Title - Long term outcomes of vitrectomy and ERM peel: Can pre-operative metamorphopsia measured using the D-Chart help improve surgical candidate selection?

PURPOSE: To assess the predictive value of pre-operative metamorphopsia, measured using the D-Chart, in patients undergoing epiretinal membrane (ERM) surgery and how this relates to improvement in quality of life after surgery. METHODS: 17 patients from vitreo-retinal surgery clinics at a tertiary ophthalmology centre were recruited when listed for pars plana vitrectomy (PPV) with ERM peel between September 2019 - February 2020. Pre-operatively patients underwent visual acuity (VA), Visual-Function Index 14 (VF-14) and metamorphopsia (D-Chart-Thomson Software Solutions) assessment and answered a questionnaire regarding cardinal ERM symptoms. Post-operatively patients were re-assessed in the same domains. RESULTS: 13 patients completed the protocol (inclusion rate 76%) with a mean follow-up of 32.1 (± 3.1) months. Mean pre-operative VA of the affected eye was 0.42 logMAR (± 0.25). Mean pre-operative VF-14 score was 81.51 (± 12.8) and mean M-Score of the affected eye was 14.6 (± 12.7). Post-operatively, mean VA of the operated eye was 0.11 logMAR (± 0.11), mean VF-14 score was 97.4 (± 3.8) and mean M-Score was 1.31 (± 2.8). Mean improvement in VA was 0.31 logMAR (p < 0.001), in VF-14 15.9 (p = 0.002), and M-Score -13.3 (p = 0.003). There was a significant association between pre-operative D-Chart score and improvement in VA (r = -0.570, p = 0.042), visual functioning (r = 0.606 p = 0.028) and metamorphopsia (r = 0.916 p < 0.001), with those demonstrating poorer D-Chart scores showing greater improvements. CONCLUSION: Pre- and post-operative visual distortion measured using the D-Chart, correlates with vision related quality of life in patients undergoing epiretinal membrane surgery. Patients with worse pre-operative distortion scores noticed the greatest improvements in distortion and vision related quality of life following surgery. With a mean follow-up time of 32.1 months, this long-term follow-up data further reinforces the efficacy of vitrectomy and ERM peel by demonstrating significant and sustained improvement in visual acuity, metamorphopsia and visual functioning. The authors suggest there is a role for D-Chart assessment pre-operatively to improve selection of patients in ERM surgery.

PACS plus criteria: a retrospective cohort review of 612 consecutive patients treated with bilateral YAG peripheral iridotomies.

INTRODUCTION: With an ageing population and better life expectancy, the prevalence of angle closure disease is expected to increase by 20% per decade. In 2022, the Royal College of Ophthalmologists (RCOphth) issued a guideline on managing angle closure disease. Hospital eye service (HES) referral and prophylactic treatment are recommended only for primary angle closure suspect (PACS) with "Plus" features only. We aimed to examine patients previously treated with YAG peripheral iridotomies (YAG PI) for the presence of "PACS Plus" features. METHODS: A retrospective cohort study of consecutive patients treated with YAG PI between 2015 and 2019 at a tertiary referral NHS eye centre was reviewed. Cases were examined to identify and classify patients into Primary Angle Closure (PAC), PACS, and Primary Angle Closure Glaucoma (PACG). Patients with PACS were studied for "Plus" features. RESULTS: Six hundred twelve patients with gonioscopy-confirmed angle closure (defined as a minimum 180 degrees iridotrabecular contact) treated with YAG PI from years 2015 to 2019 were included in the analysis. The mean age of patients presenting with angle closure disease was 68.5 years (SD 11.3). There were 390 (63.7%) patients with PACS, 102 (16.6%) with PAC and 120 (19.7%) with PACG. Of the PACS patients, 159(40.8%) patients had no "Plus" features. 181 (40.2%) patients had 1 "Plus" feature, 37 (9.5%) had 2 "Plus" features and 13 (3.3%) patients had 3 "Plus" features. CONCLUSION: In our cohort, a considerable proportion (40.8%) of PACS patients treated with YAG PI did not have Plus features and therefore that would not meet the proposed criteria for HES referral and YAG PI. With the proposed guidance, we expect a considerable reduction in HES referrals. Nonetheless, community optometry services should be supported and trained to provide monitoring for patients with PACS not referred to the HES.

Adherence to topical glaucoma therapy in patients attending virtual clinics.

BACKGROUND/OBJECTIVES: Poor adherence to medical therapy is a major challenge to the effective treatment of chronic diseases including glaucoma. Potential factors influencing adherence include treatment complexity and patient understanding of disease and health beliefs. An increasing number of patients are seen in virtual clinics, where there is no face-to-face consultation, potentially reducing opportunities for patient education and reinforcement of the importance of treatment. The aim of this study was to examine adherence among patients attending a virtual glaucoma clinic. METHODS: 100 consecutive patients attending the virtual clinic were surveyed, with 78 using topical medications included in the analysis. All patients completed a validated adherence questionnaire with a score of >2 defined as poor adherence. The relationship between adherence and age, sex, duration since diagnosis, and disease severity was examined. RESULTS: The mean age was 73.1 ± 13.4 years, with an average mean deviation of -5.9 ± 5.5 dB and duration since first diagnosis of 9.0 ± 5.7 years. 93.6% reported self-instilling eye drops. Seventy-one patients (91.0 %) had good self-reported adherence. Multivariate logistic regression revealed those instilling eye drops independently had higher odds of good adherence. CONCLUSIONS: The level of medication adherence in the virtual glaucoma clinic was higher than adherence in previous studies examining patients attending face-to-face clinics. Virtual clinics should incorporate methods to ensure effective two-way communication with patients and strategies for patient education.

Novel biallelic USH2A variants in a patient with usher syndrome type IIA- a case report.

BACKGROUND: Usher Syndrome is the commonest cause of inherited blindness and deafness. The condition is clinically and genetically heterogeneous, with no current treatment. We report a case carrying novel biallelic variants in USH2A causing progressive early adolescent onset visual and hearing impairment consistent with Usher Syndrome Type IIA. CASE PRESENTATION: Our patient presented at age 13 with progressive visual field loss and hearing loss, associated with early onset of cataract in her 40s requiring lens extraction. Now 52 years old, latest best corrected visual acuity (BCVA) stands at Logmar Right Eye (RE) 0.8 and Left Eye (LE) 0.2, with significantly constricted visual fields bilaterally. She was registered partially sighted age 46. Clinical and molecular genetic assessment of the proband was consistent with a diagnosis of Usher Syndrome Type IIA. Genetic testing identified two novel USH2A variants, resulting in the premature termination codon p.Leu30Ter and a missense mutation p.Cys3251Tyr. Segregation analysis confirmed that these variants were biallelic in the affected case. Comprehensive in silico analysis confirmed that these mutations are the probable cause of Usher Syndrome Type IIA in this individual. CONCLUSIONS: The identification of novel mutations in USH2A increases the spectrum of genetic variations that lead to Usher Syndrome, aiding genetic diagnosis, assessment of patient prognosis, and emphasising the importance of genetic testing to identify new mutations in patients with undiagnosed progressive visual loss.

Ten-year mortality and long-term visual acuity outcomes in patients with exudative age-related macular degeneration treated with intravitreal anti-vascular endothelial growth factor injections.

PURPOSE: There are limited real-world data on long-term mortality and visual outcomes in patients treated with anti-vascular endothelial growth factor (VEGF) for exudative age-related macular degeneration (exudative AMD). We assessed 10-year mortality and clinical outcomes in exudative AMD patients treated with intravitreal therapy (IVT) anti-VEGF injections on a pro-re-nata (PRN) regime following a standard loading regime. METHODS: Retrospective cohort study of the first 216 exudative AMD patients receiving IVT anti-VEGF for exudative AMD at a public tertiary referral hospital in Scotland. Main outcome measures were mortality, cause of death and best-corrected visual acuity (BCVA). RESULTS: A total of 216 patients were included. Mean age at presentation was 79.1 years [standard deviation (SD) 6.9]. Mean follow-up duration was 6.6 years (SD 3.2) during which there was a mean 24.3 Early Treatment Diabetic Retinopathy Study (ETDRS) letter loss in BCVA (P < 0.0001). Patients received a mean of 2.2 (SD 1.8) injections per year of follow-up. Overall, 52.6% (113/216) died during the period studied. Observed annual mortality incidence risk was 6.5% (SD 3.1) and was found to be significantly lower (P = 0.0064) than the expected annual death incidence risk (9.6%, SD 1.5) based on age and sex standardised Scottish mortality risk. The most common causes of death were malignancies (21.3%) and infection (20.0%). CONCLUSIONS: This study highlights the relatively good long-term prognosis in vision and mortality in exudative AMD treated with a PRN regime in the real world. Although the majority lost vision, the rate of decline was significantly slower than that which would have been experienced in the pre-anti-VEGF era and reassuringly standardised mortality risk was lower than the national average.

A modified transconjunctival technique for botulinum toxin chemodenervation of levator palpebrae superioris for corneal protection.

BACKGROUND: Botulinum toxin (BTX) is useful for inducing temporary ptosis in patients with ocular surface disease. However, transcutaneous BTX often causes inadvertent superior rectus (SR) paresis. Furthermore, Muller's muscle is unaffected by transcutaneous BTX, resulting in lagophthalmos and incomplete ptosis. METHODS: We report a novel BTX injection technique, in which the upper lid is double everted over a Desmarres retractor, and BTX injected transconjunctivally at the superior aspect of Muller's muscle, where it lies close to levator palpebrae superioris. RESULTS: In our series of 21 patients, one had inadvertent subcutaneous BTX and developed incomplete ptosis. The remaining 20 patients had complete ptosis within 48 h. No patients had SR underaction. CONCLUSION: We conclude that transconjunctival BTX injection is safe, effective, and superior to transcutaneous BTX injection, because of the low risk of superior rectus underaction and incomplete ptosis.

A short-sighted approach to high myopia-not just an eye problem.

We present the first case of rapid onset high myopia in early childhood as the presenting feature of Loeys-Dietz syndrome. The patient progressed from a normal degree of hyperopia (+2 diopter sphere [DS]) at 18 months of age to high myopia (-10 DS) 9 months later. Subsequent genetic testing revealed both her brothers and her father to carry the same TGFB3 pathogenic variant. This case aims to highlight the importance of considering systemic conditions in children with high myopia.

Visual Field Artifacts From Face Mask Use.

PURPOSE: The coronavirus (COVID-19) pandemic has had a profound impact on how glaucoma care is delivered, necessitating reduced clinic flow, social distancing, and use of face coverings by patients and staff. This case highlights the need to be aware of improperly fitted face masks as a cause of artifact on standard automated perimetry (SAP). CLINICAL PRESENTATION: A 32-year-old female underwent SAP with the 24-2 SITA Fast test of the Humphrey Field Analyzer wearing an ear-loop surgical face mask. At the end of testing, it was noted that the mask had ridden up the patient's face. Small amounts of condensate were noted on the perimeter lens. CLINICAL FINDINGS: SAP demonstrated good reliability indices but in both eyes, there was a marked reduction in sensitivity inferiorly. The glaucoma hemifield test was outside normal limits. It was ensured the upper border of the mask was well sealed with the loops secured around the ears and nasal strip of the mask pinched down. Visual fields were repeated and were found to be normal. CONCLUSIONS: Poorly fitting face masks represent a new cause of visual field artifact which may mimic pathologic field defects. Without careful attention during testing, the cause of such artifacts may not be apparent, especially as reliability indices may be normal. Adjustments to the fit of face masks may help prevent fogging or mask slippage and increase test reliability.

"First do no harm." A systematic review of the prevalence and management of antipsychotic adverse effects.

AIMS: We aim to identify the prevalence and management strategies of nine clinically important categories of antipsychotic adverse effects, namely: extrapyramidal symptoms; sedation; weight gain; type II diabetes; hyperprolactinaemia; metabolic syndrome, dyslipidaemia; sexual dysfunction; and cardiovascular effects. BACKGROUND: Antipsychotic drugs are widely prescribed for schizophrenia and other mental disorders. The adverse effects of antipsychotics are common, with a potential negative impact on adherence and engagement. Despite this, the scientific study of the prevalence or management of adverse antipsychotic effects is a neglected area. METHOD: A systematic review was undertaken using pre-defined search criteria and three databases, with hand searching of citations and references. Inclusion was agreed on by two independent researchers after review of abstracts or full text. Quality analysis of included studies was conducted using pre-agreed criteria. RESULTS: In total, 53 studies met inclusion criteria, revealing the following: (1) antipsychotic polypharmacy was associated with increased frequency of adverse effects, and (2) a longer duration of treatment is associated with greater severity (e.g. higher BMI); (3) clozapine was more strongly associated with metabolic disturbance than other antipsychotics in three studies and olanzapine was associated with the most weight gain in three studies; (4) hyperprolactinaemia was more common in women than men, but 50% men noted sexual dysfunction versus 25-50% in women; (5) despite clinical guideline recommendations there is a low rate of baseline testing for lipids and glucose; and (6) seven studies described adverse effect management strategies, but only two examined their efficacy - one found a significant reduction in weight with non-pharmacological group therapy and the other found a significant reduction in dyslipidaemia with statins. CONCLUSIONS: Antipsychotic adverse effects are diverse and frequently experienced, but are not often systematically assessed. There is a need for further scientific study concerning the management of these side effects.