Intermediate-term and long-term outcome of piggyback drainage: connecting glaucoma drainage device to a device in-situ for improved intraocular pressure control.

IMPORTANCE: This study provides results of a treatment option for patients with failed primary glaucoma drainage device. BACKGROUND: The study aimed to describe and evaluate the long-term intraocular pressure control and complications of a new technique joining a second glaucoma drainage device directly to an existing glaucoma drainage device termed 'piggyback drainage'. DESIGN: This is a retrospective, interventional cohort study. PARTICIPANTS: Eighteen eyes of 17 patients who underwent piggyback drainage between 2004 and 2013 inclusive have been studied. All patients had prior glaucoma drainage device with uncontrolled intraocular pressure. METHODS: The piggyback technique involved suturing a Baerveldt (250 or 350 mm) or Molteno3 glaucoma drainage device to an unused scleral quadrant and connecting the silicone tube to the primary plate bleb. MAIN OUTCOME MEASURES: Failure of intraocular pressure control defined as an intraocular pressure greater than 21 mmHg on maximal therapy on two separate occasions or further intervention to control intraocular pressure. RESULTS: The intraocular pressure was controlled in seven eyes (39%) at last follow-up with a mean follow-up time of 74.2 months. The mean preoperative intraocular pressure was 27.1 mmHg (95% confidence interval 23.8-30.3) compared with 18.4 mmHg (95% confidence interval 13.9-22.8) at last follow-up. The mean time to failure was 57.1 months (95% confidence interval 32.2-82), and the mean time to further surgery was 72.3 months (95% confidence interval 49.9-94.7). Lower preoperative intraocular pressure was associated with longer duration of intraocular pressure control (P = 0.048). If the intraocular pressure was controlled over 2 years, it continued to be controlled over the long term. Two eyes (11%) experienced corneal decompensation. CONCLUSIONS: Piggyback drainage represents a viable surgical alternative for the treatment of patients with severe glaucoma with failing primary glaucoma drainage device, particularly in those at high risk of corneal decompensation.

Increasing trends in the use of the Precivia® intravitreal injection assist device across the UK.

BACKGROUND: Intravitreal anti-VEGF injections are the most frequently performed outpatient procedure in the UK, the need for which continues to rise. To meet this demand, injection assist devices such as Precivia® are increasingly adopted to aid in their prompt and safe delivery. We present data on the usage of Precivia® intravitreal injection assist device across two district general hospitals and its distribution across the UK over five years. METHODS: A retrospective review was undertaken of all Precivia® assisted intravitreal injections delivered at Great Western Hospitals NHS Trust (GWH), and Gloucestershire and Cheltenham Hospitals NHS Trust (GCH) between 2015-2020. Data were also obtained from the Precivia® device UK distributor; Veni Vidi Medical. RESULTS: In GCH, 47,968 intravitreal injections were administered with Precivia®: 5947 in year 1; 7058 in year 2; 9893 in year 3; 11,503 in year 4 and 13,567 injections in year 5, observing a 128.13% increase in the use of Precivia® over the five-year-period. In GWH, 26,923 injections were administered with Precivia®: 4232 in year 1; 5117 in year 2; 5437 in year 3; 5878 in year 4 and 6259 in year 5, observing a 47.89% increase in Precivia® injections over a five-year study period. The number of Precivia® devices distributed across the UK similarly increased including 42,150 devices sold in 2015; 68,125 in 2016; 72,575 in 2017; 88,325 in 2018; 112,850 in 2019 and 115,125 in 2020 observing a 173.31% increase in five years. CONCLUSION: An increasing trend in the use of the Precivia® intravitreal injection assist device was observed across the UK.

A smartphone lens attachment improves the quality of referrals to eye casualty.

BACKGROUND/OBJECTIVES: In recent years, eye casualty clinics have seen significant increases in patient numbers with reduced capacity. COVID-19 has exacerbated this issue and demonstrated the potential of telemedicine as a solution. Our study evaluated the potential benefit of a smartphone-based lens attachment to improve the referral pathway for anterior segment related complaints in eye casualty. SUBJECTS/METHODS: Fifty-four consecutive patients with anterior segment complaints were recruited. A questionnaire was completed with each patient to simulate the history from the point of referral. White light and cobalt blue photos were captured using a smartphone lens. The clinician reviewing the patient was asked to document the actual diagnosis and the appropriate time-frame within which they felt the patient could safely have been seen within; both with and without the option of management advice at the time of triage. The subsequent images and questionnaires were reviewed by a single consultant Ophthalmologist who was independent to the data collection process. The assessor was asked to make a diagnosis and management plan based upon the questionnaire ('History'), and the questionnaire with the photo ('History with Image'), as well as rate their clinical confidence on a 1-5 scale. RESULTS: Diagnostic accuracy was significantly higher in "History with Image" (98.2%), when compared to "History" only (48.2%). "History with Image" prevented significantly more appointments when compared to "History" alone, at similar levels to retrospective clinic review. Preventable appointments were increased if clinical advice was possible. Timeframe of appointments between 'History with Image' and 'Clinic' appointments was similar. Clinical'Confidence was significantly higher at 4.5 with 'History with Image' when compared to 2.37 with 'History Only'. CONCLUSION: A low-cost smartphone lens attachment, alongside a standardised clinical questionnaire, can improve the referral pathway to the hospital eye service by reducing unnecessary appointments, while improving clinical confidence and diagnostic accuracy during triage. Further work to evaluate referral pathways, including the development of systems that allow for secure image transmission are needed to understand the feasibility for the widespread adoption of this technology.

Safety and efficacy of nurse led intravitreal injection service with Precivia® injection assist device.

INTRODUCTION: Intravitreal anti-VEGF injections are the most frequently performed outpatient procedure in the UK. Ophthalmic allied healthcare professionals are replacing medical professionals in delivering injections nationwide. The use of injection assist devices such as Precivia® has been well established and increasingly adopted to aid in their safe delivery. We present outcomes of nurse-led intravitreal injections using the Precivia® injection assist device over a five-year period in the UK. METHODS: A retrospective review was completed of all anti-VEGF intravitreal injections delivered at the Great Western Hospital between May 2015 and May 2020. RESULTS: Over the five-year study period, 2318 patients underwent a total of 26,923 intravitreal injections; 20,421 (75.8%) of which were delivered by appropriately trained ophthalmic nurses. The annual number of injections increased year-on-year from 2112 injections in 2015-2016 to 5410 injections in 2019-2020. The mean age of patients was 75.7±12.2 years with a female-to-male ratio was 1.17:1. Wet age-related macular degeneration represented the major indication for injections followed by retinal vein occlusion and diabetic maculopathy respectively. Three cases of post-injection endophthalmitis out of 20,421 (0.015%) injections in nurse injection group were identified during the study period. There were no cases of lens touch, retinal detachment or systemic thromboembolic events. CONCLUSION: Use of the Precivia® intravitreal injection assist device by trained ophthalmic allied health professionals is a safe and cost-effective way to deliver intravitreal injections service.

Assessing the Clinical Utility of Point of Care HbA1c in the Ophthalmology Outpatient Setting.

BACKGROUND/AIMS: Effective management of diabetic retinopathy requires multidisciplinary input. We aimed to evaluate the impact of point of care (POC) HbA1c testing as a tool to identify patients most in need of specialist diabetologist input and assess the accuracy and determinants of patients' insight into their glycaemic and blood pressure control. METHODS: Forty-nine patients with diabetic retinopathy were recruited from the eye clinic at Great Western Hospital. Patients completed a questionnaire and POC HbA1c and blood pressure values were measured. Statistical analysis was completed with SPSS v23. RESULTS: Mean age was 64.4 years, median interval since the last formal HbA1c reading was 10.2 months and the mean POC HbA1c was 64.1 mmol/mol. HbA1c significantly correlated with the degree of retinopathy. Of the patients, 81.6% had POC readings above the levels recommended by the National Institute for Health and Care Excellence, with only 16.3% having insight into this. Insight to HbA1c levels was predicted by age but not by duration of disease. Fourteen patients (33.3%) identified with high HbA1c readings were referred to secondary diabetic services and 88.8% of patients felt that the test was useful and likely to improve their diabetic control. CONCLUSION: The majority of patients had poor insight into their diabetes control, with sub-optimal treatment and follow-up. Poor insight is high in younger patients, suggesting that POC HbA1c testing is particularly important in educating younger patients who may be Type 1 diabetics with more severe disease. POC HbA1c represents a cost-effective, reproducible and clinically significant tool for the management of diabetes in an outpatient ophthalmology setting, allowing the rapid recognition of high-risk patients and appropriate referral to secondary diabetic services.

In Utero Gene Therapy (IUGT) Using GLOBE Lentiviral Vector Phenotypically Corrects the Heterozygous Humanised Mouse Model and Its Progress Can Be Monitored Using MRI Techniques.

In utero gene therapy (IUGT) to the fetal hematopoietic compartment could be used to treat congenital blood disorders such as ß-thalassemia. A humanised mouse model of ß-thalassemia was used, in which heterozygous animals are anaemic with splenomegaly and extramedullary hematopoiesis. Intrahepatic in utero injections of a ß globin-expressing lentiviral vector (GLOBE), were performed in fetuses at E13.5 of gestation. We analysed animals at 12 and 32 weeks of age, for vector copy number in bone marrow, peripheral blood liver and spleen and we performed integration site analysis. Compared to noninjected heterozygous animals IUGT normalised blood haemoglobin levels and spleen weight. Integration site analysis showed polyclonality. The left ventricular ejection fraction measured using magnetic resonance imaging (MRI) in treated heterozygous animals was similar to that of normal non-ß-thalassemic mice but significantly higher than untreated heterozygous thalassemia mice suggesting that IUGT ameliorated poor cardiac function. GLOBE LV-mediated IUGT normalised the haematological and anatomical phenotype in a heterozygous humanised model of ß-thalassemia.

Publisher Correction: In Utero Gene Therapy (IUGT) Using GLOBE Lentiviral Vector Phenotypically Corrects the Heterozygous Humanised Mouse Model and Its Progress Can Be Monitored Using MRI Techniques.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Multi-stage bioengineering of a layered oesophagus with in vitro expanded muscle and epithelial adult progenitors.

A tissue engineered oesophagus could overcome limitations associated with oesophageal substitution. Combining decellularized scaffolds with patient-derived cells shows promise for regeneration of tissue defects. In this proof-of-principle study, a two-stage approach for generation of a bio-artificial oesophageal graft addresses some major challenges in organ engineering, namely: (i) development of multi-strata tubular structures, (ii) appropriate re-population/maturation of constructs before transplantation, (iii) cryopreservation of bio-engineered organs and (iv) in vivo pre-vascularization. The graft comprises decellularized rat oesophagus homogeneously re-populated with mesoangioblasts and fibroblasts for the muscle layer. The oesophageal muscle reaches organised maturation after dynamic culture in a bioreactor and functional integration with neural crest stem cells. Grafts are pre-vascularised in vivo in the omentum prior to mucosa reconstitution with expanded epithelial progenitors. Overall, our optimised two-stage approach produces a fully re-populated, structurally organized and pre-vascularized oesophageal substitute, which could become an alternative to current oesophageal substitutes.