Setting up a successful nurse-led intravitreal injections service: pearls from Swindon.

The demand for performing intravitreal injections has increased in recent years, prompting the need for more nurse training in their administration. The Great Western Hospitals NHS Trust in Swindon has developed a structured nurse training programme and now has 8 independent nurse injectors trained to undertake injections independently; nurse practitioners now contribute upwards of 85% of the total number of injections. The authors have also demonstrated the financial benefits of using injection assistant devices and shown the positive impact such devices have on training. In September 2019, the authors organised the first course to offer nurses and doctors hands-on experience in administering injections, using the Swindon training model to provide participants with a structured approach to learn how to perform intravitreal injections safely. Nurses made up 96% of participants; the remainder were doctors and managers; 6% had never performed an intravitreal injection; of units where they had, disposable drapes and a speculum were used in 71% of these. The number of injections performed per session at participants' units at the time they attended the course was: 17 or more injections=46%, 13-14=39%, and 11-12=15%. The course was rated 8.9/10 overall for content, with 85% very likely to recommend it to colleagues. All participants indicated that using the Swindon model made them feel confident to deliver injections safely. The authors demonstrated that using a structured training protocol and intravitreal assistant device improves the quality of nurse training and increases confidence in administering intravitreal injections.

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.

Acute syphilitic necrotizing retinitis associated with placoid chorioretinitis in an immunocompetent patient.

PURPOSE: We report an atypical case of combined acute syphilitic necrotizing retinitis and a contiguous acute syphilitic posterior placoid chorioretinitis (ASPPC) in an HIV-negative, immunocompetent patient. METHOD: Observational case report. RESULTS: A 56-year-old male presented with a one-week history of pain and blurred vision in the left eye. He also complained of left-sided hearing loss for several months. Ocular examination demonstrated a unilateral panuveitis with a yellowish placoid macular lesion involving the outer retina contiguous with an ovoid area of full-thickness retinitis extending temporally. Vitreal polymerase chain reaction (PCR) analysis for HSV, CMV, VZV and T. gondii were negative but syphilis serology was reported as positive. An MRI of the head revealed bilateral enhancement along the facial nerves, more marked on the left side, consistent with syphilitic involvement. He was treated as neurosyphilis with a 14-day course of systemic procaine penicillin and oral probenecid. Oral prednisolone (1 mg/kg/day) was commenced 24 hours prior to initiating antibiotics to prevent Jarisch-Herxheimer reaction and treat his panuveitis. CONCLUSION: To our knowledge, this is the first report of combined syphilitic necrotizing retinitis and ASPPC occurring in continuity in the same eye. This case highlights the diversity of possible presentations of ocular syphilis, even in HIV-negative immunocompetent patients.

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.

Surgical Grade and Repeat Laser Peripheral Iridotomy Procedures with Risk Stratification and Educational Considerations.

BACKGROUND/AIMS: Peripheral laser iridotomy (PLI) is a commonly performed procedure. While effective, repeat procedures (RPs) may be required for a variety of causes. We report the causes and rate of RP PLI and whether surgical grade is a risk factor. METHODS: Two years of retrospective data from 282 patients who had undergone PLI at a single UK ophthalmology department were retrieved using an electronic medical record system (Medisoft, Leeds, UK). RESULTS: A total of 253 patients underwent analysis with 20 requiring RPs. Our data identified a correlation between experience of the operating surgeon and an increase in RP rate, with statistical significance (p=0.036) observed between consultants and registrars. No other statistically significant risk factors were identified from our study. Prescriber preference for iopidine was observed. From our findings and the current literature, prognostic factors that appear to influence RP rate include surgical grade, patient compliance, Asian ethnicity, and anticoagulation. CONCLUSION: RP rate increases in PLI when a junior surgeon is performing the procedure, and thus cases with established prognostic factors for RPs should have senior input. Formal and standardized YAG-laser training should be implemented alongside risk stratification of patients to improve both trainee education and patient care.

Smart phone ophthalmoscopy: a potential replacement for the direct ophthalmoscope.

PURPOSE: The purpose of this study is to evaluate a commercially available smartphone ophthalmoscope, D-EYE, as compared with the direct ophthalmoscope when used by a cohort of final-year medical students in a prospective study. METHODS: Two-hundred fundal examinations were performed on the eyes of 10 mannequins featuring 5 unique fundal images by 20 final-year medical students from Newcastle University. Each student examined the five fundal images twice, once each with a direct ophthalmoscope and D-EYE in a random order. Students recorded their findings at the optic nerve, macula, and retina in an objective questionnaire, and the findings were analysed by an observer masked to the examination technique. RESULTS: Students provided more accurate clinical descriptions of their findings when using D-EYE as opposed to using the direct ophthalmoscope (p < 0.05). In addition, we found that students were overall more likely to make a correct diagnosis based on their findings when using D- EYE compared with the direct ophthalmoscope. CONCLUSION: Our study suggests that the use of a smartphone-based alternative to the direct ophthalmoscope may improve the accuracy and quality of fundal examinations by non-ophthalmologists.

Bilateral Birdshot Retinochoroiditis and Retinal Astrocytoma.

Background. This case highlights the importance of recognising multiple pathologies within the eye which may not necessarily be linked. Both birdshot retinochoroiditis and astrocytoma are rare conditions. The case underlines the need for early identification and treatment of birdshot retinochoroiditis with steroids and disease modifying drugs. Astrocytoma in the absence of tuberous sclerosis is also uncommon. Case Presentation. A 36-year-old male presented with 3-month history of bilateral progressive flashing lights and floaters. He was systemically well with no significant past medical history. Fundal examination revealed retinal vasculitis and active creamy lesions in the choroid radiating from the optic nerve. In the supranasal periphery of the right eye there was a raised white, jagged lesion protruding into the vitreous. Fluorescein angiogram and indocyanine green showed marked venous vasculitis, hypofluorescence, and disc leakage in keeping with birdshot retinochoroiditis. The supranasal lesion features were in keeping with astrocytoma and this was thought to be a coincidental finding. Conclusions. Retinal astrocytoma may be present as an isolated ocular finding; however, patients must still be investigated for tuberous sclerosis which is the most common association. Birdshot retinochoroiditis typically responds well to steroid therapy, and disease modifying drugs should be considered as soon as possible.

Optimizing Medical Management in Patients with Sight-Threatening Diabetic Retinopathy.

INTRODUCTION: Diabetic retinopathy is a leading cause of blindness in adults of working age. Patients with sight-threatening diabetic retinopathy (STDR) often have poor control of modifiable risk factors, including blood pressure and blood glucose. Patients in our eye department with STDR whose diabetes was managed only by their general practitioner (GP) were referred to a diabetes specialist. We have reviewed these referrals and assessed the control of modifiable risk factors in these patients at the time of referral. METHODS: A retrospective study was performed which identified 54 patients with STDR who had been referred from our eye department to a diabetes specialist between May 2013 and August 2014. Patient demographics, grades of retinopathy, glycated hemoglobin (HbA1c) levels, blood pressure, and lipid profiles were noted from the initial clinic visit and the first clinic appointment after 12 months. Initial management and any subsequent changes to management were recorded. RESULTS: Of the 54 patients initially referred to the dedicated diabetic retinopathy clinic, data from 32 patients were available for analysis; 22 patients failed to attend the clinic. The majority of patients who presented to the clinic were found to have inadequate control of modifiable risk factors. At the initial clinic visit, nine of the 32 (28%) patients had a blood pressure that was less than the target of 130/80 mmHg and only two (6%) had a HbA1c level of less than the target of 48 mmol/L for type 2 diabetes and 58 mmol/L for type 1 diabetes, respectively. Changes were made to the management in 24 (75%) of the patients. Blood pressure management was changed in 18 (56%) patients. Overall, changes were made to blood pressure management and lipid and glycemic medication, including insulin. CONCLUSION: The majority of patients with STDR were receiving suboptimal medical management. Collaboration between GPs, diabetes specialists, and ophthalmologists can lead to optimized medical management. All eye departments should develop protocols specifying when patients with diabetic retinopathy should be referred for to a diabetes specialist for input.