Retina Society 2022 Day 1: Real World vs Clinical Trial BCVA, Women Authorship Trends in Retina, Ocular Trauma during the 2020 Protests, and Cost Analysis of anti-VEGF Injections

Rachel Israilevich, MS4
Wills Eye Hospital
Thomas Jefferson University

The Retina Society 2022 annual meeting kicked off this past Wednesday in Pasadena, CA. The opening day featured an engaging retinal cases and videos conference, followed by an interesting scientific session on current socioeconomic and demographic topics within retina. This session featured talks from Jason Hsu, MD, Ankur Nahar, BS, Stavros N. Moysidis, MD, and Shriji Patel, MD, MBA.

Jason Hsu presented on the magnitude of visual acuity (VA) change with EDTRS vs. Snellen testing in clinical trials, and what this means for real-world outcomes. Real-world anti-VEGF studies have shown worse visual outcomes compared to pivotal clinical trials. This is thought to be attributed to differences in inclusion criteria, VA measurements, fewer injections and less adherence to treatment in real world studies. The purpose of this study was to compare changes in VA from study entry to exit using standardized EDTRS BCVA and compare this to non-standardized Snellen VA among subjects enrolled in clinical trials. In the 273 included eyes, EDTRS letter scores were generally higher than the converted Snellen scores at both study entry and exit. Interestingly, when baseline VA was worse (≤20/80), there was a great discrepancy in letter changes favoring the Snellen method, while better baseline VA (>20/80) favored the EDTRS method. This means that in real-world studies, if 90% of subjects have a baseline VA of ≤20/80, this would correlate to a 6-letter loss, thus favoring the Snellen VA and suggesting that vision is not as good as we think. Similarly, if 90% of subjects were >20/80 at baseline, this would correlate to a 4-letter gain, thus favoring EDTRS and suggesting that vision is better than we think. In summary, this study found that real-world studies using Snellen charts underestimate the magnitude of VA change in eyes with better baseline VA and overestimate the magnitude of VA change in eyes with worse baseline VA when comparing to EDTRS, suggesting that such studies may need to analyze VA distribution at baseline when comparing VA change to clinical trials.

Ankur Nahar then presented a 25-year analysis of authorship trends of women in retina. There has steadily been an increase in the percentage of women in ophthalmology, from 24% in 2003 to 34% in 2017; this change is largely due to an increase in female assistant professors rather than women in higher academic rank. Authorship is important to look at due to its critical component in career advancement within academia, and was thus used as a proxy for gender disparities in retina in this study. The results showed that the percent of women in first and last authorship positions both significantly increased from 1995 to 2020, and first authors were more likely to be women when the last authors were also women. Furthermore, the productivity of female last authors was significantly disproportionate to their representation in the field. Similarly, the study found that women disproportionately chose academic positions relative to their representation in the field. In conclusion, while a disparity in authorship persists in ophthalmic subspecialties, Retina is a field where the gap is improving, emphasizing the important role of female mentorship in ensuring gender representation and closing the gender gap.

Stavros N. Moysidis followed with a study on ocular trauma and death during the U.S. protests and riots of 2020. On May 25, 2020, George Floyd was killed by a police offer and many protests followed. At a number of these protests, there were severe eye injuries form rubber bullets, and the AAO consequently issued a statement urging the immediate cessation of rubber bullets (also referred to as kinetic impact projectiles) use at protests. The purpose of this study was to better understand the extent of ocular and adnexal injuries, and deaths occurring during protests and riots in the U.S. in 2020 based on the mechanism. The results found that the majority of injured people were protesters (73.1%), but bystanders, law enforcement, and journalists were affected as well. Most (76.1%) were not wearing eye protection, and 1/3 suffered orbital fractures. Most injuries (78.3%) were closed-globe, zone 1 injuries. The open-globe injuries (21.7%) were conversely mostly zone 3 injuries. There were many mechanisms for trauma, including non-KIP projectiles (28%) and direct KIP trauma (22%). Direct KIP trauma resulted in the worst visual sequela, with final VA ranging from HM-LP. Two-thirds of eyes experiencing direct KIP trauma had a subsequent retinal detachment, and 40% required eventual enucleation. All eyes requiring enucleation were injured by direct KIP trauma, and patients with eye protection fared better. Furthermore, each protest in which KIPs were used was associated with 16.5 more subsequent protests and a higher number of subsequent deaths. In peaceful protests where police committed acts of violence deemed unfair by protestors, violence ensued. In contrast, if 20% of protestors were violent, there was less total violence when police were present at the start of the protest, and a higher peak of violence when police arrived later. In conclusion, the use of KIPs at protests should be avoided as they carry a high risk of blindness and loss of the eye. Eye protection led to better outcomes, KIPs were associated with more protests and protest-related deaths, and early police presence with non-violent tactics led to better outcomes.

To finish off the session, Shriji Patel presented a cost analysis of routine office intravitreal injections. Many medical cases and procedures are undervalued by CMS reimbursement and often only approach profitability when they are not complex and done reasonably quickly. The purpose of this study was to understand the costs of intravitreal injections. The authors defined cost to account for supplies, personnel, and space (which is often a hidden, non-tangible cost). A process flow-map was created to follow patients throughout the office, and understand all their contact points and resources used at each one. The cost of delivering intravitreal injections was found to be $180 per injection (accounting for work input, practice expense, and malpractice input). This compares to a maximum Medicare allowance of $122, resulting in a deficit of $459,500 per fiscal year. Dr. Patel highlighted that this may be due to the fact that the methodology for CMS reimbursement has not been updated in over a decade, and thus outdated inputs are being used to determine the current injection administration costs. In conclusion, the true cost of these intravitreal injections outweighs the maximum allowable Medicare reimbursement by 47%.