February 10, 2021

Is pre-cataract surgery testing worth the wait?

Ophthalmology
Just like you wouldn't order a D-dimer in a patient with a swollen left leg, a recent flight, and shortness of breath...the same might go for pre-operative testing in cataract patients, such as ocular biometry. Most ophthalmologists and patients consider these preoperative tests to be harmless, except for the minor inconvenience of delayed surgery. However, authors here sought to determine if delays in surgery due to these tests contributed to increased patient falls using a 5% Medicare sample from 2006-2014. To do so, they categorized physicians as "high-testing" if they carried out routine preoperative testing in greater than 75% of their patients within 30 days of surgery; all others were "low-testing". Fewer patients of "high-testing" physicians underwent cataract surgery within 30 days of biometry (64.6%) versus "low-testing" physicians (72.4%), and more patients of "high-testing" physicians waited longer than 90 days (8.2% vs. 5.5%). Perhaps more importantly, there was a 43% increase in fall events after biometry and before cataract surgery for patients of "high-testing" physicians (1.0% vs. 0.7%), though no difference was noted in the year preceding biometry. Other findings included an adjusted 8 extra days between biometry and surgery for "high-testing" physicians, increased time for the Northeast US geographic region, and certain demographic groups, among others. Overall, while pre-operative testing is often thought of as a worthwhile minor inconvenience, it may be causing more harm than good, and physicians should be cognizant of these concerns when approaching their patients.

Bias in ophthalmic cost-utility analysis

JAMA Ophthalmology
Cost-utility analyses have been a mainstay in evaluating whether expensive ophthalmic interventions are worth it for patients, but is this practice biased? Cost-utility analysis evaluates health care interventions by integrating objective improvement in patient quality of life. Utilities in ophthalmic studies typically quantify the quality of life on a scale ranging from 0.00 (death) to 1.00 (normal vision permanently), and these scenarios usually collect vision utilities from individuals without ophthalmic disease. However, these researchers note that mean vision utilities acquired from real patients with diverse vision levels are typically lower than vision utilities acquired from surrogate respondents, and thus may be biasing results. The purpose of this study is to perform an economic evaluation of cataract surgery and intravitreal ranibizumab therapy for neovascular age-related macular degeneration (NVAMD) using vision utilities acquired from both patients with ophthalmic disease (ophthalmic patient utilities) and from surrogate individuals (non-ophthalmic patient vision utilities). Cost-utility analyses of these two interventions using nonpatient vision utilities decreased preference-based comparative effectiveness and cost-effectiveness, potentially biasing against disabled, elderly, and minority populations. This negative potential bias could theoretically result in beneficial intervention denial, less research dollars, curbed therapeutic advances, and decreased interventional reimbursement. Researchers performing future cost-utility analyses should realize these phenomena and consider correcting the potential discrimination against disabled, elderly, and African American populations.

Treat-and-Extend for Macular Edema in Central Retinal Vein Occlusion

American Journal of Ophthalmology
Treat and extend (T&E) may sound like a way to train your Goldendoodle, but it also describes a tailored way to reduce the burden of intravitreal injections (and win brownie points from your patients). In an open-label phase 4 Clinical study called CENTERA, Korobelnik et al. studied the efficacy and safety of intravitreal aflibercept (IVT-AFL) T&E dosing in patients with macular edema secondary to central retinal vein occlusion (CRVO). Patients received 2mg IVT-AFL at baseline and every 4 weeks until disease stability criteria were met (or until week 20), at which point intervals were adjusted in 2 week increments based on functional (BCVA) and anatomic (cysts and CRT on OCT) outcomes. 65.6% of patients gained ≥15 letters from baseline to week 76, with an average of +20.3 letters gained and mean central retinal thickness improvement of -496.1μm. During the T&E phase, 45.0% of patients achieved a mean treatment interval of ≥ 8 weeks, and the last and next planned interval of ≥8 weeks was achieved by 63.1% and 67.5% of patients, respectively. With a similar safety profile to previous studies, CENTERA suggests meaningful and significant improvements in functional and anatomic outcomes can be achieved with IVT-AFL using T&E regimen.

A New Tool for Eye Drop Delivery 

Ophthalmology Glaucoma
We’ve all seen a misplaced eye drop or two, and maybe even been at fault for it once or twice. Moreover, we know that eye drop adherence is one of the greatest barriers of glaucoma treatment. Now there’s a new device -- a nose-pivoted drop delivery device (NPDD) -- getting tested as a potential new tool to help improve eye drop delivery and adherence. Researchers evaluated drop delivery techniques of the NPDD compared to both “traditional” drop delivery technique at baseline and traditional technique after a standardized tutorial. Participants rated their experience of using the NPDD, while graders reviewed videos to ensure accurate placement, no bottle tip contact, and proper number of drops dispensed. 94% of participants preferred the NPDD and 98% found it more comfortable to use than traditional drop delivery. The graders found that the bottle tip contacted the ocular surface fewer times and fewer drops wasted when using the NPDD compared to traditional technique both at baseline and after teaching. All three techniques resulted in >90% of drops reaching the ocular surface. Tools like these can potentially improve drop adherence in glaucoma patients while minimizing ocular contact and decreasing drop waste -- how brilliant! 

Seeing a Difference: Cataract Practices Globally

BMJ Open Ophthalmology
Sweden, Netherlands, Japan, India. These aren’t just the places we want to go when the COVID-19 pandemic is over, but also some of the countries with the highest per-capita numbers of cataract surgery. There are greater than 20 million cataract surgeries globally each year, and the authors of this study sought to determine the universality of cataract practice globally by creating a survey to assess preoperative measures, intraoperative practices, and postoperative care. A diverse group or respondents was represented in terms of location (38 different countries), surgical volume, and practice setting. In terms of pre-operative testing, 51.7% of surveyed institutions conducted pre-op ECG and blood testing, 60% had the ophthalmologist interview the patient, and 27% had the anesthesiologist; 6% did not ask for any pre-op testing. The type of institution (academic, private practice, vs. public) was related to differences in pre-operative care, though surgical volume was not. Intraoperatively, the type of institution influenced the number of surgeons present in the OR with private practices more likely to have surgeons operating alone. Similarly, vascular access was more frequent in public hospitals and least in private practices. A number of other differences in pre-, intra-, and post-operative care existed across countries and institution type. This global inconsistency should be addressed with cost effective solutions that can simultaneously lead to increased patient safety.