Tablet-based tests of everyday visual function in a diabetic macular oedema (DME) clinic waiting area: A feasibility study.

PURPOSE: (1) To assess the feasibility of conducting tablet-based vision tests in hospital clinic waiting areas; (2) To test the hypothesis that increasing severity of diabetic macular oedema (DME) is associated with the performance of tablet-based surrogates of everyday tasks and self-reported visual function. METHODS: Sixty-one people with mild (n = 28), moderate (n = 24) or severe (n = 9) DME performed two tablet-based tests of 'real-world' visual function (visual search and face recognition) while waiting for appointments in a hospital outpatient clinic. Participants also completed a tablet-based version of a seven-item, visual-functioning (VF-7) patient-reported outcome measure. Test performance was compared to previously published 99% normative limits for normally sighted individuals. RESULTS: Thirty-four participants (56%; 95% confidence interval [CI] 43%-68%) exceeded normative limits for visual search, while eight (13%; 95% CI 65%-24%) exceeded normative limits for face discrimination. Search duration was significantly longer for people with severe DME than those with mild and moderate DME (p = 0.01). Face discrimination performance was not significantly associated with DME severity. VF-7 scores were statistically similar across DME severity groups. Median time to complete all elements (eligibility screening, both tablet-based tasks and the VF-7) was 22 (quartiles 19, 25) min. Further, 98% and 87% of participants, respectively, reported the search task and face discrimination task to be enjoyable, while 25% and 97%, respectively, reported finding the two tasks to be difficult. CONCLUSIONS: Portable tablet-based tests are quick, acceptable to patients and feasible to be performed in a clinic waiting area with minimal supervision. They have the potential to be piloted in patients' homes for self-monitoring.

COMPARING FUNDUS FLUORESCEIN ANGIOGRAPHY AND SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN THE EVALUATION OF DIABETIC MACULAR PERFUSION.

PURPOSE: To compare fundus fluorescein angiography (FFA) and swept-source optical coherence tomography angiography (SS-OCTA) in the evaluation of macular perfusion in diabetic patients. METHODS: Forty-one eyes (21 diabetic patients) seen at Moorfields Eye Hospital (London) over a 1-month interval underwent color fundus photography, FFA, and SS-OCTA imaging of the capillary superficial plexus using 2 different protocols: 3 × 3 mm and 4.5 × 4.5 mm. Quantitative assessment (foveal avascular zone diameters and area), qualitative analysis (macroscopic and microscopic levels) and Early Treatment Diabetic Retinopathy Study diabetic macular ischemia grading were performed. Artifacts were recorded. Intraclass correlation coefficients and weighted kappa values were calculated. RESULTS: Mean (SD) foveal avascular zone area was 0.695 (0.52) mm on FFA, 0.627 (0.54) mm on SS-OCTA 3 × 3 and 0.701 (0.54) mm on SS-OCTA 4.5 × 4.5 protocol. Intraclass correlation coefficients showed good agreement between FFA and SS-OCTA for both vertical diameter and foveal avascular zone area measurements. The agreement between SS-OCTA 3 × 3 and 4.5 × 4.5 was good for all quantitative measurements. Weighted kappa for diabetic macular ischemia grading showed low to fair agreement between FFA and SS-OCTA, whereas the agreement was good between two different SS-OCTA protocols. CONCLUSION: Swept-source OCTA is a reproducible technique in the assessment of macular perfusion in diabetic patients with special regards to foveal avascular zone analysis. The agreement with FFA is limited especially for diabetic macular ischemia grading. Fundus fluorescein angiography is more sensitive in identifying microaneurysms.

Predicting Visual Acuity by Using Machine Learning in Patients Treated for Neovascular Age-Related Macular Degeneration.

PURPOSE: To predict, by using machine learning, visual acuity (VA) at 3 and 12 months in patients with neovascular age-related macular degeneration (AMD) after initial upload of 3 anti-vascular endothelial growth factor (VEGF) injections. DESIGN: Database study. PARTICIPANTS: For the 3-month VA forecast, 653 patients (379 female) with 738 eyes and an average age of 74.1 years were included. The baseline VA before the first injection was 0.54 logarithm of the minimum angle of resolution (logMAR) (±0.39). A total of 456 of these patients (270 female, 508 eyes, average age: 74.2 years) had sufficient follow-up data to be included for a 12-month VA prediction. The baseline VA before the first injection was 0.56 logMAR (±0.42). METHODS: Five different machine-learning algorithms (AdaBoost.R2, Gradient Boosting, Random Forests, Extremely Randomized Trees, and Lasso) were used to predict VA in patients with neovascular AMD after treatment with 3 anti-VEGF injections. Clinical data features came from a data warehouse (DW) containing electronic medical records (41 features, e.g., VA) and measurement features from OCT (124 features, e.g., central retinal thickness). The VA of patient eyes excluded from machine learning was predicted and compared with the ground truth, namely, the actual VA of these patients as recorded in the DW. MAIN OUTCOME MEASURES: Difference in logMAR VA after 3 and 12 months upload phase between prediction and ground truth as defined. RESULTS: For the 3-month VA forecast, the difference between the prediction and ground truth was between 0.11 logMAR (5.5 letters) mean absolute error (MAE)/0.14 logMAR (7 letters) root mean square error (RMSE) and 0.18 logMAR (9 letters) MAE/0.2 logMAR (10 letters) RMSE. For the 12-month VA forecast, the difference between the prediction and ground truth was between 0.16 logMAR (8 letters) MAE/0.2 logMAR (10 letters) RMSE and 0.22 logMAR (11 letters) MAE/0.26 logMAR (13 letters) RMSE. The best performing algorithm was the Lasso protocol. CONCLUSIONS: Machine learning allowed VA to be predicted for 3 months with a comparable result to VA measurement reliability. For a forecast after 12 months of therapy, VA prediction may help to encourage patients adhering to intravitreal therapy.

PREVALENCE OF FOVEOLAR LUCENCY WITH DIFFERENT GAS TAMPONADES IN SURGICALLY CLOSED MACULAR HOLES ASSESSED BY SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY.

PURPOSE: To evaluate the prevalence of foveolar lucency (FL) in surgically closed macular holes by spectral domain optical coherence tomography. METHODS: One hundred forty-two eyes of 132 patients underwent pars plana vitrectomy, internal limiting membrane peeling, and gas tamponade in a 60-month time frame. Anatomical success and FL rates assessed by spectral domain optical coherence tomography, mean preoperative, and postoperative best-measured visual acuity and surgical details were retrospectively analyzed. RESULTS: Spectral domain optical coherence tomography confirmed closed holes with FL in 33.7% (34/101) of eyes at 1 month, 7.3% (9/123) at 3 months, 4.6% (6/129) at 6 months, and 3% (4/133) at 12 months. Prevalence of FL in closed holes at Month 1 was lower in C3F8-treated eyes (9.5%, 2/21) compared with C2F6 (40.9%, 18/44, P = 0.03) and SF6-treated eyes (38.9%, 14/36, P = 0.05). No differences were observed at Month 3. No differences in best-measured visual acuity change were observed between closed holes with or without FL at Month 1 (-0.14 ± 0.19 vs. -0.11 ± 0.23, P = 0.48) or any of the other time points. CONCLUSION: Temporary FL is a highly prevalent feature in successfully closed macular holes. Eyes treated with C3F8 gas had lower rates of FL at Month 1 than C2F6 and SF6-treated eyes. The presence of FL in closed holes does not seem to have any effect on the visual outcomes.

COMPLIANCE AND ADHERENCE OF PATIENTS WITH DIABETIC MACULAR EDEMA TO INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN DAILY PRACTICE.

PURPOSE: We assessed differences in compliance and adherence (lateness of patients, visual acuity, reasons for abstaining) between patients with diabetic macular edema (DME) and patients with age-related macular degeneration (AMD), both under anti-vascular endothelial growth factor therapy. METHODS: We included 136 patients with DME (36% women, 65 years, 22 visits, 13.9 injections, and 29.9 months of follow-up) and 109 patients with AMD (59% women, 76 years, 20 visits, 14.7 injections, and 22.3 months of follow-up) (minimum follow-up of 12 months and at least 5 injections). We assessed missed appointments (lateness >14 days) and therapy break-offs (lateness >100 days). All delayed patients were called and interviewed for abstaining reasons. RESULTS: Forty-six percent of patients with DME and 22% of patients with AMD had at least one break-off. Thirty-five percent of patients with DME and 50% of patients with AMD were always on schedule. In patients with DME, there was significant correlation (P = 0.017) between the number of break-offs and change of visual acuity. In 60% DME and 38% AMD of break-off cases, visual acuity was worse than the before break-off. The most common reason for abstaining was comorbidities (33% AMD and 20% DME). CONCLUSION: There are significant differences between patients with AMD and DME regarding compliance and adherence, which also affects outcome. Strategies to tie patients with DME to costly intravitreal therapy need to be developed to improve outcomes and efficacy.

Optical Coherence Tomography Features Of Active And Inactive Retinal Neovascularization In Proliferative Diabetic Retinopathy.

PURPOSE: To describe spectral domain-optical coherence tomography features of retinal neovascularization in proliferative diabetic retinopathy and thus to identify novel signs of new vessel activity. METHODS: Retrospective, cross-sectional study. Data were collected over a 9-month period. Spectral domain optical coherence tomography scans were performed over areas of new vessel complexes (NVC) in both the disk and elsewhere, and were qualitatively graded by two masked observers. New vessel complexes activity was determined using clinical and angiographic criteria and correlated with spectral domain optical coherence tomography features. RESULTS: Forty-three eyes of 30 patients with proliferative diabetic retinopathy were included. Sixty-one NVC lesions (neovascularization of the disk-37.7%, neovascularization elsewhere-62.3%) were captured by spectral domain-optical coherence tomography and analyzed. Among them, 63.9% were classified as active and 36.1% as quiescent. Five distinctive features were identified as significantly different between active and quiescent NVC: the presence of vitreous hyperreflective dots in active NVC (P = 0.002) and the presence of epiretinal membrane (P = 0.04), inner retinal tissue contracture (P = 0.03), vitreous invasion (P = 0.02), and protrusion towards vitreous (P = 0.002) in quiescent NVC. CONCLUSION: In this exploratory study, the presence of vitreous hyperreflective dots, epiretinal membrane, inner retinal tissue contracture, vitreous invasion, and vitreous protrusion were identified as distinct signs of disease activity. Such parameters may be useful as a noninvasive imaging modality in eyes undergoing treatment for proliferative diabetic retinopathy.

Optical Coherence Tomography Angiography for Anterior Segment Vasculature Imaging.

PURPOSE: To evaluate the application of an optical coherence tomography angiography (OCTA) system adapted for the assessment of anterior segment vasculature. DESIGN: Cross-sectional, observational study. PARTICIPANTS: Consecutive subjects with normal eyes on slit-lamp clinical examination and patients with abnormal corneal neovascularization. METHODS: All scans were performed using a commercially available AngioVue OCTA system (Optovue, Inc., Fremont, CA) using an anterior segment lens adapter and the split-spectrum amplitude decorrelation angiography algorithm. Each subject underwent scans from 4 quadrants (superior, inferior, nasal, and temporal) in each eye by 2 trained, independent operators. MAIN OUTCOME MEASURES: Analysis of signal strength, image quality, and reproducibility of corneal vascular measurements was performed. RESULTS: In our study of 20 normal subjects (10 men, 10 women; mean age, 25.3±7.8 years), we found good repeatability (κ coefficient, 0.76) for image quality score and good interobserver agreement for vasculature measurements (intraclass coefficient, 0.94). After optimization of the angiography scan protocol, vascular measurements within the regions of interest were compared in the superior versus inferior quadrants (mean vascular loops, 3.34±1.16 vs. 3.12 ± 0.90 [P = 0.768]; segment-to-loop ratio, 4.18±0.71 vs. 4.32±0.87 [P = 0.129]; fractal dimension [Df] value, 1.78±0.06 vs. 1.78±0.06 [P = 0.94]; vascular loop area, 25.9±14.5 vs. 25.9±10.7 × 10(-3) mm(2) [P = 0.21]) and nasal versus temporal quadrant (mean vascular loops, 2.89±0.98 vs. 3.57±0.99 [P < 0.001]; segment-to-loop ratio, 3.94±0.69 vs. 4.55±0.78 [P = 0.897]; Df value, 1.78±0.06 vs. 1.77±0.06 [P = 0.14]; vascular loop area, 29.7±15.7 vs. 22.1±7.1 × 10(-3) mm(2) [P = 0.38]. We then used the established OCTA scanning protocol to visualize abnormal vasculature successfully in 5 patients with various corneal pathologic features, including graft-associated neovascularization, postherpetic keratitis scarring, lipid keratopathy, and limbal stem cell deficiency. CONCLUSIONS: This preliminary study describes a method for acquiring OCTA images of the cornea and limbal vasculature with substantial consistency. This technique may be useful for the objective evaluation of corneal neovascularization in the future.

Automated retinal image analysis for diabetic retinopathy in telemedicine.

There will be an estimated 552 million persons with diabetes globally by the year 2030. Over half of these individuals will develop diabetic retinopathy, representing a nearly insurmountable burden for providing diabetes eye care. Telemedicine programmes have the capability to distribute quality eye care to virtually any location and address the lack of access to ophthalmic services. In most programmes, there is currently a heavy reliance on specially trained retinal image graders, a resource in short supply worldwide. These factors necessitate an image grading automation process to increase the speed of retinal image evaluation while maintaining accuracy and cost effectiveness. Several automatic retinal image analysis systems designed for use in telemedicine have recently become commercially available. Such systems have the potential to substantially improve the manner by which diabetes eye care is delivered by providing automated real-time evaluation to expedite diagnosis and referral if required. Furthermore, integration with electronic medical records may allow a more accurate prognostication for individual patients and may provide predictive modelling of medical risk factors based on broad population data.

Retinal vessel caliber changes in vasculitis.

BACKGROUND: Retinal vasculitis is a potentially sight-threatening inflammation of the retinal vessels, but little is known about the in vivo vascular changes, which occur in affected eyes. The authors therefore sought to measure vessel caliber in eyes with vasculitis. METHODS: Retrospective case-control study. Vasculitis was confirmed using fluorescein angiography. Vessel calibers were measured using validated semiautomated software. RESULTS: There were 21 eyes from 15 patients with vasculitis and 33 control eyes from 21 control subjects. Most cases were diagnosed with idiopathic vasculitis. All had periphlebitis, and one eye also had arteritis. After adjustment for age and gender, mean arteriolar caliber was 143 µm (95% confidence interval [CI], 134-152) in cases and 158 µm (95% CI, 151-165) in controls (P = 0.01). Venular caliber was similar in cases (229 µm; 95% CI, 215-243) and controls (228 µm; 95% CI, 217-234; P = 0.91), whereas arteriole-to-venule ratio was smaller in cases (0.63; 95% CI, 0.60-0.66) compared with controls (0.70; 95% CI, 0.02-0.11; P = 0.004). CONCLUSION: Retinal vasculitis was associated with narrower arteriolar caliber, whereas venular caliber was similar to controls. This resulted in a smaller arteriole-to-venule ratio in eyes with vasculitis.

Characterization of punctate inner choroidopathy using enhanced depth imaging optical coherence tomography.

PURPOSE: To perform qualitative and quantitative analyses of retinal and choroidal morphology in patients with punctate inner choroidopathy (PIC) using enhanced depth imaging optical coherence tomography (EDI-OCT). DESIGN: Cross-sectional, consecutive series. PARTICIPANTS: A total of 2242 patients attending 2 tertiary referral uveitis clinics at Moorfields Eye Hospital were screened; 46 patients with PIC diagnosis were identified, and 35 eyes (35 patients) had clinically inactive PIC had EDI-OCT images that met the inclusion criteria. METHODS: Punctate inner choroidopathy lesions were qualitatively assessed for retinal features, such as (1) focal elevation of the retinal pigment epithelium (RPE), (2) focal atrophy of the outer retina/RPE, and (3) presence of sub-RPE hyperreflective deposits and choroidal features: (a) presence of focal hyperreflective dots in the inner choroid and (b) focal thinning of the choroid adjacent to PIC lesions. Quantitative analyses of the retina, choroid, and choroidal sublayers were performed, and associations with clinical and demographic data were examined. MAIN OUTCOME MEASURES: Prevalence of each lesion pattern and thickness of retinal and choroidal layers. RESULTS: A total of 90 discrete PIC lesions were captured; 46.6% of PIC lesions consisted of focal atrophy of the outer retina and RPE; 34.4% consisted of sub-RPE hyperreflective deposits; and 18.8% consisted of localized RPE elevation with underlying hyporeflective space. Focal hyperreflective dots were seen in the inner choroid of 68.5% of patients, with 17.1% of eyes presenting focal choroidal thinning underlying PIC lesions. By excluding high myopes, patients with "atypical" PIC had reduced retinal thickness compared with patients with "typical" PIC (246.65±30.2 vs. 270.05±24.6 µm; P = 0.04), and greater disease duration was associated with decreases in retinal thickness (r = -0.53; P = 0.01). A significant correlation was observed between best-corrected visual acuity and foveal retinal thickness (r = -0.40; P = 0.03). CONCLUSIONS: In a large series of patients with clinically inactive PIC, one fifth of the lesions analyzed revealed RPE elevation with underlying hyporeflective space, described before as a sign of activity and suggesting subclinical inflammation. Retinal thickness seems to be associated with disease type and duration of disease in non-highly myopic eyes. Improved visualization of the inner choroid using EDI-OCT may allow noninvasive assessment of inflammatory status.

Objective measurement of vitreous inflammation using optical coherence tomography.

PURPOSE: To obtain measurements of vitreous signal intensity from optical coherence tomography (OCT) image sets in patients with uveitis, with the aim of developing an objective, quantitative marker of inflammatory activity in patients with this disease. DESIGN: Retrospective, observational case-control series. PARTICIPANTS: Thirty patients (30 eyes) with vitreous haze secondary to intermediate, posterior, or panuveitis; 12 patients (12 eyes) with uveitis but without evidence of vitreous haze; and 18 patients (18 eyes) without intraocular inflammation or vitreoretinal disease. METHODS: Clinical and demographic characteristics were recorded, including visual acuity (VA), diagnosis, and anatomic type of uveitis. In each eye, the anterior chamber (AC) was graded for cellular activity and flare according to standardized protocols. The presence and severity of vitreous haze were classified according to the National Eye Institute system. Spectral-domain OCT images were analyzed using custom software. This software provided an "absolute" measurement of vitreous signal intensity, which was then compared with that of the retinal pigment epithelium (RPE), generating an optical density ratio with arbitrary units ("VIT/RPE-Relative Intensity"). MAIN OUTCOME MEASURES: Correlation between clinical vitreous haze scores and OCT-derived measurements of vitreous signal intensity. RESULTS: The VIT/RPE-Relative Intensity was significantly higher in uveitic eyes with known vitreous haze (0.150) than in uveitic eyes without haze or in healthy controls (0.0767, P = 0.0001). The VIT/RPE-Relative Intensity showed a significant, positive correlation with clinical vitreous haze scores (r = 0.566, P = 0.0001). Other ocular characteristics significantly associated with VIT/RPE-Relative Intensity included VA (r = 0.573, P = 0.0001), AC cells (r = 0.613, P = 0.0001), and AC flare (r = 0.385, P = 0.003). Measurement of VIT/RPE-Relative Intensity showed a good degree of intergrader reproducibility (95% limits of agreement, -0.019 to 0.016). CONCLUSIONS: These results provide preliminary evidence that OCT-derived measurements of vitreous signal intensity may be useful as an outcome measure in patients with uveitis. If validated in future studies, such measures may serve as an objective, quantitative disease activity end point, with the potential to improve the "signal:noise" ratio of clinical trials in this area, thus enabling smaller studies for the same power. The incorporation of automated vitreous analysis in commercial OCT systems may, in turn, facilitate monitoring and re-treatment of patients with uveitis in clinical practice.

Determinants of non-attendance at face-to-face and telemedicine ophthalmic consultations.

BACKGROUND/AIMS: Evaluation of telemedicine care models has highlighted its potential for exacerbating healthcare inequalities. This study seeks to identify and characterise factors associated with non-attendance across face-to-face and telemedicine outpatient appointments. METHODS: A retrospective cohort study at a tertiary-level ophthalmic institution in the UK, between 1 January 2019 and 31 October 2021. Logistic regression modelled non-attendance against sociodemographic, clinical and operational exposure variables for all new patient registrations across five delivery modes: asynchronous, synchronous telephone, synchronous audiovisual and face to face prior to the pandemic and face to face during the pandemic. RESULTS: A total of 85 924 patients (median age 55 years, 54.4% female) were newly registered. Non-attendance differed significantly by delivery mode: (9.0% face to face prepandemic, 10.5% face to face during the pandemic, 11.7% asynchronous and 7.8%, synchronous during pandemic). Male sex, greater levels of deprivation, a previously cancelled appointment and not self-reporting ethnicity were strongly associated with non-attendance across all delivery modes. Individuals identifying as black ethnicity had worse attendance in synchronous audiovisual clinics (adjusted OR 4.24, 95% CI 1.59 to 11.28) but not asynchronous. Those not self-reporting their ethnicity were from more deprived backgrounds, had worse broadband access and had significantly higher non-attendance across all modes (all p<0.001). CONCLUSION: Persistent non-attendance among underserved populations attending telemedicine appointments highlights the challenge digital transformation faces for reducing healthcare inequalities. Implementation of new programmes should be accompanied by investigation into the differential health outcomes of vulnerable populations.

Choroidal assessment in idiopathic panuveitis using optical coherence tomography.

BACKGROUND: Idiopathic panuveitis is a diagnosis of exclusion that lacks distinguishing features on fluorescein and indocyanine green angiography. Choroidal hypoperfusion or ischaemia has been implicated in panuveitis of different aetiologies. In this study, we use enhanced depth imaging optical coherence tomography (OCT) to examine the choroid and its vasculature in patients with this disease. METHODS: In this retrospective, cross-sectional study, OCT-derived measurements of retinal and choroidal thickness were obtained after manual segmentation using custom software. Choroidal measurements were further subdivided into Haller's large vessel layer (HLVL) and Sattler's medium vessel layer (SMVL), and correlated with clinical parameters. RESULTS: Twenty-one eyes from 21 patients were included. A reduction in hypo-reflective spaces, corresponding to vascular lumens, was observed in HLVL. The mean thickness of both the choroid (233.7 ± 73.3 µm), and HLVL (167.8 ± 53.7 µm), was less than that previously reported for normal eyes. Choroidal thickness expressed as a ratio to retina thickness showed significant correlation to visual acuity (r = 0.58, p = 0.006). This correlation was maintained in the ratio between HLVL and retinal thickness (r = 0.56, p = 0.009), but not in SMVL to retinal thickness (r = 0.352, p = 0.12). CONCLUSIONS: This study reports novel OCT-derived parameters in patients with idiopathic panuveitis. We noted loss of hyporeflectivity in HLVL, and thinning of both HLVL and the choroid as a whole. The observed correlation between visual acuity and the ratio of choroidal to retinal thickness is a strong enhanced depth imaging (EDI)-OCT derived candidate for prospective validation in future studies.

Expansion of patient eligibility for virtual glaucoma clinics: a long-term strategy to increase the capacity of high-quality glaucoma care.

AIMS: The virtual glaucoma clinic (VGC) is a well-established diagnostic pathway for delivery of glaucoma care. Current UK national guidance recommends VGCs for patients with ocular hypertension, glaucoma suspects or early glaucoma. This study evaluates whether expanded eligibility criteria, including other glaucoma phenotypes and disease stages, can deliver safe and effective care with a positive patient experience. METHODS: Records of over 8000 patients were reviewed in order to determine suitability for VGC attendance using expanded eligibility criteria. Patients with three prior consecutive visits within the glaucoma service were included. Follow-up interval, clinic type, visual acuity (VA), intraocular pressure (IOP) and visual field performance were recorded. Patient satisfaction was recorded for a sample of 118 patients. RESULTS: 2017 patients over 31 months were included. Two-thirds of eyes had ocular comorbidities, a fifth of eyes had undergone prior cataract surgery and 10% of eyes had undergone a prior laser treatment for glaucoma. After three visits, 32% of patients remained in the VGC, 42% were seen in face-to-face clinics and 25% were discharged. There were no clinically significant changes in VA, IOP and visual field performance during follow-up. 72% of patients expressed a preference to continue their care within VGCs. CONCLUSIONS: This study demonstrates that VGCs with expanded patient eligibility criteria can deliver high-quality glaucoma care that is safe, effective and with high levels of patient satisfaction. This approach provides a long-term solution to adapt delivery of glaucoma care to our expanding and ageing population.

System usability, user satisfaction and long-term adherence to mobile hyperacuity home monitoring-prospective follow-up study.

PURPOSE: To evaluate the usability and long-term adherence to the mobile hyperacuity app Alleye in patients with retinal pathology. METHODS: We enroled 72 patients (95 eyes) mainly treated for wet AMD (48/95; 50.5%). We calculated changes of clinical characteristics and the System Usability Score (SUS), and personal ratings of usefulness and number of tests performed per month at a follow-up visit of eighteen months. RESULTS: At baseline, mean best corrected visual acuity (BCVA) was 74.9 letters (SD 14.8), mean age was 69.9 (SD 11.4) and 39/72 (54.2%) were female. Of included patients, 47/72 (65.2%) reported to use mobile devices daily. The retention rate until last follow-up was 73.6 % (53/72). The median SUS score at baseline was 90 (interquartile range (IQR) 82.5-95) and 92.5 (IQR 82.5-95) in the follow-up. No association between changes of SUS and clinical characteristics was seen. At baseline, 76.4% (55/72) stated that they would recommend the app to a friend, 83.3% (60/72) were very satisfied with the app and 58/72 (80.6%) of respondents said they trusted the app. These assessments remained similar among patients remaining on the program until the follow-up. Patients who dropped out of the study (n = 19) did not differ in age, gender, BCVA, and SUS at baseline, but stated that they did not use the mobile device daily (Odds Ratio 7.40 (95%CI: 2.32-23.65); p = 0.001). CONCLUSIONS: The majority of users willing to perform home monitoring with the Alleye app are satisfied with the usability and have a positive attitude towards its trustworthiness and usefulness.

Creating a secure clinical 'Bring Your Own Device' BYOD photography service to document and monitor suspicious lesions in the lid oncology clinic.

BACKGROUND: Ophthalmic examinations are mostly documented using sketches and written descriptions. Improvements in app security and IT infrastructure mean that high-quality anterior segment photographs can be routinely collected with smartphones alone. The lid oncology team relied on pre-operative formal slit-lamp imaging in the one-stop biopsy clinic, a lengthy process with capacity limitations, that risked delays to care. METHODS: A Bring Your Own Device (BYOD) photography service was developed through a series of iterations and collaborations. Healthcare Assistants took photographs on iPhone SE with Quikvue lens attachments in Pando app. Lesions requiring a slit lamp were photographed by the doctor. Images were uploaded to the patient record twice weekly. The service was evaluated using time-motion studies, imaging quality and utility grading, and patient feedback. RESULTS: BYOD photography saved lid oncology patients 41 min (one-third of total appointment time) and reduced delays to treatment to zero. A patient survey reflected the acceptability of the service, with 100% feeling photography was important at every visit. In terms of utility, 97.5% of smartphone images were suitable for monitoring lesions and making management decisions. The management plan based on the smartphone photographs was consistent with the management plan formulated face-to-face in clinic in 92.5% images. CONCLUSION: BYOD photography has replaced formal slit-lamp imaging in the lid oncology service. This sustainable, cost-effective BYOD solution requires little training and can be adapted, reproduced, and scaled globally. BYOD photography can offer detailed records to monitor progress, contribute to remote care models, improve patient experience, and reducing medical error.

Transforming ophthalmology in the digital century-new care models with added value for patients.

Ophthalmology faces many challenges in providing effective and meaningful eye care to an ever-increasing group of people. Even health systems that have so far been able to cope with the quantitative patient increase, due to their funding and the availability of highly qualified professionals, and improvements in practice routine efficiency, will be pushed to their limits. Further pressure on care will also be caused by new active substances for the largest group of patients with AMD, the so-called dry form. Treatment availability for this so far untreated group will increase the volume of patients 2-3 times. Without the adaptation of the care structures, this quantitative and qualitative expansion in therapy will inevitably lead to an undersupply.There is increasing scientific evidence that significant efficiency gains in the care of chronic diseases can be achieved through better networking of stakeholders in the healthcare system and greater patient involvement. Digitalization can make an important contribution here. Many technological solutions have been developed in recent years and the time is now ready to exploit this potential. The exceptional setting during the SARS-CoV-2 pandemic has shown many that new technology is available safely, quickly, and effectively. The emergency has catalyzed innovation processes and shown for post-pandemic time after that we are equipped to tackle the challenges in ophthalmic healthcare - ultimately for the benefit of patients and society.

Introducing the 'Benign Eyelid Lesion Pathway': 1 year experience of synchronous tele-oculoplastics in a tertiary hospital.

BACKGROUND: Patients with benign eyelid lesions make up a large proportion of referrals to the oculoplastic service and lend themselves well to telemedicine with assessments heavily reliant on history, observation-based examination and photographs to enable management decision-making. Our tertiary unit set up tele-oculoplastics clinics for all new patients referred for benign eyelid lesions comprising tele-consultation with antecedent patient photograph: Benign Eyelid Lesion Pathway (BELP). One year on, we describe a retrospective analysis of 974 patients looking at distinct parameters of effectiveness. METHODS: We retrospectively collected data from electronic patient records (EPR) for BELP patients from July 2020 to August 2021 (n = 974). We analysed time efficiency (referral time to treatment plan, consultation duration in minutes, average waiting times, number of patients seen per clinician and DNA rate), accessibility, safety (via video surveillance clinic) and theatre utilisation. RESULTS: 57.3% (n = 558) were listed for a surgical procedure direct from tele-consultation with 94.9% (n = 513) of these proceeding to surgery; 22.8% (n = 222) were discharged, 10.7% (n = 104) had further video follow-up and 6.7% (n = 65) required face-to-face follow-up. Our results showed efficient referral-to-treatment times, waiting times, consultation times and non-attendance rate. There was only a 2.57% non-attendance rate. There was no missed diagnosis of a malignancy of a presumed benign lesion. CONCLUSION: Tele-oculoplastics provides a streamlined, safe, effective, and logistically convenient way to review benign eyelid lesions. With the increased waiting times for referral to biopsy of eyelid lesions, this clinic shows it is imperative to provide digital accessibility for patient assessment and booking to operating theatre.

Practical implementation of a q4-q16 aflibercept treat-and-extend pathway for the treatment of neovascular age-related macular degeneration: Updated guidance from a UK expert panel.

OBJECTIVES: This report, based on guidance from a panel of UK retina specialists, introduces a revised intravitreal aflibercept (IVT-AFL) treat-and-extend (T&E) pathway for the treatment of neovascular age-related macular degeneration (nAMD). The T&E pathway incorporates the updated IVT-AFL label (April 2021) allowing flexible treatment intervals of 4 weeks to 16 weeks, after three initiation doses and a further dose after 8 weeks. Practical guidance is provided on the clinical implementation of the revised pathway, with the aim of supporting clinical decision-making to benefit patients and addressing capacity issues in nAMD services. METHODS: Three structured round-table meetings of UK retina specialists were held online on 19 May, 16 June and 13 October 2021. These meetings were organised and funded by Bayer. RESULTS: The authors revised the previously published consensus pathway to reflect the changes to the IVT-AFL label and developed guidelines for the implementation of the pathway in UK clinical practice. The guidelines include topics such as recommendations for extending patients with 2- or 4-week adjustments, extending patients to 16-week treatment intervals, managing fellow eye involvement, and reducing treatment intervals for patients with particularly active disease. CONCLUSIONS: The revised IVT-AFL T&E nAMD pathway offers guidance to clinicians seeking to increase the dosing flexibility of IVT-AFL, with 4- to 16-week treatment intervals, in line with the updated IVT-AFL label, to meet the continually evolving demands of nAMD service provision.