Cost-utility model of new intravitreous units vs. current patient journey model in Spain.

AIM: To compare the effectiveness and costs of the implementation of the Intravitreal Therapy Unit Model, endorsed by the SERV, SECA, SEO and SEDISA, compared to the usual procedure. METHOD: Analytical decision model that compares an UTI-type healthcare organization with 4 usual practice scenarios in Spain, in terms of quality-of-life results due to loss of visual acuity and the use of resources. The probability, cost, and quality-adjusted life years (QALYs) were estimated for each scenario proposed. A univariate sensitivity analysis was performed for each of the parameters used in the model. RESULT: The model showed that from any of the initial scenarios of the usual practice, transitioning to the UTI-type implementation improves the quality of life of patients and requires lower cost. UTI-type is dominant respect usual practice. The sensitivity analysis showed that the results would not change sign with the variation of any starting variable. CONCLUSIONS: Shorten suspicion-needle times is key to maintaining functional vision in patients requiring intravitreal treatment. The UTI-type model seeks the efficiency of ophthalmology services and can produce savings that vary between Є175 and Є85 per patient attended per year.

Evaluation of non-exudative tomographic signs in cases of exudative age-related macular degeneration.

OBJECTIVE: To analyse the prevalence of non-exudative tomographic signs (onion sign, pseudoswelling, external retinal tubulation, pseudocysts, subretinal clefts and macular atrophy) in patients with neovascular age-related macular degeneration. MATERIAL AND METHODS: A total of 174 eyes of patients with neovascular age-related macular degeneration who had not received previous treatment were included in the study. Visual acuity, neovascularization activity, and the appearance or not of the different signs under study were assessed at times 0 (initial visit), 4 months, one year, year and a half, and at 2 and 3 years of follow-up. The following were also evaluated: age, sex, affected eye and type of neovascularization (1, 2, 3, polypoid or mixed). The analysis were performed using the statistical software R (version 3.3.2) and the glmmADMB package (version 0.8.3.3). RESULTS: The presence of pseudocysts and external retinal tubulation increases throughout the follow-up. The onion sign begins with an ascending frequency up to 12 months, then decreases at 18 months and increases again at 24 months. Regarding pseudowelling, it maintains an increase until 18 months to finally decrease. Subretinal clefts is the rarest sign, presenting in 1.1% on the first visit. Finally, macular atrophy, present in 12.6% of the eyes initially, is found in 25% after 2 years. CONCLUSION: Pseudocysts, external retinal tubulation and macular atrophy were the most prevalent signs, while subretinal clefts were the most infrequent.

Retinal age as a predictive biomarker of the diabetic retinopathy grade.

OBJECTIVE: To apply artificial intelligence (AI) techniques, through deep learning algorithms, for the development and optimization of a system for predicting the age of a person based on a color retinography and to study a possible relationship between the evolution of retinopathy diabetes and premature ageing of the retina. METHODS: A convolutional network was trained to calculate the age of a person based on a retinography. Said training was carried out on a set of retinographies of patients with diabetes previously divided into three subsets (training, validation and test). The difference between the chronological age of the patient and the biological age of the retina was defined as the retinal age gap. RESULTS: A set of 98,400 images was used for the training phase, 1000 images for the validation phase and 13,544 for the test phase. The retinal gap of the patients without DR was 0.609 years and that of the patients with DR was 1905 years (p < 0.001), with the distribution by degree of DR being: mild DR: 1541 years, moderate DR: 3017 years, DR severe: 3117 years and proliferative DR: 8583 years. CONCLUSIONS: The retinal age gap shows a positive mean difference between diabetics with DR versus those without DR, and it increases progressively, according to the degree of DR. These results could indicate the existence of a relationship between the evolution of the disease and premature ageing of the retina.

Update on the utility of en face optical coherence tomography in the assessment of vitreoretinal diseases.

En face optical coherence tomography (EF-OCT) is a rapid, non-invasive, high-resolution imaging technique that has evolved in recent years to be a routine examination for the assessment and follow-up of various vitreoretinal diseases. With the introduction of swept-source OCT (SS-OCT), which can achieve up to 100,000 A-scans per second and better-quality imaging of deeper structures using a longer wavelength (1050nm), EF-OCT reconstruction can produce high-resolution frontal images of the retina and choroid (C-Scans) that give an overview of disease extent. These images allow a more accurate study of vitreoretinal interface pathologies such as epiretinal membranes, macular holes, and vitreomacular traction. They also provide key information in the study of various retinal vascular diseases and the differential diagnosis of cystic macular edema. EF-OCT provides valuable information about the severity of vitreoretinal interface alterations and precisely assesses the choriocapillaris and choroidal vasculature in pachychoroid disorders. Finally, this technique provides valuable information about atrophic and neovascular age-related macular degeneration and various uveitic entities. This review aims to describe the current clinical applications of EF-OCT in various vitreoretinal diseases as well as the latest findings and future perspectives.

Dexamethasone implant prior to anti-VEGF therapy in pigment epithelium detachments with high-risk rupture characteristics secondary to neovascular age-related macular degeneration.

OBJECTIVE: Evaluate the incidence of pigment epithelial tear when intravitreal delayed-release dexamethasone implant is administered (off-label use) prior to antiangiogenic treatment in pigment epithelium detachments (PED) secondary to neovascular age-related macular degeneration (nAMD) with high-risk rupture characteristics and investigate if it causes a decrease in the PED size. METHODS: Patients with nAMD, PED height >500 microns and Ozurdex implant prior to the antiangiogenic therapy were included. The presence of pigment epithelium rupture in optical coherence tomography scans, best-corrected visual acuity (BCVA) and PED measurements (maximum height and diameter) were registered. RESULTS: The study included 14 eyes of 14 patients: mean age 77 ±â€¯7 years, 11 (79%) females. 25 ±â€¯13 days after the Ozurdex, patients started with at least 3 anti-VEGF monthly injections. BCVA improved from 64 ±â€¯14-69 ±â€¯11 letters after anti-VEGF therapy (p > 0.05). Mean baseline PED height was 817 ±â€¯269 µm, being 639 ±â€¯268 µm after Ozurdex and 370 ±â€¯260 µm after anti-VEGF injections (p = 0.035 and p = 0.009). One retinal pigment epithelium tear occurred (7%). No other adverse effects were reported. CONCLUSIONS: Dexamethasone implant prior to anti-VEGF therapy may represent a promising therapeutic modality for large PED in nAMD, reducing PED dimensions and the risk of pigment epithelium tears prior to anti VEGF therapy.

Assessment of the perception of healthcare barriers and the impact of intravitreal injections on neovascular age-related macular degeneration.

AIM: To evaluate the perception of barriers in healthcare and the impact of intravitreal injections in patients with neovascular age-related macular degeneration (nAMD). METHODS: Cross-sectional study including 108 patients with nAMD in treatment with intravitreal injections. The patients answered a questionnaire with 26 questions (score from 1 to 5) divided in three sections: 1) the disease and its treatment with injections, 2) healthcare barriers and 3) new technologies. RESULTS: The mean age was 80.4 ±â€¯7.0 years and visual acuity (VA) was 75.2 ±â€¯12.4 letters. The main barriers in healthcare were long waiting times (72%), followed by other comorbidities (10%). Some 63% of patients have to wait between 3 and 5 h to attend their clinical visit. Significant anxiety due to the injections (2.8 ±â€¯1.3) was observed, being present in 71% of the cases the day before. A great fear of blindness and losing independence was observed (4.4 ±â€¯0.9 and 4.3 ±â€¯1.1), with no differences in relation to VA, age or sex (p ≥ 0.135). Moreover, 28% of the patients reported that it was quite or very difficult for them to attend the clinical visit, with 69% of the total showing great interest in having a diagnostic device at home. CONCLUSION: The nAMD and its treatment represent a significant burden on patients, among whom there is a great fear of blindness and of losing their independence, the main barrier being the long waiting time for the clinical visit.

Assessment of vision-related quality of life and depression and anxiety rates in patients with neovascular age-related macular degeneration.

PURPOSE: To assess the vision-related quality of life and the depression and anxiety rates in patients with neovascular Age-Related Macular Degeneration (nAMD). METHODS: A cross-sectional study of patients with nAMD treated with intravitreal injections was performed. The patients completed two validated questionnaires: the Visual Functioning Questionnaire (VFQ-25, score from 0 to 100), and the Hospital Anxiety and Depression Scale (HADS) questionnaire. Age, gender and visual acuity (VA) in the Early Treatment Diabetic Retinopathy Study (ETDRS) scale was registered. RESULTS: Fifty-five patients with nAMD participated with a mean age of 80.9 ± 6.6 years-old (range 67-93) and a mean VA in the best eye of 73.5 ± 12.7 letters (range 44-95). The global VFQ-25 mean score was 57.4 ± 21.9 being 38.9 ± 13.2 for the general vision and 42.0 ± 19.5 for the general health. VA in the best eye was associated with the global score of the VFQ-25 scale (R = 0.608; P < .001), but no correlation was observed with general health (P = .936). In the HADS scale, 26.9% and 25.5% of patients had symptoms of depression and anxiety respectively. A negative correlation was found between the HADS and VFQ-25 scales for the general vision score (R = -0.438). CONCLUSION: This study elucidates the impact of vision impairment and the visual functioning in nAMD, describing an important rate of depression and anxiety symptoms.

Update on the management of chronic central serous chorioretinopathy. / Actualización en el tratamiento de la coriorretinopatía serosa central crónica.

Central serous chorioretinopathy (CSC) is one of the main causes of impaired visual acuity in patients younger than 60 years. Its pathophysiology remains partially unknown, although it has been postulated that choroidal hyper-permeability may be involved. This typically produces a neurosensory retinal detachment and/or a detachment of the retinal pigment epithelium in the posterior pole. Although acute CSC generally does not require treatment, when chronic it must be treated to avoid visual impairment. With the development of new imaging techniques, there has been an improvement in diagnosis, and different therapeutic strategies have been proposed. Various treatments for the management of chronic CSC have currently been shown to be useful to improve or stabilise visual acuity, the resolution of subretinal fluid, and to prevent recurrences. The most commonly used treatments today are photodynamic therapy, micropulse subthreshold laser, mineralocorticoid antagonists, or anti-vascular endothelial growth factor drugs. There are also other proposals and new treatments being developed, with promising results. This review aims to provide the reader with an overview of the current scientific evidence of the different treatment options available for CSC in order to help decision-making in clinical practice.