An observational clinical study of the influence of phacoemulsification on choroidal neovascular membrane activity in age related macular degeneration.

BACKGROUND: Thousands of phacoemulsification surgeries are performed on eyes with age-related macular degeneration (AMD) complicated by choroidal neovascular membrane (CNV) in the United Kingdom each year. As populations age this number is expected to rise. Controversy over phacoemulsification's influence on CNV activity limits the information which clinicians and these patients use to decide on surgery. This observational study aims to resolve this controversy by reporting on intravitreal injection (IVI) frequency as a pragmatic marker of CNV activity in a large cohort. METHODS: A cohort of eyes with AMD complicated by CNV (n = 327) that underwent cataract surgery at a single tertiary centre from 2014 to 2019 were identified. These cases were matched by interval since CNV diagnosis at a specified 'time zero' within the follow-up of pseudophakic eyes with AMD (n = 327). Data concerning demographics, visual acuity (VA) and intravitreal injection frequency before and after 'time zero'/phacoemulsification were collected. RESULTS: Following 'time zero'/phacoemulsification' the mean reduction in annual IVI frequency was 0.6 injections/year (95% CI 0.4,0.9) and 0.4 injections/year (95% CI 0.1,0.7) in the comparison and phacoemulsification cohorts respectively. The mean VA gain 12 months after phacoemulsification in the intervention cohort was 11.3 (95% CI 9.2,13.4) early treatment of diabetic retinopathy study (ETDRS) letters, with 214 eyes (65.4%) having gained ≥5 ETDRS letters after surgery. CONCLUSIONS: Phacoemulsification has no clinically significant impact on the activity of pre-existent CNV secondary to AMD. Phacoemulsification should be offered to patients with AMD and cataract that limits vision, regardless of CNV activity.

Economic Impact Analysis of Custom Pak® on Cataract and Vitreoretinal Surgery in the United States.

Purpose: Implicit costs of surgical preparation and materials management for cataract/anterior segment and retinal/posterior segment procedures are often unquantified. Use of ophthalmological surgical procedure packs is common in these surgeries; however, there is little in the literature demonstrating their time and cost impacts. Understanding the costs and potential benefits of surgical pack procedure use is important for administrators in purchasing decision-making. The objective of this study is to estimate the economic impact of Alcon Custom Pak® on cataract and vitreoretinal (retina) surgery in hospitals and ambulatory surgical centers (ASCs) across operating room (OR), materials management, and accounting departments. Methods: We conducted a study in 2019 among US hospitals and ASCs using an online survey and a surgery timing exercise. Surgical technicians and supply chain managers were surveyed regarding current cataract and retina surgery practices including OR, materials management, and accounting tasks. Surgical technicians timed cataract and retina surgeries, recording activity timestamps and surgical supply use from Alcon Custom Pak and other sources. Using the survey and timing exercise inputs and literature and government sources, we developed a budget impact model (BIM) to quantify hidden costs of time and labor spent across the entire surgery supply life cycle. Results: Representing a geographical mix of 99 facilities, surgical technicians (56 cataract/46 retina) and supply chain managers (23 cataract/24 retina) provided data for their institutions. Technicians timed 290 cataract and 250 retina surgeries. In the BIM, increasing baseline Custom Pak utilization to 100% of surgeries while also sourcing all relevant supplies from Custom Pak results in annual cost savings ranging from $92,273 to $217,675 across procedure type and setting, allowing for between 75 (retina ASC) and 266 (cataract hospital) potential additional procedures per facility/year. Conclusion: This study demonstrates that increasing Custom Pak usage can potentially save time, reduce hidden costs, and increase throughput.

Ranibizumab and aflibercept intravitreal injection for treatment naïve and refractory macular oedema in branch retinal vein occlusion.

BACKGROUND: Branch retinal vein occlusion complicated by macular oedema is a common disease treated with intravitreal injection of anti-vascular endothelial growth factor. Controversy exists surrounding anti-vascular endothelial growth factor selection for both treatment naïve and refractory cases. METHODS: A retrospective electronic medical record review at a single UK centre generated a cohort of 259 treatment naïve eyes from 258 patients receiving ranibizumab, aflibercept or a combination (n = 83, 97 and 79, respectively) from 2013 to 2018 with ⩾6 months follow-up. Number of intravitreal injections, visual acuity and macular oedema presence were noted at 3, 6, 12, 24, 36 and 48 months. A subgroup analysis examined refractory cases switched from ranibizumab to aflibercept (n = 77) or maintained on ranibizumab (n = 35). RESULTS: Eyes receiving ranibizumab or aflibercept had equivocal vision gain at 1 year, 8.0 (95% CI 5.0-11.0) and 9.6 (7.2-12.1) Early Treatment of Diabetic Retinopathy Study letters, respectively. About 35.6% had no macular oedema at 12 months with ranibizumab compared with 50.0% with aflibercept (p = 0.07) following 5.1 (4.7-5.6) and 6.0 (5.6-6.4) intravitreal injections, respectively. Visual prognosis declined significantly as treatment delay extended (p = 0.003) which was only apparent with ⩾3 months delay. Eyes with refractory macular oedema also had equivocal functional and anatomical outcomes whether they were maintained on ranibizumab or switched to aflibercept. CONCLUSION: These real world data demonstrate more modest clinical improvements from anti-vascular endothelial growth factor treatment than reported in clinical trials. The functional outcomes of ranibizumab and aflibercept in both treatment naïve and refractory cases were equivocal while the anatomical outcomes of aflibercept may be superior.

Real-World Visual and Neovascularisation Outcomes from anti-VEGF in Central Retinal Vein Occlusion.

PURPOSE: Central retinal vein occlusion (CRVO) can be complicated by macular oedema, requiring intravitreal injection (IVI) of anti-vascular endothelial growth factor (VEGF). CRVO can cause neovascularisation, potentially causing persistent pain if not identified early. Whilst clinical trial data describe visual and anti-neovascular benefit from anti-VEGF there are limited real-world data. METHODS: A retrospective cohort study of a consecutive series of patients found from a review of the electronic medical record at a single UK centre. Visual acuity, macula status, number of IVIs and neovascular status were extracted at standardised timepoints. RESULTS: In total, 231 eyes from 231 patients were identified with 6-48 months of follow up. Twenty-four months after treatment initiation, 81 eyes (53.3%) had no remaining macula oedema and mean visual acuity gained was 8.9 (SD 19.0) Early Treatment of Diabetic Retinopathy Study (ETDRS) letters following a mean of 10.1 (3.9) IVIs. Of 222 eyes that had no initial neovascularisation, 11 went on to develop it, with iris involvement in 10 eyes. Median time from treatment initiation to neovascularisation was 17.2 (range 5.0-44.1) months, and the median time from latest IVI to neovascularisation was 9.6 (2.9-27.6) months after a median of 4 (3-10) IVIs. CONCLUSIONS: Visual acuity in CRVO complicated by macular oedema improves following anti-VEGF treatment but real-world gains are more modest than those from clinical trials. Neovascularisation following CRVO can be substantially delayed by anti-VEGF treatment and so if individuals who have received IVIs are to be effectively screened for neovascularisation long-term surveillance is necessary.