Aim To describe the frequency of neovascular age-related macular degeneration (nAMD) in second eyes of patients undergoing ranibizumab therapy in their first eye and to evaluate the patterns of optical coherence tomography (OCT) abnormalities in fellow eyes before nAMD. Method Patients who developed choroidal neovascularization (CNV) in the second eye while on treatment for the first eye were identified. OCT scans of the second eyes, performed before the onset of CNV, were retrospectively examined and graded. Frequency of second eye involvement was estimated and patterns of progression of OCT abnormalities were described and classified. Results In all, 65 out of 749 consecutive patients required ranibizumab in their second eye for treatment-naïve nAMD over a 2-year period. The mean interval from commencement of ranibizumab in first eye to conversion in second eye was 12 months (2-35.5 months). There were three patterns of CNV development: group A (12%, n ¼ 8) had no OCT abnormalities in the second eye just before developing CNV; group B (38%, n ¼ 25) had no abnormalities at baseline but developed OCT changes more than one visit before conversion and group C (50%, n ¼ 32) had OCT changes from baseline, which did not progress until just before conversion. ConclusionPatients with retinal pigment epithelial elevation without sub-retinal fluid on OCT in their fellow eyes have a high risk of progression to require therapy within a 2-year period. An anticipatory approach may be warranted, but a small group with completely normal OCT appearances can still develop lesions between visits.

BackgroundThe aim of this study was to describe bilateral visual outcomes and the effect of incomplete follow-up after 3 years of ranibizumab therapy for neovascular age-related macular degeneration. Secondarily, the demands on service provision over a 3-year period were described.MethodsData on visual acuity, hospital visits, and injections were collected over 36 months on consecutive patients commencing treatment over a 9-month period. Visual outcome was determined for 1) all patients, using last observation carried forward for missed visits due to early discontinuation and 2) only those patients completing full 36-month follow-up.ResultsOver 3 years, 120 patients cumulatively attended hospital for 1,823 noninjection visits and 1,365 injection visits. A visual acuity loss of <15 letters (L) was experienced by 78.2% of patients. For all patients (n=120), there was a mean loss of 1.68 L using last observation carried forward for missing values. Excluding five patients who died and 30 who discontinued follow-up, mean gain was 1.47 L. In bilateral cases, final acuity was on average 9 L better in second eyes compared to first eyes. Also, 91% of better-seeing eyes continued to be the better-seeing eye.ConclusionWe have demonstrated our approach to describing the long-term service provision and visual outcomes of ranibizumab therapy for neovascular age-related macular degeneration in a consecutive cohort of patients. Although there was a heavy burden with very frequent injections and clinic visits, patients can expect a good level of visual stability and a very high chance of maintaining their better-seeing eye for up to 3 years.

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Background:The National Institute for Clinical Excellence (NICE) Guidance TA155 for the treatment of wet age-related macular degeneration was issued in August 2008. In this work we describe our experience in the application of an audit tool for auditing the implementation of this guidance in our hospital setting and report on the specific and wider aspects of auditing guidance implementation. Method: Case notes of patients were retrospectively reviewed for compliance to the NICE Guidance TA155, using the audit tool provided, which investigated five domains. A full audit cycle was completed. Results: Our initial audit failed to reach a satisfactory level of compliance with NICE Guidance TA155 in one domain, which related to dissemination of patient information and documentation of treatment eligibility. To address this issue, we introduced specific changes to our processes, and on reaudit, were able to achieve a satisfactory level of compliance in all criteria. Conclusion: Audits on implementation of NICE guidance have not been widely reported in the clinical governance literature due to the specific relevance to individual departments. Our experience has demonstrated not only the usefulness of the audit tool in ensuring that our service was in adherence with NICE guidance but also, that as a result of introducing changes to ensure compliance, the quality of service provided to patients was further improved. Implementation of NICE guidance is an intrinsic part of the clinical governance process, and audits on the implementation of NICE guidance are requirements of all service providers, to ensure that there is uniform and systematic uptake of evidence-based medicine throughout the National Health Service.