Ethnic Differences in the Rates of Posterior Capsule Rupture and Long-Term Sequelae in Phacoemulsification Cataract Surgery.

Purpose The purpose of this study is to investigate the rates of posterior capsular rupture (PCR) and its sequelae during phacoemulsification across different ethnicities. Methods This is a retrospective cohort study of all consecutive phacoemulsification cases complicated by PCR that met the inclusion criteria over a four-year period at a single tertiary eye centre in the United Kingdom (UK). Results PCR occurred in 0.85% of cases overall (157/18,481). PCR rates were 1.8% (26/1485), 1.2% (51/4350), and 0.7% (75/10,927) in African-Caribbean, Indian subcontinent, and Caucasian patients, respectively (p < 0.001). Mean final corrected distance visual acuity improved (p < 0.05) in all ethnic groups (0.40 ± 0.57 logMAR) compared to pre-op (0.78 ± 0.61 logMAR). Post-operative cystoid macular oedema and unstable intraocular pressure rates following PCR did not statistically differ amongst ethnicities (p = 0.37 and p = 0.75, respectively). However, post-operative uveitis rates significantly differed at 11.5%, 15.7%, and 1.3% amongst the three ethnic groups, respectively (p = 0.01). Conclusion This is the first study to highlight a possible link between patient ethnicity and the risk of PCR during phacoemulsification cataract surgery. We observed significantly greater numbers of PCR cases amongst certain ethnic groups (highest in African-Caribbean eyes, then Indian subcontinental eyes, and lowest in Caucasian eyes) within the same multi-cultural urban population. Ethnicity may therefore be a contributing factor for PCR and should potentially be taken into consideration during preoperative risk stratification.

Differentiating stages of functional vision loss from glaucoma using the Disc Damage Likelihood Scale and cup:disc ratio.

BACKGROUND: Glaucoma staging is critical for treatment planning but has rarely been tested in severe/end-stage disease. We compared the performance of the Disc Damage Likelihood Scale (DDLS) and cup:disc ratio (CDR) using a functional glaucoma staging system (GSS) as the reference standard. METHODS: Post hoc analysis of a randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Tanzania. Eligible participants (aged ≥18 years) with open-angle glaucoma, intraocular pressure (IOP) of >21 mm Hg, were randomised to timolol 0.5% eye drops or selective laser trabeculoplasty. Fundoscopy established vertical and horizontal CDRs and DDLS. Visual acuity and static visual fields were graded (GSS). The study used area under the receiver operating characteristic (AROC) curves and Spearman's rank correlation coefficients to compare staging systems. Logistic regression with generalised estimating equations determined risk factors of functional severe/end-stage glaucoma. RESULTS: 382 eyes (201 participants) were evaluated; 195 (51%) had severe or end-stage glaucoma; mean IOP was 26.7 (SD 6.9) mm Hg. DDLS yielded an AROC of 0.90 (95% CI 0.87 to 0.93), vertical cup:disc ratio (vCDR) of 0.88 (95% CI 0.85 to 0.91, p=0.048) for identifying severe/end-stage disease. Correlation coefficients comparing GSS to DDLS and vCDRs were 0.73 and 0.71, respectively. Advanced structural stages, vision impairment, higher IOP and less financial resources were risk factors of functional severe/end-stage glaucoma. CONCLUSION: This study indicates that both structural staging systems can differentiate severe/end-stage glaucoma from less severe disease, with a moderate advantage of DDLS over CDR. Clinical examination of the optic disc plays an important role in addition to functional assessment when managing severe/end-stage glaucoma.

The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE: This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS: Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS: Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION: Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Mapping vision loss of patients in a glaucoma backlog following the COVID-19 pandemic: a real-world analysis using the Glauc-Strat-Fast risk stratification tool.

INTRODUCTION: Glauc-Strat-Fast is a clinical tool recommended by The Royal College of Ophthalmologists to classify glaucoma patients into strata of risk for significant future sight loss and an estimate of resource requirement. The aim of this study was to map the movement of glaucoma patients across stratification boundaries on Glauc-Strat-Fast during the COVID-19 pandemic. SUBJECTS AND METHODS: Glauc-Strat-Fast was applied to a consecutive sample of 100 primary open angle glaucoma patients in a backlog at Worcestershire Acute Hospitals NHS Trust. Stratification outcomes were compared between clinic visits prior to the COVID-19 pandemic versus the follow-up visit. Patients were stratified twice separately based on their worse eye (i.e., most affected) and better eye (i.e., least affected) according to Glauc-Strat-Fast. RESULTS: Amount of slippage (difference between target follow-up and actual follow-up) ranged from 2 to 32 months. There was a statistically significant average reduction in visual field mean deviation for better and worse eyes between visits (p = <0.001). At follow-up, no worse eyes were classified as being low risk (green), while 96 were classified as high risk (red). For better eyes, elevation of risk into the highest strata of Glauc-Strat-Fast observed a three-fold increase in patients (19 versus 56) between visits. DISCUSSION: This retrospective real-world analysis highlights patients' movement into the highest strata on the Glauc-Strat-Fast tool and demonstrates a significant deterioration in visual outcomes during a period of extensive appointment slippage. The findings demonstrate the utility of Glauc-Strat-Fast as a tool for improved patient management.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis.

TOPIC: This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE: Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS: PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS: Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS: The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Current practice of trabeculectomy in a cohort of experienced glaucoma surgeons in Australia and New Zealand.

BACKGROUND/OBJECTIVES: To evaluate current routine trabeculectomy technique preferences among Australian and New Zealand Glaucoma Society surgeons regularly performing trabeculectomy surgery. SUBJECTS/METHODS: Survey of experienced surgeons who perform trabeculectomy. RESULTS: Forty-nine surgeons (33 male:16 female) participated in the survey. Trabeculectomy was performed as day surgery (39/47, 83.0%) under local anesthesia (44/47, 93.6%). The surgical techniques most commonly used were a corneal traction suture (44/47, 93.6%), fornix-based conjunctival flap (43/47, 91.5%) and half-thickness scleral flap (38/47, 81.0%). Mitomycin C antifibrotic agent was used in routine cases by 45/46 (97.8%) surgeons. Surgeons applied the antifibrotic agent under the Tenon layer with a pledget (36/46, 78.2%) with a concentration of 0.02% (37/46, 80.4%) for 2 (11/46, 23.9%) or 3 min (30/46, 65.2%). The Kelly (26/46, 56.5%) and the Khaw Descemet (19/46, 41.3%) punches were used to perform the sclerostomy. Most surgeons performed a peripheral iridectomy in all phakic patients (46/47, 97.9%), but less commonly in pseudophakic patients (34/47, 72.3%). Techniques for closure of the limbal conjunctival edge were quite varied with a combination of suturing including purse string (21/47, 57.4%), wing (20/47, 42.6%) and horizontal mattress sutures (33/47, 70.2%). Surgeons reviewed their routine patients four times in the first month (29/47, 61.7%) and continued the postoperative topical steroids for 3-4 months (28/47, 59.6%). CONCLUSIONS: Although a wide range of techniques for trabeculectomy exists among surgeons, there are consistent procedures currently in use to optimize patient outcomes. This report will assist surgeons in choosing which surgical techniques fit their best practice.

Only eye study 3 (OnES 3): a qualitative study into how surgeons approach surgery in patients with only one seeing eye.

OBJECTIVE: Performing surgery on an 'only eye' patient is considered high stakes. The purpose of this study is to explore the process of only eye surgery from the perspective of ophthalmic surgeons and improve both patient and surgeon experience. DESIGN, SETTING AND PARTICIPANTS: A cohort of 76 Australian consultant ophthalmologists, divided into three focus groups, were recruited via online webinar to participate in a guided focus group discussion about only eye surgery. Qualitative data regarding participant experience of performing only eye surgery were collected in audio and text form. Thematic analysis was conducted to identify patterns in the data. MAIN OUTCOME MEASURE: Identification of themes relevant to only eye surgery. RESULTS: Five overarching themes relevant to only eye surgery were identified: (1) differences in the surgical decision-making process; (2) differences in the approach to consent, (3) implementation of additional risk reduction strategies, (4) value of having colleagues to discuss and plan surgery with and (5) psychological challenges. A divergent theme was identified: (6) that all surgery, only eye or not, should be treated the same. CONCLUSIONS: This study identifies challenges associated with clinical management of only eye patients across their surgical journey. A conceptual framework to guide surgeons when managing only eye patients is provided which has potential to promote a more unified approach to treating this high-stakes cohort.

Selective laser trabeculoplasty versus 0·5% timolol eye drops for the treatment of glaucoma in Tanzania: a randomised controlled trial.

BACKGROUND: Glaucoma is a major cause of sight loss worldwide, with the highest regional prevalence and incidence reported in Africa. The most common low-cost treatment used to control glaucoma is long-term timolol eye drops. However, low adherence is a major challenge. We aimed to investigate whether selective laser trabeculoplasty (SLT) was superior to timolol eye drops for controlling intraocular pressure (IOP) in patients with open-angle glaucoma. METHODS: We did a two-arm, parallel-group, single-masked randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Moshi, Tanzania. Eligible participants (aged ≥18 years) had open-angle glaucoma and an IOP above 21 mm Hg, and did not have asthma or a history of glaucoma surgery or laser. Participants were randomly assigned (1:1) to receive 0·5% timolol eye drops to administer twice daily or to receive SLT. The primary outcome was the proportion of eyes from both groups with treatment success, defined as an IOP below or equal to target pressure according to glaucoma severity, at 12 months following randomisation. Re-explanation of eye drop application or a repeat SLT was permitted once. The primary analysis was by modified intention-to-treat, excluding participants lost to follow-up, using logistic regression; generalised estimating equations were used to adjust for the correlation between eyes. This trial was registered with the Pan African Clinical Trials Registry, number PACTR201508001235339. FINDINGS: 840 patients were screened for eligibility, of whom 201 (24%) participants (382 eligible eyes) were enrolled between Aug 31, 2015, and May 12, 2017. 100 (50%) participants (191 eyes) were randomly assigned to the timolol group and 101 (50%; 191 eyes) to the SLT group. After 1 year, 339 (89%) of 382 eyes were analysed. Treatment was successful in 55 (31%) of 176 eyes in the timolol group (16 [29%] of 55 eyes required repeat administration counselling) and in 99 (61%) of 163 eyes in the SLT group (33 [33%] of 99 eyes required repeat SLT; odds ratio 3·37 [95% CI 1·96-5·80]; p<0·0001). Adverse events (mostly unrelated to ocular events) occurred in ten (10%) participants in the timolol group and in eight (8%) participants in the SLT group (p=0·61). INTERPRETATION: SLT was superior to timolol eye drops for managing patients with open-angle high-pressure glaucoma for 1 year in Tanzania. SLT has the potential to transform the management of glaucoma in sub-Saharan Africa, even where the prevalence of advanced glaucoma is high. FUNDING: Christian Blind Mission, Seeing is Believing Innovation Fund, and the Wellcome Trust. TRANSLATIONS: For the Kiswahili, French and Portuguese translations of the abstract see Supplementary Materials section.

Low systemic vitamin D as a potential risk factor in primary open-angle glaucoma: a review of current evidence.

Currently, intraocular pressure is the only modifiable risk factor for glaucoma; thus, identifying other modifiable determinants may have far-reaching outcomes. There has been increasing interest in vitamin D status and glaucoma pathogenesis as low vitamin D has been identified by some studies as an independent risk factor for glaucoma. Although the exact mechanism of vitamin D in glaucoma remains uncertain, there is sufficient evidence to continue research in this area. There is a potential physiological role for vitamin D as an anti-inflammatory agent in the oxidative stress-driven pathogenesis of primary open-angle glaucoma, and further studies are required to evaluate the temporal and causal relationship. Ocular vitamin D status in the tear, aqueous and vitreous fluid is a prospective gap in research.

Only eye study 2 (OnES 2): 'Am I going to be able to see when the patch comes off?' A qualitative study of patient experiences of undergoing high-stakes only eye surgery.

OBJECTIVES: Ocular surgery is a source of significant concern for many patients, especially in high-stakes circumstances. The purpose of this study was to explore patient experiences of undergoing surgery on their only-seeing eye. DESIGN: A qualitative investigation using semistructured face-to-face interviews. Transcripts were analysed using thematic analysis. SETTING: Hospital eye service in the UK. PARTICIPANTS: Twelve participants with a diagnosis of glaucoma with worse eye visual acuity <3/60± end-stage visual field loss. All participants had experience of undergoing surgery on their better-seeing (ie, 'only') eye. RESULTS: Data were coded into three key themes relating to (1) emotional impact of surgery, (2) burden of visual loss and (3) coping with surgery. Patients reported depressive symptoms at all stages of their surgical journey; concern about poor visual outcomes was a common feature. Only eye surgery imposes an emotional burden due to the uncertainty regarding individuals' ability to continue daily activities and maintaining social roles. Burden extended to the inconvenience of frequent hospital visits and difficulties with follow-up care. Participants' ability to cope effectively with surgery appeared to be linked to extent of support from healthcare professionals. Key areas in developing trust and support were an open and transparent dialogue between surgeons and patients, continuity of care, patient inclusion in decision-making, and observable empathy. CONCLUSIONS: The findings indicate a need for an enhanced model of care in only eye surgery to better target patient preferences and allay concerns inherent with these procedures.

The Uveitis Patient Passport: A Self-Care Tool.

Purpose: Patient self-care tools can improve patient outcomes in chronic disease. In uveitis, there is an unmet need for the innovative Uveitis Patient Passport (UPP). This study aims to evaluate the success of the passport's introduction into a tertiary uveitis service through patient experience.Methods: The UPP, created in consultation with patients and the multidisciplinary team, was evaluated using a patient questionnaire and mixed quantitative and qualitative methodology.Results: Key themes emerged, with the passport used by participants as a self-care resource and an aid for cross-specialty communication. Patient involvement in evaluation identified key areas for passport development in line with patient needs. These included improving clinician engagement and future transference into a smartphone application.Conclusion: The introduction of the first UPP was a success, especially as a self-care tool for supporting patients in managing their uveitis with the potential to improve patient outcomes.