Journal of VitreoRetinal Diseases最新文献

Purpose:To determine the economic impact of insurance company prior authorizations (PAs) for anti-vascular endothelial growth factor (anti-VEGF) therapies on society. Methods: PA denial and delay rates were derived from a large electronic database (SamaCare PA). Data were analyzed in a theoretical cost-effectiveness model to calculate the increased costs of PAs (in 2025 U.S. dollars). Results: Of 33 178 total PA requests, the majority were from Medicare Advantage plans (18 769, 58.2%), followed by commercial insurance carriers (10 047, 31.1%) and Medicaid (3438, 10.7%). Commercial carriers had the highest mean PA denial rates and approval delays (3.95% denials, 4.95 days delayed), followed by Medicaid (3.87% denials, 4.11 days delayed) and Medicare Advantage (1.18% denials, 1.54 days delayed). Over the average patient's lifetime, the PA process increased total societal costs by a mean $10,842.24 (range, $228.11-$90, 322.69), and the direct savings from denying a PA was only $27.11 per injection (range, $3.06-49.99). Each PA request increased the mean total societal costs by an additional $637.78 in the reference case (range, $25.35-$4,105.58). PAs annually cost the workplace an extra $588.17 (range, $9.98-$3,513.90), the patient and family an extra $362.92 (range, $20.93-$1,743.63), the provider an extra $11.61 (range, $1.14-$324.18), and the insurer an extra $4.92 per year (range, -$40.85 to $76.03). PAs were not cost saving in >99.9% of modeled scenarios. Insurance companies were the only sector of society to potentially save money. Conclusions: PA requests were ultimately approved in 97.7% of all cases, with 97.9% being delayed. The PA process was not cost-saving and increased the total societal costs of anti-VEGF treatments.

Purpose: To characterize retina specialist and patient attitudes toward artificial intelligence (AI) in retina clinical care. Methods: A parallel survey was concurrently administered to retina specialists electronically and to patients in 5 retina practices. Responses were based on a 5-point Likert scale. Data were analyzed using χ² and Mann-Whitney U tests. Results: A total of 291 (97%) of 300 patients approached participated, while 78 (17%) of 447 physicians responded electronically. Major differences (mean differences > 0.5) were seen in opinions on patients choosing whether AI is used in their care (mean, 3.3 for physicians vs 4.2 for patients; P < .0001), desire for AI use in clinical care (3.7 for physicians vs 2.9 for patients; P < .0001), and physicians being responsible for harm caused by AI (3.4 for physicians vs 4.1 for patients; P < .0001). Both groups aligned on discomfort with AI taking clinical roles such as deciding on treatments (2.6 for both; P = .9) and answering patients' questions about diagnosis and treatment (2.7 for both; P = .9). Conclusions: The present study demonstrated important differences in retina specialist and patient perceptions on the use of AI in clinical care, particularly pertaining to patient autonomy. Both groups expressed discomfort with AI taking direct clinical roles. As AI integration in clinical care progresses, physicians and developers should continue to understand and address patient concerns.

Purpose: To evaluate the real-world safety and efficacy of the 0.19 mg fluocinolone acetonide intravitreal implant for the management of diabetic macular edema (DME).

Methods: This retrospective study included 94 eyes from 58 patients, of whom all but 1 had type 2 diabetes. The mean age (± SD) was 75.5 ± 2.12 years. Each patient received at least 1 fluocinolone acetonide implant after a corticosteroid trial without significant intraocular pressure elevation. Data were collected from visits up to 18 months preimplantation (mean, 14.6 months) and 3 years postimplantation (mean, 51 months). Key outcomes included central subfield thickness (CST), visual acuity (VA), intraocular pressure, retinal thickness variability measures, and treatment frequency.

Results: Mean baseline VA remained stable, decreasing from 61.5 ± 1.5 Early Treatment Diabetic Retinopathy Study (ETDRS) letters preimplantation to 58.2 ± 0.3 ETDRS letters postimplantation (P = .034). Mean CST decreased significantly from 427.6 ± 20.8 µm 1 month preimplantation to 310.6 ± 11.4 µm at final follow-up (P < .001). Annual treatment frequency dropped significantly from 4.6 ± 0.95 injections preimplantation to 2.3 ± 0.25 injections postimplantation (P = .021). Retinal thickness variability improved significantly (80.4 ± 5.8 µm to 63.8 ± 4.6 µm; P = .027), with a corresponding CST area under the curve (351.1 ± 13.5 µm² to 296.7 ± 10.9 µm²; P = .002). Intraocular pressure remained stable, increasing slightly from 15.8 mmHg to 16.3 mmHg. No new safety signals were observed.

Conclusions: The fluocinolone acetonide implant demonstrated sustained visual stability, significant anatomical improvement, reduced treatment burden, and a manageable safety profile. These findings support its role as an effective long-term therapeutic option for DME, including in vitrectomized eyes.

Purpose: To analyze anti-vascular endothelial growth factor (anti-VEGF) injection trends for Medicare Part B beneficiaries during the period 2013-2021, as well as before and after step therapy implementation. Methods: This study examined ophthalmologists administering intravitreal anti-VEGF injections to Medicare Part B beneficiaries from January 1, 2013 through December 31, 2021. Data were gathered from the Medicare Physician & Other Practitioners - by Provider and Service database and identified using Current Procedural Terminology codes specific to bevacizumab, ranibizumab, and aflibercept. Statistical analyses were conducted using R. Results: Among 26 602 816 total injections performed from 2013 to 2021, relative usage of aflibercept increased by 158.3%, while relative usage decreased by 27.5% for ranibizumab and 49.6% for bevacizumab. After step therapy implementation, relative usage of aflibercept increased by 32.0%, while there was a decrease in relative usage of bevacizumab by 33.2% and ranibizumab by 4.3%. When ophthalmologists were grouped according injection volume for each medication in 2021 (ie, top 10%, or high-volume injectors), the proportion of aflibercept injections performed by high-volume aflibercept injectors (32.3% of total nationwide aflibercept injections) was lower than the proportion of ranibizumab injections performed by high-volume ranibizumab injectors (43.2% of total nationwide ranibizumab injections) and the proportion of bevacizumab injections performed by high-volume bevacizumab injectors (41.2% of total nationwide bevacizumab injections). Ranibizumab was less frequently used than aflibercept or bevacizumab. Ophthalmologists in the study time period primarily treated patients with aflibercept and bevacizumab or aflibercept and ranibizumab, with many fewer using primarily ranibizumab and bevacizumab. Conclusions: Aflibercept usage has continued to rise, matched by a decline in bevacizumab usage and a modest decrease in ranibizumab usage. Step therapy has not significantly increased bevacizumab usage on an aggregate level.

Purpose: To evaluate the rate and impact of fibrosis on visual outcomes by choroidal neovascularization (CNV) type, based on spectral-domain optical coherence tomography (SD-OCT), in patients with neovascular age-related macular degeneration (nAMD). Methods: Fibrosis status and location at month 24, stratified by baseline CNV type, were evaluated using data from the HARBOR trial (NCT00891735). All patients (n = 1097) received pro re nata or monthly ranibizumab treatment. Results: Fibrosis was most common in eyes with type 2 CNV lesions (53%) compared with other types (type 1, 31%; mixed type 1 or 2, 45%; any type 3, 33%; P < .0001). The rate of fibrosis differed by less than or equal to 6% between monthly and pro re nata treatment regimens. In eyes with subretinal fibrosis, most (65% to 78%) showed subfoveal involvement at month 24. Mean visual acuity gains at month 24 were not negatively affected by the presence of fibrosis (type 1, 8.0 letters; type 2, 11.0; mixed type 1 or 2, 7.8; any type 3, 16.2), regardless of treatment regimen. Male sex and current smoking status were associated with significantly higher rates of fibrosis at month 24 (P < .0001 and P = .003, respectively). Conclusions: Many patients with nAMD develop fibrosis despite antivascular endothelial growth factor therapy, and the prevalence of fibrosis is affected by baseline CNV type.

Purpose: To assess quality of life over long-term follow-up in patients who received sutureless pars plana vitrectomy for symptomatic vitreous floaters, with short-term safety reexamined. Methods: A single-center, consecutive case series with retrospective analysis of clinical and surgical records preceding and following sutureless pars plana vitrectomy was conducted from May 2022 to December 2022. Descriptive statistics compared data preceding surgery to last clinic visit. A 10-item quality-of-life questionnaire was then distributed to patients 4 to 7 years following surgery, after institutional review board-approved consent was obtained via telephone. Results: A total of 142 eyes (117 patients) underwent sutureless 25- or 27-gauge pars plana vitrectomy for symptomatic vitreous floaters. Overall mean (± SD) best-available Snellen visual acuity was 20/30 (0.2 ± 0.2 logMAR) preoperatively, which improved to 20/25 (0.1 ± 0.2 logMAR) postoperatively (P < .01). Early postoperative complications occurred in 7 (4.9%) of 142 eyes, of which 4 had transient cystoid macular edema, and 3 had a vitreous hemorrhage (1 of which had an additional surgery). Survey responses were collected on 71.1% of eyes, with 91.1% of patients rating the procedure a "complete or significant success," and the same percentage recommending family members undergo the procedure. Floaters impacted quality of life moderately or severely before vitrectomy in 94.1% of patients. Recurrence of any floaters occurred in 31.7% of eyes, with 26.7% experiencing only mild symptoms, 3% having no symptoms at the time of survey, and 2% having significant floaters. No specific preoperative characteristics were found to be predictive of a dissatisfied patient or a significant recurrence of vitreous floaters. Conclusions: Long-term patient-reported outcomes of sutureless pars plana vitrectomy for symptomatic floaters demonstrated improvements in patient quality of life and visual outcomes, with a low rate of complications. Sutureless vitrectomy should be considered for symptomatic patients who report their subjective severity of daily symptoms as "moderate" or "severe" floaters.

Purpose: To describe a case of retinal vasculitis as a presenting sign of atypical neurosarcoidosis with occult central nervous system involvement. Methods: A case report and literature review are presented, highlighting the role of the ophthalmic examination and the importance of early neurologic workup for diagnosis and treatment. Results: A 27-year-old woman presented with monocular blurry vision, central scotoma, and headache. Ophthalmic examination demonstrated retinal vasculitis bilaterally, and systemic steroid treatment was initiated. Further neurologic workup with brain magnetic resonance imaging revealed multiple enhancing foci, consistent with features of inflammation. The neurologic disease was recalcitrant, showing no response to multiple steroid-sparing therapies over 2 years. Further workup was pursued, including a brain biopsy showing noncaseating granulomas with small-vessel vasculitis. The ophthalmic and neurologic presentation was consistent with a diagnosis of atypical neurosarcoidosis. Clinical resolution was ultimately achieved after treatment with infliximab. Conclusions: Retinal vasculitis should have a low threshold for initiating early neurologic workup to assess central nervous system involvement.

Purpose: To describe pseudoexfoliation glaucoma, the most common cause of secondary open-angle glaucoma, and its role in predisposing patients to lens dislocation owing to aggregation of fibrillar extracellular material on the zonules. Methods: Case report and retrospective review. Results: We describe a 78-year-old man with pseudoexfoliation glaucoma and a visually significant epiretinal membrane who experienced spontaneous crystalline lens dislocation during initiation of core vitrectomy with membrane peel. Phacofragmentation was performed to remove the dislocated crystalline lens. Conclusions: This case highlights pseudoexfoliation glaucoma as a risk factor for crystalline lens dislocation during core vitrectomy. Awareness of this complication can influence preoperative counseling and improve surgical planning.

Purpose: To characterize an asymptomatic carrier of ocular albinism without a known family history of visual impairment. Methods: Chart review of the patient's medical records. Results: Genetic testing revealed a deletion of exon 3 in her GPR143 gene (LCA5 c.1273 deletion). Conclusions: The patient showed characteristics of heterozygous carrier status for GPR143 alterations, including linear pigmentary changes in the fundus. This case is notable for the absence of a known family history of visual impairment and may represent a sporadic GPR143 deletion. Further studies are needed to examine genetic variants and deletions with ocular albinism type 1.