I have seen so many changes in my career that some days I go home talking to myself. Understandably, many of these changes have been very positive for both my patients and myself, as ophthalmology has witnessed truly miraculous advances in the past decades. However, all too many changes have been a burden, and in that regard, I feel we are to enter a whole new period of disruption. We now hear of the unthinkable as medical practices near bankruptcy and how young physicians feel their future is not a bright as that of their predecessors. Not the environment one wants to be in, given the mental and physical demands of the job, let alone the liability.

Constant battles with insurance companies over pharmaceutical approvals and surgical precertifications, along with an ever-increasing burden of regulation, oversight and so on and so forth have complicated an already demanding job. Over the next decade, as baby-boomers age and consume greater healthcare dollars, I fear we, as physicians, will be put in the middle as the messengers of news patients may not like to hear. This information will not be about a serious diagnosis, but more so about what their insurance company or the government has determined they are due in terms of care.

Additionally, significant costs will be placed upon practices to provide information technology upgrades and additions for the purposes of the monitoring of care and increasing efficiency all at the same time that reimbursements are threatened. Sounds like loads of fun.

Organized medicine needs to become more organized. We need to fashion a very clear message in terms of where we are willing to work with the system to benefit our patients and where we will not go. We must not forget why we chose our profession and must defend its nobility. I strongly believe that once the right folks realize they pushed the docs too far, meaningful changes will occur, but not one second before.

Stephen Pascucci, MD, FACS

In this 2-year, single-center, randomized controlled trial, investigators randomized 80 patients with center-involving clinically significant macular edema (CSME) and visual acuity of 20/40 to 20/320 to receive either bevacizumab or macular laser therapy (MLT). The purpose of the study was to report the 2-year outcomes of the BOLT study, a prospective randomized controlled trial evaluating intravitreous bevacizumab and modified Early Treatment Diabetic Retinopathy Study (ETDRS) MLT in patients with persistent CSME.

Primary outcome was the difference in ETDRS best-corrected visual acuity (BCVA) between arms. Secondary outcomes were the mean change in BCVA, proportion gaining at least 15 and at least 10 ETDRS letters, losing fewer than 15 and at least 30 letters, change in central macular thickness, ETDRS retinopathy severity, and safety outcomes.

The study investigators reported that at 2 years, mean (SD) ETDRS BCVA was 64.4 (13.3) (ETDRS equivalent Snellen fraction: 20/50) in the bevacizumab arm and 54.8 (12.6) (20/80) in the MLT arm (p = .005). They also noted that the bevacizumab arm gained a median of 9 ETDRS letters vs 2.5 letters for MLT (p = .005), with a mean gain of 8.6 letters for bevacizumab vs a mean loss of 0.5 letters for MLT. A total of 49% of patients gained 10 or more letters (p = .001) and 32% gained at least 15 letters (p = .004) for bevacizumab vs 7% and 4% for MLT. Percentage who lost fewer than 15 letters in the MLT arm was 86% vs 100% for bevacizumab (p = .03). Mean reduction in central macular thickness was 146 µm in the bevacizumab arm vs 118 µm in the MLT arm. The median number of treatments over 24 months was 13 for bevacizumab and 4 for MLT.

This study provides evidence supporting longer-term use of intravitreous bevacizumab for persistent center-involving CSME.