Purpose: This meta-analysis aimed to investigate the efficacy and safety of pars plana vitrectomy (PPV), scleral buckle (SB), and pneumatic retinopexy (PR) for the management of rhegmatogenous retinal detachments (RRDs).

Setting: Meta-analysis.

Methods: A systematic literature search was performed on Ovid MEDLINE, EMBASE and Cochrane CENTRAL from inception to July 2019. Randomized controlled trials (RCTs) comparing RRD management options were included. Outcomes were reported via risk ratios (RR) for categorical variables and weighted mean differences (WMD) for continuous parameters with 95% confidence intervals (95%CI). Risk of bias assessment was conducted using the Cochrane criteria and a random-effects model was used for analysis. The visual recovery and incidence of complications were primary endpoints, while primary reattachment rate was a secondary outcome.

Results: Sixteen RCTs and 2613 eyes were included. For PPV versus SB, early postoperative visual acuity favoured SB (weighted mean less than 1 month postoperatively: ~20/1000 for PPV versus ~20/160 for SB, p=0.03), but differences between groups were non-significant at other timepoints (e.g. 12+ months: ~20/60 for PPV and ~20/70 for SB). There was no difference between PPV and SB for primary reattachment (RR=1.05, 95%CI=[0.98,1.14], p=0.16). PPV was associated with a lower rate of choroidal detachment (RR=0.19, 95%CI=[0.06,0.60], p=0.004, NNT=11), hypotony (RR=0.08, 95%CI=[0.01,0.61], p=0.01, NNT=4) and strabismus/diplopia (RR=0.17, 95%CI=[0.03,0.96], p=0.04, NNT=25) relative to SB, while SB was associated with a lower incidence of iatrogenic breaks (RR=12.02, 95%CI=[2.31,62.55], p=0.003). Combination management was non-significantly different relative to PPV or SB alone for final CDVA, complications and reattachment rate. One trial comparing PR and PPV showed superior visual recovery and final acuity, less vertical metamorphopsia and reduced morbidity following PR.

Conclusions: PPV is associated with a slower visual recovery and less morbidity but similar final visual acuity and primary reattachment rate relative to SB. Combination procedures did not improve primary reattachment rates or vision and were associated with comparable safety outcomes. Emerging data suggests that, in certain primary RRDs, PR should be a first-line intervention over PPV.

Presentations

1. Popovic MM, Muni RH, Nichani P, Kertes PJ. (Oct 2020). Pars plana vitrectomy, scleral buckle, pneumatic retinopexy and combination procedures for the management of rhegmatogenous retinal detachment: A meta-analysis. European Society of Retina Specialists EURetina, Virtual Meeting (oral). View presentation here.

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Presentations

1. Nichani P, Popovic MM, Muni RH, Mireskandari K, Tehrani NN, Kertes PJ. (2020). Intravitreal injections versus laser photocoagulation for retinopathy of prematurity: A meta-analysis of 3701 eyes. American Academy of Ophthalmology, Las Vegas, NV, United States (ePoster). Spotlighted by OphthalmologyAdvisor.com and PracticeUpdate.com. View ePoster with narration here.
2. Popovic MM, Nichani P, Muni RH, Mireskandari K, Tehrani NN, Kertes PJ. (2020). Intravitreal injections versus laser photocoagulation for retinopathy of prematurity: A meta-analysis of 3701 eyes. European Society of Retina Specialists EURetina, Virtual Meeting (oral). View presentation here.
3. Popovic MM, Nichani P, Muni RH, Mireskandari K, Tehrani NN, Kertes PJ. (2020). Intravitreal injections versus laser photocoagulation for retinopathy of prematurity: A meta-analysis of 3701 eyes. UofT Department of Ophthalmology & Vision Sciences 62nd Research Day, Toronto, ON (oral). Alumni Award for Best Resident Research Presentation. View presentation here.

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Abstract

Topic: The role of topical nonsteroidal anti-inflammatory drugs (NSAIDs) for the reduction of ocular pain after intravitreal injections (IVIs) has been explored. To provide clarity on the evidence for these agents, the present meta-analysis of randomized controlled trials (RCTs) was undertaken.

1. Popovic MM, Muni RH, Nichani P, Kertes PJ. (Oct 2020). Topical non-steroid anti-inflammatory drugs for pain from intravitreal injections: A meta-analysis. European Society of Retina Specialists EURetina, Virtual Meeting (ePoster). View ePoster here.

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1. Nichani P, Micieli JA. (Jun 2020). Retinal manifestations of idiopathic intracranial hypertension. Canadian Ophthalmological Society Annual Meeting & Exhibition, Virtual Meeting (oral). View presentation here.

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Purpose: Micro-invasive glaucoma surgery (MIGS) is a less traumatic and potentially safer surgical method for patients with open-angle glaucoma. However, it is a recent development for which the high-quality literature must be evaluated.

Study design: Systematic review.

Methods: A review of MIGS was conducted by searching Ovid MEDLINE, EMBASE, and Cochrane CENTRAL (2006 to 2019). The primary efficacy indicators were reductions in intraocular pressure (IOP) and topical medication use postoperatively. Adverse event analysis was conducted; risk of bias assessment was performed using the Cochrane, Newcastle-Ottawa, and World Glaucoma Association recommendations.

Results: From 10076 articles identified, 3476 baseline eyes across 20 trials met all eligibility criteria and were included. The mean age was 69.5 ± 2.9, 53.7% were female, 77.4% were Caucasian, and 80% of included studies were randomized controlled trials. One study had last follow-up at less than one year, fifteen studies had follow-up extending 1-2 years, and four had longer than two years of follow-up. MIGS procedures or devices assessed included ab interno canaloplasty (ABiC), cyclophotocoagulation (CPC), CyPass^® Micro-Stent, excimer laser trabeculotomy (ELT), Hydrus^® Microstent, iStent^® (1^st generation), iStent^® inject (2^nd generaton), Kahook Dual Blade^®, micropulse (MDLT), Trabectome^®, and XEN^® Gel Stent. A pattern of more significant IOP and medication reduction was observed in patients who received a MIGS device relative to control intervention. Across all studies at last follow-up, the mean IOP reduction was 8.0 ± 2.2 mmHg (n = 2067; range: 2.4–16.5 mmHg) vs. 7.1 ± 3.3 mmHg (n = 1234; range: 1.7–16 mmHg) and the mean reduction of topical medications was 1.4 ± 0.4 (n = 1864; range: -0.2–3 mmHg) vs. 1.0 ± 0.7 (n = 1234; range: -1–3 mmHg) in MIGS vs. control eyes, respectively. The 1^st generation iStent had the most literature supporting its efficacy, followed by the Hydrus. Adverse events were more common among phaco-only eyes (42.3%) vs. standalone-MIGS eyes (21.9%); the rate was 45.0% for phaco-MIGS eyes. The most common adverse events following MIGS implantation included stent obstruction, inflammation, and repeat surgical intervention.

Conclusions: Overall, there is some evidence to support the role of trabecular bypass and suprachoroidal MIGS devices in the treatment armamentarium for glaucoma. MIGS can effectively reduce IOP, decrease the number of topical medications taken, and minimize the number of complications associated with more invasive surgical devices, thus improving quality of life. We await the upcoming RCT evidence from other MIGS devices including the XEN^® Gel Stent and InnFocus MicroShunt and hope through this iterative process to elucidate the comparative efficacy, safety, and future role of MIGS in the glaucoma surgical paradigm.

Keywords: MIGS; ocular drainage implant; glaucoma surgery; filtration surgery; open-angle glaucoma; IOP reduction

Presentations

1. Nichani P, Popovic M, Schlenker MB, Park J, Ahmed IIK. (2020). Micro-invasive glaucoma surgery: A selected review of studies. Canadian Ophthalmological Society Annual Meeting & Exhibition, Virtual Meeting (ePoster). 2^nd Place Poster Award. View presentation, references, and conflicts of interest here.
2. Nichani P, Popovic M, Schlenker MB, Park J, Ahmed IIK. (2020). Micro-invasive glaucoma surgery: A selected review of studies. UofT Department of Ophthalmology & Vision Sciences 62nd Research Day, Toronto, Ontario, Canada (oral). View presentation, references, and conflicts of interest here.

Notes

Studies Included in Analysis:

1. Ab Interno Canaloplasty (ABiC)
   • Gandolfi; J Ophthalmol. 2016;2016:3410469 .
2. Micropulse Cyclophotocoagulation (CPC)
   • Aquino; Clin Exp Ophthalmol. 2015;43(1):40-6. (NCT00349414)
3. CyPass® Micro-Stent
   • Vold; Ophthalmology. 2016;123(10):2103-12. (NCT01085357)
4. Excimer Laser Trabeculectomy
   • Babighian; Eye. 2010;24(4):632-8.
5. Hydrus® Microstent
   • Samuelson; Ophthalmology. 2019;126(1):29-37. (NCT01539239)
   • Pfeiffer; Ophthalmology. 2015;122(7):1283-93. (NCT01818115)
6. Hydrus® Microstent vs. iStent®
   • Ahmed; Ophthalmology. 2019:1-10. (NCT02023242)
7. iStent® (G1) and iStent® Inject (G2)
   • Samuelson; Ophthalmology. 2019;126(6):811-21. (NCT00323284)
   • Katz; Clin Ophthalmol. 2018;12:255-62. (NCT01517477)
   • Vold; Ophthalmol Ther. 2016;5(2):161-72. (NCT01443988)
   • Fea; Clin Ophthalmol. 2014;8:875-82.
   • Samuelson; Ophthalmology. 2011;118(3):459-67. (NCT00323284)
   • Fernández-Barrientos; Invest Ophthalmol Vis Sci. 2010;51(7):3327-32. (NCT00326066)
8. Kahook Dual Blade® (KDB)
   • Le; Adv Ther. 2019;36(9):2515-27.
9. Micropulse Diode Laser Trabeculoplasty (MDLT)
   • Detry-Morel; Bull Soc Belge Ophtalmol. 2008;(308):21-8.
10. Trabectome®
    • Sato; BMJ Open Ophthalmol. 2018;3(1):1-7. (UMIN000021170)
    • Ting; Can J Ophthalmol. 2018;53(6):588-94. (NCT00901108)
11. XEN® Gel Stent
    • Schlenker; Ophthalmology. 2017;124(11):1579-88.

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Purpose: This analysis aims to: 1) determine the frequency and source of eyeglass insurance coverage in Ontario and changes from 2003 to 2013/14; 2) examine socio-demographic factors associated with eyeglass insurance; and 3) investigate if having eyeglass insurance is associated with increased use of eye care providers in a publicly-funded healthcare system.

Methods: Cross-sectional data from Ontario respondents aged 12+ to the Canadian Community Health Survey in 2003 (n=42,777), 2005 (n=41,766) and 2013/14 (n=42,553) was analyzed.

Results: Insurance covered all or part of the cost of prescription eyewear for 62.3% of Ontarians in 2003, 62.1% in 2005, and 62.0% in 2013/14. In 2005, 86% of those covered had employer-sponsored insurance, 9% had government-sponsorship, and 6% had a private plan. Corresponding numbers were 84%, 10% and 7% in 2013/14. From 2005 to 2013/14, government coverage increased from 29% to 42% (p<0.0001) for those without a secondary school diploma and from 30% to 38% (p<0.0001) for those with household income under middle-level. Employer-sponsored coverage remained unchanged (92%) for individuals with household income above middle-level but decreased from 67% to 55% (p<0.0001) for Ontarians without a secondary school diploma and from 64% to 53% (p<0.0001) for those with under middle-level income. An estimated 4.2 million Ontarians did not have any source of insurance in 2013/14.

In all survey years, factors associated with having insurance were age <65, post-secondary education, household income above middle-level, aboriginal status, and those in married/common-law relationships.

In age groups with routine eye exams covered by government, having eyeglass insurance versus none was associated with increased use of eye care providers with a difference of 6% for the 12-19 group and 7% for the 65+ group. Among those without government-funded routine eye exams, the difference in use of eye care providers between those with and without eyeglass insurance was 15% for the 20-39 group and 11% for the 40-64 group.

Conclusions: Eyeglass insurance coverage was 62% in Ontario and varied little from 2003 to 2013/14. The largest source of insurance was employer-sponsored, primarily covering high income earners; government insurance significantly increased in lower income and education groups in recent years. Having eyeglass insurance was associated with significantly increased use of eye care providers.

Acknowledgements: This research was supported by funds to the Canadian Research Data Centre Network (CRDCN) from the Social Science and Humanities Research Council (SSHRC), the Canadian Institute for Health Research (CIHR), the Canadian Foundation for Innovation (CFI) and Statistics Canada. Although the research and analysis are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada or the Canadian Research Data Centre Network (CRDCN).

Presentations

1. Nichani P, Trope GE, Buys YM, Markowitz SN, Liu, SY, Ngo G, Markowitz M, Jin YP. (2019). Frequency and source of eyeglass insurance coverage in Ontario: Results from 2003 to 2013/14. Canadian Ophthalmological Society Annual Meeting & Exhibition, Québec City, QC (oral). View presentation here.
2. Nichani P, Trope GE, Buys YM, Markowitz SN, Liu, SY, Ngo G, Markowitz M, Jin YP. (2019). Frequency and source of eyeglass insurance coverage in Ontario: Results from 2003 to 2013/14. UofT Department of Ophthalmology & Vision Sciences 61st Research Day, Toronto, ON (poster). View poster here.
3. Nichani P, Trope GE, Buys YM, Markowitz SN, Liu, SY, Ngo G, Markowitz M, Jin YP. (2019). Frequency and source of eyeglass insurance coverage in Ontario: Results from 2003 to 2013/14. Invest Ophthalmol Vis Sci, 60(9):5451. Association for Research in Vision and Ophthalmology Annual Meeting, Vancouver, ON (poster). View poster here.

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