Treatment choices for diabetic macular oedema: a guideline for when to consider an intravitreal corticosteroid, including adaptations for the COVID-19 era.

First-line treatment of centrally involved diabetic macular oedema (CI-DMO) is often with an anti-vascular endothelial growth factor (anti-VEGF) agent. Although this can provide efficacy in the majority of eyes, a sizeable proportion do not respond sufficiently and many continue to receive anti-VEGF therapy after it may be optimal. This imposes a treatment burden on both patients and clinicians and, most importantly of all, can be sight threatening. Changing treatment to an intravitreal corticosteroid implant at the appropriate time may help optimise patient outcomes and reduce injection frequency, thereby reducing treatment burden. Eight retina specialists convened to discuss how to ensure eyes with CI-DMO receiving intravitreal anti-VEGF therapy are evaluated for a potential change to intravitreal corticosteroid therapy at the most effective time in their treatment journey. They concluded that clear criteria on when to consider changing treatment would be helpful and so developed a consensus guideline covering key decision points such as when and how to assess response to anti-VEGF therapy, when to consider a change to corticosteroid therapy and when and how to assess the response to corticosteroid therapy. The guideline was developed before the COVID-19 pandemic but, with the additional challenges arising from this including even greater pressure on clinic capacity, it is more important than ever to reconsider current working practices and adopt changes to improve patient care while also easing pressure on clinic capacity, reducing hospital visits and maintaining patient safety. This publication therefore also includes suggestions for adapting the guidelines in the COVID-19 era.

Importance of Anatomical Efficacy for Disease Control in Neovascular AMD: An Expert Opinion.

BACKGROUND: Neovascular age-related macular degeneration (nAMD) presents a significant treatment burden for patients, carers and medical retina services. However, significant debate remains regarding how best to manage nAMD when assessing disease activity by optical coherence tomography (OCT), and particularly the significance of different types of fluid and how the understanding of anatomical efficacy can influence treatment strategies. This article provides opinion on the practical implications of anatomical efficacy and significance of fluid in the management of nAMD and proposes recommendations for healthcare professionals (HCPs) to improve understanding and promote best practice to achieve disease control. METHODS: An evidence-based review was performed and an expert panel debate from the Retina Outcomes Group (ROG), a forum of retinal specialists, provided insights and recommendations on the definition, role and practical implications of anatomical efficacy and the significance of fluid at the macula in the management of nAMD. RESULTS: The ROG has developed recommendations for achieving disease control through a zero-tolerance approach to the presence of fluid in nAMD as patients who avoid fluctuations in fluid at the macula have better visual outcomes. Recommendations cover five key areas: service protocol, training, regimen, multidisciplinary teams and engagement. This approach facilitates more standardised protocol-based treatment strategies. CONCLUSIONS: Targeting a fluid-free macula and aiming for disease control are essential to improve outcomes. As new therapies and technologies become available, drying the macula and maintaining disease control will become even more achievable. The outlined recommendations aim to promote best practice among HCPs and medical retina services to improve patient outcomes.

Prevalence of cystoid macular oedema, epiretinal membrane and cataract in retinitis pigmentosa.

BACKGROUND/AIMS: To report the prevalence of treatable complications (cystoid macular oedema, CME; epiretinal membrane, ERM and cataract) in patients with retinitis pigmentosa (RP). METHODS: Consecutive patients with RP attending a tertiary eye clinic in 2012. Spectral domain-optical coherence tomography was used to determine presence of CME and ERM. Clinic records were reviewed to identify cataract and pseudophakia. Multivariable analyses adjusted for age, gender and other confounders. RESULTS: Data are presented for 338 eyes from 169 patients. CME was present in 58.6% of patients and 50.9% of eyes and was bilateral in 73.7%. ERM, cataract and pseudophakia were present in 22.8%, 23.4% and 11.2% eyes, respectively. In multivariable analyses, CME was associated with younger age (OR 0.81, 95% CI 0.67 to 0.98) but not with gender. Patients with ERM and cataract/pseudophakia were less likely to also have CME (OR 0.19, 95% CI 0.09 to 0.40 and OR 0.37, 95% CI 0.16 to 0.84, respectively). CME was most prevalent in patients with autosomal-dominant inheritance (71.4%), followed by autosomal recessive/sporadic inheritance (58.9%) and least likely in persons with X linked inheritance (12.5%, p<0.001). CONCLUSIONS: The prevalence of treatable RP complications is high and suggests it may be clinically beneficial to screen patients with RP to identify those who may benefit from current or future interventions.

Initiation and maintenance of a Treat-and-Extend regimen for ranibizumab therapy in wet age-related macular degeneration: recommendations from the UK Retinal Outcomes Group.

The treatment of neovascular (wet) age-related macular degeneration (AMD) with ranibizumab is now very well established in terms of efficacy and safety. Recent clinical trials and real-world studies have demonstrated the advantages of a Treat-and-Extend (T&E) regimen, and many hospital departments are now in the process of adopting this new regimen in favor of the pro re nata regimen for initiating and continuing ranibizumab therapy for patients with wet AMD. The comprehensive spectrum of issues related to implementation of the regimen is covered qualitatively in ten didactic topics provided by a group of clinicians with direct experience of this regimen in their department. The topics include definition, new and previously treated eyes, management of high-frequency injections, maximum extensions, discontinuing T&E, bilateral cases, clerical, audit, and patient counseling. This article aims to provide a useful resource for the implementation of the T&E regimen. A quantitative summary of the visual outcomes in key publications is also provided in this article. This article should be a valuable resource for staff training.

VITREOMACULAR TRACTION AFFECTS ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR TREATMENT OUTCOMES FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To evaluate the effect of vitreomacular traction (VMT) on visual acuity outcomes and central retinal thickness (CRT) measurements after intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for treatment of exudative age-related macular degeneration (AMD). METHODS: In this retrospective series, the authors evaluate the clinical records and optical coherence tomography of 34 eyes of 32 patients, with VMT confirmed on optical coherence tomography at baseline, to assess the effects of VMT on anti-VEGF therapy for newly diagnosed exudative wet AMD. Best-corrected visual acuity at baseline, 1, 3, 6, 9, and 12 months and CRT at baseline, 3, 6, and 12 months were assessed. Comparison was made with a control group of 29 eyes of 28 patients with wet AMD and no VMT on optical coherence tomography and with key variable-dosing studies for anti-VEGF in exudative AMD (CATT, HARBOR, PrONTO, SUSTAIN, and Gupta et al). RESULTS: Best-corrected visual acuity results showed a visual acuity improvement that peaked at 3 months with 2.47 letters, well below other variable-dosing studies for anti-VEGF therapy in exudative AMD. This was then followed by a steady decline with mean best-corrected visual acuity at 12 months ending below the baseline level (-1.00 letters) compared with a gain of 9.39 letters in the control group at 12 months. Comparison of the mean CRT in the VMT group between baseline and 12 months showed no significant difference (P = 0.67), whereas the PrONTO study and control groups showed a highly significant difference at 12 months compared with baseline (P < 0.001). Mean CRT values at 6 months and 12 months were essentially at baseline levels (0.26 µm, -0.62 µm, respectively). CONCLUSION: Vitreomacular traction at baseline, existing concurrently with newly diagnosed exudative AMD treated with intravitreal anti-VEGF therapy on a variable-dosing regime, was associated with poorer visual outcomes and a decreased response to reduction in CRT, compared with a control group of wet AMD without VMT and compared with major variable-dosing studies for intravitreal anti-VEGF in exudative AMD.

Electronic prescribing and prescription design in ophthalmic practice.

PURPOSE: Prescription and drug errors are common causes of adverse clinical events, posing a significant risk to safe patient care. Although there has been a movement to increase the use of electronic prescribing, concerns over feasibility suggest that improving the design of written prescriptions to minimize missing information may still be worthwhile. This retrospective cross-sectional study examined the effect on prescription completeness of electronic prescriptions and adding information prompts to written prescriptions. We hypothesized that electronic prescription would be superior to written prescriptions on prescription completeness and the inclusion of information prompts in written prescriptions would result in increased recording of the prompted information. METHODS: Chi-square analysis was used to examine differences among 50 consecutive electronic discharge prescriptions, 100 consecutive outpatient prescriptions (with prompts for medicine duration but not form, frequency, or laterality), and 100 consecutive day surgery prescriptions (with prompts for form, frequency, and laterality) in the provision of 10 key pieces of information. RESULTS: Electronic prescriptions resulted in 100% complete information across all domains and more complete information on medicine duration than day surgery prescriptions. Written outpatient prescriptions (with duration prompts but not laterality prompts) were superior in recording duration and inferior in recording laterality than day surgery prescriptions (without duration prompts but with laterality prompts). CONCLUSIONS: Our results support the use of electronic prescribing. Where written prescribing must be used, our study highlights the importance of including information prompts to minimize missing information and improve patient safety.

Which quality of life score is best for glaucoma patients and why?

BACKGROUND: The glaucomas are generally asymptomatic diseases until they are very advanced. They affect 2% of the population over 40 years of age and therefore represent a significant public health issue. There have been a number of attempts to develop quality of life scales for the disease. This review discusses the pros and cons of these scales and suggests the best of the current ones for use in a clinical setting. METHODS: Medline, Embase and Google Scholar were searched for relevant articles. No time period was defined and all types of article were included. RESULTS: 11 Quality of Life scores were identified that have been used with glaucoma patients. CONCLUSION: There is no generally accepted 'best' Quality of Life instrument for use in glaucoma. Many of the scales are biased towards physical symptoms and do little to address the personal or social factors of the disease. Further work is needed to produce scales that address all these areas as well as being simple to administer in a clinical setting.

High altitude and retinal detachment.

We describe the case of a 38-year-old man who presented with bilateral retinal detachments following a trek in Tibet during which time he took acetazolamide for prophylaxis of acute mountain sickness (AMS). This is the first time that retinal detachment has been described following a sojourn to high altitude. Acetazolamide has not been previously associated with retinal detachment when used for prophylaxis of AMS or indeed during its many ophthalmic applications. The patient made a good recovery following surgery, and we speculate that, although this could be coincidental and the patient did have risk factors for retinal detachment, the possibility of a causal link to high altitude should at least be entertained. We hypothesize that vitreous dehydration may have caused vitreoretinal traction and that hypobaric hypoxia may have changed the dynamic relationship between vitreous, retina, retinal pigment epithelium (RPE) and choroid, causing preexisting retinal holes to open, allowing subretinal fluid to accumulate and detach the retina.

Unilateral external ophthalmoplegia in Miller Fisher syndrome: case report.

BACKGROUND: A description of the diagnostic features of Miller Fisher syndrome. CASE PRESENTATION: The clinical presentation, investigation, and subsequent progress of our patient with clinical unilateral external ophthalmoplegia. CONCLUSION: Our case demonstrates the presentation of clinical unilateral external ophthalmoplegia as part of the full triad of Miller Fisher syndrome.