Cost-effectiveness of various interventions for newly diagnosed diabetic macular edema.

OBJECTIVE: Anti-vascular endothelial growth factor therapies have revolutionized the treatment of clinically significant diabetic macular edema (CSDME); yet these agents are expensive, and whether they are cost-effective is unclear. The purpose of this study is to determine the most cost-effective treatment option for patients with newly diagnosed CSDME: focal laser photocoagulation alone (L), focal laser plus intravitreal ranibizumab (L+R), focal laser plus intravitreal bevacizumab (L+B), or focal laser plus intravitreal triamcinolone (L+T) injections. DESIGN: Cost-effectiveness analysis. PARTICIPANTS: Hypothetical cohort of 57-year-old patients with newly diagnosed CSDME. METHODS: By using a Markov model with a 25-year time horizon, we compared the incremental cost-effectiveness of treating patients with newly diagnosed CSDME using L, L+R, L+B, or L+T. Data came from the DRCRnet randomized controlled trial, the Medicare fee schedule, and the medical literature. MAIN OUTCOME MEASURES: Costs, quality-adjusted life years (QALYs), and incremental costs per QALY gained. RESULTS: Compared with L, the incremental cost-effectiveness of L+R and L+B was $89903/QALY and $11138/QALY, respectively. L+T was dominated by L. A probabilistic sensitivity analysis demonstrated that, at a willingness to pay (WTP) of $50000/QALY, L was approximately 70% likely to be the preferred therapy over L+R and L+T. However, at a WTP of $100000/QALY, more than 90% of the time, L+R therapy was the preferred therapy compared with L and L+T. In the probabilistic sensitivity analysis, L+B was found to be the preferred therapy over L and L+T for any WTP value >$10000/QALY. Sensitivity analyses revealed that the annual risk of cerebrovascular accident would have to be at least 1.5% higher with L+B than with L+R for L+R to be the preferred treatment. In another sensitivity analysis, if patients require <8 injections per year over the remainder of the 25-year time horizon, L+B would cost <$100000/QALY, whereas L+R would be cost-effective at a WTP of $100000/QALY if patients require fewer than 0.45 injections per year after year 2. CONCLUSIONS: With bevacizumab and ranibizumab assumed to have equivalent effectiveness and similar safety profiles when used in the management of CSDME, bevacizumab therapy confers the greatest value among the different treatment options for CSDME. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Presumed choroidal metastasis secondary to clear cell sarcoma of the right knee.

To present a case of choroidal metastasis of clear cell sarcoma of the tendons and aponeuroses. Observational case report. A 63-year-old woman with multiple systemic metastasis secondary to clear cell sarcoma of the tendons and aponeuroses in her right knee presented with a 3 days history of blurred vision in her left eye. At the time of presentation, her visual acuity was 20/125 in her left eye. Fundus examination of the left eye showed three amelanotic choroidal lesions associated with subretinal fluid. The patient was diagnosed with presumed choroidal metastasis secondary to clear cell sarcoma of the tendons and aponeuroses. Clear cell sarcoma of the tendons and aponeuroses rarely metastasize to the choroid.

Systematic Review of Community-Engaged Research in Ophthalmology.

INTRODUCTION: Community-engaged research (CEnR) allows researchers and community organizations to partner together to improve health outcomes and to decrease health disparities. While prevalent in other fields of medicine, it is rarely used in ophthalmology. AREAS COVERED: A comprehensive search of Ovid MEDLINE, NLM Pubmed, Ovid Embase, Scopus and the Cochrane Library for the Medical Subject Headings (MeSH) "Community-based participatory research" and text word variations including participatory research, community engagement, community research, partnered research, community-institutional relations, CENR, CBPR in addition to variations on ophthalmology, eye diseases, vision disorders and eye injuries yielded 451 unique references. Two ophthalmologists (KN, PANC) reviewed the titles and abstracts and identified 37 relevant studies. Expert consultation yielded an additional reference. After reviewing the full texts and excluding non-English texts, 18 articles met the necessary criteria. The eighteen articles all utilized at least one of the nine principles of CEnR. EXPERT COMMENTARY: Ophthalmology is perfectly positioned to benefit from CEnR. Increased community engagement in ophthalmic research would expand the reach of our work and address some of the most difficult problems in vision disparities and outcomes.

Beyond HbA1c: Environmental Risk Factors for Diabetic Retinopathy.

Diabetic retinopathy affects 4.2 million people in the United States and is the leading cause of blindness in working-aged people. As the prevalence of diabetes continues to rise, cost-effective interventions to decrease blindness from diabetic retinopathy will be paramount. While HbA1c and duration of disease are known risk factors, they account for only 11% of the risk of developing microvascular complications from the disease. The assessment of environmental risk factors for diabetic eye disease allows for the determination of modifiable population-level challenges that may be addressed to facilitate the end of blindness from diabetes.