Brian L. VanderBeek

Diabetic Retinopathy: A Position Statement by the American Diabetes Association.

Diabetic retinopathy diagnostic assessment and treatment options have improved dramatically since the 2002 American Diabetes Association Position Statement (1). These improvements include the widespread adoption of optical coherence tomography to assess retinal thickness and intraretinal pathology and wide-field fundus photography to reveal clinically silent microvascular lesions. Treatment of diabetic macular edema is now achieved by intravitreous injection of anti–vascular endothelial growth factor agents, and the same drugs are now used for proliferative diabetic retinopathy. Improvements in medications and devices for the systemic therapy of diabetes have also improved the ability of patients to optimize their metabolic control. This Position Statement incorporates these recent developments for the use of physicians and patients. Diabetic retinopathy is a highly specific neurovascular complication of both type 1 and type 2 diabetes, the prevalence of which strongly correlates to both the duration of diabetes and level of glycemic control. A pooled meta-analysis involving 35 studies conducted worldwide from 1980 to 2008 estimated global prevalence of any diabetic retinopathy and proliferative diabetic retinopathy (PDR) among patients to be 35.4% and 7.5%, respectively (2). Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20–74 years in developed countries. Glaucoma, cataracts, and other disorders of the eye occur earlier and more frequently in people with diabetes. In addition to diabetes duration, factors that increase the risk of or are associated with retinopathy include chronic hyperglycemia (3,4), nephropathy (5), hypertension (6), and dyslipidemia (7). Intensive diabetes management with the goal of achieving near-normoglycemia has been shown in large prospective randomized studies to prevent and/or delay the onset and progression of diabetic retinopathy (8,9). Lowering blood pressure has been shown to decrease retinopathy progression in people with type 2 diabetes, although tight targets (systolic blood pressure <120 mmHg) do …

Racial differences in age-related macular degeneration rates in the United States: a longitudinal analysis of a managed care network.

PURPOSE To compare the incidence, prevalence, and hazard of nonexudative and exudative age-related macular degeneration (AMD) among different races throughout the United States. DESIGN Retrospective longitudinal cohort study. METHODS Billing records of all encounters for 2 259 061 beneficiaries aged ≥40 enrolled in a large, national US managed care network from 2001 through 2007 were reviewed and the incidence and prevalence of nonexudative and exudative AMD were determined and stratified by race. Cox regression analyses determined the hazard of nonexudative and exudative AMD for each race, with adjustment for confounders. RESULTS During the study, 113 234 individuals (5.0%) were diagnosed with nonexudative and 17 181 (0.76%) with exudative AMD. After adjustment for confounders, blacks had a significantly reduced hazard of nonexudative (hazard ratio [HR]=0.75, 95% confidence interval [CI]: 0.71-0.79) and exudative AMD (HR=0.70, 95% CI: 0.59-0.83) at age 60 and a reduced hazard of nonexudative (HR=0.56, 95% CI: 0.52-0.60) and exudative AMD (HR=0.45, 95% CI: 0.37-0.54) at age 80 relative to whites. Similar comparisons for Latinos demonstrated an 18% reduced hazard for nonexudative AMD at age 80 (HR=0.82, 95% CI: 0.76-0.88) relative to whites. Asian Americans showed a 28% increased hazard for nonexudative AMD at age 60 (HR=1.28, 95% CI: 1.20-1.36) but a 46% decreased hazard for exudative AMD at age 80 (HR=0.54, 95% CI: 0.40-0.73). CONCLUSIONS Racial minorities, including Latinos and Asian Americans, do not appear to have similar risks of developing nonexudative and exudative AMD as whites. Additional studies using other sources should be conducted to determine the generalizability of this studys findings to other groups.

The diversity of traction mechanisms in myopic traction maculopathy.

PURPOSE To identify the major traction mechanisms that cause myopic traction maculopathy and to determine whether surgery can be tailored successfully to the specific mechanism involved. DESIGN Nonrandomized, retrospective, interventional case series. METHODS We performed a chart review of consecutive patients who underwent vitreoretinal surgery for myopic traction maculopathy by a single surgeon at a tertiary referral center. Traction mechanisms were identified based on preoperative and intraoperative findings and postoperative response to a tailored surgical approach. RESULTS Six eyes of 6 patients with a minimum follow-up of 6 months were included. Major pathogenic traction mechanisms included perifoveal posterior vitreous detachment with vitreomacular traction in 3 eyes, noncompliance of native internal limiting membrane in 2 eyes, epiretinal membrane in 1 eye, and remnant cortical vitreous layer after posterior vitreous detachment in 1 eye. One eye exhibited 2 traction mechanisms. The surgical approach addressed only the major traction mechanism(s) identified in each eye. After surgery, the visual acuity improved by 2 lines or more in all eyes, and macular thickening resolved completely in 5 (83%) of 6 eyes and partially in the remaining eye. CONCLUSIONS The traction mechanisms causing myopic traction maculopathy are diverse. Vitreoretinal surgical repair for this condition is successful when the major traction mechanisms causing tautness of the inner retina are identified and relieved.

Association of Compounded Bevacizumab With Postinjection Endophthalmitis

IMPORTANCE Current draft guidelines set forth by the US Food and Drug Administration for compounded or repackaged medications would greatly limit the availability and use of bevacizumab by ophthalmologists across the country. Little evidence beyond highly publicized case reports exists for or against the need for additional regulation of compounded bevacizumab. OBJECTIVE To determine whether the distribution of bevacizumab through compounding pharmacies increases the risk for endophthalmitis compared with the distribution of single-use vials of ranibizumab from the manufacturer. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using medical claims data from ambulatory care centers across the United States that were submitted to a large, national US insurer. Cohorts were created using information on 530 382 intravitreal injections administered from January 1, 2005, through December 31, 2012. Any individual from this data set who received an intravitreal injection of bevacizumab or ranibizumab (n=383 810) and had at least 6 months of data before and 1 month after the injection was eligible. After exclusions (any previous diagnosis of endophthalmitis, multiple injected drugs given on the index day, or intraocular surgery within 15 days of the injection or between the injection and a diagnosis of endophthalmitis), our analysis involved 383 810 intravitreal injections given to 58 612 patients. Data collection and analysis occurred from February 16 through April 7, 2015. MAIN OUTCOMES AND MEASURES The odds of developing endophthalmitis after an intravitreal injection of bevacizumab compared with ranibizumab. RESULTS In total, 296 565 injections of bevacizumab were given to 51 116 patients and 87 245 injections of ranibizumab were given to 7496 patients. We found 71 cases of endophthalmitis (49 in the bevacizumab cohort and 22 in the ranibizumab cohort) for an endophthalmitis rate of 0.017% (95% CI, 0.012%-0.021%; 1 case per 6061 injections) for bevacizumab and 0.025% (95% CI, 0.015%-0.036%; 1 case per 3968 injections) for ranibizumab. After controlling for age, race, sex, injection-related diagnosis, and year of injection, we found no significant association with development of endophthalmitis after a bevacizumab injection compared with ranibizumab (odds ratio, 0.66 [95% CI, 0.39-1.09]; P = .11). CONCLUSIONS AND RELEVANCE The results of this study suggest bevacizumab as currently used across the United States does not increase the risk for endophthalmitis; therefore, additional regulations on the use of repackaged bevacizumab may be unnecessary.

Role of statins in the development and progression of age-related macular degeneration.

Purpose: To determine if statins are associated with the development or progression of age-related macular degeneration (AMD). Methods: A large, national insurance claims database was reviewed to identify individuals aged 60 years or older who were enrolled for ≥2 years and had ≥1 visits to an eye provider. Prescription claims for statins within a 24-month look-back period and outpatient lipid laboratory values were also reviewed. Cox regression analysis was used to determine whether statin use was associated with the development of nonexudative or exudative AMD or progressing from nonexudative to exudative AMD. Results: Of the 107,007 beneficiaries eligible for the nonexudative AMD analysis, 4,647 incident cases of nonexudative AMD occurred. Seven hundred and ninety-two incident cases of exudative AMD were found among the 113,111 beneficiaries eligible for the exudative AMD analysis. Of the 10,743 beneficiaries with known nonexudative AMD eligible for the progression model, 404 progressed to exudative AMD during their time in the plan. After multivariable analysis, statin use was not associated with the development of nonexudative AMD (P > 0.05). Statin use of >12 months was associated with an increased hazard for developing exudative AMD (P < 0.005). Among those taking statins, only enrollees with the highest lipid levels had an increased hazard of developing exudative AMD (P < 0.05). Conclusion: In those with elevated lipid levels, >1 year of statin use was associated with an increased hazard for exudative AMD. Lipid status influences the relationship between statins and the risk of AMD. Because of a number of limitations in study design, these observations warrant further study and should not be the rationale for any changes in the use of statins to treat dyslipidemias.

Rates of Nonexudative and Exudative Age-Related Macular Degeneration among Asian American Ethnic Groups

PURPOSE To determine whether the risk for nonexudative and exudative age-related macular degeneration (AMD) varies for Americans of different Asian ethnicities. METHODS Claims data from a large national United States managed care network were reviewed to identify Asian Americans age 40 and older who had ≥ 1 eye care visits from 2001 to 2007. International Classification of Disease (ICD-9CM) billing codes were used to identify enrollees with nonexudative and exudative AMD. Incidence and prevalence rates were calculated for nonexudative and exudative AMD and were stratified by Asian ethnicity. Cox regression analyses were performed to determine the relative risk for developing nonexudative and exudative AMD for persons of different Asian ethnicities, with adjustment for sociodemographic factors and ocular and medical conditions. RESULTS Of the 44,103 Asian Americans who met the inclusion criteria, 2221 (5.04%) had nonexudative AMD and 217 (0.49%) had exudative AMD. Chinese Americans (adjusted hazard ratio [HR], 1.63; 95% confidence interval [CI], 1.50-1.77) and Pakistani Americans (HR, 1.97, 95% CI, 1.40-2.77) had a significantly increased risk for nonexudative AMD compared with non-Hispanic white Americans. By contrast, Japanese Americans had a 29% decreased risk for nonexudative AMD compared with non-Hispanic white Americans (HR, 0.71; 95% CI, 0.59-0.85). There were no significant differences in risk for exudative AMD for any of the Asian ethnicities compared with white Americans. CONCLUSIONS Asian Americans are the second fastest growing racial group in the United States. Eye care providers must be aware of the overall disease burden of AMD within this group and appreciate how disease rates can vary substantially among different Asian ethnicities.

Risk of retinal tear or detachment with oral fluoroquinolone use: a cohort study

The aim of this study is to determine if oral fluoroquinolone exposure is associated with an increased hazard for having a retinal tear or detachment.

Retrospective illumination correction of retinal fundus images from gradient distribution sparsity

We present a novel technique for retrospective illumination correction of retinal fundus images from the sparsity property of image gradient distribution. It can automatically estimate the illumination inhomogeneity given an arbitrary retinal fundus image. Experimental results on 665 high resolution fundus images show both the efficiency of our algorithm on illumination correction and its high value on improving the accuracy of blood-vessel segmentation.

Volume And Composition Of Reflux After Intravitreal Injection

Purpose: To quantify the amount of drug loss from cadaveric human eyes, which are injected via the pars plana with a known volume of dye at variable intraocular pressures. Methods: Eight cadaver eyes were divided into 2 intraocular pressure groups: normal (15 mmHg; 4 eyes) or high (30 mmHg; 4 eyes). Each eye was injected with 50 &mgr;L of hematoxylin dye, and the subsequent reflux was immediately collected on a Schirmer’s test strip. The test strip was scanned and digitally analyzed to determine the area of saturation and total color intensity present. Using a previously established equation, total volume of reflux and the amount of dye within that reflux were calculated. Results: The average total volume of refluxed fluid was 1.68 &mgr;L (median, 0.62 &mgr;L), with a range of 0 &mgr;L to 8.05 &mgr;L. The average volume of refluxed dye was 0.37 &mgr;L (median, 0.08 &mgr;L), with a range of 0 &mgr;L to 2.15 &mgr;L. On average, only 0.74% of the original 50 &mgr;L of injected dye was lost (median, 0.15%), with a range from 0% to 4.30%. Conclusion: Although the presence of subconjunctival bleb formation after intravitreal injection may be a concern to the clinician, data from the present study shows that only a very small amount of the injected therapeutic agent is lost in the reflux.

Outcomes, Impact on Management, and Costs of Fungal Eye Disease Consults in a Tertiary Care Setting

OBJECTIVE To determine the frequency of clinical management changes resulting from inpatient ophthalmic consultations for fungemia and the associated costs. DESIGN Retrospective case series. PARTICIPANTS Three hundred forty-eight inpatients at a tertiary care center between 2008 and 2012 with positive fungal blood culture results, 238 of whom underwent an ophthalmologic consultation. METHODS Inpatient charts of all fungemic patients were reviewed. Costs were standardized to the year 2014. The Student t test was used for all continuous variables and the Pearson chi-square test was used for categorical variables. MAIN OUTCOME MEASURES Prevalence of ocular involvement, rate of change in clinical management, mortality rate of fungemic patients, and costs of ophthalmic consultation. RESULTS Twenty-two (9.2%) of 238 consulted patients with fungemia had ocular involvement. Twenty patients had chorioretinitis and 2 had endophthalmitis. Only 9 patients (3.7%) had a change in management because of the ophthalmic consultation. One patient underwent bilateral intravitreal injections. Thirty percent of consulted patients died before discharge or were discharged to hospice. The total cost of new consults was