Cognitive bias evaluation on the choice of treatment in common retinal disorders among retina specialists in 2023.

PURPOSE: The study aimed to discern the intent to treat with the therapeutic agents prescribed first or second line in the following eye conditions: neovascular age-related macular Degeneration (nAMD), diabetic macular edema (DME), retinal vein occlusion (RVO), and myopic maculopathy with choroidal neovascularization (MMNV). The study also aimed to distinguish the ophthalmologists' intended treatment for their patients from those that they would prescribe for themselves if they were affected by the above macular conditions. METHODS: The study utilized an online survey of 243 French ophthalmologists practicing medical retina, with males accounting for 54.3% of the participants. Data was obtained using a questionnaire that focused on the ophthalmologists' experience with various agents as well as their first and second line choices for nAMD, DME, RVO, and MMNV. RESULTS: The vast majority of French ophthalmologists (99%) had experience with the most widely used anti-vascular endothelial growth factors (anti-VEGFs); ranibizumab, bevacizumab, and aflibercept. Fewer than 8% reported experience with anti-VEGF drug reservoirs, biosimilars, or faricimab. The study findings also showed ranibizumab and aflibercept as the commonly prescribed first line choices for the above-mentioned ocular conditions. For the second line choice, the study showed that aflibercept and dexamethasone intravitreal implants were the most common across the four retinal conditions studied. The only difference in intent to treat for "patients" versus "yourself" was for biosimilars (0% to 0.8%, P=0.001). CONCLUSION: The findings regarding the first and second line choices for the mentioned ocular disorders were found to agree with the findings of published literature currently used in practice, with a tendency to prefer ranibizumab as first line therapy for neovascular disorders and aflibercept as first line therapy for macular edema. In addition, there were no differences between choices for first and second line therapy for patients vs. ophthalmologists.

[Update from France Macula Federation: Treatment of Wet AMD]. / Actualisations de la Fédération France Macula : prise en charge thérapeutique de la DMLA exsudative.

PURPOSE: To update the recommendations of the France Macula Federation for treatment of wet age-related macular degeneration (AMD). METHODS: Analysis of literature and expert opinion. RESULTS: The FFM recommends initiating anti-VEGF therapy as soon as possible after diagnosis of exudative AMD. There has been no major change in the last several years concerning the procedure of intravitreal injection itself. However, the litigious points are discussed: simultaneous bilateral injection; antibiotic therapy; medico-legal aspects. All anti-VEGF strategies possess advantages and limitations. The strategy should be left to the ophthalmologists' preference. However, the chosen strategy should be explained to patients and strictly followed. CONCLUSION: The treatment of wet-AMD is more precisely codified than before. However, various strategies still coexist.

[Update from France Macula Federation: Diagnosis of wet AMD]. / Actualisations de la Fédération France Macula : diagnostic de la DMLA exsudative.

PURPOSE: To update the recommendations of the France Macula Federation for the diagnosis of wet age-related macular degeneration (AMD). METHODS: Analysis of literature and expert opinion. RESULTS: The FMF recommends diagnosing wet AMD by combining the results of fundus examination (or color or monochromatic fundus photographs), optical coherence tomography (OCT) showing exudative signs, and morphological visualization of the neovascular membrane, which may be obtained non-invasively (OCT-angiography) or invasively (fluorescein and/or indocyanine green angiography). Under optimal conditions in which all these tools are available, the FMF recommends using non-invasive methods as first-line tools and resorting to dye angiography if diagnostic doubt remains. CONCLUSION: As observed in other fields of medical imaging, non-invasive methods are preferred to invasive methods for the diagnosis of wet AMD, while the latter are reserved for more difficult cases.

[Interest of optical coherence tomography performed immediately before intravitreal injection of anti-VEGF in exudative AMD]. / Intérêt de la tomographie à cohérence optique réalisée immédiatement avant injection intra-vitréenne d'anti-VEGF sur récidive exsudative dans la DMLA.

INTRODUCTION: Two or three systematic intravitreal injections (IVT) may be prescribed in a PRN approach to treat an exudative recurrence of neovascular age-related macular degeneration (AMD), according to the phenotype. Optical coherence tomography (OCT) may be performed immediately before the 2nd or the 3rd scheduled IVT, making it possible to cancel the procedure in the absence of exudation. The aim of the study was to evaluate the usefulness of this OCT examination and to assess the percentage of IVT cancelled, in order to evaluate a potential medico-economic benefit. METHODS: Monocentric retrospective study, in which were included 292 consecutive eyes with exudative recurrence of AMD, for which 2 or 3 IVT were scheduled between January 1st and April 30th, 2014. All patients received a first systematic IVT in the seven days following the diagnosis. Then, on the days of the 2nd and 3rd scheduled IVT, each patient had a visual acuity measurement and a Spectral domain-OCT (Spectralis, HRA Heidelberg Engineering). This measurement allowed for the IVT to be either performed as scheduled or cancelled. Both ranibizumab and aflibercept were used. A Chi(2) test was used to compare the qualitative variables and an adjusted Wilcoxon test for the quantitative values. RESULTS: Two hundred and ninety-two consecutive eyes were included; 172 in the "2 scheduled IVT" group (group A) and 120 in the "3 scheduled IVT" group (group B). At the first follow-up, 37.6% of scheduled IVT were cancelled after the OCT (44.1% in group A and 28.3% in group B). At the second follow-up, 33.3% of IVT were cancelled in group B. Overall, 150/412 (36.4%) IVT were avoided in this series. Presence of serous retinal detachment, retinal edema and increased central macular thickness were statistically correlated with confirmation of the scheduled IVT at the two follow-ups (P<0.001, P<0.001 and P=0.002, respectively). A savings of 429.80 € per patient was calculated during this short period of follow-up. CONCLUSION: An average non-injection rate of 36.4% of scheduled IVT was found in this protocol of management of recurrences with OCT performed the day of IVT. This protocol allowed to avoid unnecessary IVT one-third of the time and appeared highly cost-effective.

[Review and expert opinion in age related macular degeneration. Focus on the pathophysiology, angiogenesis and pharmacological and clinical data]. / Expertises croisées dans la dégénérescence maculaire liée à l'âge. Focus sur la physiopathologie, l'angiogenèse, les données pharmacologiques et cliniques.

Age related macular degeneration (AMD) is a pathological aging of the macula, brought about by the interaction of genetic and environmental factors. It induces geographic atrophy of the retina and/or choroidal neovascularization. In the latter, abnormal vessels develop from the choriocapillaris, with the involvement of VEGF (vascular endothelial growth factor). The VEGF family includes several factors, including VEGF-A, B, C, D, F and PlGF (placental growth factor). Their biological properties and their affinities to the VEGFR1, VEGFR2 and VEGFR3 receptors found on endothelial cells differ. Exudative AMD involves mainly VEGF-A and VEGF-R2. Anti-VEGF agents used in ophthalmology (ranibizumab, bevacizumab and aflibercept) are designed to primarily target this pathway. In vitro, all have sufficient affinity to their ligands. Their therapeutic efficacy must therefore be judged based on clinical criteria. In clinical practice, the minimum number of injections required for a satisfactory result appears to be comparable with all the three. The few available studies on therapeutic substitutions of anti-VEGF compounds suggest that some patients may benefit from substituting the anti-VEGF in cases of an unsatisfactory response to an initial molecule. Although local side effects, including increased risk of geographic atrophy, and systemic effects, including vascular accidents, have been suggested, these risks remain low, specially compared to the benefits of the treatment. Differences in safety between anti-VEGF are theoretically possible but unproven.

[Treatment of myopic choroidal neovascularization: recommendations of the Fédération France Macula]. / Traitement des néovaisseaux choroïdiens de lamyopie forte : recommandations de la Fédération France Macula.

Myopic choroidal neovascularization is a frequent cause of visual acuity loss that can affect young individuals. Through a group of experts belonging to the Fédération France Macula, we review the treatment of myopic choroidal neovascularization and provide recommendations related to the treatment of this complication.

[Current uses and indications for indocyanine green angiography]. / Intérêt et indications actuelles de l'angiographie au vert d'indocyanine (ICG).

A full interpretation of indocyanine green angiography images involves not only optical issues but also pharmacokinetic and biochemical aspects. These issues may involve biochemical changes in the fluorescence yield and the affinity of the molecule for lipoproteins and phospholipids. For age related macular degeneration (AMD), the advent of photodynamic therapy and especially anti-VEGF drugs has increased the use of OCT in assessing treatment response and guiding retreatment. The ease and advantages of OCT have become increasingly associated with a decreasing interest in ICG angiography, which is becoming less well suited for the current management of AMD. An aging population, the efficacy of anti-VEGF drugs and the relative rarity of polypoidal choroidal vasculopathy (PCV) in Europe are factors contributing to our proportional increase in AMD patients. However, aside from AMD, the indications for ICG angiography remain little changed over the last decade: it remains important in diagnosing PCV and choroidal hemangiomas, since their prognosis and treatment are specific. Similarly, for certain inflammatory conditions such as Multiple Evanescent White Dot Syndrome (MEWDS) or Birdshot chorioretinitis, the value of ICG angiography remains significant. In addition, for the treatment of chronic Central Serous Chorioretinopathy, ICG angiography helps to find sites of leakage which otherwise might have been missed. The ICG angiographic appearance in this setting may also have prognostic value. Although the indications for ICG angiography are currently decreasing for AMD, these other conditions represent a large enough number of patients to justify the continued use of this original test, which remains complementary to other chorioretinal imaging techniques.

[Retinal vein occlusion: anti-VEGF treatments]. / Occlusions veineuses rétiniennes : traitements anti-VEGF.

To date, there is no consistently effective proven therapy for patients with macular edema resulting from central retinal vein occlusion. Grid laser treatment only showed visual acuity benefit in branch retinal vein occlusion. Other treatment like intravitreal triamcinolone acetonide demonstrated transient inconsistent benefit with potential complications. As retinal vein occlusion is associated with increased levels of Vascular Endothelial Growth Factor (VEGF), anti-VEGF therapy was proposed to be a promising strategy for retinal vein occlusion. We reviewed the current literature on this topic: case reports, non controlled and non randomized trials. Short term results are encouraging with visual acuity benefit associated with reduction of retinal central thickness but multiple injections seems to be necessary to achieve visual stabilization. Further randomized and controlled clinical trials are necessary to confirm the long term safety and efficacy of bevacizumab in the care of retinal vein occlusion edema treatment.

[Evolving intravitreous injection technique]. / Evolution des pratiques pour la réalisation des injections intravitréennes.

The technique of intravitreous injections has been well documented for several years. Recently, a descriptive article on the intravitreous injections procedure was published in the Journal Français d'Ophtalmologie, and the AFSSAPS (French agency for drug safety) released recommendations concerning this matter on the occasion of commercial launch of pegaptanib. Since that time, the number of intravitreal injections has considerably increased, because anti-VEGF drugs had been made available to ophthalmologists, and several teams have performed a large number of procedures, allowing them to better comprehend intravitreous injections. The present paper describes our current practice of intravitreous injections. Several specialists have exchanged their experiences and issued a common synthesis. Detailed modifications of the initial recommendations have been suggested, with such basic changes such as abandoning preoperative pupil dilatation and easing postsurgical monitoring. Follow-up examinations should be adapted to each patient rather than being systematic. The suggested modifications do not change the procedure of intravitreous injections substantially, but they simplify many steps and detail the various procedures when consensus is lacking.

Cost-effectiveness sequential modeling of ranibizumab versus usual care in age-related macular degeneration.

AIMS: To assess effectiveness, cost, and cost-effectiveness of ranibizumab versus the current medical practices of treating age-related macular degeneration in France. METHODS: A simulation decision framework over 1 year compared ranibizumab versus the usual care using two effectiveness criteria: the "visual acuity improvement rate" (greater than 15 letters on the ETDRS scale) and the "rate of legal blindness avoided". Two decision trees included various sequences of current treatments, with or without ranibizumab. RESULTS: Ranibizumab appeared significantly more effective than the usual care (p < 0.001), providing greater treatment success rate of visual acuity improvement (48.8% versus 33.9%). The cost of the ranibizumab strategy was higher (9,123 euros over 1 year for ranibizumab versus 7,604 euros for the usual care) but the average cost-effectiveness was lower--18,721 euros/success for ranibizumab versus 22,543 euros/success for usual care (p < 0.001). Considering the "legal blindness avoided" success criterion, the ranibizumab strategy appeared significantly more effective (p < 0.001), providing greater treatment success rate for of legal blindness avoided than usual care (99.7% versus 93.1%) although it was more expensive (9,196 euros over 1 year for ranibizumab versus 5,713 euros for the usual care). CONCLUSION: Ranibizumab significantly improved the rate of visual acuity improvement and reduced the rate of legal blindness. Ranibizumab appeared significantly more cost-effective than the usual treatments in terms of visual acuity improvement.

[Age-related macular degeneration and antivascular endothelial growth factor: a review]. / Utilisation des anti-VEGF dans la dégénérescence maculaire liée à l'âge.

We provide an overview of new anti-VEGF treatments for exudative age-related macular degeneration. We reviewed the current literature on this topic (including randomized controlled trials, nonrandomized and noncontrolled trials, and case reports). The efficacy and safety of anti-VEGF therapies for AMD are reported. We discuss combined therapy approaches, treatment frequency, and emerging therapies for exudative AMD. Therapies that target VEGF greatly improve treatment for exudative AMD. However, many questions are still being debated.

[Monitoring anti-VEGF drugs for treatment of exudative AMD]. / Injections intra-vitréennes d'anti-VEGF pour la dégénérescence maculaire liée à l'âge exsudative: place des examens complémentaires dans les décisions de retraitement.

AIM: Anti-VEGF drugs are the most recent treatments for choroidal neovascularization, the most severe complication of the age-related macular degeneration (AMD). These drugs are administered by intravitreal injections. Several clinical studies have demonstrated their advantages. However, these same studies have not established the modalities for monitoring their efficacy. The aim of this paper is to provide an in-depth look at the existing practices in monitoring anti-VEGF therapy among different French specialists. METHODS: Several meetings were held with specialists coming from both the hospital setting and private practice to share their practices in monitoring anti-VEGF therapy and to propose more rational monitoring to standardize practices. RESULTS: The physicians attached an increasing importance to optical coherence tomography (OCT) in monitoring anti-VEGF drugs after intravitreal injection. They acknowledged the value of fluorescein angiography when initiating the treatment and 3 months after beginning anti-VEGF therapy. They advise using fluorescein angiography every time that functional results are not at the level expected by the physician or the patient. The authors provide a flow chart that should help in deciding on retreatment. CONCLUSION: The authors suggest the use of a flow chart aimed to define indications of retreatment according to clinical response and OCT results.

Types of choroidal neovascularisation in newly diagnosed exudative age-related macular degeneration.

AIM: To describe the types and location of choroidal neovascularisation (CNV) in exudative age-related macular degeneration (AMD), including vascularised pigment epithelial detatchments (PED), and most recently described subtypes, such as retinal choroidal anasmostosis, also termed "retinal angiomatous proliferation" (RAP). METHODS: Prospective multicentre consecutive descriptive case series. A total of 207 consecutive cases of newly diagnosed exudative AMD undergoing fluorescein angiography (FA) were recruited by 7 French referral hospital-based or private centres. Indocyanine green angiography (ICG) also was performed, when judged necessary by investigators. Types and location of CNV were classified by two independent experts and adjudicated by a third when discordant. RESULTS: All patients had FA, while ICG was performed in 50% of subjects. A total of 17.6% had classic CNV only, 5.4% and 8.3% had predominantly and minimally classic CNV, respectively. Occult CNV could be classified in occult CNV without PED (32.7%) and occult CNV with PED, ie, vascularised PED (23.9%). RAP was observed in 15.1% of cases, and accounted for 30% of vascularised PED. In 5.8% of the cases there was haemorrhagic AMD and 4.8% had fibrovascular scars. Lesions were mainly subfoveal (80%). Agreement between the centre's ophthalmologist and the final validated expert classification was moderate (kappa = 0.52 for location and 0.59 for type of lesion). CONCLUSION: This study confirms that newly diagnosed cases of exudative AMD are mainly occult and subfoveal. RAP appeared as a common lesion in patients with newly diagnosed exudative AMD.

Prevalence of reticular pseudodrusen in age-related macular degeneration with newly diagnosed choroidal neovascularisation.

AIM: To investigate the prevalence of reticular pseudodrusen (RPD) in eyes of patients presenting with newly diagnosed choroidal neovascularisation (CNV) in age-related macular degeneration (AMD), and to analyse the association between RPD, age-related maculopathy (ARM) and AMD. METHOD: Two observational consecutive prospective series. In series 1, patients with AMD with newly diagnosed CNV were sampled to determine the incidence of RPD. Eyes with and without RPD were compared by the Mann-Whitney non-parametric test and Fisher's exact test for age, sex of patients, the eye involved and type of CNV. Series 2 comprised 100 patients referred for fundus photography, fluorescein and/or indocyanine green angiography, for whom pictures showed RPD. This second cohort was then selected from a larger group of patients. RESULTS: Patients with newly diagnosed CNV in series 1 comprised 67 women and 33 men, aged 57-96 years (mean 79.5). CNV was "classic" (32 eyes), "occult" (41) or exhibited vascularised pigment epithelial detachment (PED, 11), retinal angiomatous proliferation (RAP) with or without PED (13), or haemorrhagic or fibrovascular scarring (3). In all, 24 (24%) eyes had RPD. The prevalence of RAP was significantly higher in eyes with RPD than in those without (p = 0.0128), despite the small number of patients with RAP. In series 2, 100 patients with RPD were enrolled in 3 months, and corresponded to 8% of the overall cases referred to our centre (Centre Ophtalmologique d'Imagerie et de Laser, Paris, France). There were 77 women and 23 men, aged 54-93 years (mean 79.2). Eyes with RPD (n = 155) usually exhibited signs of ARM or AMD, including soft drusen (101 eyes) and/or retinal pigment epithelium abnormalities (70), geographical atrophy (27) and/or CNV (61). In both studies, examination of blue-light fundus pictures was extremely helpful in diagnosing RPD. CONCLUSION: RPD have a high prevalence among patients with AMD with newly diagnosed CNV (24% of cases). RPD were commonly associated with ARM or AMD. This study suggests that eyes with RPD could be classified as a phenotype of ARM.

[How to perform intravitreal injections]. / Description des pratiques pour la réalisation des injections intravitréennes.

Drugs to treat retinal diseases are often injected intravitreally. This procedure can cause severe complications. We present ways to minimize the risk for complications. Rigorous preoperative antisepsis with povidone iodine, a sterile environment (using gloves and a mask for the injector, a lid speculum, and a drape on the eye to be injected), and immediate follow-up after injection are key issues of the injection technique.