Volume 20, Number 12Monday, March 16, 2020MARCH IS WORKPLACE EYE WELLNESS MONTH Management & Outcomes for nAMD: Analysis of U.S. EHRsResearchers assessed anti-vascular endothelial growth factor management patterns, and anatomic and visual acuity outcomes among individuals with neovascular age-related macular degeneration in U.S. clinical practice, as part of a retrospective, observational cohort study.A total of 30,106 individuals (37,021 study eyes) initiating intravitreal anti-VEGF treatment for nAMD between October 2009 and November 2016, were included. Researchers performed an analysis of longitudinal electronic health records from the USRetina database Main outcome measures included intravitreal injections, optical coherence tomography scans and fluorescein angiography procedures received per study eye during the first 12 months; corrected visual acuity and central retinal thickness at 12 months (absolute value and change from baseline); and number of ophthalmologist visits, stratified by index anti-VEGF agent. Here were some of the findings: • Over the first 12 months, patients made a mean of 8.1 ophthalmologist visits (range: 1 to 39), and received a mean of six intravitreal anti-VEGF injections (range: one to 27), 7.2 OCT scans and 5.3 FA procedures per study eye. • For eyes with paired baseline and 12-month anatomic and visual readings, mean CRT declined from 320 to 271 μm (mean change: -48 μm), and mean VA increased from 60.3 to 61 approximate ETDRS (approxETDRS) letters (mean change: +0.6). • Twelve months after initiating index treatment: 19.3 percent (bevacizumab), 15.8 percent (ranibizumab) and 15.5 percent (aflibercept) of eyes showed >10-letter gain, whereas 13.2 percent (bevacizumab), 14.7 percent (ranibizumab) and 14.4 percent (aflibercept) of eyes showed >10-letter loss. • Mean change from baseline in VA at 12 months tended to increase linearly with the number of anti-VEGF injections administered over the first 12 months: +1.79 vs. -0.95 approxETDRS letters for eyes receiving at least seven injections vs. those receiving less than seven. • Similarly, the magnitude of the reduction from baseline in CRT at 12 months tended to increase linearly as the number of anti-VEGF injections increased. • Multivariate linear regression analysis, adjusted for covariates, indicated a significant association between cumulative number of anti-VEGF injections and change from baseline in VA at 12 months, with each unit increase producing an estimated gain of 0.37 approxETDRS letters. Researchers wrote that the analysis of combined morphological/functional outcomes of anti-VEGF therapy, the largest conducted to date in nAMD, identified relatively low anti-VEGF injection frequencies, coupled with moderate anatomic and limited visual acuity improvements, in U.S. clinical practice. SOURCE: Kiss S, Campbell J, Almony A, et al. Management and outcomes for neovascular age-related macular degeneration: Analysis of us electronic health records. Ophthalmology 2020; Feb 27. [Epub ahead of print]. Comparison Study Between SAP & Eye Movement PerimetryInvestigators wrote that their eye movement perimetry study described the development of saccadic reaction time (SRT)-based visual field plots which could effectively display the presence, location and extent of glaucomatous defects, and support clinical decision making. Source: Mazumdar D, Pel J, Kadavath Meethal NS, et al. Visual field plots: A comparison study between standard automated perimetry and eye movement perimetry. J Glaucoma 2020; Feb 27. [Epub ahead of print.] DRCR Retina Network Management Approach with Initial Observation for Center-involved DME & Good VAScientists aimed to assess the DRCR Retina Network protocol-defined approach and outcomes of initial observation with aflibercept only if VA worsened. This post hoc secondary analysis of a randomized clinical trial of the DRCR Retina Network Protocol V included 91 U.S. and Canadian sites from November 2013 to September 2018.Adults (n=236) with type 1 or 2 diabetes, one study eye with center-involved diabetic macular edema (CI-DME) and VA letter score of at least 79 (Snellen equivalent, 20/25 or better) were assigned to initial observation. Data were analyzed from March 2019 to November 2019. Initial observation and follow-up included aflibercept only for VA loss of at least 10 letters from baseline at one visit, or five to nine letters at two consecutive visits. Follow-up occurred at eight weeks and then every 16 weeks unless VA or optical coherence tomography central subfield thickness worsened. Main outcomes and measures included whether individuals received aflibercept. Here were some of the findings: • Among 236 eyes in 236 individuals (149 [63 percent] male; median age, 60 years [interquartile range: 53 to 67 years]) randomly assigned to initial observation, 80 (34 percent) were treated with aflibercept during two years of follow-up. • At two years, the median VA letter score was 86 (interquartile range: 89 to 81; median Snellen equivalent: 20/20 [20/16 to 20/25]). • Receipt of aflibercept was more likely: o in eyes with baseline central subfield thickness at least 300 μm (Zeiss-Stratus equivalent) vs. less than 300 μm (45 percent vs. 26 percent; hazard ratio [HR]: 1.98 [CI, 1.26 to 3.13], continuous p=0.005); o in eyes with moderately severe nonproliferative diabetic retinopathy (Early Treatment Diabetic Retinopathy Study retinopathy severity level 47) and above vs. moderate nonproliferative diabetic retinopathy (retinopathy severity level 43) and below (51 percent vs. 27 percent; HR, 2.22 [CI, 1.42 to 3.47], ordinal p<0.001); and o among participants whose nonstudy eye received DME treatment within four months of randomization vs. not (52 percent vs. 25 percent; HR: 2.55 [CI, 1.64 to 3.99], p<0.001). Scientists found that most eyes managed with initial observation plus aflibercept only if VA worsened maintained good vision at two years and didn’t require aflibercept for VA loss. However, trial eyes were approximately twice as likely to receive aflibercept for VA loss if they had greater baseline central subfield thickness, worse diabetic retinopathy severity level or a non-study eye receiving treatment for DME. SOURCE: Adam Glassman, Baker CW, Beaulieu WT, et al. Assessment of the DRCR retina network approach to management with initial observation for eyes with center-involved diabetic macular edema and good visual acuity. JAMA Ophthalmol 2020; Feb 20. [Epub ahead of print]. Minimizing Hyperopic Shift Post-DMEKResearchers evaluated different corneal parameters in identifying patients at risk of a hyperopic shift after Descemet’s membrane endothelial keratoplasty. The retrospective study included 92 eyes with Fuchs’ endothelial corneal dystrophy (FECD) after DMEK surgery.Pachymetry parameters, various tomographic parameters and densitometry values before and after DMEK were determined using a rotating Scheimpflug system (Pentacam HR, Oculus). To assess the posterior to anterior corneal curvature relationship, researchers calculated the RPA (posterior to anterior corneal curvature radii ratio). • The average keratometry reading of the posterior corneal surface (KmB) increased and the total corneal refractive power (TCRP) decreased significantly after surgery (p<0.001). • Researchers found a significant difference between the preoperative and postoperative RPA (p<0.001) and the posterior Q value (p<0.001). • The strongest correlation was found between the change in the KmB and the preoperative RPA (Spearman’s correlation coefficient=0.872, p<0.001). • In the receiver operating characteristic analysis, the highest area under the curve values (for ∆KmB) among the different preoperative parameters tested were obtained for RPA (0.95 area under the ROC [AUROC]; and posterior Q value (Asph. QB)(0.89 AUROC). Researchers determined that the Q value and the RPA showed the highest correlation with the change in corneal refractive power and the greatest AUC. They added that these parameters could be used as surrogate markers to identify eyes that might be at risk for a greater postoperative hyperopic shift, which would allow for a more accurate setting of refractive goals. SOURCE: Diener R, Eter N, Alnawaiseh M, et al. Using the posterior to anterior corneal curvature radii ratio to minimize the risk of a postoperative hyperopic shift after Descemet membrane endothelial keratoplasty. Graefes Arch Clin Exp Ophthalmol 2020; Jan 31. [Epub ahead of print]. 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