Maintenance of Vision Needed to Drive after Intravitreal Anti-VEGF Therapy in Patients with Neovascular Age-related Macular Degeneration and Diabetic Macular Edema

OBJECTIVE

To evaluate the association between intravitreal anti-VEGF therapy and visual acuity (VA)/driving vision maintenance over 4 years in patients with neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME).

DESIGN

Retrospective, observational, clinical practice cohort study using data from the Vestrum Health database.

PARTICIPANTS

Initial diagnosis (January 1, 2014 to June 30, 2019) of nAMD or DME and ≥ 1 year of treatment/follow-up history. The VA analysis required 4 years of treatment/follow-up history. For the driving vision maintenance analysis, patients required Snellen VA of 20/40 or better at baseline and for ≥ 6 months during year 1 after index intravitreal anti-VEGF treatment in the better-seeing eye.

METHODS

A loss-of-driving event was the first clinic visit with VA worse than 20/40 sustained for ≥ 6 consecutive months. Kaplan-Meier analyses estimated the probability of maintaining driving vision over 4 years stratified by year-1 injection number. Cox proportional hazard models examined associations between baseline clinical characteristics and year-1 injection frequency and the risk of losing driving vision.

MAIN OUTCOME MEASURES

Mean change in VA over time and by baseline VA, driving vision maintenance probability over time and stratified by anti-VEGF injection frequency, and baseline factors predictive of driving vision maintenance.

RESULTS

In year 1, the nAMD and DME cohorts gained 8.5 and 9.5 ETDRS letters, respectively. Between years 1 and 4, patients with nAMD and DME lost 6.6 and 2.7 ETDRS letters, respectively. The probability of maintaining driving vision over 4 years was 56% (nAMD) and 72% (DME); among patients who received 1 to 5, 6 to 7, and ≥ 8 anti-VEGF injections in year 1, corresponding probabilities were 50%, 56%, and 65% (nAMD; P < 0.001) and 63%, 72%, and 77% (DME; P < 0.001). Baseline factors associated with driving vision loss included older age, worse index VA, geographic atrophy (nAMD), and worsening baseline diabetic retinopathy (DME).

CONCLUSIONS

Older age and worse index VA were risk factors for driving vision loss, whereas a greater year-1 injection number was associated with driving vision maintenance through year 4, supporting early initiation and frequent anti-VEGF injections for maintaining driving vision in nAMD or DME.

FINANCIAL DISCLOSURE(S)

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

Anti-vascular endothelial growth factor dosing frequency and visual outcomes in macular oedema following branch retinal vein occlusion

OBJECTIVES

To determine the relationship between treatment frequency with intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents and visual acuity (VA) outcomes in eyes with macular oedema (MO) secondary to branch retinal vein occlusion (BRVO) in US clinical practice.

METHODS

Study eyes that initiated anti-VEGF injections between January 2012 and May 2016 were followed for ≥1 year in a retrospective analysis of medical records (Vestrum Health database). Eyes were analysed in 2 cohorts by treatment duration (years 1 and 2) and then in 2 subcohorts by injection frequency (≤6 or ≥7 injections/year).

RESULTS

Among 3099 eyes with MO secondary to BRVO, 1197 (38.6%) received ≤6 injections (mean injections, 4.6; baseline mean VA, 53 letters) and 1902 (61.4%) received ≥7 injections through 1 year (mean injections, 8.8; baseline mean VA, 52 letters). At year 1, mean VA gain from baseline was 10.4 versus 13.9 letters in eyes receiving ≤6 versus ≥7 injections (p < 0.001). At year 2, mean VA in eyes receiving ≤6 (n = 42) versus ≥7 injections (n = 227) was 64 versus 68 letters, respectively (p = 0.19). Mean VA change between the start and end of year 2 in eyes receiving ≥7 injections in year 1 and ≤6 in year 2 differed significantly from that of eyes receiving ≥7 injections in both years (-3.0 vs 0.7 letters, respectively; p < 0.001).

CONCLUSIONS

In routine clinical practice, more frequent dosing with anti-VEGF agents was associated with greater visual benefits in eyes with MO secondary to BRVO.

Levodopa Is Associated with Reduced Development of Neovascular Age-Related Macular Degeneration

OBJECTIVE

To determine whether levodopa (L-DOPA) is associated with a reduced likelihood of developing neovascular age-related macular degeneration (AMD).

DESIGN

Three studies were performed: retrospective analyses in the Vestrum Health Retina Database (#1-2) and case-control analysis in the Merative MarketScan Research Databases (#3).

PARTICIPANTS

Eyes with neovascular AMD and 2 years of follow-up (#1). Eyes with non-neovascular AMD and 1 to 5 years of follow-up (#2). Patients aged ≥ 55 years with newly diagnosed neovascular AMD matched to controls without neovascular AMD (#3).

METHODS

Eyes were divided into 2 groups (#1-2): exposed to L-DOPA before or on the date of neovascular (#1) or nonneovascular (#2) AMD diagnosis, and eyes not exposed to L-DOPA. We extracted AMD risk factors, number of intravitreal injections (#1), and conversion rate to neovascular AMD (#2). We calculated the percentage of newly diagnosed neovascular AMD cases and matched controls exposed to any L-DOPA and determined the cumulative 2-year dose in grams by tertiles (< 100 mg, approximately 100-300 mg, and approximately > 300 mg per day, #3).

MAIN OUTCOME MEASURES

Number of intravitreal injections (#1) and detection of new-onset neovascular AMD (#2-3) after adjusting for AMD risk factors.

RESULTS

In the Vestrum database, eyes with neovascular AMD that were exposed to L-DOPA underwent 1 fewer intravitreal injection over 2 years (N = 84 088 control vs. 530 L-DOPA eyes, P = 0.006). In eyes with nonneovascular AMD (N = 42 081-203 155 control vs. 314-1525 L-DOPA eyes), L-DOPA exposure was associated with a reduced risk of conversion to neovascular AMD by 21% at year 2 (P = 0.029), 35% at years 3 to 4 (P < 0.001), and 28% at year 5 (P = 0.024). In the MarketScan databases (N = 86 900 per group), cumulative 2-year doses of L-DOPA between approximately 100 to 300 mg per day and approximately > 300 mg were associated with decreased odds of developing neovascular AMD by 15% (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.75-0.97) and 23% (OR, 0.77; 95% CI, 0.67-0.87), respectively.

CONCLUSIONS

Levodopa use was associated with reduced detection of new-onset neovascular AMD. A prospective, randomized clinical trial should be considered to investigate whether low-dose L-DOPA reduces neovascular AMD conversion.

FINANCIAL DISCLOSURE(S)

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

Opportunity Cost of Vitreoretinal Surgeries

Purpose: To compare physician reimbursements for vitreoretinal surgeries with office-based patient care. Methods: A theoretical model was performed comparing physician work reimbursements for the 10 most common vitreoretinal surgeries with office-based work relative value units (wRVUs) that could have been generated during the same global time period. The reference physician was modeled at 40 patients per 8-hour workday. A lower volume physician and higher volume physician were modeled at 30 patients/day and 50 patients/day, respectively. The reimbursement rates and allocated times for surgery were based on the 2021 values set by Medicare, and the average wRVU per office visit was based on 2021 real-world data from the Vestrum Retinal Healthcare Database. Results: In the reference case, performing any of the 10 most common vitreoretinal surgeries was associated with an opportunity cost with a weighted mean of 49% (range, 40%-68%) relative to lost office productivity. The Centers for Medicare & Medicaid Services (CMS) allocated a weighted mean intraservice time of 73 minutes; however, the reference physician would have to complete the surgery with a weighted average of 5 minutes (range, -31-12 minutes) for surgical wRVUs to equal office-based reimbursements. Performing these 10 surgeries was associated with a 25% opportunity cost even for the lower volume physician and 61% for the higher volume physician. Probability sensitivity analysis with a range of conditions identified opportunity costs from surgery in over 99% of simulated scenarios. Conclusions: Medicare reimbursements for the physician work component of vitreoretinal surgeries represented a significant opportunity cost for the physician relative to office-based patient care of equivalent time, especially for busier physicians. The model did not explore practice overhead and professional liability insurance, which are factored separately by CMS and may influence the opportunity cost depending on utilization. The average threshold surgery times for surgical reimbursements to equal office-based reimbursements may be difficult to achieve.

Evolving Treatment Patterns in Diabetic Macular Edema Between 2015 and 2020

Purpose: To explore the recent evolution of diabetic macular edema (DME) treatment practice patterns over 5 years among retina specialists in the United States. Methods: This retrospective analysis assessed 306 700 eyes with newly diagnosed DME from the Vestrum Health database between January 2015 and October 2020. The year-over-year and cumulative 5-year distributions of eyes treated with antivascular endothelial growth factor (anti-VEGF) agents, steroids, focal laser, or any combination and those of untreated eyes were calculated. Changes from baseline visual acuity were assessed. Results: Yearly treatment patterns changed significantly from 2015 (n = 18056) to 2020 (n = 11042). The proportion of untreated patients declined over time (32.7% vs 27.7%; P < .001), the use of anti-VEGF monotherapy increased (43.5% vs 61.8%; P < .001), the use of focal laser monotherapy declined (9.7% vs 3.0%; P < .001), and the use of steroid monotherapy remained stable (0.9% vs 0.7%; P = 1.000). Of eyes that maintained follow-up for 5 years (from 2015 to 2020), 16.3% were untreated while 77.5% were treated with anti-VEGF agents (as monotherapy or combination therapy). Vision gains in treated patients remained approximately stable from 2015 (3.6 letters) to 2020 (3.5 letters). Conclusions: From 2015 to 2020, treatment patterns for DME evolved toward greater anti-VEGF monotherapy, stable steroid monotherapy, less laser monotherapy, and fewer untreated eyes.

Analysis of Posterior Vitreous Detachment and Development of Complications Using a Large Database of Retina Specialists

PURPOSE

To examine the incidence of complications after posterior vitreous detachment (PVD) through an extended follow-up period and to identify patient-specific factors associated with a greater incidence of complication.

DESIGN

Multicenter, retrospective observational study.

PARTICIPANTS

Eyes with acute PVDs between 2015 and 2019 were identified through the Vestrum Health database.

METHODS

Complications (vitreous hemorrhage, retinal break, and retinal detachment) were evaluated after acute PVD at presentation and throughout the 6-month follow-up period.

MAIN OUTCOME MEASURES

Rate of complications throughout the 6 month follow-up period after PVD and odds of complications by patient-specific factors.

RESULTS

A total of 9635 eyes were included. The rate of any complication was 25.0%, isolated vitreous hemorrhage was 13.1%, retinal breaks without detachment was 16.0%, and retinal detachment was 4.2%. The majority of each complication was noted at presentation; however, 8.0% of isolated vitreous hemorrhages, 19.2% of retinal breaks without detachment, and 25.8% of retinal detachments were first noted within the 6-month follow-up period. Men experienced a significantly higher rate of any complication than women (30.0% versus 21.7%, P < 0.001), as well as retinal breaks and retinal detachments at both presentation and within 6-month follow-up. Patients with pseudophakia experienced significantly higher rates of delayed retinal detachment than phakic eyes (odds ratio, 1.85 [1.13, 3.04], P = 0.01). Among eyes with lattice/peripheral retinal degeneration, 44.2% experienced any complication throughout the clinical course. The presence of a retinal break in the fellow eye and retinal detachment in the fellow eye was associated with a significantly increased rate of any complication at any time point (retinal break: P < 0.0001; retinal detachment: P = 0.02), as well as each individual complication within the 6 month follow-up period. Among eyes with vitreous hemorrhage at presentation, 42.0% had a concurrent or delayed retinal break and 10.5% had concurrent or delayed retinal detachments.

CONCLUSIONS

A clinically significant proportion of PVD-related complications are detected late, warranting extended follow-up, especially in higher-risk groups such as men, pseudophakic eyes, eyes with lattice/peripheral retinal degeneration, and eyes with a history of retinal breaks or detachment in the fellow eye.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Evaluating the Effect of Hypoglycemic Agents on Diabetic Retinopathy Progression

BACKGROUND AND OBJECTIVE

Newer hypoglycemics such as dipeptidyl peptidase 4 (DPP-4) inhibitors, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists have been increasingly used in diabetes. This study aimed to assess the relationship between usage of these hypoglycemic agents and effect on diabetic retinopathy (DR).

MATERIALS AND METHODS

Using the Vestrum Health Retina Database, patients with DR with 1 year follow-up after use of a hypoglycemic agent were included and stratified by agent, including no pharmacotherapy.

RESULTS

Of 60,649 eyes, in 1 year after hypoglycemic agent usage, progression rates from severe nonproliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy (PDR) were the following: DPP-4 (17%), SGLT-2 (12%), GLP-1 (21%), metformin (18%), and none (20%). Progression rates from moderate NPDR to severe NPDR or PDR were the following: DPP-4 (11%), SGLT-2 (10%), GLP-1 (11%), metformin (10%), none (13%). Progression rates from mild NPDR to moderate/severe NPDR or PDR were the following: DPP-4 (6%), SGLT-2 (9%), GLP-1 (9%), metformin (7%), and none (10%).

CONCLUSIONS

Within a large real-world database, patients prescribed GLP-1 agonists were found to have DR progression rates comparable to those of patients receiving no hypoglycemic agents. [Ophthalmic Surg Lasers Imaging Retina 2023; 54(3):158-165.].

Anaesthesia for vascular emergencies - a state of the art review

In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.

Opportunity Cost of Retinal Detachment Surgery vs Office-Based Patient Care

Purpose: This work compares physician reimbursements for retinal detachment (RD) surgery with office-based patient care. Methods: A theoretical model was constructed from the physician’s perspective for performing a 90-minute uncomplicated RD surgery with its associated perioperative work in the global period (Current Procedural Terminology code 67108) compared with managing 40 patients per 8-hour clinic day in the equivalent time period. The reimbursement rates were based on the 2019 values set by the US Centers for Medicare and Medicaid Services (CMS). Sensitivity analyses were performed varying the perioperative times, clinical productivity, and postoperative visits. Results: The CMS physician reimbursement rate for 67108 surgery was 17.13 work relative value units (wRVUs); meanwhile, the physician in the reference case could have generated 40.89 wRVUs in the office. CMS reimbursement therefore represented a 58% opportunity cost relative to lost office productivity for the physician. A significant disparity was still present even when modeling 30 patients per day. In sensitivity analyses, clinical productivity exceeded surgical compensation in 99% of modeled scenarios. In threshold analyses, the surgeon in the reference case would have to complete the surgery and all immediate perioperative care within 18 minutes to equal the total CMS valuation. Conclusions: CMS reimbursement for RD surgery resulted in a significant opportunity cost for the physician relative to office-based patient care, which was more pronounced for more efficient clinicians in the office. The sensitivity analyses supported the robustness of the model. Reductions in surgery reimbursements relative to office-based patient care might disincentivize busy clinicians.

REGIONAL POPULATION MOBILITY AND OUTPATIENT RETINA VISITS IN THE UNITED STATES DURING THE COVID-19 PANDEMIC

PURPOSE

To characterize how community mobility patterns across the United States correlate with local changes in retina visits during the pandemic.

METHODS

Outpatient retina clinic visits were linked to population mobility by combining multiple public data sets, including the Google Community Mobility Reports and data from the Centers for Disease Control and Infection. Percentage change from baseline in daily-average number of retina visits by county and mobility were measured by county.

RESULTS

A total of 2,159,689 patient visits were examined across 332 counties. Daily-average retina visits decreased by 7.0%, 19.0%, 5.0%, and 4.0% from Quarter 1 to 4 of 2020. This decrease was negatively correlated with increased incident of COVID-19 deaths for Quarters 1 to 3 (r = -0.13, r = -0.16, and r = -0.15, respectively, P < 0.001) and increased incident cases for Quarters 1 and 2 (r = -0.18, r = -0.13, respectively, P < 0.001). Daily-average retina visits relative to baseline were significantly lower for metropolitan counties in Quarters 1 and 2, compared with urban and rural (P < 0.001). The decline in retina visits had greatest association with decline in workplace visits in Quarters 1 to 3 (r = 0.27, r = 0.09, r = 0.12, respectively, P < 0.001 for all).

CONCLUSION

This study provides insight into how regional mobility patterns may help to explain and predict patient behaviors and retina outpatient visit responses during the COVID-19 pandemic.

Incidence of Retinal Artery and Vein Occlusions During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVE

To examine whether new cases of retinal artery occlusion (RAO) or retinal vein occlusion (RVO) increased during the coronavirus 209 (COVID-19) pandemic.

PATIENTS AND METHODS

This was a retrospective cohort study of patients visiting retina clinics with a new diagnosis in two time periods: between January 1, 2019, and February 29, 2020 (the pre-COVID-19 period), and between March 1, 2020, and December 31, 2020 (the COVID-19 period). The key outcome was the percentage of newly diagnosed central RAO (CRAO), branch RAO (BRAO), central RVO (CRVO), and branch RVO (BRVO) seen in each period.

RESULTS

The study population included 285,759 new patients in the pre-COVID-19 period and 156,427 new patients in the COVID-19 period. The overall number of new patients dropped dramatically during the first few months of the COVID-19 pandemic (24%, 66%, and 51% less new patients in March, April, and May 2020 than in the same months in 2019; P < .0001 for all 3 months). However, the decrease in the number of newly diagnosed patients with CRAO, CRVO, and BRAO during these months was less dramatic. As most states reopened in June and the number of patients in retina clinics started to increase, the newly diagnosed patients with these conditions as a percentage of all new diagnoses returned to similar trends as seen in the pre-COVID-19 period.

CONCLUSIONS

The percentage of new cases of RAO and RVO with respect to all new diagnoses in retina clinics remained stable for the majority of the COVID-19 period. There was an increase in these percentages during the first few months of the COVID-19 pandemic, particularly for CRAO, CRVO, and BRAO, which may have led to the presumption that more patients presented with these conditions during the COVID-19 period evaluated in this study. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:22-30.

Antivascular Endothelial Growth Factor Dosing Frequency and Visual Outcomes in Macular Edema Following Central Retinal Vein Occlusion

Purpose:

We evaluated the relationship between dosing frequency of intravitreal antivascular endothelial growth factor (anti-VEGF) agents and visual acuity (VA) outcomes over 2 years in eyes with macular edema (ME) secondary to central retinal vein occlusion (CRVO) in the US routine clinical practice setting.

Methods:

This retrospective analysis assessed electronic medical records of eyes with ME secondary to CRVO that received their first anti-VEGF injection January 1, 2012, to May 31, 2016, and were followed for 1 year or more in the US-based Vestrum Health Treatment and Outcomes database. Eyes were divided into 2 injection frequency subcohorts (≤6 or ≥7 injections/year).

Results:

Overall, 851 (34.6%) of 2458 eyes with ME secondary to CRVO received 6 or fewer injections, and 1607 (65.4%) received 7 or more injections through 1 year. The mean number of injections in patients receiving 6 or fewer injections and 7 or more injections was 4.7 and 8.8, respectively, and baseline mean VA was 35 and 37 letters, respectively. At year 1, mean letter gain from baseline was less in eyes receiving 6 or fewer injections vs in those receiving 7 or more injections (7.0 vs 12.2, P < .001). Mean VA at year 2 was 50 letters in eyes receiving 6 or fewer injections (n = 50) and 55 letters in eyes receiving 7 or more injections (n = 157).

Conclusions:

In routine clinical practice, more frequent dosing with anti-VEGF agents was associated with greater visual benefits in eyes with ME secondary to CRVO.

Rates of Suspected Endophthalmitis Following Intravitreal Injections in Clinical Practices in the United States

BACKGROUND AND OBJECTIVE

To evaluate rates of suspected endophthalmitis following intravitreal injections of aflibercept, bevacizumab, ranibizumab (vial and pre-filled), dexamethasone implant, and triamcinolone in clinical practice.

PATIENTS AND METHODS

Retrospective study of aggregated electronic medical records from the Vestrum Health Database. Eyes with a diagnosis of suspected endophthalmitis based on billing codes between January 2013 and June 2019 were included.

RESULTS

Total number of injections, suspected endophthalmitis cases, and medication rate, respectively, were: aflibercept (1,412,699; 687; 0.049%); bevacizumab (1,467,722; 379; 0.026%); ranibizumab vial (884,061; 233; 0.026%), ranibizumab pre-filled (427,763; 96; 0.022%); dexamethasone implant (49,464; 53; 0.107%); and triamcinolone (75,038; 110; 0.147%). Rates were lower for bevacizumab and ranibizumab (vial and pre-filled) compared to aflibercept, dexamethasone implant, and triamcinolone (P < .05). Triamcinolone had a higher rate compared to all of the other medications (P < .05).

CONCLUSIONS

Suspected endophthalmitis rates following anti-vascular endothelial growth factor injections in clinical practice were similar to reported rates in clinical trials. Rates of suspected endophthalmitis following steroid injections trended higher with significantly higher rates with triamcinolone. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:312-318.].

Visual Acuity Outcomes in Patients Receiving Frequent Treatment of Neovascular Age-Related Macular Degeneration in Clinical Practice

Purpose:

This work evaluates dosing frequency with intravitreal antivascular endothelial growth factor (anti-VEGF) agents over 2 years and visual acuity (VA) outcomes in neovascular age-related macular degeneration (nAMD).

Methods:

This retrospective analysis assesses electronic medical record data (Vestrum Health treatment and outcomes database) of newly diagnosed nAMD in patients who were initiated on intravitreal anti-VEGF treatment at US clinical sites. Eyes were divided into 2 injection frequency subcohorts (≤ 6 or > 6 injections/y); treatment frequency and change in mean VA (Early Treatment Diabetic Retinopathy Study letters) were evaluated.

Results:

Overall, 8127 of 213 824 eyes met inclusion criteria in year 1 and 4968 in year 2. During year 1, 77% of the eyes received more than 6 injections (n = 6287), the majority of which received injections at the same frequency during year 2. Mean VA gain from baseline at year 1 was lower in the ≤ 6 than > 6 injections/y subcohort (2.2 vs 6.5, P < .001). Decrease in mean VA from the end of year 1 to year 2 was significantly greater for eyes administered 6 or fewer injections in year 2 than those that received more frequent injections, irrespective of the frequency of injections in the first year.

Conclusions:

In routine clinical practice, most eyes with nAMD that completed at least 1 year of follow-up were treated with more than 6 injections of anti-VEGF agents during the first year of treatment, resulting in better VA gains than eyes treated less frequently during the same period.

Evaluation of Patients Receiving Intravitreal Antivascular Endothelial Growth Factor for Diabetic Macular Edema in Clinical Practice in the United States

Purpose

We assessed the effect of treatment frequency with intravitreal antivascular endothelial growth factor (anti-VEGF) agents on visual acuity (VA) in diabetic macular edema (DME).

Methods

This retrospective analysis assessed electronic medical records of eyes newly diagnosed with DME and treated with an anti-VEGF agent at US clinics using the Vestrum Health (Naperville, Illinois) treatment and outcomes database. Eyes were divided into 2 injection frequency subcohorts (≤ 6 vs > 6 injections/y); treatment frequency and change in mean VA (Early Treatment Diabetic Retinopathy Study letters) were evaluated.

Results

Among 155 240 eyes assessed, 3028 met inclusion criteria for analysis in year 1 and 1292 in year 2. During year 1 of treatment, 57% (n = 1725) received > 6 injections; most continued to receive the same injection frequency during year 2. Mean VA gain from baseline at year 1 was lower in the ≤ 6 than in the > 6 injections/year subcohort (3.7 vs 8.0 letters, respectively; P < .001). Mean VA change from the end of year 1 to year 2 for eyes receiving ≤ 6 injections in year 1 generally remained unchanged, irrespective of year 2 dosing frequency. In eyes that received > 6 injections in year 1, mean VA loss was significantly greater for eyes receiving less-frequent dosing in year 2 than in those maintained on > 6 injections.

Conclusions

More than 50% of eyes with DME in routine clinical practice that completed at least 1 year of follow-up received > 6 injections of an anti-VEGF agent during the first year, resulting in better VA gains than eyes treated less frequently.

Increasing Incidence and Prevalence of Common Retinal Diseases in Retina Practices Across the United States

BACKGROUND AND OBJECTIVE

To provide an updated estimate of incidence and prevalence of the foremost retinal diseases in the U.S.

PATIENTS AND METHODS

Retrospective study of the Vestrum Health Database evaluating eyes with diagnoses of wet or dry age-related macular degeneration (AMD), diabetic macular edema (DME), diabetic retinopathy (DR), branch or central retinal vein occlusion (BRVO; CRVO) from January 2014 to December 2019 across 58 retina practices.

RESULTS

Of the 3,086,791 eyes examined, 490,881 (15.9%) had dry AMD, 294,041 (9.5%) wet AMD, 270,703 (8.8%) DME, 254,690 (8.3%) DR without DME, 73,617 (2.4%) BRVO, and 50,670 (1.6%) CRVO. Dry AMD had the highest incidence. These diseases comprised 61.0% of total prevalence and 54.3% of incidence among patients at the retina practices analyzed.

CONCLUSIONS

Based on a diverse database, these diseases comprised the majority of U.S. retina practice cases, with increasing annual incidences. AMD is the most common diagnosis, then diabetic eye disease. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:29-36.].

A phase Ib study of oxaliplatin in combination with fluorouracil (5FU) and leucovorin (LV) in pediatric patients (pts) with advanced solid tumors

9548

Background: Platinums have significant activity in a wide variety of pediatric tumors, and oxaliplatin exhibits synergy with 5FU and LV in adults with colorectal cancer in FOLFOX regimens. The primary objectives of this study are to determine the maximum tolerated dose (MTD) of the modified FOLFOX6 regimen in pediatric tumors. Secondary objectives include safety, PK pharmacokinetic (PK) and PET scan efficacy analyses. Methods: Pts age <21 years with advanced cancers and adequate organ function are eligible. Patients are stratified by tumor type (CNS or non-CNS) to better delineate the potential neurotoxicity in patients with altered neurologic function. Pts received oxaliplatin starting at 85 mg/m2 and LV 400 mg/m2 over 2 hours on day 1 followed by a 5FU bolus of 400 mg/m2 then 2,400 mg/m2 continuous infusion over 46 hours, every 2 weeks (3 courses = 1 cycle), with integrated PK sampling in a limited dose escalation design. Standard 3+3 dose escalation, definitions of dose limiting toxicity (DLT), and dose modification for toxicity are implemented. The MTD is expanded to 15 patients to confirm and further characterize tolerability and toxicity. Results: To date, 15 very heavily pre-treated patients (7 M, 8 F) have received 25 cycles (range 1–4, median 2) of treatment at 2 dose levels. One of 8 pts at dose level 2 (oxaliplatin 100 mg/m2) developed DLT (delay in repeat treatment > 14 days due to grade 3 platelets). Treatment has been well tolerated. The most frequently reported related grade 3–4 adverse events (AEs) are reversible leukocytes (29%), neutropenia (43%), platelets (35%) and lymphopenia (21%). 31 of 90 courses (34%) have been delayed for neutropenia and thrombocytopenia. Anti-tumor activity to date includes a confirmed partial response lasting 15 weeks in a patient with osteosarcoma, and prolonged stable disease in 5 other pts with brain tumors (2), hepatoblastoma (2) and sarcoma (1). Conclusions: The modified FOLFOX6 regimen has significant but reversible myelosuppression in heavily pre-treated pediatric patients, but is tolerable and has promising activity in several tumor types. Cohort expansion continues at 100 mg/m2 of oxaliplatin. PET scan and pharmacokinetic analyses will be presented.

No significant financial relationships to disclose.

Phase I pharmacokinetic (PK) and pharmacodynamic (PD) study of 17-Allylamino-17-demethoxygeldanamycin (17AAG) in children with solid tumors

9022

Background: 17AAG is a benzoquinone ansamycin that binds to heat shock protein 90 (Hsp90) and alters levels of cancer-associated proteins that are regulated by Hsp90. 17AAG has been well-tolerated in adults, but has not previously been administered to children. Methods: A Phase I study of 17AAG was initiated to define the maximally tolerated dose and toxicity profile of this drug in children. PK and PD were also studied. Cohorts of 3–6 patients with recurrent or refractory solid tumors were treated every 21 days with escalating doses of 17AAG twice weekly for two weeks. Plasma PK of 17AAG and its major metabolite, 17AG, were measured on day 1 by HPLC. Changes in levels of the inducible isoform of Hsp70 were assessed by Western blot using peripheral blood mononuclear cells (PBMCs) obtained 24 h after the 17AAG infusion. Actin was measured for comparison. Because 17AAG is a substrate for CYP3A4/5 and MDR1, pharmacogenetic analyses have been undertaken to determine if genotypes including CYP3A4*1B, CYP3A5*3, and MDR1 G2677T/A and C3435T influence 17AAG disposition. Results: 12 pts (median age 11 years, range 5–18) with neuroblastoma (5), osteosarcoma (4), Ewing’s family tumors (2), and desmoplastic small round cell tumor (1) have been treated with 17AAG. An MTD has yet to be defined though one dose limiting toxicity (Grade 3 hypoxia) was observed at Dose Level 4 (360 mg/m2). The AUC of 17AAG increased with dose, with a linear relationship between end of infusion 17AAG plasma concentration and AUC. The AUC of 17AAG increased with dose, with a linear relationship between end of infusion 17AAG plasma concentration and AUC. Clearance ranged between 12.5 and 29.6 l/hr/m2 (median, 21.6 l/h/m2) and did not change with increasing doses. Post-treatment increases in Hsp70 in PBMCs have been observed in pts treated with 17AAG doses at or above 150 mg/m2. Declines in Akt and IGF1R in PBMCs have been seen in some but not all pts following treatment. Conclusions: 17AAG is well tolerated in children at dose levels studied to date. 17AAG dose escalation continues and at the time of the meeting, updated data will be reported.

No significant financial relationships to disclose.

A +2138InsCAGACC polymorphism of the melanocortin receptor 3 gene is associated in human with fat level and partitioning in interaction with body corpulence

BACKGROUND

The melanocortin system includes five receptors (MC1R to MC5R), and mouse and human MC4R has been shown to be involved in the regulation of feeding, and mouse MC3R in body composition. To verify a possible similar effect of MC3R in humans, we analyzed one insertion and one single nucleotide polymorphism by restriction fragment length polymorphisms (RFLP), and a microsatellite (D20S32e) in relation to body composition and glucose metabolism.

METHODS

Eight hundred twelve subjects of the Québec Family Study (QFS) cohort were analyzed for body composition, food intake, and energy metabolism phenotypes. Southern Blot with the complete MC3R cDNA was used to detect a new +2138InsCAGACC variant by Pst1 restriction. PCR-RFLP with BsaJ1 was used to type amino acid polymorphism V81I arising from a G241A nucleotide change. PCR and automatic DNA sequencers were used for the analysis of the TG dinucleotide repeat D20S32e located between -1933/-1892 of MC3R. In a covariance analysis among genotypes, phenotypes were adjusted for age and sex as covariates. Food intake and energy metabolism phenotypes were also adjusted for body mass index (BMI), and leptin and abdominal fat, as assessed by a computed tomography scan, for fatness using six skinfold thicknesses.

RESULTS

An association between the +2138InsCAGACC MC3R polymorphism was observed with fat mass (FM), percent body fat (%FAT), and total abdominal fat (ATF). Homozygote subjects for the +2138 insertion variant allele in normal weight (BMI < 25 kg/m(2)) and overweight (25 < or = BMI < 30 kg/m(2)) subjects showed a similar level of fatness despite the overall difference in BMI. In normal weight, homozygotes for the insertion allele showed higher mean values than heterozygotes and homozygotes for wild-type allele without insertion (%FAT: 24.0 +/- 1.1 versus 19.3 +/- 0.9 and 20.5 +/- 0.8, p = 0.0005; FM: 15.7 +/- 0.9 kg versus 11.7 +/- 0.7 kg and 12.6 +/- 0.6 kg, p = 0.0003). In contrast, overweight subjects homozygote for the variant allele showed lower mean values (%FAT: 27.0 +/- 1.2 versus 31.4 +/- 0.8 and 30.9 +/- 0.7, p = 0.002; FM: 18.3 +/- 1.0 kg versus 22.8 +/- 0.8 kg and 22.0 +/- 0.6 kg, p = 0.0001). This resulted in a similar level of body fat between both BMI groups for subjects homozygote for the insertion allele versus wild-type allele carriers (%FAT: +/-2-3% versus +/-10-12%; FM: +/-2 kg versus +/-9-11 kg). In obese subjects (BMI > or = 30 kg/m(2) ), a lower level of ATF was seen (-15%, p = 0.002). Other polymorphisms and phenotypes tested showed no association.

CONCLUSION

A new 12138InsCAGACC MC3R polymorphism is associated with the level of adiposity and with body fat partitioning in interaction with corpulence in humans.

Electrophysiological and behavioral output of the rat basal ganglia after intrastriatal infusion of d-amphetamine: lack of support for the basal ganglia model

Dopamine, by acting upon D1 and D2 dopamine receptors located on striatonigral and striatopallidal neurons, respectively, has been postulated to inhibit output from the substantia nigra pars reticulata (SNpr) and internal pallidal segment (GPi). The inhibition of the SNpr/GPi should, in turn, disinhibit the thalamus to facilitate movement. The present study tests this prediction in intact (unlesioned) rats by attempting to correlate changes in the single unit activities of SNpr neurons with motor (i.e. behavioral) responses in the 20-30 min after infusions of d-amphetamine into the striatum. Unilateral injections of amphetamine (20 microg/microl) into either the dorsal-rostral, central, or ventral-lateral striatum failed to appreciably alter behavior and, in parallel electrophysiological studies, failed to consistently or significantly alter the activities of SNpr neurons in either chloral hydrate-anesthetized rats or awake locally anesthetized rats. However, when amphetamine was infused bilaterally into the ventral-lateral striatum (VLS; 20 microg/microl per side), a robust behavioral activation ensued (increased locomotor activity, oral movements, and sniffing) with an onset ranging from immediate to 20 min post-infusion and persisting for at least 40 min. In parallel studies, bilateral amphetamine infusions into VLS also caused changes in the firing frequency of a majority of SNpr neurons. However, the changes in firing were extremely variable and, contrary to expectation, the net population response of SNpr neurons was an increase in firing which corresponded in time with the period of peak behavioral activation. These results show that (i) bilateral but not unilateral activation of striatal dopamine receptors is needed to elicit behavioral and electrophysiological output from the basal ganglia, and (ii) motor activation is apparently not signaled by a generalized inhibition of SNpr firing, as is predicted by the basal ganglia model.

Intratester and intertester reliability of the Cybex electronic digital inclinometer (EDI-320) for measurement of active neck flexion and extension in healthy subjects

This study examined the intratester and intertester reliability of the electronic digital goniometer EDI-320 for the measurement of active neck flexion and extension in healthy subjects. In the context of evidence-based practice, the EDI-320 instrument has the potential to improve patient assessment, provide a clearer picture of patient progress, and confirm the effectiveness of physiotherapy interventions. However, the psychometric properties of the EDI-320 have not yet been documented for cervical spine range of motion. Forty-four individuals with no known history of cervical disorder within the three months prior to the testing, voluntarily consented to participate in this study. Repeated measurements with the EDI-320 were taken by two trained testers (TH1 and TH2) and data were recorded by two separate observers. Subjects performed a standardized warm-up. Testers were required to repeat palpation of bony landmarks prior to each trial. Measurements were taken at the end-range of active cervical flexion and extension for each subject. Both testers measured each subject twice. The intraclass correlation coefficients (ICC) were derived from one-way ANOVA for intratester reliability and a two-way ANOVA for intertester reliability. Paired t -tests were then applied to verify for systematic error. Moderate intratester reliability was found for both testers for flexion (TH1: ICC=0.77; 95% CI: 0.62-0.87; TH2: ICC=0.77; 95% CI: 0.58-0.87). As for extension, high intratester reliability was found for TH1 (ICC=0.79; 95% CI: 0.65-0.88) and moderate for TH2: (ICC=0.83; 95% CI: 0.63-0.92). Intertester reliability results showed a moderate reliability for both flexion and extension (ICC=0.66; 95% CI: 0.24-0.84) on the first trial. On the second trial, reliability was moderate for flexion (ICC=0.73; 95% CI: 0.53-0.85) and high for extension (ICC=0.80; 95% CI: 0.64-0.89). The t -test analysis revealed the inclusion of systematic error by Tester 2 for intratester reliability. This error was also found for all but one of the intertester reliability calculations. This study has shown that the EDI-320 is a moderately reliable instrument for quantifying cervical flexion and extension range of motion. The presence of systematic error in the study highlights the importance of following standardized procedures and suggests that the EDI-320 could be more reliable than reported in this study. Further psychometric studies investigating the validity of the EDI and reliability with subjects affected by cervical pathology is warranted.

Development of a very sensitive luminescence assay for the measurement of paclitaxel and related taxanes

A rapid and very sensitive enzyme immunoassay was developed for the measurement of paclitaxel and related taxanes in crude extracts of Taxus sp., in human serum and in culture medium of paclitaxel-producing microorganisms such as Erwinia taxi. For the ELISA, paclitaxel was chemically modified by the introduction of an amine to enable coupling with biotin. The presence of paclitaxel or related taxanes competitively inhibited the binding of paclitaxel-biotin to anti-taxane monoclonal antibody. This method detected paclitaxel in concentrations as low as 33 pM; the affinity of the antibody was higher for paclitaxel than for cephalomanine, baccatin and DAB. The sensitivity of this assay makes it useful for estimating the paclitaxel and taxanes content of Taxus sp. extracts, monitoring the paclitaxel serum level of paclitaxel treated patients and in other biological fluids.

Expression of the GALalpha(1-3)GAL epitope on pig islets

Expression of Galalpha(1-3)Gal on endothelium has been implicated in the rejection of porcine xenografts. The aim of this study was to determine whether expression of Galalpha(1-3)Gal on pig islets varies between pigs aged 5, 12 and 24 weeks, and to investigate whether it is expressed on islets isolated by collagenase digestion or islets maintained in tissue culture. Samples of pancreas were obtained from pigs aged 5, 12 and 24 weeks. Islets were isolated by manual collagenase digestion and density gradient separation. Samples were taken immediately after isolation or after maintenance in tissue culture. Pancreas and islet samples were processed, sectioned and stained with the lectin BS1-B4 (which binds to Galalpha(1-3)Gal residues), and anti-insulin antibody using a double staining technique. There was no significant difference in the staining patterns to sections of pancreas obtained from 5, 12 and 24 week old pigs. Vascular endothelium, connective tissue and the luminal surface of duct epithelial cells stained with BS1-B4 in all sections; endocrine and exocrine cells did not stain. Preliminary experiments showed that lectin staining to isolated islets was inconsistent between preparations, but expression did not appear to differ significantly between ages: lectin staining of some beta-cells was evident in the majority of freshly isolated preparations, but was not detectable on beta-cells following tissue culture. In conclusion, expression of Galalpha(1-3)Gal did not differ significantly in pancreata from 5, 12 and 24 week old pigs. Preliminary experiments showed that Galalpha(1-3)Gal was expressed by beta-cells immediately following isolation, but not after maintenance in culture.

CD28 expression in T cell aging and human longevity

Functional decrements of the immune system have a major contribution to aging and age-related diseases. Here, we further characterize the decline in proportion of CD28-positive T cells previously identified in centenarians. Cohorts of 97 centenarians, 40 subjects aged 70-90 (ELD group), and 40 young adults (under age 40) were phenotyped for T cell surface expression of CD28, CD4, and CD8 antigens. The significant decline in T cells expressing CD28 (p < 10(-4) for comparisons between adults and either ELD or centenarians) affects preferentially the CD8+ subset of T cells. This decline accounts largely for the age-related diminution of T cell responsiveness to mitogenic signals. CD28 expression is modulated in T cell cultures in a growth-related fashion and this modulation is dampened in cultures from centenarians. We propose that the decrease in CD28 expression reflects a compensatory adaptation of the immune system during aging in the face of chronic stimulation.

[Cellular senescence and survival of T lymphocytes]

In order to study cellular senescence in T lymphocytes and its link with aging, we have undertaken long-term cultures from adult individuals (aged from 20 to 40) and centenarians. The proliferative advantage of CD4+ over CD8+ T cells is reversed after the second stimulation. Periodically stimulated cultures remained exponentially growing during nearly 200 days, whereas 2 of them that were continued for 300 days stopped proliferating. However, once this phase of senescence is reached, the cells do not die out. Six other cultures remained viable for 34 months without proliferation but with conservation of the cell number. Three of these cultures have clonal karyotypic abnormalities: trisomy 2 and telomeric fusions.

Decline in CD28+ T cells in centenarians and in long-term T cell cultures: a possible cause for both in vivo and in vitro immunosenescence

The dramatic decline in immune function with age, especially in T cell proliferative activity, has been documented extensively in experimental animal models and in clinical studies of the elderly. A similar proliferative decline is also seen in long-term T lymphocyte cultures used to study in vitro cellular senescence. We have compared the peripheral blood T lymphocytes of centenarians and younger controls for the cell surface expression of CD28, a costimulatory molecule that is required for optimal activation and proliferation following engagement of the T cell receptor. Our analysis shows a significant decrease (p < 0.001) in the percentage of T cells expressing CD28 in the elderly cohort, with values ranging from 44% to 90%, as compared to the mean control value of 91%. The decline in the percentage of CD28+ T cells correlates with a reduction in the CD4/CD8 ratio (r2 = 0.695, p < 0.0001). Concommitantly, experiments using an in vitro T cell culture system showed a progressive loss of CD28 expression with culture "age." The concordance of proliferative decline and loss of CD28 in the centenarians and in the in vitro cultures suggest that a Hayflick phenomenon may operate in vivo leading to immunosenescence.

Heat-stress stimulation of oxygen uptake by Photosystem I involves the reduction of superoxide radicals by specific electron donors

A Photosystem I submembrane fraction isolated from spinach was used to study the mechanism of heat-stress stimulation of oxygen uptake by the photosystem. Various artificial electron donors were shown to generate electron transport reactions with various degrees of thermally induced stimulation. A strong stimulation was observed with durohydroquinone as electron donor with a maximal effect at 50 °C. The degree of stimulation obtained was independent from the redox potential of the electron donors and from their oxidation site because the enzyme superoxide dismutase fully inhibited the stimulation. Instead, it is proposed that thermal stress causes the release of membrane bound superoxide dismutase from the thylakoids thus allowing the reduced form of electron donors with specific properties to reduce O2 (-) radicals to H2O2 besides the usual disproportionation of O2 (-) into O2 and H2O2.

Heat-stress stimulation of electron flow in a photosystem I submembrane fraction

Oxygen uptake using methyl viologen as the terminal electron acceptor was recorded in digitonin-derived photosystem I submembrane fractions incubated at either 25 or 50 degrees C. A two- to four-fold heat-stress stimulation of electron flow was detected at 50 degrees C when reduced 2,6-dichlorophenol-indophenol was used as the primary electron donor. However, no stimulation was seen with N,N,N',N'-tetramethylphenylenediamine as the donor. The stimulation was enhanced by specific cations (Mg2+, Na+, K+), but not by Mn2 or Ca2+. The enhancement obtained with Mg2+ could be eliminated by incubating for a prolonged period. It is proposed that the observed heat-stress stimulation is due to a conformational change at the level of the cytochrome b6-f complex. This change increased the affinity of the protein complex for 2,6-dichlorophenol-indophenol at its oxidation sites. The involvement of a conformational modification is demonstrated by the absence of heat-stress stimulation in submembrane fractions immobilized in an albumin-glutaraldehyde cross-linked matrix.