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Purpose To evaluate costs of panretinal photocoagulation (PRP) vs. intravitreal ranibizumab (IVR) for proliferative diabetic retinopathy (PDR). Design A Markov-style model of cost-effectiveness and cost utility. Participants There were no participants. Methods Based on results from Diabetic Retinopathy Clinical Research (DRCR) Network Protocol S, we performed a Markov-style analysis to generate the total 2-year costs for each treatment arm. The cost per line-year saved and cost utility were calculated based on the estimated life years remaining. Both treatment arms were assumed to result in 9 lines of vision saved in 20% of patients. Medicare reimbursement data were acquired to determine costs, which were then separately calculated for practice settings of a hospital-based facility as the highest end of the cost range and a nonfacility in the same geographic area as the lowest end. Cost parameters for a prototypical patient's life expectancy also were modeled and calculated. Main Outcome Measures Inputed cost of therapy, cost per line saved, cost per line-year saved, and cost per quality-adjusted life years (QALY). Results When PRP was the primary treatment, the 2-year cost in the facility setting was $13 053, with cost per line saved $7252, cost per line-year $240, and cost per QALY $7988. In the nonfacility setting costs were approximately 21% lower. When IVR was the primary treatment, the 2-year cost in the facility setting was $30 328, cost per line saved was $16 849, cost per line-year $575, and cost per QALY $19 150. In the nonfacility setting costs were approximately 15% lower. Extrapolation to lifetime therapy yielded the cost per QALY with PRP treatment of $14 219 to $24 005 and with IVR of $138 852 to $164 360. Cost utility for PRP would be 85% lower than IVR in the facility setting and 90% lower than IVR in the nonfacility setting. Conclusions PRP compared with IVR as primary treatment for PDR is less expensive over 2 years, but both fall well below the accepted cost per QALY upper limit. However, over an average lifetime, the cost differential between PRP and IVR increases, and IVR therapy may exceed the typical accepted limit of cost per QALY.

The benefit of the ␤ 2 -adrenergic agonist, clenbuterol, in left ventricular assist device patients with dilated cardiomyopathy has been reported, but its effect on ischemic heart failure (HF) is unknown. We investigated whether clenbuterol improves left ventricular remodeling, myocardial apoptosis and has synergy with a ␤ 1 antagonist, metoprolol, in a model of ischemic HF. Rats were randomized to: 1) HF only; 2) HF ϩ clenbuterol; 3) HF ϩ metoprolol; 4) HF ϩ clenbuterol ϩ metoprolol; and 5) rats with sham surgery. HF was induced by left anterior descending artery (LAD) artery ligation and confirmed by decreased left ventricular fractional shortening, decreased maximum left ventricular dP/dt (dP/dt max ), and elevated left ventricular end-diastolic pressure (LVEDP) compared with sham rats (p Ͻ 0.01). After 9 weeks of oral therapy, echocardiographic, hemodynamic, and ex vivo end-diastolic pressure-volume relationship (EDPVR) measurements were obtained. Immunohistochemistry was performed for myocardial apoptosis and DNA damage markers. Levels of calcium-handling proteins were assessed by Western blot analysis. Clenbuterol-treated HF rats had increased weight gain and heart weights versus HF rats (p Ͻ 0.05). EDPVR curves revealed a leftward shift in clenbuterol rats versus metoprolol and HF rats (p Ͻ 0.05). The metoprololtreated group had a lower LVEDP and higher dP/dt max versus the HF group (p Ͻ 0.05). Clenbuterol and metoprolol groups had decreased myocardial apoptosis and DNA damage markers and increased DNA repair markers versus HF rats (all p Ͻ 0.01). Protein levels of the ryanodine receptor and sarcoplasmic reticulum calcium-ATPase were improved in clenbuterol-, metoprolol-, and clenbuterolϩmetoprolol-treated groups versus HF rats. However, as a combination therapy, there were no synergistic effects of clenbuterolϩmetoprolol treatment. We conclude that clenbuterol ameliorates EDPVR, apoptosis, and calcium homeostasis but does not have synergy with metoprolol in our model of ischemic HF.Clenbuterol is a ␤ 2 -adrenergic receptor agonist first used in the mid-1970s to treat asthma and is approved for this indication in Europe (Salorinne et al., 1975). The drug bears structural similarity to albuterol but has enhanced oral absorption and ␤ 2 -selectivity. Clenbuterol also increases muscle bulk (Choo et al., 1992;Maltin et al., 1993;Carter and Lynch, 1994) because of an anabolic effect that may be mediated via long-term ␤ 2 -activation (MacLennan and Edwards, 1989;Choo et al., 1992). Because of this anabolic action, oral clenbuterol has been abused by athletes to enhance size and strength (Beckett, 1992;Perry, 1993). Article, publication date, and citation information can be found at http://jpet.aspetjournals.org.

Early PPV as a strategy for treatment of PDR without macular edema demonstrates cost-utility similar to management with PRP and more favorable cost-utility compared with IVR in the short term. This advantage over IVR continues when lifetime costs are factored.

Objective To evaluate costs and treatment benefits of rhegmatogenous retinal detachment (RD) repair. Design A Markov model of cost-effectiveness and utility. Participants There were no participants. Methods Published clinical trials (index studies) of pneumatic retinopexy (PR), scleral buckling (SB), pars plana vitrectomy (PPV) and laser prophylaxis were used to quantitate surgical management and visual benefits. Markov analysis, with data from the Center of Medicare and Medicaid Services (CMS), was used to calculate adjusted costs of primary repair by each modality in a hospital-based and ambulatory surgery center (ASC) setting. Main Outcome Measures Lines of visual acuity (VA) saved, cost of therapy, adjusted cost of therapy, cost per line saved, cost per line-year saved, cost per quality-adjusted life years (QALY) saved. Results In the facility, hospital surgery setting, weighted cost for PR ranged from $3,726 to $5,901 depending on estimated success rate of primary repair. Weighted cost for SB was $6,770, for PPV was $7,940 and for laser prophylaxis was $1,955. The dollars per line saved ranged from $217 to $1,346 depending on the procedure. Dollars per line-year saved ranged from $11 to $67. Dollars per QALY saved ranged from $362 to $2,243. In the non-facility, ASC surgery setting, weighted cost for PR ranged from $1,961 to $3,565 depending on the success rate of primary repair. The weighted costs for SB, PPV and laser prophylaxis were $4,873, $5,793 and $1,255, respectively. Dollars per line saved ranged from $139 to $982. The dollars per line-year saved ranged from $7–$49 and the dollars per QALY saved ranged from $232 to $1,637. Conclusions Treatment and prevention of RD is extremely cost-effective when compared to other treatment of other retinal diseases regardless of treatment modality. RD treatment costs did not vary widely, suggesting providers can tailor patient treatments solely on the basis of optimizing anticipated results since there were not overriding differences in financial impact.

Purpose Using standard screening techniques, sickle retinopathy reportedly occurs in 10% of adolescents with sickle cell disease (SCD). We performed a prospective, observational clinical study to determine if ultra-widefield fluorescein angiography (UWFA), spectral-domain optical coherence tomography (SD-OCT) and optical coherence tomography angiography (OCT-A) detect more frequent retinopathy in adolescents with SCD. Design Cross-sectional study. Methods Setting Institutional. Subjects Sixteen adolescents with SCD, ages 10–19 years, (mean age 14.9 years) and 5 age-equivalent controls (mean age 17.4 years). Observation Procedures Examinations including acuity, standard slit-lamp biomicroscopy, UWFA, SD-OCT and OCT-A were performed. Main Outcome Measures Sickle retinopathy defined by biomicroscopic changes, Goldberg stages I–V, Penman scale, flow void on OCT-A, or macular thinning on SD-OCT. Results While 22/32 SCD eyes (68.8%) had retinopathy on biomicroscopy, by UWFA 4/24 (16.7%) SCD eyes had peripheral arterial occlusion (Goldberg I), and 20/24 eyes (83.3%) had peripheral arteriovenous anastomoses (Goldberg II) in addition. No patients had Goldberg stages III–V. By SD-OCT and OCT-A, thinning of the macula and flow voids in both the superficial and deep retinal capillary plexus were found in 6/30 (20%) eyes. Conclusions All 24 eyes with adequate UWFA studies demonstrated sickle retinopathy. SD-OCT and OCT-A, which have not been previously reported in the adolescent population, detected abnormal macular thinning and flow abnormalities undetected by biomicroscopy. These findings suggest that pediatric sickle retinopathy may be more prevalent than previously suspected. If these findings are confirmed with larger cross-sectional and prospective analyses, these approaches may enhance early screening for sickle retinopathy.

Objective/Purpose To review data for ophthalmologists published online from the Physician Payments Sunshine Act. Design Retrospective data review using a publicly available electronic database Methods: Main Outcome Measures A database was downloaded from the Centers for Medicare and Medicaid Services (CMS) Website under Identified General Payments to Physicians and a primary specialty of ophthalmology. Basic statistical analysis was performed including mean, median and range of payments for both single payments and per provider. Data were also summarized by category of payment, geographic region and compared with other surgical subspecialties. Results From August 1, 2013 to December 31, 2013, a total of 55,996 individual payments were reported to 9,855 ophthalmologists for a total of $10,926,447. The mean amount received in a single payment was $195.13 (range $0.04–$193,073). The mean amount received per physician ID was $1,108 (range $1–$397,849) and median amount $112.01. Consulting fees made up the largest percentage of fees. There was not a large difference in payments received by region. The mean payments for the subspecialties of dermatology, neurosurgery, orthopedic surgery and urology ranged from $954–$6,980, and median payments in each field by provider identifier ranged from $88–$173. Conclusions A large amount of data was released by CMS for the Physician Payment Sunshine Act. In ophthalmology, mean and median payments per physician did not vary greatly from other surgical subspecialties. Most single payments were under $100, and most physicians received less than $500 in total payments. Payments for consulting made up the largest category of spending. How this affects patient perception, patient care and medical costs warrants further study.

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