Cost-effectiveness of dexamethasone and triamcinolone for the treatment of diabetic macular oedema in Finland: A Markov-model.

PURPOSE: Diabetic macular oedema (DMO), a complication of diabetes, causes vision loss and blindness. Corticosteroids are usually used as a second-line treatment. The aim of this study was to analyse the cost-effectiveness of dexamethasone implants compared to cheaper and more frequently applied triamcinolone injections. METHODS: Markov-modelling, which incorporated both eyes, was used for economic evaluation. The model consisted of five health states based on visual acuity, illustrating the progression of DMO. A cycle length of five months was chosen for dexamethasone and four months for triamcinolone. Time horizons of two and five years were applied. Transition probabilities and health state utilities were sourced from previous studies. The perspective used in this analysis was the hospital perspective. The health care costs were acquired from Kuopio University Hospital in Finland. RESULTS: In this cost-effectiveness analysis, the incremental cost-effectiveness ratio ICER with 3% discount rate was €56 591/QALY for a two-year follow-up and -€1 110 942/QALY for a five-year follow-up. In order to consider dexamethasone as cost-effective over a 2-year time horizon, the WTP needs to be around €55 000/QALY. Over the five-year follow-up, triamcinolone is clearly a dominant treatment. Sensitivity analyses support the cost-effectiveness of dexamethasone over a 2-year time horizon. CONCLUSIONS: Since the sensitivity analyses support the results, dexamethasone would be a cost-effective treatment during the first two years with WTP threshold around €55 000/QALY, and triamcinolone would be a convenient treatment after that. This recommendation is in line with the guidelines of EURETINA.

Visual processing in patients with age-related macular degeneration performing a face detection test.

PURPOSE: People with age-related macular degeneration (AMD) have difficulties in familiar face recognition and facial expression discrimination. Our aim was to evaluate the visual processing of faces in AMD patients and whether this would be improved by anti-vascular endothelial growth factor therapy. This was a prospective interventional cohort study. PATIENTS: Twelve patients with monocular wet AMD and 6 control subjects were recruited. Face detection processes were studied using cortical event-related potentials (ERPs). Patients received 3 bevacizumab intravitreal injections to the single affected eye. At baseline and 4-6 weeks after the last injection, clinical presentation and ERPs of the face task were evaluated. Face pictures were shown as targets (16.7%) among standard pictures of pixelated faces in an oddball-type paradigm. RESULTS: Face pictures elicited well-defined electrical components in occipital and parieto-occipital cortical areas at baseline and after treatment. The face-specific N170 component was evident in all subjects with longer peak latency in patients than in controls (170±13 vs 155±14, P=0.032). Unexpectedly, an early component reflecting unintentional prediction of perceiving a face, that is, deviance-related negativity, was present in patients and controls. Visual acuity of the affected eye seemed improved in patients from logarithm of the minimum angle of resolution 0.71 (±0.33) to 0.52 (±0.39) by 119 (±23) days without accompanying significant change in face-specific ERPs. CONCLUSIONS: Monocular wet AMD distinctly influenced face-specific brain electrophysiological components. However, the anti-vascular endothelial growth factor treatment did not improve the binocular face detection ability. The EudraCT number of this study is 2012-000765-20.

Cost-effectiveness of treating wet age-related macular degeneration at the Kuopio University Hospital in Finland based on a two-eye Markov transition model.

PURPOSE: Wet age-related macular degeneration (AMD) is the leading cause of blindness worldwide, which can be treated with regular intraocular anti-vascular endothelial growth factor (VEGF) injections. In this study, we wanted to evaluate whether less frequent injections of aflibercept would make it more cost-effective when compared with ranibizumab and low priced bevacizumab. METHODS: We used a two-eye model to simulate the progression and the treatment of the disease. We selected an 8-year period, 3-month cycles and five health states based on the visual acuity of the better-seeing eye. The transition probabilities and utilities attached to the health states were gathered from previous studies. We conducted the analysis from the hospital perspective and we used the health care costs obtained from Kuopio University Hospital. The costs of intraocular adverse events were taken into account. RESULTS: The incremental cost-effectiveness ratio (ICER) with 3% discount rate (€/QALY) for aflibercept compared with monthly bevacizumab was 1 801 228 and when compared with ranibizumab given as needed, the ICER was minus 3 716 943. The sensitivity analysis showed that a change of 20% of the estimated model parameters or a longer follow-up period did not influence these conclusions. CONCLUSION: A two-eye Markov transition model was developed to analyse the cost-effectiveness of wet AMD treatment, as quality of life years (QALYs) are largely based on the visual acuity of the better-seeing eye. Monthly injected bevacizumab was the most cost-effective treatment and monthly ranibizumab the least effective.

Best-corrected visual acuity and retinal thickness are associated with improved cortical visual processing in treated wet AMD patients.

PURPOSE: In response to anti-VEGF treatment for wet AMD retinal anatomy and visual acuity is often remedied. In our previous study, we showed that visual evoked potentials (VEP) improve following successful anti-VEGF treatment. The aim of this study was to investigate, how visual acuity and retinal thickness changes are reflected in VEP parameters. Moreover, we wanted to assess the feasibility of VEP as a novel monitoring tool for wet AMD patients. METHODS: A total of 16 patients and six control subjects were enrolled in this study. Patients received three bevacizumab intravitreal injections. At the beginning of the study and four to 6 weeks after the last injection, the best-corrected visual acuity (BCVA) test, full biomicroscope examination, OCT analysis and VEP were performed. RESULTS: In treated eyes, logMAR visual acuity improved on average 0.18 ± 0.32 units, OCT retinal thickness decreased 170 ± 200 micrometres and VEP amplitude increased 1.0 ± 1.4 microvolts. All changes were significant at p < 0.05. There was a significant correlation between the relative changes of VEP amplitude and retinal thickness r = -0.630 (p < 0.05), and between visual acuity (logMAR) and retinal thickness r = 0.576 (p < 0.05). CONCLUSION: We showed that both the increase in VEP amplitude and the improvement in visual acuity are associated with the decrease in retinal thickness in treated wet AMD patients. The results do not indicate additional usefulness of VEP in the diagnosis or monitoring of wet AMD.

Changes in neurophysiologic markers of visual processing following beneficial anti-VEGF treatment in macular degeneration.

PURPOSE: Antivascular endothelial growth factor (VEGF) agents have been shown to improve visual acuity and prevent vision loss in exudative age-related macular degeneration. As the vision improves relatively quickly in response to intravitreal injections, we wanted to know whether this improvement is reflected in electrophysiological markers of visual cortical processing. PATIENTS AND METHODS: Our interventional case series included six elderly patients who underwent injection treatment to the affected eye. Their visual acuity, tomographic images of retinal thickness, and visual evoked potentials (VEP) were assessed before treatment and six weeks after the last injection. RESULTS: All patients showed improved visual acuity and reduced retinal fluid after the treatment. All but one patient showed increased VEP P100 component amplitudes and/or shortened latencies in the treated eye. These VEP changes were consistent with improved vision while the untreated eyes showed no changes. CONCLUSIONS: Our results indicate that antivascular endothelial growth factor injections improved visual function of the treated eyes both in the level of the retina and in the level of visual cortical processing.

Electrocardiographic left ventricular hypertrophy has low diagnostic accuracy in middle-aged subjects.

OBJECTIVE: To evaluate the usefulness of electrocardiographic left ventricular hypertrophy (ECG LVH) as a marker of LVH in middle-aged subjects. METHODS: LVH was determined by cardiovascular magnetic resonance imaging (MRI) in 188 apparently healthy middle-aged [97 men (45+/-7 years) and 91 women (47+/-6 years)]. Receiver operating characteristic (ROC) curves, test sensitivity, specificity, positive and negative predictive values for identifying LVH at different ECG criteria were calculated. RESULTS: Systolic and diastolic blood pressures were 142+/-13 mmHg and 90+/-8 mmHg in men and 139+/-10 mmHg and 90+/-8 mmHg in women, respectively. LVMI was 78+/-17 g/m2 in men and 67+/-12 g/m2 in women, and 14% of men and 22% of women had LVH in cardiac MRI. Only Sokolow-Lyon and Sokolow-Lyon product had the area under the ROC curve over 0.70. Sokolow-Lyon product had the highest sensitivity (47%). All ECG criteria had high negative predictive values, but the positive predictive values were below 46%. CONCLUSIONS: Commonly used ECG criteria of LVH have low discrimination ability in middle-aged subjects. ECG LVH alone should not be used as a marker of target organ damage in middle-aged, never treated and apparently healthy hypertensives.