MicroShunt versus Trabeculectomy for Surgical Management of Glaucoma: A Retrospective Analysis.

This case-control study aims to compare the efficacy, safety, and postoperative burden of MicroShunt versus trabeculectomy. The first consecutive cohort of MicroShunt procedures (n = 101) was matched to recent historical trabeculectomy procedures (n = 101) at two London hospital trusts. Primary endpoints included changes in intraocular pressure (IOP) and glaucoma medications. Secondary outcome measures included changes in retinal nerve fibre layer (RNFL) thickness, rates of complications, further theatre interventions, and the number of postoperative visits. From the baseline to Month-18, the median [interquartile range] IOP decreased from 22 [17-29] mmHg (on 4 [3-4] medications) to 15 [10-17] mmHg (on 0 [0-2] medications) and from 20 [16-28] mmHg (on 4 [3-4] medications) to 11 [10-13] mmHg (on 0 [0-0] medications) in the MicroShunt and trabeculectomy groups, respectively. IOP from Month-3 was significantly higher in the MicroShunt group (p = 0.006), with an increased number of medications from Month-12 (p = 0.024). There were greater RNFL thicknesses from Month-6 in the MicroShunt group (p = 0.005). The rates of complications were similar (p = 0.060) but with fewer interventions (p = 0.031) and postoperative visits (p = 0.001) in the MicroShunt group. Therefore, MicroShunt has inferior efficacy to trabeculectomy in lowering IOP and medications but provides a better safety profile and postoperative burden and may delay RNFL loss.

Perceptions of training in gonioscopy.

PURPOSE: To evaluate ophthalmology trainees' perception of their gonioscopy learning experience in the Ophthalmology Specialty Training programme. MATERIALS AND METHODS: A cross-sectional electronic survey was conducted amongst ophthalmology trainees across London Deaneries. The ten questions survey collected parameters, including training grade, previous level of gonioscopy training, confidence in performing the procedure, level of satisfaction with the training formats received, potential barriers and improvements to the training programme. The respondents were also invited to express any additional comments. RESULTS: Fifty-seven complete responses were analysed. The respondents included 25 junior trainees (ST1-3) and 32 senior trainees (ST4-7 and fellows). One-fifth of the respondents (11/57) were unconfident in performing gonioscopy, the majority being junior trainees (9/11). Over a quarter of the respondents were dissatisfied with the quantity of the gonioscopy training received. Teaching formats, such as consultant teaching (mean 8.0 ± 0.50), self-directed learning (mean 8.0 ± 0.38) and small-group tutorials (mean 7.6 ± 1.6) were all well received. Overall, lack of clinical time was considered as the major barrier to gonioscopy training; however, lack of training was considered as the major barrier in the low-confidence group. CONCLUSIONS: This study highlighted ophthalmology trainees' dissatisfaction in the current gonioscopy training curriculum and a lack of confidence in performing the procedure. Appropriate modifications to the Ophthalmology Specialty Training programme could enhance trainees' gonioscopy learning experience.

Correction: How do paper and electronic records compare for completeness? A three centre study.

Following the publication of the above article the authors noted an error in the author list, 2 authors were mistakenly omitted. Zena Rodrigues and Faisal Ahmed have now been added to the author list and the PDF and HTML versions of the paper have been corrected.

How do paper and electronic records compare for completeness? A three centre study.

OBJECTIVES: Medical records are legal documentation of patients' care hence must be accurate and complete for both medical and legal purposes. Electronic patient record (EPR) systems aim to improve the accuracy of documentation, provide better organisation and access of data. This study compares the completeness of traditional note records and EPR in glaucoma patients. METHODS: Using criteria from the April 2009 National Institute for Health and Care Excellence (NICE) guidelines completeness of data entry was compared between EPR and paper notes in three units. Moorfields Eye Hospital (City Road) uses the Openeyes EPR. Bedford Hospital (Moorfields Eye Centre) and Western Eye Hospital use the Medisoft EPR. The standard was set at 100% compliance for predetermined parameters. RESULTS: One hundred seventy paper notes and 270 electronic records were analysed. With the exception of central corneal thickness (p = 0.31), all other key parameters were more consistently recorded in the paper records than in the EPR. Intraocular pressure (p = 0.004), anterior chamber configuration and depth assessments using gonioscopy (p < 0.001), fundus examination (p = 0.015), past medical history (p < 0.001), medication including glaucoma medication (p < 0.001) and drug allergies (p < 0.001). CONCLUSIONS: Our results show that paper records are significantly more complete than EPR. This is the case for two different EPRs and three separate sites. We propose additional training to aid data-collection; improving the design of EPRs by investigating factors such as layout and use of forced choice fields.

Management of glaucoma as a neurodegenerative disease.

Glaucoma is a neurodegenerative disease with an estimated prevalence of 60 million people, and the most common cause of irreversible blindness worldwide. The mainstay of treatment has been aimed at lowering intraocular pressure, currently the only modifiable risk factor. Unfortunately, despite adequate pressure control, many patients go on to suffer irreversible visual loss. We first briefly examine currently established intraocular pressure lowering-treatments, with a discussion of their roles in neuroprotection as demonstrated by both animal and clinical studies. The review then examines currently available intraocular pressure independent agents that have shown promise for possessing neuroprotective effects in the management of glaucoma. Finally, we explore potential future treatments such as immune-modulation, stem cell therapy and neural regeneration as they may provide further protection against the neurodegenerative processes involved in glaucomatous optic neuropathy.

Patient Perception and Emotional Disturbance in Out-of-Hour Ophthalmic Emergency Care.

PURPOSE: To investigate patient's perception of the severity of their symptoms, reasons for attending an ophthalmic emergency department (ED) out of hours, and to review the prevalence of anxiety and depression. METHODS: We carried out a prospective analysis of the cases presenting out of hours (8:30 PM to 8:30 AM) over a four-month period. We also conducted two questionnaire studies. First, patient's perception of the severity of their symptoms (graded from 1-10). A score of 7 or above was defined as significant. A second questionnaire study used the Hospital Anxiety and Depression Scale (HADS), with a maximum score of 21. Patients who scored between 7-10 points on either anxiety or depression scales are defined as borderline; above 10 as pathological. RESULTS: A total of 1,531 patients attended the out-of-hours service. The most common diagnoses were trauma (22.8%), infective conjunctivitis (10.2%), and contact-lens-related problems (6.6%). Of 175 completed questionnaires, worry about sight impairment and pain were the most common concerns for attendance. A total of 91% of patients believed their conditions were emergencies that require medical review within 24 hours. 127 HADS questionnaires were completed, showing that 18.9% and 15.0% of patients were suffering from borderline and pathological anxiety, respectively, with a mean HADS-A score of 6.5, SD=3.9. The prevalence of possible and pathological depression was 14.2% and 6.3%, mean=4.9 (SD=3.6). There was no statistical significance difference of score with the time of patient presentation. CONCLUSION: The prevalence of anxiety and depression is relatively high in patients who attended the ophthalmic ED and awareness of psychological impact should be raised amongst healthcare professionals.

Iritis, glaucoma and corneal decompensation associated with BrightOcular cosmetic iris implant.

PURPOSE: NewColorIris cosmetic iris implants have a record of high ocular morbidity and are no longer in use. Newer generation of iris implants, BrightOcular, have patented posterior grooves in order to decrease iris touch and facilitate aqueous flow around the implant. However, little is known about their safety despite their implantations in 10 countries. METHODS: Collaborative case series of patients who had bilateral implantation of cosmetic iris implants solely for cosmetic reasons. RESULTS: 12 cases were collected being distributed as Caucasian (10) and Asian (2), women (11) and man (1) and with a mean age of 32 years. Ocular manifestations were present in 11 subjects and included anterior uveitis (10 of 12; 83.3%), glaucoma (7 of 12; 58.3%) and corneal decompensation (6 of 12; 50%). Visual acuity was normal in seven, decreased in five with two having visual recovery following explantation of the implant. Glaucoma could not be controlled medically in two patients. CONCLUSIONS: Cosmetic iris implants carry the risk of ocular damage when implanted in the anterior chamber of normal phakic eyes.

Macular Hole Progression following Ocriplasmin Intravitreal Injection.

Ocriplasmin is a protease which has been approved for the treatment of symptomatic vitreomacular adhesion (VMA). A 63-year-old presented with blurred vision in the left eye and a best corrected visual acuity of 6/18. Optical coherence tomography revealed VMA with an underlying macular hole and she subsequently underwent a left intravitreal ocriplasmin injection. One week after the injection, VMA had been released but with enlargement of the macular hole and a drop in her BCVA to 6/60. This persisted at 1 month after the injection. It is important to warn patients that ocriplasmin may lead to an enlargement of their macular hole with resultant loss in visual acuity.