Ophthalmology. Retina最新文献

Topic: Macular atrophy incidence in neovascular age-related macular degeneration (AMD) patients undergoing anti-vascular endothelial growth factor (VEGF) treatment.

Clinical relevance: Macular atrophy is a significant event that may occur in eyes with neovascular AMD treated with anti-VEGF therapy.

Methods: We conducted a systematic review and meta-analysis following PRISMA guidelines (PROSPERO, CRD42024474924). A comprehensive literature search of MEDLINE, EMBASE, and Web of Science was performed up to November 1, 2023. Randomized and non-randomized studies of treatment-naïve neovascular AMD patients reporting macular atrophy incidence at 24±3 months after anti-VEGF therapy were eligible for inclusion in this review. Two independent reviewers conducted screening, data extraction, and quality assessment. For randomized controlled trials, the Cochrane Risk of Bias 2 tool was employed, while non-randomized studies were evaluated using the ROBINS-I tool. Random-effects meta-analysis models were used for quantitative synthesis, accounting for study variability. Heterogeneity was assessed with the I² statistic, and publication bias by funnel plots and Egger's test. The primary outcome was the incidence of new macular atrophy at 24 months post-anti-VEGF therapy, with secondary outcomes at 12 months. Atrophy was diagnosed using color fundus photograph (CFP), fluorescein angiography (FA), fundus autofluorescence (FAF), optical coherence tomography (OCT), or multimodal imaging.

Results: Twenty-three studies met the inclusion criteria for qualitative analysis, with 11 included in the meta-analysis (N=3,013 eyes). The pooled 24-month incidence of macular atrophy was 29% (95% confidence interval [CI]:20%-38%,I²=93%). Subgroup analysis revealed incidence rates of 26% (95% CI:15%-37%,I²=88%) for 814 eyes with Type 1/2 macular neovascularization (MNV), 49% (95% CI:18%-80%,I²=92%) for Type 3 MNV (N=230 eyes), and 29% (95% CI:18%-40%,I²=96%) for all MNV types (N=2,131 eyes). The pooled 12-month incidence among 2,214 eyes was 11% (95% CI:4%-18%,I²=93%). The certainty of evidence regarding the incidence of macular atrophy after anti-VEGF treatment, as assessed by GRADE, was low.

Conclusions: While this meta-analysis has limitations, including a moderate risk of bias in non-randomized studies, inconsistencies in the results indicated by high heterogeneity, and imprecision due to the different imaging modalities used to diagnose macular atrophy, our results suggest that macular atrophy could be a common complication in neovascular AMD patients receiving anti-VEGF therapy.

Purpose: Laser photocoagulation (LPC) has been a traditional treatment for retinopathy of prematurity (ROP). However, intravitreal anti-VEGF agents such as bevacizumab and ranibizumab (IVR) have also been increasingly used. This meta-analysis aims to rigorously compare IVR to LPC in the treatment of ROP.

Methods: Medline, Embase and Cochrane CENTRAL were used to identify studies comparing IVR monotherapy to LPC (PROSPERO ID: CRD42023390855). The primary outcome was ROP regression. Secondary outcomes included likelihood of additional treatment, time from treatment to reactivation or re-treatment, refractive outcomes and adverse events such as retinal detachment, cataract, macular dragging/ectopia, vitreous or retinal hemorrhage, glaucoma, and endophthalmitis. A random effects meta-analysis was designed.

Results: 2361 articles were identified. 1947 eyes from 7 cohort studies, 1 case-control study and 2 RCTs were included with a median follow-up of 21 months (range: 11-75 months). There was no significant difference in disease regression between IVR and LPC (risk ratio [RR]=0.96, 95% confidence interval [CI] [0.83, 1.10], p=0.52), however, eyes that underwent IVR were associated with a higher likelihood of requiring additional treatment (RR= 2.70, CI= [1.55, 4.68], p<0.001). Although less frequent, retreatment occurred earlier with LPC compared to IVR (weighted mean difference (WMD)= -4.29 weeks, CI= [-6.48, -2.10], p<0.001). Furthermore, eyes that received IVR had a lower refractive error, with a WMD of -0.93 diopters (CI= [-1.54, -0.32], p=0.003) at a median age of assessment of 5.0 years (range 1.5-6.3 years). There was no difference in the rate of adverse events between LPC and IVR (p>0.05 for RD, MDR, VH and cataract). Quality of evidence was rated moderate for likelihood and time of additional treatment, as well as refractive error, but was considered low for disease regression and adverse events.

Conclusion: Compared to LPC, IVR was associated with a higher likelihood of requiring additional treatment but a lower risk of myopia. More studies are needed to evaluate dose-response relationships and temporal trends in ROP regression following these treatments.

Topic: To evaluate the prognosis of retinal fluid resolution in neovascular age-related macular degeneration (nAMD) after initiating treatment in terms of the prevalence of eyes with retinal fluid, the proportion of eyes which never achieve a fluid-free retina throughout the course of treatment, and the relationship between retinal fluid and visual acuity outcome.

Clinical relevance: Retinal fluid often persists or recurs after initiating treatment for nAMD. It is unclear what proportion never achieve fluid resolution throughout their treatment course.

Methods: MEDLINE, Embase, and Web of Science were searched till May 2024 for randomized control trials (including post-hoc analyses) and prospective studies treating nAMD patients with intravitreal anti-VEGF injections (CRD42023437516). To investigate the prevalence of persistent fluid, a meta-analysis of proportions was conducted at key time-points. To estimate the proportion of poor-responding patients, iterative algorithms were used to simulate individual-patient-data from time-to-fluid fluid-resolution Kaplan-Meier curves. Cure fractions from Weibull non-mixture cure models were meta-analysed. Finally, the weighted mean BCVA difference (WMD) between patients with and without any fluid, SRF or IRF was calculated.

Results: Fifty articles were included across the meta-analysed outcomes. The pooled prevalence of retinal fluid was 41.4% (95%CI:35.0%-48.0%) at 1 year, and 47.4% (95%CI:38.5%-56.5%) at 2 years. The pooled median time-to-first fluid-resolution was 10.2 weeks (95%CI:7.66-14.59 weeks). Cure modelling suggests that 17.6% (95%CI: 11.9%-25.3%) of patients may never achieve a fluid-free finding in the long run despite prolonged treatment. Eyes with SRF had significantly higher BCVA compared to eyes without SRF at 12m (WMD 2.39 letters; 95%CI, 0.27-4.52; p<0.05). Eyes with IRF had significantly poorer BCVA compared to eyes without IRF at 12m (WMD -5.38 letters; 95% CI, -8.65 - -2.11; p<0.05). At long follow-up (>60m), eyes with SRF had significantly higher BCVA compared to eyes without SRF (WMD 7.69 letters; 95%CI, 2.79-12.59; p<0.05).

Conclusions: Notwithstanding the heterogeneity in studies included, our analysis estimates that nearly half of all treated patients have persistent retinal fluid after initiating treatment and a substantial 18% of patients may never attain complete fluid resolution. We confirm that SRF is associated with better visual outcomes, while IRF is associated with worse visual outcomes.

Time-driven activity-based costing analysis of panretinal photocoagulation shows 47.8% of cases have a negative margin relative to maximum Medicare reimbursement, with large financial disincentives for bilateral cases, which may disincentivize high-value care for vulnerable patients.

Purpose: We surveyed vitreoretinal (VR) fellowship program directors (PDs) to elucidate how they assess surgical competency among VR fellows. In addition, we also surveyed fellowship program graduates for the years 2022 and 2023 regarding assessment metrics and tools used during VR fellowship training.

Design: Web-based, cross-sectional descriptive study.

Subjects: Fellowship PDs and recent fellowship graduates in the United States and Canada METHODS: The survey, distributed via email, queried participants about several aspects of assessing surgical competency in VR training including surgical numbers, teaching/assessment methods used to assess fellow surgical competency, comfort of fellows for various surgical procedures, appropriate degree of supervision, and criteria for a hypothetical national competence standard. A Likert scale was utilized for questions capturing participants opinion. Mean response scores were reported.

Main outcome measure: Comparison of responses between PDs and fellows RESULTS: Forty-two PDs (42.1%) (33: University-based and 9: Private institutions) and forty fellows (16.8%) (28: Academic and 12: Private institutions) responded to survey. Fellows expect a higher minimum number of vitrectomies (at least 300) by graduation compared to PDs (at least 200). Both PDs and fellows ranked direct observation of fellow (4.95), discussion with other faculty on fellow surgical performance (3.93), and outcomes of fellow surgical cases (3.88) (p>0.05), as top three teaching tools. Both PDs and fellows expressed high comfort levels with various complex surgeries, such as primary scleral buckle (4.45), proliferative vitreoretinopathy detachments (4.57), advanced diabetic retinal detachments (4.57), and giant retinal tears (4.64), by the time of graduation. Autonomy was also considered an important indicator of surgical competence by both groups. However, apart from direct surgical experience, fellows rated other educational tools lower than PDs. There was overall agreement between the groups on several aspects of a hypothetical national competence standard.

Conclusion: This survey identified key tools utilized to assess surgical proficiency were direct observation of surgery by attending, discussions about fellow performance among faculty, and outcomes of fellow surgical cases. Both groups emphasized that by graduation, fellows should be proficient in several complex vitreoretinal surgeries. These findings suggest a need for a more systematic approach to assess surgical competency of VR fellow.