Cost-Effectiveness of Screening for Open Angle Glaucoma Compared With Opportunistic Case Finding.

PRCIS: The manuscript evaluates cost-effectiveness of glaucoma screening with imaging devices and telemedicine based on a screening campaign performed in Spain. The screening strategy implemented in our analysis was cost-effective compared with opportunistic case finding. INTRODUCTION: Open angle glaucoma is an asymptomatic ocular disease that represents one of the first causes of blindness. Diagnosis is currently made by opportunistic case finding, usually by community optometrists or general ophthalmologists. The aim of this study was to assess the cost-effectiveness of a screening strategy based on optical coherence tomography and fundus photographs in glaucoma detection. MATERIALS AND METHODS: A cost-effectiveness analysis was carried out to compare 2 alternative strategies: opportunistic finding versus screening. A Markov tree model was carried out with 10 health states according to disease progression. Quality-adjusted life years (QALYs) were used as a measure of effectiveness. We included short-term and long-term direct health costs and a discount rate of 3%. We performed a probabilistic sensitivity analysis and several 1-way sensitivity analyses. RESULTS: The cohort in the screening program entailed an increase in 0.097 QALYs and additional costs of €1187 versus opportunistic finding, with an incremental cost-effectiveness ratio of about €12.214/QALY. The 1-way sensitivity analysis showed that inputs related to age and screening program (cost and detection rate) were those most strongly influencing the results of the analysis. Probabilistic sensitivity analyses showed that the model was robust to significant changes in the main variables of the analysis. CONCLUSIONS: The screening strategy implemented in our analysis was cost-effective compared with opportunistic finding in patients with glaucoma in this Spanish setting.

Clinical Results of Diffractive, Refractive, Hybrid Multifocal, and Monofocal Intraocular Lenses.

PURPOSE: To present the outcomes of hybrid multifocal and monofocal intraocular lenses (IOLs) and to compare with refractive and diffractive multifocal IOLs (MFIOLs). METHODS: Three hundred twenty eyes (160 patients) underwent cataract surgery with randomized IOLs bilateral implantation. Changes in uncorrected and distance-corrected logMAR distance, intermediate and near (UNVA and DCNVA) visual acuity (VA), contrast sensitivity (CS), presence of dysphotopsia, spectacle independence, and patient satisfaction were analyzed. RESULTS: Postoperative VA in the hybrid (OptiVis) group was improved in all distances (p < 0.001). OptiVis acted superiorly to monofocal IOLs in UNVA and DCNVA (p < 0.001 for both) and to refractive ones in DCNVA (p < 0.005). Distance, mesopic, without glare CS in OptiVis was lower than in the monofocal group and similar to other MFIOLs. No differences in dysphotopsia pre- and postoperatively and spectacle independence in near for OptiVis and refractive MFIOLs were detected. OptiVis patients were more satisfied than those with monofocal IOLs (p=0.015). CONCLUSIONS: After cataract surgery, patients with OptiVis improved VA in all distances. Near and intermediate VA was better than monofocal, and DCNVA was better than the refractive group. CS was lower in OptiVis than in the monofocal group, but there was no difference between MFIOLs. Patient satisfaction was higher in OptiVis than in the monofocal group. This trial is registered with NCT03512626.

Visual outcome and complications of cataract extraction after pars plana vitrectomy.

PURPOSE: To evaluate the visual outcomes and complications of phacoemulsification in previously vitrectomized eyes. PATIENTS AND METHODS: A retrospective analysis of 87 consecutive vitrectomized eyes (87 patients) which had undergone phacoemulsification with intraocular lens implantation between 2013 and 2016. RESULTS: The mean interval from pars plana vitrectomy (PPV) to cataract surgery (CS) was 18.8 months. Mean age at CS was 61.5 years. Intraoperative complications included anterior rhexis tear (1 eye) and hyphema (1 eye). Postoperative complications included macular edema (17.2%, mean 42 days), posterior capsule opacification (13.8%, mean 14 months), ocular hypertension (11.5%), and anterior uveitis (1.1%). Preoperative mean best-corrected visual acuity improved from 20/50 to 20/25. Ninety-one percent of the eyes gained 2 or more lines, and 95% achieved visual acuity ≥20/40 after CS. Preoperative mean spherical equivalent improved from -4.35 to -0.17. Eyes with clear lens prior to the PPV had later CS (clear lens 27.1 vs no clear lens 9.7 months; p=0.016). Patients >55 years with clear lens at PPV (n=21) had earlier CS than younger ones with clear lens (n=24) (11.8 vs 40.5 months; p=0.033). Mean follow-up was 14.5 months. CONCLUSION: Phacoemulsification is a safe procedure in vitrectomized eyes, with substantial gains in vision in most cases. Patients of advanced age and eyes without clear lens prior to the PPV had earlier CS.

SURGICAL OUTCOME OF LATE IN-THE-BAG INTRAOCULAR LENS DISLOCATION TREATED WITH PARS PLANA VITRECTOMY.

PURPOSE: To present the visual outcome and postoperative complications of pars plana vitrectomy and intraocular lenses (IOL) removal with or without IOL exchange of late in-the-bag IOL dislocation after uneventful cataract surgery. METHODS: Retrospective analysis of a consecutive series of 83 eyes with late in-the-bag dislocated IOL treated with pars plana vitrectomy and anterior chamber IOL (25 eyes), transscleral suture-fixated posterior chamber IOL (38 eyes), or aphakia (20 eyes). RESULTS: High myopia was the major predisposing factor (40%). The interval between cataract surgery and the dislocation was 10.9 years. The complication rate after the second surgery was 43%; being transient hypotony (19%) and hypertension (15%) the most frequent. Postoperative best-corrected visual acuity improvement was statistically significant (P < 0.001), with a mean of 3 Snellen lines. This improvement was also significant in 2 subgroups, patients with sutured posterior chamber IOL (20/80-20/40; P < 0.001) and in patients with anterior chamber IOL (20/125-20/40; P < 0.001). However, best-corrected visual acuity did not improve in aphakic patients (20/63-20/63; P = 0.13). Postoperative astigmatism increased significantly (P < 0.001), with a mean of -1 D. Mean follow-up was 24 months. CONCLUSION: The major predisposing factor for late in-the-bag IOL dislocation is myopia. Despite a complication rate of 43%, mostly minor and transient, IOL exchange surgery is an effective procedure with a good visual outcome (mean 3 Snellen lines improvement). There were no statistically significant differences in the final best-corrected visual acuity or complication rate between anterior chamber IOL and sutured posterior chamber IOL, thus, both surgical techniques may be considered to treat this condition.

Evaluation of the Retinal Nerve Fiber Layer Thickness, the Mean Deviation, and the Visual Field Index in Progressive Glaucoma.

PURPOSE: To determine and compare the retinal nerve fiber layer (RNFL) thickness, the mean deviation, and the visual field index (VFI) in glaucoma cases with progression detected by spectral domain optical coherence tomography, standard automated perimetry (SAP), and optic disc stereophotographs. METHODS: The authors studied 246 eyes of 148 patients prospectively (97 glaucoma cases, 132 suspects, and 17 healthy eyes). SAP fields, optical coherence tomography (OCT) images, and optic disc stereophotographs were obtained every 6 to 12 months. Progression was determined in SAP and in OCT with a Glaucoma Progression Analysis software, and also by masked assessment of the stereophotograph series. The Kruskal-Wallis test was applied to evaluate differences between methods in RNFL thickness, visual field (VF) mean deviation, and VFI. The relationship between the baseline classification and the detection of glaucomatous progression by the different tests was assessed by the χ statistic. RESULTS: Ninety-nine eyes (40.2%) presented glaucomatous progression detected by at least 1 examination method. Progressing eyes detected only by OCT had a higher mean RNFL thickness and mean VFI than progressing eyes detected only by VF or stereophotographs (P<0.003). Most progressive cases detected by OCT (68%) were initially classified at baseline as suspects, whereas most eyes with VF progression (61%) were initially classified as glaucoma. The initial classification was significantly related to the presence of progression by different tests [χ (2)=9.643 for VF event analysis and 7.290 for OCT event analysis (P<0.005)]. CONCLUSIONS: Different tests are more likely to detect the progression in different clinical circumstances or stages of glaucoma; these should be taken into consideration when performing the difficult task of progression detection.

Comparison of retinal nerve fiber layer thickness values using Stratus Optical Coherence Tomography and Heidelberg Retina Tomograph-III.

PURPOSE: To evaluate the usefulness of retinal nerve fiber layer (RNFL) thickness measurements using the Heidelberg Retina Tomograph-III (HRT-III) in normal, ocular hypertensive, and glaucomatous eyes and compare the thickness measurements using HRT-III and Stratus Optical Coherence Tomography-3 (OCT-3). METHODS: Sixty-nine normal eyes, 60 eyes ocular hypertensive, and 111 glaucomatous were included. All participants underwent visual field, HRT-III, and OCT-3 examinations on the same day. Patients were classified into 3 groups according to intraocular pressure and visual field damage. The sensitivity/specificity of RNFL thickness measurements and RNFL thickness classifications using HRT-III and OCT-3 were calculated. The sensitivity/specificity of the height variation contour (HVC) from the HRT-III were calculated. The receiver operating characteristic curves (ROC) and areas under the ROC were plotted. Agreement was calculated using Bland-Altman method and the kappa coefficient. RESULTS: The RNFL thickness sensitivity/specificity were 32.4%/87%, for the HRT-III and 72.97%/81.15% for the OCT-3 in relation to the glaucoma diagnosis (least specific criteria). The RNFL thickness sensitivities/specificities were lower in early glaucoma. The areas under the ROC for RNFL measurements were 0.72 using HRT-III, 0.86 with OCT-3 (P=0.001), and 0.54 for the HVC. The RNFL classification kappa coefficient was 0.36. Bland-Altman analysis confirmed that the RNFL measurements were not interchangeable. CONCLUSIONS: The sensitivity of RNFL damage detection using HRT-III was lower compared with OCT-3, especially in early glaucoma. RNFL thickness agreement between HRT-III and OCT-3 was only fair. HVC was not useful for glaucoma detection.