From the editors of Review of Ophthalmology:
MARCH IS WORKPLACE EYE WELLNESS MONTH
In this issue: (click heading to view article)
Management & Outcomes for nAMD: Analysis of U.S. EHRs
Researchers assessed anti-vascular endothelial growth factor management patterns, and anatomic and visual acuity outcomes among individuals with neovascular age-related macular degeneration in U.S. clinical practice, as part of a retrospective, observational cohort study.
A total of 30,106 individuals (37,021 study eyes) initiating intravitreal anti-VEGF treatment for nAMD between October 2009 and November 2016, were included.
Researchers performed an analysis of longitudinal electronic health records from the USRetina database
Main outcome measures included intravitreal injections, optical coherence tomography scans and fluorescein angiography procedures received per study eye during the first 12 months; corrected visual acuity and central retinal thickness at 12 months (absolute value and change from baseline); and number of ophthalmologist visits, stratified by index anti-VEGF agent. Here were some of the findings:
• Over the first 12 months, patients made a mean of 8.1 ophthalmologist visits (range: 1 to 39), and received a mean of six intravitreal anti-VEGF injections (range: one to 27), 7.2 OCT scans and 5.3 FA procedures per study eye.
• For eyes with paired baseline and 12-month anatomic and visual readings, mean CRT declined from 320 to 271 μm (mean change: -48 μm), and mean VA increased from 60.3 to 61 approximate ETDRS (approxETDRS) letters (mean change: +0.6).
• Twelve months after initiating index treatment: 19.3 percent (bevacizumab), 15.8 percent (ranibizumab) and 15.5 percent (aflibercept) of eyes showed >10-letter gain, whereas 13.2 percent (bevacizumab), 14.7 percent (ranibizumab) and 14.4 percent (aflibercept) of eyes showed >10-letter loss.
• Mean change from baseline in VA at 12 months tended to increase linearly with the number of anti-VEGF injections administered over the first 12 months: +1.79 vs. -0.95 approxETDRS letters for eyes receiving at least seven injections vs. those receiving less than seven.
• Similarly, the magnitude of the reduction from baseline in CRT at 12 months tended to increase linearly as the number of anti-VEGF injections increased.
• Multivariate linear regression analysis, adjusted for covariates, indicated a significant association between cumulative number of anti-VEGF injections and change from baseline in VA at 12 months, with each unit increase producing an estimated gain of 0.37 approxETDRS letters.
Researchers wrote that the analysis of combined morphological/functional outcomes of anti-VEGF therapy, the largest conducted to date in nAMD, identified relatively low anti-VEGF injection frequencies, coupled with moderate anatomic and limited visual acuity improvements, in U.S. clinical practice.
SOURCE: Kiss S, Campbell J, Almony A, et al. Management and outcomes for neovascular age-related macular degeneration: Analysis of us electronic health records. Ophthalmology 2020; Feb 27. [Epub ahead of print].
Comparison Study Between SAP & Eye Movement Perimetry
Investigators wrote that their eye movement perimetry study described the development of saccadic reaction time (SRT)-based visual field plots which could effectively display the presence, location and extent of glaucomatous defects, and support clinical decision making.
Eye Movement Perimetry (EMP) is capable of discriminating normal from glaucomatous VF defects based on average delays in SRT. To classify the presence and extent of age-corrected VF defects, it is required to create SRT-based probability maps. Investigators aimed to create VF probability plots based on SRTs and evaluate their clinical applicability by two glaucoma specialists.
The development phase included 95 controls segregated into five age-bins to estimate normative limits of SRT. Next, for the testing phase, a set of 28 healthy subjects and 24 glaucoma patients were recruited who underwent standard automated perimetry and EMP VF testing. Fifty-two SAP and EMP plots were presented to two glaucoma specialists to classify them as normal/abnormal, and to identify the defect location and pattern as one or more of seven predefined categories. Here were some of the findings:
• The glaucoma specialists showed a sensitivity of 100 percent, and a specificity of 93 percent for identifying normal VF vs. 96 percent for identifying abnormal VF.
• Eighty-five percent of EMP reports for specialist one, and 92 percent of EMP reports for specialist two were assigned to the same category as SAP; the reports that didn’t agree with SAP were graded to a higher defect pattern.
• The inter-method agreement for specialist one was kappa 0.92, and for specialist two was kappa 0.96.
Investigators reported that SRT-based VF probability plots provided a comprehensive summary of an individual’s VF status and showed comparable clinical applicability to that of SAP plots.
Source: Mazumdar D, Pel J, Kadavath Meethal NS, et al. Visual field plots: A comparison study between standard automated perimetry and eye movement perimetry. J Glaucoma 2020; Feb 27. [Epub ahead of print.]
DRCR Retina Network Management Approach with Initial Observation for Center-involved DME & Good VA
Scientists aimed to assess the DRCR Retina Network protocol-defined approach and outcomes of initial observation with aflibercept only if VA worsened. This post hoc secondary analysis of a randomized clinical trial of the DRCR Retina Network Protocol V included 91 U.S. and Canadian sites from November 2013 to September 2018.
Adults (n=236) with type 1 or 2 diabetes, one study eye with center-involved diabetic macular edema (CI-DME) and VA letter score of at least 79 (Snellen equivalent, 20/25 or better) were assigned to initial observation. Data were analyzed from March 2019 to November 2019.
Initial observation and follow-up included aflibercept only for VA loss of at least 10 letters from baseline at one visit, or five to nine letters at two consecutive visits. Follow-up occurred at eight weeks and then every 16 weeks unless VA or optical coherence tomography central subfield thickness worsened. Main outcomes and measures included whether individuals received aflibercept. Here were some of the findings:
• Among 236 eyes in 236 individuals (149 [63 percent] male; median age, 60 years [interquartile range: 53 to 67 years]) randomly assigned to initial observation, 80 (34 percent) were treated with aflibercept during two years of follow-up.
• At two years, the median VA letter score was 86 (interquartile range: 89 to 81; median Snellen equivalent: 20/20 [20/16 to 20/25]).
• Receipt of aflibercept was more likely:
o in eyes with baseline central subfield thickness at least 300 μm (Zeiss-Stratus equivalent) vs. less than 300 μm (45 percent vs. 26 percent; hazard ratio [HR]: 1.98 [CI, 1.26 to 3.13], continuous p
o in eyes with moderately severe nonproliferative diabetic retinopathy (Early Treatment Diabetic Retinopathy Study retinopathy severity level 47) and above vs. moderate nonproliferative diabetic retinopathy (retinopathy severity level 43) and below (51 percent vs. 27 percent; HR, 2.22 [CI, 1.42 to 3.47], ordinal p
o among participants whose nonstudy eye received DME treatment within four months of randomization vs. not (52 percent vs. 25 percent; HR: 2.55 [CI, 1.64 to 3.99], p
Scientists found that most eyes managed with initial observation plus aflibercept only if VA worsened maintained good vision at two years and didn’t require aflibercept for VA loss. However, trial eyes were approximately twice as likely to receive aflibercept for VA loss if they had greater baseline central subfield thickness, worse diabetic retinopathy severity level or a non-study eye receiving treatment for DME.
SOURCE: Adam Glassman, Baker CW, Beaulieu WT, et al. Assessment of the DRCR retina network approach to management with initial observation for eyes with center-involved diabetic macular edema and good visual acuity. JAMA Ophthalmol 2020; Feb 20. [Epub ahead of print].
Minimizing Hyperopic Shift Post-DMEK
Researchers evaluated different corneal parameters in identifying patients at risk of a hyperopic shift after Descemet’s membrane endothelial keratoplasty. The retrospective study included 92 eyes with Fuchs’ endothelial corneal dystrophy (FECD) after DMEK surgery.
Pachymetry parameters, various tomographic parameters and densitometry values before and after DMEK were determined using a rotating Scheimpflug system (Pentacam HR, Oculus). To assess the posterior to anterior corneal curvature relationship, researchers calculated the RPA (posterior to anterior corneal curvature radii ratio).
• The average keratometry reading of the posterior corneal surface (KmB) increased and the total corneal refractive power (TCRP) decreased significantly after surgery (p
• Researchers found a significant difference between the preoperative and postoperative RPA (p
<0.001) and the posterior Q value (p
• The strongest correlation was found between the change in the KmB and the preoperative RPA (Spearman’s correlation coefficient=0.872, p
• In the receiver operating characteristic analysis, the highest area under the curve values (for ∆KmB) among the different preoperative parameters tested were obtained for RPA (0.95 area under the ROC [AUROC]; and posterior Q value (Asph. QB)(0.89 AUROC).
Researchers determined that the Q value and the RPA showed the highest correlation with the change in corneal refractive power and the greatest AUC. They added that these parameters could be used as surrogate markers to identify eyes that might be at risk for a greater postoperative hyperopic shift, which would allow for a more accurate setting of refractive goals.
SOURCE: Diener R, Eter N, Alnawaiseh M, et al. Using the posterior to anterior corneal curvature radii ratio to minimize the risk of a postoperative hyperopic shift after Descemet membrane endothelial keratoplasty. Graefes Arch Clin Exp Ophthalmol 2020; Jan 31. [Epub ahead of print].
Alert: Coronavirus Recommendations for Ophthalmologists
The American Academy of Ophthalmology is sharing important ophthalmology-specific information related to the novel coronavirus—severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly contagious virus that can cause a severe respiratory disease known as COVID-19. Here is some of the information shared:
• Several reports suggest the virus can cause conjunctivitis and possibly be transmitted by aerosol contact with conjunctiva.
• Patients who present for conjunctivitis who also have fever and respiratory symptoms including cough and shortness of breath, and who have recently traveled internationally, particularly to areas with known outbreaks (China, Iran, Italy, Japan and South Korea), or who have family members recently back from one of these countries, could represent cases of COVID-19.
• The Academy and federal officials recommend protection for the mouth, nose and eyes when caring for patients potentially infected with SARS-CoV-2.
• The virus causing COVID-19 is likely susceptible to the same alcohol- and bleach-based disinfectants that ophthalmologists commonly use to disinfect ophthalmic instruments and office furniture. To prevent SARS-CoV-2 transmission, the same disinfection practices already used to prevent office-based spread of other viral pathogens are recommended before and after every patient encounter.
Recommended Protocols When Scheduling or Seeing Patients
• During visit reminders by phone, have office personnel reschedule appointments for patients with nonurgent ophthalmic problems who have respiratory illness, fever or who have returned from a high-risk area within the past two weeks.
• Patients who come to an appointment should be asked prior to entering the waiting room about respiratory illness and if they or a family member have traveled to a high-risk area in the past 14 days. If they answer yes to either question, they should be sent home and told to speak to their primary care physician.
• Keep the waiting room as empty as possible, and reduce the visits of the most vulnerable patients.
• Sick patients who possibly have COVID-19 with an urgent eye condition can be seen, but personal protective equipment should be worn by all who come in contact with the patient. The CDC's recommendations for personal protective equipment include gloves, gowns, respiratory protection and eye protection. Place a facemask on the patient and isolate him in an examination room with the door closed; use airborne infection isolation rooms (AIIR) if available. Read more on these CDC recommendations.
• Rooms and instruments should be thoroughly disinfected afterward based on current CDC recommendations specific to COVID-19. Read more on these CDC recommendations. Slit lamps, including controls and accompanying breath shields, should be disinfected after every patient, particularly where patients rest their hands and faces.
ImprimisRx Announces Supply Agreement with iOR Partners
ImprimisRx agreed to a product supply agreement with iOR Partners. Under the agreement, ImprimisRx will provide a variety of formulations needed for in-office surgeries, including the MKO Melt and various injectable and topical products. iOR Partners specializes in office-based cataract surgery. Read more.
Zeiss Announces Change in Leadership
Zeiss announced that, effective 1 May, Jim Mazzo will retire from his position as president ophthalmic devices and head of the ophthalmic devices strategic business unit. He will continue to support Zeiss as an advisor. Euan Thomson, PhD, will succeed Mazzo. Dr. Thomson is head of the digital business unit for Zeiss and will continue to guide digital activities. Most recently, Dr. Thomson led digital technology development for Johnson & Johnson Medical Devices. Read more.
ARVO Annual Meeting Canceled
Per a March 12 update on its website, the Association for Research in Vision and Ophthalmology announced it was canceling its annual meeting, scheduled for May 1 to 7 in Baltimore. Leaders wrote that the difficult decision came after monitoring the COVID-19 (coronavirus) situation over the past week. They wrote that “the health, safety and well-being of the ARVO global community is our highest priority.” The group encouraged individuals to watch for additional communications over the next two weeks that would offer alternative presentation options as the group worked through the details. Read more.
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