Patient-reported benefit from oculoplastic surgery.

PURPOSE: It is vital that surgeons undertaking oculoplastic procedures are able to show that the surgery they perform is of benefit to their patients. Not only is this fundamental to patient-centred medicine but it is also important in demonstrating cost effectiveness. There are several ways in which benefit can be measured, including clinical scales, functional ability scales, and global quality-of-life scales. The Glasgow benefit inventory (GBI) is an example of a patient-reported, questionnaire-based, post-interventional quality-of-life scale that can be used to compare a range of different treatments for a variety of conditions. METHODS: A cross-sectional study was undertaken using the GBI to score patient benefit from four commonly performed oculoplastic procedures. It was completed for 66 entropion repairs, 50 ptosis repairs, 41 ectropion repairs, and 41 external dacryocystorhinostomies (DCR). The GBI generates a scale from -100 (maximal detriment) through zero (no change) to +100 (maximal benefit). RESULTS: The total GBI scores of patients undergoing surgery for entropion, ptosis, ectropion, and external DCR were: +25.25 (95% CI 20.00-30.50, P<0.001), +24.89 (95% CI 20.04-29.73, P<0.001), +17.68 (95% CI 9.46-25.91, P<0.001), and +32.25 (95% CI 21.47-43.03, P<0.001), respectively, demonstrating a statistically significant benefit from all procedures. CONCLUSION: Patients derived significant quality-of-life benefits from the four most commonly performed oculoplastic procedures.

A pilot study on the combination treatment of reduced-fluence photodynamic therapy, intravitreal ranibizumab, intravitreal dexamethasone and oral minocycline for neovascular age-related macular degeneration.

AIM: To assess the safety and efficacy of the combined treatment of reduced-fluence verteporfin photodynamic therapy (PDT), intravitreal ranibizumab, intravitreal dexamethasone and oral minocycline for choroidal neovascularisa- tion (CNV) secondary to age-related macular degeneration (AMD). METHODS: Nineteen patients with subfoveal CNV secondary to AMD were recruited into the trial. All study eyes (n = 19) received a single cycle of reduced-fluence (25 mJ/cm(2)) PDT with verteporfin followed by an intravitreal injection of ranibizumab 0.3 mg/0.05 ml and dexamethasone 200 µg at baseline. Oral minocycline 100 mg daily was started the following day and continued for 3 months. Patients were followed up monthly for 12 months. Repeat intravitreal ranibizumab was given if best-corrected visual acuity (BCVA) deteriorated by >5 letters on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart or central retinal thickness (CRT) on ocular coherence tomography increased >100 µm. RESULTS: Eighteen patients completed the 12-month study. Stable vision (loss of ≤15 ETDRS letters) was maintained in 89% eyes (16/18). The mean change in BCVA was -5.0 ± 10.5 ETDRS letters. The mean number of ranibizumab injections was 3.4 (range 2-6). The mean reduction in the CRT was 66.3 µm (±75). CONCLUSION: This open-label clinical trial has demonstrated the safety in terms of adverse effects and maintenance of stable vision of combination treatment with verteporfin, ranibizumab, dexamethasone and minocycline in exudative AMD. However, the outcomes with reduced-fluence PDT combination therapy does not differ significantly with outcomes of clinical trials on combination treatment with standard dose PDT and intravitreal ranibizumab in neovascular AMD.

Diurnal variation of macular oedema in CRVO: prospective study.

INTRODUCTION: Patients with central retinal vein occlusion (CRVO) may experience reduced vision in the morning. This may be due to increased cystoid macular oedema (CMO), which can be measured on optical coherence tomography (OCT). METHODS: A prospective study was performed on ten patients. Retinal thickness measurements were made with the Topcon 3D OCT-1000: at 9 A.M., 11 A.M., 1 P.M., 3 P.M., 5 P.M. In addition, at 9 A.M. and 5 P.M. visual acuity was recorded using ETDRS LogMAR. RESULTS: There were seven males and three females with average age of 59.4 years (range 40-80 years). The average duration of symptoms was 5.4 months (range 3-9 months). In eyes with CRVO, median central macular thickness (CMT) significantly reduced from 571 microm at 9 A.M. to 475 microm at 5 P.M. (p < 0.05). Comparison of CMT at 9 A.M. to each of the subsequent time intervals found that there was a significant reduction in the central macula thickness late in the day (p < 0.05). There was no statistical difference in the visual acuity and change in macular thickness did not correlate with change in visual acuity in eyes affected by CRVO. DISCUSSION: Patients with CRVO demonstrate increase in CMO in morning compared with late morning and afternoon. Possible causes are diurnal variation in blood pressure, retinal metabolism and erect posture. Interventions designed to influence these factors could be used to try to reduce CMO severity.

Computerized model of cost-utility analysis for treatment of age-related macular degeneration.

PURPOSE: To present a computerized model assessing individualized cost utility for current treatments for neovascular age-related macular degeneration (AMD) to enhance discussion regarding treatment options. DESIGN: Case- and eye-specific cost-utility analysis using individual case scenarios. PARTICIPANTS: Visual acuity data from published randomized controlled trials are incorporated into this analysis. METHODS: Computerized model (Microsoft Visual Basic 6.0 programming) to establish preference-based cost-utility analysis in association with individual cost of treatment and blindness for neovascular AMD for both the better and worst seeing eye, with extrapolation of results over a 5-year term. MAIN OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) and cost per QALY gained for comparison of treatments for specific visual acuities. RESULTS: All treatments show an increase in utility in comparison with best supportive care (BSC) if the better-seeing eye is treated. Ranibizumab, using the Phase IIIb, Multicenter, Randomized, Double-Masked, Sham Injection-Controlled Study of the Efficacy and Safety of Ranibizumab in Subjects with Subfoveal Choroidal Neovascularisation (CNV) with or without Classic CNV Secondary to AMD (PIER) regimen, is the most cost effective at $626 938 per QALY gained for treatment of the better seeing eye. To increase utility value when treating the worst seeing eye, the vision must improve to such a degree that it becomes the better seeing eye. This level of improvement is only possible if there is <9 letters difference between the 2 eyes and treated with ranibizumab. Over 5 years, increasing influence from the cost of blindness results in increasing costs for those treatments unable to stabilize vision. Within 5 years, the cost per QALY for the BSC is greater than all treatments except monthly ranibizumab injections. CONCLUSIONS: Assessment of cost of treatment incorporates both effectiveness of treatment, cost of treatment, and cost of blindness. Cost analysis enables incorporation of these aspects of treatment with the quality of life data to provide a better comparison of treatments over time. This analysis has provided a method for individual analysis and therefore can provide the structure for resource allocation. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Age-related macular degeneration: a perspective on genetic studies.

AIM: Age-related macular degeneration (AMD) is a common macular disease in the developed world and recent studies have shown that specific genes may be associated with it and may contribute to a higher risk of developing AMD. OBJECTIVE: Our objective was to review systematically recent publications related to the genetics of AMD and provide relevant information that would help both scientists and clinicians in advising patients. METHOD: A systematic search was performed on PubMed, Medline, and National Library of Medicine as well as ARVO abstracts using key words relevant to the genetic associations of AMD. RESULTS: The most important genetic associations in AMD involved the complement factor H (CFH) gene, which showed that possession of the variant Y402H polymorphism significantly increases the risk for AMD. Protective genes have also been identified such as those on either factor B (BFor complement factor B (CFB)) or complement component 2 (C2) genes. The genes involved in inherited macular dystrophies such as ATP-binding cassette, subfamily A (ABC1), member 4 (ABCA4), vitelliform macular dystrophy (VMD2), tissue inhibitor of matrix metalloproteinase-3 (TIMP3), and EFEMP1have yielded some important information but further confirmatory work has yet to establish a clear association with AMD. CONCLUSION: Patients with AMD possess specific genetic variants of the CFHgene, which put them at a higher risk of developing the disease. Other unaffected individuals may possess certain protective genetic variants, which could prevent them from developing AMD. Further research will no doubt shed light on other such mechanisms and these will be useful in identifying possible direct targets for drugs or indirectly through modulation of the genes responsible for disease presentation.

Pulsatile ocular blood flow in asymmetric age-related macular degeneration.

PURPOSE: Ocular perfusion abnormalities have been proposed in the pathogenesis of age-related macular degeneration (AMD) with differences in pulsatile ocular blood flow (POBF) in eyes with asymmetric AMD in Japanese and Taiwanese patients. The purpose of our study was to observe POBF difference in the fellow eyes of Caucasians with asymmetric AMD. METHODS: This was a cross-sectional study comparing POBF in three groups of patients with asymmetric AMD in the fellow eyes: Group 1 (n=21) with drusen and active choroidal neovascularisation (CNV); Group 2 (n=18) with drusen and disciform scar; Group 3 (n=8) with CNV and disciform scar. The POBF was adjusted for intraocular pressure (IOP), pulse rate (PR), and axial length using multiple regression analysis. Generalised estimation equation model was used to include both eyes in each group. RESULTS: The geometric mean (95% confidence interval) POBF values were as follows: Group 1 with drusen 1097.9 microl/min (957.0, 1259.7) in one eye and the fellow eye with CNV 1090.1 microl/min (932.3, 1274.7); Group 2 with drusen 946.0 microl/min (794.2, 1126.7) and disciform scar 966.2 microll/min (780.3, 1196.4); Group 3 with CNV 877.1 microl/min (628.3, 1224.6) and disciform scar 767.2 microl/min (530.5, 1109.7). Adjusting for differences in axial length, pulse rate and intraocular pressure, no statistically significant difference in POBF was found between fellow eyes in the same subject. CONCLUSIONS: POBF is not different between fellow eyes of Caucasian patients with asymmetric AMD.