Homeopathic Agents or Vitamins in Reducing Ecchymosis after Oculofacial Surgery: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature to determine the efficacy and safety of homeopathic agents or vitamins in reducing ecchymosis after oculofacial surgery or laser surgery. METHODS: A literature search was conducted in the PubMed database initially in December 2019 and updated in March 2020 to identify all studies in the English language literature on the use of homeopathic agents or vitamins in oculofacial procedures, including laser surgery. The search yielded 124 citations, and 11 articles met all inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study. Eleven studies met inclusion criteria; 9 were rated level I, and 2 were rated level III. RESULTS: The agents studied in the articles identified included oral or topical Arnica montana (AM), oral Melilotus extract, topical vitamin K oxide, and topical AM combined with Rhododendron tomentosum. Metrics to describe ecchymosis varied. In 7 controlled studies, perioperative AM provided no or negligible benefit versus placebo. In 2 studies, vitamin K cream was equivalent to placebo. One study of oral Melilotus extract had less ecchymosis compared with controls in paranasal and eyelid ecchymosis at postoperative day (POD) 7, but not at PODs 1 and 4. A lone cohort study of combined topical AM and R. tomentosum lacked objective metrics and adequate controls. No serious side effects from administration of homeopathic agents or vitamins were identified. CONCLUSIONS: The current literature does not support the use of AM, vitamin K oxide, R. tomentosum, or Melilotus extract for reducing ecchymosis after oculofacial surgery or pulsed dye laser surgery.

Intense Pulsed Light for Meibomian Gland Disease: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the literature on the efficacy of intense pulsed light (IPL) on the eyelids in the management of meibomian gland disease (MGD) and meibomian gland-related ocular surface disease. METHODS: A literature search was last conducted on May 15, 2019, in the PubMed and Cochrane Library databases for English-language original research that assessed the effect of IPL on MGD in adult patients. Thirty-three articles were identified, and 12 studies were determined to be relevant to the criteria outlined for assessment. The panel methodologist (V.K.A.) assigned a level of evidence rating to each study; 4 studies were rated level II, and 8 studies were rated level III. Five studies had potential conflicts of interest and design limitations that affected interpretation of results. RESULTS: All studies documented improvement in clinically meaningful metrics, including tear breakup time (TBUT), corneal staining and eyelid margin measurements, meibum quality, meibomian gland expressability, ocular surface disease index (OSDI), and standard patient evaluation of eye dryness (SPEED) questionnaire scores. Side effects were relatively uncommon but included discomfort, cutaneous erythema, blistering, eyelash loss, and floaters; these were uniformly self-limited. CONCLUSIONS: Although methodological limitations and potential conflicts of interest in some studies raised concern, the existing body of literature demonstrates improvements in the signs and symptoms of MGD after IPL therapy.

Peek Community Eye Health - mHealth system to increase access and efficiency of eye health services in Trans Nzoia County, Kenya: study protocol for a cluster randomised controlled trial.

BACKGROUND: Globally, eye care provision is currently insufficient to meet the requirement for eye care services. Lack of access and awareness are key barriers to specialist services; in addition, specialist services are over-utilised by people with conditions that could be managed in the community or primary care. In combination, these lead to a large unmet need for eye health provision. We have developed a validated smartphone-based screening algorithm (Peek Community Screening App). The application (App) is part of the Peek Community Eye Health system (Peek CEH) that enables Community Volunteers (CV) to make referral decisions about patients with eye problems. It generates referrals, automated short messages service (SMS) notifications to patients or guardians and has a program dashboard for visualising service delivery. We hypothesise that a greater proportion of people with eye problems will be identified using the Peek CEH system and that there will be increased uptake of referrals, compared to those identified and referred using the current community screening approaches. STUDY DESIGN: A single masked, cluster randomised controlled trial design will be used. The unit of randomisation will be the 'community unit', defined as a dispensary or health centre with its catchment population. The community units will be allocated to receive either the intervention (Peek CEH system) or the current care (periodic health centre-based outreach clinics with onward referral for further treatment). In both arms, a triage clinic will be held at the link health facility four weeks from sensitisation, where attendance will be ascertained. During triage, participants will be assessed and treated and, if necessary, referred onwards to Kitale Eye Unit. DISCUSSION: We aim to evaluate a M-health system (Peek CEH) geared towards reducing avoidable blindness through early identification and improved adherence to referral for those with eye problems and reducing demand at secondary care for conditions that can be managed effectively at primary care level. TRIAL REGISTRATION: The Pan African Clinical Trials Registry (PACTR), 201807329096632 . Registered on 8 June 2018.

Glaucoma surgery preferences when the surgeon adopts the role of the patient.

BACKGROUND/OBJECTIVES: To survey the members of the American Glaucoma Society (AGS) to determine which glaucoma procedures they would prefer to have performed on themselves. SUBJECTS/METHODS: We distributed an anonymous, electronic survey via the AGS listserv. The participants were asked to adopt the role of a patient with primary open angle glaucoma with progressive visual field loss in need of glaucoma surgery. Three preoperative intraocular pressure (IOP) levels were provided (>26 mmHg, 21-26 mmHg, and <21 mmHg), and the participants were asked to choose a glaucoma procedure they would prefer performed on themselves under each preoperative IOP levels from a list of fifteen procedures. RESULTS: Out of 289 responses (representing 27.4% of active and provisional AGS members), the most preferred procedures were ab interno trabeculotomy (20.3%), Xen gel stent (18.6%), iStent with two devices (14.3%) and traditional trabeculectomy augmented with mitomycin C (14.1%). 17.6% and 6.9% of participants preferred a trabeculectomy performed or a glaucoma drainage device (GDD) implanted on themselves, which is a lower than what would be offered to a hypothetical patient. Significant proportions of participants prefer non-bleb forming or conjunctiva-sparing procedures, even with low preoperative IOP levels. Older participants were more likely to prefer traditional trabeculectomy and having a single procedure across all levels of preoperative IOP. CONCLUSIONS: The majority of AGS participants in the survey would prefer micro-invasive glaucoma surgery over traditional trabeculectomy or a GDD performed on themselves as a primary glaucoma procedure, and most would prefer non-bleb forming and conjunctiva-sparing procedures.

Eye care utilisation in Newfoundland and Labrador: access barriers and vision health outcomes.

OBJECTIVE: Our prior study revealed significantly lower use of eye care providers in Newfoundland and Labrador (NFLD). This study reports factors associated with this low use and related vision health outcomes. DESIGN: Cross-sectional survey. PARTICIPANTS: A total of 14 925 Caucasian respondents to the Canadian Community Health Survey - Healthy Aging 2008/2009 aged ≥65 years. METHODS: Univariate and multivariate analyses were performed using self-reported survey data. RESULTS: NFLD, along with 3 other provinces, does not insure seniors for routine eye examinations. Among seniors without self-reported glaucoma, cataracts, and diabetes, the use of eye care providers in NFLD (36.3%) is the lowest compared with provinces with (50.7%, p < 0.05) and without (42.2%, p > 0.05) government-insured eye examinations. Among seniors with known eye disease insured for eye care in all provinces, eye care utilisation in NFLD (63.1%) is still the lowest across all provinces (69.4%-71.3%, p > 0.05). Compared with the national average, NFLD seniors have significantly higher proportions of low income (61.7% vs 47.4%), no postsecondary education (53.6% vs 42.2%), and rural residency (40.6% vs 18.9%). These factors are all associated with low levels of eye care utilisation. Compared with insured provinces, NFLD has a significantly lower prevalence of self-reported cataracts (16.7% vs 23.1) and glaucoma (3.8% vs 7.0%), and a slightly higher prevalence of presenting visual impairment (4.0% vs 3.5%). CONCLUSIONS: Lack of government insurance, low socioeconomic status, and living in nonurbanised areas all contribute to the underutilisation of eye care providers in NFLD. This underutilisation appears to be associated with reduced detection of eye diseases.

Leaving No One Behind: Strengthening Access to Eye Health Programs for People With Disabilities in 6 Low- and Middle-Income Countries.

PURPOSE: To assess the impact of inclusive eye health programs for people with disabilities. DESIGN: A synthesis evaluation study. METHODS: A cross-disciplinary team of ophthalmologists, evaluation, and disability-inclusive development advisors purposively selected evaluation reports of CBM-supported inclusive eye health programs in low- and middle-income countries. Employing a change-promoting paradigm, salient achievements and challenges were narratively analyzed and recommendations suggested based on a previously developed framework for strengthening disability inclusion in eye health programs. RESULTS: Evaluations from 10 programs implemented in 6 countries (Cambodia, Egypt, Ethiopia, Indonesia, Pakistan, Vietnam) from 2011 to 2016 were identified. Training of medical staff and government officials resulted in increased awareness about disability rights and improved physical accessibility of eye health facilities. Relevant information about inclusion in eye health was incorporated in national eye health training curricula in some countries. Information, education, and communication material about eye health neglected patients with hearing and learning impairments. An overly narrow focus on disability inclusion confounded intersectoral barriers to eye health services. Collaboration of eye health staff with disability peoples organizations improved significantly but evidence of its impact was elusive. Collection of disability-disaggregated data posed significant challenges and made it difficult to demonstrate increased access to eye health programs by people with disabilities. CONCLUSIONS: Introduction of disability inclusion in eye health systems of countries with limited resources poses significant challenges. Future programs striving to improve access to eye health services for marginalized populations including people with disabilities might consider more flexible and contextualized approaches.

Distribution and extent of electronic medical record utilisation in eye units across the United Kingdom: a cross-sectional study of the current landscape.

OBJECTIVES: Ophthalmology units across the UK vary widely in their adoption of electronic medical records (EMR). There is a lack of evidence to show the extent and progress of EMR adoption. The aim of this study was to capture a snapshot of the current landscape of EMR use, as a baseline for comparison in future studies. SETTING: An electronic survey questionnaire was sent to all NHS ophthalmology Units in the UK. PARTICIPANTS: A total of 104 National Health Service (NHS) ophthalmology units participated in the survey, which was carried out over 6 months from December 2013 to June 2014. PRIMARY AND SECONDARY OUTCOME MEASURES: Respondents were asked about technology usage pertaining to specific processes in the clinic workflow. This allowed us to determine the extent of EMR usage and details about current use or planned implementation by each unit. RESULTS: 77.6% (n=104) of NHS ophthalmology units responded. 45.3% (n=48) of units were currently using an EMR and a further 26.4% (n=28) of units plan to implement EMR within 2 years. 70.8% of units with a current EMR system use Medisoft. EMR is used by all clinicians in 37.5% and by all subspecialties offered at the unit in 27.0%. In 56.3%, new clinical notes are entered into EMR only by clinicians. All imaging devices are networked to EMR in 28.3%. In 46.7%, EMR is accessible by other specialties within the same hospital. 71.1% would recommend EMR to a colleague. CONCLUSIONS: EMR has the potential to address current limitations of patient information transfer and sharing in ophthalmology. It is pleasing to see a significant proportion of units already engaging with EMR or having plans to do so in the near future. However, differing EMR systems and lack of remote access mean further optimisation of these record systems are needed to allow data transfer between units.

Refractive error in underserved adults: causes and potential solutions.

PURPOSE OF REVIEW: To evaluate the epidemiology of uncorrected refractive errors (URE) in adults both in the United States and globally, health outcomes impacted by URE, common barriers to treatment, and propose potential interventions. RECENT FNDINGS: URE is the main cause of visual impairment and the second leading cause of blindness globally. Rates of URE are rising, and cause disability that reduces productivity, economic earnings, and the quality of life of affected individuals. Economic barriers, healthcare access, and sociocultural constraints are among the most fundamental barriers to correcting URE. However, innovative approaches are poised to lower rates of URE. SUMMARY: URE is a leading cause of preventable visual impairment with serious health consequences. Numerous social and financial barriers are associated with the high prevalence of URE in low-income adults. Novel delivery programs for eyeglasses and programs to provide refractive surgery to correct refractive error could decrease rates of URE.

Electronic Referrals and Digital Imaging Systems in Ophthalmology: A Global Perspective.

Ophthalmology departments face intensifying pressure to expedite sight-saving treatments and reduce the global burden of disease. The use of electronic communication systems, digital imaging, and redesigned service care models is imperative for addressing such demands. The recently developed Scottish Eyecare Integration Project involves an electronic referral system from community optometry to the hospital ophthalmology department using National Health Service (NHS) email with digital ophthalmic images attached, via a virtual private network connection. The benefits over the previous system include reduced waiting times, improved triage, e-diagnosis in 20% without the need for hospital attendance, and rapid electronic feedback to referrers. We draw on the experience of the Scottish Eyecare Integration Project and discuss the global applications of this and other advances in teleophthalmology. We focus particularly on the implications for management and screening of chronic disease, such as glaucoma and diabetic eye disease, and ophthalmic disease, such as retinopathy of prematurity where diagnosis is almost entirely and critically dependent on fundus appearance. Currently in Scotland, approximately 75% of all referrals are electronic from community to hospital. The Scottish Eyecare Integration Project is globally the first of its kind and unique in a national health service. Such speedy, safe, and efficient models of communication are geographically sensitive to service provision, especially in remote and rural regions. Along with advances in teleophthalmology, such systems promote the earlier detection of sight-threatening disease and safe follow-up of non-sight-threatening disease in the community.

Right services to right patients at right time in right setting in Tays Eye Centre.

PURPOSE: The report describes the concepts behind procedures implemented in Tays Eye Centre to enable improved access to care and improved productivity. METHODS: The strategy was developed in 2009 after hospital district decided to construct a new eye hospital which was opened in 2012. The following principles were implemented: (i) identification of high-volume patient groups: the 'big four' eye diseases accounting for 70% of patient visits and costs: age-related macular degeneration (AMD), glaucoma, retinal diseases and cataract; (ii) stratification and prioritization of patient care based on risk of permanent visual disability; (iii) standardization of services for low-risk patients; (iv) maximization of productivity; and (v) shared care. The impact of the new strategy on access to care and productivity is reported for years 2011-2015. RESULTS: In 2011-2015, the total number of services provided increased 46% while the work contribution increased 15%. The number of referrals increased 76% and the number of outpatient appointments increased 2.5-fold. Simultaneously, the number of delayed follow-up visits decreased to zero. Age-related macular degeneration (AMD) injections increased 1.8-fold. However, after 50% yearly increase in Age-related macular degeneration (AMD) injections, a plateau was reached in 2014 with a 3% decline in 2014-2015 with no changes in treatment indications. In the beginning of 2016, the number of injections has started to increase again (+9% compared to 2015).  The total number of surgical procedures increased 98%. The annual number of cataract surgeries increased 64% and bilateral surgeries from 11% to 39%. CONCLUSION: Revised operational concepts and new facilities together with a 15% increase in work contribution led to a 46% increase in overall productivity, improved access to care and the clearance of delayed services. Efforts continue to further refine cost-effective care and to define the appropriate levels of services.

Diabetic Retinopathy Screening and Monitoring of Early Stage Disease in Australian General Practice: Tackling Preventable Blindness within a Chronic Care Model.

INTRODUCTION: Diabetic retinopathy (DR) is the leading cause of preventable blindness in Australia. Up to 50% of people with proliferative DR who do not receive timely treatment will become legally blind within five years. Innovative and accessible screening, involving a variety of primary care providers, will become increasingly important if patients with diabetes are to receive optimal eye care. METHOD: An open controlled trial design was used. Five intervention practices in urban, regional, and rural Australia partnered with ophthalmologists via telehealth undertook DR screening and monitoring of type 2 diabetes patients and were compared with control practices undertaking usual care 2011-2014. RESULTS: Recorded screening rates were 100% across intervention practices, compared with 22-53% in control practices. 31/577 (5%) of patients in the control practices were diagnosed with mild-moderate DR, of whom 9 (29%) had appropriate follow-up recorded. This was compared with 39/447 (9%) of patients in the intervention group, of whom 37 (95%) had appropriate follow-up recorded. DISCUSSION AND CONCLUSION: General practice-based DR screening via Annual Cycle of Care arrangements is effective across differing practice locations. It offers improved recording of screening outcomes for Australians with type 2 diabetes and better follow-up of those with screen abnormalities.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of vitreoretinal surgery: report 5, anaesthetic techniques.

AIMS: To explore trends over time and variation in the use of anaesthetic techniques for vitreoretinal (VR) surgery in the UK. METHODS: Prospectively collected data from 13 centres contributing >50 VR operations, including either pars plana vitrectomy (PPV) or scleral buckle (SB), between May 2000 and November 2010 were retrospectively analysed. Anaesthesia was categorised as general anaesthesia (GA) or local anaesthesia (LA) and results were reported by year, centre, grade of surgeon and type of operation. RESULTS: 160 surgeons performed 12 124 operations on 10 405 eyes (9935 patients); 6054 (49.9%) under GA and 6070 (50.1%) under LA. The percentage performed under GA decreased from 95.3% in 2001 to 40.9% in 2010. Within LA techniques, peribulbar or retrobulbar injection was used in 2783 (45.8%) operations and sub-Tenon's cannula in 3287 (54.2%). The proportions of operations performed under GA or LA were similar for consultants and trainees. Primary SB, primary combined PPV and SB for retinal detachment (RD), repeat RD surgery and complex vitrectomy surgery were more commonly performed under GA (85.8%, 67.0%, 63.5% and 69.4%, respectively), while primary PPV for RD, simple vitrectomy surgery and macular surgery were more commonly performed under LA (58.1%, 53.7% and 58.2%, respectively). Marked intercentre variation existed with the extremes being one centre with 100% of operations performed under GA and one centre with 98.3% under LA. CONCLUSIONS: LA for VR surgery has steadily increased over the last decade in the UK but marked intercentre variation exists.

The Capacity of Eye Care Services for Patients with Glaucoma in Botswana.

PURPOSE: To evaluate current delivery of glaucoma care in Botswana; in particular, the service infrastructure available and glaucoma-related workload. METHODS: A multi-center cross-sectional study was undertaken comprising government eye care institutions and ophthalmic personnel across Botswana. Data on human resources, equipment types and numbers, diagnostic criteria routinely used, treatments routinely provided, and new and repeat glaucoma consultations were obtained through quantitative and qualitative surveys. RESULTS: In 27 government eye care institutions there were two general ophthalmologists, neither of whom had a subspecialty interest in glaucoma, 64 ophthalmic nurses, two optometrists, one low vision therapist, one refractionist, and two equipment technicians. Only 8.5% of available ophthalmic human resources were taken up with provision of glaucoma care. About 1/3 of hospitals did not have tonometers, most primary hospitals lacked slit lamp biomicroscopes and most hospitals lacked sensitive diagnostic equipment. A diagnosis of glaucoma was made by either an ophthalmic nurse or an ophthalmologist, but only 10% of institutions could meet recommendations for follow-up assessment. Topical glaucoma medications were prescribed by almost all hospital clinics, usually by ophthalmic nurses. Drug choices were largely determined by local availability. Glaucoma surgery accounted for 0.8% of total eye operations. Glaucoma patients took up 8.5% of total clinic visits. The total number of glaucoma visits was highest in the two hospitals with ophthalmologists. New glaucoma cases took up 10.3% of total glaucoma visits. CONCLUSION: This study highlights the challenges faced in caring for glaucoma patients in Botswana; in particular, lack of professional human resources, equipment and availability of effective treatments.

Clinical model assisting with the collaborative care of glaucoma patients and suspects.

BACKGROUND: Optimizing patient management will reduce unnecessary vision loss in glaucoma through early detection. One method is the introduction of collaborative care schemes between optometrists and ophthalmologists. DESIGN: We conducted a retrospective study to evaluate the impact of the Centre for Eye Health (CFEH) on glaucoma patient outcomes and management in primary optometric care. PARTICIPANTS: Patients referred to CFEH by optometrists for a glaucoma assessment were eligible for this study if written consent was provided (500 participants were randomly chosen). METHODS: Clinical data were classified according to disease risk and implemented patient care and analysed against the original diagnosis and patient parameters, followed by statistical analysis. MAIN OUTCOME MEASURES: Two main parameters were evaluated; suitable referral of patients for glaucoma condition assessment and appropriate implementation of follow-up care. RESULTS: The majority of patients referred for glaucoma assessment (86.2%) were classified as glaucoma suspects or likely to have glaucoma, indicating suitable referral of patients for a CFEH evaluation. Further, the involvement of CFEH resulted in a false positive rate of 7.8% for those patients who proceeded to ophthalmological care. However, long-term optometric patient care was not maintained for up to a third of primarily lower risk patients. CONCLUSIONS: The investigated collaborative eye health-care model led to a substantial improvement in appropriate referrals of glaucoma patients to ophthalmologists and could be suitable for optimizing patient care and utilization of resources. Improvement in follow-up of patients by optometrists is required to minimize inappropriately discontinued patient care.

[Establishment of diagnosis and treatment patterns of holistic integrated medicine for neuro-ophthalmology].

Neuro-ophthalmology, as an interdisciplinary, covers at least three disciplines- ophthalmology, neurology and neurosurgery. With limited knowledge in each discipline, doctors often make misdiagnoses for neuro-ophthalmology diseases. Therefore, it is imperative to abandon the distinction between disciplines and combine all the knowledge to diagnose and treat patients in patterns of holistic integrated medicine in order to effectively improve the diagnosis and treatment of neuro-ophthalmology.

Models for joint ophthalmology-optometry patient management.

PURPOSE OF REVIEW: American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery (ASCRS) presented a joint position paper in February 2000 declaring that they do not support routine comanagement of patients with the optometrists. American Optometric Association and American Academy of Optometry quickly responded in support of AAO and ASCRS. All four entities did not preclude legitimate and proper comanagement arrangements. RECENT FINDINGS: Since that time, the pattern of practice has changed, requiring us to rethink our positions. SUMMARY: This paper is written to provide a possible model for the ophthalmology-optometry practice management in ophthalmic surgeries including refractive surgery. Since the publication of the Joint Position Paper, the concept of comanagement has faded and a new model of integrated management has evolved. This has occurred as the changes in the employment pattern of the ophthalmic practice have incorporated optometrists into its fold. This evolution allowed ophthalmic and optometric community to co-exist and thrive to provide better patient care.

Coordination of outreach eye services in remote Australia.

BACKGROUND: This paper aims to describe models for service integration between ophthalmology and optometry when conducting outreach eye services. The effect of good coordination on clinical activity and cost-effectiveness is examined. DESIGN: Cross-sectional case study based on remote outreach ophthalmology services in Australia. PARTICIPANTS: Key stake-holders from eye services in nine outreach regions participated in the study. METHODS: Semistructured interviews were conducted to perform a qualitative assessment of outreach eye services' levels of coordination. Records of clinical activity were used to statistically compare the effects of good coordination. MAIN OUTCOME MEASURES: Clinical activity (surgery and clinic consultation rates), waiting times and costs per attendance. Surgical case rate being the proportion of surgery that results from a clinic. RESULTS: Service integration between optometry and ophthalmology resulted in an increased surgical case rate for ophthalmology clinics (R(2) = 0.57). There were trends towards increased clinical activity and reduced waiting times, and costs/attendance were stable. CONCLUSIONS: Coordination of eye services with better integration of ophthalmology and optometry roles may improve efficiency of services for patients. Coordination of eye services has multiple facets including facilitating engagement with the local community, eye professions and health facilities. The varied roles of eye health coordination require further definition and appropriate funding.