Journal of VitreoRetinal Diseases最新文献

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.

Purpose: To examine the long-term visual and morphologic outcomes in a large series of patients with pachychoroid neovasculopathy (PNV) treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Methods: A retrospective, observational study of anti-VEGF injections in 249 eyes of 237 patients with PNV at 1 retina center over 7 years. Results: Mean patient age was 65.5 years and mean follow-up was 1.91 years (range 3 months to 7.14 years). At baseline, mean best-corrected visual acuity (BCVA) was 20/60 Snellen, with an improvement of 2.30 ETDRS letters by the study endpoint (P = .04). From baseline to endpoint, mean central subfield thickness decreased by 78.2 μm, and mean choroidal thickness decreased by 35.4 μm (each P < .05). Treat-and-extend was utilized in 192 eyes (77.9%), with a 42.3% recurrence rate on extension. Treatment cessation was trialed in 70 eyes (28.1%), of which 53 eyes required no further treatment. Adjunct photodynamic therapy was utilized in 34 eyes (13.7%), resulting in a mean vision improvement of 0.44 ETDRS letters, compared with a mean improvement of 2.30 ETDRS letters in patients who received anti-VEGF only (P = .6). Conclusions: Anti-VEGF therapy improved BCVA and anatomic features in this large cohort of patients with PNV. Continued treatment was required in 196 eyes (78.7%) at the study endpoint.

Purpose: To evaluate the association between central subfield thickness (CST) fluctuations and visual acuity (VA) outcomes in eyes with diabetic macular edema (DME) undergoing antivascular endothelial growth factor (anti-VEGF) therapy. Methods: We conducted a retrospective review of patients with DME who initiated treatment between 2016 and 2017 at a multicenter retina practice. Eligible eyes had a follow-up period of 40 weeks or longer and received 3 or more anti-VEGF injections. CST fluctuations were determined using the SD of CST measurements across visits and stratified into quartiles. Stepwise linear regression analysis determined the impact of factors on best-corrected VA (BCVA). Results: A total of 499 eyes from 333 subjects were included. Eyes received a mean of 15.7 anti-VEGF injections (range, 3-50) over 18.8 visits (range, 3-67) across a mean of 121.3 weeks (range, 40.6-230.3). Mean (± SD) CST at DME diagnosis and at the final visit was 353.7 ± 134.8 µm and 287.2 ± 78.9 µm, respectively; mean change was 42.4 ± 47.3 µm. Eyes with the greatest CST fluctuations had worse baseline and final VA, as well as baseline and final CST (P < .0001). Each 100 μm increase in CST SD was independently associated with 12.9 fewer letters read at 121.3 weeks. Factors independently associated with better final VA were smaller CST SD, smaller final CST, a greater number of anti-VEGF injections, and younger age. Conclusions: Consistent with previous analyses, increased CST fluctuation was independently associated with worse final BCVA. Large CST fluctuations may serve as a poor prognosticator for visual outcomes among patients with DME.

Purpose: To describe a novel surgical approach for eyes with persistent macular edema (ME) complicated by intracystic hyperreflective material. Methods: Pars plana vitrectomy and dye-assisted internal limiting membrane (ILM) peeling were performed in cases with chronic and/or refractory intracystic hyperreflective material. Microscope-integrated optical coherence tomography (OCT) was used to localize cysts and intracystic hyperreflective material, perform cyst puncture, and monitor cyst collapse. Functional and structural outcomes were assessed longitudinally over a minimum follow-up of 3 months. Results: Decimal visual acuity improved from a median of 0.28 (20/71.4) to 0.50 (20/40) over a median follow-up of 6 months. No patient required repeat intravitreal injection or experienced recurrence of intracystic hyperreflective material. Conclusions: ILM peeling combined with integrated OCT-guided cyst puncture may improve outcomes and reduce treatment burden in eyes with persistent ME and intracystic hyperreflective material. Additional controlled studies are needed to establish the broader utility of this technique.

Purpose: To use time-driven activity-based costing to calculate the complete cost profile of new uveitis patient visits. Methods: A multicenter cohort of consecutive patients referred for new uveitis evaluation, including all anatomic locations of uveitis, was included for economic analysis. Process flow mapping, electronic health record time logs, and manual validation were used for time-driven activity-based costing analysis. Imaging time and resources, which are billed separately, were excluded. Results: Time-driven activity-based costing analysis of new uveitis patient visits resulted in an average total cost of $550.50 per visit, including $56.78 of overhead (95% CI, $493.74 to $607.27). On average, patient visits required 36.6 minutes of physician time pre-visit, 30.1 minutes during the visit, and 31.7 minutes post-visit. Relative to Medicare reimbursement, the average cost resulted in losses of $325.78 for Current Procedural Terminology (CPT) code 99205 and $380.16 for CPT code 99204. The G2211 add-on CPT code compensated for 3.23 minutes of in-visit physician time. Conclusions: The cost of new uveitis patient visits exceeds maximum Medicare reimbursement in both academic and private practice settings. These findings may inform policy discussions on reimbursement to better reflect the time and expertise required for complex uveitis patient evaluation and management.