Treatment of Diabetic Macular Edema or Macular Edema Following Retinal Vein Occlusion Based on Repeated Injection of the Dexamethasone Intravitreal Implant: A Retrospective Real-World Analysis.

Purpose: To assess the "real world" utility of repeated injection with the dexamethasone intravitreal implant (DEX) in routine practice. Methods: This was a retrospective, single-center analysis of consecutive patients with diabetic macular edema, or macular edema following retinal vein occlusion, treated with DEX. None had received prior intravitreal steroid treatment. DEX was implanted as per the manufacturer's instructions. Results: Seventy-eight individuals (95 eyes) were included (50.0% female; mean age: 68.1 ± 12.4 years; mean duration of macular edema: 13.2 ± 12.9 months). Thirty-three eyes (34.7%) had received previous treatment with an anti-vascular endothelial growth factor (anti-VEGF) and/or laser. Thirty eyes (31.6%) underwent one round of DEX implantation; the remainder received 2-5 cycles (total: 225 cycles). Initial DEX treatment led to significant increases in visual acuity (VA) at 6 weeks (mean change: 4.6 letters; P=0.004). Greater VA improvements during the first treatment cycle were associated with inferior baseline VA (P=0.02), borderline associated with baseline central macular thickness (CMT; P=0.06), and independent of prior anti-VEGF treatment (P=0.39). In an analysis of all DEX injections, VA improvements were robust across cycles 1 and 2 but reduced in cycle 3 (P=0.03). CMT improvements did not differ based on injection number (P=0.20). Increases in intraocular pressure (IOP) were largest over the first 6 weeks (but rebounded towards baseline more rapidly) in cycle 1 versus cycles 2 and 3 (P<0.001). IOP rises were typically manageable with topical medications. Conclusion: This analysis confirms the broad utility of DEX and may inform decision-making in routine practice.

Stress and cataract surgery: A nationwide study evaluating surgeon burnout.

BACKGROUND: We aimed to evaluate the nationwide prevalence of stress induced burnout among cataract surgeons. We believe that knowledge of these factors can help formulate a solution to this underreported problem. METHODS: A three-part nationwide cross-sectional survey was disseminated with via the Royal College of Ophthalmologists (RCOphth) in the United Kingdom(UK). All consultants, trainees and specialty doctors and associate specialists(SAS) were invited to participate. We evaluated burnout using the Maslach Burnout Inventory (MBI). Logistic regression modelling was completed to look at factors linked to high level burnout in certain domains. RESULTS: A total of 406 respondents completed our survey. Prevalence of cataract surgery-related high burnout was estimated at 3.45% (Section A and/or B) and 40% within Personal Accomplishment (PA)(Section C of the MBI). Multiple factors were associated with increased burnout within PA: Increasing age: 61+ OR: 2.99 (1.02-8.78, p = 0.05), Number of cataract operations completed: >3000 OR 2.98 (1.03-8.64, p = 0.04), Lists per week: 2: OR 2.99 (1.38-6.47, p < 0.01), 2.5: OR 8.95 (2.58-31.02, p < 0.01), 3 or more: OR 2.64 (1.07-6.54, p = 0.04). Sleeping 8 h or more was found to be protective OR 0.52 (0.28-0.96, p = 0.04). 17% of respondents indicated they would be willing to give up cataract surgery if given the opportunity. CONCLUSION: The prevalence of stress induced burnout by cataract surgery appears to be present in a minority of surgeons. There appears to be a significant reduction in the feeling of personal achievement within the profession. A large proportion of this cohort appears to be willing to give up surgical responsibilities.

Bilateral 0.19 mg Fluocinolone Acetonide Intravitreal Implant in the Successful Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis and Secondary Macular Oedema: A Case Report and Review of Intravitreal Therapies.

INTRODUCTION: Treatment of juvenile idiopathic arthritis (JIA)-associated uveitis necessitates the use of long-term corticosteroids or immunosuppressive agents, each of which poses their own significant side effect profile. Initial treatment requires intensive topical glucocorticoids, with a step-up approach employing immunosuppressive agents for those cases with poor response or high-risk complications such as macular oedema. To date, there is minimal evidence to support a specific approach to such complicated subgroups. We present the first case to successfully employ the 0.19 mg fluocinolone acetonide implant (ILUVIEN®, Alimera Sciences, Hampshire, UK) as a novel device for prolonged intravitreal administration of disease-modifying agents for patients with JIA complicated by uveitis. METHODS: This retrospective case report describes a 20-year old woman diagnosed with oligoarticular JIA complicated by chronic uveitis and associated cystoid macular oedema (CMO). Considering factors including the patient's non-compliance, age, lens status, non-steroid response, and good response to short-term intravitreal steroid therapy, the 0.19 mg fluocinolone acetonide intravitreal implant was deemed an appropriate step-up treatment option. RESULTS: At 12-month follow-up, the left eye (OS) showed an improvement in visual acuity to 6/15 - 1 from 6/60 + 1 (0.42 from 0.98 logMAR) (pre-insertion) and a reduction in central retinal thickness (CRT) of 199 µm from 471 µm. The right eye (OD), treated 10 months later, showed an improvement in visual acuity to 6/7.5 from 6/24 - 1 (0.10 from 0.56 LogMAR) and a reduction in CRT of 327 µm 6 months after treatment. CONCLUSION: In this case, the 0.19 mg fluocinolone acetonide implant provided safe and effective long-term treatment of JIA-associated uveitis and secondary CMO. This potentially offers an alternative approach to complex cases that show good response to short-term corticosteroid use.

One-year real-life results on effect of intravitreal aflibercept in patients with diabetic macular oedema switched from ranibizumab.

PURPOSE: To assess visual and optical coherence tomography-derived anatomical outcomes of treatment with intravitreal aflibercept (Eylea®) for diabetic macular oedema in patients switched from intravitreal ranibizumab (Lucentis®). DESIGN: Retrospective, cohort study. PARTICIPANTS: Ninety eyes (of 67 patients) receiving intravitreal anti-vascular endothelial growth factor therapy were included. METHODS: This is a retrospective, real-life, cohort study. Each patient had visual acuity measurements and optical coherence tomography scans performed at baseline and 12 months after the first injection of aflibercept was given. MAIN OUTCOME MEASURES: We measured visual acuities in Early Treatment Diabetic Retinopathy Study letters, central foveal thickness and macular volume at baseline and at 12 months after the first aflibercept injection was given. RESULTS: Ninety switched eyes were included in this study. The mean (standard deviation) visual acuity was 63 (15.78) Early Treatment Diabetic Retinopathy Study letters. At baseline, the mean (standard deviation) central foveal thickness was 417.7 (158.4) µm and the mean macular volume was 9.96 (2.44) mm3. Mean change in visual acuity was +4 Early Treatment Diabetic Retinopathy Study letters (p = 0.0053). The mean change in macular volume was -1.53 mm3 in SW group (p = 0.21), while the change in central foveal thickness was -136.8 µm (p = 0.69). CONCLUSION: There was a significant improvement in visual acuity and in anatomical outcomes in the switched group at 12 months after commencing treatment with aflibercept for diabetic macular oedema.

Intravitreal aflibercept for diabetic macular oedema in real-world: 36-month visual acuity and anatomical outcomes.

BACKGROUND/AIMS: To assess structural and functional outcomes of treatment with intravitreal aflibercept (®Eylea) for diabetic macular oedema in treatment-naïve patients. METHODS: Sixty-four eyes receiving intravitreal anti-vascular endothelial growth factor therapy were included in the data analysis of this retrospective, real-life study which follow-up was 3 years. Each patient had corrected visual acuity in Early Treatment Diabetic Retinopathy Study letters and optical coherence tomography central foveal thickness and macular volume performed at baseline, 12, 24 and 36 months. Patients were initiated on a loading phase of five 1-monthly intravitreal aflibercept injections, followed by injections if needed as per clinicians' discretion. RESULTS: The mean number of aflibercept injections received over 3 years was 12.59. At baseline, the mean visual acuity (standard deviation) (Snellen) was 61.45 (16.30) (20/63) Early Treatment Diabetic Retinopathy Study letters, the mean central foveal thickness (standard deviation) was 422 (138) µm, while the mean macular volume (standard deviation) was 9.51 (2.01) mm3. At 36 months, the mean visual acuity (standard deviation) (Snellen) was 68.34 (13.66) (20/50) Early Treatment Diabetic Retinopathy Study letters (p = .0003). Mean central foveal thickness (standard deviation) was 303 (106) µm (p < .0001) and mean macular volume (standard deviation) was 8.35 (1.62) mm3 (p = .0022) at 36 months. Sixteen (25%) eyes gained ≥15 ETDRS letters at month 36, and 33 (52%) eyes had a decrease in central foveal thickness of ≥ 100 µm at the same time. CONCLUSION: There was a significant improvement in visual acuity and in anatomical outcomes in aflibercept-treated eyes at 36 months after commencing treatment for diabetic macular oedema in real-life settings. The good vision and anatomical outcomes were maintained over second and third year of treatment with mean 2.93 and 2.57 intravitreal injections, respectively.

Agreement between ophthalmologists and optometrists in the certification of vision impairment.

BACKGROUND/OBJECTIVES: The certification process to register patients as sight impaired or severely sight impaired is undertaken by consultant ophthalmologists, in the UK. We sought to assess the agreement between optometrists and a consensus panel, in identifying patient eligibility for certification, relative to the agreement between ophthalmologists and the consensus panel. METHODS: The consensus panel (4 consultant ophthalmologists and 3 optometrists with a formal accreditation in low vision), 30 consultant ophthalmologists and 99 low vision optometrists reviewed 40 randomly selected abridged cases. The eligibility outcomes from the ophthalmologists and the optometrists were compared with the consensus panel outcomes. RESULTS: For ophthalmologists and optometrists, the median (IQR) number of cases in which there was agreement with the consensus panel was 33.0 (31.0, 33.0) and 36.0 (34.0, 36.5), respectively. In severely sight impaired cases, the probabilities of agreeing on eligibility for certification were 76.0% (95% CIs 71.4%, 80.1%) for ophthalmologists and 61.8% (59.0%, 64.6%) for optometrists. In sight impaired cases, the corresponding values were 51.6% (46.7%, 56.4%) for ophthalmologists and 72.2% (69.8%, 74.5%) for optometrists. In cases of bilateral atrophic age-related macular degeneration (AMD), both groups were more likely to agree with the consensus panel and the differences between optometrists and ophthalmologists were less marked. CONCLUSIONS: Optometrists demonstrated a comparable agreement relative to ophthalmologists, with the consensus panel on the eligibility of randomly selected, abridged cases for certification. The findings support the clinical decision-making ability of low vision optometrists in the certification of patients with vision impairment and provide evidence in support of policy change to allow low vision optometrists to certify individuals with atrophic AMD.

Patient preference and pain-reported outcomes for topical versus subtenon anesthetic for cataract surgery.

PURPOSE: Cataract extraction and lens implantation is the most common surgical procedure performed worldwide, with surgeons opting for either a topical or a subtenon anesthetic in majority of cases. While complication rates and pain scores have been previously examined in a bid to determine which modality was better, patients who have had both eyes operated upon under different techniques have never previously been asked which method they prefer. We undertook this study to fill in this crucial gap in our knowledge. METHODS: This is a retrospective study of patients who have undergone bilateral cataract surgery with one eye operated on with topical anesthesia and the other eye with subtenon anesthesia. Patients were identified who had had surgery undertaken in the previous 6 months at Singleton Hospital, Swansea, where both eyes had been operated upon using different anesthetic techniques. Telephone interviews with these patients were performed and their pain scores recorded on a scale from 0 (no pain) to 10 (severe pain) for both eyes, with the patients then being asked which the method of anesthetic they preferred. Statistical analysis of pain scores was compared using Wilcoxon rank-sum testing. RESULTS: One hundred and fifty-two patients in total were identified. One hundred and forty-one of the applicable patients participated in the study. Of these, 78 patients received topical anesthesia for their first operation and 63 had subtenon block for their first operation. The mean pain scores reported for surgery with topical anesthesia and subtenon block were 2.30 and 1.38, respectively. The pain data were analyzed using a Wilcoxon signed-rank test, returning a z-score of 4.038. This result therefore suggests that patients experience statistically significantly less pain from cataract surgery when given a subtenon block. Patients expressed a preference for subtenon anesthesia, with 70% preferring subtenon block, 23% preferring topical anesthesia, and 7% having no preference. CONCLUSIONS: Patients report less pain with subtenon anesthesia compared with topical anesthesia in cataract surgery, where both eyes were operated upon with different anesthetic techniques. This is the first study in which patients who have had both anesthetic techniques performed independently for cataract surgery have had their pain scores reported and statistically analyzed.

Intravitreal aflibercept for diabetic macular oedema: Moorfields' real-world 12-month visual acuity and anatomical outcomes.

OBJECTIVES: To assess structural and functional outcomes of treatment with intravitreal aflibercept (Eylea®) for diabetic macular oedema in treatment-naive patients. DESIGN: This is a retrospective, real-life, cohort study. PARTICIPANTS AND METHODS: In all, 92 diabetic patients (102 eyes) receiving intravitreal anti-vascular endothelial growth factor therapy were included. A total of 99 aflibercept-treated eyes were included in the statistical analysis. Each patient had corrected visual acuity in Early Treatment Diabetic Retinopathy Study letters and optical coherence tomography central foveal thickness and macular volume performed at baseline and 12 months. Patients were initiated on a loading phase of five monthly intravitreal aflibercept injections, followed by injections if needed as per clinicians' discretion. RESULTS: The mean number of aflibercept injections received was 6.92. At baseline, the mean visual acuity (standard deviation; Snellen) was 59.7 (16.1) (20/63) Early Treatment Diabetic Retinopathy Study letters, the mean central foveal thickness (standard deviation) was 431 (129) µm, while the mean macular volume (standard deviation) was 9.53 (1.79) mm3. At 12 months, the mean visual acuity (standard deviation; Snellen) was 69.6 (15.2; 20/40) Early Treatment Diabetic Retinopathy Study letters (p < .0001). Mean central foveal thickness (standard deviation) was 306 (122) µm (p < .0001) and mean macular volume (standard deviation) was 8.43 (1.58) mm3 (p < .0001) at 12 months; 33 (33.67%) eyes gained ⩾15 Early Treatment Diabetic Retinopathy Study letters at month 12, and 50 (55.55%) eyes had a decrease in central foveal thickness of ⩾100 µm. CONCLUSION: There was a significant improvement in visual acuity and in anatomical outcomes in aflibercept-treated eyes at 12 months after commencing treatment for diabetic macular oedema in real-life settings.

Diagnostic dilemma of ocular lymphoma.

We report a very unusual presentation of primary intraocular lymphoma masquerading as anterior uveitis with atypical symptoms. A 68-year-old man, initially presented with a 4-day history of painless, left blurred vision. Examination revealed 2 or more anterior chamber cells, mutton-fat keratic precipitates and posterior synechiae. Treatment was initiated, the eye settled, and the patient was discharged. He re-presented 7 months later with hypopyon, a hazy cornea, fibrin deposits and a narrowed anterior chamber angle. Over the coming weeks, it became apparent that the temporal iris was thickened, involving the angle, and his intraocular pressure increased despite topical dorzolamide. Following advice from a tertiary centre and referral to a regional ocular oncology centre, a transscleral biopsy was performed and suggested a ciliary body melanoma. Enucleation was advised and performed, with histological examination revealing features consistent with an ocular diffuse large B-cell lymphoma not involving the optic nerve, sclera or cornea. This is the first ever published report of a case of ocular lymphoma masquerading in this way.

Assessing patient acceptance of laser pretreatment to reduce injection burden in diabetic macular edema: a large scale postal survey.

OBJECTIVE: To canvass views about whether argon laser pretreatment to ischemic areas of retina would be acceptable if it resulted in a reduced burden of intravitreal injections. METHOD: A postal survey was mailed to all 813 patients under the care of the diabetic eye clinic at Singleton Hospital with 10 questions, explanatory information, and a stamp-addressed envelope available for returning completed questionnaires. RESULTS: Patients were strongly supportive (9.14 out of 10) of the idea of undergoing laser pretreatment if it meant less injections were needed for diabetic macular edema. CONCLUSION: This is the first time any survey has analyzed patient attitude to laser pretreatment and showed that patients were strongly in favour if it was found to reduce the need for intravitreal injections.

Assessing patient acceptance of virtual clinics for diabetic retinopathy: a large scale postal survey.

OBJECTIVE: To explore the views of patients with diabetic retinopathy and maculopathy on their acceptance of virtual clinic review in place of face-to-face clinic appointments. METHODS: A postal survey was mailed to all 813 patients under the care of the diabetic eye clinic at Singleton Hospital with 7 questions, explanatory information, and a stamped, addressed envelope available for returning completed questionnaires. RESULTS: Four hundred and ninety-eight questionnaires were returned indicating that 86.1% were supportive of the idea of virtual clinics, although only 56.9% were prepared for every visit to be virtual. Of respondents, 6.6% not happy to attend any virtual clinic. CONCLUSION: This is by far the largest survey of patients' attitudes regarding attending virtual clinics and confirms that the vast majority are supportive of this mode of health care delivery.

Retroviral insertional mutagenesis implicates E3 ubiquitin ligase RNF168 in the control of cell proliferation and survival.

The E3 ubiquitin ligase RNF168 is a ring finger protein that has previously been identified to play an important regulatory role in the repair of double-strand DNA breaks.  In the present study, an unbiased forward genetics functional screen in mouse granulocyte/ macrophage progenitor cell line FDCP1 has identified E3 ubiquitin ligase RNF168 as a key regulator of cell survival and proliferation. Our data indicate that RNF168 is an important component of the mechanisms controlling cell fate, not only in human and mouse haematopoietic growth factor-dependent cells, but also in the human breast epithelial cell line MCF-7. These observations therefore suggest that RNF168 provides a connection to key pathways controlling cell fate, potentially through interaction with PML nuclear bodies and/or epigenetic control of gene expression. Our study is the first to demonstrate a critical role for RNF168 in the in the mechanisms regulating cell proliferation and survival, in addition to its well-established role in DNA repair.