Journal of VitreoRetinal Diseases最新文献

Purpose: To compare the modeled costs of the Protocol AC bevacizumab-first treatment protocol (with a switch to aflibercept for sub-responders) with real-world costs for treatment-naïve patients with diabetic macular edema (DME) over a 2-year period. Methods: Published data from the Diabetic Retinopathy Clinical Research Network (DRCR) Protocol AC bevacizumab-first arm (154 eyes) were used to model 2-year treatment costs. Real-world costs were modeled using data from the Vestrum Health electronic medical records database from a 2016 to 2018 cohort of treatment-naïve eyes with DME (n = 1062) treated with antivascular endothelial growth factor monotherapy. The visual acuity (VA) before treatment in the real-world cohort was matched to Protocol AC. A secondary cost analysis further matched VA gains after treatment in the real-world cohort (n = 346) to Protocol AC. Results: In Protocol AC, the modeled 2-year DME treatment cost in the bevacizumab-first arm was $18,952, with a mean of 16.1 injections over 22.5 visits and 70% of eyes being switched to aflibercept by year 2. (Within 2 years, 57% of injections were bevacizumab and 43% were aflibercept.) Over the same period, the modeled 2-year real-world cost ($11,459) was 40% lower, with a mean of 8.6 injections over 13.8 visits (42% bevacizumab, 45% aflibercept, 13% ranibizumab). Even when matched for baseline VA and a 14-letter VA gain over 2 years, the real-world cost ($15,394) was still 19% lower than the modeled cost in the Protocol AC bevacizumab-first arm. Conclusions: The real-world cost of treating DME over 2 years was significantly lower than the Protocol AC bevacizumab-first cost. Application of Protocol AC findings into real-world utilization, as with step therapy mandates, should only be considered if the same intensive protocol could be followed. These data suggest that existing real-world costs that reflect physician choice are already significantly lower than protocol-mandated step therapy, even when controlling for similar VA outcomes.

Purpose: To describe a single case of systemic lymphoma recurring in the iris and ciliary body. Methods: A retrospective case review was performed. Results: A 75-year-old woman presented to the retina service with an iris mass in the left eye. Her medical history was significant for previous systemic diffuse large B-cell lymphoma treated with systemic chemotherapy. Aqueous sampling was significant for recurrence of the disease. Local therapy with intravitreal (IVT) methotrexate was initiated. Although there was initial improvement, an increased interval between injections led to disease recurrence. External beam radiation to the left eye was then applied, leading to a complete clinical remission. Conclusions: Systemic lymphoma presenting in the iris is a rare manifestation that should be considered on the differential for an amelanotic iris lesion. Although monotherapy with IVT methotrexate did not control the ocular disease in this patient, subsequent external beam radiation resulted in complete clinical remission.

Purpose: To report a pediatric case of Coats plus syndrome that initially presented resembling familial exudative vitreoretinopathy (FEVR). Methods: A single case was analyzed. Results: A pediatric patient was referred at 2 years of age to the retina clinic for exotropia and decreased visual acuity in the right eye and was found to have a dense vitreous hemorrhage. She later developed persistent gastrointestinal bleeding requiring regular blood transfusions and intravenous bevacizumab. Treatment with systemic bevacizumab resolved the patient's cystoid macular edema (CME). Although her presentation and examination were initially suggestive of FEVR, genetic analysis revealed heterozygous biallelic mutations in the STN1 gene, mutations that are known to be associated with Coats plus syndrome. Conclusions: Coats plus syndrome is a rare and life-threatening microangiopathy that affects the retina, central nervous system, and gastrointestinal system. The patient's resulting CME significantly improved with intravenous bevacizumab.

Purpose: To describe the early presentation of successive acute retinal necrosis (ARN) decades after the initial infection. Methods: A single case and its findings were analyzed. Results: A 62-year-old man with a remote history of left-sided ARN presented for evaluation of right-sided blurry vision. An examination showed 1+ anterior chamber cells and mild vitritis with multiple small patches of white retinitis. The lesions progressed despite treatment with oral antivirals, eventually requiring multiple doses of intravitreal antiviral agents and hospitalization for intravenous antiviral therapy. Despite a characteristic clinical picture consistent with ARN, multiple aqueous samples tested negative for viral etiologic agents. Conclusions: ARN is a rapidly progressive disease, and the diagnosis is clinical. Our patient was treated aggressively with antiviral therapy on the basis of the clinical picture without confirmatory testing, which remained negative. The lesions responded well to treatment and 20/25 visual acuity was maintained. Regardless of confirmatory testing, timely treatment is critical in cases of suspected ARN.

Purpose: To describe the spontaneous closure of a chronic, persistent, stage 4 full-thickness macular hole (FTMH) that did not respond to surgical treatment but closed after an episode of cystoid macular edema (CME) secondary to acute iritis. Methods: A single case was evaluated. Results: A 71-year-old woman presented with decreased vision in the left eye for 6 months. A chronic stage 4 FTMH was identified. Surgical treatment consisting of pars plana vitrectomy and internal limiting membrane peeling was unsuccessful, and the patient declined a repeat operation. Two months later, she presented with acute iritis and CME. Imaging showed incidental closure of the FTMH. The iritis resolved after a sub-Tenon triamcinolone injection. At the 3-month follow-up, the FTMH remained closed without CME or iritis. Conclusions: This case highlights the potential importance of CME in the closure of a chronic FTMH after unsuccessful primary surgical repair and suggests clinicians should consider this mechanism in the management of chronic FTMH.

Purpose: To analyze the outcomes and complications of immediate (within 24 hours) small-gauge (23-gauge, 25-gauge) pars plana vitrectomy (PPV) for all causes of exogenous endophthalmitis. Methods: A retrospective case series was evaluated. Results: The study included 107 patients who had immediate PPV for exogenous endophthalmitis between 2016 and 2022. The primary outcome measures were the change from baseline best-corrected visual acuity (BCVA) to the final follow-up and the complications after PPV. Causes of exogenous endophthalmitis included intravitreal injections (62.6%), PPV (18.7%), cataract surgery (11.2%), glaucoma surgery (5.6%), and trauma (1.9%). The most common complications were retinal detachment (17.8%) and secondary glaucoma (9.3%). The mean logMAR BCVA improved significantly from the initial diagnosis to the final follow-up (2.26 vs 1.21) (P < .0001). Conclusions: In most cases, immediate small-gauge vitrectomy for exogenous endophthalmitis leads to an improvement in VA, regardless of the VA at presentation. Patients should be counseled about the potential risks associated with PPV surgery.

Purpose: To present a case of acute B-cell lymphoblastic leukemia (B-ALL) ocular relapse treated with chimeric antigen receptor T-cell (CAR T) therapy. Methods: A retrospective case review was evaluated. Results: A 69-year-old woman with a history of B-ALL presented with bilateral hypopyons and 3+ anterior chamber cells that responded to topical prednisolone. Six months later, she developed recurrent hypopyons, iris neovascularization, and iris nodularity in both eyes. A fine-needle aspiration biopsy confirmed ocular infiltration of B-ALL. A single infusion of CAR T therapy resulted in remission of the systemic and ocular findings. The clinical course was complicated by cytokine release syndrome and neurotoxicity, which improved with medical management. The patient remained in remission for 7 months after a single CAR T infusion. Conclusions: CAR T therapy may be effective in treating systemic leukemia and uveal infiltration, with an ocular side-effect profile and visual outcomes. The systemic side effects of CAR T therapy may be managed medically.

Purpose: To describe a case of lipemia retinalis, a rare ocular manifestation of hypertriglyceridemia that is characterized by a creamy-white to salmon-colored appearance to the fundus. Methods: A 55-year-old man was referred for an evaluation for diabetic retinopathy and was subsequently found to have marked lipemia retinalis. Results: The patient's triglyceride levels were 3141 mg/dL; therefore, treatment was initiated with high-intensity statin therapy and lifestyle modifications. At the 3-month follow-up, the patient had significantly reduced triglyceride levels (689 mg/dL) and full resolution of lipemia retinalis. Conclusions: Lipemia retinalis may be an initial finding of a severe systemic problem and a harbinger for more severe, and potentially fatal, consequences. Thus, a complete systemic assessment is warranted for any patient with signs of lipemia retinalis.

Introduction: To explore the effect of cigarette smoking on the risk for developing diabetic macular edema (DME) among patients with diabetes. Methods: This retrospective exactly-matched cohort study used claims data for patients from all 50 states in the United States from 2010 through 2020. Patients with an initial diagnosis of diabetes were stratified into 3 cohorts as follows: active smokers, never smokers, and former smokers. After exact matching based on demographics and comorbidities, Kaplan-Meier survival functions for the 3 cohorts were compared using pairwise log-rank tests. Results: After matching, there were 42 298 patients in each cohort. Over 6 years of follow-up, the cumulative risk for DME was significantly higher among never smokers (1.18%) than among active smokers (0.88%) and former smokers (0.90%) (both P < .001). Conclusions: Among patients with diabetes, smoking may decrease the risk for developing DME. Although the harms of smoking far outweigh any potential protective benefits, further investigation into the mechanisms behind these findings has potential to uncover new therapeutic targets.

Purpose: To determine the efficacy of switching to intravitreal (IVT) faricimab in patients with treatment-resistant neovascular age-related macular degeneration (nAMD) and determine the rates of reversion to original antivascular endothelial growth factor (anti-VEGF) therapy. Methods: A retrospective chart review was performed of patients with nAMD and persistent fluid on optical coherence tomography previously treated with anti-VEGF injections who received at least 1 IVT faricimab injection between March 1, 2022, and January 31, 2023. Results: The study comprised 135 eyes of 119 patients. Before switching to IVT faricimab, the mean number of anti-VEGF injections in the previous 12 months was 10.7 ± 2.6 (SD) with a mean interval of 4.8 ± 1.3 weeks (range, 2-8). The mean follow-up was 11.6 ± 2 months. Thirty eyes (22.2%) switched to IVT faricimab returned to the original therapy. Of 105 eyes remaining on IVT faricimab, 66 (62.9%) had no fluid at the last follow-up. Compared with the original treatment, there was a significant improvement in logMAR visual acuity at the last follow-up in eyes on IVT faricimab (0.42 vs 0.38; P < .01) and in central subfield thickness (286 µm vs 246 µm; P < .0001). There was also a significant increase in the dosing interval after the third injection vs before IVT faricimab was prescribed (4.8 weeks vs 5.5 weeks; P < .001). Conclusions: Faricimab has a potent drying effect and potential for increasing the injection interval in many eyes with nAMD and persistent fluid on other anti-VEGF agents. Although nearly 25% of eyes reverted to the original therapy because of an insufficient response or adverse events, the majority did not achieve fluid resolution after reversion.