From the editors of Review of Ophthalmology:
Monday, December 17, 2018
DECEMBER IS SAFE TOYS AND CELEBRATIONS MONTH
In this issue: (click heading to view article)
Vascular Remodeling of CNV in Older Myopes Treated With Ranibizumab
Researchers assessed morphological changes in myopic choroidal neovascularization using optical coherence tomography angiography after treatment with ranibizumab, as part of a retrospective analysis of consecutive cases over a 24-month period.
All treatment-naïve mCNV was imaged at baseline with color pictures, spectral-domain OCT and OCTA, and fluorescein angiography in selected cases. Researchers classified CNV morphology at baseline and at six months, and compared CNV lesion surfaces.
A total of 29 individuals with a mean age of 70.3 ±10.1 years were included. They received a mean number of 2.65 injections over six months. Best-corrected visual acuity improved from 62.2 to 68.5 letters (p=0.004), with regression of exudation in 24 eyes (82.7 percent). Baseline CNV was classified into tree-in-bud (16 eyes), medusa (nine eyes) or sea-fan (four eyes) patterns. At six months, no abnormal blood flow was observed in CNV in 13 eyes. Eyes with complete regression or evolution towards an indistinct pattern more often showed complete regression of exudation than eyes with unchanged pattern (p=0.007). The mean CNV surface significantly decreased from 0.19 to 0.08 mm2 (p<0.0001).
Researchers determined that an unchanged pattern was more often associated with exudation persistence, while a complete regression or evolution towards an indistinct pattern was always associated with vascular inactivity. However, they added that variable changes in mCNV were observed after anti-VEGF. Thus, researchers concluded, OCTA could be more useful in the diagnosis than in follow-up of mCNV.
SOURCE: Cohen SY, Tabary S, El Ameen A, et al. Vascular remodeling of choroidal neovascularization in older myopic patients treated with ranibizumab. Graefes Arch Clin Exp Ophthalmol 2018; Dec. 7. [Epub ahead of print].
Association of an EHR-linked Glaucoma Medical Reminder With Patient Satisfaction
Investigators examined the feasibility of implementing an electronic health record-linked, automated reminder system for glaucoma medications, and assessed associated patient satisfaction. In the prospective, cross-sectional study, individuals receiving glaucoma medications were recruited from a university-based glaucoma clinic.
A web-based application was added to the EHR patient portal, enabling users to configure telecommunication-based reminders for their glaucoma medications. For all potential participants, basic information was collected to determine risk of nonadherence with glaucoma medications. Individuals consenting to participate answered questions on medication adherence, reminders, and the likelihood of using EHR-linked reminders. Reminders were then instituted in the EHR portal. After three months, participants answered questions about their satisfaction with the system.
Of the 147 individuals approached, 100 (68 percent) agreed to participate; the majority were men (54 [54 percent]) and white (51 [51 percent]), with a mean age of 65 ±12.4 years.
• No differences were found between those willing and unwilling to participate, except for a slightly lower self-reported medication adherence rate among those who participated (mean, 91 ±13.6 percent vs. 97 ±6 percent).
• Based on a previously validated risk assessment score, 9 percent (nine of 100) of participants were categorized as being at high risk for poor adherence (≥50 percent probability of nonadherence) compared with 11 percent (five of 47) of nonparticipants.
• Of 100 participants, 94 ultimately configured reminders, and 89 (95 percent) completed follow-up.
• On follow-up, 74 percent (n=66; CI, 65 to 83) of participants found the reminders to be useful, 15 percent (n=13) were neutral and 11 percent (n=10) found them not useful.
• Most participants (72 [81 percent]; CI, 77 to 85) had help configuring reminders.
Investigators found that EHR-linked reminders had good uptake and were well-received among individuals at a tertiary glaucoma clinic. They wrote that such portals might represent a new and convenient method of enabling patients to link their glaucoma medications to automated reminders, adding that the generalizability of these results and the effect on glaucoma outcomes remains unknown.
SOURCE: Varadaraj V, Friedman DS, Boland MV, et al. Association of an electronic health record-linked glaucoma medical reminder with patient satisfaction. JAMA Ophthalmol 2018; Dec. 13. [Epub ahead of print].
New AI Tools May Assist DR Grading
Scientists aimed to understand the impact of deep learning diabetic retinopathy algorithms on physician readers in computer-assisted settings, as part of an evaluation of diagnostic technology,
They reviewed 1,796 retinal fundus images from 1,612 diabetic cases. A total of 10 ophthalmologists (five general ophthalmologists, four retina specialists, one retina fellow) read images for DR severity based on the International Clinical Diabetic Retinopathy disease severity scale in one of three conditions: Unassisted, Grades Only, or Grades + Heatmap. For Grades Only assistance, scientists created a histogram of DR predictions from a trained deep-learning model. For Grades + Heatmap, they additionally showed explanatory heatmaps.
For each experiment arm, scientists computed the sensitivity and specificity of each reader and the model for different levels of DR severity against an adjudicated reference standard. They also measured accuracy (exact 5-class level agreement and Cohen’s quadratically weighted kappa), reader-reported confidence (5-point Likert scale) and time on task.
• Readers graded more accurately with model assistance than without for the Grades Only condition (p<0.001).
• Grades + Heatmaps improved accuracy for cases with DR (p<0.001), but reduced accuracy for cases without DR (p=0.006).
• For moderate NPDR or worse, both Grades Only and Grades + Heatmaps increased readers’ sensitivity:
o Unassisted: mean 79.4 percent
o Grades Only: mean 87.5 percent
o Grades + Heatmap: mean 88.7 percent
• For moderate NPDR or worse, Grades Only and Grades + Heatmaps increased readers’ sensitivity without a corresponding drop in specificity:
o Unassisted: mean 96.6 percent
o Grades Only: mean 96.1 percent
o Grades + Heatmap: mean 95.5 percent
• Model assistance increased the accuracy of retina specialists beyond that of the unassisted reader or model alone.
• Model assistance increased grading confidence and time on task. For most cases, Grades + Heatmap was only as effective as Grades Only.
• Over the course of the experiment, time on task decreased across all conditions, although most sharply for Grades + Heatmap.
Scientists found that deep learning algorithms could improve the accuracy of, and confidence in, DR diagnosis in an assisted reading setting. They added that the algorithms also might increase time on task, although these effects may be ameliorated with experience.
SOURCE: Sayres R, Taly A, Rahimy E, et al. Using a deep learning algorithm and integrated gradients explanation to assist grading for diabetic retinopathy. Ophthalmology 2018; Dec. 13. [Epub ahead of print].
Corneal Epithelial Remodeling in LASIK vs. SMILE
Researchers evaluated three-dimensional epithelial remodeling in individuals undergoing myopic laser in situ keratomileusis and small incision lenticule extraction.
In the prospective, randomized, contralateral eye study of LASIK vs. SMILE procedures, researchers assessed 21 consecutive cases (42 eyes) with corneal epithelial mapping by anterior segment optical coherence tomography for up to two years.
• In the LASIK group, central epithelial thickness increased from 52.38 ±2.57 μm to 57 ±4.23 μm and remained almost stable at this level for up to 24 months.
• In SMILE eyes, central epithelial thickness increased from 52.52 ±3.01 μm to 57.15 ±4.57 μm and remained stable for up to 24 months.
• Both techniques created the same level of epithelial thickness increase and variation, with a significantly higher mid-peripheral epithelial thickness increase.
• The differences between preoperative and postoperative changes were found to be statistically significant, but not different between the two techniques at any given time.
Researchers reported that LASIK and SMILE resulted in significant epithelial thickening in a unexpectedly similar manner. They wrote that the findings suggested that epithelial remodeling might correlate with relative curvature changes resulting after both techniques, rather than the obvious difference of subepithelial corneal denervation changes.
SOURCE: Kanellopoulos, Anastasios J. Comparison of corneal epithelial remodeling over 2 years in LASIK versus SMILE. Cornea 2018; Dec. 5. [Epub ahead of print].
Avedro's Announces Anthem Joins Commercial Plans Covering Corneal Cross-Linking & CMS Issues J Code for Photrexa Drug Formulations
Avedro announced that Anthem, the largest member of the Blue Cross Blue Shield Association, issued a positive coverage policy for Avedro’s FDA-approved corneal cross-linking procedure, bringing the total number of commercial plans covering the Photrexa drug formulations and the KXL System to 60. The addition of the nation’s second largest commercial plan affects 31 million beneficiaries.
In addition, the Centers for Medicare and Medicaid Services recently issued a product-specific J code for Photrexa Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) and Photrexa (riboflavin 5’-phosphate ophthalmic solution). The new J code, J2787, will become effective on Jan. 1, 2019. Read more.
Topcon to Provide Free Cloud Storage on OCT Devices
Topcon Medical Systems is offering a new add-on feature for its OCT product line. All Maestro SD-OCT and Triton SS-OCT purchases now come with 20GB of free storage on the Topcon Cloud platform. Built as an add-on module for IMAGEnet 6 software, Topcon Cloud is an automated, cloud-based, device backup solution that meets medical privacy requirements, provides scalable storage options and supports disaster recovery plans. By transferring the storage of large files and patient data to the cloud, the backup solution helps prevent the slowdown of instruments. Read more.
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