Researchers evaluating the optimum medical strategy to prevent cystoid macular edema after cataract surgery concluded that topical non-steroidal anti-inflammatory drugs significantly reduced the odds of developing CME, as compared to topical corticosteroids, in non-diabetic and mixed-population groups. A combination of topical NSAIDs and corticosteroids reduced the odds of developing CME in nondiabetic and diabetic patients, as compared to topical corticosteroids.
Cochrane, Medline and Embase databases were searched to identify the eligible randomized clinical trials (comparing medical strategies to prevent CME after uncomplicated cataract surgery in non-diabetic and diabetic patients) for systematic review and meta-analysis. The data were extracted independently by two authors. The quality of individual RCTs was assessed using the Cochrane Collaboration’s tool for assessing risk of bias and Delphi criteria.
The primary outcome measured was the odds of developing CME within three months postop. Secondary outcome measures were foveal thickness, macular volume and corrected distance visual acuity change as compared to baseline, also within three months postop. Of the 30 identified trials included in the systematic review, 17 reported incidence rates. Eleven trials included only non-diabetic patients, while 7 trials included only diabetic patients. There were 12 other trials that included patients with and without diabetes or did not report the incidence of diabetes in the study population; these trials were clustered and are referred to as “mixed populations” for the purpose of reporting results.
Topical NSAIDs significantly reduced the odds of developing CME as compared to topical corticosteroids in non-diabetic populations (odds ratio: 0.11; 95 percent confidence interval, 0.03 to 0.37) and mixed populations (OR: 0.05; 95 percent CI, 0.02 to 0.11). A combination of topical corticosteroids and NSAIDs significantly reduced the odds of developing CME as compared to topical corticosteroids alone in non-diabetic (OR: 0.21; 95 percent CI, 0.10 to 0.44) and diabetic patients (OR: 0.17; 95 percent CI, 0.05 to 0.5). Intravitreal corticosteroid or anti-VEGF injections did not show any additional benefit in diabetic subjects.
Am J Ophthalmol 2015;160:5:968-981.
Wielders L, Lambermont V, Schouten J, Van den Biggelaar F, et al.
MIVI-TRUST Trials Patients Report Visual Function Improvement
Results of the Microplasmin for Intravitreous Injection-Traction Release Without Surgical Treatment (MIVI-TRUST) trials suggest that ocriplasmin produces clinically meaningful improvement in patient-reported visual function in symptomatic vitromacular adhesion and vitromacular traction.
To determine the impact of intravitreal ocriplasmin on patient-reported visual function, researchers used the 25-item National Eye Institute Visual Function Questionnaire during a six-month follow-up in patients with symptomatic VMA. Patients were recruited to two multicenter, randomized clinical trials at clinic-based centers in the United States and Europe. A total of 652 patients with symptomatic VMA/VMT, including when associated with a macular hole 400 μm or smaller, were studied. Analysis was by intent-to-treat population.
The patients were randomly assigned (2:1 in Group 1, 3:1 in Group 2) to receive a single intravitreal injection of ocriplasmin 125 μm or placebo. The NEI VFG-25 was administered at baseline and six months following the ocriplasmin injection. The mean changes between baseline and six-month follow-up NEI VFQ-25 composite and subscale scores and the proportion of patients with a clinically meaningful change (≥five points) in scores were measured.
Across the two studies, 464 patients received ocriplasmin and 188 received placebo. At six months, the ocriplasmin group reported greater mean improvements from baseline in the NEI VFQ-25 composite score than the placebo group (mean change, 3.4 vs. 0.7, p=0.005). Improvements were also noted in subscale scores, with the following respective mean changes for the ocriplasmin vs. placebo groups: vision-related dependency, 1.7 vs. -2.1 (p=0.009); driving difficulty, 2.7 vs. -1.5 (p=0.03); distance vision activities, 4.1 vs. 0.8 (p=0.03); and general vision, 6.1 vs. 2.1 (p=0.003). A higher proportion of the ocriplasmin group had a clinically meaningful (≥five point) improvement in NEI VFQ-25 composite score from baseline than placebo group (36 percent vs. 27.2 percent, p=0.03). Fewer ocriplasmin-treated patients had a clinically meaningful worsening in their visual function than the placebo group (15 percent vs. 24.3 percent, p=0.005). Changes in NEI VFQ-25 composite score and various subscale scores were observed in ocriplasmin-treated patients who achieved VMA resolution at day 28.
The article’s authors disclose financial interest in the products and/or companies referenced in the article.
JAMA Ophthalmol 2015;133:9:997-1004.
Varma R, Haller J, Kaiser P.
Combining Glaucoma Screening Technologies for Better Detection
A multi-institutional research team has determined that a multivariable model including GDx-TSNIT (scanning laser polarimetry temporal-superior-nasal-inferior-temporal), number of abnormal points (NAP) on frequency doubling technology (FTC), and the interaction GDx-TSNIT x NAP-FDT provides the best glaucoma prediction with all other multivariable and univariable models. Combining the FDT C-20-5 screening protocol and scanning laser polarimetry with variable corneal compensation (GDx-VCC) improves glaucoma detection compared with using GDx or FDT alone.
Normal (n=110) and glaucomatous (n=114) subjects were tested with the FDT C-20-5 screening protocol and the GDx-VCC. The discriminating ability was testing for each device individually and for both devices combined using GDx-NFI (nerve fiber indicator), GDx-TSNIT, number of missed points FDT and normal or abnormal FDT. Measures of discrimination included sensitivity, specificity, area under the curve (AUC), Akaike’s information criterion (AIC) and prediction confidence interval lengths.
For detecting glaucoma severity, the multivariable model resulting from the combinations of GDx-TSNIT, NAP-FDT and the interaction GDx-TSNIT x NAP-FDT (AIC: 88.28, AUC: 0.959, sensitivity: 94.6 percent, specificity: 89.5 percent) outperformed the best single-variable model provided by GDx-NFI (AIC: 120.88, AUC: 0.914, sensitivity: 87.8 percent, specificity: 84.2 percent). The multivariable model combining GDx-TSNIT, NAP-FDT and interaction GDx-TSNIT x NAP-FDT consistently provided better discriminating abilities for detecting early, moderate and severe glaucoma than the best single-variable models.
J Glaucoma 2015;24:561-567.
Mwanza J, Warrn J, Hochberg J, Budenz D, et al.
Incidence of Late-Stage AMD in American Whites
Population health researchers from London have concluded that estimating age-related macular degeneration incidence from prevalence allows for a better characterization at older ages and by AMD subtype where longitudinal data from incidence studies are limited.
The researchers did a systematic review and meta-analysis of prospective cohort studies of AMD incidence in populations of white European ancestry published in Medline, Embase and Web of Science. Fourteen publications in 10 populations that examined AMD incident cases were identified. Data on age-sex specific incidence of late AMD, geographic atrophy and neovascular atrophy, as well as year of recruitment, AMD grading method and continent were extracted. The annual incidence of late AMD, geographic atrophy and neovascular AMD by age-sex in American whites aged ≥50 years from a Bayesian meta-analysis of incidence studies was compared with incidence extrapolated from published prevalence estimates.
Incidence rates from the review agreed with those derived from prevalence, but the latter were based on more data, especially at older ages and by AMD subtype. Annual incidence (estimated from prevalence) of late AMD in American whites was 3.5 per 1,000 aged ≥50 years, equivalent to 293,000 new cases in American whites per year. Incidence rates approximately quadrupled per decade in age, while annual geographic atrophy rates were 1.9 per 1,000 aged ≥50 years and neovascular AMD rates were 1.8 per 1,000. Late AMD incidence was 38 percent higher in women vs. men.
Am J Ophthalmol 2015;160:1:85-93.
Rudnicka AR, Kapetanakis VV, Jarrar Z, Wathern AK, Wormald R, et al.
A Meta-Analysis of Anti-VEGF For Diabetic Retinopathy
A review of 22 studies involving 1,397 subjects supports the use of anti-vascular endothelial growth factor agents as adjuncts to pan-retinal photocoagulation and pars plana vitrectomy in patients with complicated proliferative diabetic retinopathy. The use of anti-VEGF agents before PRP results in superior functional and structural outcomes at three to four months. The use of anti-VEGF agents before PPV results in decreased duration of surgery, fewer breaks and less intraoperative bleeding. Although there is evidence for a decreased incidence of early postop vitreous hemorrhage, the quality of evidence is low. Thus, using anti-VEGF agents is primarily a means of facilitating and potentially minimizing the iatrogenic damage that can result from PRP and PPV procedures.
The authors identified randomized controlled trials using anti-VEGF agents, either as stand-alone therapy or combined with other interventions, in the management of proliferative diabetic retinopathy. The primary outcome measures were change in best-corrected visual acuity and (in the context of vitrectomy) duration of surgery and postop vitreous hemorrhage. Secondary outcomes were change in central retinal thickness and (in context of vitrectomy) intraoperative variables suggestive of complex surgery (retinal breaks, intraoperative bleeding, endodiathermy applications). The quality of evidence for all outcomes was appraised using the GRADE criteria.
Of the 22 studies that met criteria for inclusion, one compared intravitreal ranibizumab with saline; one compared intravitreal pegaptanib to PRP; one compared intravitreal bevacizumab to PRP; three compared combined intravitreal ranibizumab/PRP to PRP; five compared combined intravitreal bevacizumab/PRP to PRP alone; and 11 compared combined intravitreal bevcizumab/PPV to PPV alone. There is high-quality evidence to suggest that, when used in conjunction with PRP, intravitreal ranibizumab is associated with superior visual acuity and central retinal thickness outcomes at three to four months. In the context of PPV, there is moderate-quality evidence to suggest that preoperative intravitreal bevacizumab results in significant reduction in the duration of surgery, fewer retinal breaks, less intraoperative bleeding and fewer endodiathermy applications. Although there is evidence to suggest occurrence of early postop vitreous hemorrhage is reduced, the quality of evidence in support of this finding is low.
Simunovic M, Maberley D.
Use of Anti-VEGF for Neovascular AMD Eyes with Low Vision
A study from Belfast supports the use of anti-VEGF agents in eyes with neovascular age-related macular degeneration presenting with very low visual acuity, particularly when fibrosis and atrophy are absent, and suggests algorithms to predict the outcome for combinations of visual acuity and lesion characteristics across the full visual acuity range.
The researchers performed a retrospective analysis of electronic patient care records of 420 eyes treated with ranibizumab between March 2010 and June 2013. The extracted data was classified into three categories based on patient best-corrected visual acuity as measured on the Early Treatment Diabetic Retinopathy Study charts: 0 to 35 letters; 36 to 69 letters; and ≥70 letters. Best BCVA achieved in year one, and average BCVA over 36 months, were computed. The neovascular lesion type; area of lesion; the presence or absence of hemorrhage; retinal pigment epithelium tear; and atrophy were systematically graded, as was the extent of fibrosis on a categorical scale. Regression anaylsis was performed with the best BCVA achieved in year one as the outcome variable and initial BCVA, person and lesion characteristics as explanatory variables.
The mean change in BCVA from the initial visit to the best-attained BCVA during year one was highly statistically significant with an improvement of 9.95 letters. The improvement from initial BCVA to average BCVA over 36 months was 4.01 letters. Regression analysis identified atrophy and fibrosis as predictors of best BCVA, with the model having an r2 of 0.71.
Toth L, Stevenson M, Chakravarthy U.
Assessing Corneal Sensitivity From Meibomian Gland Testing
A study looking at the association between corneal sensitivity and clinical tests that assess the tear film and meibomian glands found that palpebral conjunctival sensitivity may be more critical when assessing dry-eye disease.
Subjects (n=57) were recruited based on the history of contact lens wear and the extent of meibomian gland dropout. The average subject age was 34.7 years (standard deviation: 15.1); 63.2 percent were female. Clinical examination included assessment of symptoms; redness of the lower eyelid margin; lipid layer thickness; esthesiometry of the inferior cornea and palpebral conjunctiva; noninvasive tear breakup time; Schirmer test assessment; and meibomian gland assessment through orifice count and expressed meibum quality grade. The subjects were grouped into a high corneal sensitivity (HS) group or low corneal sensitivity (LS) group, based on the median sensitivity measure. Groups for palpebral conjunctival sensitivity were created in the same manner. Mann-Whitney U tests were used for comparisons of sensitivity groups, and a Spearman rho correlation coefficient was used to study the associations between each tear film characteristic and the sensitivities.
The median corneal and conjunctival thresholds for sensation were 0.5 and 1.4 g/mm2. The average noninvasive tear breakup time (HS group: 7.8 seconds, interquartile range (IQR) = 5.7; LS group: 11.6 seconds, IQR = 8.4; p=0.05) and Schirmer test assessments (HS group: 16.0 mm, IQR = 15.0; LS group: 25.0 mm, IQR = 19.0; p=0.04) were significantly different between the palpebral conjunctival HS and LS groups. All other group comparisons and correlations were not statistically significant.
Cox S, Nichols J.