Early Experience With Full-scope Shared-care Teleglaucoma in Canada.

PRCIS: Large Canadian full-scope, shared-care teleglaucoma facilitates efficient management and diversion of medically stable patients away from overburdened subspecialty clinics while allowing patients the convenience of shorter travel, shorter wait time, and continuity with one provider. This report shares Care1 protocol, early patient characteristics, and quality data. PURPOSE: This paper describes early experience with Care1, a large full-scope, shared-care teleglaucoma program. Optometrists located in high-demand locations saw patients in-person, acquired clinical history, performed a physical examination, organized diagnostic testing, then uploaded data to a proprietary online platform where they were able to collaborate with participating ophthalmologists to make plans for patient care. MATERIALS AND METHODS: The Care1 database was queried for all patients with a diagnosis of glaucoma or glaucoma suspect seen between February 2016 and March 2017. Clinical characteristics like diagnosis, ocular medication history, best-corrected visual acuity, intraocular pressure, cup-to-disc ratios, optical coherence tomography imaging results, and central corneal thickness were collected. Quality metrics studied included rates of referral to an in-person ophthalmologist and consistency of cup-to-disc assessments between in-person optometrists and remote ophthalmologists. RESULTS: A total of 4070 patients received care at a Care1 teleophthalmology site in 2 provinces for glaucoma assessment from February 2016 to March 2017. The population was 55.1% female, and the average age was 57.8 years. Overall, 97.3% of patients had a best-corrected visual acuity between 20/20 and 20/40 and 3.3% had an intraocular pressure >26. An in-person consultation with an ophthalmologist was recommended for 1.9% of patients. CONCLUSION: Early experience with this full-scope, shared-care teleglaucoma program in Canada indicates it is a convenient, collaborative model of care for glaucoma suspects, and medically stable glaucoma patients.

Phenotypic Spectrum of Peters Anomaly: Implications for Management.

PURPOSE: The aim of this study was to characterize the wide phenotypic spectrum of Peters anomaly and to suggest a management algorithm based on disease phenotype. METHODS: The charts of all children diagnosed with Peters anomaly between January 2000 and December 2013 were reviewed retrospectively. Anterior segment color photographs, anterior segment optical coherence tomography, and ultrasound biomicroscopy images were used to phenotype disease severity and to guide management. Disease severity was categorized to Peters anomaly type I and II according to lens involvement. Peters anomaly type I and II were further categorized from mild to severe disease according to the size and location of corneal opacity. Associated systemic findings were also documented. RESULTS: Eighty eyes of 54 patients with Peters anomaly were identified, of which 28 (51.9%) had unilateral disease. Peters anomaly type I was present in 40 patients (57 eyes, 71.2%) and Peters anomaly type II in 14 patients (23 eyes, 28.8%). Nine eyes (11.3%) had phenotypic features that required observation only, 24 eyes (30%) were amenable to pupillary dilation, 43 eyes (53.8%) with large, dense central opacity required penetrating keratoplasty, and 4 eyes (5.0%) had no intervention because of very poor prognostic features. Associated systemic abnormalities occurred frequently in Peters anomaly (n = 20, 37.0%), with congenital heart defect being the most common morbidity (n = 10, 18.5%). CONCLUSIONS: Peters anomaly presents with a variable phenotype ranging from minimal peripheral corneal opacity to extensive iris and lens adhesions with dense central corneal opacity detrimental to vision. Management can be standardized and guided by an algorithm based on phenotypic severity. Systemic abnormalities should be ruled out, regardless of the severity of Peters anomaly.

Long-Term Visual Outcomes and Clinical Course of Patients With Peters Anomaly.

PURPOSE: To present long-term clinical and visual outcomes of patients with Peters anomaly. METHODS: The charts of all patients diagnosed with Peters anomaly from January 2000 to December 2012 were reviewed retrospectively. Peters anomaly was classified as type I (with no lens involvement) or type II (presence of keratolenticular adhesions or cataract), with further severity grading to mild, moderate, and severe disease depending on corneal opacity location and size. Mild cases were observed. Moderate cases were managed with pupillary dilation either pharmacologically or surgically. Penetrating keratoplasty (PKP) was reserved for more severe opacity. The main outcome measures were final best spectacle-corrected visual acuity (BSCVA), incidence of glaucoma, graft survival, and nystagmus rates. RESULTS: Sixty eyes of 40 patients were included in the study. The median age of patients at presentation was 0.5 ± 20.7 months (range, 0.0-111.0 months), with a mean follow-up time of 75.8 ± 52.9 months (range, 12.1-225.3 months). Overall, final best spectacle-corrected visual acuity ranged from 0.1 logMAR to no light perception with 33 eyes (55.9%) achieving vision of 1.0 logMAR or better. Clear grafts at the last follow-up were obtained in 67.6% (25/37) of transplanted eyes, 76.0% (19/25) in Peters type I, and 50.0% (6/12) in Peters type II (P = 0.11). The probability of a clear graft at 10 years was 74.2% and 38.9% for type I and type II, respectively. Glaucoma was diagnosed in 33.3% eyes, 90.0% of which occurred after PKP. Nystagmus was highly associated with PKP intervention, occurring in 81.1% (30/37) of eyes undergoing PKP compared with 34.8% (8/23) of eyes with no PKP (P = 0.0003). CONCLUSIONS: Visual rehabilitation in Peters anomaly remains a challenge, but outcomes can be optimized using a comprehensive clinical management algorithm according to disease severity.

Incidence of nonarteritic ischemic optic neuropathy following topical clear corneal cataract surgery: survey and meta-analysis.

OBJECTIVE: We estimate the incidence and characteristics of post-cataract-surgery nonarteritic ischemic optic neuropathy (PCNAION) after topical clear corneal cataract extraction (CCCE) in Canada. DESIGN: Canada-wide internet survey and meta-analysis PARTICIPANTS: All certified Canadian ophthalmologists in the Canadian Ophthalmological Society directory, or belonging to a provincial ophthalmology internet group. METHODS: Identical surveys were distributed to 5 regions in Canada. CCCE surgeons were asked to estimate the number of CCCE they had performed in their career, and the number of PCNAION events that occurred within 1 year after CCCE. The results were analyzed using a random effects meta-analysis of proportions for rare events. RESULTS: The estimated survey response rate was 18%-32%. The 182 survey respondents performed a total of 1 499 694 CCCE with 107 events of PCNAION. Twenty-six percent of surgeons had at least one patient with PCNAION. Meta-analysis revealed a pooled estimate incidence of 2.8 PCNAION events (95% confidence interval 1.6-4.7) per 100 000 cataract procedures during the year after cataract surgery. Seventy-seven percent (82/107) of the PCNAION cases occurred within 3 weeks of surgery, and 7 patients had bilateral PCNAION. CONCLUSIONS: PCNAION is a rare complication after topical CCCE. Its incidence is important to estimate for patient care and epidemiologic reasons.

Optimizing preoperative requirements for outpatient cataract surgery at the Royal Alexandra Hospital.

OBJECTIVE: To evaluate preoperative testing for cataract surgery, implement stakeholder-driven change, and increase the number of patients who arrived for surgery with complete preoperative requirements, for the purpose of delivering safe, high-quality, and cost-effective care for patients. DESIGN: Quality improvement. PARTICIPANTS: Cataract surgery patients, health care staff in Ophthalmology Day Surgery, an Ophthalmology improvement team, the Clinical Section Heads of Ophthalmology and Anaesthesia, Quality Consultants, and members of the Quality Council participated in this study. METHODS: A lean quality improvement approach was used to define and build understanding of the problem. Between July and November 2016, a chart-based reporting system captured all patients who arrived for cataract surgery with expired or incomplete preoperative requirements. A cost analysis was completed, and evidence was reviewed to ensure alignment with best practice preoperative recommendations. RESULTS: On average, 25% (619/2451 over a 17-week period) of patients per day arrived at the Ophthalmology Day Surgery for cataract surgery with incomplete and/or expired physical history forms and ECGs. An improvement team worked to implement a radical improvement idea and relied on an existing questionnaire to ensure patient safety preoperatively. CONCLUSIONS: Based on the literature, best practice guidelines, and a cost analysis, it was decided that patients undergoing routine cataract surgery in Edmonton Zone Hospitals under regional anaesthesia would no longer require physician history and physicals and ECGs. Elimination of the preoperative requirements for all but select high-risk patients meant that 100% of patients who arrived for cataract surgery would not have outstanding presurgery requirements.