Projected cost comparison of Trabectome, iStent, and endoscopic cyclophotocoagulation versus glaucoma medication in the Ontario Health Insurance Plan.

PURPOSE: To compare the direct cost of treating glaucoma patients with Trabectome, iStent, and endoscopic cyclophotocoagulation (ECP) versus topical medications in Ontario, Canada. Costs are projected over a 6-year period, and presented on a per-patient level from the perspective of the Ontario Health Insurance Plan (OHIP). METHODS: The per-bottle cost of each medication was obtained from the 2011 Ontario Drug Benefit (ODB) formulary. A wastage adjustment fee was added to the cost, as was a pharmacy markup, and an ODB dispensing fee. Previously published medication prescription rates were used to determine the frequency with which each medication is prescribed. We estimated the overall cost by taking a weighted average of the cost of each class of glaucoma medications.The cost of each glaucoma device was determined by contacting local distributors. We then added the cost of disposables used during surgery (viscoelastic and keratome) to the cost of each procedure. Start-up costs for each device and surgeons' fees were excluded from the overall cost. RESULTS: At 6 years, treatment with the Trabectome offered a cumulative cost savings of $279.23, $1572.55, and $2424.71 per patient versus monodrug, bidrug, and tridrug therapy, respectively. A cumulative cost difference of -$20.77, $1272.55, and $2124.71 per patient were found when comparing iStent versus monodrug, bidrug, and tridrug therapy, respectively. Treatment with ECP yielded a cost savings of $779.23, $2072.55, and $2924.71 per patient versus monodrug, bidrug, and tridrug therapy, respectively. CONCLUSIONS: Over a projected period of 6 years, the Trabectome, iStent, and ECP may all offer a modest cost savings to OHIP versus the cost of glaucoma medication. Further analysis of direct and indirect costs to patients as well as quality of life assessments will help further delineate the role of these treatments in the glaucoma treatment paradigm.

Hypertropia following Spontaneous Resolution of Brown's Syndrome.

PURPOSE: To report a case of bilateral Brown's syndrome with unilateral spontaneous resolution causing hypertropia and significant head tilt. CASE REPORT: A 3 ½-year-old girl presented with bilateral typical Brown's syndrome and orthophoria in the primary position; she presented with unilateral resolution of right Brown's syndrome 6 months later, causing right hypertropia and gradually deteriorating left head tilt. She benefited from right superior rectus muscle recession to help correct her head posture. CONCLUSION: This is the first report of a patient presenting with known bilateral Brown's syndrome with subsequent documented unilateral resolution causing a significant hypertropia of the resolved side and contralateral head tilt. Our case provides evidence in support of Clark and Noël's [Can J Ophthalmol 1993;28:213-216] hypothesis that patients who present with unilateral Brown's syndrome and contralateral inferior oblique muscle overaction might originally have had bilateral Brown's syndrome with spontaneous resolution of 1 side only.

Comparison of outcomes after switching treatment from intravitreal bevacizumab to ranibizumab in neovascular age-related macular degeneration.

OBJECTIVE: To compare visual acuity and central retinal thickness in patients initially treated with bevacizumab (Avastin) and switched to ranibizumab (Lucentis) for neovascular age-related macular degeneration (AMD). DESIGN: A retrospective chart review. PARTICIPANTS: This study included 87 eyes from 80 patients over the age of 65 with neovascular AMD. METHODS: Patients were initially treated with bevacizumab injections every 6 weeks and then switched to ranibizumab every 4 weeks when it became publicly funded by the Ontario government. Outcomes include comparison of visual acuity and central retinal thickness after bevacizumab treatment, and after switching to ranibizumab. RESULTS: Visual acuity improved significantly versus initial baseline values following a treatment course of 3 or more injections of bevacizumab (0.58 logMar, SD = 0.30 vs 0.73 logMar, SD = 0.41; p = 0.0007). Patients then showed a further significant improvement in visual acuity after switching and receiving a course of ranibizumab (0.51 logMar, SD = 0.32) (p = 0.0122). Mean central retinal thickness as measured by optical coherence tomography significantly decreased after a course of bevacizumab (p = 0.0158), and a further decrease was noted after a subsequent course of ranibizumab (p < 0.0001). CONCLUSIONS: There was a significant improvement in visual acuity and central retinal thickness in patients with neovascular AMD initially treated with bevacizumab. When these patients were uniformly switched to ranibizumab there was a further significant improvement in visual acuity and a reduction of retinal thickness. It appears that ranibizumab can maintain, or improve the effect achieved after an initial course of bevacizumab.

Image-guided transnasal endoscopic techniques in the management of orbital disease.

PURPOSE: To assess the utility of image-guided transnasal endoscopic surgery for a variety of orbital diseases requiring decompression of at least one orbital wall. METHOD: A descriptive case series of consecutive orbital procedures requiring decompression of at least one wall. All procedures were performed using a transnasal endoscopic approach and an intraoperative image-guided LandmarX system for anatomical guidance. RESULTS: A 3-year review yielded 17 cases, including 6 cases with compressive mucoceles, 4 neoplasms, 4 patients with proptosis secondary to Graves' Ophthalmopathy, 1 case of an intraorbital abscess, 1 fungal mycetoma, and 1 hemangioma. These cases all had improved postoperative clinical status without any serious complications. The LandmarX system was a valuable intraoperative tool in all 17 cases. CONCLUSIONS: The endoscopic transnasal approach to orbital decompression surgery allows for good visualization and is minimally invasive. Using this approach in conjunction with the LandmarX image-guided system allows for improved anatomical localization and provided good results in all cases.

Indoor soccer-related eye injuries: should eye protection be mandatory?

BACKGROUND: Our objectives were to present the spectrum of eye injuries caused by indoor soccer, as seen at our institution, and to initiate discussion as to whether eye protection should become mandatory for this indoor sport. METHODS: Chart review of patients presenting to our institution with eye injuries from indoor soccer. RESULTS: Five cases were identified from 2001-2005, all occurring during the winter or late fall. Each injury was due to contact with the soccer ball itself. Initially, all 5 patients presented with commotio retinae (1 with a prominent retinal and vitreous hemorrhage and 2 with smaller retinal hemorrhages), 2 with hyphema and traumatic mydriasis, 1 with subconjunctival hemorrhage, and 1 with upper lid edema and ecchymosis. Three resolved uneventfully with 20/20 or better vision; however, in 2 there were findings of choroidal rupture with chorioretinal scarring. One of these had 20/20 vision and a discontinuous choroidal rupture peripherally, and the other had 20/40 vision and extensive chorioretinal scarring. One patient also showed a peculiar persistent iris scar. INTERPRETATION: Soccer-related eye injuries have been recognized as an important ophthalmologic problem in Europe and now increasingly so in North America. With the increasing popularity of indoor soccer in Canada, serious eye injuries have become more prevalent. On the basis of the prevalence and the nature and mechanism of the ocular trauma, we believe there may be a need to make eye protection mandatory for all forms of soccer.

Ophthalmic findings in Setleis syndrome: two new cases in a mother and son.

CASE REPORT: Setleis syndrome is a rare ectodermal dysplasia with characteristic ophthalmic findings. We describe the first 2 reported cases in Canadian individuals of Aboriginal descent. COMMENTS: Although most ophthalmic findings are benign, it is important to recognize the clinical significance for management and genetic counselling. We postulate an autosomal dominant inheritance in our cases.