Quresh Mohamed

Bevacizumab for neovascular age related macular degeneration (ABC Trial): multicentre randomised double masked study.

Objectives To evaluate the efficacy and safety of intravitreous bevacizumab injections for the treatment of neovascular age related macular degeneration. Design Prospective, double masked, multicentre, randomised controlled trial. Setting Three ophthalmology centres in the United Kingdom. Participants 131 patients (mean age 81) with wet age related macular degeneration randomised 1:1 to intervention or control. Interventions Intravitreous bevacizumab (1.25 mg, three loading injections at six week intervals followed by further treatment if required at six week intervals) or standard treatment available at the start of the trial (photodynamic treatment with verteporfin for predominantly classic type neovascular age related macular degeneration, or intravitreal pegaptanib or sham treatment for occult or minimally classic type neovascular age related macular degeneration). Main outcome measures Primary outcome: proportion of patients gaining ≥15 letters of visual acuity at one year (54 weeks). Secondary outcomes: proportion of patients with stable vision and mean change in visual acuity. Results Of the 131 patients enrolled in the trial, five patients did not complete the study because of adverse events, loss to follow-up, or death. In the bevacizumab group, 21 (32%) patients gained 15 or more letters from baseline visual acuity compared with two (3%) in the standard care group (P<0.001); the estimated adjusted odds ratio was 18.1 (95% confidence interval 3.6 to 91.2) and the number needed to treat was 4 (3 to 6). In addition, the proportion of patients who lost fewer than 15 letters of visual acuity from baseline was significantly greater among those receiving bevacizumab treatment (91% (59) v 67% (44) in standard care group; P<0.001). Mean visual acuity increased by 7.0 letters in the bevacizumab group with a median of seven injections compared with a decrease of 9.4 letters in the standard care group (P<0.001), and the initial improvement at week 18 (plus 6.6 letters) was sustained to week 54. Among 65 patients treated with bevacizumab, there were no cases of endophthalmitis or serious uveitis related to the intervention. All end points with respect to visual acuity in the study eye at 54 weeks favoured bevacizumab treatment over standard care. Conclusions Bevacizumab 1.25 mg intavitreous injections given as part of a six weekly variable retreatment regimen is superior to standard care (pegaptanib sodium, verteporfin, sham), with low rates of serious ocular adverse events. Treatment improved visual acuity on average at 54 weeks. Trial registration number Current controlled trials ISRCTN83325075

Intravitreal bevacizumab (Avastin) for neovascular age-related macular degeneration using a variable frequency regimen in eyes with no previous treatment

Purpose:  To evaluate a variable frequency regimen with intravitreal bevacizumab for treatment of neovascular age‐related macular degeneration (AMD) in eyes that have not received any previous treatment.

Incidence and baseline clinical characteristics of treated neovascular age-related macular degeneration in a well-defined region of the UK

Aims To analyse the incidence and baseline clinical characteristics of patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections in a defined UK region. Methods A standardised dataset was collected prospectively using an electronic medical record (EMR) system from 1 January 2008 to 21 June 2012 for all patients living in Gloucestershire who received intravitreal anti-VEGF injections for nAMD. Results Over the study period, 1207 eyes from 1033 patients began intravitreal anti-VEGF injections for nAMD. The annual incidence in the years after National Institute for Health and Care Excellence (NICE) technology appraisal 155 implementation was stable at 120 (95% CI 110 to 138) eyes or 100 (89 to 115) people per 100 000 population. The most common indication was occult choroidal neovascularisation (51%). Median baseline visual acuity (VA) was significantly higher for second treated than first treated eyes (66 and 56 letters, respectively; p<0.0001). Median baseline VA of fellow eyes increased from 47 (2008) to 67 letters (2012; p<0.005). The proportion of patients with baseline VA in the better eye ≥70 letters increased from 27.6% (2008) to 51.4% (2012; p<0.0001), while the proportion eligible at baseline for full or partial certificate of visual impairment decreased from 13.8% (2008) to 7.1% (2012; p<0.05). Conclusions The incidence of patients undergoing anti-VEGF therapy for nAMD increased substantially following NICE approval of ranibizumab (August 2008), and has been stable since 2009. This equates to an annual UK incidence of 26 850 (21 320 to 32 440) eyes, similar to NICE estimates. Patients eligible for blindness certification before treatment decreased by half from 2008–2012. Prospective data collection using an EMR system is invaluable for efficient monitoring of real-world clinical care.

Which visual acuity measurements define high-quality care for patients with neovascular age-related macular degeneration treated with ranibizumab?

PurposeThe purpose of this study is to define which visual acuity (VA) measurements are the best indicators of high-quality care for patients receiving intravitreal ranibizumab for neovascular age-related macular degeneration (nAMD).MethodsAnalysis of prospectively collected data recorded within an electronic medical record system on treatment-naive, first-eligible eyes with nAMD, treated with ranibizumab using an as-needed treatment regimen with a minimum follow-up of 1 year. Data collection included the following: age, gender, laterality, type of nAMD, VA, central 1 mm OCT retinal thickness, number of intravitreal injections, and number of follow-up assessments.ResultsData were available on the first-treated eye from 406 patients with at least 1 year follow-up; of these, 198 had data at 2 years. The mean baseline VA of 54.4 Early Treatment Diabetic Retinopathy Study letters improved to 58.5 letters at 12 months and to 56.8 letters at 24 months. The mean VA changes from baseline to 1 year were +6.5, +7.5, +1.7, and −1.5 letters, respectively, for baseline VA categories of 23–35, 36–55, 56–70, and >70 letters. Change in mean VA from the end of the loading phase to year 1 ranged from −2.9 to +1.4 letters for the different baseline VA categories. The mean number of injections were similar across baseline VA categories ranging from 5.7 to 6.0 injections in year 1 and from 3.3 to 3.8 in year 2.ConclusionsThis large, real-world series demonstrates that mean change in VA is largely a function of selection criteria and baseline VA. The quality of a service is therefore better judged by actual VA outcomes and maintenance of vision after the loading phase.

Retinopathy, plasma glucose, and the diagnosis of diabetes.

700 www.thelancet.com Vol 371 March 1, 2008 in key tasks or to improve exercise capacity. When improvements in muscle strength or aerobic exercise are needed, sufficient effort must be applied over several weeks before physiological and functional gain can be expected. Care interventions must be tailored to need, and a one-size-fits-all approach is unlikely to be effective in terms of cost or health. The people most likely to gain from multifactorial intervention are those at highest risk of admission to hospitals or nursing homes. Simple and effective screening is needed to document previous falls, difficulties with activities of daily living, and cognition. Cognitive impairment and dementia are associated with physical frailty and with high risk of falls and hospital or nursing-home admission. People with dementia should not be automatically excluded from community-based assessment and rehabilitation, as happens in many programmes. Today’s review does not address the needs of nursing-home residents; in the UK there are major concerns over a “lost tribe” of elderly people in care who are denied access to appropriate assessment and rehabilitation. Exclusion of such patients is clearly inappropriate. There are major challenges in the establishment of access to multifactorial intervention for frail older people living in the community. The numbers of qualified health-care workers are limited, and the number of older people that might benefit is growing. However, benefits will be maximised if we avoid ineffective or poorly coordinated systems of care, and concentrate on trying to replicate what we know works. It is vital we get this right—there is the potential to improve the quality of life for elderly people and their carers, and possibly even to reduce the costs of health and social care.

Prevalence and incidence of blindness and other degrees of sight impairment in patients treated for neovascular age-related macular degeneration in a well-defined region of the United Kingdom

AimsThis study aimed to evaluate the incidence and prevalence of blindness, sight impairment, and other visual acuity (VA) states in patients receiving ranibizumab for neovascular age-related macular degeneration (nAMD) in Gloucestershire.MethodsSerial VA and injection data for all treatment-naive patients receiving their first intravitreal injections of ranibizumab for nAMD in the Gloucestershire National Health Service Ophthalmology department between 2008 and 2010 were extracted from an electronic medical record system.ResultsThe prevalence of blindness (VA in the better-seeing eye ≤25 Early Treatment Diabetic Retinopathy Study (ETDRS) letters) at the time of first intravitreal injection was 0.8%, increasing to 3.5% after 3 years. The prevalence of sight impairment (VA in the better-seeing eye 26–39 ETDRS letters) increased from 4.1% at baseline to 5.5% after 3 years. The incidence of initiating ranibizumab treatment for nAMD in people aged ≥50 years in Gloucestershire was 111 people per 100 000 population in 2009, and 97 people in 2010. The incidence of patients meeting the visual criteria for blindness and sight impairment registration from treated nAMD in people aged ≥50 years in Gloucestershire was 3.5 and 9.7 people, respectively per 100 000 population in 2010.ConclusionThis is the first real-world study on the incidence and prevalence of eligibility for blindness and sight impairment registration in treated nAMD in the UK based on VA data. The incidence and prevalence of eligibility for certification of blindness or sight impairment in patients treated with ranibizumab for nAMD is low in Gloucestershire, with only 3.6% of the incident population progressing to blindness in 2010.

Ocular imaging in diabetic retinopathy

Imaging of the fundus has revolutionized our understanding of the pathogenesis of diabetic retinopathy (DR), allowed standardized grading and follow-up with the ability to evaluate treatments in randomized clinical studies. Ocular imaging provides the tools for screening of diabetic individuals to detect and treat changes before vision loss. Modern instruments allow rapid in vivo imaging of the diabetic fundus using multiple modalities with higher resolution. Images can be transmitted, manipulated, analyzed, and graded with increasing ease. These imaging techniques are now entwined in the paradigms for newer treatments for DR. This paper aimed to provide a brief overview of current imaging modalities including conventional and digital fundus imaging, scanning laser ophthalmoscopy, fluorescein angiography, wide-field retinal imaging, and optical coherence tomography. Future developments in these imaging techniques are discussed.