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OBJECTIVE: The fragility index (FI) of a meta-analysis evaluates the extent that the statistical significance can be changed by modifying the event status of individuals from included trials. Understanding the FI improves the interpretation of the results of meta-analyses and can help to inform changes to clinical practice. This review determined the fragility of ophthalmology-related meta-analyses. METHODS: Meta-analyses of randomized controlled trials with binary outcomes published in a journal classified as 'Ophthalmology' according to the Journal Citation Report or an Ophthalmology-related Cochrane Review were included. An iterative process determined the FI of each meta-analysis. Multivariable linear regression modeling evaluated the relationship between the FI and potential predictive factors in statistically significant and non-significant meta-analyses. RESULTS: 175 meta-analyses were included. The median FI was 6 (Q1-Q3: 3-12). This meant that moving 6 outcomes from one group to another would reverse the study's findings. The FI was 1 for 18 (10.2%) of the included meta-analyses and was ≤5 for 75 (42.4%) of the included meta-analyses. The number of events (p < 0.001) and the p-value (p < 0.001) were the best predictors of the FI in both significant and non-significant meta-analyses. CONCLUSION: The statistical significance of meta-analyses in ophthalmology often hinges on the outcome of a few patients. The number of events and the p-value are the most important factors in determining the fragility of the evidence. The FI is an easily interpretable measure that can supplement the reader's understanding of the strength of the evidence being presented. PROSPERO REGISTRATION: CRD42022377589.
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OBJECTIVE: To assess the effect of the COVID-19 pandemic on injection intervals among patients treated for neovascular age-related macular degeneration. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients treated at a single practice using a treat-and-extend regimen with intravitreal aflibercept between December 2018 and April 2021. METHODS: The primary outcome was the change in injection intervals. Secondary outcomes included differences in best-recorded visual acuity (BRVA) and central subfield thickness (CST). Associations were evaluated with linear mixed-effects modelling. RESULTS: This study included 1839 injections from 185 eyes (141 patients). The median (interquartile range) injection intervals in the pre-COVID-19 and COVID-19 periods were 60 (42-70) and 70 (49-90) days, respectively. The pandemic was associated with a mean injection interval lengthening of 7.2 days (P < 0.001), a decrease in BRVA of 3.1 Early Treatment Diabetic Retinopathy Study letters (P < 0.001), and a reduction in CST of 14.7 µm (Pâ¯=â¯0.003). The presence of exudative intraretinal fluid was associated with a reduction in treatment intervals of 11.1 days (P < 0.001), a reduction in BRVA of 1.9 Early Treatment Diabetic Retinopathy Study letters (P < 0.001), and an increase in CST of 52.4 µm (P < 0.001). The presence of subretinal fluid was associated with a reduction in treatment intervals of 8.5 days (P < 0.001) and an increase in CST of 21.6 µm (P < 0.001). CONCLUSIONS: This real-world study estimated that the severe acute respiratory syndrome coronavirus 2 pandemic resulted in an injection extension of 7.2 days with associated decreases in BRVA and CST that are unlikely clinically significant on a population basis. This builds on evidence suggesting that long-term vascular endothelial growth factor suppression can facilitate meaningful interval extensions while maintaining visual acuity.
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INTRODUCTION: The objective of this study was to examine the association between retinal thickness (RT) fluctuations and best corrected visual acuity (BCVA) in eyes with neovascular AMD, macular edema secondary to RVO, and DME treated with anti-VEGF therapy. METHODS: A systematic search of Ovid MEDLINE, EMBASE, and the Cochrane Library was performed from January 2006 to March 2024. Studies comparing visual or anatomic outcomes of patients treated with anti-VEGF therapy, stratified by magnitudes of RT fluctuation, were included. ROBINS-I and Cochrane RoB 2 tools were used to assess risk of bias, and certainty of evidence was evaluated with GRADE criteria. Meta-analysis was performed with a random-effects model. Primary outcomes were final BCVA and change in BCVA relative to baseline. RESULTS: 15,725 articles were screened; 15 studies were identified in the systematic review and 5 studies were included in the meta-analysis. Final ETDRS VA was significantly worse in eyes with the highest level of RT fluctuation (weighted mean difference [WMD] = 7.86 letters; 95% CI, 4.97, 10.74; p < 0.00001; I2 = 81%; 3,136 eyes). RT at last observation was significantly greater in eyes with high RT fluctuations (WMD = -27.35 µm; 95% CI, -0.04, 54.75; p = 0.05; I2 = 88%; 962 eyes). CONCLUSIONS: Final visual outcome is associated with magnitude of RT fluctuation over the course of therapy. It is unclear whether minimizing RT fluctuations would help optimize visual outcomes in patients treated with anti-VEGF therapy. These findings are limited by a small set of studies, risk of bias, and considerable heterogeneity.
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BACKGROUND/OBJECTIVE: To utilize ultra-widefield multimodal imaging (Optos PLC) to describe novel findings in degenerative retinoschisis. METHODS: This retrospective, non-comparative case series of degenerative retinoschisis received a waiver of consent from Advarra IRB, Protocol 00066379. Initial ultra-widefield pseudocolour, colour-separated, autofluorescence, and peripheral OCT imaging were analysed for characterizing features. RESULTS: In total, 139 eyes were included. A hyporeflective reticular pattern associated with retinoschisis was seen on pseudocolour images in 39% of cases, but visible in 53% on green-separated images. Fine hyper-reflective foci were observed in 49%. In 27%, retinoschisis was confirmed with OCT. CONCLUSIONS: Ultra-widefield pseudocolour and green-separated images are valuable for the diagnosis and characterization of degenerative retinoschisis. The findings described may prompt the evaluation of subtle retinoschisis with peripheral OCT.
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Angiofluoresceinografia , Imagem Multimodal , Retinosquise , Tomografia de Coerência Óptica , Humanos , Retinosquise/diagnóstico , Estudos Retrospectivos , Tomografia de Coerência Óptica/métodos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Angiofluoresceinografia/métodos , Adulto , Fundo de Olho , Retina/diagnóstico por imagem , Retina/patologia , Idoso de 80 Anos ou mais , Acuidade VisualRESUMO
PURPOSE: To assess efficacy and safety outcomes of subretinal fluid drainage methods during pars plana vitrectomy for rhegmatogenous retinal detachment. METHODS: A systematic search strategy was conducted for studies published between January 2000 and October 2022. Included studies reported on either the safety or efficacy of two or more drainage methods during pars plana vitrectomy for patients with rhegmatogenous retinal detachment. RESULTS: Two randomized and five observational studies consisting of 1,524 eyes were included. Best-corrected visual acuity at the last study observation and primary reattachment rates were similar across groups. A significantly lower risk of epiretinal membrane formation was associated with draining subretinal fluid through preexisting retinal breaks (risk ratio = 0.70, 95% confidence interval = [0.60, 0.83], P = <0.01, I 2 = 0%) or with perfluorocarbon liquid (risk ratios = 0.70, 95% confidence interval = [0.59, 0.83], P = <0.01, I 2 = 0%) compared with posterior retinotomy. The risk of an abnormal foveal contour was significantly greater in perfluorocarbon liquid-treated eyes relative to posterior retinotomy (risk ratios = 1.56, 95% confidence interval = [1.13, 2.17], P = <0.01, I 2 = 0%). CONCLUSION: No significant differences were observed in the final best-corrected visual acuity at the last study observation and primary reattachment rates across different drainage methods. There remains limited information on the topic, so future research is warranted.
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Drenagem , Descolamento Retiniano , Vitrectomia , Humanos , Drenagem/métodos , Descolamento Retiniano/cirurgia , Líquido Sub-Retiniano , Acuidade Visual/fisiologia , Vitrectomia/métodosRESUMO
INTRODUCTION: Artificial intelligence (AI) development has led to improvements in many areas of medicine. Canada has workforce pressures in delivering cataract care. A potential solution is using AI technology that can automate care delivery, increase effectiveness and decrease burdens placed on patients and the healthcare system. This study assesses the use of 'Dora', an example of an AI assistant that is able to deliver a regulated autonomous, voice-based, natural-language consultation with patients over the telephone. Dora is used in routine practice in the UK, but this study seeks to assess the safety, usability, acceptability and cost-effectiveness of using the technology in Canada. METHODS AND ANALYSIS: This is a two-phase prospective single-centred trial. An expected 250 patients will be recruited for each phase of the study. For Phase I of the study, Dora will phone patients at postoperative week 1 and for Phase II of the study, Dora will phone patients within 24hours of their cataract surgery and again at postoperative week 1. We will evaluate the agreement between Dora and a supervising clinician regarding the need for further review based on the patients' symptoms. A random sample of patients will undergo the System Usability Scale followed by an extended semi-structured interview. The primary outcome of agreement between Dora and the supervisor will be assessed using the kappa statistic. Qualitative data from the interviews will further gauge patient opinions about Dora's usability, appropriateness and level of satisfaction. ETHICS AND DISSEMINATION: Research Ethics Board William Osler Health System (ID: 22-0044) has approved this study and will be conducted by guidelines of Declaration of Helsinki. Master-linking sheet will contain the patient chart identification (ID), full name, date of birth and study ID. Results will be shared through peer-reviewed journals and presentations at conferences.
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Inteligência Artificial , Catarata , Humanos , Estudos Prospectivos , Cuidados Pós-Operatórios , Estudos de ViabilidadeRESUMO
The aim of the study was to determine the efficacy and safety of combined anti-VEGF and steroid therapy in treatment refractory DME patients. We conducted a systematic review and meta-analysis of peer-reviewed articles reporting on visual, anatomical and adverse outcomes to compare the efficacy and safety of combined intravitreal anti-VEGF/steroids versus anti-VEGF monotherapy for refractory DME. Seven studies (4 RCTs and 3 observational studies) reporting on 452 eyes were included. Our systematic review showed that combination therapy is significantly more effective for anatomical outcomes in the treatment of resistant DME compared to anti-VEGF monotherapy in six studies. Two studies found that addition of intravitreal steroids promoted faster visual improvement, but not significantly better final visual outcomes compared to anti-VEGF monotherapy. Combination therapy was associated with a higher incidence of IOP-related adverse events (RR = 0.10, 95% CI = [0.02, 0.42], p = 0.002) and cataract-related adverse events (RR = 0.10, 95% CI = [0.01, 0.71], p = 0.02). Our systematic review and meta-analysis of seven studies and 452 eyes revealed that combination therapy of anti-VEGF and steroid intravitreal drugs in the management of treatment refractory DME resulted in superior anatomical outcomes in all but one study. Combination therapy led to superior short-term visual outcomes in two studies, while others reported no difference between treatment groups. Meta-analysis revealed that combination therapy was associated with more adverse events. Future research should provide guidance on the standard definitions for treatment resistance and therapeutic alternatives for DME patients with sub-optimal response to anti-VEGF treatment.
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Retinopatia Diabética , Edema Macular , Humanos , Retinopatia Diabética/tratamento farmacológico , Injeções Intravítreas , Edema Macular/tratamento farmacológico , Esteroides , Fator A de Crescimento do Endotélio VascularRESUMO
BACKGROUND: The comparative safety and efficacy of different doses of intravitreal triamcinolone acetonide (IVTA) for diabetic macular edema (DME) and macular edema (ME) secondary to retinal vein occlusion (RVO) is unclear. OBJECTIVES: This meta-analysis aimed to compare the safety and efficacy of different doses of IVTA in this setting. METHODS: A systematic literature search for randomized clinical trials (RCTs) was conducted on Cochrane Library, Ovid MEDLINE, and EMBASE from January 2005 to May 2022. Studies that reported on patients with DME or ME secondary to RVO that received treatment with different doses of IVTA were included. A random-effects meta-analysis was performed. Cochrane's Risk of Bias Tool 2 was used to assess the risk of bias, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines were used to assess certainty of evidence. RESULTS: Five RCTs reporting on 1,041 eyes at baseline were included in this meta-analysis. In eyes with ME secondary to RVO, high-dose (4 mg) IVTA achieved a significantly better change in best-corrected visual acuity (WMD = -4.75 ETDRS letters, 95% CI = [-7.73, -1.78], p = 0.002) and reduction in retinal thickness (WMD = -93.02 µm, 95% CI = [-153.23, -32.82], p = 0.002) at months 4-6 compared to low-dose (1-2 mg) IVTA. However, high-dose IVTA had a higher risk of intraocular pressure-related adverse events (RR = 2.99, 95% CI = [1.05, 8.50], p = 0.04) and cataract surgery (RR = 5.67, 95% CI = [3.09, 10.41], p < 0.00001) than low-dose IVTA in eyes with ME secondary to RVO. These efficacy and safety differences in high-dose and low-dose IVTA were not observed in DME eyes. CONCLUSIONS: The RCT evidence in this setting is limited. High-dose IVTA achieved greater improvements in visual acuity and reductions in retinal thickness than low-dose IVTA at months 4-6. However, high-dose IVTA had a less favorable safety profile than low-dose IVTA. The significance of these outcomes was based on patients with ME secondary to RVO, but not DME.
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Diabetes Mellitus , Retinopatia Diabética , Edema Macular , Oclusão da Veia Retiniana , Humanos , Triancinolona Acetonida/efeitos adversos , Edema Macular/diagnóstico , Edema Macular/tratamento farmacológico , Edema Macular/etiologia , Glucocorticoides/uso terapêutico , Oclusão da Veia Retiniana/complicações , Oclusão da Veia Retiniana/diagnóstico , Oclusão da Veia Retiniana/tratamento farmacológico , Injeções Intravítreas , Retinopatia Diabética/complicações , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/tratamento farmacológico , Resultado do Tratamento , Diabetes Mellitus/induzido quimicamente , Diabetes Mellitus/tratamento farmacológicoRESUMO
INTRODUCTION: There are no guidelines on the optimal anti-vascular endothelial growth factor (anti-VEGF) monotherapy regimen for patients with polypoidal choroidal vasculopathy (PCV). In this study, we aimed to assess the comparative safety and efficacy of different treatment regimens of anti-VEGF monotherapy for PCV. METHODS: We conducted a systematic literature search on Ovid MEDLINE, Embase, and Cochrane Library from January 2000 to May 2023 for comparative articles reporting on different treatment regimens of anti-VEGF agents in PCV. Our primary outcomes were the final best-corrected visual acuity (BCVA) and the change in BCVA from baseline. Secondary outcomes were the final retinal thickness (RT), the change in RT from baseline, the rate of polyp closure, and the incidence of adverse events. RESULTS: A total of 10,440 studies were screened, and seven studies reporting on 636 eyes with PCV at baseline were included in this systematic review. One RCT of 53 eyes found a similar final BCVA, change in BCVA from baseline, final RT, and complete polyp closure rate between a treat-and-extend (T&E) regimen and a bimonthly fixed-dosing regimen of aflibercept. This trial also found superiority of T&E for change in RT from baseline. One observational study of 33 eyes found a similar BCVA at last study observation between a pro re nata (PRN) regimen and bimonthly fixed-dosing regimen of aflibercept. One observational study of 42 eyes found a similar change in BCVA from baseline and complete polyp closure rate between a PRN regimen and bimonthly fixed-dosing regimen of aflibercept. One RCT of 249 eyes found a similar change in BCVA and RT from baseline, as well as polyp closure, between a T&E regimen and fixed 12-week dosing regimen of conbercept. One observational study of 30 eyes found a superiority of T&E aflibercept for change in BCVA and risk of polyp recurrence, compared to a PRN regimen. CONCLUSION: Overall, there is a paucity of evidence comparing various treatment regimens of anti-VEGF therapy in patients with PCV. This limited evidence suggests that current treatment regimens are similarly efficacious, though T&E aflibercept achieved superior outcomes when compared to bimonthly dosing or PRN in some individual studies. Further trials are needed to confirm or refute these findings.
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Inibidores da Angiogênese , Vasculopatia Polipoidal da Coroide , Humanos , Receptores de Fatores de Crescimento do Endotélio Vascular , Retina , Fator A de Crescimento do Endotélio Vascular , Fatores de Crescimento do Endotélio Vascular , Injeções Intravítreas , Proteínas Recombinantes de Fusão , Resultado do Tratamento , Estudos Observacionais como AssuntoRESUMO
TOPIC: We reviewed the use of patient-reported outcome measures (PROMs) in the treatment of ophthalmologic conditions as recommended by the Clinical Practice Guidelines (CPGs) published by the American Academy of Ophthalmology (AAO). CLINICAL RELEVANCE: Patient-reported outcome measures are standardized instruments that provide information regarding a patient's health status or health-related quality of life. Patient-reported outcome measures are increasingly used to inform study end points in ophthalmology studies. However, the extent to which PROMs are ultimately informing patient management recommendations in ophthalmology as part of CPGs remains an area of evidence gap. METHODS: We included all CPGs published by the AAO from inception to June 2022. We also included all primary studies and systematic reviews cited in the treatment sections of the CPGs evaluating treatment of an ophthalmic condition. The primary outcome was the frequency of PROMs discussed in CPGs and in cited studies evaluating treatment. Secondary outcomes included frequency of minimal important difference (MID) use to contextualize PROM results and percentage of strong and discretionary recommendations supported by PROMs. We published a study protocol a priori on PROSPERO (CRD42022307427). Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We assessed risk of bias using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument. RESULTS: We identified 24 eligible CPGs, providing 2458 cited studies (2191 primary, 267 secondary) evaluating treatment of eye conditions. Ten CPGs (41.7%) reported consideration of PROMs. Of these, 31 of 94 (33%) recommendations were informed by studies evaluating a PROM as an outcome. Across all studies cited in the development of CPGs, 221 (9.0%) used PROMs as a primary or secondary outcome, of which 4 PROM results (1.8%) were interpreted using an empirically determined MID. Overall, the risk of bias was low for all CPGs. CONCLUSIONS: Overall, outcomes of PROMs are seldom used in ophthalmology CPGs published by the AAO and in cited primary and secondary research on treatments. When PROMs were considered, their interpretation was seldom based on an MID. To improve patient care, guideline developers may consider incorporating PROMs and applicable MIDs to inform key outcomes when formulating treatment recommendations. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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TOPIC: This systematic review and meta-analysis provides a summary of the efficacy and safety of ranibizumab biosimilars relative to reference ranibizumab anti-vascular endothelial growth factor (VEGF) therapy for the treatment of neovascular age-related macular degeneration (nAMD). METHODS: We conducted systematic searches from January 2003 to August 2022 on Ovid MEDLINE, EMBASE and the Cochrane Controlled Register of Trials. We included studies reporting changes in early treatment diabetic retinopathy study-measured best-corrected visual acuity (BCVA), number of patients who lost or gained more than 15 letters in BCVA from baseline, changes in retinal thickness and adverse events between treatment arms. The following studies were excluded: studies that did not report visual outcomes following biosimilar and reference ranibizumab intravitreal injections, study arms combining anti-VEGF agents with laser or steroid injections, sham injections as a control comparator, studies without English full texts and non-comparative, observational study design. RESULTS: Five studies reported on four randomised controlled trials (RCTs) and 1544 eyes at baseline were included in this systematic review and meta-analysis. The studies in our systematic review found no significant differences between reference ranibizumab and ranibizumab biosimilar medications (FYB201, SB11, RanizuRel and Lupin's ranibizumab) for visual and anatomical outcomes. No significant differences were detected between biosimilar and reference ranibizumab for treatment emergent adverse events (risk ratio, RR 1.06, 95% CI (0.91 to 1.23), p=0.45, I2=52%) or IOP-related adverse events with significant heterogeneity (RR 2.59, 95% CI (0.11 to 62.25), p=0.56, I2=76%). CONCLUSION: This systematic review of four RCTs demonstrated no significant difference in visual outcomes, retinal thickness outcomes, as well as meta-analysis of adverse events between biosimilar and reference ranibizumab therapies for nAMD treatment.
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Medicamentos Biossimilares , Ranibizumab , Humanos , Ranibizumab/efeitos adversos , Medicamentos Biossimilares/efeitos adversos , Inibidores da Angiogênese/efeitos adversos , Bevacizumab/efeitos adversos , Fator A de Crescimento do Endotélio Vascular , Receptores de Fatores de Crescimento do Endotélio Vascular/uso terapêutico , Fatores de Crescimento do Endotélio Vascular , Estudos Observacionais como AssuntoRESUMO
There remains limited agreement regarding the efficacy and safety of different antivascular endothelial growth factor (anti-VEGF) agents for the management of polypoidal choroidal vasculopathy (PCV). Our meta-analysis compares different anti-VEGF agents for PCV treatment. Ovid MEDLINE, EMBASE, and Cochrane Library were systematically searched from January 2000 to July 2022. We included articles comparing the efficacy and safety of different anti-VEGF agents, specifically bevacizumab (BEV), ranibizumab (RAN), aflibercept AFL), and brolucizumab (BRO), for patients with PCV. 10,440 studies were identified, 122 underwent full-text review, and seven were included. One study was a randomized trial, and six were observational studies. Ranibizumab and aflibercept were associated with a similar best-corrected visual acuity (BCVA) at the last visit in three observational studies (P = 0.10), similar retinal thickness at the last visit in two observational studies (P = 0.85). One observational study comparing BEV versus RAN found comparable outcomes for final BCVA, retinal thickness, and polyp regression. One randomized trial on BRO versus AFL found comparable outcomes for improvement in BCVA, while anatomical outcomes favored BRO. The available evidence suggests that final BCVA is comparable across different anti-VEGF agents, however, further investigation is warranted due to paucity of evidence.
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Inibidores da Angiogênese , Ranibizumab , Humanos , Ranibizumab/uso terapêutico , Inibidores da Angiogênese/uso terapêutico , Fator A de Crescimento do Endotélio Vascular , Vasculopatia Polipoidal da Coroide , Bevacizumab/uso terapêutico , Injeções Intravítreas , Estudos Observacionais como AssuntoRESUMO
OBJECTIVE: The Eyesi Surgical Simulator (VRmagic, Mannheim, Germany) is the most commonly used ophthalmic virtual reality surgical simulator. While studies have demonstrated improved trainee skill acquisition with simulation-based training tools, a systematic review and meta-analysis evaluating Eyesi specifically has yet to be conducted. The aim of this study was to meta-analyze studies comparing Eyesi with other methods of technical skill teaching for trainees. METHODS: MEDLINE, Embase, and CENTRAL databases were searched. Articles included compared Eyesi Surgical Simulator use with alternative methods of technical skill training for medical students or residents. A pairwise meta-analysis using inverse variance random effects was performed. Standardized mean differences (SMDs) were used as the primary outcome measure to account for differences in surgical skill evaluation tools. RESULTS: From 207 citations, 8 studies with 108 learners using Eyesi and 123 learners not using Eyesi were included. Improvements in technical skill scores were significantly greater with the use of Eyesi (3 studies; SMDâ¯=â¯2.02; 95% CI, 1.47-2.57; p < 0.001; I2â¯=â¯0%). There was a significant reduction in the number of learners experiencing post-training technical errors in the Eyesi group (5 studies: odds ratioâ¯=â¯0.43; 95% CI, 0.20-0.90; pâ¯=â¯0.03; I2â¯=â¯30%). There were no significant differences in post-training time to task completion between groups (3 studies; SMDâ¯=â¯1.96; 95% CI, -1.96-5.88; pâ¯=â¯0.33; I2â¯=â¯97%). CONCLUSIONS: The Eyesi Surgical Simulator may improve technical skill acquisition (grade: low certainty of evidence) and decrease technical errors (grade: very low certainty of evidence) during cataract surgery among trainees. Further prospective studies evaluating Eyesi modules with standardized scoring systems is warranted.
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TOPIC: Diabetic macular edema (DME) can be treated with either intravitreal anti-VEGF injections or intravitreal corticosteroid injections. CLINICAL RELEVANCE: We provide an updated meta-analysis of the comparative efficacy and safety of intravitreal steroids and anti-VEGF agents for DME. METHODS: A systematic search was performed on Ovid MEDLINE, Embase, and Cochrane Controlled Register of Trials from January 2005 to November 2021. Inclusion criteria included published randomized clinical trial data comparing the efficacy and safety of intravitreal steroids versus anti-VEGF agents for DME. Nonrandomized, noncomparative, and non-English studies were excluded. RESULTS: Fourteen randomized clinical trials reporting on 827 eyes were included. Between these 2 treatments, our analysis revealed no significant difference in best-corrected visual acuity (BCVA) outcomes at 3 months (P = 0.11), 6 months (P = 0.21), 12 months (P = 0.24), and final follow-up (P = 0.91). Retinal thickness was significantly lower with steroid treatment at 3 months (P = 0.04), 6 months (P < 0.00001), and final follow-up (weighted mean difference = 39.99 µm; 95% confidence interval [CI] = 14.58,65.41; P = 0.002); however, there was no significant difference at 12 months (P = 0.18). Intravitreal anti-VEGF agents were associated with a lower incidence of intraocular pressure-related adverse events (risk ratio = 0.13; 95% CI = 0.05, 0.34; P < 0.00001). There was no significant difference between comparators for other adverse events, including cataract-related adverse events (P = 0.22). CONCLUSIONS: Overall, intravitreal steroid treatment for DME was associated with no significant differences in BCVA, a significantly lower retinal thickness, and a higher risk of intraocular pressure-related events. The certainty of evidence ranged from low to moderate and the analysis was limited by heterogeneity. Our results reinforce the importance of a continual reevaluation of the role of intravitreal steroids in DME management. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.
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Diabetes Mellitus , Retinopatia Diabética , Edema Macular , Humanos , Edema Macular/tratamento farmacológico , Retinopatia Diabética/tratamento farmacológico , Ranibizumab , Bevacizumab , Fator A de Crescimento do Endotélio Vascular , Esteroides/uso terapêutico , Diabetes Mellitus/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Purpose: To review current eyedrop instillation techniques, common difficulties faced by patients instilling eyedrops, available eyedrop assistive devices, and patient education regarding eyedrop instillation. Methods: PubMed, Embase, and Google Scholar were searched from conception until June 2022 for articles on eyedrop instillation difficulties, techniques, tools, and patient education. Results: Instillation involves pulling down the lower eyelids and placing drops on the corneal surface or conjunctival fornix, followed by closing of the eyelids for about 1 min. Examples of techniques include eyelid closure and nasolacrimal obstruction techniques. Patients encounter many difficulties when administering eyedrops, including but not limited to poor visibility, squeezing the dropper bottle, aiming the bottle, and accidentally blinking. However, devices are available that assist with aim and dropper compression-force reduction in eyedrop instillation. These can be particularly useful in patient demographics with diminished manual dexterity or the ability to generate force from their fingers. Furthermore, despite patient education in eyedrop instillation not being a common practice, it has been found that adequate patient education can lead to significant improvement in eyedrop instillation technique. Conclusions: While many factors are associated with poor eyedrop instillation technique, there are many solutions available including assistive devices and proper instillation education.
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BACKGROUND: Intravitreal anti-vascular endothelial growth factor (anti-VEGF) and steroid treatment are both used for macular edema (ME) secondary to retinal vein occlusion (RVO), however a continual reevaluation of their comparative efficacy is required. OBJECTIVES: This meta-analysis aimed to compare the efficacy and safety of intravitreal anti-VEGF agents and intravitreal steroids for the treatment of ME secondary to RVO. METHODS: A systematic literature search was conducted on Ovid MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials for studies published between January 2005 and November 2021. Randomized controlled trials (RCTs) reporting on patients with ME secondary to RVO who were treated with intravitreal steroids or anti-VEGF agents were included. A random effects meta-analysis was performed. RESULTS: 879 eyes from 11 RCTs were included. At the last study observation, intravitreal anti-VEGF agents were associated with a significantly better best corrected visual acuity (WMD = -0.14 logMAR, 95% CI = [-0.19, -0.09], p < 0.00001) and lower retinal thickness (WMD = -38.01 µm, 95% CI = [-56.17, -19.85], p < 0.0001) relative to intravitreal steroids. Similar findings were found at 3-12 month time points. Intravitreal anti-VEGF agents were associated with a significantly lower incidence of IOP-related adverse events (RR = 0.28, 95% CI = [0.15, 0.51], p < 0.0001), cataract development/progression (RR = 0.22, 95% CI = [0.09, 0.49], p = 0.0003), and conjunctival hemorrhage (RR = 0.52, 95% CI = [0.32, 0.86], p = 0.01). CONCLUSIONS: Our meta-analysis found superiority of intravitreal anti-VEGF agents relative to intravitreal steroids for the treatment of ME secondary to RVO with regards to visual acuity, anatomic outcomes, and safety endpoints.
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Edema Macular , Oclusão da Veia Retiniana , Humanos , Ranibizumab/uso terapêutico , Oclusão da Veia Retiniana/complicações , Oclusão da Veia Retiniana/diagnóstico , Oclusão da Veia Retiniana/tratamento farmacológico , Bevacizumab/efeitos adversos , Fator A de Crescimento do Endotélio Vascular , Edema Macular/diagnóstico , Edema Macular/tratamento farmacológico , Edema Macular/etiologia , Fatores de Crescimento do Endotélio Vascular , Esteroides/uso terapêutico , Injeções Intravítreas , Inibidores da Angiogênese/uso terapêuticoRESUMO
INTRODUCTION: Glaucoma is a progressive, chronic condition that can have a significant impact on a patient's health-related quality of life (HRQoL). Validated, disease-specific HRQoL tools such as the Health Utility for Glaucoma (HUG-5) tool and the Glaucoma Quality of Life Questionnaire (GlauQoL-17) can be used to monitor a patient's quality of life. However, the utility of these tools in outpatient clinic practice is not well established. The primary objective of this study is to characterise the feasibility of administering periodic HRQoL questionnaires in glaucoma using a semi-automated workflow. METHODS AND ANALYSIS: This study will be a single-centre, unblinded, randomised, parallel-group study with an exploratory data analysis framework. We aim to determine the feasibility of administering the HUG-5 in an outpatient clinic using a semi-automated workflow and determine patient engagement through email and telephone contact methods. We will also be investigating the association of the HUG-5 and GlauQoL-17 with patient visual field testing and visual acuity. Mean differences between groups will be tested with analysis of variance to determine if the frequency of calls affects burden, satisfaction and perceived value of information. ETHICS AND DISSEMINATION: This study has been approved by the Hamilton Integrated Research Ethics board (ID: 13046) and will be conducted within Canadian Tri-Council Statement policy. Personal information of the study's participants will be anonymised with identification codes and data will be kept on an encrypted server. Results of this study will be disseminated through peer-reviewed journals, conferences and internal meetings.