PHACOVITRECTOMY FOR PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT REPAIR: A Retrospective Review.

PURPOSE: To analyze the single surgery success rate and anterior segment complications related to phacoemulsification and intraocular lens implantation in a series of patients undergoing phacovitrectomy for all types of primary rhegmatogenous retinal detachment. METHODS: We performed a retrospective interventional case series on 302 eyes undergoing phacovitrectomy for primary rhegmatogenous retinal detachment repair between November 1, 2016, and February 2, 2019, in Edmonton, Canada. Primary outcomes included single surgery retinal reattachment rate and anterior segment complications. Secondary outcomes included the effects of proliferative vitreoretinopathy and macula and/or peripheral internal limiting membrane peeling on the rate of surgical success. RESULTS: The single surgery success rate of phacovitrectomy for all types of primary rhegmatogenous retinal detachment was 85.1%. The presence of proliferative vitreoretinopathy was associated with lower surgical success (odds ratio, 0.33; P = 0.01). Macular internal limiting membrane peeling was associated with higher surgical success (odds ratio, 2.4; P = 0.05). Anterior segment complications included posterior capsular opacification (28.8%), posterior synechiae (10.9%), and posterior capsular rupture (2.3%). CONCLUSION: Phacovitrectomy is a safe and effective treatment option for the primary repair of rhegmatogenous retinal detachments. This study provides evidence to support the safe incorporation of phacoemulsification and intraocular lens implantation with retinal surgery.

An evaluation of Alberta retina health service delivery in an office setting: a cross-sectional survey of patient experience.

BACKGROUND: Retina sub-specialists provide much of the retina related eye care across Canada. In the province of Alberta, 18 retina sub-specialists work across six different offices. The purpose of this study was to assess the quality of care provided by Alberta retina sub-specialists in an office setting by administering a patient satisfaction survey. The results of this survey were provided to the same retina specialists to promote improvements in patient-centered health care delivery. METHODS: A cross sectional patient satisfaction survey was performed using a thirty-part questionnaire developed in collaboration with the Physician Learning Program at the University of Alberta. The survey was modelled after other similar patient satisfaction surveys used in other areas of medicine. Patients from ten of the eighteen retina practices in Alberta participated in this survey. Topics of the survey included pre-appointment experience, physician-patient interactions and quality, comments/ feedback and patient demographics. RESULTS: 214 randomly sampled patients completed the survey from three geographically separate office locations in Calgary and Edmonton. 90% of patients responded that their retina sub-specialist listened adequately and provided quality care in a timely manner. Patients felt that there could be improvements to accessibility to the clinic and reduced wait times, as well as in the pre-operative consent process. Including a more complete explanation of the procedure as well as the potential risks and benefits. Only 51% of patients felt that the risks of a potential surgery had been adequately explained to them. There was a statistically significant association found between overall satisfaction and lower wait times, understanding of procedural risks and time with, listening to and involving the patient in care. There were no correlations found with other demographics such as ethnicity, sex, distance traveled or age. CONCLUSIONS: This patient satisfaction survey provided valuable patient care feedback to the retina sub-specialists of Alberta. The survey results will assist this group to improve the consent process and thereby improve patient centered health care delivery. We would recommend the distribution of this survey or other similar patient satisfaction questionnaire by retina sub-specialists to their patients to improve patient centered care in their clinics.

VITRECTOMY WITH SUBRETINAL TISSUE PLASMINOGEN ACTIVATOR AND GAS TAMPONADE FOR SUBFOVEAL HEMORRHAGE: Prognostic Factors and Clinical Outcomes.

PURPOSE: To study the prognostic factors and clinical outcomes of patients who underwent pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and gas tamponade for the treatment of subfoveal hemorrhage (SFH). METHODS: A retrospective noncomparative interventional case series. RESULTS: Seventy-eight eyes from 77 patients were included. A total of 84.6% of eyes developed SFH from age-related macular degeneration. Partial or complete displacement of the SFH was achieved in 91.5% of eyes within 2 months of surgery. Visual acuity improved from 20/1,449 preoperatively to 20/390 after a mean follow-up time of 6.3 months, corresponding to approximately 5 lines of Snellen acuity improvement (P < 0.001). Better visual acuity was associated with the absence of age-related macular degeneration (P = 0.02) and less hemorrhage superior to the fovea (P < 0.001). Final visual acuity was not associated with the area of SFH (P = 0.17), use of anticoagulants (P = 0.14), or visibility of the ellipsoid layer by optical coherence tomography (P = 0.64). Nine patients (11.5%) developed a recurrence of SFH within the follow-up period. Recurrence of SFH was not associated with concurrent anticoagulant therapy (P = 0.52). CONCLUSION: An etiology other than age-related macular degeneration with less hemorrhage superior to the fovea predicts a better outcome in patients with SFH treated with pars plana vitrectomy, subretinal tissue plasminogen activator, and gas tamponade.

Success Rates for Retinal Detachment Repair in Alberta: A Physician Learning Program Initiative.

OBJECTIVE: To identify primary surgical success rates for retinal detachment repair in Alberta and compare functional outcomes of methods of repair. METHODS: Data was retrospectively extracted from the Alberta Health Services Discharge Abstract Database and the National Ambulatory Care Reporting System for all patients diagnosed with retinal detachment and vitreoretinal procedures during the 2008/09 to 2012/13 fiscal years. RESULTS: Of the 5,433 surgeries for retinal detachment identified, 279 were excluded due to invalid provincial health numbers, unidentified procedure location, and/or treating physician other than an Alberta retina surgeon. The final analysis included 4,336 detachments in 4,020 patients. The average primary retinal detachment success rate was 84.9% (3,680/4,336). Primary success rates varied between vitrectomy only (84.9%, 2,149/2,532), vitrectomy and scleral buckle (85.5%, 818/957), and scleral buckle (84.4%, 702/832). CONCLUSIONS: Alberta retina surgeons have an average primary success rate of 84.9% (3,680/4,336) for repair of retinal detachments. This result is in keeping with other published retinal detachment success rate studies.

LONG-TERM OUTCOMES FOR OPTIC DISK PIT MACULOPATHY AFTER VITRECTOMY.

PURPOSE: To evaluate the efficacy of pars plana vitrectomy for congenital optic disk pit maculopathy with various adjuvant techniques, including gas tamponade, internal limiting membrane peel, and temporal optic disk endolaser in a multicenter study with long-term follow-up. METHODS: A retrospective chart review was performed to identify eyes that underwent surgical repair for congenital optic disk pits and serous macular detachment with or without macular retinoschisis from four retinal centers across Canada from 2003 to 2013. Data collected included surgeries performed, preoperative and postoperative vision, central retinal thickness, and presence or absence of subretinal fluid. Optical coherence tomography was used to define anatomical success (i.e., foveal reattachment). RESULTS: Thirty-two eyes of 32 patients with optic disk pits and serous macular detachments were identified that had undergone surgical repair. All eyes underwent pars plana vitrectomy and induction of posterior vitreous detachment if one was not present. Additional procedures performed on occasion included internal limiting membrane peel (n = 8), temporal optic disk pits endolaser (n = 7), and gas tamponade (air, C3F8 or SF6; n = 31). After vitrectomy surgery, foveal attachment was achieved in 26 of 32 eyes (81.3%). The average number of surgeries required was 1.4 ± 0.6, with a maximum of 3 vitrectomies (n = 2). Mean change in best-corrected visual acuity was -0.47 ± 0.54 logMAR units, which corresponds to approximately 5 lines of visual improvement (P < 0.001). Median time to reattachment was 416 days. Preoperative vision, preoperative symptom days, and age were not associated with postoperative reattachment. Similarly, internal limiting membrane peel and temporal endolaser were not associated with postoperative reattachment, nor was there a difference between air and SF6 and C3F8 gas tamponade. Elevated preoperative central retinal thickness was associated with a lower chance of postoperative reattachment (P = 0.007) and was also the best prognostic indicator of success (P = 0.039). CONCLUSION: Vitrectomy for macular detachment due to optic disk pit has good long-term success and results in an improvement in visual acuity. However, adjuvant techniques such as internal limiting membrane peel and temporal endolaser may not improve outcomes, nor does there seem to be a difference between short- and long-acting gases. Patients should be made aware that it can take more than a year and multiple surgeries to achieve foveal reattachment and that increased baseline central retinal thickness is a poor prognostic sign.

Comparison of Endophthalmitis Rates after Alcohol-Based Chlorhexidine and Povidone-Iodine Antisepsis for Intravitreal Injections.

OBJECTIVE: Intravitreal injections (IVIs) are the most frequently performed intraocular procedure in Canada. Povidone-iodine (PI) is the current gold standard for antisepsis for IVI and is widely used; chlorhexidine (CH) is a possible alternative antiseptic agent. This study aims to compare rates of endophthalmitis after IVI with 0.05% chlorhexidine with a 4% alcohol base antisepsis to rates of endophthalmitis after IVI with 10% PI antisepsis. DESIGN: Retrospective cohort study. SUBJECTS: Eyes that received IVI between May 2019 and October 2022 at a group retina practice in Edmonton, Canada. METHODS: Eyes at a single center received focal conjunctival application of either 10% PI antisepsis or 0.05% CH in 4% alcohol antisepsis for 30 seconds before each IVI. MAIN OUTCOME MEASURE: Rates of endophthalmitis between the PI and CH groups. RESULTS: A total of 170 952 IVIs were performed during the study period. A total of 31 135 were performed using CH prophylaxis compared with 139 817 with PI prophylaxis. Among all IVIs there were 49 total cases of endophthalmitis, 29 in the PI group (0.021%) and 20 in the CH group (0.064%). There was a statistically significant difference in the rates of endophthalmitis between the 2 groups (P < 0.001). The odds ratio for developing endophthalmitis with CH antisepsis was 3.1 (95% confidence interval, 1.9-5.2) compared with PI antisepsis. There were increased odds of developing endophthalmitis with aflibercept injection compared with bevacizumab (odds ratio, 3.48; 95% confidence interval, 2.09-7.24). CONCLUSIONS: There is a statistically significant difference in rates of endophthalmitis between alcohol-based CH and PI antisepsis for IVI in our patient population utilizing the methods discussed. In our center, alcohol-based CH is now considered a second-line antiseptic agent. Further studies are warranted to further assess the endophthalmitis rate utilizing these 2 antiseptic agents. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Dismantling sociocultural barriers to eye care with tele-ophthalmology: lessons from an Alberta Cree community.

PURPOSE: There are significant disparities in access to health care amongst Aboriginal Canadians. The purpose of this study was to determine whether tele-ophthalmology services, provided to Aboriginal Canadians in a culturally-sensitive community-based clinic, could overcome social and cultural barriers in ways that would be difficult in the traditional hospital-based setting. METHODS: The Aboriginal Diabetes Wellness Program of Alberta incorporates culturally-sensitive health-related activities and rituals as a component of a diabetic retinopathy tele-ophthalmology screening program. Metrics of program attendance were collected while stakeholders participated in a survey to identify barriers to healthcare delivery. RESULTS: Aboriginal patients, cultural liaison, nurses and program administrators revealed economic, geographic, social and cultural barriers to healthcare faced by Aboriginal people. It was found that the introduction of culturally-sensitive programs led to increased appointment attendance; from 25% to 85%. Involvement of Aboriginal nurses, inclusion of culturally-sensitive activities and participation in spiritual ceremonies led to qualitative accounts of increased patient satisfaction, trust towards the healthcare team and communication amongst participants. CONCLUSIONS: A culturally-sensitive model of healthcare delivery in a community-based health clinic improved access to tele-ophthalmology services. This was demonstrated by increased attendance at appointments and increased satisfaction amongst patients.

Decrease in Anti-VEGF Injections After Post-injection Endophthalmitis in Patients With Neovascular Age-Related Macular Degeneration.

Introduction: To evaluate the effect of antivascular endothelial growth factor (anti-VEGF)-related endophthalmitis on intravitreal injection (IVI) frequency in patients with neovascular age-related macular degeneration (nAMD). Methods: A retrospective chart review was performed of all cases of post IVI endophthalmitis that occurred in Edmonton, Alberta, Canada, between 2012 and 2019. Contralateral eyes affected by nAMD but without endophthalmitis served as a control group. The main outcome measures were the frequency of anti-VEGF injections, visual acuity, and activity of choroidal neovascularization before and after endophthalmitis. Results: Seventeen eyes met the inclusion criteria, 2 (12%) of which never resumed IVI after endophthalmitis because of the quiescence of disease. Post-endophthalmitis eyes received IVI less frequently in the 1 year after endophthalmitis (mean 0.52 ± 0.42 IVI/month) than those that received IVI 1 year before endophthalmitis (1.09 ± 0.36 IVI/month) (P = .001). The 17 contralateral eyes also received anti-VEGF injections less frequently after endophthalmitis than before (P = .001). There was no significant change in optical coherence tomography markers of disease activity in cases or controls. Conclusions: In patients with nAMD, endophthalmitis resolution is associated with a decrease in anti-VEGF injection frequency. The same decrease in anti-VEGF injection frequency is also seen in contralateral eyes unaffected by endophthalmitis. Markers of disease activity remain unchanged in both eyes, suggesting disease quiescence despite reduced IVI frequency.

Outcomes of Combined Scleral Buckling Plus Pneumatic Retinopexy Vs. Scleral Buckling for Primary Rhegmatogenous Retinal Detachment.

PURPOSE: To evaluate the outcomes and complications of scleral buckle surgery alone or combined with pneumatic retinopexy (pneumatic buckle) for the treatment of primary rhegmatogenous retinal detachment. DESIGN: Retrospective chart review. PARTICIPANTS: Two hundred thirteen patients with rhegmatogenous retinal detachment of whom 101 underwent primary scleral buckle surgery at Rabin Medical Center in 2005-2015 (SB group) and 112 underwent pneumatic buckle surgery at Royal Alexandra Hospital in 2013-2015 (PB group). METHODS: All patients were followed for ≥12 months. Data on clinical and surgical parameters, outcome, and complications were collected from the medical files. MAIN OUTCOME MEASURES: Best corrected visual acuity and anatomical outcomes. RESULTS: At 12 months, average best corrected visual acuity was 0.3 logMar in the SB group and 0.42 logMar in the PB group (P < 0.05). Rates of anatomical reattachment were high and similar in the two groups (99% and 97%, respectively, P = 0.623). The SB group had a higher percentage of patients requiring additional laser applications (21% vs. 7%; P < 0.01) and buckle readjustment surgery (6% vs. 0; P = 0.01), and the PB group had a higher percentage of patients who required postoperative pars plana vitrectomy (30% vs. 17%; P = 0.03). CONCLUSION: Scleral buckle surgery alone is efficient for the treatment of rhegmatogenous retinal detachment. Its combination with pneumatic retinopexy usually has no significant added value in terms of anatomical reattachment rate. Outcomes of Pneumatic buckling vs Scleral Buckling for RRD.

Prevalence and severity of diabetic retinopathy in Northwest Cameroon as identified by teleophthalmology.

OBJECTIVE: Diabetic retinopathy is a common ocular complication of diabetes mellitus, which can lead to significant visual impairment. The present study is the first to characterize the prevalence and severity of diabetic retinopathy and other ocular pathologies in a population of patients with diabetes who live in Northwest Cameroon using teleophthalmology. MATERIALS AND METHODS: A retrospective review of the electronic charts of patients at the Banso Baptist Hospital and in neighboring communities between July 1, 2007 and June 30, 2008 was completed. The eyes of 253 consecutive patients with diabetes mellitus who attended mobile teleophthalmology clinics in Northwest Cameroon were included in the study. Eyes were graded for diabetic retinopathy using stereoscopic seven-field digital retinal images obtained by a mobile team in Cameroon and graded by ophthalmologists in Canada utilizing Early Treatment Diabetic Retinopathy Study criteria. RESULTS: Diabetic retinopathy was identified in 20.6% of eyes (18.2% nonproliferative, 2.4% proliferative) and in 24.3% of patients. About 8.0% of eyes demonstrated evidence of macular edema. Additional nondiabetes-related ocular pathologies were identified in 14.6% of eyes. CONCLUSIONS: Diabetic retinopathy was found to be common in people with diabetes who attended teleophthalmology clinics in Northwest Cameroon. The prevalence of treatable disease including macular edema and retinal neovascularization suggests that improved patient access to laser photocoagulation and vitreoretinal surgery would be beneficial in reducing vision loss in this vulnerable population. As the prevalence of diabetes increases across sub-Saharan Africa, the challenge of diagnosing and managing the complications of diabetes will increase.

Intravitreal bevacizumab alone versus combined verteporfin photodynamic therapy and intravitreal bevacizumab for choroidal neovascularization in age-related macular degeneration: visual acuity after 1 year of follow-up.

PURPOSE: The purpose of the study was to compare the mean change in visual acuity between bevacizumab and combined bevacizumab and photodynamic therapy for the treatment of choroidal neovascularization from age-related macular degeneration after 12 months of follow-up. METHODS: This study included a retrospective cohort of patients with untreated choroidal neovascularization. The generalized estimating equation was used to account for the correlation between eyes and to construct multivariate models to control for confounding factors of visual acuity change. RESULTS: One hundred and thirty-nine eyes treated with bevacizumab were compared with 236 eyes that received bevacizumab and photodynamic therapy (combination treatment). The monotherapy eyes showed an improvement of 0.101 +/- 0.619 logarithm of minimum angle of resolution units (5.05 letters) after a mean follow-up of 409.6 days versus 0.096 +/- 0.611 (4.8 letters) after a mean follow-up of 416.7 days with combination therapy; there was no difference between the groups (P = 0.970). The monotherapy eyes received 3.32 +/- 1.71 injections versus 3.14 +/- 1.52 injections in the combination therapy group (P = 0.665). The multivariate analysis did not show any difference between groups at the end of the study period in terms of visual improvement, worsening, stabilization, or the number of bevacizumab injections used. CONCLUSION: Long-term visual outcomes for the treatment of choroidal neovascularization in age-related macular degeneration are not improved with the addition of photodynamic therapy to bevacizumab nor are fewer injections needed.

Diffuse Pigmented Lesions in the Outer Retina: An Unusual Fundus Appearance.

Purpose: This report describes and provides a differential diagnosis for a patient with unusual bilateral retinal pigmented lesions. Methods: A 40-year-old woman was found to have multiple flat, gray lesions scattered across her fundi, becoming larger and more confluent toward the periphery. There were small drusenlike deposits in her foveae. The hyperpigmented lesions demonstrated hypoautofluorescence with thickening of the retinal pigment epithelium and disruption of the overlying layers on optical coherence tomography (OCT). Full-field electroretinography revealed generalized reduced a- and b-wave amplitudes. Results: Chest x-ray, breast ultrasound, mammography, and pelvic ultrasound findings were negative for malignant etiologic factors. Panel testing results for hereditary retinal dystrophy were negative. Conclusions: Although the clinical and OCT appearance of the lesions is similar to congenital grouped pigmentation, the symmetric and bilateral nature of ocular findings coupled with electroretinographic changes suggest a possible retinal dystrophy. This case adds to the phenotypic diversity of pigmented fundus lesions.

Distinguishing Central Serous Chorioretinopathy From Neovascular Age-Related Macular Degeneration: A Prospective Study.

Purpose: This article identifies clinical features that differentiate central serous chorioretinopathy (CSR) from neovascular age-related macular degeneration (nAMD) and uses this information to develop a diagnostic tool. Methods: A prospective observational study was conducted of patients with a new diagnosis of CSR, nAMD, or indeterminate presentation. All patients underwent clinical assessment, axial length measurement, enhanced-depth imaging-optical coherence tomography, and intravenous fluorescein angiography. A final consensus diagnosis was derived following review of these factors. Results: A total of 56 eyes of 56 patients were enrolled (CSR = 34; nAMD = 22). The subfoveal choroidal thickness was greater in the CSR group (421 ± 106 µm) than the nAMD group (219 ± 91 µm, P < .001). The following odds ratio of CSR reached statistical significance: age 70 and younger (72.00, 95% CI: 11.99-432.50), subfoveal choroidal thickness greater than or equal to 300 µm (33.92, 95% CI: 4.06-283.18), dome-shaped neurosensory detachment (13.24, 95% CI: 3.22-54.45), retinal pigment epithelial changes (0.31, 95% CI: 0.10-0.97), subretinal hyperreflective material (0.11, 95% CI: 0.03-0.42), and fibrovascular pigment epithelial detachment (0.05, 95% CI: 0.01-0.47). A stepwise CSR vs nAMD clinical decision-making algorithm is proposed. Conclusions: Choroidal thickness is increased in CSR when compared with nAMD. The presented odds ratios and the CSR vs nAMD clinical decision-making tool can be applied to distinguish CSR from nAMD.

A retrospective cohort study of radial optic neurotomy for severe central retinal vein occlusions.

BACKGROUND: Radial optic neurotomy (RON) is a new surgical procedure that has, until now, been studied only in a case series format. This study was designed to evaluate the efficacy of RON in improving visual acuity in patients suffering from central retinal vein occlusion (CRVO) with visual acuity equal to or worse than 20/100. METHODS: A retrospective cohort study was conducted of consecutive CRVO patients, consisting of 19 who underwent RON and 38 observation subjects matched on presenting visual acuity. RESULTS: The observation group worsened by 0.25 logMAR units from baseline, whereas the surgery group improved by 0.29 logMAR. Multivariate linear regression modelling found that, having controlled for other significant predictors and confounders, the change in visual acuity in the surgery patients was 0.63 logMAR units better than in the observation patients. INTERPRETATION: Our data suggest that RON is a promising treatment for visual acuity loss in severe CRVO causing visual acuity equal to or worse than 20/100. These results should be interpreted cautiously because of the limitations of the study, including the retrospective study design and the use of Snellen visual acuity. Our data suggest that further evaluation of RON is warranted.

Optometric referrals to retina specialists: evaluation and triage via teleophthalmology.

A retrospective noncomparative consecutive case series was conducted to evaluate the clinical outcomes of a novel teleophthalmology program linking optometrists to retina specialists in Alberta, Canada. One hundred seventy-one patients, referred by optometrists via teleophthalmology to a group retina practice between June 2004 and May 2006 underwent stereoscopic, mydriatic digital photography. Images were transmitted to a secure Web server and analyzed by a retina specialist. Diagnosis and recommendations were sent back to the optometrist and, if necessary, patients were referred for additional testing and clinical evaluation. A chart review of all clinical encounters was performed and the data was tabulated. Demographic features, diagnosis, testing, treatment, distance and time traveled by patient, durations between telemedicine referral, teleophthalmology consultation, in-person consultation, testing, and treatment were recorded. One hundred seventy patients were assessed via teleophthalmology for a total of 190 consultations. Eighty-nine patients (52.0%) required conventional in-person consultation with a referral completion success of 92.1% (82 patients). Fifty of these patients underwent additional diagnostic testing including fluorescein angiography (41), optical coherence tomography (14), laboratory testing (5), visual fields (2), carotid Doppler ultrasound (2), and ocular ultrasound (2). Twenty-five patients required surgical or medical treatment including focal argon laser (10), photodynamic therapy (8), panretinal photocoagulation (2), vitrectomy (2), scleral buckle (1), and other procedures (8). Average wait time between telemedicine referral and teleophthalmology review of images by the retina specialist was 1.9 days (maximum = 20 days). For those patients requiring office evaluation, the average wait time between teleophthalmology referral and in-person evaluation was 25.1 days. Twenty-one of the 25 patients (84.0%) requiring treatment underwent examination, testing, and treatment in a single day. When compared to conventional consultation methods, teleophthalmology reduced average travel distance and time by 219.1 km and 2.7 hours, respectively. Teleophthalmology reduced office visits to the retina specialist by 48% while improving the efficiency of clinical examination, testing, and treatment. Patients benefited through reduced travel time and distance.

Deep learning in ophthalmology: a review.

Deep learning is an emerging technology with numerous potential applications in Ophthalmology. Deep learning tools have been applied to different diagnostic modalities including digital photographs, optical coherence tomography, and visual fields. These tools have demonstrated utility in assessment of various disease processes including cataracts, glaucoma, age-related macular degeneration, and diabetic retinopathy. Deep learning techniques are evolving rapidly, and will become more integrated into ophthalmic care. This article reviews the current evidence for deep learning in ophthalmology, and discusses future applications, as well as potential drawbacks.

Review of economic evaluations of teleophthalmology as a screening strategy for chronic eye disease in adults.

BACKGROUND/AIMS: Teleophthalmology is well positioned to play a key role in screening of major chronic eye diseases. Economic evaluation of cost-effectiveness of teleophthalmology, however, is lacking. This study provides a systematic review of economic studies of teleophthalmology screening for diabetic retinopathy (DR), glaucoma and macular degeneration. METHODS: Structured search of electronic databases and full article review yielded 20 cost-related articles. Sixteen articles fulfilled the inclusion criteria and were retained for a narrative review: 12 on DR, 2 on glaucoma and 2 on chronic eye disease. RESULTS: Teleophthalmology for DR yielded the most cost savings when compared with traditional clinic examination. The study settings varied among urban, rural and remote settings, community, hospital and health mobile units. The most important determinant of cost-effectiveness of teleophthalmology was the prevalence of DR among patients screened, indicating an increase of cost savings with the increase of screening rates. The required patient pool size to be screened varied from 110 to 3500 patients. Other factors potentially influencing cost-effectiveness of teleophthalmology were older patient age, regular screening and full utilisation of the equipment. Teleophthalmology for glaucoma was more cost-effective compared with in-person examination. Similarly, increasing number of glaucoma patients targeted for screening yielded more cost savings. CONCLUSIONS: This economic review provides supportive evidence of cost-effectiveness of teleophthalmology for DR and glaucoma screening potentially increasing screening accessibility especially for rural and remote populations. Special selection of the targeted screening population will optimise the cost-effectiveness of teleophthalmology.

Two-Year Results After AAV2-Mediated Gene Therapy for Choroideremia: The Alberta Experience.

PURPOSE: To assess the safety of a recombinant adeno-associated viral vector expressing REP1 (rAAV2.REP1) in choroideremia subjects. METHODS: Design: Phase I clinical trial. PARTICIPANTS: Six adult male subjects, 30-42 years of age, with genetically confirmed choroideremia (CHM) were enrolled. The eye with the worse vision, for all subjects, received a single subfoveal injection of 0.1 mL rAAV2.REP1 containing 1011 genome particles. Subjects were followed up for 2 years thereafter. OUTCOME MEASURES: The primary outcome measure was safety, determined by the number of ocular and systemic adverse events assessed by ophthalmic examination, spectral-domain optical coherence tomography (SD-OCT), and short-wavelength autofluorescence (FAF). Secondary outcome measures were the change from baseline in best-corrected visual acuity (BCVA) in the treated eye compared to the untreated eye, changes in visual function using microperimetry, and the area of retinal pigment epithelium (RPE) preservation by FAF. RESULTS: One subject had an 8-ETDRS-letter BCVA loss from baseline measured at 24 months, while 1 subject had a ≥15-letter BCVA gain. A similar improvement was noted in the untreated eye of another subject throughout the follow-up period. Microperimetry sensitivity showed no improvement or significant change up to 2 years after vector administration. The area of preserved RPE as measured by FAF was noted to decline at a similar rate between the treated and untreated eyes. One subject experienced a serious adverse event: a localized intraretinal immune response, resulting in marked decline in visual function and loss of SD-OCT outer retinal structures. CONCLUSIONS: One serious adverse event was experienced in 6 subjects treated with a subfoveal injection of AAV2.REP1. The area of remaining functional RPE in the treated eye and untreated eye declined at the same rate over a 2-year period. Fundus autofluorescence area is a remarkably predictive biomarker and objective outcome measure for future studies of ocular gene therapy in CHM subjects.

Web-based grading of compressed stereoscopic digital photography versus standard slide film photography for the diagnosis of diabetic retinopathy.

PURPOSE: To evaluate the ability of Joint Photographic Experts Group (JPEG) compressed, stereoscopic, digital photography to identify clinical levels of diabetic retinopathy, detect clinically significant macular edema (CSME), and make appropriate referral recommendations as compared with Early Treatment Diabetic Retinopathy Study (ETDRS) standard film photography. DESIGN: Prospective, clinic-based, comparative photographic format validation study. PARTICIPANTS: Two hundred four eyes from 102 consecutive, new, diabetic patients with a median duration of diabetes of 12.5 years were enrolled and analyzed. METHODS: After pupillary dilation, a trained ophthalmic photographer obtained 2 sets of images: standard ETDRS, stereoscopic 7-field 35-mm film photographs and high-resolution, digital images of the same 7 standard fields (stereoscopic images of fields 1 and 2). Two masked readers graded both sets of images. The 35-mm film photographs were graded by hand using a written template. Digital photographs were compressed, uploaded to a web site, and graded by a web-based, computer-assisted ETDRS algorithm. The ETDRS level of diabetic retinopathy, presence of retinal thickening, and referral recommendation based on these 2 diagnoses were recorded and compared. MAIN OUTCOME MEASURES: The presence of CSME, ETDRS level of diabetic retinopathy, and referral threshold diabetic retinopathy. RESULTS: Film and compressed digital grading levels were compared using a simplified ETDRS categorization scheme. Film and digital gradings were highly correlated with exact agreements for level of diabetic retinopathy, CSME, and referral thresholds >87% and kappa levels >0.71. McNemar's testing found no statistically significant difference between compressed digital images and film when comparing referral thresholds (defined as the presence of CSME and/or ETDRS level > or = 61; P = 0.76). CONCLUSIONS: A modified ETDRS protocol (stereoscopic images of fields 1 and 2 only) with 16:1 JPEG image compression and computer-assisted ETDRS grading algorithm has excellent reproducibility when compared to standard ETDRS stereoscopic slide-film photography. An internet-based teleophthalmology system can correctly and reliably (kappa = 0.78) identify patients requiring referral for CSME and proliferative diabetic retinopathy (PDR; ETDRS level > or = 61).