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.

Implementing integrated care in ophthalmology: a community case study.

Introduction: In 2017, in a context of financial and patient care challenges, Moorfields Eye Hospital in the borough of Croydon launched the first Ophthalmology Integrated Care Contract in the United Kingdom. Description: A realistic, systematic approach is presented for an efficient implementation of an integrated care ophthalmology contract under a lead provider. The main elements of the new contract are portrayed. Discussion: A new healthcare contract that would lead to system-wide transformation requires significant time commitment, vision, shared narrative, leadership, multi-functional working culture, shared accountability of all participating parties and education and support of all parties involved. Key levers to elevate the quality of care are collaborative relationships between health professionals, investing in information and technology and facilitating bottom-up innovation. Conclusion: System-wide changes such, as integrated care contracts are possible, although the interplay between context, design and implementation is more complex than expected.

Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma: An Overview of Cochrane Systematic Reviews and Network Meta-analysis.

IMPORTANCE: Glaucoma affects more than 75 million people worldwide. Intraocular pressure (IOP)-lowering surgery is an important treatment for this disease. Interest in reducing surgical morbidity has led to the introduction of minimally invasive glaucoma surgeries (MIGS). Understanding the comparative effectiveness and safety of MIGS is necessary for clinicians and patients. OBJECTIVE: To summarize data from randomized clinical trials of MIGS for open-angle glaucoma, which were evaluated in a suite of Cochrane reviews. DATA SOURCES: The Cochrane Database of Systematic Reviews including studies published before June 1, 2021. STUDY SELECTION: Reviews of randomized clinical trials comparing MIGS with cataract extraction alone, other MIGS, traditional glaucoma surgery, laser trabeculoplasty, or medical therapy. DATA EXTRACTION AND SYNTHESIS: Data were extracted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines by one investigator and confirmed by a second. Methodologic rigor was assessed using the AMSTAR 2 appraisal tool and random-effects network meta-analyses were conducted. MAIN OUTCOMES AND MEASURES: The proportion of participants who did not need to use medication to reduce intraocular pressure (IOP) postsurgery (drop-free). Outcomes were analyzed at short-term (<6 months), medium-term (6-18 months), and long-term (>18 months) follow-up. RESULTS: Six eligible Cochrane reviews were identified discussing trabecular bypass with iStent or Hydrus microstents, ab interno trabeculotomy with Trabectome, subconjunctival and supraciliary drainage devices, and endoscopic cyclophotocoagulation. Moderate certainty evidence indicated that adding a Hydrus safely improved the likelihood of drop-free glaucoma control at medium-term (relative risk [RR], 1.6; 95% CI, 1.4 to 1.8) and long-term (RR, 1.6; 95% CI, 1.4 to 1.9) follow-up and conferred 2.0-mm Hg (95% CI, -2.7 to -1.3 mm Hg) greater IOP reduction at long-term follow-up, compared with cataract surgery alone. Adding an iStent also safely improved drop-free disease control compared with cataract surgery alone (RR, 1.4; 95% CI, 1.2 to 1.6), but the short-term IOP-lowering effect of the iStent was not sustained. Addition of a CyPass microstent improved drop-free glaucoma control compared with cataract surgery alone (RR, 1.3; 95% CI, 1.1 to 1.5) but was associated with an increased risk of vraision loss. Network meta-analyses supported the direction and magnitude of these results. CONCLUSIONS AND RELEVANCE: Based on data synthesized in Cochrane reviews, some MIGS may afford patients with glaucoma greater drop-free disease control than cataract surgery alone. Among the products currently available, randomized clinical trial data associate the Hydrus with greater drop-free glaucoma control and IOP lowering than the iStent; however, these effect sizes were small.

Subconjunctival draining minimally-invasive glaucoma devices for medically uncontrolled glaucoma.

BACKGROUND: Glaucoma is a leading cause of irreversible blindness. Subconjunctival draining minimally-invasive glaucoma devices such as the Xen gelatin implant and InnFocus stent have been introduced as a treatment to prevent glaucoma progressing.These implants provide a channel to allow aqueous humour from the anterior chamber of the eye to drain into the subconjunctival space on the surface of the eye thus reducing intraocular pressure (IOP) and mimicking the mechanism of the most commonly undertaken glaucoma surgery, trabeculectomy. OBJECTIVES: To evaluate the efficacy and safety of subconjunctival draining minimally-invasive glaucoma devices in treating people with open angle glaucoma and ocular hypertension whose condition is inadequately controlled with drops. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2018, Issue 6); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 10 July 2018. SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) of Xen gelatin implant or InnFocus MicroShunt to other surgical treatments (other minimally-invasive glaucoma device techniques, trabeculectomy), laser treatment or medical treatment. We also planned to include trials where these devices were combined with phacoemulsification compared to phacoemulsification alone. DATA COLLECTION AND ANALYSIS: We planned to have two review authors independently extract data from reports of included studies using a data collection form and analyse data based on methods expected by Cochrane. Our primary outcome was mean change in IOP. Secondary outcomes included proportion of participants who were drop-free; proportion of participants who achieved an IOP of 21 mmHg or less, 17 mmHg or less or 14 mmHg or less; and proportion of participants experiencing intra- and postoperative complications. We planned to measure all outcomes in the short-term (six to 18 months), medium-term (18 to 36 months), and long-term (36 months onwards). MAIN RESULTS: We found no completed RCTs that met our inclusion criteria. We found one ongoing study (NCT01881425). The study compares InnFocus MicroShunt to trabeculectomy in people with primary open angle glaucoma. The primary outcome is greater than 20% IOP reduction from baseline to 12 months' follow-up. A total of 889 people aged between 40 and 85 years have been enrolled. The estimated study completion date is November 2019. AUTHORS' CONCLUSIONS: There is currently no high-quality evidence for the effects of subconjunctival draining minimally-invasive glaucoma devices for medically uncontrolled open angle glaucoma. Properly designed RCTs are needed to assess the medium- and long-term efficacy and safety of this technique.

A Pilot Study on Ocular Safety and Efficacy of Infliximab as an Antifibrotic Agent After Experimental Glaucoma Filtration Surgery.

INTRODUCTION: Tumor necrosis factor-α (TNF-α) is a multifunctional, proinflammatory cytokine that mediates pleiotropic biological functions, especially inflammation and immunoregulation. We hypothesized that blocking TNF-α with a monoclonal antibody would decrease inflammation and subconjunctival scarring in an animal model of experimental filtration surgery. METHODS: In a randomized, prospective, masked-observer study, 30 New Zealand albino rabbits underwent glaucoma filtration surgery. The animals were allocated to receive either intraoperative application of infliximab (group A) or mitomycin C (MMC) at a concentration of 0.2 mg/ml (group B) or balanced salt solution (BSS, control) (group C). Different infliximab doses, namely 1.0, 2.0, 3.0, 4.0, 5.0 mg in 0.1 ml, were applied. Bleb survival and characteristics were evaluated over a 30-day period. The animals were killed on postoperative day 15 or 30. Histology of the operated eyes was performed to evaluate and grade the amount of scarring in each group. Cellular density was evaluated in each case. RESULTS: Infliximab did not appear to improve outcomes in this model of glaucoma filtration surgery. Bleb survival was significantly higher in the MMC group compared to the other groups (p < 0.001 for both comparisons). Vascularity was also significantly lower in the MMC group compared to the other groups (p = 0.018 for both comparisons). There was a significant decrease in cellular density in the MMC group compared to the control (p = 0.0352) and the infliximab group (p < 001). CONCLUSION: Our results have shown that trabeculectomies in the infliximab group failed faster and displayed more scarring, compared to the control and MMC groups. This outcome suggests that the infliximab doses used in this pilot study resulted in a subconjunctival TNF-α concentration, which acted as a stimulator to fibroblasts.

Spontaneous Dislocation of Trabeculectomy Scleral Flap in the Anterior Chamber in a Patient With Pseudoxanthoma Elasticum.

We report a case of a 54-year-old man, known to have pseudoxanthoma elasticum (PXE), who had a trabeculectomy in his left eye for secondary glaucoma following blunt trauma. Ten years after augmented trabeculectomy, the patient presented to casualty clinic with an inferiorly dislocated, anterior chamber (AC), scleral trabeculectomy flap. Corrected vision was hand movement with an intraocular pressure of 17 mm Hg. There was significant AC inflammation (cells 2+). Gonioscopy revealed a residual mobile scleral flap. The bleb was cystic with no leak. To our knowledge this is the first report of a trabeculectomy scleral flap dislocation into the AC in a patient with PXE. Ophthalmologists should be aware of this complication in patients with PXE.

In Vivo 3-Dimensional Strain Mapping of the Optic Nerve Head Following Intraocular Pressure Lowering by Trabeculectomy.

PURPOSE: To map the 3-dimensional (3D) strain of the optic nerve head (ONH) in vivo after intraocular pressure (IOP) lowering by trabeculectomy (TE) and to establish associations between ONH strain and retinal sensitivity. DESIGN: Observational case series. PARTICIPANTS: Nine patients with primary open-angle glaucoma (POAG) and 3 normal controls. METHODS: The ONHs of 9 subjects with POAG (pre-TE IOP: 25.3±13.9 mmHg; post-TE IOP: 11.8±8.6 mmHg) were imaged (1 eye per subject) using optical coherence tomography (OCT) (Heidelberg Spectralis, Heidelberg Engineering GmbH, Heidelberg, Germany) before (<21 days) and after (<50 days) TE. The imaging protocol was repeated for 3 controls in whom IOP was not altered. In each post-TE OCT volume, 4 tissues were manually segmented (prelamina, choroid, sclera, and lamina cribrosa [LC]). For each ONH, a 3D tracking algorithm was applied to both post- and pre-TE OCT volumes to extract IOP-induced 3D displacements at segmented nodes. Displacements were filtered, smoothed, and processed to extract 3D strain relief (the amount of tissue deformation relieved after TE). Strain relief was compared with measures of retinal sensitivity from visual field testing. MAIN OUTCOME MEASURES: Three-dimensional ONH displacements and strain relief. RESULTS: On average, strain relief (averaged or effective component) in the glaucoma ONHs (8.6%) due to TE was higher than that measured in the normal controls (1.07%). We found no associations between the magnitude of IOP decrease and the LC strain relief (P > 0.05), suggesting biomechanical variability across subjects. The LC displaced posteriorly, anteriorly, or not at all. Furthermore, we found linear associations between retinal sensitivity and LC effective strain relief (P < 0.001; high strain relief associated with low retinal sensitivity). CONCLUSIONS: We demonstrate that ONH displacements and strains can be measured in vivo and that TE can relieve ONH strains. Our data suggest a wide variability in ONH biomechanics in the subjects examined in this study. We further demonstrate associations between LC effective strain relief and retinal sensitivity.

Missed Hospital Appointments of Patients Receiving Ranibizumab Therapy for Neovascular Age-Related Macular Degeneration.

INTRODUCTION: The aim of this study was to investigate the frequency and duration of missed hospital appointments (MHAs) in a consecutive cohort of patients treated with ranibizumab for neovascular age-related macular degeneration (nAMD) and to assess their impact on outcomes of therapy in a real-world clinical setting. METHODS: Retrospective, cross-sectional study of consecutive patients attending medical retina clinics for nAMD treatment with ranibizumab. RESULTS: Seventy-eight eyes of 78 patients met the inclusion criteria for data analysis. Mean age was 78 years with mean follow-up of 27 months. Mean visual acuity (VA) was 52 ± 16 letters at baseline, 56 ± 17 letters at year 1 and 58 ± 16 letters at year 2. At the end of the second year, 90% of the patients had lost <15 letters, 26% had gained ≥15 letters and 10% had lost ≥15 letters. Nineteen patients had at least one MHA (24%) over 2 years. There were 26 MHA episodes in total leading to a median duration of 79 days (range 35-159) between attended hospital visits. None of these MHAs occurred during the first 3 months after treatment initiation. Mean VA and central retinal thickness difference between 2 years and baseline for the MHA group was not statistically different compared with the non-MHA group. CONCLUSIONS: Our data suggest that MHA may be a relatively common occurrence in AMD treatment clinics, but good outcomes of treatment can be achieved over 2 years despite missed hospital visits if patients are reviewed on average six times in the first year after an initial loading phase of three injections and nine times in the second year of treatment.

Long-term follow-up of standard photodynamic therapy with standardized small spot size for diffuse retinal pigment epitheliopathy.

PURPOSE: To evaluate the long-term efficacy and safety of standard-fluence photodynamic therapy (PDT) with verteporfin using the minimum PDT spot size in patients with diffuse retinal pigment epitheliopathy (DRPE). METHODS: This is a retrospective study of 67 DRPE cases treated with PDT using a standardized minimum spot size of 850 µm. Indocyanine green angiography (ICGA) was used to guide and determine the outcome of PDT treatment. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), recurrences, and adverse events were recorded and analyzed. RESULTS: The mean follow-up period of the study was 35.8 ± 16.6 months. There was a statistically significant difference in BCVA between baseline and the end of the follow-up (p<0.001). The BCVA improved in 41 eyes (61.2%), remained stable in 20 eyes (29.9%), and deteriorated in 6 eyes (9%). Accordingly, there was a statistically significant difference in CRT between the baseline and the last follow-up visit (p<0.001). The recurrence rate was 13.4% and only one eye presented a recurrence at the same site as the laser treatment. No adverse events were noted. CONCLUSIONS: Application of ICGA-guided standard PDT, with a laser spot size of minimum diameter, on the site of active leakage seems to be effective and safe in a long-term follow-up period, presenting improvement in BCVA, decrease in CRT, and low rate of recurrence.

Idiopathic retinal vasculitis, arteriolar macroaneurysms and neuroretinitis: clinical course and treatment.

BACKGROUND: The purpose of the study is to describe the clinical course and treatment of idiopathic retinitis, vasculitis, aneurysms and neuroretinitis. The study utilized non-randomized, retrospective and interventional case series. The eight eyes of six patients were analysed. Testing included wide fluorescein angiography, indocyanine green angiography and systemic evaluation. Treatment involved observation, panretinal laser photocoagulation (PRP) for peripheral retinal ischemia, grid laser for macular oedema and focal laser on the macroaneurysms. The main outcome measures were initial visual acuity (VA), initial stage at diagnosis, clinical course, surgical intervention, final VA, final stage and complications of disease. RESULTS: Five out of eight eyes with retinal ischemia in more than two quadrants that were treated with PRP and grid laser for macular oedema maintained excellent VA and demonstrated no progression of retinal ischemia during follow-up. The two eyes which exhibited retinal ischemia in less than two quadrants and macular oedema were treated with grid laser and focal laser on the macroaneurysms, but did not undergo PRP. VA improved by two lines of the Snellen chart, and there was no progression of retinal ischemia during the 3 and 4 years of follow-up. One eye with neither retinal ischemia nor macular oedema was not treated, and the clinical picture remained stable during the follow-up. CONCLUSION: Early PRP may be considered in the presence of angiographic evidence of peripheral retinal non-perfusion. However, treatment could be withheld until the patient develops retinal ischemia in more than two quadrants.

Anterior chamber morphology before and after laser peripheral iridotomy determined by Scheimpflug technology in white patients with narrow angles.

PURPOSE: To investigate the changes of anterior segment morphology in patients with narrow angles using a rotating Scheimpflug camera before and after laser peripheral iridotomy (LPI). MATERIALS AND METHODS: Forty-six eyes of 46 patients classified as primary angle closure suspect, primary angle closure, primary angle closure glaucoma, acute angle closure glaucoma, fellow eyes of acute angle closure glaucoma, and iris plateau configuration were enrolled in this prospective interventional case series. Anterior chamber volume (ACV), anterior chamber depth (ACD), and anterior chamber angle (ACA) were evaluated with an Scheimpflug camera, before and after LPI. RESULTS: After LPI, the average anterior chamber depth increased from 1.88 ± 0.36 to 1.93 ± 0.32 mm (P=0.49). The mean ACV increased from 74.6 ± 25 to 89.4 ± 21.1 mm (P=0.003). The average ACA increased from 21.1 ± 4.8 to 23.4 ± 3.8 degrees (P=0.01). Eyes with synechial angle closure (primary angle closure and primary angle closure glaucoma) demonstrated a significantly smaller change in ACV compared with eyes with appositional angle closure (primary angle closure suspect). CONCLUSIONS: ACV and ACA determined by Scheimpflug technology increase to a statistically significant degree and this change appears to be more pronounced in cases of appositional angle closure.

Exemestane-induced corneal epithelial changes.

We report a case of corneal epithelial changes that occurred as ocular side effects of treatment with exemestane, a selective steroidal aromatase inhibitor. A 55-year-old woman presented to our outpatient department for routine eye examination. Clinical examination revealed bilateral corneal gray-white bands appearing as intraepithelial microcysts. Her past medical history included breast cancer, for which she underwent chemotherapy and subsequent treatment with exemestane. She was followed up for 1 year, during which the clinical picture of the cornea remained unchanged in both eyes and visual acuity remained unaffected. A causal connection seems to be possible between systemic treatment with exemestane and persisting corneal intraepithelial cysts.

A rare case of peripheral ulcerative keratitis in temporal arteritis.

PURPOSE: To present a case of peripheral ulcerative keratitis (PUK) that progressed to corneal perforation in the setting of recently diagnosed temporal arteritis. METHODS: A 76-year-old man presented with a 2-week history of red eye and gradual loss of vision in the right eye. His medical history included recently diagnosed temporal arteritis without previous eye involvement. Clinical examination revealed severe peripheral corneal melting leading to corneal perforation. RESULTS: The patient was treated in the acute phase with topical dexamethasone drops and oral prednisolone. Perforation was sealed with cyanoacrylate glue. Azathioprine was also administered. Inflammation was resolved and his eye remains quiet. CONCLUSIONS: To our knowledge, this is the first reported case of PUK in the background of temporal arteritis.