Erythropoiesis-Stimulating Agents and the Risk of Vision-Threatening Diabetic Retinopathy

PURPOSE

Animal studies have suggested that Erythropoiesis-Stimulating Agents (ESAs) may increase vascular endothelial growth factor (VEGF)-related retinopathies, but this effect is unclear in humans. This study evaluates the risk of vision-threatening diabetic retinopathy (VTDR), defined as either diabetic macular edema (DME) or proliferative diabetic retinopathy (PDR), in patients exposed to an ESA.

METHODS

Two analyses were performed. First, a retrospective matched-cohort study was designed using a de-identified commercial and Medicare Advantage medical claims database. The ESA cohort of non-proliferative diabetic retinopathy patients who were new users of an ESA from 2000 to 2022 was matched to controls up to a 3:1 ratio. Exclusion criteria included less than 2 years in the plan, history of VTDR or history of other retinopathy. Multivariable Cox proportional hazards regression with inverse proportional treatment weighting (IPTW) was used to assess the hazard of developing VTDR, DME, and PDR. The second analysis was a self-controlled case series (SCCS) evaluating the incidence rate ratios (IRR) of VTDR during 30-day periods before and after initiating an ESA.

RESULTS

After inclusion of 1502 ESA-exposed patients compared with 2656 controls, IPTW-adjusted hazard ratios found the ESA cohort had an increased hazard of progressing to VTDR (HR = 3.0 95%CI:2.3-3.8;p < .001) and DME (HR = 3.4,95%CI:2.6-4.4,p < .001), but not PDR (HR = 1.0,95%CI:0.5-2.3,p = .95). Similar results were found within the SCCS which demonstrated higher IRRs for VTDR (IRRs = 1.09-1.18;p < .001) and DME (IRRs = 1.16-1.18;p < .001), but not increased IRRs in PDR (IRR = 0.92-0.97,p = .02-0.39).

CONCLUSION

ESAs are associated with higher risks for VTDR and DME, but not PDR. Those studying ESAs as adjunctive therapy for DR should be cautious of possible unintended effects.

Real-world socioeconomic determinants of corneal crosslinking in a national cohort

PURPOSE

To characterize recent socioeconomic trends in patients with keratoconus/corneal ectasias undergoing corneal crosslinking (CXL).

SETTING

A deidentified administrative medical claims database comprised commercial and Medicare Advantage health claims from across the United States.

DESIGN

Population-based retrospective cohort study.

METHODS

This study identified 552 patients with keratoconus/corneal ectasia who underwent CXL and 2723 matched controls who did not undergo CXL based on Current Procedural Terminology coding from a U.S. national insurance claims database from 2016 to 2020. For each patient, characteristics, including sex, race, age, household net worth, education level, insurance plan type, and geographic region, were extracted. Multivariate logistic regression was conducted to determine the odds of undergoing crosslinking.

RESULTS

Age 30 years or older (odds ratio [OR], 0.34, P < .001) was associated with decreased likelihood of undergoing CXL. Sex, race, education, and patient income were not associated with odds of undergoing CXL. Patients with health maintenance organization insurance had lower odds of undergoing CXL (OR, 0.64, P = .047). Geographically, patients on the east coast (OR, 0.37, P < .001) and Lower Midwest (OR, 0.31, P < .001) had statistically lower odds of undergoing crosslinking.

CONCLUSIONS

This is the first study to identify socioeconomic determinants of CXL, and it highlights that geographic location and insurance type may limit accessibility to patients.

SGLT2 inhibitors and diabetic retinopathy progression

PURPOSE

To evaluate whether sodium-glucose co-transporter 2 (SGLT2) inhibitors affect progression of non-proliferative diabetic retinopathy (NPDR) compared to standard of care.

METHODS

A retrospective cohort study compared subjects enrolled in a commercial and Medicare Advantage medical claims database who filled a prescription for a SGLT2 inhibitor between 2013 and 2020 to unexposed controls, matched up to a 1:3 ratio. Patients were excluded if they were enrolled for less than 2 years in the plan, had no prior ophthalmologic exam, had no diagnosis of NPDR, had a diagnosis of diabetic macular edema (DME) or proliferative diabetic retinopathy (PDR), had received treatment for vision-threatening diabetic retinopathy (VTDR), or were younger than 18 years. To balance covariates of interest between the cohorts, an inverse probability treatment weighting (IPTW) propensity score for SGLT2 inhibitor exposure was used. Multivariate Cox proportional hazard regression modeling was employed to assess the hazard ratio (HR) for VTDR, PDR, or DME relative to SGLT2 exposure.

RESULTS

A total of 6065 patients who initiated an SGLT2 inhibitor were matched to 12,890 controls. There were 734 (12%), 657 (10.8%), and 72 (1.18%) cases of VTDR, DME, and PDR, respectively, in the SGLT2 inhibitor cohort. Conversely, there were 1479 (11.4%), 1331 (10.3%), and 128 (0.99%) cases of VTDR, DME, and PDR, respectively, among controls. After IPTW, Cox regression analysis showed no difference in hazard for VTDR, PDR, or DME in the SGLT2 inhibitor-exposed cohort relative to the unexposed group [HR = 1.04, 95% CI 0.94 to 1.15 for VTDR; HR = 1.03, 95% CI 0.93 to 1.14 for DME; HR = 1.22, 95% CI 0.89 to 1.67 for PDR].

CONCLUSION

Exposure to SGLT2 inhibitor therapy was not associated with progression of NPDR compared to patients receiving other diabetic therapies.

Visit Adherence and Visual Acuity in Study of COmparative Treatments for REtinal Vein Occlusion 2 (SCORE2)

PURPOSE

We quantify the association between visit adherence and visual acuity (VA) in retinal vein occlusions (CRVO).

METHODS

The SCORE2 protocol included a visit every 4 weeks (every 28-35 days) during the first year. Visit adherence was measured as follows: number of missed visits, average and longest (avg and max days) visit interval, and average and longest (avg and max missed days) and unintended visit interval. Avg and max missed days were categorized as on time (0 days), late (>0-60 days), and very late (>60 days). The primary outcome was a change in the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity letter score (VALS) between baseline study visit and last attended visit during Year 1, using multivariate linear regression models controlling for numerous demographic and clinical factors.

RESULTS

After adjustment, for each visit missed, patients lost 3.0 letters (95% CI: -6.2, 0.2) of vision (p = .07). On average, the 48 patients who missed at least 1 visit lost 9.4 letters (95% CI: -14.4, -4.3, p < .001) of vision after adjustment. Average days and maximal intervals between visits were not associated with changes in VALS (p > .22) for both comparisons. However, when a visit was missed, the average missed days between missed visits and the max missed interval were both associated with loss of VALS (both variables: 0 days missed as reference, late [1-60 days] -10.8 letters [95% CI: -16.9, -4.7], very late [>60 days] -7.3 letters [95% CI: -14.5, -0.2]; p = .003 for both).

CONCLUSIONS

Visit adherence is associated with VALS outcomes in CRVO patients.

Risk Factors for Chalazion Diagnosis and Subsequent Surgical Excision

PURPOSE

To identify factors associated with chalazion diagnosis and surgical excision.

METHODS

Patients with an incident chalazion diagnosis from 2002 to 2019 were compared 1:5 with matched controls. Multivariable logistic regression was performed to identify variables associated with diagnosis and surgical excision.

RESULTS

Chalazion patients (n = 134,959) and controls (678,160) were analyzed. Risk factors for diagnosis included female sex, non-white race, northeast location, conditions affecting periocular skin and tear film (blepharitis, meibomian gland dysfunction, rosacea, pterygium), non-ocular inflammatory conditions (gastritis, inflammatory bowel disease, sarcoidosis, seborrheic dermatitis, Graves' disease), and smoking (p < .001 for all comparisons). Thirteen percent of patients with chalazion underwent subsequent surgical excision. Diabetes and systemic sclerosis diagnoses decreased odds of diagnosis (p < .001). Male sex, rosacea diagnosis, Black and Hispanic race, antibiotic use, and doxycycline use increased odds of surgery (p < .001).

CONCLUSION

Female sex, non-white race, conditions affecting periocular skin and the tear film, several non-ocular inflammatory conditions, and smoking were risk factors for chalazion diagnosis. Male sex, rosacea diagnosis, Black and Hispanic race, antibiotic use, and doxycycline use were risk factors for surgical intervention for chalazion. Our results prompt further study of these variables and their relationship to chalazion diagnosis to understand physiology and improve clinical outcomes. Furthermore, the results of this study suggest early recognition and treatment of concomitant rosacea may serve an important role in the management of chalazion and in the prevention of surgical intervention.

The association of stroke with herpes zoster ophthalmicus

BACKGROUND/OBJECTIVES

Studies have reported an association between herpes zoster ophthalmicus (HZO) and stroke. We sought to validate this association with rigorous controls for both medical comorbidities and social factors using a nationwide U.S. administrative medical claims database.

SUBJECTS/METHODS

A two-step approach was taken: first a retrospective case-control study was performed, followed by a self-controlled case series (SCCS). For the case control study, cox proportional hazard regression with inverse proportional treatment weighting assessed the hazard for stroke. In the SCCS, incidence of stroke was compared prior to and after the diagnosis of HZO.

RESULTS

For the case-control study, 25,720 cases and 75,924 controls met our eligibility criteria. 1712 (6.7%) and 4544 (6.0%) strokes occurred in the case and control groups respectively, conferring an 18% increased risk of stroke in the observed 1-year post-HZO period (HR = 1.18, 95% CI: 1.12-1.25, p < 0.001). SCCS analysis showed the risk for stroke was highest in the month immediately after HZO episode compared to any other time range (1-30 days after, relative risk 1.58, p < 0.001) and even higher when assessing time more distal time points prior to the HZO diagnosis (days 1-30 after HZO diagnosis had RR = 1.69 (95% CI: 1.38-2.07) and RR = 1.93 (95% CI: 1.55-2.39) compared with days -120 to -91 and -150 to -121 prior to index, respectively (p < 0.001).

CONCLUSIONS

After accounting for stroke risk factors, our analysis confirms the association between HZO and stroke, with highest risk in the immediate month after an episode.

Systemic disease associations with angioid streaks in a large healthcare claims database

BACKGROUND/OBJECTIVES

To assess systemic associations of angioid streaks (AS) using a large US healthcare database.

SUBJECTS/METHODS

A retrospective cross-sectional study was conducted of patients diagnosed with AS in a large, national US insurer from 2000-2019. Cases were matched 1:5 to controls. The prevalence rates of established associated disease states and other systemic diseases were calculated and compared using logistic regression. Additionally, the rate of anti-VEGF treatment was assessed as a proxy for the incidence of choroidal neovascularization (CNV).

RESULTS

One thousand eight hundred fifty-two cases of AS and 9028 matched controls were included. The rates of association between AS and the well-characterized conditions included: Pseudoxanthoma elasticum (PXE)-228 patients (12.3%), Ehlers-Danlos syndrome-18 patients (1.0%), Paget's disease-6 patients (0.3%), hemoglobinopathies-30 patients (1.6%), and idiopathic-1573 patients (84.9%). There was a statistically higher prevalence of the following less classically associated diseases among patients with AS compared to controls: hereditary spherocytosis (1.7% vs. 0.6%, p < 0.001), connective tissue disease (1.0% vs 0.3%, p < 0.001) and non-exudative age-related macular degeneration (33.9% vs 10.6%, p < 0.001). Among 1442 eligible cases analyzed, 427 (29.6%) received at least 1 anti-VEGF injection with 338 (23.4%) patients having the injection after their AS diagnosis.

CONCLUSIONS

In the largest collection of AS patients to date, the classical teaching of systemic disease associations occur at rates far, far lower than previously reported. The association of AS with other less reported diseases highlights new potential associations and may contribute to the understanding of AS formation.

Dual-Energy X-Ray Absorptiometry Scan Utilization and Skeletal Fragility Among Non-Infectious Uveitis Patients Exposed to Oral Glucocorticoids

INTRODUCTION

Currently, little is known regarding bone health surveillance for glucocorticoid-exposed non-infectious uveitis (NIU) patients or their baseline risks of skeletal fragility outcomes.

METHODS

Using claims data, we calculated rates of dual-energy x-ray absorptiometry (DXA) screening for glucocorticoid-exposed NIU and rheumatoid arthritis (RA) patients. Separately, we compared risks of skeletal fragility metrics amongst NIU patients, RA patients, and controls, independent of glucocorticoid use.

RESULTS

The adjusted hazard ratio (aHR) of NIU patients to have a DXA scan was 0.64 (95% CI, 0.63-0.65; p < .001) compared to RA patients. The aHR for any skeletal fragility outcome amongst NIU patients was 0.97 (p < .02) compared to normal controls, while RA patients had excess risk (aHR, 1.15; p < .001).

CONCLUSIONS

NIU patients are 36% less likely to receive a DXA scan after high-dose glucocorticoid exposure compared with RA patients. No elevated risk of osteoporosis for NIU patients was found compared to normal controls.

Association of Proton Pump Inhibitor/Histamine-2 Blocker Use and Ocular Toxoplasmosis: Findings from a Large US National Database

OBJECTIVE

To test the hypothesis that the use of proton pump inhibitors (PPIs) is associated with an increased risk of being diagnosed with toxoplasmic retinochoroiditis.

DESIGN

Retrospective, matched case-control study using data from 2000 to 2020.

PARTICIPANTS

Patients with ocular toxoplasmosis and controls were matched 5:1 for age, sex, and race, with the eligibility date ± 3 months from the index date of exposed match. Patients aged < 18 years with congenital toxoplasmosis, having < 2 years in the insurance plan before the index date, and without ≥ 1 visit to an eyecare provider before the index date were excluded from the study.

METHODS

Patients with ocular toxoplasmosis were identified using the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes, and PPI use or diseases highly associated with PPIs were identified using national drug codes from an administrative medical claims database.

MAIN OUTCOME MEASURES

The primary outcome was defined as having a prescription for a PPI or histamine-2 (H2) blocker. Multivariable logistic regression analyses were performed, controlling for demographic and systemic health variables.

RESULTS

A total of 4069 cases and 19 177 controls met the eligibility criteria. Of the 4069 patients with ocular toxoplasmosis, 989 (24.3%) were on PPI/H2 blockers compared with 3763 of 19 177 (19.2%) controls. The adjusted logistic regression model demonstrated 1.28 greater odds of PPI/H2 blocker use in cases of ocular toxoplasmosis than matched controls (95% confidence interval, 1.17-1.40; P < 0.001).

CONCLUSIONS

Proton pump inhibitor/H2 blocker exposure was associated with an increased risk of being diagnosed with ocular toxoplasmosis, corroborating findings from a prior case series.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Glucagon-like peptide 1 receptor agonist use is associated with reduced risk for glaucoma

BACKGROUND/AIMS

Glucagon-like peptide-1 receptor (GLP-1R) agonists regulate blood glucose and are commonly used to treat type 2 diabetes mellitus. Recent work showed that treatment with the GLP-1R agonist NLY01 decreased retinal neuroinflammation and glial activation to rescue retinal ganglion cells in a mouse model of glaucoma. In this study, we used an insurance claims database (Clinformatics Data Mart) to examine whether GLP-1R agonist exposure impacts glaucoma risk.

METHODS

A retrospective cohort of patients who initiated a new GLP-1R agonist was 1:3 age, gender, race, classes of active diabetes medications and year of index date matched to patients who initiated a different class of oral diabetic medication. Inverse probability of treatment weighting (IPTW) was used within a multivariable Cox proportional hazard regression model to test the association between GLP-1R agonist exposure and a new diagnosis of primary open-angle glaucoma, glaucoma suspect or low-tension glaucoma.

RESULTS

Cohorts were comprised of 1961 new users of GLP-1R agonists matched to 4371 unexposed controls. After IPTW, all variables were balanced (standard mean deviation <|0.1|) between cohorts. Ten (0.51%) new diagnoses of glaucoma were present in the GLP-1R agonist cohort compared with 58 (1.33%) in the unexposed controls. After adjustment, GLP-1R exposure conferred a reduced hazard of 0.56 (95% CI: 0.36 to 0.89, p=0.01), suggesting that GLP-1R agonists decrease the risk for glaucoma.

CONCLUSIONS

GLP-1R agonist use was associated with a statistically significant hazard reduction for a new diagnosis of glaucoma. Our findings support further investigations into the use of GLP-1R agonists in glaucoma prevention.

Association of Treatment Type and Loss to Follow-up With Tractional Retinal Detachment in Proliferative Diabetic Retinopathy

Importance

The association of proliferative diabetic retinopathy (PDR) interventions of panretinal photocoagulation (PRP) and intravitreal injections (IVIs) with tractional retinal detachment (TRD) is unclear.

Objectives

To determine whether different treatment types or a 6-month or longer period of loss to follow-up (LTFU) is associated with TRD.

Design, Setting, and Participants

This nested case-control study included data from January 1, 2000, to June 30, 2021, of patients with PDR. Those who progressed to TRD were matched to non-TRD controls up to a 5:1 ratio. Exclusion criteria included 2 or fewer years in the plan, history of nondiabetic retinopathy, vitreous hemorrhage, previous RD, or any other surgically indicated diagnosis. Patient data were obtained from a deidentified commercial and Medicare Advantage medical claims database. Statistical analysis was performed from January to May 2022.

Exposures

Primary exposures of interest were prior treatment (PRP, IVI, both) and any period of 6 months or longer in which the patient received no eye care.

Main Outcomes and Measures

Odds ratios (ORs) of IVI only compared with PRP and 6-month or longer LTFU on development of TRD.

Results

After application of inclusion and exclusion criteria, a total of 214 patients (mean [SD] age, 55.6 [12.4] years; 115 female [53.7%]) with PDR and TRD were matched to 978 controls (mean [SD] age, 65.6 [11.3] years; 507 female [51.8%]) with only PDR. Among patients with TRD, 69 (32.2%) were treated with laser only, 17 (7.9%) were treated with injection only, 39 (18.2%) were treated with both, and 89 (41.6%) had no prior treatment. Among patients in the PDR-only group, 207 (21.2%) received laser only, 83 (8.5%) received injection only, 57 (5.8%) received both, and 631 (64.5%) received no treatment. After adjusted analysis, no difference in odds of TRD for patients who received injection only compared with patients who received laser only was found (adjusted OR [aOR], 0.56; 95% CI, 0.27-1.14). Patients who received both treatments had higher odds of TRD compared with those who received laser only (aOR, 2.33; 95% CI, 1.21-4.48), and patients who had no treatment had lower odds of TRD (aOR, 0.46; 95% CI, 0.29-0.71; P < .001 for treatment category). Similarly, no difference was seen in the odds of TRD between those with LTFU for 6 months or longer and those without LTFU (aOR, 0.72; 95% CI, 0.49-1.07; P = .11).

Conclusions and Relevance

Results of this case-control analysis suggest that there is no increased risk of TRD associated with IVI-only treatment or with 6-month or longer periods of LTFU, which supports the findings of other investigations. Nonetheless, LTFU rates continue to remain high in patients with PDR, which can contribute to substantial vision loss regardless of treatment regimen.

Recent Practice Patterns in Acute Retinal Artery Occlusions in the United States

PURPOSE

To determine how to practice patterns for work-up of incident retinal artery occlusion (RAO) compare to the American Academy of Ophthalmology (AAO) guidelines.

METHODS

In this cohort study, patients receiving a new diagnosis of RAO, either central (CRAO) or branch (BRAO), were identified between 2002 and 2020 from a large US medical claims database. Claims were reviewed for diagnostic tests specified by the AAO as essential components of an RAO work-up including carotid ultrasound, echocardiogram, magnetic resonance imaging (MRI) and emergency department (ED) referral. Outcomes included rates of and time to completion of work-up.

RESULTS

18697 new outpatient diagnoses of RAO (11348 BRAO, 7349 CRAO) were analyzed. 15.9% and 30.4% of patients received carotid ultrasounds within 7 and 30 days, respectively. 9.4% and 21.1% of patients received echocardiograms within 7 and 30 days, respectively. 4.9% and 8.1% of patients received a brain MRIs within 7 and 30 days, respectively. Only 4.1% of patients were referred to the ED within a day of diagnosis. Ophthalmologists diagnosed the majority (78.7%) of RAOs compared to neurologists (0.6%). Patients diagnosed by ophthalmologists were significantly more likely to have carotid ultrasound within 7 days, but those diagnosed by neurologists were more likely to have echocardiogram, MRI, and ED referral (p < .01 for all comparisons). The rates of adherence to the AAO care guidelines increased significantly between 2002 and 2020 (p < .01).

CONCLUSIONS

The referral and work-up practices demonstrated in this new RAO diagnosis patient cohort have improved with time but are still far below the standard recommended by the AAO.

Fibroblast Growth Factor Receptor Inhibitor–Associated Multifocal Serous Retinal Detachments: A Case Report

Purpose:

This report aims to describe a case of bilateral, multifocal neurosensory retinal detachments that developed during erdafitinib therapy for metastatic urothelial carcinoma.

Methods:

A case report with color fundus imaging and spectral-domain optical coherence tomography imaging is presented.

Results:

A 50-year-old man with metastatic urothelial carcinoma had an unremarkable baseline ophthalmic examination prior to starting erdafitinib. At 3-month follow up, an examination revealed bilateral, multifocal retinal detachments. Because the patient was asymptomatic and erdafitinib was the only drug to which his tumor had responded, he was kept on the medication with close ophthalmic monitoring.

Conclusions:

Erdafitinib, a fibroblast growth factor receptor inhibitor, can cause bilateral, multifocal retinal detachments. Continuation of erdafitinib may be considered in patients without significant visual impairment when the overall benefit of the medication appears to outweigh the risks.

Association of Fenofibrate Use and the Risk of Progression to Vision-Threatening Diabetic Retinopathy

Importance

Diabetic retinopathy (DR) may progress from nonproliferative DR (NPDR) to vision-threatening DR (VTDR). Studies have investigated fenofibrate use as a protective measure with conflicting results, and fenofibrate is not typically considered by ophthalmologists in the management of DR currently.

Objective

To assess the association between fenofibrate use and the progression from NPDR to VTDR, proliferative DR (PDR), or diabetic macular edema (DME).

Design, Setting, and Participants

This multicenter cohort study used medical claims data from a large US insurer. Cohorts were created from all patients with NPDR 18 years or older who had laboratory values from January 1, 2002, to June 30, 2019. Exclusion criteria consisted of any previous diagnosis of PDR, DME, proliferative vitreoretinopathy, or treatment used in the care of VTDR. Patients were also excluded if they had a diagnosis of VTDR within 2 years of insurance plan entry, regardless of when NPDR was first noted in the plan.

Exposures

Fenofibrate use.

Main Outcomes and Measures

The main outcomes were a new diagnosis of VTDR (a composite outcome of either PDR or DME) or DME and PDR individually. A time-updating model for all covariates was used in multivariate Cox proportional hazard regression to determine hazards of progressing to an outcome. Additional covariates included NPDR severity scale, systemic illnesses, demographics, kidney function (based on estimated glomerular filtration rate level), hemoglobin A1c, hemoglobin, and insulin use.

Results

A total of 5835 fenofibrate users with NPDR at baseline (mean [SD] age, 65.3 [10.4] years; 3564 [61.1%] male; 3024 [51.8%] White) and 144 417 fenofibrate nonusers (mean [SD] age, 65.7 [12.3] years; 73 587 [51.0%] male; 67 023 [46.4%] White) were included for analysis. Of these, 27 325 (18.2%) progressed to VTDR, 4086 (2.71%) progressed to PDR, and 22 750 (15.1%) progressed to DME. After controlling for all covariates, Cox model results showed fenofibrates to be associated with a decreased risk of VTDR (hazard ratio, 0.92 [95% CI, 0.87-0.98]; P = .01) and PDR (hazard ratio, 0.76 [95% CI, 0.64-0.90]; P = .001) but not DME (hazard ratio, 0.96 [95% CI, 0.90-1.03]; P = .27).

Conclusions and Relevance

In this study, fenofibrate use was associated with a decreased risk of PDR and VTDR but not DME alone. These findings support the rationale for additional clinical trials to determine if these associations may be representative of a causal relationship between fenofibrate use and reduced risk of PDR or VTDR.

The association of stroke with central and branch retinal arterial occlusion

OBJECTIVES

To determine the near-term risk of stroke following a retinal artery occlusion (RAO).

METHODS

The risk of stroke was assessed in two manners; with a self-controlled case series (SCCS) and a propensity score (PS) matched cohort study using a US medical claims database. The date of RAO diagnosis was assigned as the index date. In the SCCS, incidence of stroke was compared in 30- and 7-day periods pre- and post-index date. In PS analysis, matched cohorts were created from patients with RAO or hip fracture. Cox proportional hazard regression assessed the hazard for stroke. Patients were censored at 1 year, upon leaving the insurance plan or if they had a qualifying event for the comparison group.

RESULTS

The SCCS included 16,193 patients with RAO. The incidence rate ratio (IRR) of new stroke in the month after RAO was increased compared to all periods >2 months before and all months after the index date (IRRs: 1.68-6.40, p < 0.012). Risk was increased in the week immediately following the index date compared to most weeks starting 2 weeks prior to and all weeks immediately after the index date (IRRs: 1.93-29.00, p < 0.026). The PS study analysed 18,213 propensity-matched patients with RAO vs. hip fracture. The HR for having a stroke after RAO compared to a hip fracture was elevated in all analyses (All RAO HR: 2.97, 95% CI: 2.71-3.26, p < 0.001; CRAO HR: 3.24, 95% CI: 2.83-3.70, p < 0.001; BRAO HR: 2.76, 95% CI: 2.43-3.13, p < 0.001).

CONCLUSIONS

The highest risk for stroke occurs in the days following a CRAO or BRAO, supporting guidelines suggesting immediate referral to a stroke centre upon diagnosis.

Statin Use and the Risk of Progression to Vision Threatening Diabetic Retinopathy

PURPOSE

This study aims to assess the effect of statins on progression from nonproliferative diabetic retinopathy (NPDR) to vision-threatening diabetic retinopathy (VTDR), proliferative diabetic retinopathy (PDR) or diabetic macular edema (DME).

METHODS

Two cohort studies using a U.S. medical claims database from 2002 to 2019 including NPDR patients 18 years or older. A risk factor analysis performed a time-updating cox regression model assessing statin usage. A second new-user active comparator design analysis replicating a previously published study. Main outcomes included a new diagnosis of VTDR (composite of either PDR or DME) or DME and PDR individually for the risk factor study and included additional outcomes of new DR, NPDR, vitreous hemorrhage (VH) and tractional retinal detachment (TRD) for the new user study.

RESULTS

Risk factor analysis included 66 617 statin users with NPDR at baseline and 83 365 nonstatin users. Of these, 27 325 (18.2%) progressed to VTDR, 4086 (2.71%) progressed to PDR, and 22 750 (15.1%) progressed to DME. After multivariable analysis, no protective effect of statin use was found for progression to VTDR, PDR, or DME (HR = 1.01-3, p >0.33 for all comparisons). Replicated new user design analysis also showed no protective effect for statins on risk of development of DR (HR = 1.03, 95% CI: 0.99-1.07, p = 0.13), PDR (HR = 0.89, 95% CI: 0.79-1.02, p = 0.09), DME (HR = 0.94, 95% CI: 0.86-1.03, p = 0.21), VH (HR = 1.00, 95% CI: 0.86-1.16, p = 0.99), and TRD (HR = 1.11, 95% CI: 0.89-1.38, p = 0.36).

CONCLUSION

Statin use was found not to be protective for progression of DR regardless of study methodology. These results suggest that the specifics of the population studied rather than differing study methodology are important in assessing the effect of statins on DR progression.

Board Certification Is Associated With a Reduced Risk of Endophthalmitis After Intravitreal Injections

Purpose:

This work investigates associations between physician qualifications and the risk of postintravitreal injection endophthalmitis.

Methods:

This retrospective analysis of data from medical claims studied Medicare beneficiaries undergoing 1 or more intravitreal injections between January 1, 2013, and December 31, 2017. Logistic regression analysis was performed to assess whether board certification status or retina subspecialty training was associated with lower risk of postinjection endophthalmitis, controlling for patient's age, race, and sex, type of agent injected, diagnosis, and year of injection. The main outcome measure was odds ratio (OR) of receiving a diagnosis of endophthalmitis in the 14 days after intravitreal injection. Clinical outcome and quality of care were not evaluated in this study.

Results:

A total of 2 907 324 intravitreal injections were performed on 219 640 patients by 4315 ophthalmologists, 3196 (74%) of whom were retina specialists and 4021 (92%) of whom were certified by the American Board of Ophthalmology (ABO). Overall, there were 1088 (0.037%) cases of postinjection endophthalmitis, of which 1024 (0.037%) were injected by ABO-certified ophthalmologists and 64 (0.050%) by non–board-certified ophthalmologists. Injections by ABO-certified ophthalmologist had 28% reduced odds of endophthalmitis (OR = 0.72; 95% CI, 0.523-0.996, P = .05). Higher odds of endophthalmitis were observed for corticosteroid injections (OR = 3.91; 95% CI, 2.75-5.56, P < .001) and aflibercept injections (OR = 1.47; 95% CI, 1.19-1.80, P < .001). Patients' sex and race, the diagnosis associated with the injection, and providers' retina subspeciality training were not associated with the rate of endophthalmitis ( P < .20 for all comparisons).

Conclusions:

We found evidence that endophthalmitis may be reduced when ABO-certified physicians perform an intravitreal injection.

Angiotensin Converting Enzyme-Inhibitors and Incidence of Non-infectious Uveitis in a Large Healthcare Claims Database

PURPOSE

To determine if angiotensin converting enzyme-inhibitors (ACE-I) alter the incidence of non-infectious uveitis (NIU).

METHODS

Patients in a large healthcare claims database who initiated ACE-I (n = 695,557) were compared to patients who initiated angiotensin receptor blockers (ARB, n = 354,295). A second comparison was also made between patients who initiated ACE-I (n = 505,958) and those who initiated beta-blockers (BB, n = 538,109). The primary outcome was incident NIU defined as a first diagnosis code for NIU followed by a second instance of a NIU code within 120 days. For the secondary outcome, a corticosteroid prescription or code for an ocular corticosteroid injection within 120 days of the NIU diagnosis code was used instead of the second NIU diagnosis code. Data were analyzed using Cox regression modeling with inverse probability of treatment weighting (IPTW). Sub-analyses were performed by anatomic subtype.

RESULTS

When comparing ACE-I to ARB initiators, the hazard ratio (HR) for incident NIU was not significantly different for the primary outcome [HR = 0.95, 95% Confidence Interval (CI): 0.85-1.07, P = .41] or secondary outcome [HR = 0.96, 95% CI: 0.86-1.07, P = .44]. Similarly, in the ACE-I and BB initiators comparison, the HR for incident NIU was not significantly different comparing ACE-I and BB initiators for either outcome definition or any of the NIU anatomical subtypes.

CONCLUSION

Our results suggest there is no evidence that ACE-I have a protective effect on NIU.

Challenges in Elucidating Ophthalmology's Standards of Care: A Review

Importance

Defining a standard of care is difficult, and physicians don't always agree on what it means in specific contexts. This is, in part, owing to constantly changing treatment patterns; but at the same time, the underlying framework that determines standards of care is continuously evolving. This situation presents clear challenges for all practicing physicians, including ophthalmologists.

Observations

Complicating the issue of defining a standard of care are the confusing origins and lexicon used to describe 3 related yet distinct ideas: standard of care, practice guidelines, and gold standards. Indeed, each of these terms is defined and influenced by many stakeholders both inside and outside the health care system. The term standard of care is one example that, although used frequently as a medical term, is often decided by courts and industry. Ophthalmology itself has provided one of the most influential cases in standard-of-care law history (Helling v Carey), which standardized the routine use of tonometry after the plaintiff lost vision because of a delayed glaucoma diagnosis. But even the courts' current view of standard of care is far different than it was at that defining moment in eye care history.

Conclusions and Relevance

Today, health care professionals typically equate standard of care with best clinical practices, and yet the law specifies a standard of minimal competence when determining standard of care. These competing definitions are, at best, misleading and, at worst, counterproductive. This narrative review examines how medical guidelines are developed, formalized, communicated, and adopted in the United States. It seeks to clarify ophthalmologists' understanding of the related but distinct ideas of standard of care, practice guidelines, and gold standards. Last, this review argues that quality of care must be distinguished from standard of care and outlines how legal definitions of standards of care can set exceedingly low benchmarks, discouraging innovation without reducing frivolous litigation.

Risk of non-infectious uveitis or myasthenia gravis in patients on checkpoint inhibitors in a large healthcare claims database

AIM

To determine if checkpoint inhibitors (CPIs) confer an increased risk of non-infectious uveitis or myasthenia gravis (MG) compared to patients on non-checkpoint inhibitor (N-CPI) chemotherapy.

METHODS

A retrospective cohort study was performed comparing patients in a large commercial and Medicare advantage database exposed to CPI compared to N-CPI. All patients who initiated a CPI (ipilimumab, pembrolizumab, nivolumab, atezolizumab, avelumab, cemiplimab and durvalumab) were eligible. Date of earliest CPI in the exposure group and N-CPI chemotherapy in the comparator group was considered the index date. Exclusion occurred in both cohorts for any history of uveitis or MG diagnosis and having <1 year in the insurance plan prior to the index date, and <6 months in plan following the index date. Every exposed patient was matched up to 1:10 based on demographics and index year to patients on N-CPI chemotherapy. Multivariate Cox proportional hazards regression modelling was performed.

RESULTS

For evaluation of incidence of non-infectious uveitis, 26 (0.3%) of 8678 patients on CPI and 123 (0.2%) of 76 153 N-CPI comparators were found to have non-infectious uveitis. After multivariate analysis, CPIs showed an increased hazard for uveitis compared to N-CPI (HR=2.09; 95% CI 1.36 to 3.22, p=0.001). For the MG analysis, 11 (0.1%) of 9210 patients developed MG in the CPI group and 36 (0.04%) of 80 620 comparators. The CPI cohort had a higher hazard of developing MG (HR=2.60; 95% CI 1.34 to 5.07, p=0.005) compared to controls in multivariate analysis.

CONCLUSIONS

Exposure to CPI confers a higher risk for non-infectious uveitis and MG compared to N-CPI chemotherapy.

Hypercoagulability Testing and Hypercoagulable Disorders in Young Central Retinal Vein Occlusion Patients

PURPOSE

To determine frequency of hypercoagulability testing and hypercoagulable states in patients with central retinal vein occlusion (CRVO) younger than 50 years.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Deidentified patients younger than 50 years with newly diagnosed CRVO from a national insurance claims database.

METHODS

The de-identified Clinformatics Data Mart Database (Optum) containing medical claims from a commercial and Medicare Advantage insurance database was used. All outpatient medical claims (office visits, associated diagnoses, and laboratory testing) and demographic data for each beneficiary during their enrollment were accessible.

MAIN OUTCOME MEASURES

Prevalence of (1) laboratory hypercoagulable workup within 90 days of CRVO diagnosis, (2) new diagnosis of a hypercoagulable state within 1 year of CRVO diagnosis, and (3) diagnosis of hypertension, diabetes mellitus (DM), and hyperlipidemia.

RESULTS

One thousand one hundred eighty-one patients met inclusion criteria. Six hundred seventy-one patients (56.8%) were men, 450 patients (38.1%) had undergone hypercoagulable testing within 90 days, and 136 patients (11.5%) were diagnosed with a hypercoagulable state within 1 year after CRVO diagnosis. This proportion was similar between those patients with DM, hypertension, or hyperlipidemia (10.5% [65/620]) and those without (12.7% [71/561]; P = 0.28). Of the 136 patients diagnosed with a hypercoagulability state, 68.4% (93/136) had undergone testing within 90 days of CRVO diagnosis and 31.6% (43/136) did not. Of those who had not undergone hypercoagulability testing, 5.9% (43/731) were diagnosed with a hypercoagulable state within 1 year compared with 20.7% (93/450) in those who were tested (P < 0.001).

CONCLUSIONS

The prevalence of a hypercoagulable state within 1 year of CRVO diagnosis in patients younger than 50 years was 11.5%, and the prevalence was similar between patients with atherosclerotic risk factors and those without. Rate of testing was only 38.1%. Future research should examine the usefulness of uniform hypercoagulable testing in young CRVO patients.

SYSTEMIC MEDICATION USE AND THE INCIDENCE AND GROWTH OF GEOGRAPHIC ATROPHY IN THE COMPARISON OF AGE-RELATED MACULAR DEGENERATION TREATMENTS TRIALS

PURPOSE

To determine associations of systemic medications with the incidence and growth of geographic atrophy (GA) in participants of the comparison of age-related macular degeneration treatments trials.

METHODS

Participants of comparison of age-related macular degeneration treatments trials with new untreated choroidal neovascularization in the study eye (one study eye per participant) were randomized to receive treatment with bevacizumab or ranibizumab. Participants were released from clinical trial treatment at 2 years and examined at approximately 5 years. Color fundus photographs and fluorescein angiograms taken at baseline, Years 1, 2, and 5 were assessed for the presence and size of GA by two masked graders. Participants were interviewed about systemic medication use at baseline. Systemic medications previously reported to be associated with age-related macular degeneration were evaluated for associations with GA incidence in study eye using univariable and multivariable Cox models and for association with the GA growth using linear mixed effects models.

RESULTS

In multivariable analysis of 1,011 study eyes without baseline GA, systemic medications, including cholinesterase inhibitors, angiotensin-converting enzyme inhibitors, calcium channel blockers, beta-blockers, diuretics, aspirin, steroids, statins, hormone replacement therapy, antacids, and drugs targeting G protein-coupled receptors, were not associated with GA incidence in the study eye (all adjusted hazard ratios ≤1.86, P ≥ 0.18). In multivariable analysis of 214 study eyes with longitudinal GA size measurements, calcium channel blockers were associated with a higher GA growth rate (0.40 vs. 0.30 mm/year, P = 0.02).

CONCLUSION

None of the systemic medications analyzed were associated with GA incidence. However, calcium channel blockers were associated with a higher growth rate of GA in the study eye.

Decreased risk of non-infectious anterior uveitis with statin therapy in a large healthcare claims database

PURPOSE

The purpose of this study is to determine if statin therapy decreases the incidence of non-infectious uveitis (NIU) using a retrospective cohort study.

METHODS

Patients enrolled in a national insurance plan who initiated statin (n = 711,734, statin cohort) or other lipid-lowering therapy (n = 148,044, non-statin cohort) were observed for NIU development. Incident NIU in the primary analysis was defined as a new diagnosis code for NIU followed by a second instance of a NIU code within 120 days. For the secondary outcome definition, a corticosteroid prescription or code for an ocular corticosteroid injection within 120 days of the NIU diagnosis code was used instead of the second NIU diagnosis code. Estimation of NIU incidence used multivariable Cox proportional hazards regression. The proportional hazards assumption was satisfied by creating two time periods of analysis, ≤ 150 and > 150 days. Subanalyses were performed by anatomic subtype.

RESULTS

Overall, the primary outcome occurred 541 times over 690,465 person-years in the statin cohort and 103 times over 104,301 person-years in the non-statin cohort. No associations were seen in the ≤ 150-day analyses (p > 0.20 for all comparisons). However, after 150 days, the statin cohort was less likely to develop any uveitis [hazard ratio (HR) = 0.70, 95% confidence interval (CI): 0.51-0.97, P = 0.03] in the primary outcome analysis, but did not meet significance for the secondary outcome (HR = 0.85, 95% CI: 0.63-1.15, P = 0.30). Similarly, in the anatomic subtype analysis, after 150 days, the statin cohort was less likely to develop anterior uveitis (HR = 0.67, 95% CI: 0.47-0.97, P = 0.03) in the primary analysis, but the association did not reach significance for the secondary outcome (HR = 0.82, 95% CI: 0.56-1.20, P = 0.31).

CONCLUSION

Our results suggest that statin therapy for > 150 days decreases the incidence of NIU.

Association of Retinal Vascular Occlusion With Women Filling a Prescription for Female Hormone Therapy

Importance

Oral contraceptives have been associated with cardiovascular disease, ischemic stroke, venous thromboembolic disease, and breast cancer. Retinal vascular occlusions share the same risk factors as cardiovascular and cerebrovascular disease.

Objective

To determine whether filling a prescription of female hormone therapy (FHT) is associated with an increased risk of retinal artery occlusion (RAO) or retinal vein occlusions (RVO).

Design, Setting, and Participants

A multiple-cohort study was conducted using an administrative claims insurance database comparing women who filled a prescription for FHT with matched control individuals. Exclusion occurred for those enrolled for less than 2 years in the plan, with no prior ophthalmologic examination, with a history of a RAO/RVO, with systemic diseases/medications that affected estrogen levels, or a disease associated with an increased risk for thromboembolism.

Main Outcomes and Measures

The primary outcome was the incidence of a new diagnosis of RAO or RVO. Cox proportional hazard regression modeling with inverse probability of treatment weight was used to assess the hazard ratio (HR) for a new diagnosis of RAO or RVO relative to filling prescription for FHT. Subanalyses were conducted to stratify by age, race/ethnicity, diabetes, and hypertension.

Results

A total of 205 304 women who filled a prescription for FHT were matched to 755 462 control individuals. After inverse probability of treatment weight, the study cohort was a mean age of 47.2 years, 71% were White, 7% were Black, 6% were Hispanic, 3% were Asian, and 3% were unknown. There were 41 cases (0.01%) of RAO and 68 cases of RVO (0.02%) in the FHT cohort. In comparison, there were 373 cases of RAO (0.05%) and 617 cases of RVO (0.08%) in the control cohort. After inverse probability of treatment weight, Cox regression analysis showed no difference in hazard for RAO, RVO, or combined outcomes in the FHT cohort relative to the control cohort (RAO HR, 1.17; 95% CI, 0.83-1.65; P = .36; RVO HR, 1.07; 95% CI, 0.82-1.39; P = .65; combined HR, 1.10; 95% CI, 0.89-1.36; P = .37). Subanalyses that stratified by age, diabetes, and hypertension similarly showed no significant associations between the FHT prescription cohort and all outcomes.

Conclusions and Relevance

These findings suggest that filling a prescription for FHT, and presumably taking FHT, does not increase the risk of RAO or RVO. Such history may not be relevant in the evaluation of an individual with an RAO or RVO nor do our results support stopping FHT in an individual who develops an RAO or RVO.

Risk of Non-infectious Uveitis with Metformin Therapy in a Large Healthcare Claims Database

PURPOSE

To determine if metformin is associated with noninfectious uveitis (NIU).

METHODS

Patients in an insurance claims database who initiated metformin (n = 359,139) or other oral anti-diabetic medications (n = 162,847) were followed for NIU development. Both cohort and case-control analyses were performed to assess differing exposure lengths using Cox and conditional logistic regression, respectively.

RESULTS

The hazard ratio (HR) for incident NIU was not significantly different between the metformin and non-metformin cohorts [HR = 1.19, 95% Confidence Interval (CI): 0.92-1.54, P = .19]. The case control analysis similarly showed no association between any metformin use 2 years before the outcome date and NIU [odds ratio (OR) = 0.64, 95% CI: 0.39-1.04, P = .07]. However, there was a protective 20 association between cumulative metformin duration [(445-729 days) adjusted OR (aOR) = 0.49, 95% CI: 0.27-0.90, P = .02] and dosage (>390,000 mg aOR = 0.44, 95% CI: 0.25-0.78, P = .001) compared with no metformin use.

CONCLUSIONS

Our results suggest metformin use for longer durations may be protective of NIU onset.

Association of metformin and development of dry age-related macular degeneration in a U.S. insurance claims database

PURPOSE

To assess whether metformin is associated with dry age-related macular degeneration (dAMD) development.

METHODS

In this retrospective cohort study, patients enrolled in a nationwide U.S. medical insurance claims database from 2002 to 2016 were included if they had diabetes mellitus, were ⩾55 years old, and were enrolled for ⩾2 years without a prior AMD diagnosis. The primary exposure was metformin use analyzed as either active or prior use or cumulative metformin dosage over the study period. A time updating Cox proportional hazard regression was used to estimate the hazard ratio of dAMD incidence with metformin exposure.

RESULTS

Among 1,007,226 diabetic enrollees, 53.3% were female and 66.4% were white with a mean hemoglobin A1c of 6.8%. Of eligible enrollees, 166,115 (16.5%) were taking metformin at the index date. Over the study period, 29,818 (3.0%) participants developed dAMD. In the active versus prior use of metformin model, active use conferred an increased hazard of developing dAMD (HR, 1.08; 95% CI, 1.04-1.12) while prior use had a decreased hazard (HR, 0.95; 95% CI 0.92-0.98). The cumulative metformin dosage model showed a significant trend toward increased hazard of dAMD incidence with increasing cumulative dosage (p < 0.001), with the lowest dosage quartile having decreased hazard of dAMD incidence (HR, 0.95; 95% CI, 0.91-0.99) and the highest having increased hazard (HR, 1.07; 95% CI, 1.01-1.13).

CONCLUSIONS

Small, conflicting associations between metformin exposure and development of dAMD were observed depending on cumulative dosage and whether drug use was active, suggesting metformin did not substantially affect the development of dAMD.

Demographic and Clinical Characteristics Associated with Minimally Invasive Glaucoma Surgery Use: An Intelligent Research in Sight (IRIS®) Registry Retrospective Cohort Analysis

PURPOSE

Minimally invasive glaucoma surgery (MIGS) is increasingly performed at the time of cataract extraction. Understanding the demographic and clinical characteristics of patients undergoing MIGS procedures may provide insight into patient selection. This study evaluates racial-ethnic and other differences in the use of MIGS in persons with cataract and open-angle glaucoma (OAG).

DESIGN

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

PARTICIPANTS

Patients aged ≥ 40 years with a diagnosis of OAG and no history of MIGS or cataract surgery who were undergoing cataract extraction, with or without MIGS, during 2013 to 2017 in the United States.

METHODS

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

MAIN OUTCOME MEASURES

Variables assessed include age, sex, race-ethnicity, disease severity, insurance type, census region, comorbidity, and cup-to-disc ratio (CDR).

RESULTS

The odds of MIGS use was greater among patients who were aged ≥ 60 years (OR, 1.10 [95% CI, 1.05-1.16]); Black (OR, 1.11 [CI, 1.07-1.15]) compared with White; a Medicare recipient (OR, 1.12 [CI, 1.10-1.15]) versus privately insured; or in the Midwest (OR, 1.32 [CI, 1.28-1.36]) or Northeast (OR, 1.26 [CI, 1.22-1.30]) compared with the South. Having moderate rather than mild glaucoma (OR, 1.07 [CI, 1.04-1.11]) and a higher CDR (OR for 0.5 to 0.8 vs. <0.5, 1.24 [CI, 1.21-1.26]; OR for >0.8 to 1.0 vs. <0.5, 1.27 [CI, 1.23-1.32]) were also each associated with increased odds of MIGS use. Use of MIGS was less likely in women (OR, 0.96 [CI, 0.94-0.98]); patients taking 5 to 7 glaucoma medications (OR, 0.94 [CI, 0.90-0.99]) compared with 1 to 2 medications; and patients with severe, compared with mild, glaucoma (OR, 0.64 [CI, 0.61-0.67]).

CONCLUSIONS

This analysis highlights the importance of capturing race-ethnicity data and other pertinent patient characteristics in electronic health records to provide insight into practice patterns. Such data can be used to assess the long-term performance of MIGS and other procedures in various patient populations.

Association of Visit Adherence and Visual Acuity in Patients With Neovascular Age-Related Macular Degeneration: Secondary Analysis of the Comparison of Age-Related Macular Degeneration Treatment Trial

Importance

Visit adherence has been shown to play a significant role in patient health outcomes. The effect of missing visits on visual acuity (VA) in individuals with neovascular age-related macular degeneration has yet to be characterized.

Objective

To quantify the association between patients' adherence to randomized clinical trial visits and VA in individuals with neovascular age-related macular degeneration based on 4 visit adherence metrics.

Design, Setting, and Participants

This is a secondary analysis of the Comparison of Age-Related Macular Degeneration Treatment Trial randomized clinical trial. Individuals with age-related macular degeneration were recruited from 44 clinical centers in the United States between February 2008 and December 2009. The 2-year study protocol required 1 visit every 4 weeks (every 21-35 days for a total of 26 visits) for monthly vs pro re nata treatments of bevacizumab vs ranibizumab. Analysis took place from November 2018 through May 2019.

Exposures

Visit adherence was measured in 4 ways: total number of missed visits, average number of days (avg days) between each visit, longest duration in days (max days) between visits, and visit constancy (the tally of 3-month periods with at least 1 visit attended). Average and max days were also categorized as on time (28-35 days), late (36-60 days), and very late (>60 days).

Main Outcomes and Measures

Change in Early Treatment Diabetic Retinopathy Study VA between the baseline and the last visit. Linear multivariate regression models were applied to analyze the association between visit adherence and change in VA, controlling for age, sex, baseline VA, anti-vascular endothelial growth factor drug, number of injections, and dosing regimen.

Results

Of 1178 patients, the mean (SD) age was 79.1 (7.3) years, and 727 (61.7%) were women. The mean (SD) number of missed visits was 2.4 (3.1). Overall, 1091 patients (92.6%) had complete visit constancy during the entire study period. Average days were categorized with 1060 patients (90.0%) classified as on time, 108 (9.2%) were late, and 10 (0.8%) were very late. For max days between visits, 197 patients (16.7%) were on time, 773 (65.6%) were late, and 208 (17.7%) were very late. After controlling for covariates, the late (avg days = -6.1; max days = -2.0) and very late (avg days = -12.5; max days = -5.9) groups saw fewer letters in both the avg and max days categories than patients in the on-time group (P < .001).

Conclusions and Relevance

These results provide evidence to support the concept that visit adherence contributes to VA outcomes in neovascular age-related macular degeneration. The magnitude of the association of visit adherence with VA outcomes in this clinical scenario suggests that substantial effort should be expended to strive for visit adherence or therapeutic strategies that reduce the visit burden without compromising VA outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT00593450.

Visit adherence and visual acuity outcomes in patients with diabetic macular edema: a secondary analysis of DRCRnet Protocol T

PURPOSE

To quantify the association between visit adherence and visual acuity (VA) in diabetic macular edema (DME).

METHODS

This secondary analysis of the 2-year DRCRnet Protocol T study of 656 patients required one visit every 4 weeks in the first year, then at variable 4-16-week intervals in the second year. Visit adherence measured as number of missed visits, average (avg days) and longest (max days) visit interval, average (avg missed days) and longest (max missed days) unintended visit interval, and visit constancy (percentage of 3-month periods with at least 1 visit). Avg and max missed days were categorized as on time (0 days), late (> 0-60 days), and very late (> 60 days). Primary outcome was change in ETDRS VA between baseline study visit and last attended visit, using multivariate linear regression models controlling for age, gender, race, ethnicity, treatment arm, baseline VA, hemoglobin A1c, insulin use, and number of lasers and injections.

RESULTS

Mean number of missed visits was 1.7. 616 (94%) patients had 100% visit constancy. A total of 331 (51%) patients were on time, 171 (26%) late, and 154 (23%) very late in avg missed days. Max missed days ranged 0-696 days. Adjusted, each missed visit was associated with 0.3-letter decrease (95%CI - 0.6, - 0.1, p = 0.02); being very late in avg and max missed days saw - 4.2 letters (95%CI - 6.4, - 2.0, p < 0.001) and - 4.0 letters (95%CI - 6.1, - 1.9, p < 0.001), respectively, than on time. Those that averaged > 4 days missed per attended visit saw 4.6 letters worse (95%CI - 7.3, - 2.0, p < 0.001).

CONCLUSIONS

Visit adherence is associated with visual acuity outcomes in DME patients.

ASSOCIATION OF DIAGNOSIS CODE-BASED AND LABORATORY RESULTS-BASED KIDNEY FUNCTION WITH DEVELOPMENT OF VISION THREATENING DIABETIC RETINOPATHY

PURPOSE

To determine how kidney function identified by diagnosis codes compares to lab results-based kidney function for predicting the risk of vision-threatening diabetic retinopathy (VTDR).

METHODS

A US medical claims database was used for this retrospective observational study. Adult patients enrolled from January 1, 2002 to December 31, 2016 with nonproliferative diabetic retinopathy (NPDR) were followed. Patients were excluded if they had any previous diagnosis or treatment of VTDR or VTDR diagnosed within 2 years of insurance plan entry. ICD9/10 Chronic kidney disease (CKD) diagnoses from outpatient claims were used to classify kidney disease with or without end-stage renal disease (ESRD). Serum creatinine was used to calculate estimated glomerular filtration rates (eGFR). Multivariate Cox models with time-dependent covariates were used to assess the associations of kidney disease diagnosis and eGFR with progression to VTDR, controlling for demographics and time-dependent covariates (systemic health, laboratory results, insulin use). C-statistic (a measure of model discrimination), hazard ratio (HR) and their 95% confidence intervals (CI) were calculated from multivariate Cox models.

RESULTS

Among 69,982 patients with NPDR, 12,770 (18.2%) developed VTDR. C-statistic was identical (0.60, 95% CI: 0.59-0.60) for the multivariate model with eGFR and for the multivariate model with kidney diagnosis codes. eGFRs lower than 30 mL/min/1.73 m²(HR>1.14, p < .02 for all comparisons), and a diagnosis of ESRD (HR = 1.07, p = .02) were associated with higher risk of progression to VTDR.

CONCLUSIONS

Both diagnosis-based and lab results-based kidney function were associated with the development of VTDR and predict the development of VTDR equally well.

Risk of Noninfectious Uveitis with Female Hormonal Therapy in a Large Healthcare Claims Database

PURPOSE

To determine if female hormonal therapy (FHT) increases the incidence of noninfectious uveitis.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Women exposed to FHT and matched women unexposed to FHT enrolled in a national insurance plan.

METHODS

Estimation of noninfectious uveitis incidence used multivariable Cox proportional hazards regression. To account for differences between the exposed and unexposed cohorts, a propensity score for being prescribed FHT was created using logistic regression, and inverse probability of treatment weighting was performed.

MAIN OUTCOME MEASURES

Incidence of noninfectious uveitis. For the primary outcome, incident noninfectious uveitis was defined as a new diagnosis code for noninfectious uveitis followed by a second instance of a noninfectious uveitis code within 120 days. For the alternative outcome definition, a corticosteroid prescription or code for an ocular corticosteroid injection within 120 days of the uveitis diagnosis code was used instead of the second uveitis diagnosis code.

RESULTS

There were 217 653 women exposed to FHT and 928 408 women not unexposed to FHT. For the primary outcome, the hazard ratio (HR) for incident noninfectious uveitis was not significantly different between the FHT and unexposed cohorts (HR, 0.99; 95% confidence interval [CI], 0.83-1.17; P = 0.87). With the alternative outcome definition, the FHT cohort was more likely to develop uveitis (HR, 1.21; 95% CI, 1.04-1.41; P = 0.01). When examined by anatomic subtype, for anterior uveitis there was a greater likelihood of incident uveitis in the exposed cohort (HR, 1.23; 95% CI, 1.05-1.45; P = 0.01) for the alternative outcome definition but not for the primary outcome. With age stratification, women exposed to FHT aged ≥45 years at the time of FHT prescription were more likely to develop uveitis (HR, 1.23; 95% CI, 1.03-1.47; P = 0.03) for the alternative outcome definition. A similar HR (1.22) was seen for women aged ≤44 years at the time of prescription, but this association did not meet statistical significance (P = 0.20).

CONCLUSIONS

Exposure to FHT increases the rate of incident noninfectious uveitis when uveitis is defined on the basis of both diagnostic codes and documentation of corticosteroid treatment. However, the risk is modest and FHT is likely safe with regard to noninfectious uveitis risk in the majority of patients exposed to these drugs.

Association of macular disease with long-term use of pentosan polysulfate sodium: findings from a US cohort

BACKGROUND/AIMS

A series at a single clinical centre recently demonstrated an association between the interstitial cystitis drug pentosan polysulfate sodium (PPS) and a vision-threatening pigmentary maculopathy. The aim of this study was to determine if an association exists between PPS use and macular disease in a large national cohort.

METHODS

A retrospective, matched cohort study using data from a large US medical claims database from 2002 to 2016 was performed. A total of 3012 and 1604 PPS users were compared with 15 060 and 8017 matched controls at 5 and 7 years, respectively. The primary outcome measures included (1) any new diagnosis of a hereditary or secondary pigmentary maculopathy (atypical maculopathy outcome), and (2) any new diagnosis of dry age-related macular degeneration (AMD) or drusen in addition to the aforementioned diagnoses (atypical maculopathy+AMD outcome).

RESULTS

At the 5-year and 7-year follow-up, 9 (0.3%) and 10 (0.6%) PPS patients progressed to the atypical maculopathy outcome compared with 32 (0.2%) and 25 (0.3%) control patients, respectively. 103 (3.4%) and 87 (5.4%) PPS patients developed the atypical maculopathy+AMD outcome compared with 440 (2.9%) and 328 (4.1%) control patients at 5 and 7 years, respectively. At 5 years, multivariate analysis showed no significant association (p>0.13). At 7 years, PPS users had significantly increased odds of having the atypical maculopathy+AMD outcome (OR=1.41, 95% CI 1.09 to 1.83, p=0.009).

CONCLUSIONS

PPS exposure was associated with a new diagnosis of macular disease at the 7-year follow-up in a large national cohort.

Association of Opioids With Incisional Ocular Surgery

Importance

Opioid abuse has been declared a public health emergency. Currently, little is known about the association between opioids and ocular surgery.

Objective

To characterize rates of filled opioid prescriptions after incisional ocular surgeries.

Design, Setting, and Participants

This cohort study included patients with incisional ocular surgeries within a large national US insurer's administrative medical claims database. All incisional ocular surgeries from January 2000 through December 2016 were evaluated. An opioid prescription was eligible if it occurred from 1 day before to 7 days after a surgery. Any surgery on a patient who was younger than 18 years, had more than 30 consecutive days of an opioid prescription in the prior 6 months, or had less than 6 months of data in the database prior to surgery was excluded. Data analysis occurred from May 2018 through November 2018.

Main Outcomes and Measures

The rate of opioid prescriptions filled for all incisional ocular surgeries from 2000 through 2016. Primary analysis looked at the rate of filled opioid prescriptions for each ophthalmic subspecialty surgery over time. Secondary analysis assessed which patient or surgical characteristics (ie, age, sex, race/ethnicity, geographic locations, yearly income, educational level, and type of eye surgery) were associated with filling an opioid prescription. Multivariate logistic regression using generalized estimating equations was used to determine odds ratios (ORs) of filling an opioid prescription.

Results

A total of 2 407 962 incisional ocular surgeries were included, of which 45 776 (1.90%) were associated with an opioid prescription. The rate of filled opioid prescriptions varied considerably over time, with the lowest rate occurring in the 2000-2001 cohort year (671 of 45 776 [1.24%]) and the highest in 2014 (5559 of 45 776 [2.51%]). An increasing trend was seen over the course of the study (2000-2001: 671 of 45 776 [1.24%]; 2016: 5851 of 45 776 [2.07%]; P < .001). Multivariate logistic regression showed that year of surgery was significantly associated with filling an opioid prescription, with the highest odds in 2014 (OR, 3.71 [95% CI, 3.33-4.1]), 2015 (OR, 3.33 [95% CI, 2.99-3.70]), and 2016 (OR, 3.27 [95% CI, 2.94-3.63]) compared with 2000 to 2001 (P < .001).

Conclusions and Relevance

These findings suggest the rate of filled opioid prescriptions are increasing for all types of incisional ocular surgery over time. Given the ongoing national opioid epidemic, understanding patterns of use can help in reversing the epidemic.

Anaemia and the risk of progression from non-proliferative diabetic retinopathy to vision threatening diabetic retinopathy

BACKGROUND/AIMS

To determine if anaemia and oxygen delivery-related co-morbidities (ODCs) affect progression from non-proliferative diabetic retinopathy (NPDR) to vision-threatening diabetic retinopathy (VTDR).

METHODS

This is a retrospective cohort study using medical claims data from a large US insurer. Cohorts were created from all NPDR patients between 2002 and 2016. Primary exclusion criteria consisted of any previous diagnosis of proliferative diabetic retinopathy (PDR), diabetic macular oedema (DME) or treatment used in the care of VTDR. The main outcome was a new diagnosis of VTDR (DME or PDR), PDR, or DME. A time-dependent, multivariate Cox proportional hazard regression was used to determine the association between anaemia and other ODCs with NPDR progression.

RESULTS

Of the total 69,982 NPDR patients included for analysis, 12,270, 2,162, and 10,322 progressed to VTDR, PDR and DME, respectively. Both mild and moderate/severe (mod/sev) anaemia were associated with an increased hazard for progression to VTDR (mild HR:1.10, 95% CI:1.04-1.16, p < 0.001; mod/sev HR:1.20, 95% CI:1.12-1.29, p < 0.001), PDR (mild HR:1.29, 95% CI:1.13-1.46, p < 0.001; mod/sev HR:1.43, 95% CI:1.21-1.69, p < 0.001), and DME (mild HR:1.06, 95% CI:1.00-1.13, p < 0.001; mod/sev HR:1.14, 95% CI:1.05-1.24, p < 0.001). ODCs such as chronic pulmonary disease and history of blood disorder/cancer were also significantly associated with an increased hazard for NPDR progression (HR > 1.00, p < 0.001 for all comparisons).

CONCLUSIONS

Anaemia, independent of kidney disease, appears to play a significant role in progression from NPDR to VTDR, PDR, or DME. Concurrently, association of ODCs with NPDR progression lends support to the underlying mechanisms of anaemia in the pathogenesis of diabetic retinopathy.

Association of Hypovitaminosis D With Increased Risk of Uveitis in a Large Health Care Claims Database

Importance

Understanding the role of vitamin D-which regulates inflammatory responses-in noninfectious uveitis (an inflammatory disease) may provide insight into treatment and prevention of this disease.

Objective

To investigate whether there is an association between hypovitaminosis D and incident noninfectious uveitis.

Design, Setting, and Participants

In a retrospective case-control study, data from a health care claims database containing deidentified medical claims from a large private insurer were used to identify 558 adults enrolled from January 1, 2000, to December 31, 2016, who received a diagnosis of noninfectious uveitis from an eye care clinician (with receipt of a confirmatory diagnosis within 120 days of the initial diagnosis) and who had a vitamin D level measured within 1 year before the first diagnosis. Exclusion criteria included having systemic disease or receiving medication known to lower vitamin D levels, having undergone intraocular surgery, and having infectious uveitis. Each case patient was matched with 5 controls on the basis of age, sex, race/ethnicity, and index date (2790 controls). The controls had vitamin D level determined either within 1 year before or within 6 months after receiving an eye examination with normal findings. Multiple logistic regression models were used to examine the association between hypovitaminosis D and noninfectious uveitis.

Main Outcomes and Measures

The primary, prespecified analysis assessed the association of noninfectious uveitis with hypovitaminosis D (vitamin D level ≤20 ng/mL).

Results

The 558 cases and 2790 controls were matched on age, and each group had a mean (SD) age of 58.9 (14.7) years. Among the cohort of 3348 patients, 2526 (75.4%) were female, and the racial/ethnic distribution in the matched samples was 2022 (60.4%) white, 552 (16.5%) black, 402 (12.0%) Hispanic, 162 (4.8%) Asian, and 210 (6.3%) unknown. Patients with normal vitamin D levels had 21% lower odds of having noninfectious uveitis than patients with low vitamin D levels (odds ratio [OR], 0.79; 95% CI, 0.62-0.99; P = .04). In a race-stratified analysis, an association between vitamin D and uveitis was found in black patients (OR, 0.49; 95% CI, 0.30-0.80; P = .004) and was qualitatively similar but nonsignificant in white patients (OR, 0.87; 95% CI, 0.62-1.21; P = .40) and Hispanic patients (OR, 0.60; 95% CI, 0.33-1.10; P = .10).

Conclusions and Relevance

This and other reports have found an association between hypovitaminosis D and noninfectious uveitis. However, these studies cannot establish a causal relationship. Prospective studies are warranted to evaluate whether hypovitaminosis D causes increased risk of uveitis and the role of vitamin D supplementation in prevention and treatment of uveitis.

Repeated intravitreal injections of antivascular endothelial growth factors and risk of intraocular pressure medication use

PURPOSE

To determine the risk of initiating ocular hypertension and glaucoma treatment with repeated injections of antivascular endothelial growth factors (anti-VEGF).

METHODS

A unique, retrospective cohort study was performed using a large national US medical claim database. The study population included patients who had 1 or more injections of an anti-VEGF agent. Exclusion occurred for any previous glaucoma, glaucoma suspect, glaucoma-related procedure, an ocular steroid injection, or not seeing an eye care provider at least once in each year of follow-up. Cohorts were divided into quartiles based on the number of injections performed over the follow-up period. Patients were observed for 2 and 3 years. The main outcome measure was defined as any new prescription for an ocular antihypertensive medication with a concurrent diagnosis of glaucoma, glaucoma suspect, or ocular hypertension. Multivariate logistic regression determined the odds of initiating glaucoma treatment in each injection quartile while controlling for numerous covariates. Sensitivity analysis assessed outcomes that included new medication only as well as a new medication plus diagnosis of glaucoma.

RESULTS

In total, 17,113 and 9992 patients met 2- and 3-year observation end points, respectively. The multivariate odds ratio for initiating glaucoma treatment at 2 years was higher in the highest quartile (OR 1.96, 95% CI 1.39-2.76, p < 0.001) compared with the lowest. The 3-year comparison had similar results with increased odds in the highest quartile (OR 1.51, 95% CI 1.07-2.13, p = 0.006) compared with the lowest. Sensitivity analyses also showed similar results with more injections being associated with initiating treatment (p < 0.053 for all comparisons).

CONCLUSIONS

Repeated anti-VEGF injections are associated with an increased odds of initiating treatment for ocular hypertension and glaucoma.

Adherence to Clinical Trial Supported Evaluation of Optic Neuritis

Purpose: The Optic Neuritis Treatment Trial showed that an MRI of the brain is a powerful predictor of developing multiple sclerosis (MS). However, surveys of practitioners suggest that the recommended use of imaging is not consistently followed in practice. With this study, we aim to assess the rate at which newly diagnosed optic neuritis (ON) patients receive brain MRIs. Methods: This is a retrospective cohort study using administrative medical claims data from a large, national US insurer. All incident cases from 2000 to 2016 of ON in patients without MS were assessed. The primary outcome was a comparison of patterns of MRI scanning usage following diagnosis of ON. Secondary outcomes evaluated steroid treatment and progression to MS. Results: Of 2865 qualified ON patients, 1755 (61.3%) received a brain MRI. At 1 year follow-up, 629 (30.3%) patients had progressed to MS, a rate that increased slightly to 34.3% (366 patients) within a 3-year period of their initial ON diagnosis. A total of 520 (18.2%) patients received intravenous steroids, and 383 (13.4%) received oral steroids within 30 days of the ON diagnosis. Conclusion: Across the United States, a surprisingly low number of individuals obtain a brain MRI following onset of ON, suggesting that physicians may not be fully assessing the risk of MS.

Determinants in Initial Treatment Choice for Diabetic Macular Edema

PURPOSE

To assess how patient choices (out-of-pocket costs, insurance plan, geographic region) impact initiation of therapy for diabetic macular edema (DME).

DESIGN

Retrospective cohort study using administrative medical claims data from a large, national insurer.

PARTICIPANTS

All patients newly diagnosed with DME from 2013 through 2016 were observed for 90 days after diagnosis or until first treatment was received.

METHODS

Multivariate logistic regression was used to create odds ratios comparing different baseline demographic and patient-related factors.

MAIN OUTCOME MEASURES

The primary outcome was the odds of receiving the different possible initial treatments for DME (anti-vascular endothelial growth factor [VEGF], focal laser treatment, steroids, or observation), no treatment, and not following up.

RESULTS

Of the 6220 newly diagnosed DME patients, 3010 (48.4%) underwent a follow-up examination within 90 days of diagnosis, and of those, 1453 patients (48.3%) received treatment in the observation window, including 614 (20.4%) with bevacizumab, 191 (6.3%) with ranibizumab or aflibercept, 560 (18.6%) with focal laser, 38 (1.3%) with steroid injection, and 50 (1.7%) with an injection of an unspecified drug. Having a copay (vs. $0) lowered the odds of receiving any treatment (odds ratio [OR] = 0.60; 95% confidence interval [CI], 0.51-0.71; P < 0.001) and of receiving each treatment individually (anti-VEGF treatment: OR = 0.72; 95% CI, 0.59-0.88; bevacizumab: OR = 0.73; 95% CI, 0.59-0.91; ranibizumab or aflibercept: OR, 0.70; 95% CI, 0.49-0.99; focal laser: OR = 0.44; 95% CI, 0.35-0.55; P < 0.001). Contrary to having a copay, having a high deductible and type of insurance plan were not associated with initiating treatment (P > 0.41 for all comparisons). Patients in the Northeast showed lower odds of initiating anti-VEGF treatment (OR = 0.60; 95%CI, 0.44-0.82; P < 0.001) and specifically bevacizumab (OR = 0.47; 95% CI, 0.33-0.67; P < 0.001). Furthermore, Northeast patients who were treated with anti-VEGF showed a higher odds of receiving ranibizumab or aflibercept compared with bevacizumab (OR = 2.39; 95% CI, 1.31-4.37; P < 0.001). Southern Midwest patients showed a higher odds of treatment (anti-VEGF: OR = 1.35; 95%CI, 1.02-1.77; P < 0.001; bevacizumab: OR = 1.40; 95% CI, 1.04-1.87; focal laser: OR = 1.39; 95% CI, 1.01-1.89; P < 0.001).

CONCLUSIONS

Patient choices such as copays and where they live are important factors in determining the initial choice of treatment for DME.

Blindness and Visual Impairment in the Medicare Population: Disparities and Association with Hip Fracture and Neuropsychiatric Outcomes

Purpose: Vision loss has been associated with negative health outcomes, but population-level data on vision loss are lacking, and there are limited data on low vision-associated outcomes among women, minorities, and older age groups. The objective of this study was to determine the prevalence of vision loss in a nationally representative sample of older US adults and examine its association with hip fracture, depression, anxiety, and dementia. Methods: Cross-sectional analysis of Medicare claims data from 2014. Blindness and low vision, hip fracture, depression, anxiety, and dementia were identified using Chronic Condition Warehouse indicator variables based on ICD-9 and CPT codes. Multivariable logistic regression models were built to examine whether sociodemographic factors were associated with vision loss and to determine the relationships between vision loss and hip fracture and neuropsychiatric outcomes. Results: The prevalence of low vision in the Medicare population was 994/100,000 and increased significantly with age, Black (1,854/100,000) or Hispanic (2,862/100,000) race/ethnicity, female gender (1,181/100,000), and Medicaid eligibility (2,975/100,000). After adjusting for relevant comorbidities, low vision was significantly associated with hip fracture (adjusted odds ratio [AOR] 2.54, 95% CI: 2.52-2.57), depression (AOR 3.99, 95% CI: 3.97-4.01), anxiety (AOR 2.93, 95% CI: 2.91-2.95), and dementia (AOR 3.91, 95% CI: 3.88-3.93). Conclusion: Blindness and low vision are common in older Americans, especially among racial and ethnic minorities and lower income individuals, and associated with hip fracture, depression, anxiety, and dementia. The prevention and treatment of vision loss may reduce health disparities and negative health outcomes in the aging population.

Predictive factors for patients receiving intravitreal anti-vascular endothelial growth factor for the treatment of diabetic macular edema

PURPOSE

To determine whether anemia and other demographic or laboratory "risk factors" impact anti-vascular endothelial growth factor treatment in diabetic macular edema patients.

METHODS

This is a retrospective, time-varying cohort study using a medical claims database to identify new diabetic macular edema patients who had received at least one intravitreal injection of anti-vascular endothelial growth factor. Exclusion occurred for having <2 years in the plan prior to diabetic macular edema diagnosis, any history of proliferative retinopathy or any treatment that is used for diabetic macular edema. Covariates of interest were demographic characteristics, laboratory values, and clinical factors such as previous anti-vascular endothelial growth factor used, number of involved eyes, year of treatment, and time since last injection. Those variables that changed with time were assessed and updated at each visit. The main outcome measure was the odds of receiving treatment at any visit.

RESULTS

In total, 189 new diabetic macular edema patients with follow-up were analyzed, covering 729 visits with 543 (74.5%) receiving treatment. Univariate analysis showed that male gender (odds ratio: 0.54, 95% confidence interval: 0.32-0.91, p = 0.03), every week since last injection (odds ratio: 0.94, 95% confidence interval: 0.91-0.97, p = 0.001), and having two eyes affected (odds ratio: 2.09, 95% confidence interval: 1.10-3.97, p = 0.02) were associated with getting an injection. After multivariate analysis, only time since previous injection with every week that passed reduced the odds on having an injection at the next visit (odds ratio: 0.95, 95% confidence interval: 0.92-0.97, p < 0.001). Anemia was not associated with receiving an injection (odds ratio: 1.05, 95% confidence interval: 0.61-1.80, p = 0.86).

CONCLUSION

This study used time-varying methodology to better identify which patients will likely need an injection at any one visit. While anemia was not found to impact injections, our results can aid future endeavors that may incorporate clinical visit information in developing a full prediction model to help make diabetic macular edema care more efficient.