To compare the relative effectiveness and side effect profiles of antimetabolite drugs in the treatment of noninfectious ocular inflammation.
Retrospective cohort study.
A total of 257 patients with ...inflammatory eye disease seen in a single-center, academic practice and treated with an antimetabolite as a first-line immunosuppressive agent from 1984 to 2006.
Data recorded included demographics, antimetabolite and prednisone doses, use of other immunosuppressive drugs, response to therapy, and side effects associated with drug use.
Ability to control ocular inflammation and to taper prednisone to <or=10 mg daily ("treatment success"); incidence of treatment-related side effects.
Ninety patients with inflammatory eye disease were treated with methotrexate, 38 patients were treated with azathioprine, and 129 patients were treated with mycophenolate. Uveitis accounted for the majority of the diagnoses (67%, 66%, and 68% for methotrexate, azathioprine, and mycophenolate, respectively), followed by scleritis (23%, 18%, 17% for methotrexate, azathioprine, and mycophenolate, respectively). The median time to treatment success was 4.0, 4.8, and 6.5 months for the mycophenolate, azathioprine, and methotrexate treatment groups, respectively (P = 0.02, log-rank test). The incidence of side effects was higher in the azathioprine group (0.29/person-year PY) compared with patients treated with methotrexate (0.14/PY) and mycophenolate (0.18/PY). More patients discontinued the drug because of side effects in the azathioprine group (0.24/PY vs 0.09/PY for the methotrexate group and 0.09/PY for the mycophenolate mofetil group).
These data suggest that the time to control of ocular inflammation is faster with mycophenolate than with methotrexate. Azathioprine therapy has a higher rate of treatment-related side effects compared with the other 2 agents.
Purpose: To describe the effectiveness of periocular corticosteroid injections in the treatment of cystoid macular edema (CME) complicating noninfectious uveitis. Design Retrospective cohort study. ...Methods A total of 126 patients (156 eyes) were evaluated for presence of CME, visual acuity, intraocular pressure, degree of intraocular inflammation, and the presence of ocular complications. Main outcome measures included resolution of CME and visual acuity at the 1- and 3-month visits, failure of periocular injection therapy, and side effects. Results Twenty-eight percent of the 156 eyes had anterior uveitis, 22% intermediate uveitis, and 31% panuveitis. Of these eyes, 53% demonstrated clinical resolution of CME at 1 month and 57% at 3 months after a single periocular corticosteroid injection. Forty eyes were treated with >1 periocular injection because the CME persisted 1 month after the first injection (1 additional injection in 21 eyes; 2 additional injections in 14 eyes; >2 additional injections in 5 eyes). For the 21 eyes treated with a second periocular corticosteroid injection, 81% had no CME 1 month after the second injection and 48% had no CME 3 months after the second injection. Twenty-three eyes (15%) failed periocular corticosteroid therapy. Of eyes initially responding to periocular injection, CME recurred in 53% (median time to recurrence = 20.2 weeks). A halving of the visual angle was observed in 52% and 57% at the 1- and 3-month visits after injection, respectively. Conclusions Fifty-three percent of eyes treated with a single periocular corticosteroid injection had clinical resolution of CME 1 month after the injection.
Background
While the development of targeted molecular therapy to inhibit vascular endothelial growth factor (VEGF) has revolutionized the treatment and visual prognosis of highly prevalent retinal ...diseases such as diabetic retinopathy and age-related macular degeneration, each intravitreal injection of these agents carries a small risk of endophthalmitis which can be visually devastating. In the absence of specific guidelines, current management of post-injection endophthalmitis is typically extrapolated from data regarding endophthalmitis occurring after cataract surgery despite potential differences in pathogenic organisms and clinical course. Here, we assess the contribution of intravitreal injections of anti-VEGF agents to all cases of endophthalmitis at our tertiary care referral center and characterize the clinical outcomes and microbial pathogens associated with post-injection endophthalmitis in order to inform management of this serious iatrogenic condition.
Results
During the 7-year study period analyzed, 199 cases of endophthalmitis were identified using billing records. Of these, the most common etiology was post-surgical, accounting for 62 cases (31.2 %), with bleb-associated, endogenous, and corneal ulcer-related infections representing the next most frequent causes, comprising 15.6 % (31/199), 13.1 % (26/199), and 13.6 % (27/199) of all cases, respectively. Intravitreal injections of anti-VEGF agents represented 8.5 % of endophthalmitis (17/199 cases). Intraocular cultures yielded positive results in 75 % of post-injection cases, with the majority associated with coagulase-negative
Staphylococcus
. Consistent with prior literature, a case of
Strep viridans
displayed more rapid onset and progression. We also report the first association of
Enterobacter cloacae
and
Lactococcus garvieae
with post-injection endophthalmitis. While all but one patient were treated with initial vitreous tap and intravitreal injection of antibiotics, both patients with these rare organisms exhibited persistent vitritis requiring subsequent vitrectomy. Long-term outcomes of post-injection endophthalmitis indicated visual recovery to baseline levels, even with resumption of anti-VEGF agents following resolution of the acute infection.
Conclusions
Acute endophthalmitis following intravitreal injections of anti-VEGF agents is an uncommon but potentially devastating complication which may be managed effectively with vitreous tap and injection of intravitreal antibiotics. However, persistent vitritis requiring subsequent vitrectomy should raise suspicion for unusual pathogens.
Background
The purpose of this study is to describe and quantify the benefit of ultra-wide-field imaging and fluorescein angiography (FA) in the management of non-infectious retinal vasculitis. In ...this prospective observational cohort series, patients with non-infectious retinal vasculitis were evaluated and enrolled by four investigators from the Divisions of Retina and Ocular Immunology at the Wilmer Eye Institute. In each patient, disease activity and the need for management changes were assessed, based on clinical examination with or without standard (60°) imaging and then with the addition of ultra-wide-field pseudo-color scanning laser ophthalmoscope (SLO) images and FA using the Optos ultra-wide-field SLO (Optos Panoramic 200MA™, Optos PLC, Dunfermline, Scotland, UK). A standardized questionnaire was completed by each investigator at the time of the clinical evaluation.
The
primary
outcome was the percentage of patients whose management was changed by clinical examination and standard FA, compared with clinical examination plus ultra-wide-field imaging. The
secondary
outcome was the percentage of patients whose disease was determined to be active based on each modality.
Results
Seventy-one visits from 23 patients were reviewed and analyzed. Based on examination plus ultra-wide-field imaging and ultra-wide-field angiography, disease activity was detected in 48/71 (68%) compared with 32/71 (45%) based on examination and standard FA (
P
= 0.0095). Based on the clinical examination alone, the decision to alter management was made in 4 of 71 visits (6%), and an additional 3 of 71 (4%) based on simulated standard FA. The addition of ultra-wide-field SLO pseudo-color images altered management in an additional 10/71 visits (14%), and 36/71 (51%) with the addition of ultra-wide-field FA.
Conclusions
Ultra-wide-field fluorescein imaging and angiography can provide additional information that may be important and relevant in the management of retinal vasculitis.
To evaluate the ocular reactivity of the rabbit to an intracameral injection of a dispersive ophthalmic viscosurgical device (OVD) containing various levels of bacterial endotoxin using slit-lamp ...biomicroscopy and laser flare photometry.
Experimental, randomized, masked animal study.
Thirty Dutch-Belted rabbits.
The rabbits were randomized into 6 groups to receive 0.05 ml of a hydroxypropyl methylcellulose-based dispersive OVD to which had been added one of 5 different doses of bacterial endotoxin ranging from 0.02 to 1.4 endotoxin units (EUs) or a vehicle control to both eyes. The eyes were evaluated for anterior segment inflammation at baseline and 3, 6, 9, 24, 48, and 72 hours after injection using slit-lamp biomicroscopy and laser flare photometry.
Corneal clarity and anterior chamber (AC) inflammation.
All the corneas remained clear throughout the study. Anterior chamber cells were seen at 6, 9, and 24 hours in 60% to 100% of the eyes intracamerally injected with endotoxin-containing OVD, and the response declined rapidly after 24 hours. A dose-response effect was seen between the concentration of endotoxin and the AC cell response. The aqueous flare response in eyes injected with the 2 highest doses of endotoxin was significantly greater (P<0.05) than that of controls. The amounts of fibrin observed in the AC were random, with no apparent dose-response effect seen. The flare values as obtained by laser flare photometry were consistent with the slit-lamp biomicroscopy flare findings up to grade 3+. However, the increase in laser flare value seemed to level off in eyes with more than 3+ flare. Neither measure of flare correlated with endotoxin level.
Among the parameters evaluated in this study, the AC cell response, evaluated by slit-lamp biomicroscopy and graded using a standard grading system, was found to be the most reliable indicator of the amount of endotoxin in the dispersive OVD. The use of laser flare photometry alone does not seem to be useful in detecting an ocular response to endotoxin contamination in OVDs.
Purpose: This work compares physician reimbursements for retinal detachment (RD) surgery with office-based patient care. Methods: A theoretical model was constructed from the physician’s perspective ...for performing a 90-minute uncomplicated RD surgery with its associated perioperative work in the global period (Current Procedural Terminology code 67108) compared with managing 40 patients per 8-hour clinic day in the equivalent time period. The reimbursement rates were based on the 2019 values set by the US Centers for Medicare and Medicaid Services (CMS). Sensitivity analyses were performed varying the perioperative times, clinical productivity, and postoperative visits. Results: The CMS physician reimbursement rate for 67108 surgery was 17.13 work relative value units (wRVUs); meanwhile, the physician in the reference case could have generated 40.89 wRVUs in the office. CMS reimbursement therefore represented a 58% opportunity cost relative to lost office productivity for the physician. A significant disparity was still present even when modeling 30 patients per day. In sensitivity analyses, clinical productivity exceeded surgical compensation in 99% of modeled scenarios. In threshold analyses, the surgeon in the reference case would have to complete the surgery and all immediate perioperative care within 18 minutes to equal the total CMS valuation. Conclusions: CMS reimbursement for RD surgery resulted in a significant opportunity cost for the physician relative to office-based patient care, which was more pronounced for more efficient clinicians in the office. The sensitivity analyses supported the robustness of the model. Reductions in surgery reimbursements relative to office-based patient care might disincentivize busy clinicians.
To investigate whether enzymatic detergents used in cleaning ophthalmic surgical instruments can cause toxic anterior segment syndrome (TASS)-like responses in a rabbit model.
Randomized, ...investigator-masked, controlled experimental animal study.
Thirty-five New Zealand white rabbits.
The rabbit eyes were randomized into 7 treatment groups to receive intracameral injection of 1 of 3 different doses of Medline Dual Detergent or Enzol Detergent, or sterile limulus amoebocyte lysate reagent water as a control. The eyes were evaluated for anterior segment inflammation at baseline and at 1, 3, 6, 24, 48, and 72 hours after treatment by slit-lamp biomicroscopy.
Anterior chamber (AC) inflammation, including cells, flare, fibrin, and iris injection; time course of inflammation; and residual detergent levels in luminated instruments.
Moderate to marked injection of the iris vessels was seen as early as 1 hour after treatment with the enzymatic detergents in 41 of 60 eyes, with the response being more severe in the Enzol Detergent-exposed eyes. Severe iris hemorrhages were accompanied by blood in the AC in 13 eyes, which usually persisted through 72 hours, with an associated increase in AC cell and flare. Corneal haze was present in 52 of 56 eyes 1 hour after treatment, but was mild and resolved within 24 hours in all but the Enzol 4.5%-exposed eyes. Median AC cell and flare peaked at 6 hours and resolved by 48 hours.
Enzymatic detergents caused a severe but unusual response from the iris when injected intracamerally into rabbit eyes. This response has not been reported in humans with TASS. The time course of inflammation was faster (peak at 6 hours) and resolved more quickly (within 48 hours) than TASS. Simulated cleaning and extraction studies indicate that the level of residual detergent to which a patient could be exposed is significantly less than the lowest dose used in this study. Because that low dose caused no significant observations other than injection of the iris vessels, these results do not support residual enzymatic detergents on surgical instruments as a cause for TASS.
Purpose:
In the United States, most intravitreal injections are performed the same day
as an office examinations; however, federal agencies and insurance payers
suggest these same-day examinations ...charges are overused and have
recommended scrutiny. In this study, we estimate the cost vs benefit to
society of same-day office examinations during intravitreal injections for
wet age-related macular degeneration (wAMD).
Methods:
An Excel spreadsheet was used to model different antivascular endothelial
growth factor treatment scenarios for wAMD, including automatic treatment,
injection series' treat and extend (T&E), and
as-needed treatment, with increasing same-day examinations in the order
listed. Treatment parameters were estimated using US population statistics,
published literature, and Centers for Medicare & Medicaid Services,
provider utilization data. Costs and benefits were compared for the 4
treatment scenarios.
Results:
Although yearly examinations and optical coherence tomography costs were
higher for injection series, T&E, and as-needed protocols compared
with automatic treatment, our model predicts reduced yearly injection and
travel costs for those same treatment scenarios also, saving $2.9
billion (injection series), $7.2 billion
(T&E), and $6.1 billion
(as-needed) annually for the US population. Same-day
injections accounted for 21%, 8%, and 9% of the
savings, respectively, because of reduced travel burden. Furthermore, early
detection of wAMD in the fellow eye during office examinations allows for a
1.8, 2.1, and 2.5 quality-adjusted life-year benefit, respectively.
Conclusions:
Office examinations–directed antivascular endothelial growth factor
therapy for wAMD reduces travel and treatment expenses and improves
screening of the fellow eye, resulting in robust cost savings and
quality-adjusted life-year benefit for the US population.
Purpose: To describe the effectiveness of periocular corticosteroid injections for the control of intraocular inflammation associated with noninfectious uveitis.
Methods: A total of 81 patients (109 ...eyes) who received a periocular injection were evaluated for active inflammation, visual acuity, intraocular pressure, degree of intraocular inflammation, and the presence of ocular complications, including macular edema.
Results: Of all eyes, 36% (95%CI: 25%, 45%) demonstrated clinical resolution of inflammation at the 1-month visit after first injection, and 48% (95%CI: 37%, 59%) at 3 months. For multiple injections, 50% (95%CI: 28%, 72%) demonstrated resolution of inflammation at 1 month after the last injection, and 41% (95%CI: 20%, 63%) resolution of inflammation at 3 months after the last injection. Of the 49 eyes that initially responded, the estimated median time to recurrence was 7.6 months.
Conclusions: Approximately half of the treated eyes had resolution of intraocular inflammation at 3 months after corticosteroid injection.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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