Science, Stanford University, Palo Alto, CA, USA
| | - Joelle A Hallak
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
24
|
Garrigan H, Hamati J, Lalakia P, Frasso R, Salzman B, Hyman L. Does Age-Related Macular Degeneration (AMD) Treatment Influence Patient Falls and Mobility? A Systematic Review. Ophthalmic Epidemiol 2021; 29:128-138. [PMID: 33993827 DOI: 10.1080/09286586.2021.1921227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: Age-related macular degeneration (AMD), a leading cause of irreversible blindness, increases fall risk through impaired central vision. Falls place an enormous economic burden on healthcare systems. We hypothesized that AMD treatments may reduce patients' falls risk. This systematic review (ID #: 172623) synthesized the current understanding of wet and dry AMD treatments' impact on patient falls and mobility, connecting these two public health issues.Methods: On April 17, 2020, PubMed, Scopus, CINAHL, and the Cochrane Central Register of Controlled Trials were queried. Clinical trials and observational studies were included, while non-English and non-primary studies were excluded. Two authors screened, extracted data, and assessed bias using RoB-2 and ROBINS-I. A third author served as a tie breaker.Results: This database search resulted in 3,525 studies, with an additional 112 identified through bibliography review. Ten articles met eligibility criteria. Most studies featured the outcome of interest as a secondary outcome (n = 4) and patient-reported adverse events (n = 5), rather than a primary focus (n = 2). Ten out of the 11 outcomes had a moderate to serious risk of bias. No two studies used the same instrument to measure falls or mobility.Conclusion: Despite the potential positive impact of AMD treatments on patient falls and mobility, quality data on this relationship are lacking. This work underscores the need to broaden ophthalmologic research outcomes beyond visual parameters to include patient-centred, functional measures. Incorporating standardized methods to track falls and screen for difficulty with walking and balance would enable evaluation of AMD treatments on functional outcomes, potentially helping guide management.
Collapse
Affiliation(s)
- Hannah Garrigan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jacquelyn Hamati
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parth Lalakia
- College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Office of Global Affairs, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,School of Osteopathic Medicine, Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Rosemary Frasso
- College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brooke Salzman
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Division of Geriatric Medicine and Palliative Care, Department of Family Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Leslie Hyman
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,The Vickie and Jack Farber Vision Research Center, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| |
Collapse
|
25
|
Banaee T, Alwan S, Kellogg C, Kornblau I, El-Annan J. PRN Treatment of Neovascular AMD with Cycles of Three Monthly Injections. J Ophthalmic Vis Res 2021; 16:178-186. [PMID: 34055255 PMCID: PMC8126743 DOI: 10.18502/jovr.v16i2.9081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 01/16/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose To report the one and two year outcome of cycles of three, monthly anti-VEGF injections given upon reactivation of the disease in eyes with neovascular age-related macular degeneration (nAMD). Methods Retrospective study of naïve nAMD cases with more than one year of follow-up, treated with a protocol of cycles of three monthly injections of anti-VEGF drugs upon reactivation. Visual acuity (VA) and central macular thickness (CMT) are the main outcome measures. Results Twenty-six patients with a mean age of 78.15 ± 9.29 years (57.7% female) were included. The mean follow-up was 30.89 ± 6.95 months. Treatment started with bevacizumab in all patients but in six patients was switched to aflibercept due to inadequate response to intravitreal bevacizumab injection. The mean VA at baseline and at 12 and 24 months was 53.87 ± 21.84, 60.54 ± 21.13, and 53.68 ± 27.16 ETDRS letters, respectively. Patients gained a mean of 6.67± 13.7 (p = 0.013, 95% CI= 0.60 to 12.65) and 0.77±15.21 (p = 0.4, 95% CI: –5.65 to 7.2) letters at 12 and 24 months. CMT at baseline, 12, and 24 months was 403.55 ± 147.59, 323.95 ± 79.58, and 298.59 ± 77.161 µm, respectively. The number of injections in the first and second years were 7.65 ± 2.64 and 5.52 ± 3.01, respectively. Three eyes (12.5%) lost >15 letters at 24 months. Conclusion This protocol can stabilize or improve vision in 87.5% of nAMD patients and can reduce the number of visits.
Collapse
Affiliation(s)
- Touka Banaee
- University of Texas Medical Branch in Galveston, Texas, USA
| | - Shadan Alwan
- University of Texas Medical Branch in Galveston, Texas, USA
| | - Clint Kellogg
- University of Texas Medical Branch in Galveston, Texas, USA
| | - Ilyse Kornblau
- University of Texas Medical Branch in Galveston, Texas, USA
| | - Jaafar El-Annan
- University of Texas Medical Branch in Galveston, Texas, USA.,University of Texas at MD Anderson, Houston, Texas, USA.,Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| |
Collapse
|
26
|
Biosimilars for Retinal Diseases: An Update. Am J Ophthalmol 2021; 224:36-42. [PMID: 33309691 DOI: 10.1016/j.ajo.2020.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To review the biosimilars of anti-vascular endothelial growth factor agents for retinal diseases and provide an update about their development. DESIGN Literature review. METHODS A comprehensive literature review was performed for scientific articles, clinical trials, and press releases for the development of biosimilars in ophthalmology. RESULTS To date, Razumab (Intas Pharmaceuticals Ltd, Ahmedabad, GJ, India) is the only approved biosimilar for ophthalmic use, but the landscape will rapidly change in the future with multiple biosimilar candidates, which are currently in phase 3 trials, showing promising early results. CONCLUSION Biosimilars hold the potential to reduce the financial burden of the highly efficacious biologic therapy in retinal pathologies. However, the off-label bevacizumab may differentiate the success of biosimilars in different geographic regions.
Collapse
|
27
|
Rosenblatt A, Hekselman I, Rosenblatt I, Hekselman I, Gaton D. Cost containment by peer prior authorization program for second line treatment in patients with retinal disease. Isr J Health Policy Res 2021; 10:4. [PMID: 33494826 PMCID: PMC7830824 DOI: 10.1186/s13584-021-00437-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022] Open
Abstract
Background High and increasing drug prices have prompted the establishment of a broad range of cost-containment treatment policies in health systems globally. In 2012, the supplemental insurance program of a large Israeli health maintenance organization (Clalit Health Services) introduced a prior authorization process for second-line use of ranibizumab in patients with retinal disease for whom treatment with bevacizumab proved to be ineffective. A Clalit steering committee established authorization criteria based on cost and periodically updated clinical considerations, while a team of ophthalmic specialists evaluated their colleagues’ individual patient subsidization requests, based on the funding criteria. The objectives of this study were to detail this unique authorization process and study its effectiveness in limiting unwarranted spending, while allowing for a smooth transition to a second-line more expensive drug when needed. Methods A retrospective cohort study including all applications for a first or ongoing treatment with ranibizumab, for one or both eyes, received during March 1, 2012 - December 31, 2015. The key parameters examined were percentages of requests from patients treated by first line treatment bevacizumab, requests approved, reapplications, and results. Requests studied include reapplications and requests for treatment continuation. Results During the study period, Clalit affiliated ophthalmologists’ submitted 16,778 funding applications for intravitreal ranibizumab treatment on behalf of 5642 patients who applied for approximately three applications. An efficient sentinel effect was achieved, resulting in only 31% of patients treated with bevacizumab applying for treatment, while maintaining extremely high accessibility to second line treatment with almost 95% of requests being approved. Conclusions The data presented shows a low request rate for funding with a high approval rate, proving this peer reviewed report-based authorization process successfully achieved a sentinel effect while controlling cost. We suggest this innovative model be considered in similar decisions processes.
Collapse
Affiliation(s)
- Amir Rosenblatt
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center (Ichilov), 6 Weizmann Street, Tel Aviv, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Igal Hekselman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Clalit Mushlam Health Insurance Systems, Clalit Health Services, Ramat Gan, Israel
| | - Irit Rosenblatt
- Department of Ophthalmology, Beilinson and Hasharon, Rabin Medical Center, Petah-Tikva, Israel
| | - Idan Hekselman
- Medical School for International Health, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Dan Gaton
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Beilinson and Hasharon, Rabin Medical Center, Petah-Tikva, Israel
| |
Collapse
|
28
|
Kertes PJ, Galic IJ, Greve M, Williams G, Baker J, Lahaie M, Sheidow T. Efficacy of a Treat-and-Extend Regimen With Ranibizumab in Patients With Neovascular Age-Related Macular Disease: A Randomized Clinical Trial. JAMA Ophthalmol 2020; 138:244-250. [PMID: 31917441 PMCID: PMC6990694 DOI: 10.1001/jamaophthalmol.2019.5540] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Although the Canadian Treat-and-Extend Analysis Trial With Ranibizumab in Patients With Neovascular Age-Related Macular Disease (CANTREAT) reported herein and the Treat and Extend study provided data to show noninferiority of treat-and-extend (T&E) at 12 months, to date there are few data on 24-month T&E trials compared with monthly dosing. Objective To compare the efficacy of ranibizumab using a T&E regimen to monthly dosing in treatment-naive patients with neovascular age-related macular degeneration (nAMD) after 24 months. Design, Setting, and Participants A randomized, open-label, multicenter, noninferiority intention-to-treat trial with a margin of -5 letters in best-corrected visual acuity (BCVA) from baseline to 12 months between groups was conducted at 27 treatment centers in Canada. Participants included 580 patients with treatment-naive choroidal neovascularization secondary to AMD. The study was conducted from May 8, 2013, to August 28, 2018, and data analysis was performed between August 29 and September 12, 2018. Interventions Patients with nAMD were randomized 1:1 to receive intravitreal ranibizumab, 0.5 mg, in either a T&E or monthly dosing regimen. Main Outcomes and Measures Mean change in BCVA in Early Treatment of Diabetic Retinopathy Study letters from baseline to month 24. Results Of the 580 randomized patients, 350 were women (60.3%) and 547 were white (94.3%). Mean (SD) age was 78.8 (7.8) years. By the end of month 24, 466 of the 580 randomized patients (80.3%) had completed the study and participants in the T&E arm received a mean of 17.6 injections compared with 23.5 injections for the monthly arm, for a difference of 5.9 injections and visits over 2 years (95% CI, 5.4-6.5; P < .001). The mean (SD) BCVA improvement was not worse with the T&E arm, 6.8 (14.1) letters vs 6.0 (12.6) letters, compared with the monthly arm (difference, 0.9; 95% CI, -1.6 to 3.3; P = .21). There was a gain of 15 or more letters in 25.5% of the T&E group and 23.1% of the monthly treatment group (difference, 2.4%; 95% CI, -6.8% to 11.6%; P = .59) and a loss of 15 or more letters in 6.5% of the T&E group and 5.8% of the monthly treatment group (difference, -0.7%; 95% CI, -9.9% to 8.5%; P = .85). Conclusions and Relevance These findings suggest that change in vision from baseline is not worse with a T&E compared with a monthly regimen of ranibizumab for nAMD through 24 months, achieving clinically meaningful improvements in BCVA despite fewer injections and visits. Trial Registration ClinicalTrials.gov identifier: NCT02103738.
Collapse
Affiliation(s)
- Peter J Kertes
- The John and Liz Tory Eye Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Ivan J Galic
- Montreal Retina Institute, Montreal, Québec, Canada.,Department of Ophthalmology & Visual Sciences, McGill University, Montreal, Québec, Canada
| | - Mark Greve
- Alberta Retina Consultants, Edmonton, Alberta, Canada.,Department of Ophthalmology & Visual Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Geoff Williams
- Calgary Retina Consultants, Calgary, Alberta, Canada.,Department of Surgery, Section Ophthalmology, University of Calgary, Calgary, Alberta, Canada
| | - Jason Baker
- Novartis Pharmaceuticals Canada Inc, Dorval, Québec, Canada
| | - Marcel Lahaie
- Novartis Pharmaceuticals Canada Inc, Dorval, Québec, Canada
| | - Tom Sheidow
- Ivey Eye Institute, London, Ontario, Canada.,Western University, London, Ontario, Canada
| |
Collapse
|
29
|
Ho AC, Kleinman DM, Lum FC, Heier JS, Lindstrom RL, Orr SC, Chang GC, Smith EL, Pollack JS. Baseline Visual Acuity at Wet AMD Diagnosis Predicts Long-Term Vision Outcomes: An Analysis of the IRIS Registry. Ophthalmic Surg Lasers Imaging Retina 2020; 51:633-639. [DOI: 10.3928/23258160-20201104-05] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/03/2020] [Indexed: 11/20/2022]
|
30
|
Li L, Lai K, Li C, Gong Y, Xu F, Zhao H, Zhou L, Huang C, Jin C. APRPG-modified nanoliposome loaded with miR-146a-5p inhibitor suppressed choroidal neovascularization by targeting endothelial cells. Cutan Ocul Toxicol 2020; 39:354-362. [PMID: 32928013 DOI: 10.1080/15569527.2020.1823406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION To explore the effect and mechanism of APRPG-modified nanoliposomes loaded with miR-146a-5p inhibitor (ANL-miR-146a-5p inhibitor) on endothelial cell proliferation, migration, tube formation, and choroidal neovascularization (CNV) in mice. METHODS ANL-miR-146a-5p inhibitors were generated by thin film hydration; in vitro, endothelial cell uptake experiment was used to detect the targeting effect of ANL-miR-146a-5p inhibitor; endothelial cells proliferation, migration, and tube formation were detected, respectively, by CCK8 assay, scratch assay, and Matrigel tube formation assay. In vivo, the mice CNV models were established by 810 nm laser photocoagulation. Mice choroidal flatmounts were performed to detect the volume of CNV after intravitreal injection of L-miR-146a-5p inhibitor, ANL-miR-146a-5p inhibitor, or normal saline; the vascular endothelial growth factor (VEGF) expression of mice choroidal tissue was detected by ELISA; HE section and electrophysiology (ERG) were performed to check the toxicity of ANL-miR-146a-5p inhibitor on mice retina. RESULTS ANL are targeted to endothelial cells and are more targeted in inflammatory environment. At the same concentration, ANL-miR-146a-5p inhibitor's ability to inhibit endothelial cell proliferation, migration, tube formation, CNV formation, and VEGF expression is better than L-miR-146a-5p inhibitor (p < 0.05); ANL-miR-146a-5p inhibitor had no toxicity on the structure of mouse retina; ANL-miR-146a-5p inhibitor had no toxicity on the a-wave and b-wave amplitudes and b-wave implicit times (p > 0.05). CONCLUSIONS ANL-miR-146a-5p inhibitor can more effectively down-regulate the expression level of VEGF through its targeting to endothelial cells, thereby more effectively inhibiting endothelial cell proliferation, migration, tube formation, and mice CNV formation.
Collapse
Affiliation(s)
- Longhui Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Kunbei Lai
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Cong Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yajun Gong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Fabao Xu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Hongkun Zhao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Lijun Zhou
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Chuangxin Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Chenjin Jin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
31
|
Brown GC, Brown MM, Rapuano S, Boyer D. Cost-Utility Analysis of VEGF Inhibitors for Treating Neovascular Age-Related Macular Degeneration. Am J Ophthalmol 2020; 218:225-241. [PMID: 32565050 DOI: 10.1016/j.ajo.2020.05.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 05/12/2020] [Accepted: 05/21/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE To perform 11- and 2-year health care sector (ophthalmic) and societal cost perspective reference case, cost-utility analyses comparing bevacizumab, ranibizumab, and aflibercept monotherapies for neovascular age-related macular degeneration (NVAMD). DESIGN Cost-utility analysis. METHODS The authors performed 11-year and 2-year ophthalmic and societal cost perspective, cost-utility analyses comparing bevacizumab, ranibizumab, and aflibercept monotherapies for neovascular age-related macular degeneration (NVAMD). We employed patient utilities, bilateral outcomes, 2018 U.S. dollars, vision-related mortality, a Medicare fee schedule, and CATT (Comparison of Age-Related Macular Degeneration Treatments) study and VIEW (VEGF Trap-Eye: Investigation of Efficacy and Safety in Wet AMD) trial. Cochrane data were also used. SETTING Center for Value-Based Medicine. Patient/study population: patients with NVAMD. INTERVENTION Cost-utility analyses using published data. Data-modeled 10-year vision outcomes were modeled forward to year 11. MAIN OUTCOME MEASUREMENT These included cost-utility ratios (CURs), costs, and quality-adjusted life-years (QALYs) gained. $100,00/QALY was considered the US cost-effectiveness upper limit. RESULTS Bevacizumab and ranibizumab each conferred an 11-year, 1.339 QALY gain versus observation. Aflibercept conferred a 1.380 QALY gain. Aflibercept conferred greater QALY gain for less cost than ranibizumab but was not cost-effective compared to bevacizumab ($1,151,451/QALY incremental CUR). The average ophthalmic cost perspective CUR for bevacizumab was $11,033/QALY, $79,600/QALY for ranibizumab, and $44,801/QALY for aflibercept. Eleven-year therapies saved a 1.0 year-of-life loss without treatment from the 11.0-year life expectancy. Early treatment was 138%-149% more cost-effective than late treatment. Two-year therapy prevented a 1-month-of-life loss, and revealed bevacizumab, ranibizumab, and aflibercept conferred 0.141, 0.141, and 0.164 QALY gains, respectively, with corresponding average CURs of $40,371/QALY, $335,726/QALY, and $168,006/QALY, respectively. CONCLUSIONS From an ophthalmic (medical) cost perspective, bevacizumab, ranibizumab, and aflibercept NVAMD monotherapies were all cost-effective over 11 years, with bevacizumab 6.21× more cost-effective than ranibizumab and 3.06× more cost-effective than aflibercept. Two-year modeling revealed bevacizumab was cost-effective, whereas ranibizumab and aflibercept were not. Early treatment was critical for obtaining optimal vision and cost-effectiveness, as is long-term follow-up and adherence to treatment.
Collapse
|
32
|
Evans RN, Reeves BC, Maguire MG, Martin DF, Muldrew A, Peto T, Rogers C, Chakravarthy U. Associations of Variation in Retinal Thickness With Visual Acuity and Anatomic Outcomes in Eyes With Neovascular Age-Related Macular Degeneration Lesions Treated With Anti-Vascular Endothelial Growth Factor Agents. JAMA Ophthalmol 2020; 138:1043-1051. [PMID: 32816002 PMCID: PMC7441468 DOI: 10.1001/jamaophthalmol.2020.3001] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 06/27/2020] [Indexed: 12/29/2022]
Abstract
Importance When initiating anti-vascular endothelial growth factor (VEGF) treatment for patients with neovascular age-related macular degeneration (nAMD), knowledge of prognostic factors is important for advising patients and guiding treatment. We hypothesized that eyes with greater fluctuation in retinal thickness over time have worse outcomes than eyes with less variation. Objective To investigate whether visual and anatomic outcomes in eyes with nAMD initiating anti-VEGF treatment are associated with fluctuations in retinal thickness. Design, Setting, and Participants In this study using data from the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) and the Inhibition of VEGF in Age-Related Choroidal Neovascularization (IVAN) randomized clinical trial, people with previously untreated nAMD were included. Data were collected from February 2008 to November 2012, and data were analyzed from April 2017 to April 2020. Main Outcomes and Measures Foveal center point thicknesses (FCPTs) were extracted from 1165 study eyes from CATT and 566 study eyes from the IVAN trial, excluding those with 3 measurements or less. For each eye, the SD of FCPT was calculated. Eyes were grouped by FCPT SD quartile. Associations of FCPT SD quartile with outcomes were quantified at month 24 or the last available visit by linear or logistic regression, adjusting for baseline best-corrected visual acuity (BCVA) and randomized allocations to drug and treatment regimen, for BCVA, development of fibrosis, and development of macular atrophy. Results Of the 1731 included patients, 1058 (61.1%) were female, and the mean (SD) age was 78.6 (7.4) years. The median (interquartile range) FCPT SD was 40.2 (27.1-61.2) in the IVAN cohort and 59.0 (38.3-89.4) in the CATT cohort. After adjustment for baseline BCVA and trial allocations, BCVA worsened significantly across the quartiles of FCPT SD; the difference between the first and fourth quartiles was -6.27 Early Treatment Diabetic Retinopathy Study letters (95% CI, -8.45 to -4.09). The risk of developing fibrosis and macular atrophy also increased across FCPT SD quartiles. Odds ratios ranged from 1.40 (95% CI, 1.03 to 1.91) for quartile 2 to 1.95 (95% CI, 1.42 to 2.68) for quartile 4 for fibrosis and from 1.32 (95% CI, 0.90 to 1.92) for quartile 2 to 2.10 (95% CI, 1.45 to 3.05) for quartile 4 for macular atrophy. Conclusions and Relevance Greater variation in retinal thickness in eyes with nAMD during treatment with anti-VEGF was associated with worse BCVA and development of fibrosis and macular atrophy in these post hoc analyses, despite protocol-directed treatment frequency. Practitioners may want to consider variation in retinal thickness when advising patients about their prognosis.
Collapse
Affiliation(s)
- Rebecca N. Evans
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Barnaby C. Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | | | - Alyson Muldrew
- Queen’s University of Belfast, Royal Victoria Hospital, Belfast, Ireland
| | - Tunde Peto
- Queen’s University of Belfast, Royal Victoria Hospital, Belfast, Ireland
| | - Chris Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Usha Chakravarthy
- Queen’s University of Belfast, Royal Victoria Hospital, Belfast, Ireland
| |
Collapse
|
33
|
Ribeiro I, Batel Marques F, Mendes D, Alves C. A Systematic Review of Economic Studies Evaluating Ophthalmic Drugs: An Analysis of the Health-state Utilities. Ophthalmic Epidemiol 2020; 27:325-338. [PMID: 32691652 DOI: 10.1080/09286586.2020.1792938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To characterize the techniques used to derive health-state utilities (HSU) in the cost-utility studies (CUS) of ophthalmic drugs. METHODS A systematic review was conducted in Pubmed/Embase until October 2019. CUS evaluating ophthalmic drugs were included. Therapeutic area, technique to derive HSU and sources of HSU were extracted. It was assessed if the HSU and the other parameters of CUS were collected from the same population. The techniques to derive HSU used in the CUS were compared to the techniques recommended by the country-specific economic evaluation guidelines. RESULTS Seventy CUS were included. Forty-three (61.4%) used direct techniques to derive HSU, 19 (27.1%) used indirect, 1 (1.4%) used direct and indirect and the remaining (n = 7; 10.0%) used other or unknown techniques. Twelve (17.1%) CUS collected the HSU and the other parameters from the same population: nine (12.9%) retrieved utility data from experimental studies, two (2.9%) from observational and one (1.4%) from other sources. Forty-eight (68.6%) CUS collected the HSU and the other parameters from different populations: eight (11.4%) retrieved utility data from experimental studies, 33 (47.1%) from observational, one (1.4%) from both experimental and observational and six (8.6%) from other sources. It was not possible to identify the population from whom data were obtained in 10 (14.3%) CUS. Eleven (15.7%) CUS followed the recommendations of guidelines, 21 (30.0%) did not follow and for 38 (54.3%), it was not possible to assess. CONCLUSION Choosing different techniques to derive HSU may result in different results, which can preclude the comparison between cost-utility studies.
Collapse
Affiliation(s)
- Inês Ribeiro
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, CHAD - Centre for Health Technology Assessment and Drug Research , Coimbra, Portugal.,Faculty of Pharmacy, University of Coimbra , Coimbra, Portugal
| | - Francisco Batel Marques
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, CHAD - Centre for Health Technology Assessment and Drug Research , Coimbra, Portugal.,Laboratory of Social Pharmacy and Public Health, Faculty of Pharmacy, University of Coimbra , Coimbra, Portugal
| | - Diogo Mendes
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, CHAD - Centre for Health Technology Assessment and Drug Research , Coimbra, Portugal
| | - Carlos Alves
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, CHAD - Centre for Health Technology Assessment and Drug Research , Coimbra, Portugal.,Laboratory of Social Pharmacy and Public Health, Faculty of Pharmacy, University of Coimbra , Coimbra, Portugal
| |
Collapse
|
34
|
Santana CP, Mansur AAP, Mansur HS, Silva-Cunha AD. Bevacizumab-Conjugated Quantum Dots: In Vitro Antiangiogenic Potential and Biosafety in Rat Retina. J Ocul Pharmacol Ther 2020; 36:467-483. [PMID: 32522096 DOI: 10.1089/jop.2019.0108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Purpose: Disturbances that affect the inside of the eyeball tend to be highly harmful since they compromise the homeostasis of this organ. Alongside this, the eyeball has several anatomical barriers that prevent the entry of substances. This way, diseases that affect the retina are among those that present greater difficulty in the treatment. In many cases, abnormal proliferation of blood vessels (neovascularization) occurs from the lower layers of the retina. This process damages its structure physiologically and anatomically, causing the rapid and irreversible loss of visual capacity. This work aims to develop nanosuspensions of quantum dots (QDs) conjugated to bevacizumab. Methods: Two types of QDs were produced by aqueous route, stabilized with chitosan conjugated to bevacizumab. The antiangiogenic activity was evaluated in the chorioallantoic membrane model, in which results indicated discrete activity at the doses tested. Samples were assessed for their biosafety in animals, after intravitreal administration, by means of electroretinography (ERG), intraocular pressure (IOP) measurement, histological, morphometric, and immunohistochemical evaluation. Results: No significant alterations were detected in ERG that suggests damage to retinal function by the samples. No significant changes in IOP were also detected. The histological sections did not show signs of acute inflammation, although there was evidence of late retinal damage. The immunohistochemical analysis did not detect any apoptotic bodies. Conclusion: Preliminary results suggest that QDs present potential applicability in ocular therapy, and it is necessary to better characterize their in vivo behavior and to optimize their dosage.
Collapse
Affiliation(s)
- Cleildo P Santana
- Technology Center in Medicine Development-CT-Tecnologia Farmacêutica, Faculty of Pharmacy, Federal University of Minas Gerais-UFMG, Belo Horizonte, Brazil
| | - Alexandra A P Mansur
- Center of Nanoscience, Nanotechnology and Innovation-CeNano2I, School of Engineering, Federal University of Minas Gerais-UFMG, Belo Horizonte, Brazil
| | - Herman S Mansur
- Center of Nanoscience, Nanotechnology and Innovation-CeNanoI, School of Engineering, Federal University of Minas Gerais-UFMG, Belo Horizonte, Brazil
| | - Armando da Silva-Cunha
- Technology Center in Medicine Development-CT-Tecnologia Farmacêutica, Faculty of Pharmacy, Federal University of Minas Gerais-UFMG, Belo Horizonte, Brazil
| |
Collapse
|
35
|
Li E, Donati S, Lindsley KB, Krzystolik MG, Virgili G. Treatment regimens for administration of anti-vascular endothelial growth factor agents for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2020; 5:CD012208. [PMID: 32374423 PMCID: PMC7202375 DOI: 10.1002/14651858.cd012208.pub2] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is one of the leading causes of permanent blindness worldwide. The current mainstay of treatment for neovascular AMD (nAMD) is intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents: aflibercept, ranibizumab, and off-label bevacizumab. Injections can be given monthly, every two or three months ('extended-fixed'), or as needed (pro re nata (PRN)). A variant of PRN is 'treat-and-extend' whereby injections are resumed if recurrence is detected and then delivered with increasing intervals. Currently, injection frequency varies among practitioners, which underscores the need to characterize an optimized approach to nAMD management. OBJECTIVES To investigate the effects of monthly versus non-monthly intravitreous injection of an anti-VEGF agent in people with newly diagnosed nAMD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, and three trials registers from 2004 to October 2019; checked references; handsearched conference abstracts; and contacted pharmaceutical companies to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared different treatment regimens for anti-VEGF agents in people with newly diagnosed nAMD. We considered standard doses only (ranibizumab 0.5 mg, bevacizumab 1.25 mg, aflibercept 2.0 mg, or a combination of these). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for trial selection, data extraction, and analysis. MAIN RESULTS We included 15 RCTs. The total number of participants was 7732, ranging from 37 to 2457 in each trial. The trials were conducted worldwide. Of these, six trials exclusively took place in the US, and three included centers from more than one country. Eight trials were at high risk of bias for at least one domain and all trials had at least one domain at unclear risk of bias. Seven trials (3525 participants) compared a PRN regimen with a monthly injection regimen, of which five trials delivered four to eight injections using standard PRN and three delivered nine or 10 injections using a treat-and-extend regimen in the first year. The overall mean change in best-corrected visual acuity (BCVA) at one year was +8.8 letters in the monthly injection group. Compared to the monthly injection, there was moderate-certainty evidence that the mean difference (MD) in BCVA change at one year for the standard PRN subgroup was -1.7 letters (95% confidence interval (CI) -2.8 to -0.6; 4 trials, 2299 participants), favoring monthly injections. There was low-certainty evidence of a similar BCVA change with the treat-and-extend subgroup (0.5 letters, 95% CI -3.1 to 4.2; 3 trials, 1226 participants). Compared to monthly injection, there was low-certainty evidence that fewer participants gained 15 or more lines of vision with standard PRN treatment at one year (risk ratio (RR) 0.87, 95% CI 0.76 to 0.99; 4 trials, 2299 participants) and low-certainty evidence of a similar gain with treat-and-extend versus monthly regimens (RR 1.11, 95% CI 0.91 to 1.36; 3 trials, 1169 participants). The mean change in central retinal thickness was a decrease of -166 μm in the monthly injection group; the MD compared with standard PRN was 21 μm (95% CI 6 to 32; 4 trials, 2215 participants; moderate-certainty evidence) and with treat-and extend was 22 μm (95% CI 37 to -81 μm; 2 trials, 635 participants; low-certainty evidence), in favor of monthly injection. Only one trial (498 participants) measured quality of life and reported no evidence of a difference between regimens, but data could not be extracted (low-certainty evidence). Both PRN regimens (standard and 'treat-and-extend') used fewer injections than monthly regimens (standard PRN: MD -4.6 injections, 95% CI -5.4 to -3.8; 4 trials, 2336 participants; treat-and-extend: -2.4 injections, 95% CI -2.7 to -2.1 injections; moderate-certainty evidence for both comparisons). Two trials provided cost data (1105 participants, trials conducted in the US and the UK). They found that cost differences between regimens were reduced if bevacizumab rather than aflibercept or ranibizumab were used, since bevacizumab was less costly (low-certainty evidence). PRN regimens were associated with a reduced risk of endophthalmitis compared with monthly injections (Peto odds ratio (OR) 0.13, 95% CI 0.04 to 0.46; 6 RCTs, 3175 participants; moderate-certainty evidence). Using data from all trials included in this review, we estimated the risk of endophthalmitis with monthly injections to be 8 in every 1000 people per year. The corresponding risk for people receiving PRN regimens was 1 in every 1000 people per year (95% CI 0 to 4). Three trials (1439 participants) compared an extended-fixed regimen (number of injections reported in only one large trial: 7.5 in one year) with monthly injections. There was moderate-certainty evidence that BCVA at one year was similar for extended-fixed and monthly injections (MD in BCVA change compared to extended-fixed group: -1.3 letters, 95% CI -3.9 to 1.3; RR of gaining 15 letters or more: 0.94, 95% CI 0.80 to 1.10). The change in central retinal thickness was a decrease of 137 μm in the monthly group; the MD with the extended-fixed group was 8 μm (95% CI -11 to 27; low-certainty evidence). The frequency of endophthalmitis was lower in the extended-fixed regimen compared to the monthly group, but this estimate was imprecise (RR 0.19, 95% CI 0.03 to 1.11; low-certainty evidence). If we assumed a risk of 8 cases of endophthalmitis in 1000 people receiving monthly injections over one year, then the corresponding risk with extended-fixed regimen was 2 in 1000 people (95% CI 0 to 9). Other evidence comparing different extended-fixed or PRN regimens yielded inconclusive results. AUTHORS' CONCLUSIONS We found that, at one year, monthly regimens are probably more effective than PRN regimens using seven or eight injections in the first year, but the difference is small and clinically insignificant. Endophthalmitis is probably more common with monthly injections and differences in costs between regimens are higher if aflibercept or ranibizumab are used compared to bevacizumab. This evidence only applies to settings in which regimens are implemented as described in the trials, whereas undertreatment is likely to be common in real-world settings. There are no data from RCTs on long-term effects of different treatment regimens.
Collapse
Affiliation(s)
- Emily Li
- Transitional Year Residency Program, Signature Healthcare Brockton Hospital, Brockton, MA, USA
| | - Simone Donati
- Department of Surgical and Morphological Sciences, Section of Ophthalmology, University of Insubria, Varese-Como, Varese, Italy
| | - Kristina B Lindsley
- Life Sciences, Oncology, & Genomics, IBM Watson Health, Baltimore, Maryland, USA
| | - Magdalena G Krzystolik
- Department of Ophthalmology, Retina Service, Mass Eye and Ear Infirmary, Providence, RI, USA
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| |
Collapse
|
36
|
Lotery A, Sivaprasad S, O'Connell A, Harris RA, Culliford L, Ellis L, Cree A, Madhusudhan S, Behar-Cohen F, Chakravarthy U, Peto T, Rogers CA, Reeves BC. Eplerenone for chronic central serous chorioretinopathy in patients with active, previously untreated disease for more than 4 months (VICI): a randomised, double-blind, placebo-controlled trial. Lancet 2020; 395:294-303. [PMID: 31982075 DOI: 10.1016/s0140-6736(19)32981-2] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/07/2019] [Accepted: 11/15/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND In chronic central serous chorioretinopathy (CSCR), fluid accumulates in the subretinal space. CSCR is a common visually disabling condition that develops in individuals up to 60 years of age, and there is no definitive treatment. Previous research suggests the mineralocorticoid receptor antagonist, eplerenone, is effective for treating CSCR; however, this drug is not licensed for the treatment of patients with CSCR. We aimed to evaluate whether eplerenone was superior to placebo in terms of improving visual acuity in patients with chronic CSCR. METHODS This randomised, double-blind, parallel-group, multicentre placebo-controlled trial was done at 22 hospitals in the UK. Participants were eligible if they were aged 18-60 years and had had treatment-naive CSCR for 4 months or more. Patients were randomly assigned (1:1) to either the eplerenone or the placebo group by a trial statistician through a password-protected system online. Allocation was stratified by best-corrected visual acuity (BCVA) and hospital. Patients were given either oral eplerenone (25 mg/day for 1 week, increasing to 50 mg/day for up to 12 months) plus usual care or placebo plus usual care for up to 12 months. All participants, care teams, outcome assessors, pharmacists, and members of the trial management group were masked to the treatment allocation. The primary outcome was BCVA, measured as letters read, at 12 months. All outcomes apart from safety were analysed on a modified intention-to-treat basis (participants who withdrew consent without contributing a post-randomisation BCVA measurement were excluded from the primary analysis population and from most secondary analysis populations). The trial is registered with ISRCTN, ISRCTN92746680, and is completed. FINDINGS Between Jan 11, 2017, and Feb 22, 2018, we enrolled and randomly assigned 114 patients to receive either eplerenone (n=57) or placebo (n=57). Three participants in the placebo group withdrew consent without contributing a post-randomisation BCVA measurement and were excluded from the primary outcome analysis population. All patients from the eplerenone group and 54 patients from the placebo group were included in the primary outcome. Modelled mean BCVA at 12 months was 79·5 letters (SD 4·5) in the placebo group and 80·4 letters (4·6) in the eplerenone group, with an adjusted estimated mean difference of 1·73 letters (95% CI -1·12 to 4·57; p=0·24) at 12 months. Hyperkalaemia occurred in eight (14%) patients in each group. No serious adverse events were reported in the eplerenone group and three unrelated serious adverse events were reported in the placebo group (myocardial infarction [anticipated], diverticulitis [unanticipated], and metabolic surgery [unanticipated]). INTERPRETATION Eplerenone was not superior to placebo for improving BCVA in people with chronic CSCR after 12 months of treatment. Ophthalmologists who currently prescribe eplerenone for CSCR should discontinue this practice. FUNDING Efficacy and Mechanism Evaluation Programme, and National Institute for Health Research and Social Care.
Collapse
Affiliation(s)
- Andrew Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Abby O'Connell
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Rosie A Harris
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Lucy Culliford
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Lucy Ellis
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Angela Cree
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Savita Madhusudhan
- Liverpool Ophthalmic Reading Centre, St Paul's Eye Unit, Royal Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Francine Behar-Cohen
- P-HP Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Ophtalmopole, Université de Paris, Paris, France; Centre de Recherche des Cordeliers, INSERM UMR 1138, Université de Paris, Sorbonne Université, Paris, France
| | - Usha Chakravarthy
- Centre for Vision Sciences, The Queen's University of Belfast, Belfast, UK
| | - Tunde Peto
- Centre for Vision Sciences, The Queen's University of Belfast, Belfast, UK
| | - Chris A Rogers
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Barnaby C Reeves
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| |
Collapse
|
37
|
Balikova I, Postelmans L, Pasteels B, Coquelet P, Catherine J, Efendic A, Hosoda Y, Miyake M, Yamashiro K, Thienpont B, Lambrechts D. Genetic biomarkers in the VEGF pathway predicting response to anti-VEGF therapy in age-related macular degeneration. BMJ Open Ophthalmol 2020; 4:e000273. [PMID: 31909188 PMCID: PMC6936450 DOI: 10.1136/bmjophth-2019-000273] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 10/18/2019] [Accepted: 11/11/2019] [Indexed: 11/17/2022] Open
Abstract
Objective Age-related macular degeneration (ARMD) is a leading cause of visual impairment.
Intravitreal injections of anti-vascular endothelial growth factor (VEGF) are the
standard treatment for wet ARMD. There is however, variability in patient responses,
suggesting patient-specific factors influencing drug efficacy. We tested whether single
nucleotide polymorphisms (SNPs) in genes encoding VEGF pathway members contribute to
therapy response. Methods and analysis A retrospective cohort of 281 European wet ARMD patients treated with anti-VEGF was
genotyped for 138 tagging SNPs in the VEGF pathway. Per patient, we collected best
corrected visual acuity at baseline, after three loading injections and at 12 months. We
also registered the injection number and changes in retinal morphology after three
loading injections (central foveal thickness (CFT), intraretinal cysts and serous
neuroepithelium detachment). Changes in CFT after 3 months were our primary outcome
measure. Association of SNPs to response was assessed by binomial logistic regression.
Replication was attempted by associating visual acuity changes to genotypes in an
independent Japanese cohort. Results Association with treatment response was detected for seven SNPs, including in FLT4
(rs55667289: OR=0.746, 95% CI 0.63 to 0.88, p=0.0005) and KDR (rs7691507:
OR=1.056, 95% CI 1.02 to 1.10, p=0.005; and rs2305945: OR=0.963, 95% CI
0.93 to 1.00, p=0.0472). Only association with rs55667289 in FLT4 survived multiple
testing correction. This SNP was unavailable for testing in the replication cohort. Of
six SNPs tested for replication, one was significant although not after multiple testing
correction. Conclusion Identifying genetic variants that define treatment response can help to develop
individualised therapeutic approaches for wet ARMD patients and may point towards new
targets in non-responders.
Collapse
Affiliation(s)
- Irina Balikova
- Department of Ophthalmology, Ghent University Hospital, Ghent University, Ghent, Belgium.,Ophthalmology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Laurence Postelmans
- Ophthalmology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Brigitte Pasteels
- Ophthalmology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Pascale Coquelet
- Ophthalmology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Janet Catherine
- Ophthalmology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Azra Efendic
- Ophthalmology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Yoshikatsu Hosoda
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahiro Miyake
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Yamashiro
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Ophthalmology, Otsu Red Cross Hospital, Otsu, Japan
| | | | - Bernard Thienpont
- Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium.,Laboratory of Functional Epigenetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Diether Lambrechts
- Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium.,VIB Center for Cancer Biology, Leuven, Belgium
| |
Collapse
|
38
|
Horani M, Mahmood S, Aslam TM. A Review of Macular Atrophy of the Retinal Pigment Epithelium in Patients with Neovascular Age-Related Macular Degeneration: What is the Link? Part II. Ophthalmol Ther 2020; 9:35-75. [PMID: 31907843 PMCID: PMC7054566 DOI: 10.1007/s40123-019-00227-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction To explore the potential link between macular atrophy (MA) of the retinal pigment epithelium (RPE) in patients with neovascular age-related macular degeneration (nAMD) and anti-vascular endothelial growth factor (anti-VEGF) treatment. Methods Through a balanced overview of the field from a largely clinical perspective, we looked at available evidence on the topic of MA correlation with anti-VEGF therapy and examined possible risk factors for MA development in the context of nAMD treatment with anti-VEGF. Results Links have been reported to connect both MA incidence and progression to treatment frequency and to the anti-VEGF drug type. Conclusions All reports agree on the fact that de novo development of MA in anti-VEGF-treated eyes is frequent and multifactorial. Research data shows an expansion of atrophy during anti-VEGF treatment. There are mixed conclusions about the correlation of MA incidence or progression with treatment-related risk factors. It mostly appears that there is no straightforward link. More clinical research is still needed to further understand this association.
Collapse
Affiliation(s)
- Mania Horani
- Manchester Royal Eye Hospital, Manchester University Foundation NHS Trust, Manchester, UK.
| | - Sajjad Mahmood
- Manchester Royal Eye Hospital, Manchester University Foundation NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Tariq M Aslam
- Manchester Royal Eye Hospital, Manchester University Foundation NHS Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, School of Health Sciences, The University of Manchester, Manchester, UK
| |
Collapse
|
39
|
Khanna S, Komati R, Eichenbaum DA, Hariprasad I, Ciulla TA, Hariprasad SM. Current and upcoming anti-VEGF therapies and dosing strategies for the treatment of neovascular AMD: a comparative review. BMJ Open Ophthalmol 2019; 4:e000398. [PMID: 31909196 PMCID: PMC6936465 DOI: 10.1136/bmjophth-2019-000398] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/05/2019] [Accepted: 11/21/2019] [Indexed: 01/12/2023] Open
Abstract
Age-related macular degeneration is the leading cause of vision loss in the developed world, with the expected number of affected elderly individuals reaching 17.8 million. Antivascular endothelial growth factor (anti-VEGF) injection therapy has been instrumental in treating a disease process that was previously thought to be untreatable. Over the past two decades, landmark studies have demonstrated the efficacy of different anti-VEGF medications and investigated the optimal dosing regimen and delivery mechanism to increase overall vision and minimise patient burden. In this review, we outline landmark neovascular age-related macular degeneration clinical trials that have demonstrated level 1 evidence for its usage or have contributed to the understanding of how to dose these agents.
Collapse
Affiliation(s)
- Saira Khanna
- Ophthalmology and Visual Sciences, University of Chicago, Chicago, Illinois, USA
| | - Rahul Komati
- Ophthalmology and Visual Sciences, University of Chicago, Chicago, Illinois, USA
| | - David A Eichenbaum
- Retina Vitreous Associates of Florida, St. Petersburg, Florida, USA.,USF Health Morsani College of Medicine, Tampa, Florida, USA
| | | | | | - Seenu M Hariprasad
- Ophthalmology and Visual Sciences, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
40
|
Sadda SR, Guymer R, Monés JM, Tufail A, Jaffe GJ. Anti-Vascular Endothelial Growth Factor Use and Atrophy in Neovascular Age-Related Macular Degeneration: Systematic Literature Review and Expert Opinion. Ophthalmology 2019; 127:648-659. [PMID: 32081493 DOI: 10.1016/j.ophtha.2019.11.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 01/15/2023] Open
Abstract
TOPIC To summarize the rates of atrophy, risk factors, and atrophy-associated visual outcomes in patients with neovascular age-related macular degeneration (nAMD) who received anti-vascular endothelial growth factor (VEGF) treatment for macular neovascularization (MNV). CLINICAL RELEVANCE Age-related macular degeneration is a leading cause of vision loss worldwide, and VEGF inhibitors are the primary treatment for nAMD. However, atrophy is observed frequently in eyes treated with anti-VEGF therapy, prompting questions regarding a causative role for these therapies in atrophy development. METHODS PubMed was searched for articles published in the past 5 years (January 1, 2014, through January 10, 2019). Studies including atrophy outcome(s) in patients with age-related macular degeneration who received anti-VEGF treatment were included. Review articles, retrospective studies, case reports or studies, preclinical studies, prevalence data reports, and non-English studies were excluded. Randomization was not required. RESULTS Overall, 145 studies were identified; 29 publications were included, with cohorts ranging from 8 to 1185 eyes. Imaging methods used to assess atrophy varied across studies. All studies confirmed the occurrence of atrophy, and when available, longitudinal data from the included studies demonstrated an increase in atrophy incidence over time. Key risk factors or phenotypes associated with atrophy were fellow eye atrophy, reticular pseudodrusen, increased injections, and type 3 lesion. In addition, visual acuity loss was noted with foveal atrophy. DISCUSSION All studies demonstrated that atrophy occurs in the context of MNV treated with anti-VEGF therapy; however, it is not clear whether anti-VEGF treatment is causative of atrophy versus being associated with atrophy development. The included studies were not designed or powered to assess atrophy as a primary outcome. In addition, it is difficult to determine whether prognostic factors directly affect atrophy. Furthermore, patient populations in clinical trials do not necessarily represent real-world patients. Although phenotypes and risk factors may help to identify those at greater risk of atrophy developing, it is important to recognize that adequately treating exudative MNV remains the best option to optimize vision outcomes in patients with nAMD, particularly given the risk of vision loss with undertreatment observed in the real world.
Collapse
Affiliation(s)
- SriniVas R Sadda
- Doheny Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
| | - Robyn Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Department of Surgery (Ophthalmology), Melbourne, Australia
| | - Jordi M Monés
- Institut de la Màcula and Barcelona Macula Foundation, Barcelona, Spain
| | - Adnan Tufail
- Institute of Ophthalmology, University College London, and Moorfields Eye Hospital, NHS Trust, London, United Kingdom
| | - Glenn J Jaffe
- Department of Ophthalmology, Duke University, Durham, North Carolina
| |
Collapse
|
41
|
Massamba N, Sellam A, Butel N, Skondra D, Caillaux V, Bodaghi B. Use of Fundus Autofluorescence Combined with Optical Coherence Tomography for Diagnose of Geographic Atrophy in Age-Related Macular Degeneration. MEDICAL HYPOTHESIS, DISCOVERY & INNOVATION OPHTHALMOLOGY JOURNAL 2019; 8:298-305. [PMID: 31788492 PMCID: PMC6778681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to demonstrate the sensitivity of Optical coherence tomography (OCT) in detection of geographic atrophy (GA) secondary to exudative age related macular degeneration (AMD). In this retrospective case series study 77 patients (53% female, with mean ± standard deviation [SD] of 82.6±9.3 years) with 97 eyes (45 OS [left eyes]/52 OD [right eyes]) were included. This was a retrospective review of the charts of patients who presented with exudative AMD at the Pitié Salpetrière Hospital, Paris, France, between December 2016 and August 2017 that received intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) therapies. At baseline, following biomicroscopy examination, multimodal imaging was performed including, fluorescein angiography (FA), fundus auto-fluorescence (FAF), spectral domain optical coherence tomography (SD-OCT) and indocyanine green angiography (ICGA). During the follow-up, SD-OCT with/without FAF and FA were performed for each patient at 6, 12 and 18 months. For investigation of the prevalence of GA in eyes undergoing intravitreal injections with anti-VEGF therapy, FAF and SD-OCT images were qualitatively reviewed by four independent observers (two graders per group). Kappa coefficient of Cohen was calculated to determine agreement between the graders. The kappa coefficient of Cohen, for inter-rater agreement in the evaluation of FAF images was 0.468, indicating a moderate agreement between the first and second raters. Thus, the sensitivity and specificity of FAF for the diagnosis of GA were 70% and 57%, respectively. If atrophy was assessed with SD-OCT image analysis, the kappa coefficient for inter-rater agreement was 0.846, implying an acceptable agreement between both readers. The sensitivity and specificity of SD-OCT were 93% and 58% respectively. In conclusion, SD-OCT image analysis was more sensitive than FAF for identifying GA in patients treated for exudative AMD.
Collapse
Affiliation(s)
- Nathalie Massamba
- Department of Ophthalmology, DHU: Handicaps and Vision Pitié Salpetrière University Hospital, University of Pierre Marie Curie, Paris, France
- Department of Ophthalmology, Visual Sciences University Hospital of Chicago, Illinois, USA
- J. Terry Ernest Ocular Imaging Center, University of Chicago, Chicago, Illinois, USA
| | - Alexandre Sellam
- Department of Ophthalmology, DHU: Handicaps and Vision Pitié Salpetrière University Hospital, University of Pierre Marie Curie, Paris, France
| | - Nathalie Butel
- Department of Ophthalmology, DHU: Handicaps and Vision Pitié Salpetrière University Hospital, University of Pierre Marie Curie, Paris, France
| | - Dimitra Skondra
- Department of Ophthalmology, Visual Sciences University Hospital of Chicago, Illinois, USA
- J. Terry Ernest Ocular Imaging Center, University of Chicago, Chicago, Illinois, USA
| | - Violaine Caillaux
- Department of Ophthalmology, DHU: Handicaps and Vision Pitié Salpetrière University Hospital, University of Pierre Marie Curie, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, DHU: Handicaps and Vision Pitié Salpetrière University Hospital, University of Pierre Marie Curie, Paris, France
| |
Collapse
|
42
|
Sodré SL, Barbosa IAF, Pacheco IE, Ferreira FDQT, David MA, Nascimento MA, Arieta CEL, Vasconcellos JPCD. Costs and benefits of bevacizumab vial sharing for the treatment of retinal diseases. BMC Public Health 2019; 19:1252. [PMID: 31510981 PMCID: PMC6740002 DOI: 10.1186/s12889-019-7562-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 08/28/2019] [Indexed: 11/23/2022] Open
Abstract
Background Antiangiogenic therapy has proved to be an important therapeutic tool for many retinal vascular diseases; however, its availability is limited in developing countries. This study sought to describe the bevacizumab vial sharing process and to evaluate the impact of this repackaging system on the costs incurred in a Brazilian public hospital. Method This retrospective study compared the number and costs of intravitreal antiangiogenic injections approved via court order in the first year of the study (2015) to the number and costs of the bevacizumab injections provided through the use of vial sharing in the second year of the study (2016). Vial sharing consists of the traditional process used to repackage bevacizumab; in this case, however, the drug samples used were the residual volume from the preparation of bevacizumab for oncology patients. The hospital adhered to the guidelines established by the Brazilian Health Surveillance Agency (ANVISA). Results In the first year of the study and using medication obtained through court orders, 550 intravitreal injections were performed in the ophthalmology ambulatory care center. Based on local pricing tables, the total cost of the medication was BRL$1,036,056.25 (USD$267,546.58), and the average cost of each application was BRL$1883.74 (USD$486.45). In the second year of the study, 1081 intravitreal applications were performed at the same hospital using doses obtained through bevacizumab vial sharing. The total cost was BRL$21,942.49 (USD$5663.30) and the per-unit cost was BRL$20.30, or USD$5.23 (a savings of 97.88%). Conclusion This study found that bevacizumab vial sharing led to a significant reduction in public health care costs associated with antiangiogenic treatment and increased the availability of the drug to public health care patients. These results can be extrapolated to other types of drugs and health care systems.
Collapse
Affiliation(s)
- Sávio Lima Sodré
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil.
| | - Italo Antunes França Barbosa
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | - Israel Emiliano Pacheco
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | | | - Milton Agrizzi David
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | - Mauricio Abujamra Nascimento
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | - Carlos Eduardo Leite Arieta
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | | |
Collapse
|
43
|
Lin T, Dans KC, Muftuoglu IK, Meshi A, Amador-Patarroyo MJ, Cheng L, Freeman WR. Factors associated with extended remission in neovascular age-related macular degeneration on pro re nata treatment protocol. Br J Ophthalmol 2019; 104:58-63. [PMID: 31302628 PMCID: PMC6922015 DOI: 10.1136/bjophthalmol-2018-313447] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 03/11/2019] [Accepted: 03/27/2019] [Indexed: 01/14/2023]
Abstract
AIM To show the characteristics and outcomes of patients with neovascular age-related macular degeneration (nAMD) who had extended remission (ER) while on a pro re nata (PRN) treatment protocol. METHODS This was a retrospective case-control study of a consecutive series of patients with nAMD treated with a PRN antivascular endothelial growth factor (anti-VEGF) drug regimen. ER was defined as the absence of haemorrhage, intraretinal/subretinal fluid on optical coherence tomography and leakage on fluorescein angiography for 52 weeks after cessation of anti-VEGF therapy. Matching patients with nAMD who did not achieve ER were included as control group. Cox regression analysis was fitted to identify predictors of time to achieve ER and time to recurrence. A logistic regression analysis of baseline characteristics was used to identify predictors of achieving ER. RESULTS Of 830 eyes treated with anti-VEGF monotherapy, 77 (9.2%) eyes achieved ER during a median follow-up of 236 weeks (range 70-525 weeks). Cox regression analysis showed that ER was achieved earlier in eyes with isolated intraretinal fluid (HR, 2.05; 95% CI 1.929 to 4.520; p=0.045) at presentation. Logistic regression analysis showed that type 3 choroidal neovascularisation (OR, 0.090; 95% CI 0.021 to 0.382; p=0.001), thinner choroid (OR, 0.993; 95% CI 0.988 to 0.998; p=0.004) and absence of macular atrophy (OR, 0.233; 95% CI 0.065 to 0.839; p=0.026) at baseline increased the likelihood of achieving ER. CONCLUSION ER is achievable in 9.2% of patients under PRN therapy for nAMD. At presentation with nAMD, anatomical features on retinal imaging may predict the likelihood of achieving ER and a shorter time to achieve ER.
Collapse
Affiliation(s)
- Tiezhu Lin
- Ophthalmology, Jacobs Retina Center, Shiley Eye Institute, University of California San Diego, San Diego, California, USA.,Ophthalmology, He Eye Hospital, He University, Shenyang, China
| | - Kunny C Dans
- Ophthalmology, Jacobs Retina Center, Shiley Eye Institute, University of California San Diego, San Diego, California, USA
| | - Ilkay Kilic Muftuoglu
- Ophthalmology, Jacobs Retina Center, Shiley Eye Institute, University of California San Diego, San Diego, California, USA.,Ophthalmology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Amit Meshi
- Ophthalmology, Jacobs Retina Center, Shiley Eye Institute, University of California San Diego, San Diego, California, USA.,Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
| | - Manuel J Amador-Patarroyo
- Ophthalmology, Jacobs Retina Center, Shiley Eye Institute, University of California San Diego, San Diego, California, USA.,Ophthalmology, Escuela Superior de Oftalmologia, Instituto Barraquer de America, Bogota, Colombia
| | - Lingyun Cheng
- Ophthalmology, Jacobs Retina Center, Shiley Eye Institute, University of California San Diego, San Diego, California, USA
| | - William R Freeman
- Ophthalmology, Jacobs Retina Center, Shiley Eye Institute, University of California San Diego, San Diego, California, USA
| |
Collapse
|
44
|
Hughes CP, O’Flynn NM, Gatherer M, McClements ME, Scott JA, MacLaren RE, Goverdhan S, Glennie MJ, Lotery AJ. AAV2/8 Anti-angiogenic Gene Therapy Using Single-Chain Antibodies Inhibits Murine Choroidal Neovascularization. Mol Ther Methods Clin Dev 2019; 13:86-98. [PMID: 30719487 PMCID: PMC6350388 DOI: 10.1016/j.omtm.2018.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/16/2018] [Indexed: 12/15/2022]
Abstract
While anti-angiogenic therapies for wet age-related macular degeneration (AMD) are effective for many patients, they require multiple injections and are expensive and prone to complications. Gene therapy could be an elegant solution for this problem by providing a long-term source of anti-angiogenic proteins after a single administration. Another potential issue with current therapeutic proteins containing a fragment crystallizable (Fc) domain (such as whole antibodies like bevacizumab) is the induction of an unwanted immune response. In wet AMD, a low level of inflammation is already present, so to avoid exacerbation of disease by the therapeutic protein, we propose single-chain fragment variable (scFv) antibodies, which lack the Fc domain, as a safer alternative. To investigate the feasibility of this, anti-vascular endothelial growth factor (VEGF)-blocking antibodies in two formats were produced and tested in vitro and in vivo. The scFv transgene was then cloned into an adeno-associated virus (AAV) vector. A therapeutic effect in a mouse model of choroidal neovascularization (CNV) was demonstrated with antibodies in both scFv and immunoglobulin G1 (IgG1) formats (p < 0.04). Importantly, the scFv anti-VEGF antibody expressed from an AAV vector also had a significant beneficial effect (p = 0.02), providing valuable preclinical data for future translation to the clinic.
Collapse
Affiliation(s)
- Chris P. Hughes
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Neil M.J. O’Flynn
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Maureen Gatherer
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michelle E. McClements
- Oxford Eye Hospital and Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Jennifer A. Scott
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Robert E. MacLaren
- Oxford Eye Hospital and Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Srinivas Goverdhan
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Martin J. Glennie
- Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Andrew J. Lotery
- Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| |
Collapse
|
45
|
McKibbin M, Downey L. Secondary End Points in the RIVAL Study. JAMA Ophthalmol 2019; 137:379-381. [DOI: 10.1001/jamaophthalmol.2018.6807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Martin McKibbin
- Leeds Teaching Hospitals National Health Service Trust, Leeds, England
| | - Louise Downey
- Hull and East Yorkshire Eye Hospitals National Health Service Trust, Yorkshire, England
| |
Collapse
|
46
|
Macular Atrophy of the Retinal Pigment Epithelium in Patients with Neovascular Age-Related Macular Degeneration: What is the Link? Part I: A Review of Disease Characterization and Morphological Associations. Ophthalmol Ther 2019; 8:235-249. [PMID: 30911999 PMCID: PMC6513937 DOI: 10.1007/s40123-019-0177-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 01/04/2023] Open
Abstract
Introduction The purpose of this review was to explore the potential link between macular atrophy (MA) of the retinal pigment epithelium in patients with neovascular age-related macular degeneration (nAMD) with the disease characteristics and morphological features. Methods To this end, we performed a search of peer-reviewed articles published on the PubMed database and included all relevant papers. We then examined these papers for possible risk factors for MA development in the context of nAMD treated with anti-vascular endothelial growth factor drugs, as well as possible protective factors. Results Our review of the relevant publications revealed that areas of MA can be directly visualized through multiple imaging modalities. Associations have been identified between MA of the retinal pigment epithelium and choroidal neovascular membrane characteristics, intra- and subretinal fluid, pigment epithelial detachment, choroidal thickness, subretinal hyperreflective material, outer retinal tubulations, hemorrhage, subretinal drusenoid deposits, refractile drusen, hyperreflective foci, retinal angiomatous proliferation, polypoidal choroidal vasculopathy, geographic atrophy in the fellow eye, genetic factors, and age. Conclusion The findings of this review indicate that a multimodal approach is recommended for the assessment of MA. The conclusions drawn to date on the correlation between MA development or progression of MA and specific risk factors and possible protective factors are mixed. More clinical research is needed to reach a better understanding of this association.
Collapse
|
47
|
Solomon SD, Lindsley K, Vedula SS, Krzystolik MG, Hawkins BS. Anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2019; 3:CD005139. [PMID: 30834517 PMCID: PMC6419319 DOI: 10.1002/14651858.cd005139.pub4] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the most common cause of uncorrectable severe vision loss in people aged 55 years and older in the developed world. Choroidal neovascularization (CNV) secondary to AMD accounts for most cases of AMD-related severe vision loss. Intravitreous injection of anti-vascular endothelial growth factor (anti-VEGF) agents aims to block the growth of abnormal blood vessels in the eye to prevent vision loss and, in some instances, to improve vision. OBJECTIVES • To investigate ocular and systemic effects of, and quality of life associated with, intravitreous injection of three anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) versus no anti-VEGF treatment for patients with neovascular AMD• To compare the relative effects of one of these anti-VEGF agents versus another when administered in comparable dosages and regimens SEARCH METHODS: To identify eligible studies for this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (searched January 31, 2018); MEDLINE Ovid (1946 to January 31, 2018); Embase Ovid (1947 to January 31, 2018); the Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to January 31, 2018); the International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com/editAdvancedSearch - searched January 31, 2018); ClinicalTrials.gov (www.clinicaltrials.gov - searched November 28, 2018); and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en - searched January 31, 2018). We did not impose any date or language restrictions in electronic searches for trials. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated pegaptanib, ranibizumab, or bevacizumab versus each other or versus a control treatment (e.g. sham treatment, photodynamic therapy), in which participants were followed for at least one year. DATA COLLECTION AND ANALYSIS Two review authors independently screened records, extracted data, and assessed risks of bias. We contacted trial authors for additional data. We compared outcomes using risk ratios (RRs) or mean differences (MDs). We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 16 RCTs that had enrolled a total of 6347 participants with neovascular AMD (the number of participants per trial ranged from 23 to 1208) and identified one potentially relevant ongoing trial. Six trials compared anti-VEGF treatment (pegaptanib, ranibizumab, or bevacizumab) versus control, and 10 trials compared bevacizumab versus ranibizumab. Pharmaceutical companies conducted or sponsored four trials but funded none of the studies that evaluated bevacizumab. Researchers conducted these trials at various centers across five continents (North and South America, Europe, Asia, and Australia). The overall certainty of the evidence was moderate to high, and most trials had an overall low risk of bias. All but one trial had been registered prospectively.When compared with those who received control treatment, more participants who received intravitreous injection of any of the three anti-VEGF agents had gained 15 letters or more of visual acuity (risk ratio [RR] 4.19, 95% confidence interval [CI] 2.32 to 7.55; moderate-certainty evidence), had lost fewer than 15 letters of visual acuity (RR 1.40, 95% CI 1.27 to 1.55; high-certainty evidence), and showed mean improvement in visual acuity (mean difference 6.7 letters, 95% CI 4.4 to 9.0 in one pegaptanib trial; mean difference 17.8 letters, 95% CI 16.0 to 19.7 in three ranibizumab trials; moderate-certainty evidence) after one year of follow-up. Participants treated with anti-VEGF agents showed improvement in morphologic outcomes (e.g. size of CNV, central retinal thickness) compared with participants not treated with anti-VEGF agents (moderate-certainty evidence). No trial directly compared pegaptanib versus another anti-VEGF agent and followed participants for one year; however, when compared with control treatments, ranibizumab and bevacizumab each yielded larger improvements in visual acuity outcomes than pegaptanib.Visual acuity outcomes after bevacizumab and ranibizumab were similar when the same RCTs compared the same regimens with respect to gain of 15 or more letters of visual acuity (RR 0.95, 95% CI 0.81 to 1.12; high-certainty evidence) and loss of fewer than 15 letters of visual acuity (RR 1.00, 95% CI 0.98 to 1.02; high-certainty evidence); results showed similar mean improvement in visual acuity (mean difference [MD] -0.5 letters, 95% CI -1.5 to 0.5; high-certainty evidence) after one year of follow-up, despite the substantially lower cost of bevacizumab compared with ranibizumab. Reduction in central retinal thickness was less among bevacizumab-treated participants than among ranibizumab-treated participants after one year (MD -11.6 μm, 95% CI -21.6 to -1.7; high-certainty evidence); however, this difference is within the range of measurement error, and we did not interpret it to be clinically meaningful.Ocular inflammation and increased intraocular pressure (IOP) after intravitreal injection were the most frequently reported serious ocular adverse events. Researchers reported endophthalmitis in less than 1% of anti-VEGF-treated participants and in no cases among control groups. The occurrence of serious systemic adverse events was comparable across anti-VEGF-treated groups and control groups; however, the numbers of events and trial participants may have been insufficient to show a meaningful difference between groups (evidence of low- to moderate-certainty). Investigators rarely measured and reported data on visual function, quality of life, or economic outcomes. AUTHORS' CONCLUSIONS Results of this review show the effectiveness of anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) in terms of maintaining visual acuity; studies show that ranibizumab and bevacizumab improved visual acuity in some eyes that received these agents and were equally effective. Available information on the adverse effects of each medication does not suggest a higher incidence of potentially vision-threatening complications with intravitreous injection of anti-VEGF agents compared with control interventions; however, clinical trial sample sizes were not sufficient to estimate differences in rare safety outcomes. Future Cochrane Reviews should incorporate research evaluating variable dosing regimens of anti-VEGF agents, effects of long-term use, use of combination therapies (e.g. anti-VEGF treatment plus photodynamic therapy), and other methods of delivering these agents.
Collapse
Affiliation(s)
- Sharon D Solomon
- Johns Hopkins University School of MedicineWilmer Eye Institute600 North Wolfe StreetMaumenee 740BaltimoreMarylandUSA21287
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, Mail Room E6132BaltimoreMarylandUSA21205
| | | | - Magdalena G Krzystolik
- Mass Eye and Ear InfirmaryDepartment of Ophthalmology, Retina Service1 Randall Square, Suite 203ProvidenceRhode IslandUSA02904
| | - Barbara S Hawkins
- Johns Hopkins University School of MedicineWilmer Eye Institute600 North Wolfe StreetMaumenee 740BaltimoreMarylandUSA21287
| | | |
Collapse
|
48
|
Braithwaite T, Calvert M, Gray A, Pesudovs K, Denniston AK. The use of patient-reported outcome research in modern ophthalmology: impact on clinical trials and routine clinical practice. PATIENT-RELATED OUTCOME MEASURES 2019; 10:9-24. [PMID: 30774489 PMCID: PMC6352858 DOI: 10.2147/prom.s162802] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This review article considers the rising demand for patient-reported outcome measures (PROMs) in modern ophthalmic research and clinical practice. We review what PROMs are, how they are developed and chosen for use, and how their quality can be critically appraised. We outline the progress made to develop PROMs in each clinical subspecialty. We highlight recent examples of the use of PROMs as secondary outcome measures in randomized controlled clinical trials and consider the impact they have had. With increasing interest in using PROMs as primary outcome measures, particularly where interventions have been found to be of equivalent efficacy by traditional outcome metrics, we highlight the importance of instrument precision in permitting smaller sample sizes to be recruited. Our review finds that while there has been considerable progress in PROM development, particularly in cataract, glaucoma, medical retina, and low vision, there is a paucity of useful tools for less common ophthalmic conditions. Development and validation of item banks, administered using computer adaptive testing, has been proposed as a solution to overcome many of the traditional limitations of PROMs, but further work will be needed to examine their acceptability to patients, clinicians, and investigators.
Collapse
Affiliation(s)
- Tasanee Braithwaite
- Centre for Patient Reported Outcomes Research and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK, .,Moorfields Eye Hospital, London, UK,
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK, .,Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Alastair K Denniston
- Centre for Patient Reported Outcomes Research and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK, .,Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHSFT, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,NIHR Biomedical Research Centre (Moorfields Eye Hospital/UCL), London, UK
| |
Collapse
|
49
|
Intralesional Macular Atrophy in Anti–Vascular Endothelial Growth Factor Therapy for Age-Related Macular Degeneration in the IVAN Trial. Ophthalmology 2019; 126:75-86. [DOI: 10.1016/j.ophtha.2018.07.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/05/2018] [Accepted: 07/13/2018] [Indexed: 01/05/2023] Open
|
50
|
van Asten F, Michels CTJ, Hoyng CB, van der Wilt GJ, Klevering BJ, Rovers MM, Grutters JPC. The cost-effectiveness of bevacizumab, ranibizumab and aflibercept for the treatment of age-related macular degeneration-A cost-effectiveness analysis from a societal perspective. PLoS One 2018; 13:e0197670. [PMID: 29772018 PMCID: PMC5957378 DOI: 10.1371/journal.pone.0197670] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The discussion on the use of bevacizumab is still ongoing and often doctors are deterred from using bevacizumab due to legal or political issues. Bevacizumab is an effective, safe and inexpensive treatment option for neovascular age-related macular degeneration (AMD), albeit unregistered for the disease. Therefore, in some countries ophthalmologists use the equally effective but expensive drugs ranibizumab and aflibercept. We describe the economic consequences of this dilemma surrounding AMD treatment from a societal perspective. METHODS We modelled cost-effectiveness of treatment with ranibizumab (as-needed), aflibercept (bimonthly) and bevacizumab (as-needed). Effectiveness was estimated by systematic review and meta-analysis. The drug with the most favourable cost-effectiveness profile compared to bevacizumab was used for threshold analyses. First, we determined how much we overspend per injection. Second, we calculated the required effectiveness to justify the current price and the reasonable price for a drug leading to optimal vision. Finally, we estimated how much Europe overspends if bevacizumab is not first choice. RESULTS Bevacizumab treatment costs €27,087 per year, about €4,000 less than aflibercept and €6,000 less than ranibizumab. With similar effectiveness for all drugs as shown by meta-analysis, bevacizumab was the most cost-effective. Aflibercept was chosen for threshold analyses. Aflibercept costs €943 per injection, but we determined that the maximum price to be cost-effective is €533. Alternatively, at its current price, aflibercept should yield about twice the visual gain. Even when optimal vision can be achieved, the maximum price for any treatment is €37,453 per year. Most importantly, Europe overspends €335 million yearly on AMD treatment when choosing aflibercept over bevacizumab. CONCLUSION Bevacizumab is the most cost-effective treatment for AMD, yet is not the standard of care across Europe. The registered drugs ranibizumab and aflibercept lead to large overspending without additional health benefits. Health authorities should consider taking steps to implement bevacizumab into clinical practice as first choice.
Collapse
Affiliation(s)
- Freekje van Asten
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Charlotte T. J. Michels
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carel B. Hoyng
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Jan van der Wilt
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B. Jeroen Klevering
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M. Rovers
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P. C. Grutters
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|