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Gruben AR, Hösel K, Roider J, Ehlken C. [Evaluation of the accuracy of clinical diagnosis of conjunctival neoplasms : Comparison with histological findings after excision]. Ophthalmologie 2024:10.1007/s00347-024-02009-5. [PMID: 38446196 DOI: 10.1007/s00347-024-02009-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Neoplasms of the conjunctiva include many different entities with a broad variety of clinical presentations. This can make a precise clinical diagnosis difficult. R0 resection is the gold standard treatment for most malignant conjunctival neoplasms, but not every benign lesions must treated by excision. In clinical practice it is important to make an accurate clinical diagnosis to enable the best possible management of conjunctival neoplasms. OBJECTIVE The aim of this study was to determine the accuracy of clinical diagnosis of neoplasms of the conjunctiva. MATERIALS AND METHODS Within a retrospective design, the data from all patients with excision of a conjunctival lesion between 2011 and 2020 in the Department of Ophthalmology of the UKSH Campus Kiel were extracted and analyzed. The specificity, sensitivity, and positive and negative predictive value for the preoperative clinical rating of dignity and diagnosis were evaluated based on the histological diagnostic findings. RESULTS Of 220 included cases, 75% were benign and 25% malignant. The most frequent neoplasm of the conjunctiva was benign conjunctival nevus. The sensitivity for clinical prediction of a benign lesion was 0.86 (95% confidence interval [CI] 0.59-0.92), the specificity 0.95 (CI 0.85-0.99), and the positive predictive value 0.98 (CI 0.94-1.0). The sensitivity for clinical prediction of malign dignity was 0.95 (CI 0.85-0.99), the specificity 0.88 (CI 0.83-0.93), and the positive predictive value 0.73 (CI 0.61-0.83). CONCLUSION The derived values for clinical diagnosis of conjunctival neoplasms can be rated as good. However, in clinical practice, untypical lesions can be hard to diagnose correctly, and the clinical diagnosis should be carefully reviewed; if in doubt, excision should be preferred.
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Affiliation(s)
- Arved Rikus Gruben
- UKSH Klinik für Ophthalmologie Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Deutschland.
| | - Kristin Hösel
- UKSH Klinik für Ophthalmologie Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Deutschland
| | - Johann Roider
- UKSH Klinik für Ophthalmologie Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Deutschland
| | - Christoph Ehlken
- UKSH Klinik für Ophthalmologie Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Deutschland
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Schaub F, Schiller P, Hoerster R, Kraus D, Holz FG, Guthoff R, Agostini H, Spitzer MS, Wiedemann P, Lommatzsch A, Boden KT, Dimopoulos S, Bemme S, Tamm S, Maier M, Roider J, Enders P, Altay L, Fauser S, Kirchhof B, Agostini H, Bartz-Schmidt KU, Bemme S, Boden K, Callizo J, Dahlke C, Eberwein P, Ehlken C, Feltgen N, Gamulescu A, Gelisken F, Gutfleisch M, Guthoff R, Haus A, Helbig H, Hermann M, Holz FG, Januschowski K, Jochmann C, Kirchhof B, Krohne T, Lagrèze W, Lange C, Lohmann C, Lommatzsch A, Macek MA, Maier M, Märker D, Mayer C, Meier P, Müther P, Prahs P, Purtskhvanidze K, Rehak M, Schaub F, Schick T, Schmitz-Valckenberg S, Schultheiß M, Skevas C, Spitzer MS, Stahl A, Szurman P, Unterlauft JD. Intravitreal 5-Fluorouracil and Heparin to Prevent Proliferative Vitreoretinopathy: results from a randomized clinical trial. Ophthalmology 2022; 129:1129-1141. [DOI: 10.1016/j.ophtha.2022.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022] Open
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Ehlken C, von Medem C, Lüdemann M, Kirsch AM, Roider JB. Patients' perspective on emergency treatment of ophthalmologic diseases during the first phase of SARS-CoV2 pandemic in a tertiary referral center in Germany - the COVID-DETOUR questionnaire study. BMC Ophthalmol 2021; 21:301. [PMID: 34399720 PMCID: PMC8366159 DOI: 10.1186/s12886-021-02054-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/28/2021] [Indexed: 01/19/2023] Open
Abstract
Background During the first wave of the COVID-19 pandemic, the need of treatment of urgent ophthalmological diseases and the possible risk of a SARS-CoV-2 infection had to be weighed against each other. In this questionnaire study, we aimed to analyze potential barriers and patients’ health beliefs during and after the lockdown early 2020 in a tertiary referral center in Kiel, Germany. Methods Patients admitted for the treatment of urgent ophthalmic diseases between March 1st, 2020, and June 3rd, 2020, were asked to participate in a questionnaire study. After informed consent was obtained, patients were interviewed using a standardized questionnaire which addressed aspects of their medical history, their health beliefs concerning the COVID-19 pandemic and barriers on their way to the treatment center. The study group was subdivided into two subgroups, depending on the occurrence of their symptoms, before and after the lockdown was ended on April 20th, 2020. Results Ninety-three patients were included, 43 in subgroup A (before April 20th) and 50 in subgroup B (April 20th or later). Retinal disorders were the most common causes for admission (approximately 60%).. Only 8 patients (8.6%) experienced a delay between their decision to visit a doctor until the actual examination. Every fourth patient was afraid of a COVID-19 infection, and expected a higher likelihood for an infection at the hospital. Patients with comorbidities tended to be more likely to be afraid of an infection (correlation coefficient 0.183, p = 0.0785) and were significantly more likely to be concerned about problems with organizing follow-up care (corr. Coefficient 0.222, p = 0.0328). Higher age was negatively correlated with fear of infection (corr. Coefficient − 0.218, p-value 0.034). Conclusion In this questionnaire study, only a minority of patients indicated a delay in treatment, regardless of whether symptoms occurred before or after the lockdown before April 20th, 2020. While patients with comorbidities were more concerned about infection and problems during follow-up care, patients of higher age – who have a higher mortality – were less afraid. Protection of high-risk groups should be prioritized during the SARS-CoV-2 pandemic. Trial registration The study was registered as DRKS00021630 at the DRKS (Deutsches Register Klinischer Studien) before the conduction of the study on May 5th, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12886-021-02054-7.
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Affiliation(s)
- Christoph Ehlken
- Klinik für Ophthalmologie des Universitätsklinikums Schleswig Holsteins, Campus Kiel, Kiel, Germany.
| | - Constantin von Medem
- Klinik für Ophthalmologie des Universitätsklinikums Schleswig Holsteins, Campus Kiel, Kiel, Germany
| | - Maya Lüdemann
- Klinik für Ophthalmologie des Universitätsklinikums Schleswig Holsteins, Campus Kiel, Kiel, Germany
| | - Anna Maria Kirsch
- Klinik für Ophthalmologie des Universitätsklinikums Schleswig Holsteins, Campus Kiel, Kiel, Germany.,Augenklinik Klinikum Kassel, Kassel, Germany
| | - Johann Baptist Roider
- Klinik für Ophthalmologie des Universitätsklinikums Schleswig Holsteins, Campus Kiel, Kiel, Germany
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Lommatzsch A, Eter N, Ehlken C, Lanzl I, Kaymak H, Schuster AK, Ziemssen F. [Adherence to anti-VEGF treatment-Considerations and practical recommendations]. Ophthalmologe 2021; 118:801-809. [PMID: 33270147 PMCID: PMC8342348 DOI: 10.1007/s00347-020-01273-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Numerous studies have identified a lack of treatment adherence as an important factor that often conflicts with the necessary number of anti-VEGF injections and therefore a better functional result. OBJECTIVE This article discusses approaches and possible measures to reduce the risk of late and infrequent intravitreal injections leading to the major issue of undertreatment. MATERIAL AND METHOD In the course of an expert dialogue, relevant parameters of treatment adherence and variables were identified. Meaningful processes were structured and assigned to organizational areas. RESULTS The compilation of meaningful measures enables practitioners to optimize their own implementation in different areas. Regular monitoring measures can identify the extent of treatment interruption and discontinuation. For specific indicators (treatments per time interval, longest pause interval, minimum coverage per unit time, delay) an effect on the development of visual function was demonstrated. Organizational measures, training of teams and referring physicians, redundant and iterative information transfer to patients have been proven in the experience of experts. The firm integration of these processes into the structures is facilitated by working with checklists. CONCLUSION An optimization of the processes is possible to improve the adherence and the functional results; however, interventional studies showing how adherence and persistence can be increased in the German treatment setting are still lacking.
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Affiliation(s)
| | - Nicole Eter
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Münster, Deutschland
| | - Christoph Ehlken
- Klinik für Ophthalmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Ines Lanzl
- Chiemsee Augen Tagesklinik, Prien, Deutschland
| | - Hakan Kaymak
- Makula-Netzhaut-Zentrum, Düsseldorf-Oberkassel, Deutschland
| | | | - Focke Ziemssen
- Department für Augenheilkunde Tübingen, Universitäts-Augenklinik, Elfriede-Aulhorn-Str. 7, 72076, Tübingen, Deutschland.
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Müller S, Junker S, Wilke T, Lommatzsch A, Schuster AK, Kaymak H, Ehlken C, Ziemssen F. Questionnaire for the assessment of adherence barriers of intravitreal therapy: the ABQ-IVT. Int J Retina Vitreous 2021; 7:43. [PMID: 34078475 PMCID: PMC8170736 DOI: 10.1186/s40942-021-00311-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/09/2021] [Indexed: 01/26/2023] Open
Abstract
Objective To develop and validate a questionnaire for the investigation of non-adherence (NA) barriers in patients receiving intravitreal injection (IVT). Design Questionnaire development and cross-sectional patient survey combined with a retrospective medical chart review. Participants German patients with neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME) receiving anti-vascular endothelial growth factor (anti-VEGF) treatment via IVT. Methods The previously validated (indications: atrial fibrillation, human immunodeficiency virus, chronic inflammatory lung disease) Adherence Barriers Questionnaire (ABQ) was revised according to specifications of IVT, within the framework of an expert panel. The ABQ-IVT, which initially consisted of 24 items formulated as statements (4-point-Likert-scale ranging from “strongly agree” to “strongly disagree”), was applied in a cross-sectional survey. Evaluation of the questionnaire included an assessment of internal consistency and factor analysis. The occurrence of potential barriers in the patient sample was evaluated using descriptive statistics. To identify patient subpopulations, hierarchical cluster analysis was performed using ABQ-IVT answers as predictors. Due to difficulties in capturing NA as an external criterion, the evaluation of the questionnaire was limited to its internal validity and reliability. Main outcome measures Patients’ answers to the ABQ-IVT questionnaire and interviews. Results Of 253 patients, 234 (92%) were able to complete the ABQ-IVT questionnaire. Within the reliability analysis, the ABQ-IVT was reduced to 17 items. The condensed questionnaire demonstrated good internal consistency (Cronbach’s alpha = 0.78), and factor analysis showed no evidence for subscales of the questionnaire. Nearly half of the patients (49%) reported being affected by at least three different barriers. On average, a patient was affected by 3.1 barriers. The most frequently reported barriers were “Challenge due to time commitment of physician visits” (45% of the patients), “Depression” (29%) and “Travel and opportunity costs” (27%). Cluster analysis identified six patient subpopulations, each affected by different sets of barriers and differed regarding their patient characteristics. Conclusions The ABQ-IVT is a practical and reliable instrument for identifying patient-specific barriers to IVT treatment adherence. In practice, the questionnaire may be useful in assessing whether individual patients are at higher risk of NA due to specific adherence barriers. Aside from better awareness, this allows earlier interventions, though these still need to be validated. Patient subpopulations face different barriers and may, therefore, need distinct preventative care. Supplementary Information The online version contains supplementary material available at 10.1186/s40942-021-00311-x.
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Affiliation(s)
- Sabrina Müller
- IPAM e.v, University of Wismar, University of Applied Sciences, Alter Holzhafen 19, 23966, Wismar, Germany.
| | - Sophia Junker
- Ingress-Health HWM GmbH, Alter Holzhafen 19, 23966, Wismar, Germany
| | - Thomas Wilke
- IPAM e.v, University of Wismar, University of Applied Sciences, Alter Holzhafen 19, 23966, Wismar, Germany
| | - Albrecht Lommatzsch
- Augenzentrum Am St. Franziskus-Hospital Münster, Hohenzollerning 74, 48145, Münster, Germany
| | - Alexander K Schuster
- MORE Reading Center, Augenklinik Und Poliklinik Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Hakan Kaymak
- Augenchirugie Clinic, Theo-Champion-Str. 1, 40549, Düsseldorf, Germany
| | - Christoph Ehlken
- Universitaetsklinikum Schleswig-Holstein Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Focke Ziemssen
- Universitäts-Augenklinik Tübingen, Elfriede-Aulhorn-Straße 7, 72076, Tübingen, Germany
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von der Burchard C, Moltmann M, Tode J, Ehlken C, Sudkamp H, Theisen-Kunde D, König I, Hüttmann G, Roider J. Self-examination low-cost full-field OCT (SELFF-OCT) for patients with various macular diseases. Graefes Arch Clin Exp Ophthalmol 2021; 259:1503-1511. [PMID: 33346888 PMCID: PMC8166739 DOI: 10.1007/s00417-020-05035-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/22/2020] [Accepted: 11/28/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The treatment guidelines for many macular diseases rely on frequent monitoring with optical coherence tomography (OCT). However, the burden of frequent disease control leads to low therapy adherence in real life. OCT home monitoring would address this issue but requires an inexpensive and self-operable device. With self-examination low-cost full-field OCT (SELFF-OCT), our group has introduced a novel technology that may fulfill both requirements. In this pilot study, we report the initial experiences with a clinical prototype. METHODS Fifty-one patients with different macular diseases were recruited in a cross-sectional study. The most common diseases were age-related macular degeneration (AMD; 39/51), diabetic macular edema (DME; 6/51), and retinal vein occlusion (RVO; 3/51). Patients received a short training in device usage and then performed multiple self-scans with the SELFF-OCT device. For comparison, scans with a standard clinical spectral domain (SD-)OCT were taken. RESULTS After a brief training, 77% of the patients were able to successfully acquire images that were clinically gradable. No significant influence on success could be found for age (p = 0.08) or BCVA (p = 0.97). Relevant disease biomarkers in the most common retinal diseases could be detected. CONCLUSIONS SELFF-OCT was used successfully for retinal self-examination and in the future could be used for retinal home monitoring. Future improvements in technology are expected to improve success rates and image quality. TRIAL REGISTRATION The Trial was registered in the German Trial Register under the number DRKS00013755 on 14.03.2018.
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Affiliation(s)
- Claus von der Burchard
- Department of Ophthalmology, University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany.
| | - Moritz Moltmann
- Medical Laser Center Lübeck GmbH, Peter-Monnik-Weg 4, 23562, Lübeck, Germany
| | - Jan Tode
- Department of Ophthalmology, University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
- University Eye Hospital, Medical School Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christoph Ehlken
- Department of Ophthalmology, University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Helge Sudkamp
- Medical Laser Center Lübeck GmbH, Peter-Monnik-Weg 4, 23562, Lübeck, Germany
| | - Dirk Theisen-Kunde
- Medical Laser Center Lübeck GmbH, Peter-Monnik-Weg 4, 23562, Lübeck, Germany
| | - Inke König
- Institute of Medical Biometry and Statistics, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Gereon Hüttmann
- Medical Laser Center Lübeck GmbH, Peter-Monnik-Weg 4, 23562, Lübeck, Germany
- Institute of Biomedical Optics, University of Lübeck, Peter-Monnik-Weg 4, 23562, Lübeck, Germany
| | - Johann Roider
- Department of Ophthalmology, University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
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von der Burchard C, Treumer F, Ehlken C, Koinzer S, Purtskhvanidze K, Tode J, Roider J. Retinal volume change is a reliable OCT biomarker for disease activity in neovascular AMD. Graefes Arch Clin Exp Ophthalmol 2018; 256:1623-1629. [PMID: 29915918 DOI: 10.1007/s00417-018-4040-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Current algorithms for automated computer interpretation of optical coherence tomography (OCT) imaging of patients suffering from neovascular age-related macular degeneration (AMD) mostly rely on fluid detection. However, fluid detection itself and correct interpretation of the fluid currently limits diagnostic accuracy. We therefore performed a detailed analysis of the requirements that would have to be met for fluid detection approaches. We further investigated if monitoring retinal volume would be a viable alternative to detect disease activity. METHODS Retrospective analysis and manual grading of 764 OCT volume scans of 44 patients with exudative AMD treated with intravitreal anti-VEGF injections at a pro-re-nata (PRN) treatment regimen for at least 24 months. RESULTS Detection of subretinal fluid (SRF) or intraretinal fluid (IRF) alone is not sufficient for disease detection. A combination of SRF and IRF can detect disease activity with a sensitivity of 98.6% and a specificity of 82%. With further characterization of IRF into exudative and degenerative cysts, specificity can be increased to 100%. However, correct characterization is currently not achieved by published fluid detection approaches. Change of macular retinal volume (MRV) can depict disease activity with sensitivity of 88.4% and specificity of 89.6%. Combination with the detection of SRF can further improve diagnostic accuracy to a specificity of 93.3% and sensitivity of 93.9% without relying on IRF or IRF characterization. CONCLUSION Fluid detection without further characterization is not sufficient for AMD monitoring. Either further distinction between exudative and degenerative cysts is necessary, or other activity markers have to be taken into account. MRV offers good potential to fill this diagnostic gap and might become an important monitoring marker.
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Affiliation(s)
- Claus von der Burchard
- Department of Ophthalmology, Christian-Albrechts-University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany.
| | - Felix Treumer
- Department of Ophthalmology, Christian-Albrechts-University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Christoph Ehlken
- Department of Ophthalmology, Christian-Albrechts-University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Stefan Koinzer
- Department of Ophthalmology, Christian-Albrechts-University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Konstantine Purtskhvanidze
- Department of Ophthalmology, Christian-Albrechts-University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Jan Tode
- Department of Ophthalmology, Christian-Albrechts-University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Johann Roider
- Department of Ophthalmology, Christian-Albrechts-University of Kiel, University Medical Center, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
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Bruender MC, Benjamin N, Agostini HT, Stahl A, Ehlken C. Subjective evaluation of visual acuity is not reliable to detect disease activity in different exudative maculopathies. Graefes Arch Clin Exp Ophthalmol 2018; 256:1565-1571. [PMID: 29858676 DOI: 10.1007/s00417-018-4021-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 05/03/2018] [Accepted: 05/23/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Patients with exudative maculopathies (neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO)) are faced with a high burden of examinations and treatments. This study was conceived to analyze the accuracy of a subjective evaluation of visual acuity (VA) and metamorphopsia to detect disease reactivation, compared to morphological signs of reactivation assessed by means of SD-OCT. METHODS Retrospective study of 888 patients treated for nAMD (n = 638), DME (84), BRVO (110), and CRVO (56) was conducted. Subjective evaluation of the patient at an examination (i.e., change of VA and/or metamorphopsia) was compared to clinical evaluation of disease activity as assessed by SD-OCT. Sensitivity and specificity, negative and positive predictive values (PPV/NPV) for detection of active disease were calculated. Factors associated with false-negative subjective evaluation were analyzed by regression analysis. RESULTS The sensitivity of the subjective evaluation to detect disease reactivation was < 0.50 in all exudative maculopathies. Sensitivity was increased to ≥ 0.60 by combining subjective worsening with loss of 1 line in the VA test in RVO, but not in DME and nAMD. The specificity was > 0.85 in all patients. PPV was > 0.85 in patients with RVO. Regression analysis did not reveal any factors that could reliably identify patient subgroups in which OCT could be omitted, though CRVO patients with a visual acuity of < 0.3 logMAR had an odds ratio of 0.20 for false-negative subjective evaluation (p = 0.009). CONCLUSION The accuracy of subjective evaluation to discriminate disease activity in patients with different exudative maculopathies was low and cannot substitute for frequent SD-OCT exams. Routinely assessed clinical parameters such as age, visual acuity, or treatment experience were of no use to predict the validity of subjective evaluation of disease activity. TRIAL REGISTRATION This trial was registered at the DRKS (Deutsches Register Klinischer Studien, drks.de; No 00006851) prior to the inclusion of the first patient.
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Affiliation(s)
- Marie-Christine Bruender
- Eye Center, Medical Center, Faculty of Medicine, Albert-Ludwigs-University, Killianstraße 5, 79106, Freiburg im Breisgau, Germany
| | - Nicola Benjamin
- Center for Pulmonary Hypertension, Thoraxclinic at the University Hospital Heidelberg, Röntgenstraße 1, 69126, Heidelberg, Germany
| | - Hansjuergen Thomas Agostini
- Eye Center, Medical Center, Faculty of Medicine, Albert-Ludwigs-University, Killianstraße 5, 79106, Freiburg im Breisgau, Germany
| | - Andreas Stahl
- Eye Center, Medical Center, Faculty of Medicine, Albert-Ludwigs-University, Killianstraße 5, 79106, Freiburg im Breisgau, Germany
| | - Christoph Ehlken
- Eye Center, Medical Center, Faculty of Medicine, Albert-Ludwigs-University, Killianstraße 5, 79106, Freiburg im Breisgau, Germany.
- Department of Ophthalmology, Faculty of Medicine, Christian-Albrechts-University, Arnold-Heller-Strasse 3, 24105, Kiel, Germany.
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Abstract
Purpose Real-life clinical outcomes of patients treated with anti-VEGF drugs for neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or macular edema secondary to branch retinal vein occlusion (BRVO) are often inferior to results from randomized clinical trials. This observational cohort study investigates treatment adherence and real-life clinical outcomes within the first year of treatment. Patients and methods A total of 708 treatment-naïve patients (466 nAMD, 134 DME, and 108 BRVO) were included. Patients were followed with a PRN treatment protocol with three intravitreal injections (IVIs) and a series of 3 monthly injections in case of persistent or recurrent disease activity, as determined by monthly follow-up exams including optical coherence tomographies. Occurrence of gaps of >56 days between treatments or follow-up (nonadherence [NA]) and the reasons for NA (patient- or center-associated) as well as disease activity within the first 12 months of treatment were analyzed. Visual acuity (VA) as well as numbers and dates of optical coherence tomography and IVI were extracted from medical records. Results NA occurred significantly more often in patients with DME (44%) than nAMD (32%) or BRVO (25%, p<0.01 between groups). NA was mainly patient-associated (nAMD: 80.0%, DME: 83.1%, BRVO: 70.4%, p=0.38 between groups). Patients with nAMD and DME and appropriate treatment/follow-up adherence had a better chance of significantly gaining or maintaining VA, respectively (19.9% vs 12.0% with 3-line-gain in nAMD and 1.3% vs 15.3% 3-line loss in DME; each p<0.05). NA did not correlate with VA outcomes in BRVO (3-line gain 30.9% vs 48.1% and 3-line loss 8.6% vs 7.4%; p>0.05). Conclusion NA to treatment and follow-up regimens is a common problem in the management of patients with AMD and DME and limits clinical treatment outcomes under real-life conditions. Patients with DME have the highest risk of patient-associated NA, associated with a higher risk for significant VA loss.
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Affiliation(s)
- Christoph Ehlken
- Ophthalmology, Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau.,Ophthalmology, Eye Center, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Mandy Helms
- Ophthalmology, Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau
| | - Daniel Böhringer
- Ophthalmology, Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau
| | - Hansjürgen T Agostini
- Ophthalmology, Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau
| | - Andreas Stahl
- Ophthalmology, Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau
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Ehlken C, Böhringer D, Agostini HT, Grundel B, Stech M. Potential selection bias in candidates for stereotactic radiotherapy for neovascular AMD. Graefes Arch Clin Exp Ophthalmol 2017; 256:105-111. [PMID: 29168044 DOI: 10.1007/s00417-017-3849-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/11/2017] [Accepted: 11/04/2017] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Stereotactic radiotherapy (SRT, IRay) was able to reduce the need for intravitreal injections of anti-VEGF (IVI) in patients with neovascular AMD (nAMD) in a phase II randomized clinical trial. Certain morphologic characteristics, such as lesion size < 4 mm2 or lack of fibrosis, were associated with a better response. The purpose of this cross-sectional study was to investigate eligibility for SRT in a clinical routine setting and to compare clinical features of eligible and non-eligible patients. METHODS Cross-sectional study of 468 patients treated for nAMD in one study center within a period of 4 months. Clinical features, such as visual acuity or number of IVI since diagnosis and within 6/12 months, as well as the presence for exclusion criteria for SRT were analyzed. Exclusion criteria were sub-divided into lesion-associated (relevant fibrosis, lesion size > 4 mm2, PE tear), ocular comorbidity (e.g., macular comorbidity, vascular disease) and systemic comorbidity (e.g., dementia or tremor). RESULTS Exclusion criteria were met by 255 patients (54.5%). Exclusion was most dominantly associated with lesion-associated criteria (80.0%) and less often with ocular (20.8%) or systemic (9.4%) comorbidity. A total of 213 patients (45.5%) fulfilled eligibility criteria. Eligible patients had a better VA at time of analysis (0.36 vs. 0.56 logMAR, p < 0.0001) and at baseline (0.38 vs. 0.56 logMAR, p < 0.0001) compared to non-eligible patients. The numbers of previous intravitreal injections since diagnosis in strictly PRN-treated patients served as a surrogate marker for lesion activity and was comparable within the last 6/12 months. Non-eligible patients had a higher number of different anti-VEGF drugs (1.8 vs. 1.6, p = 0.038). CONCLUSIONS SRT in addition to anti-VEGF can be an option in every second patient with nAMD. Due to morphological exclusion criteria, patients eligible for SRT had a better VA and a better clinical response compared to non-eligible patients.
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Affiliation(s)
- Christoph Ehlken
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Department of Ophthalmology, University Hospital Schleswig-Holstein, Kiel, Germany.
| | - Daniel Böhringer
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hansjürgen T Agostini
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bastian Grundel
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Milena Stech
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Ehlken C, Guichard MM, Schlunck G, Bühler AD, Martin G, Agostini HT. Expression of Angiogenic and Inflammatory Factors in Choroidal Neovascularisation-Derived Retinal Pigment Epithelium. Ophthalmic Res 2017; 61:174-182. [DOI: 10.1159/000481260] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/31/2017] [Indexed: 11/19/2022]
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Müller S, Ehlken C, Bauer-Steinhusen U, Lechtenfeld W, Hasanbasic Z, Agostini H, Wilke T. Treatment of age-related neovascular macular degeneration: the patient's perspective. Graefes Arch Clin Exp Ophthalmol 2017; 255:2237-2246. [PMID: 28776095 PMCID: PMC5640748 DOI: 10.1007/s00417-017-3739-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 06/12/2017] [Accepted: 07/03/2017] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess patients' views and expectations with regard to neovascular age-related macular degeneration (nAMD) and intravitreal anti-VEGF therapy (IVT). METHODS We conducted a multicenter, non-interventional, prospective cohort study including nAMD patients treated with IVT in Germany. Patients with at least one IVT before study enrollment and aged ≥50 years were included. Three telephone interviews were conducted during a 12-month observational period. Here, patient's beliefs/expectations with regard to the nAMD disease and the IVT treatment were discussed. Only patients who completed all three phone interviews were included in the analyses. We used a two-step cluster analysis to identify patient clusters regarding specific patient attitudes towards nAMD and its treatment. RESULTS Three hundred and thirty-two patients completed all interviews (mean age of 76.4 ± 7.2 years, 59.0% women). Out of these, 57.8% acknowledged that they needed general assistance in daily life, while 77.4% stated being able to attend general medical appointments on their own. However, 64.7% needed a driver or an accompanying person to attend their IVT appointments. In addition, 3.9% of the patients were afraid of IVT side effects. Also, 87.3% and 43.1% of the patients could name their disease or the anti-VEGF drug administered, respectively. More than three-quarters of the patients (83.1%) were aware of possible consequences of nAMD by stating vision loss or blindness, but only 16.6% knew that nAMD is a chronic disease. Generally, patients were optimistic: 70.2%, 5.1% and 13.0% of them expected stable visual acuity (VA), a significant improvement or expected worsening of VA in the next year, respectively. Almost two thirds of patients who provided their therapy expectations (47.0%) anticipated fewer injections/discontinuation of IVT. We identified five patient clusters differing significantly from each other with regard to four variables: being afraid of IVT, nAMD disease awareness, optimism with regard to effectiveness of IVT, and nAMD disease and treatment knowledge. CONCLUSIONS Only a minority of patients is aware of the chronic nature of nAMD. To motivate patients to accept a life-long IVT treatment, physicians and caregivers must know that there exist different patient types with significant differences in communication needs.
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Affiliation(s)
- S Müller
- IPAM - Institute for Pharmacoeconomics and Medication Logistics, University of Wismar, Alter Holzhafen 19, 23966, Wismar, Germany.
| | - C Ehlken
- Department of Ophthalmology, Universitäts-Klinikum Schleswig-Holstein, Campus Kiel, Germany
| | - U Bauer-Steinhusen
- Bayer Vital GmbH, Medical Affairs, Kaiser-Wilhelm-Allee 70, 51373, Leverkusen, Germany
| | - W Lechtenfeld
- PRO RETINA Deutschland e.V, Vaalser Str. 108, 52074, Aachen, Germany
| | - Z Hasanbasic
- Bayer Vital GmbH, Medical Affairs, Kaiser-Wilhelm-Allee 70, 51373, Leverkusen, Germany
| | - H Agostini
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Killianstraße 5, 79106, Freiburg, Germany
| | - T Wilke
- IPAM - Institute for Pharmacoeconomics and Medication Logistics, University of Wismar, Alter Holzhafen 19, 23966, Wismar, Germany
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Wecker T, Ehlken C, Bühler A, Lange C, Agostini H, Böhringer D, Stahl A. Five-year visual acuity outcomes and injection patterns in patients with pro-re-nata treatments for AMD, DME, RVO and myopic CNV. Br J Ophthalmol 2016; 101:353-359. [PMID: 27215744 PMCID: PMC5339568 DOI: 10.1136/bjophthalmol-2016-308668] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/20/2016] [Accepted: 04/26/2016] [Indexed: 11/15/2022]
Abstract
Background Anti vascular endothelial growth factor (VEGF) therapy is an established treatment for various retinal diseases. Long-term data on injection frequencies and visual acuity (VA), however, are still rare. Methods Five-year analysis of real-life VA developments and injection patterns from 2072 patients (2577 eyes; 33 187 injections) with chronically active disease undergoing pro-re-nata treatment for age-related macular degeneration (AMD), diabetic macular oedema (DME), retinal vein occlusion (RVO) and myopic choroidal neovascularisation (CNV). Results Maximum mean VA gain in year 1 was+5.2 letters in AMD, +6.2 in DME, +10 in RVO and+7.2 in myopic CNV. Over 5 years, however, VA in patients with AMD declined. By year 5, 34% of patients with AMD had experienced VA loss of >15 letters, 56% had remained stable and 10% had gained >15 letters. Long-term VA developments in DME and RVO were more favourable with 81% of DME and 79% of patients with RVO gaining or maintaining vision at 5 years. In AMD, median injection frequency was six in year 1 and between four and five in consecutive years. In DME and RVO, median injection frequency was six in year 1 but lower compared with AMD in consecutive years. Injection frequency in DME was weakly associated with patient age (rs=0.1; p=0.03). Conclusions In AMD, the initial VA gain was not maintained long term despite higher injection numbers compared with DME, RVO and myopic CNV. The presented real-world data provide a peer-group-based estimate of VA developments and injection frequencies for counselling patients undergoing long-term anti-VEGF therapy.
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Affiliation(s)
- Thomas Wecker
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Christoph Ehlken
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Anima Bühler
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Clemens Lange
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Hansjürgen Agostini
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Daniel Böhringer
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Andreas Stahl
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, Germany
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Cakir B, Fischer F, Ehlken C, Bühler A, Stahl A, Schlunck G, Böhringer D, Agostini H, Lange C. Clinical experience with eplerenone to treat chronic central serous chorioretinopathy. Graefes Arch Clin Exp Ophthalmol 2016; 254:2151-2157. [DOI: 10.1007/s00417-016-3373-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 03/31/2016] [Accepted: 04/25/2016] [Indexed: 01/31/2023] Open
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Mueller S, Agostini H, Ehlken C, Bauer-Steinhusen U, Hasanbasic Z, Wilke T. Patient Preferences in the Treatment of Neovascular Age-Related Macular Degeneration: A Discrete Choice Experiment. Ophthalmology 2016; 123:876-83. [PMID: 26778346 DOI: 10.1016/j.ophtha.2015.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The objective of our study was to investigate preferences of patients with neovascular age-related macular degeneration (nAMD) for different anti-vascular endothelial growth factor (VEGF) treatment schemes. DESIGN We used a discrete choice experiment (DCE) design as part of a telephone interview. PARTICIPANTS Patients with nAMD aged at least 50 years were included in the study. METHODS Telephone interviews were done between November 2012 and October 2013. MAIN OUTCOME MEASURES In our DCE survey, we measured patient preferences toward specific levels of attributes that describe different options in the everyday intravitreal injection treatment setting: (1) treatment scheme; (2) change of visual acuity (VA); and (3) time the patient needs for each visit to the eye specialist. RESULTS A total of 284 patients with nAMD with a mean age of 77.4±7.1 years (women: 59.9%) completed the DCE interviews. Of them, 22.9% had poor VA at study inclusion, 54.9% had moderate VA, and 14.1% had good VA; VA was not available for 8.1% of the patients. Generally, patients preferred the attribute levels "improvement in VA" and "short time per specialist visit." The results for the attribute "treatment scheme" were inconclusive because none of the attribute levels (injections every 4 weeks, every 8 weeks, and pro re nata) were associated with statistically significant utility differences. This also mirrors the relative importance of the different attributes in patient decisions: "Change of VA" influenced decision making for a treatment option in 73.6% of cases; "waiting, treatment, and travel time" influenced decision making in 21.0% of cases; and "treatment scheme" influenced decision making for a treatment option in 5.4% of cases. To obtain improved VA instead of a worsening VA, patients in our study stated to be willing to accept a very long time needed per physician visit of 21.2 hours (8.5 hours for improved rather than stable VA and 12.7 hours for stable VA rather than worsening VA). CONCLUSIONS To prevent deterioration of VA, patients with nAMD seem to be willing to accept a high treatment burden with regular intravitreal injections at short intervals and long periods of waiting, treatment, and traveling for their consultations.
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Affiliation(s)
- Sabrina Mueller
- Institut für Pharmakoökonomie und Arzneimittellogistik (IPAM), University of Wismar, Wismar, Germany.
| | - Hansjürgen Agostini
- Eye Center, Medical Center, University of Freiburg, Baden-Württemberg, Germany
| | - Christoph Ehlken
- Eye Center, Medical Center, University of Freiburg, Baden-Württemberg, Germany
| | | | - Zoran Hasanbasic
- Medizinische Abteilung für Ophthalmologie, Bayer HealthCare Germany, Leverkusen, Germany
| | - Thomas Wilke
- Institut für Pharmakoökonomie und Arzneimittellogistik (IPAM), University of Wismar, Wismar, Germany
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Schmucker CM, Rücker G, Sommer H, Virgili G, Loke YK, Oeller P, Agostini H, Ehlken C. Treatment as Required versus Regular Monthly Treatment in the Management of Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0137866. [PMID: 26368921 PMCID: PMC4569266 DOI: 10.1371/journal.pone.0137866] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 08/24/2015] [Indexed: 11/28/2022] Open
Abstract
Background To investigate whether treatment as required ‘pro re nata’ (PRN) versus regular monthly treatment regimens lead to differences in outcomes in neovascular age-related macular degeneration (nAMD). Regular monthly administration of vascular endothelial growth factor (VEGF) inhibitors is an established gold standard treatment, but this approach is costly. Replacement of monthly by PRN treatment can only be justified if there is no difference in patient relevant outcomes. Methods Systematic review and meta-analysis. The intervention was PRN treatment and the comparator was monthly treatment with VEGF-inhibitors. Four bibliographic databases were searched for randomised controlled trials comparing both treatment regimens directly (head-to-head studies). The last literature search was conducted in December 2014. Risk of bias assessment was performed after the Cochrane Handbook for Systematic Reviews of Interventions. Findings We included 3 head-to-head studies (6 reports) involving more than 2000 patients. After 2 years, the weighted mean difference in best corrected visual acuity (BCVA) was 1.9 (95% CI 0.5 to 3.3) ETDRS letters in favour of monthly treatment. Systemic adverse events were higher in PRN treated patients, but these differences were not statistically significant. After 2 years, the total number of intravitreal injections required by the patients in the PRN arms were 8.4 (95% CI 7.9 to 8.9) fewer than those having monthly treatment. The studies were considered to have a moderate risk of bias. Conclusions PRN treatment resulted in minor but statistically significant decrease in mean BCVA which may not be clinically meaningful. There is a small increase in risk of systemic adverse events for PRN treated patients. Overall, the results indicate that an individualized treatment approach with anti-VEGF using visual acuity and OCT-guided re-treatment criteria may be appropriate for most patients with nAMD.
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Affiliation(s)
- Christine M. Schmucker
- Cochrane Germany, Medical Center – University of Freiburg, Berliner Allee 29, 79110 Freiburg, Germany
- * E-mail:
| | - Gerta Rücker
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
| | - Harriet Sommer
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
| | - Gianni Virgili
- Department of Translational Surgery and Medicine, University of Florence, Florence, Italy
| | - Yoon K. Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Patrick Oeller
- Cochrane Germany, Medical Center – University of Freiburg, Berliner Allee 29, 79110 Freiburg, Germany
| | | | - Christoph Ehlken
- University Eye Center Freiburg, Killianstr. 5, 79106 Freiburg, Germany
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Ehlken C, Jungmann S, Böhringer D, Agostini HT, Junker B, Pielen A. Switch of anti-VEGF agents is an option for nonresponders in the treatment of AMD. Eye (Lond) 2014; 28:538-45. [PMID: 24722504 DOI: 10.1038/eye.2014.64] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/25/2013] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Although anti-VEGF therapy of exudative AMD with bevacizumab and ranibizumab proved efficacious in the majority of patients, CNV activity does not respond to continued treatment after repeated injections in a considerable amount of patients. These are referred to as nonresponders. A change of the drug to bevacizumab or ranibizumab could possibly offer an alternative option for the treatment of nonresponding exudative AMD. METHODS AND MATERIALS A total of 138 nonresponders who switched therapy from bevacizumab to ranibizumab (n=114) or vice versa (n=24) were included in a retrospective study. Visual acuity (VA) and foveal thickness before and after the switch of therapy were compared. By means of linear regression analysis, we analyzed possible prognostic factors associated with a favorable outcome for visual acuity. RESULTS Linear regression analysis revealed a statistically significant benefit for nonresponders when treatment was changed to a different anti-VEGF drug (bevacizumab or ranibizumab). VA at the time of the switch was positively correlated with a beneficial development of VA after changing the drug. There was no significant correlation with age, macular thickness, number of injections before the switch, or the development of VA under treatment before the switch. Both patients switching to Avastin and Lucentis benefitted without statistically significant differences. CONCLUSIONS An exchange of bevacizumab with ranibizumab or vice versa should be considered in nonresponders in the treatment of exudative AMD. Further prognostic factors may help to identify patients who might benefit from a switch. These factors should be investigated in further studies.
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Affiliation(s)
- C Ehlken
- Eye Center, Albert-Ludwigs-University, Freiburg, Germany
| | - S Jungmann
- Eye Center, Albert-Ludwigs-University, Freiburg, Germany
| | - D Böhringer
- Eye Center, Albert-Ludwigs-University, Freiburg, Germany
| | - H T Agostini
- Eye Center, Albert-Ludwigs-University, Freiburg, Germany
| | - B Junker
- 1] Eye Center, Albert-Ludwigs-University, Freiburg, Germany [2] Hannover Medical School, Hannover, Germany
| | - A Pielen
- 1] Eye Center, Albert-Ludwigs-University, Freiburg, Germany [2] Hannover Medical School, Hannover, Germany
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Ehlken C, Martin G, Stahl A, Agostini HT. Reduction of Vascular Endothelial Growth Factor A in Human Breast Milk After Intravitreal Injection of Bevacizumab but Not Ranibizumab. ACTA ACUST UNITED AC 2012; 130:1226-7. [DOI: 10.1001/archophthalmol.2012.112] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Schmucker C, Ehlken C, Agostini HT, Antes G, Ruecker G, Lelgemann M, Loke YK. A safety review and meta-analyses of bevacizumab and ranibizumab: off-label versus goldstandard. PLoS One 2012; 7:e42701. [PMID: 22880086 PMCID: PMC3411814 DOI: 10.1371/journal.pone.0042701] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/10/2012] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We set out a systemic review to evaluate whether off-label bevacizumab is as safe as licensed ranibizumab, and whether bevacizumab can be justifiably offered to patients as a treatment for age-related macular degeneration with robust evidence of no differential risk. METHODS AND FINDINGS Medline, Embase and the Cochrane Library were searched with no limitations of language and year of publication. We included RCTs with a minimum follow-up of one year which investigated bevacizumab or ranibizumab in direct comparison or against any other control group (indirect comparison). Direct comparison (3 trials, 1333 patients): The one year data show a significantly higher rate of ocular adverse effects (AE) with bevacizumab compared to ranibizumab (RR = 2.8; 95% CI 1.2-6.5). The proportion of patients with serious infections and gastrointestinal disorders was also higher with bevacizumab than with ranibizumab (RR = 1.3; 95% CI 1.0-1.7). Arterial thromboembolic events were equally distributed among the groups. Indirect comparison: Ranibizumab versus any control (5 trials, 4054 patients): The two year results of three landmark trials showed that while absolute rates of serious ocular AE were low (≤ 2.1%), relative harm was significantly raised (RR = 3.1; 95% CI 1.1-8.9). A significant increase in nonocular haemorrhage was also observed with ranibizumab (RR = 1.7; 95% CI 1.1-2.7). Bevacizumab versus any control (3 trials, 244 patients): We were unable to judge the safety profile of bevacizumab due to the poor quality of AE monitoring and reporting in the trials. CONCLUSIONS Evidence from head-to-head trials raises concern about an increased risk of ocular and multiple systemic AE with bevacizumab. Therefore, clinicians and patients should continue to carefully weight up the benefits and harms when choosing between the two treatment options. We also emphasize the need for studies that are powered not just for efficacy, but for defined safety outcomes based on the signals detected in this systematic review.
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Affiliation(s)
- Christine Schmucker
- German Cochrane Institute, Institute of Medical Biometry and Medical Informatics, Department of Medical Biometry and Statistics, University Medical Centre Freiburg, Freiburg, Germany.
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Schmucker C, Loke YK, Ehlken C, Agostini HT, Hansen LL, Antes G, Lelgemann M. Intravitreal bevacizumab (Avastin) versus ranibizumab (Lucentis) for the treatment of age-related macular degeneration: a safety review. Br J Ophthalmol 2011; 95:308-17. [PMID: 20971791 DOI: 10.1136/bjo.2009.178574] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To conduct a systematic review in order to compare adverse effects (AE) and the reporting of harm in randomised controlled trials (RCTs) and non-RCTs evaluating intravitreal ranibizumab and bevacizumab in age-related macular degeneration. METHODS Medline, Embase and the Cochrane Library were searched with no limitations of language and year of publication. Studies which compared bevacizumab or ranibizumab as monotherapy with any other control group were included. Case series were included if they met predefined quality standards. RESULTS The 2 year results of phase III trials evaluating ranibizumab show that the rates of serious ocular AE were low (≤2.1%) but indicate major safety concerns (RR 3.13, 95% CI 1.10 to 8.92). A possible signal with regard to thromboembolic events (RR 1.35, 95% CI 0.66 to 2.77) and a significant increase in non-ocular haemorrhage (RR 1.62, 95% CI 1.03 to 2.55) were also noted. In contrast to ranibizumab trials, the RCTs evaluating bevacizumab are of limited value. The main shortcomings are small sample sizes and an apparent lack of rigorous monitoring for AE. A critical assessment of the large number of published case series evaluating bevacizumab also shows that no reliable conclusions on safety can be drawn using this study design. Therefore, any perception that intravitreal bevacizumab injections are not associated with major ocular or systemic AE are not supported by reliable data. CONCLUSION The bevacizumab studies show too many methodological limitations to rule out any major safety concerns. Higher evidence from ranibizumab trials suggests signals for an increased ocular and systemic vascular and haemorrhagic risk which warrants further investigation.
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Affiliation(s)
- Christine Schmucker
- German Cochrane Centre, Institute of Medical Biometry and Medical Informatics, Department of Medical Biometry and Statistics, University Medical Centre Freiburg, Berliner Allee 29, Freiburg 79110, Germany.
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Ehlken C, Martin G, Lange C, Gogaki EG, Fiedler U, Schaffner F, Hansen LL, Augustin HG, Agostini HT. Therapeutic interference with EphrinB2 signalling inhibits oxygen-induced angioproliferative retinopathy. Acta Ophthalmol 2011; 89:82-90. [PMID: 19764912 DOI: 10.1111/j.1755-3768.2009.01609.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE To investigate whether EphrinB2 (EfnB2) or EphB4 influence retinal angiogenesis under physiological or pathological conditions. METHODS Using the mouse model of oxygen-induced proliferative retinopathy (OIR), the expression of EfnB2, EphB4, vascular endothelial growth factor (VEGF), VEGFR1 and VEGFR2 was quantified by quantitative polymerase chain reaction (qPCR) and localized in EfnB2- and EphB4-lacZ mice. Angioproliferative retinopathy was manipulated by intravitreal injection of dimeric EfnB2 and monomeric or dimeric EphB4. RESULTS Dimeric EphB4 (EphB4-Fc) and EfnB2 (EfnB2-Fc) enhanced hypoxia-induced angioproliferative retinopathy but not physiological angiogenesis. Monomeric EphB4 (sEphB4) reduced angiogenesis. The messenger RNA (mRNA) level of EfnB2 increased significantly in the hyperoxic phase (P7-P12), while EphB4, VEGF, VEGFR1 and VEGFR2 showed a significant - up to fivefold - increased expression at P14, the start of morphologically visible vasoproliferation caused by relative hypoxia. CONCLUSION The ephrin/Eph system is involved in angioproliferative retinopathy. Stimulation of EphB4 and EfnB2 signalling using EfnB2-Fc and EphB4-Fc, respectively, enhanced hypoxia-induced angiogenesis. In contrast, sEphB4 inhibited hypoxia-induced angiogenesis. Therefore, angiogenesis is enhanced by signalling through both EphB4 (forward) and EfnB2 (reverse). The distinction in the expression kinetics of EphB4 and EfnB2 indicates that they govern two different signalling pathways and are regulated in diverse ways. sEphB4 might be a useful drug for antiangiogenic therapy.
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Stahl A, Boeker M, Ehlken C, Agostini H, Reinhard T. [Evaluation of an internet-based e-learning ophthalmology module for medical students]. Ophthalmologe 2010; 106:999-1005. [PMID: 19609779 DOI: 10.1007/s00347-009-1916-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 2006, the University Eye Hospital Freiburg (Germany) introduced an Internet-based e-learning module as part of the ophthalmology training for medical students. METHODS In the e-learning module, the students encounter the same cases as discussed during lectures and seminars. The case presentation is based on an interactive question-and-answer game. Content, format, usability, and effectiveness of the e-learning module were evaluated by the students over two terms. RESULTS Of 307 students, 272 used the e-learning module. On average, 94% of the content was processed per student. More than 75% stated that they had fun working with the e-learning module. Students with frequent e-learning use tended to achieve higher marks in their final ophthalmology exams. CONCLUSION E-learning represents a sensible addendum to the established ophthalmology training for medical students. It is comparably easy to integrate into the curriculum and is well accepted by medical students.
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Affiliation(s)
- A Stahl
- Universitäts-Augenklinik Freiburg, Killianstr. 5, 79106 Freiburg, Deutschland
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Lange C, Ehlken C, Martin G, Konzok K, Moscoso Del Prado J, Hansen LL, Agostini HT. Intravitreal injection of the heparin analog 5-amino-2-naphthalenesulfonate reduces retinal neovascularization in mice. Exp Eye Res 2007; 85:323-7. [PMID: 17662276 DOI: 10.1016/j.exer.2007.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 05/29/2007] [Accepted: 05/30/2007] [Indexed: 11/16/2022]
Abstract
The effect of the heparin analog 5-amino-2-naphthalenesulfonate (5-amino-2-NMS) on retinal neovascularization was investigated in the mouse model for oxygen-induced retinopathy (OIR). From postnatal day 7 (P7) until P12, mice were kept in a 75% oxygen environment. On P12, they received an intravitreal injection of 10mM 5-amino-2-NMS in one eye and PBS as control substance in the fellow eye. The animals were intracardially perfused with fluorescein-dextran solution on P17. Retinal whole mounts were prepared and ischemic retinopathy was evaluated in 30 animals using a standardized retinopathy score. A single intravitreal injection of 5-amino-2-NMS reduces significantly angioproliferative changes (blood vessel tufts, extra-retinal neovascularization, and blood vessel tortuosity) compared to the contralateral control eye (p=0.025). The median retinopathy score (maximal 13) for the 5-amino-2-NMS treated eyes was 6 versus 8 for the control eyes. 5-Amino-2-NMS binds to the heparin-binding site of FGF1 and FGF2 and thus may be a promising substance for the local treatment of retinal neovascularization.
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Affiliation(s)
- Clemens Lange
- Augenklinik, Universitätsklinikum Freiburg, Killianstrasse 5, 79106 Freiburg, Germany
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Kuiper EJ, Roestenberg P, Ehlken C, Lambert V, van Treslong-de Groot HB, Lyons KM, Agostini HJT, Rakic JM, Klaassen I, Van Noorden CJF, Goldschmeding R, Schlingemann RO. Angiogenesis is not impaired in connective tissue growth factor (CTGF) knock-out mice. J Histochem Cytochem 2007; 55:1139-47. [PMID: 17625227 PMCID: PMC3957533 DOI: 10.1369/jhc.7a7258.2007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Connective tissue growth factor (CTGF) is a member of the CCN family of growth factors. CTGF is important in scarring, wound healing, and fibrosis. It has also been implicated to play a role in angiogenesis, in addition to vascular endothelial growth factor (VEGF). In the eye, angiogenesis and subsequent fibrosis are the main causes of blindness in conditions such as diabetic retinopathy. We have applied three different models of angiogenesis to homozygous CTGF(-/-) and heterozygous CTGF(+/-) mice to establish involvement of CTGF in neovascularization. CTGF(-/-) mice die around birth. Therefore, embryonic CTGF(-/-), CTGF(+/-), and CTGF(+/+) bone explants were used to study in vitro angiogenesis, and neonatal and mature CTGF(+/-) and CTGF(+/+) mice were used in models of oxygen-induced retinopathy and laser-induced choroidal neovascularization. Angiogenesis in vitro was independent of the CTGF genotype in both the presence and the absence of VEGF. Oxygen-induced vascular pathology in the retina, as determined semi-quantitatively, and laser-induced choroidal neovascularization, as determined quantitatively, were also not affected by the CTGF genotype. Our data show that downregulation of CTGF levels does not affect neovascularization, indicating distinct roles of VEGF and CTGF in angiogenesis and fibrosis in eye conditions.
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Affiliation(s)
- Esther J. Kuiper
- Ocular Angiogenesis Group, Departments of Ophthalmology and Cell Biology and Histology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Peggy Roestenberg
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Christoph Ehlken
- Department of Ophthalmology, University of Freiburg, Freiburg, Germany
| | - Vincent Lambert
- Laboratory of Tumor and Development Biology and Department of Ophthalmology, University Hospital Liège, Sart Tilman, Liège, Belgium
| | | | - Karen M. Lyons
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | | | - Jean-Marie Rakic
- Laboratory of Tumor and Development Biology and Department of Ophthalmology, University Hospital Liège, Sart Tilman, Liège, Belgium
| | - Ingeborg Klaassen
- Ocular Angiogenesis Group, Departments of Ophthalmology and Cell Biology and Histology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Cornelis J. F. Van Noorden
- Ocular Angiogenesis Group, Departments of Ophthalmology and Cell Biology and Histology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Goldschmeding
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Reinier O. Schlingemann
- Ocular Angiogenesis Group, Departments of Ophthalmology and Cell Biology and Histology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Correspondence to: Dr. R.O. Schlingemann, Department of Ophthalmology, Academic Medical Center, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands. E-mail:
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