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Purpose: To find the best cost-effective neovascular age-related macular degeneration (nAMD) treatment to improve vision while avoiding complications. The model is based on a cost-risk tradeoff analysis from policymakers' perspective., Design: A powerful and flexible simulation modeled outcomes of 2 years of treatment with the 4 commonly used anti-vascular endothelial growth factor drugs (bevacizumab, ranibizumab, aflibercept, and brolucizumab) across 3 injection protocols, building on prior findings that these drugs are noninferior. The model incorporates blinding complications, their management, and associated costs to society. Each option and several what-if scenarios were simulated 1,000 times with 100,000 hypothetical patients., Participants: One hundred thousand simulated patients using data from published clinical trials., Method: Case- and eye-specific cost-risk economic analysis., Main Outcome Measures: Costs of nAMD treatment per patient and number of eyes that become blind as a result of treatment over 2 years., Results: Using published prices and fees, the injection protocol that follows published clinical studies, results showed that the mean±standard deviation cost per patient were $16,859 ± $3.65, $32,949 ± $3.27, $39,831 ± $3.80, and $53,056 ± $2.99 for bevacizumab, brolucizumab, aflibercept, and ranibizumab, respectively. The numbers±standard deviations of treated eyes that became blind were 108 ± 10.18, 694 ± 26.66, 168 ± 12.83, and 108 ± 10.52, respectively. We further provide a lower bound (when all patients are maximally extended) and upper bound (when no patient is extended) to these numbers. For brolucizumab, the upper bound is the 2-month interval injection protocol., Conclusions: Taking a policymaking perspective, this study suggested that bevacizumab is the preferred first-line therapy. Recommendation for second-line therapy depends on the extent of the policymaker's risk aversion because of the tradeoff between cost and risk of blindness as a result of treatment. If risk neutral, the least expensive option (brolucizumab) is preferred. But if policymakers are moderately to highly risk averse, then aflibercept or ranibizumab are preferred. Because medical advances and different costs may change our findings, we provide a free application (https://eye-inj.shinyapps.io/calc/) for readers who wish to use different cost structures. Simulating outcomes is an innovative approach, unique in ophthalmology, and presents a significant opportunity because it can be adapted easily to different settings (using different costs, risks, and protocols) and to other diseases (e.g., diabetic macular edema), to ultimately improve wide-scale decision-making and use of funds., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to identify baseline optical coherence tomography (OCT) factors in branch retinal vein occlusion (BRVO) that predict response to bevacizumab injections., Methods: It is a retrospective case series of consecutive patients that underwent OCT at diagnosis, and the central macular thickness (CMT), extent of disorganized retinal inner layers, and outer retinal layers including external limiting membrane, ellipsoid zone (EZ), and cone outer segment tips (COST) were measured. Patients received 3 consecutive monthly injections of bevacizumab followed by pro re nata treatment. The main outcome measure was improvement in best-corrected visual acuity (BCVA) after 1 year. Results are expressed as mean ± SD, and p value <0.05 was considered statistically significant., Results: Overall, 66 eyes of 66 patients, with an average age of 68.5 ± 11.4 years, were included. The mean BCVA improved significantly from 0.68 logMAR at baseline to 0.50 logMAR at 1 year (p < 0.001). Baseline logMAR BCVA (r = 0.41, p < 0.001) and CMT (r = 0.23, p = 0.04) were associated with improvement while EZ (r = -0.24, p = 0.05) and COST (r = -0.32, p = 0.01) disruption with deterioration in BCVA., Conclusion: In patients with naïve BRVO treated with bevacizumab, BCVA improvement at 1 year can be predicted from baseline BCVA, CMT, extent of COST disruption, and EZ disruption., (© 2021 The Author(s). Published by S. Karger AG, Basel.)

Purpose: To evaluate the efficacy of micropulse laser in the early treatment of diabetic macular edema (DME) and its associated burden of anti-vascular endothelial growth factor (VEGF) injections., Methods: This retrospective comparative study compared a group of 19 eyes with DME treated with micropulse laser to a matched control group of 19 eyes with DME treated with ranibizumab injections without micropulse laser. Recorded parameters included previous medical and ocular history, previous and subsequent ranibizumab injections administered for DME, visual acuity (VA), central macular thickness throughout the follow-up period, and the occurrence of any complications., Results: The improvement in VA was comparable in both groups, at 12 months and at the final follow-up. Patients treated with micropulse laser required significantly fewer ranibizumab injections than their controls, both at 12 months (1.7 ± 2.3 vs 5.6 ± 2.1) and by the end of the follow-up (2.6 ± 3.3 vs 9.3 ± 5.1) (p<0.001 for both). No complications related to the micropulse laser were encountered., Conclusions: Micropulse laser is a safe and effective treatment for DME, which may achieve comparable improvement in VA along with a significant reduction in the burden of anti-VEGF injections. We suggest a treatment approach for its inclusion in the early stages of DME.

Purpose: To evaluate the efficacy of switching from bevacizumab to ranibizumab in patients with diabetic macular edema (DME)., Methods: This was a retrospective study of patients with DME initially treated with bevacizumab and switched to ranibizumab. Visual acuity (VA) and central retinal thickness (CRT) were retrieved at fixed timepoints prior to and after the switch., Results: Forty eyes of 32 patients were included in the study. The difference in VA between any of these fixed timepoints was not statistically significant. A significant gain in VA was found in eyes that lost more than 0.1 logMAR during treatment with the last 3 bevacizumab injections. The mean CRT was significantly lower after the first 3 ranibizumab injections and at the final follow-up (p<0.001), a 67 ± 14 μm and 78 ± 18 μm reduction in thickness, respectively., Conclusions: Switching to ranibizumab resulted in a significant decrease in the CRT of eyes with DME, and should be considered when there is a lack of response or deterioration while on bevacizumab injections. A significant gain in VA was observed in a subgroup of eyes that lost more than one line while receiving the last 3 bevacizumab injections prior to the switch.

Diabetic macular edema (DME) is the most common cause of vision loss in diabetic patients, and its management is often a long process requiring frequent monitoring and therapeutic interventions. During the past several decades, numerous treatments have been developed for the treatment of DME. Although many of them have been found to be effective and safe, there is relatively little comparative data, and no established guidelines for the optimal treatment approach exist. In this chapter, the evolution of DME therapies is reviewed, and the current common practice patterns are discussed. Available data from clinical trials on the commonly used agents, as well as comparative studies and combination therapies are reviewed. Additionally, recent advances and novel treatment options that are currently being investigated are also discussed., (© 2017 S. Karger AG, Basel.)

Diabetic macular edema is a common condition frequently encountered by ophthalmologists. In this piece we briefly review its definition, pathogenesis, clinical aspects, imaging, and treatment., (© 2017 S. Karger AG, Basel.)

Drug delivery into the posterior segment of the eye is complicated by the existence of the blood-ocular barrier. Strategies for delivering drugs to the posterior segment include systemic administration, modification of the barrier, and local drug delivery (including transcorneal, transscleral, and intravitreal). The most commonly used method for drug delivery into the posterior segment is by intravitreal injection. Other routes that can be used to achieve therapeutic drug levels in the posterior segment include topical, iontophoretic, and juxtascleral delivery. Extended-release intravitreal drug delivery systems can achieve sustained therapeutic levels with the goal of providing a prolonged clinical benefit with significantly fewer interventions., (© 2017 S. Karger AG, Basel.)

Purpose: To review the current practice of retreatment with Ozurdex injections in patients with macular edema (ME) secondary to retinal vein occlusion (RVO), and to recommend simple guidelines for Ozurdex reinjection in management of RVO., Methods: This was a multicenter retrospective study of patients who received more than 2 Ozurdex injections for the treatment of ME in RVO. Recorded parameters included percent of patients with a 15-letter gain, visual acuity (VA) improvement from baseline, change in central macular thickness (CMT), time to reinjection, and occurrence of any complications., Results: A total of 128 patients were included, 58 (45.3%) with central RVO (CRVO) and 70 (54.7%) with branch RVO (BRVO). Mean interval for Ozurdex reinjection was 5.9 months following the first injection and 8.7 months following the second. A >15-letter gain in VA was observed in 34 (48.8%) patients with CRVO and 16 (28%) patients with BRVO. Mean overall VA improvement at month 6 did not show significance (p>0.05); however, a significantly better mean VA improvement was seen in treatment-naïve eyes (p<0.03). The CMT was significantly reduced compared to baseline. The mean CMT decreased by 214.6 µm in eyes with BRVO (n = 53) and by 355.1 µm in eyes with CRVO (n = 63) (p = 0.002). Complication rates were very low., Conclusions: Repeated injections of Ozurdex are effective and have a favorable safety profile. In current practice, the retreatment interval with Ozurdex injections might be too long, precluding the full therapeutic potential of this treatment modality. A strategy for managing RVO patients treated with Ozurdex on an as-needed basis is provided.

Purpose: To evaluate the long-term visual prognosis and complications of patients who received intravitreal Ozurdex injections for the treatment of macular edema (ME) due to retinal vein occlusion (RVO)., Methods: A total of 17 patients who received Ozurdex injections in our institution as part of the GENEVA study were recalled for examination. Recorded parameters included final visual acuity (VA), final retinal thickness by optical coherence tomography, persistence of ME, and the occurrence of any complications., Results: Mean follow-up time was 50.5 months. Patients with branch RVO (BRVO) had a more favorable prognosis than central RVO (CRVO), and their mean VA had improved significantly, whereas the mean VA for the patients with CRVO did not improve significantly. Retinal thickness had reduced significantly in the whole group and in each subgroup separately. Complications included 10 patients with cataract progression, 1 with elevated intraocular pressure, and 1 with neovascularization and vitreous hemorrhage., Conclusions: This is the first reported long-term evaluation of patients treated with Ozurdex. Our results indicate that it has favorable long-term safety profile, and may have a beneficial effect on the visual prognosis in BRVO even in the absence of continuous treatment. Further research is required to establish the optimal retreatment schedule for Ozurdex.