Disease Burden in the Treatment of Age-Related Macular Degeneration
Prenner et al. performed a mixed-methods study using surveys, interviews, site visits, and time-and-motion observations to examine the burden that managing neovascular age-related macular degeneration (AMD) imposes on physicians, staff, patients, and caregivers.
The multicenter study was conducted from March 2011 through August 2012. First, the researchers conducted ethnographic research by means of site visits at 10 practices, where they “shadowed” AMD patients and conducted postobservational interviews with physicians and staff. They followed this phase with qualitative research involving in-depth interviews with a total of 30 AMD patients and caregivers. Finally, they conducted quantitative research through surveys of retina specialists who administered 50 or more anti-VEGF injections monthly (56 physicians completed records on 221 AMD patients) as well as surveys of 75 AMD patients.
The study found that neovascular AMD patients accounted for 20% of the health care staff’s time per week, involving an average of 23 staff members. An average patient visit for neovascular AMD was 90 minutes. Patients reported that the average time associated with each visit was almost 12 hours, including preappointment preparation, travel, waiting time, treatment time, and postappointment recovery. Patients stated that caregivers took time away from work and personal activities to provide transportation to appointments.
Based on surveys and interviews of retina physicians and patients, the study quantitatively confirmed that neovascular AMD management imposes a substantial time burden on patients, caregivers, and practices. The authors suggested that additional support and/or reimbursement is needed for services required by patients and caregivers and provided by physicians.
Corneal Collagen Cross-linking for Progressive Corneal Ectasia
In a study conducted in France, Poli et al. evaluated 6-year results of standardized epithelium-off corneal collagen cross-linking (CXL) for treatment of progressive corneal ectasia using a prospective consecutive, interventional case series. At 6 years, CXL had maintained long-term results in halting the progression of corneal ectasia, with significant improvement in corrected distance visual acuity and long-term stability of keratometry.
Thirty-six eyes of 25 consecutive patients with documented progressive primary or iatrogenic corneal ectasia underwent CXL following the Siena protocol. The main outcome measures at the endpoint, compared with baseline, were the following: uncorrected distance visual acuity, –0.08 ± 0.36 logMAR; corrected distance visual acuity, –0.14 ± 0.28 logMAR; topography-derived steep (Kmax, +0.11 ± 1.70 D) and flat (Kmin, –0.25 ± 1.25 D) keratometry; central corneal thickness, –16.38 ± 37 µm; IOP, +1.0 ± 2.3 mm Hg; and endothelial cell density, +31 ± 400 cells/mm2. Bilateral macular optical coherence tomography was performed at the endpoint visit. The mean follow-up was 66 months.
At 6 years, CXL had stabilized primary and iatrogenic corneal ectasia in 89% of the patients. In bilateral CXL, the progression of the first eye was highly predictive of the fellow eye’s outcome. No cases of macular toxicity or severe adverse events were reported.
Retinal Toxicity From High-Dose Hydroxychloroquine
Leung et al. report on the rapid onset of retinal toxicity in a series of oncology patients receiving a high-dose (1,000 mg daily) hydroxychloroquine regimen. This retrospective observational case study was conducted among patients who were part of a multicenter open-label, randomized controlled trial of hydroxychloroquine with or without erlotinib for advanced non–small cell lung cancer.
At most of the study centers, ophthalmic surveillance was performed using the FDA-recommended screening protocol, which included visual acuity testing, dilated fundus examination, Amsler grid testing, and color vision testing. However, at the Stanford University center, the following sensitive screening procedures were added at the discretion of the retinal physician: high-resolution spectral-domain optical coherence tomography (OCT), fundus autofluorescence (FAF) imaging, Humphrey visual field (HVF) testing, and multifocal electroretinography (mfERG).
Of the 7 patients at the Stanford site who had exposure of at least 6 months, 2 patients developed retinal toxicity (at 11 and 17 months of exposure). Damage was identified by OCT imaging, mfERG testing, and, in 1 case, HVF testing. FAF imaging remained normal. Neither patient had symptomatic visual acuity loss.
These cases suggest that high doses of hydroxychloroquine can initiate the development of retinal toxicity within 1 to 2 years. Although synergy with erlotinib is theoretically possible, there are no prior reports of erlotinib-associated retinal toxicity despite more than a decade of use. The authors encouraged other investigators to incorporate modern, sensitive retinal screening techniques into their surveillance plans for future trials of high-dose hydroxychloroquine regimens.
Cataract Surgery Outcomes in Glaucomatous Eyes
Turalba et al. compared visual acuity outcomes, vision-related quality of life, and complications related to cataract surgery in eyes with and without glaucoma, using a retrospective cohort study design. They found that eyes with glaucoma were more likely than those without glaucoma to experience cataract surgery complications.
Cataract surgery outcomes in eyes with glaucoma (cases) and without glaucoma (controls) from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project were compared. The researchers identified 608 glaucoma cases and 4,306 controls who were undergoing planned cataract surgery. After adjustment for many factors, the glaucoma cases were more likely than the controls to have posterior capsular tear with vitrectomy and sulcus IOL placement during cataract surgery. Glaucoma cases were also more likely to have postoperative inflammation, prolonged elevated IOP, and additional surgery within 30 days.
Mean best-corrected visual acuity (BCVA) and Visual Function Questionnaire (VFQ) scores significantly improved after cataract surgery in both groups, but there were larger improvements in BCVA and VFQ composite scores in the controls than in the glaucoma cases. A postoperative BCVA of 20/40 or better was attained in 94% of control eyes and in 89% of glaucoma case eyes.
Eyes with glaucoma had a higher risk for complications related to cataract surgery, even when the researchers controlled for risk factors such as age, pseudoexfoliation, small pupils, shallow anterior chamber depth, and prior ocular surgery. Glaucoma cases experienced more modest visual improvement compared with control eyes. Nevertheless, glaucoma patients still experienced substantial benefits in BCVA and vision-related quality-of-life outcomes after cataract extraction.
American Journal of Ophthalmology summaries are edited by Thomas J. Liesegang, MD.
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