Purpose Tacrolimus is an immunosuppressant drug which is often used after allogenic transplant to prevent organ rejection. It blocks T‐cell development and inhibits cytokine synthesis. We report the case of a patient who developed bilateral optic neuropathy as a suspected complication of tacrolimus therapy. Methods A 75 year‐old man who underwent orthotopic kidney transplant in 2013 was treated with tacrolimus since that moment without toxic blood levels at any moment. He had a history of moderate hypertension but neither other atherosclerotic risk factors nor ophthalmological disease associated. He came to the Emergency department for the first time in 2015, when he noticed sudden blurred vision in his left. His best corrected visual acuity (BCVA) in his left eye was 20/30. Dilated fundus examination revealed hyperemia, haemorrhages and swelling of the disc with distended veins. Visual field analyser showed a superior altitudinal defect in the left eye. Complete blood count, erythrocyte sedimentation and C‐reactive protein were normal. He underwent oral treatment with prednisone 60 mg in descendent pattern. In the follow‐up the visual field worsened, with abolished visual field, BCVA was hand movement at one meter distance and a relative afferent pupillary defect in his right eye was demonstrated. Optic disc showed evidence of atrophy. The right eye examination was unremarkable. Results Two years later in 2017 the patient came back to the Emergency department complaining of severe painless visual loss in his left eye. Fundoscopy revealed an optic disc edema with splinter haemorrhages which was confirmed with the OCT where we could see a diffuse edema of the fibre layer. Conclusions We should be aware of ophthalmological symptoms in patients who have been receiving therapy with tacrolimus, even in the absence of toxic blood levels of that drug.
Purpose To report the use of photodynamic therapy without verteporfin as treatment for patients with focal retinal pigment epithelial leaks secondary to central serous chorioretinopathy (CSC). Methods Four symptomatic patients with CSC without clinical improvement in a period of time up to three months were included. Photodynamic therapy without verteporfin was applied without any other treatment. Results Neurosensory detachment and fluorescein leakage resolved in all patients within two months. Visual acuity improved in all of them and none lost vision or suffered any treatment‐related complications. Conclusion The treatment of CSC with photodynamic therapy without verteporfin may result in resolution of persistent neurosensory detathment and fluorescein leakage. Although this case series is limited in follow‐up and number of patients, the encouraging results, lack of complications and cheap procedure suggest that further investigation is warranted. Commercial interest
Background To assess the cost-effectiveness of the delayed-release device of dexamethasone compared with aflibercept in the treatment of patients with naïve diabetic macular edema (DME) from a societal perspective in the healthcare sector Zaragoza III in Spain. Methods A Markov model with five states defined by visual acuity (VA) in the better-seeing eye (Snellen scale) and an additional death state were constructed. Two cohorts of patients were distributed along the VA states and treated during a year with either dexamethasone or aflibercept. One-year follow-up on each group was performed. Medical costs related to the DME treatment and follow-up, medical costs related to the DME comorbidities, and non-medical-related costs were taken into account. Costs (2020 €), health outcomes (Quality-Adjusted Life Years-QALYs), both discounted at a 3.5% annual rate, and incremental cost-effectiveness ratios (ICER: €/QALY) were determined for a lifetime horizon in the base case analysis. Results Patients treated with dexamethasone were €77,349 more costly and provided 2.667 additional QALYs (€29,002/QALY) than those treated with aflibercept. The variable efficiency per patient was calculated dividing the improvement in quality of life (on the VFQ-25 scale) by the cost of the treatment. With the obtained results it can be concluded that the efficiency of treating the patients with dexamethasone is significantly superior than the efficiency of treating them with aflibercept. Conclusions The cost per QALY gained with the delayed-release device of dexamethasone compared with the one obtained by aflibercept in the naïve DME population is just below the €30,000 threshold, below which, new drugs are sometimes regarded as cost-effective strategies in Spain. In this model, the key variables with greater impact on the cost-effectiveness results were the selected time horizon, the chosen extrapolation method and the number of aflibercept and dexamethasone injections.
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