Resource Planning in Glaucoma: A Tool to Evaluate Glaucoma Service Capacity.

BACKGROUND: The National Patient Safety Agency (2009) publication advising timely follow-up of patients with established glaucoma followed several reported instances of visual loss due to postponed appointments and patients lost to follow-up. The Royal College of Ophthalmologists Quality Standards Development Group stated that all hospital appointments should occur within 15% of the intended follow-up period. AIM: To determine whether: 1. Glaucoma follow-up appointments at a teaching hospital occur within the requested time 2. Appointments are requested at appropriate intervals based on the NICE Guidelines 3. The capacity of the glaucoma service is adequate Methods: A two-part audit was undertaken of 98 and 99 consecutive patients respectively attending specialist glaucoma clinics. In the first part, the reasons for delayed appointments were recorded. In the second part the requested follow-up was compared with NICE guidelines where applicable. Based on the findings, changes were implemented and a re-audit of 100 patients was carried out. RESULTS: The initial audit found that although clinical decisions regarding follow-up intervals were 100% compliant with NICE guidelines where applicable, 24% of appointments were delayed beyond 15% of the requested period, due to administrative errors and inadequate capacity, leading to significant clinical deterioration in two patients. Following the introduction of an electronic appointment tracker and increased clinical capacity created by extra clinics and clinicians, the re-audit found a marked decrease in the percentage of appointments being delayed (9%). CONCLUSIONS: This audit is a useful tool to evaluate glaucoma service provision, assist in resource planning for the service and bring about change in a non-confrontational way. It can be widely applied and adapted for use in other medical specialities.

No sutures corneal grafting--a novel use of overlay sutures and fibrin glue in Deep Anterior Lamellar Keratoplasty.

PURPOSE: To describe a case where Deep Anterior Lamellar Keratoplasty (DLK) was performed using overlay sutures and fibrin glue alone, without the need to directly suture the corneal button. METHODS: Deep Anterior Lamellar Keratoplasty was performed using a modified Melles technique on a 21-year-old patient who had stromal scarring secondary to severe infective keratitis. Overlay sutures and fibrin glue were used to secure the donor button and then a bandage contact lens was inserted. No sutures were required to directly suture the donor button to host tissue. All securing sutures were removed 4 weeks after the surgery. Six months post surgery, the graft was clear and the patient rehabilitated by wearing acceptable astigmatic spectacle correction. RESULTS: The patients visual acuity in the affected eye was 6/12 wearing a spectacle prescription of -0.25/-3.25x160. CONCLUSION: The use of overlay sutures and fibrin glue in DLK is a time efficient and effective technique. We propose that this technique may be used routinely in cases where donor corneal button appears to fit well in the stromal bed at the time of surgery, that is, where there is no disparity in the thickness of the donor button compared to the host bed.

A National Survey of Glaucoma Specialists on the Preoperative (Trabeculectomy) Management of the Ocular Surface (.).

BACKGROUND: Preserved anti-glaucoma drops cause ocular surface disease (OSD), which is increasingly being recognized as a likely cause of trabeculectomy failure. AIM: To determine the routine pre-trabeculectomy management of the ocular surface by glaucoma specialists. METHODS: A questionnaire consisting of 11 questions was posted to 146 UK glaucoma specialists. RESULTS: The first-time response rate was 43.8%. Regarding routine pre-operative management, 40.6% of specialists use preservative-free drops, 29.7% commence a drop holiday, and 53% advise lid hygiene. 42.1% prescribe lubricants, 50% prescribe topical steroids, 7.8% topical NSAIDs, and 34.4% systemic tetracyclines. 84.4% of specialists change their routine management if OSD is present. Pre-operative optimization of the ocular surface is viewed "necessary" by 48.4% and "beneficial" by 85.9%. CONCLUSION: A wide variation exists in the routine pre-operative management of the ocular surface. Research to determine the impact of different pre-operative interventions upon trabeculectomy outcomes is required.

Decorin Reduces Intraocular Pressure and Retinal Ganglion Cell Loss in Rodents Through Fibrolysis of the Scarred Trabecular Meshwork.

PURPOSE: To investigate whether Decorin, a matrikine that regulates extracellular matrix (ECM) deposition, can reverse established trabecular meshwork (TM) fibrosis, lower IOP, and reduce progressive retinal ganglion cell (RGC) death in a novel rodent model of TM fibrosis. METHODS: Adult rats had intracameral (IC) injections of human recombinant (hr) TGF-ß over 30 days (30 d; to induce TM fibrosis, raise IOP, and initiate RGC death by 17 d) or PBS (controls) and visually evoked potentials (VEP) were measured at 30 d to evaluate resultant visual pathway dysfunction. In some animals TGF-ß injections were stopped at 17 d when TM fibrosis and IOP were consistently raised and either hrDecorin or PBS IC injections were administered between 21 d and 30 d. Intraocular pressure was measured biweekly and eyes were processed for immunohistochemical analysis of ECM deposition to assess TM fibrosis and levels of matrix metalloproteinases (MMP) and tissue inhibitors of matrix metalloproteinases (TIMP) to assess fibrolysis. The effect of hrDecorin treatment on RGC survival was also assessed. RESULTS: Transforming growth factor-ß injections caused sustained increases in ECM deposition in the TM and raised IOP by 17 d, responses that were associated with 42% RGC loss and a significant decrease in VEP amplitude measured at 30 d. Decorin treatment from 17 d reduced TGF-ß-induced TM fibrosis, increased levels of MMP2 and MMP9 and lowered TIMP2 levels, and lowered IOP, preventing progressive RGC loss. CONCLUSIONS: Human recombinant Decorin reversed established TM fibrosis and lowered IOP, thereby rescuing RGC from progressive death. These data provide evidence for the candidacy of hrDecorin as a treatment for open-angle glaucoma.

Ocular surface disease exacerbated glaucoma: optimizing the ocular surface improves intraocular pressure control.

PURPOSE: To describe a series of 4 patients with inadequately controlled primary open angle glaucoma and ocular surface disease (OSD) in whom a combination approach was used to manage the OSD resulting in improved intraocular pressure (IOP) control. PATIENTS AND METHODS: A retrospective review of the clinical notes of 4 patients referred to a tertiary surgical glaucoma service was performed. At the initial visit, measures to control the OSD were employed in all patients; twice-daily lid hygiene measures, a 3-month course of 50 mg daily oral doxycycline, topical carmellose sodium (celluvisc) 0.5% 4 to 6 times daily, and preservative-free equivalents of topical antiglaucoma medications as deemed appropriate, depending on the perceived severity of the OSD. RESULTS: Patients were reviewed for a maximum of 24 months after intervention. In all patients treatment resulted in a marked symptomatic and clinical improvement in the ocular surface with a reduction in hyperemia, meibomian gland dysfunction and superficial keratopathy. A reduction in the IOP also occurred in all patients, obviating the need for glaucoma drainage surgery during the study period. CONCLUSIONS: Patients with severe OSD often have glaucoma that is refractive to medical therapy. Furthermore, the surgical success of glaucoma filtering surgery is compromised in patients with scarring and inflammation of the conjunctiva. The term we postulate is "OSD exacerbated glaucoma." This is the first study to suggest that the use of a combination approach comprising medical treatment to manage the OSD in patients with primary open angle glaucoma may lead to an improvement in the IOP control and the management of glaucoma.