Visual fields in glaucoma: Where are we now?

Visual fields are an integral part of glaucoma diagnosis and management. COVID has heightened the awareness of the potential for viral spread with the practice of visual fields modified. Mask artefacts can occur due to fogging of the inferior rim of the trail lens. Fortunately, the risk of airborne transmission when field testing is low. The 24-2c may be useful to detect early disease and the 10-2 more sensitive to detect advanced loss. The SITA faster test algorithm is able to reduce testing time thereby improving clinic efficiency, however, may show milder results for moderate or severe glaucoma. The technician has an important role of supervising the visual field performance to achieve reliable output. Home monitoring can provide earlier detection of progression and thus improve monitoring of glaucoma as well as reduce the burden of in-clinic assessments. Artificial Intelligence has been found to have high sensitivity and specificity compared to expert observers in detecting field abnormalities and progression as well as integrating structure with function. Although these advances will improve efficiency and guide accuracy, there will remain a need for clinicians to interpret the results and instigate management.

Long-term limitations and complications of trans-scleral diode laser cycloablation for refractory glaucoma.

BACKGROUND: Trans-scleral diode laser cycloablation (cyclodiode) is effective in the short-term management of refractory glaucoma where alternative treatments are not feasible. Long-term outcomes of 5-years or more are not well-documented, particularly in relation to intraocular pressure (IOP) control, need for further procedures and complications such as hypotony and phthisis. METHODS: A review was undertaken of patient medical records with refractory glaucoma who underwent cyclodiode at City Eye Centre in Brisbane from 2012 to 2016. Data included sex, age, laterality, type of glaucoma, cyclodiode parameters, number of glaucoma medications, visual acuity and treatment with acetazolamide. Data were analysed using generalised linear modelling and Kaplan-Meier analysis. RESULTS: A total of 54 eyes in 54 patients (29 M:25F) with a mean age of 66 years (range 15-85 years) with a minimum of 5 years follow up were included. The mean number of burns was 23.3 (range 12-40) over 180-270 degrees, mean power per burn was 1967 mW (range 1500-2000 mW), with a mean duration of 1981 ms (1500-2000 ms). The mean pre-treatment IOP was 31.5 mmHg (range 17-56 mmHg) and mean IOP 5 years post-treatment was 16.1 mmHg (2-42 mmHg). The mean number of pre-treatment medications was 3.6 (range 1-6) and 2.7 (range 0-5) 5 years post treatment, including 5 (8.3%) on oral acetazolamide. Complications of cyclodiode were seen in 6 (11.1%) patients, including 3 (5.0%) cases of hypotony, and 2 (3.3%) phthisis. CONCLUSION: Cyclodiode is often utilised for end-stage glaucoma when the IOP is uncontrolled on medical treatment and drainage surgery is not indicated, resulting in long-term reduction of IOP and the number of medications, including acetazolamide. Hypotony and phthisis can be significant complications.

Lessons learned from the development and implementation of a patient-reported outcome and experience measure (POEM) in an Australian glaucoma practice.

BACKGROUND: A patient's perception of how their glaucoma is managed will influence both adherence to their medication and outcome measures such as quality of life. METHODS: Prospective consecutive study using a Glaucoma Patient-reported Outcome and Experience Measure (POEM) modified for an Australian ophthalmic private clinical practice setting. The Australian Glaucoma POEM consists of eight items related to the patient's understanding of the diagnosis and management, acceptability of the treatment, whether they feel their glaucoma is getting worse, interfering with their daily life and concerns regarding loss of vision as well as addressing whether they feel safe under the care of their glaucoma team and how well their care is organised. RESULTS: Two hundred and two patients (M:F 91:111) participated in the study. Mean ± standard deviation for subject age was 69 ± 13 years. Patient's overall perception of their treatment and outcome was favourable. Younger patients felt their glaucoma interfered more with their daily lives and were more worried about losing vision from glaucoma. The greater the number of medications in use, the more they felt their glaucoma was getting worse and that glaucoma interfered with their daily lives. With all other variables accounted for by the multivariate linear model, female patients more strongly agreed that they understood their glaucoma diagnosis and glaucoma management. The patients with a severe visual defect in their worse eye, reported a greater perceived understanding of their glaucoma diagnosis and management and that they felt that glaucoma had a greater interference on their daily life. They were also more concerned about losing vision from glaucoma than their fellow glaucoma patients with less severe or no visual field deficit in the worse eye. CONCLUSIONS: The modified POEM demonstrates potential to capture the concerns of a practice's glaucoma cohort with a view to enhancing the quality of glaucoma care delivered.

Managing corneal foreign bodies in office-based general practice.

BACKGROUND: Patients with a corneal foreign body may first present to their general practitioner (GP). Safe and efficacious management of these presentations avoids sight-threatening and eye-threatening complications. Removal of a simple, superficial foreign body without a slit lamp is within The Royal Australian College of General Practitioners' (RACGP's) curriculum and scope of practice. Knowing the rele-vant procedural skills and indications for referral is equally important. OBJECTIVE: The objective of this article is to provide an evidence-based and expert-based guide to the management of corneal foreign bodies in the GP's office. DISCUSSION: History is key to identifying patient characteristics and mechanisms of ocular injury that are red flags for referral. Examination tech-niques and methods of superficial foreign body removal without a slit lamp are outlined, as well as the procedural threshold for referral to an ophthalmologist.

Trabeculectomy: the limitations for registrar training.

BACKGROUND: Trainee exposure to glaucoma surgery was analysed and outcomes compared with those of consultant cases. DESIGN: Retrospective review was carried out at Princess Alexandra Hospital and Royal Brisbane and Women's Hospital, two major tertiary teaching hospitals in Brisbane, Queensland, Australia. PARTICIPANTS: Two hundred and forty-eight consecutive public patients undergoing primary trabeculectomy surgery between 2003 and 2010. METHODS: The rate of trabeculectomy performed by trainees, the success and complication rates were examined and compared with those of consultant ophthalmologists. MAIN OUTCOME MEASURES: Intraocular pressure was divided into two groups of ≤21 mmHg and ≤15 mmHg and visual field progression. RESULTS: Two hundred and forty-eight primary trabeculectomy cases were performed between 2003 and 2010. Trainees carried out 145 cases (59%), making the rate of trabeculectomy operations 1.1 per trainee per year (16-17 trainees) as compared with 1.6 per trainee per year from 1996 to 2002 at the same institutions. Complications rates in the first postoperative week were similar between consultants and trainees, the most common being wound leak and hyphaema. An intraocular pressure of ≤15 mmHg without the use of topical medications was achieved in 25 out of 50 (50%) glaucoma-interest consultant, 24 out of 53 (45.3%) general consultant and 68 out of 145 (46.9%) trainee cases (P = 0.951). The rate of visual field progression was also statistically similar between trainees and consultants (19.5% and 21.3%), respectively. CONCLUSION: With increasing trainee numbers, the rate of trabeculectomy surgery is declining compared with previous years, with less trainee exposure to trabeculectomy surgery and inability to achieve surgical competency levels.

Incidence of hypotony and sympathetic ophthalmia following trans-scleral cyclophotocoagulation for glaucoma and a report of risk factors.

OBJECTIVE: To report the incidence and risk factors for hypotony and estimate the risk of sympathetic ophthalmia following diode laser trans-scleral cyclophotocoagulation (TSCPC). DESIGN: Retrospective study using data from a private tertiary glaucoma clinic and review of the literature. PARTICIPANTS: Seventy eyes of 70 patients with refractory glaucoma who received TSCPC treatment. METHODS: Review of the records of consecutive patients who underwent TSCPC by a single ophthalmic surgeon and review of the literature. MAIN OUTCOME MEASURES: Hypotony (including phthisis bulbi), sympathetic ophthalmia. RESULTS: Seven eyes (10%; CI 5-19%) developed hypotony and included 4 eyes that developed phthisis. Higher total energy delivered during TSCPC treatment was associated with an increased risk of hypotony: eyes that developed hypotony received a mean total energy of 192.5 ± 73.2 joules, compared to a mean of 152.9 ± 83.2 joules in hypotony-free cases. The risk of sympathetic ophthalmia estimated from a review of the published literature and current series was one in 1512, or 0.07% (CI 0.03%-0.17%). CONCLUSIONS: Total laser energy is one of several risk factors that act in a sufficient component cause-model to produce hypotony in an individual patient. The small sample size precluded inference for other individual putative risk factors but titrating laser energy may help decrease the occurrence of hypotony. The risk of sympathetic ophthalmia calculated from the literature is likely an overestimate caused by publication bias.

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.

Retropupillary iris claw intraocular lens for aphakia.

BACKGROUND: To assess outcomes of the iris claw intraocular lens implanted in the retropupillary position for correction of aphakia without adequate capsular support. DESIGN: Retrospective study of patients consulted at two private practices and a tertiary public hospital clinic in Brisbane, Queensland. SAMPLES: Thirty-two consecutive patients who underwent posterior chamber insertion of the iris claw intraocular lens alone or in combination with other procedure/s by the same consultant ophthalmologist (GL). METHODS: Lens power was calculated using an A-constant of 117.0. MAIN OUTCOME MEASURES: Clinical examination. RESULTS: Thirty-four eyes in 32 patients (23 male, 9 female) were included in the study. Indications for surgery were pseudophakic bullous keratopathy (n = 14), aphakia from previous lens extraction/lensectomy (n = 9), subluxation of intraocular lens (n = 7), cataract extraction (n = 2), explantation of anterior chamber intraocular lens due to uveitis (n = 1) and for Baerveldt tube insertion (n = 1). Follow-up duration ranged from 1 to 68 months. Of the 26 eyes followed for at least 6 months, the final vision improved in 69% (n = 18), remained unchanged in 8% (n = 2) and worsened in 23% (n = 6). Final visual acuity was 6/12 or better in 58% (n = 15). Complications included iris trauma/defect (n = 8), pupil irregularity/ovalization (n = 6), microhyphaema (n = 2) and lens decentration (n = 2). CONCLUSION: Implantation of the iris claw intraocular lens in the retropupillary position is a useful technique for correction of aphakic eyes with sufficient iris support, avoiding the corneal complications of an anterior chamber intraocular lens and the surgical challenge of a sutured posterior chamber intraocular lens.