VISUAL ACUITY IMPROVEMENT WHEN SWITCHING FROM RANIBIZUMAB TO AFLIBERCEPT IS NOT SUSTAINED.

PURPOSE: To assess whether visual benefits exist in switching to aflibercept in patients who have been chronically treated with ranibizumab for neovascular age-related macular degeneration. METHODS: A multicenter, national, electronic medical record database study was performed. Patients undergoing six continuous monthly ranibizumab injections and then switched to continuous aflibercept were matched to those on continuous ranibizumab therapy. Matching was performed in a 2:1 ratio and based on visual acuity 6 months before and at the time of the switch, and the number of previous ranibizumab injections. RESULTS: Patients who were switched to aflibercept demonstrated transiently significant improvement in visual acuity that peaked at an increase of 0.9 Early Treatment Diabetic Retinopathy Study letters 3 months after the switch, whereas control patients continued on ranibizumab treatment showed a steady decline in visual acuity. Visual acuity differences between the groups were significant (P < 0.05) at 2, 3, and 5 months after the switch. Beginning at 4 months after the switch, the switch group showed a visual acuity decline similar to the control group. CONCLUSION: Transient, nonsustained improvement in visual acuity occurs when switching between anti-vascular endothelial growth factor agents, which may have implications in treating patients on chronic maintenance therapy on one anti-vascular endothelial growth factor medication.

Bilateral Uveitis and Keratitis Following Nivolumab Treatment for Metastatic Melanoma.

BACKGROUND: Inflammatory eye disease has been reported as a side effect with Nivolumab. CASE PRESENTATION: We report a case of a 92-year-old woman presenting with bilateral and simultaneous keratitis and uveitis in the setting of recurring infusions of nivolumab for metastatic melanoma. The patient underwent successful coordinated treatment of both eyes coinciding with ongoing systemic infusion treatments with ophthalmic topical medications alone. CONCLUSION: The interest of this case resides in the simultaneous nature of presentation of eye inflammation both internally and of the ocular surface. Prior case reports have cited uveitis or ocular surface disease, however not in simultaneous fashion. Clinicians should raise their index of suspicion of side effects of nivolumab systemic infusion for any vision or eye symptom changes around the timing of treatment.

Disparities in delivery of ophthalmic care; An exploration of public Medicare data.

PURPOSE: Cataract is a major cause of age-related eye diseases in the United States, and cataract extraction is the most commonly performed surgery on Medicare beneficiaries. Analyzing the pattern in delivery of cataract care at the national level can highlight areas of disparities. We evaluated geographic disparities seen in cataract surgery delivery to Medicare beneficiaries in the United States. SETTING: Cataract extractions across the United States in 2012. DESIGN: Cross-sectional study examining distance to provider and observed versus expected number of cataract extractions. METHODS: Cataract extraction current procedural terminology codes were used to sum the total observed number of cataract extractions per cataract surgeon. Epidemiology data on expected number of cataract surgeries in one year by decade of life were extrapolated via a Gaussian Process model. A linear regression model was used to compare differences in delivery of care between US economic regions. RESULTS: 2.2 million patients underwent cataract surgery in the Medicare dataset in 2012. The average distance to the nearest provider was 9.846 miles (standard deviation: 11.410 miles). This distance was statistically significant (p < 2.0 x 10-22) in the New England (5.935 mi), Mideast (6.356 mi), Great Lakes (8.733 mi), Far West (9.038 mi), Southeast (9.793 mi), Southwest (12.711 mi), Plains (16.047 mi), and Rocky Mountain (17.934 mi) regions. The total number of expected cataract surgeries greater than 100 miles to the nearest cataract surgeon was 1,901, where Montana, South Dakota, and Texas each had over 200 of these expected distances. CONCLUSIONS: A large discrepancy exists in cataract delivery to the Medicare population based on geographic factors. Patients who live in rural areas travel farther on average to see ophthalmologists, resulting in a lower observed than expected rate of cataract surgery. Our results have implications in future allocation of resources and ophthalmologists.

The United Kingdom Diabetic Retinopathy Electronic Medical Record Users Group: Report 3: Baseline Retinopathy and Clinical Features Predict Progression of Diabetic Retinopathy.

PURPOSE: To determine the time and risk factors for developing proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH). DESIGN: Multicenter, national cohort study. METHODS: Anonymized data of 50 254 patient eyes with diabetes mellitus at 19 UK hospital eye services were extracted at the initial and follow-up visits between 2007 and 2014. Time to progression of PDR and VH were calculated with Cox regression after stratifying by baseline diabetic retinopathy (DR) severity and adjusting for age, sex, race, and starting visual acuity. RESULTS: Progression to PDR in 5 years differed by baseline DR: no DR (2.2%), mild (13.0%), moderate (27.2%), severe nonproliferative diabetic retinopathy (NPDR) (45.5%). Similarly, 5-year progression to VH varied by baseline DR: no DR (1.1%), mild (2.9%), moderate (7.3%), severe NPDR (9.8%). Compared with no DR, the patient eyes that presented with mild, moderate, and severe NPDR were 6.71, 14.80, and 28.19 times more likely to develop PDR, respectively. In comparison to no DR, the eyes with mild, moderate, and severe NPDR were 2.56, 5.60, and 7.29 times more likely to develop VH, respectively. In severe NPDR, the eyes with intraretinal microvascular abnormalities (IRMA) had a significantly increased hazard ratio (HR) of developing PDR (HR 1.77, 95% confidence interval [CI] 1.25-2.49, P = .0013) compared with those with venous beading, whereas those with 4-quadrant dot-blot hemorrhages (4Q DBH) had 3.84 higher HR of developing VH (95% CI 1.39-10.62, P = .0095). CONCLUSIONS: Baseline severities and features of initial DR are prognostic for PDR development. IRMA increases risk of PDR whereas 4Q DBH increases risk of VH.

Comparison of retina specialist preferences regarding spectral-domain and swept-source optical coherence tomography angiography.

PURPOSE: The aim of this study was to compare physician preferences regarding the commercially available spectral-domain (SD) optical coherence tomography angiography (OCTA) and swept-source (SS) OCTA prototype device. DESIGN: Comparative analysis of diagnostic instruments was performed. PATIENTS AND METHODS: Subjects at the University of Washington Eye Institute and Harborview Medical Center were prospectively recruited and imaged with the Zeiss SD OCTA (HD-5000, Angioplex) and Zeiss SS OCTA (Plex Elite, Everest) devices on the same day. The study included 10 eyes from 10 subjects diagnosed with a retinal/choroidal disease. Deidentified images were compiled into a survey and sent to retina specialists in various countries. The survey presented masked SD and SS images of each eye for each retinal sublayer side by side. Respondents were asked about their image preference and impact on clinical management. A priori and post hoc preferences for SD vs SS were collected. RESULTS: Fifty-four retina specialists responded to the survey. Median years in practice was 3.00 (interquartile range [IQR] 1.50-17.00). At baseline, 23 (48%) physicians owned an OCTA machine. The majority of physician responses showed a preference for the SS over SD OCTA, independent of the retinal pathology shown (n=454 overall responses, 74%). Nevertheless, the majority indicated that both SD and SS would be equally valuable in informing clinical decisions (n=374 overall responses, 61%). CONCLUSION: These findings indicate that the majority of retina specialists surveyed prefer SS over SD OCTA based on image quality, regardless of the retinal pathology shown. Regarding the clinical utility of each modality, the majority of physicians perceive SD and SS as equally effective.

Validation of the Total Visual Acuity Extraction Algorithm (TOVA) for Automated Extraction of Visual Acuity Data From Free Text, Unstructured Clinical Records.

PURPOSE: With increasing volumes of electronic health record data, algorithm-driven extraction may aid manual extraction. Visual acuity often is extracted manually in vision research. The total visual acuity extraction algorithm (TOVA) is presented and validated for automated extraction of visual acuity from free text, unstructured clinical notes. METHODS: Consecutive inpatient ophthalmology notes over an 8-year period from the University of Washington healthcare system in Seattle, WA were used for validation of TOVA. The total visual acuity extraction algorithm applied natural language processing to recognize Snellen visual acuity in free text notes and assign laterality. The best corrected measurement was determined for each eye and converted to logMAR. The algorithm was validated against manual extraction of a subset of notes. RESULTS: A total of 6266 clinical records were obtained giving 12,452 data points. In a subset of 644 validated notes, comparison of manually extracted data versus TOVA output showed 95% concordance. Interrater reliability testing gave κ statistics of 0.94 (95% confidence interval [CI], 0.89-0.99), 0.96 (95% CI, 0.94-0.98), 0.95 (95% CI, 0.92-0.98), and 0.94 (95% CI, 0.90-0.98) for acuity numerators, denominators, adjustments, and signs, respectively. Pearson correlation coefficient was 0.983. Linear regression showed an R2 of 0.966 (P < 0.0001). CONCLUSIONS: The total visual acuity extraction algorithm is a novel tool for extraction of visual acuity from free text, unstructured clinical notes and provides an open source method of data extraction. TRANSLATIONAL RELEVANCE: Automated visual acuity extraction through natural language processing can be a valuable tool for data extraction from free text ophthalmology notes.

Evaluation of bilateral central retinal artery occlusions with optical coherence tomography-based microangiography: a case report.

BACKGROUND: We report a case of bilateral central retinal artery occlusion and the evaluation of retinal vasculature and capillaries by using optical coherence tomography angiography. CASE PRESENTATION: A 75-year-old white man presented with central retinal artery occlusion in one eye and underwent a carotid angioplasty. Upon discontinuing anticoagulant, he had a subsequent central retinal artery occlusion in the other eye. Optical coherence tomography angiography images were obtained to compare the retinal microvasculature in both eyes. CONCLUSIONS: Atrophy of the involved retina continues for several weeks after central retinal artery occlusion but the loss of retinal capillaries is immediate and stable over time. The presence of cilioretinal arteries that perfuse the central macula can prevent profound vision loss.