Prevalence and Associations of Epiretinal Membranes in an Elderly English Population: The Bridlington Eye Assessment Project.

Purpose: To determine the prevalence and risk factors of epiretinal membranes (ERMs) in an adult English population. Methods: The Bridlington Eye Assessment Project is a population-based study of eye disease among residents aged 65 years or older. Comprehensive interviews and ophthalmic examinations were conducted to assess potential risk factors. Digital mydriatic nonstereoscopic 30° colour fundus photography (CFP) was performed. ERMs were classified as primary/idiopathic or secondary on the basis of findings from the ocular examination and the structured questionnaire. Logistic regression models were used to determine the independence of potential risk factors for idiopathic ERMs. Results: In a comprehensive screening of 3588 patients aged over 65, we identified an eye-based prevalence of ERMs of 4.26% and a subject-based prevalence of ERMs of 6.88%. The majority of these cases were idiopathic in nature (90.7%), while 9.3% were secondary ERMs; predominantly, there was a history of cataract surgery (43.5%). No significant correlation between idiopathic ERMs and factors such as age, gender, diabetes, hypertension, a history of stroke, or the presence of AMD was found. Conclusions: The prevalence of ERMs in an elderly English population and the proportion of idiopathic and secondary ERMs are similar to previous reports. However, in elderly patients aged over 65 years, age is not a risk factor for the presence of idiopathic ERMs. The presence of diabetes, hypertension, a history of stroke, and AMD of any grade was not associated with ERMs.

Optical coherence tomography angiography: a review of the current literature.

This narrative review presents a comprehensive examination of optical coherence tomography angiography (OCTA), a non-invasive retinal vascular imaging technology, as reported in the existing literature. Building on the coherence tomography principles of standard OCT, OCTA further delineates the retinal vascular system, thus offering an advanced alternative to conventional dye-based imaging. OCTA provides high-resolution visualisation of both the superficial and deep capillary networks, an achievement previously unattainable. However, image quality may be compromised by factors such as motion artefacts or media opacities, potentially limiting the utility of OCTA in certain patient cohorts. Despite these limitations, OCTA has various potential clinical applications in managing retinal and choroidal vascular diseases. Still, given its considerable cost implications relative to current modalities, further research is warranted to justify its broader application in clinical practice.

Combined aqueous misdirection and persistent choroidal effusions following implantation of a Preserflo MicroShunt.

AIM: To describe a case of aqueous misdirection complicated by subsequent persistent choroidal effusions following implantation of a Preserflo MicroShunt (PMS) device to treat advanced closed angle glaucoma. METHODS: A 67-year-old caucasian female with advanced primary angle-closure glaucoma on four medications with an intraocular pressure (IOP) of 26 mm Hg was listed for a PMS insertion with mitomycin C (MMC). RESULTS: Past ocular history was significant for pseudophakia and previous yttrium aluminum garnet (YAG) peripheral iridotomy. Surgery was uneventful but on the first postoperative day, she developed aqueous misdirection complicated by subsequent development of persistent uveal effusions. Conventional treatment strategies including atropine drops, YAG hyaloidotomy and choroidal effusion drainage proved ineffective. A combination of oral steroids and pars plana vitrectomy (PPV) along with an irido-zonulo-hyloidectomy (IZH) proved efficacious. CONCLUSION: To the best of the author's knowledge, this is the first published case of aqueous misdirection complicated with the presence of significant, unresolving choroidal effusions, highlighting the possibility and sequelae of comorbid pathology in nanophthalmic eyes.

Hinged tarsal flap: A novel technique for canthal tendon reconstruction.

BACKGROUND/OBJECTIVES: Reconstruction of the medial canthal region is challenging due to the complex regional anatomy. Options to reconstruct a medial canthal tendon sacrificed during tumour removal is limited. We present a novel surgical technique where hinged tarsal flap serves to substitute the canthal tendons. METHODS: This is a retrospective consecutive case series of five patients that underwent canthal reconstruction using this novel technique between May and December 2020. Electronic patient records and medical photograph database were reviewed. Patient demographics, co-morbidities, location and histology of the lesion, size of the resultant defect, reconstructive technique and post-operative complications were noted. RESULTS: All patients had good eyelid stability with no malposition, lagophthalmos or exposure keratopathy. No or minimal distraction of the eyelid from the globe, good cosmetic outcomes and no troublesome watering was reported. No wound dehiscence, no sight loss and no further surgical intervention was warranted. CONCLUSION: Multiple techniques have previously been described to reattach the medial canthal tendon with silk or supramid sutures. Transnasal wiring, stainless-steel screw and mini-plate fixation are also described, but carry a high risk of complications and are unfamiliar amongst most oculoplastic surgeons. Our technique is quick and simple and utilises autogenous tissue without breaching the periosteum which acts as a natural barrier to tumour infiltration.Refashioning the canthal tendon aids to lengthen the remaining eyelid stump, reducing the horizontal length required to reform the newly constructed eyelid and facilitates the reconstruction.

Prevalence of Reduced Vision among UK Elderly Drivers: The Bridlington Eye Assessment Project (BEAP)-A Cross-Sectional Study.

Self-assessment of driving fitness is mandatory in the United Kingdom. A paucity of data on visual function among drivers exists. We report prevalence of elderly drivers below legal visual acuity (VA) standard from a population study (The Bridlington Eye Assessment Project (BEAP)) conducted from 2002 to 2006. All residents aged ≥65 years were invited, 3459 undergoing structured interviews/ophthalmic examinations. Driving status was recorded, VA measured, and visual field (VF) testing performed. Outcomes were prevalence and characteristics of drivers below VA legal standard and prevalence of bilateral VF defects. Conditions causing reduced VA were explored and those with treatable conditions allowing visual improvement identified. Duration since last optometry review was recorded. Associations were explored using unpaired t-tests for continuous and chi-squared for discrete variables. Logistic regression was used for multivariate analysis and to determine odd ratios in the final adjusted model. Statistical analysis was performed using Stata 14.0 (Stata Corp, Tx). Within this sample, 7.1% (95% CI 6.0-8.3) of drivers fell below the VA legal driving standard (6/12) in their better eye, with 20% not having seen an optometrist for 2 years, including 8.2% who had not attended for over 5 years. The percentage of drivers falling below the VA minimum increases with age reaching 22.8% (95% CI 13.7-35.3) among those aged 85-89 years. 7.2% (95% CI 6.2-8.6) of drivers had bilateral visual field defects. 93% of drivers with reduced VA below legal standard had a cataract, refractive error or both in at least one eye. Significant numbers of elderly drive with VA below legal standard, most having easily correctable causes. Poor attendance with optometrists appears commonplace. Public education raised awareness of legal driving standards and encouraged compliance are required. Regular eye tests, appropriate refractive correction, and cataract surgery when needed should be encouraged.

The Impact of the COVID-19 Pandemic and Lockdown on Macular Hole Surgery Provision and Surgical Outcomes: A Single-Centre Experience.

Purpose: We aimed to report the impact of the COVID-19 pandemic and related health policies and restrictions on the provision and efficacy of macular hole (MH) surgery. Methods: We carried out a retrospective cohort study. Two MH patient cohorts, those treated during the COVID-19 pandemic (12 months) and the pre-COVID-19 period (12 months before the lockdown) were reviewed and compared. Patient characteristics, time to consultation and surgery, MH size, baseline and postoperative visual acuity (VA) and failure rate were recorded and analysed. Results: A reduction of 43% in MH surgery occurred during the COVID-19 period (93 eyes vs. 53 eyes). Mean time to consultation and time to surgery increased significantly (52.7 days vs. 86.3 days, p < 0.01 and 51.3 days vs. 83.6 days, p = 0.01, respectively), while mean baseline and postoperative vision was significantly lower in the COVID-19 group (0.75 LogMAR vs. 0.63 LogMAR, p < 0.01 and 0.61 LogMAR vs. 0.44 LogMAR, p < 0.01, respectively). The median MH size was significantly larger in the COVID-19 group (296 µm vs. 365 µm, p = 0.016), and the failure rate increased from 7.6% to 15.4% (odds ratio 2.2 (95% CI: 0.72−6.8)). Conclusions: Our findings suggest the COVID-19 pandemic caused a significant reduction in MH surgery, increased waiting times and led to poorer surgical outcomes. For future pandemics, better strategies are required that allow semi-elective and elective surgery to continue in a timely fashion. Health providers should preserve the delivery of ophthalmological care, with enhanced encouragement to seek medical help for acute symptoms.

Upper eyelid reconstruction using an advancement tarso-conjunctival flap.

PURPOSE AND CONTEXT: Upper eyelid reconstruction is particularly complex due to its functional and aesthetic importance. We aim to assess the outcomes/ complications of patients who undergo upper eyelid reconstruction of the posterior lamellae with an advancing tarsonconjunctival flap from the same affected eyelid, following excision of a periocular malignancy by Mohs Micrographic Surgery. METHOD: A retrospective consecutive case note review of all eight patients who underwent the procedure between May 2016 and Jan 2021 were included. Patient demographics and factors influencing outcomes (smoking status, use of blood thinners, past medical/ drug history, size/location of the defect), follow up duration and complications were recorded. KEY RESULTS: Minor post-operative complications included an eyelid notch and retraction. There was one patient with lagophthalmos, but no exposure keratopathy. Two patients had misdirected lashes, one requiring electrolysis. Both monocular patients, who required the procedure in their only seeing eye, and were unable to tolerate a compressive dressing, had wound dehiscence. One patient was on steroids and the other on warfarin and a diabetic. No vision loss ensued and no-one underwent surgical revision. Follow up ranged from 4-52 months. CONCLUSIONS: An advancing tarso-conjunctival flap is an expedient single-stage reconstructive technique that can be used to reform up to two- thirds of the posterior lamellae in full thickness upper eyelid defects involving the lid margin. Complications are minor. It is of particular benefit in patients where occlusion of the visual axis is unacceptable, although the risk of wound dehiscence is high. This technique forms a valuable part of the systematic reconstructive algorithm.

Surgical Management of Paediatric Aphakia in the Absence of Sufficient Capsular Support.

There are several available options for the demanding surgical correction of paediatric aphakia without sufficient capsular support. The literature suggests the implantation of a transscleral fixated posterior chamber-intraocular lens (PCIOL), an intrascleral fixated PCIOL, an iris-sutured intraocular lens (IOL), or an anterior chamber iris-claw IOL. We searched for reports on the management of paediatric aphakia in case of inadequate capsular support that delineated the diverse surgical approaches and their postoperative results. Analysis demonstrated that different complications can be encountered depending on IOL placement technique, such as suture rupture, IOL dislocation, secondary glaucoma, endophthalmitis, vitreous hemorrhage, and endothelial cell loss. However, it was shown that various IOL designs have similar visual outcomes. Taking into consideration the advantages and disadvantages of each surgical technique, ophthalmic surgeons can determine the safest and most efficient approach for paediatric aphakic patients.

Topical use of alcohol in ophthalmology - Diagnostic and therapeutic indications.

Alcohol (ethanol) has been used in medicine since time immemorial. In ophthalmic practice, besides as an antiseptic, it was given as retrobulbar injections to relieve severe ocular pain. Alcohol can be applied topically to the surface of neoplastic or suspicious lesions to kill cells that might desquamate and seed during surgical excision, to treat epithelial ingrowth that can occur following corneal surgeries, particularly laser in situ keratomileusis (LASIK), and to treat superficial infectious keratitis. In view of its ability to achieve a smooth cleavage plane between the epithelium and the Bowman's layer, alcohol-assisted delamination (ALD) of the corneal epithelium has been used widely and effectively for a variety of diagnostic and therapeutic indications, at times delivering both outcomes. Diagnostically, ALD yields an intact epithelial sheet which can be fixed flat to provide excellent orientation for histopathological evaluation. Therapeutically, it is most commonly used to treat recurrent corneal erosion syndrome, where its efficacy is comparable to that of phototherapeutic keratectomy but with several advantages. It has also been used to treat various forms of epithelial/anterior stromal dystrophies, which can obviate or delay the need for corneal transplantation for several years. In addition, ALD is performed in corneal collagen cross-linking and corneal refractive surgery for relatively atraumatic removal of the epithelium. In this review, we aimed to provide a comprehensive overview of the diagnostic and therapeutic use of topical alcohol in ophthalmology, to describe the surgical and fixation techniques of ALD, and to highlight our experience in ALD over the past decade.

Incidence of Clinically Significant Aniseikonia Following Encircling Scleral Buckle Surgery: An Evaluation of Refractive and Axial Length Changes Requiring Intervention.

To evaluate the incidence of symptomatic anisometropia and aniseikonia requiring intervention following surgery with combined pars plana vitrectomy (PPV) and broad 276 style encircling scleral buckle (ESB) for the repair of rhegmatogenous retinal detachments (RRD) and to report axial length (AL) and keratometry changes, a retrospective review of consecutive RRD patients treated with combined PPV and ESB between June 2016 until September 2019 was performed. All patients with symptomatic optically induced aniseikonia requiring additional interventions or surgical procedures including clear lens exchanges, secondary intraocular lens implants or contact lenses were documented. Keratometry and AL measurements were recorded for each eye and changes calculated. In total, 100 patients underwent combined PPV, ESB and endotamponade with mean age of 59.47 years (SD 11.49). AL was significantly increased (25.39 mm [SD 1.27] to 26.54 mm [SD 1.16], p = 0.0001), with a mean change of 1.15 mm (SD 0.67). Mean corneal astigmatism increased by -0.95 D (SD 0.51) in control eyes preoperatively and -1.33 (SD 0.87) postoperatively (p = 0.03). Over half of phakic patients (39/61; 64%) developed a visually significant cataract, subsequently undergoing surgery. Six of 100 patients developed symptomatic anisometropia with aniseikonia postoperatively (6%). Four proceeded with clear lens exchange despite absence of visually significant cataract (4%). Two of these initially trialled contact lenses (2%). One was intolerant, while the other decided to proceed with clear lens exchange for convenience. Only one patient (1%), being pseudophakic in both eyes, had persistent anisometropia/aniseikonia. AL and keratometry changes induced by encirclement with broad solid silicone rubber buckles are acceptable and similar to those reported previously using narrow encircling components, being unlikely to induce troublesome symptomatic anisometropia/aniseikonia. Many patients are phakic and develop visually significant cataracts, allowing correction of changes induced with the aim of visual restoration. A minority require more prolonged methods of visual rehabilitation, such as contact lens wear or clear lens exchanges. Caution and appropriate consent should be made in patients that are pseudophakic in both eyes at presentation.

Characteristics of Geographic atrophy in an elderly UK population-The Bridlington Eye Assessment Project (BEAP): a cross-sectional study (2002-2006).

BACKGROUND/OBJECTIVES: Geographic atrophy (GA) is a common cause of visual loss. The UK population prevalence is unknown. We studied GA prevalence, characteristics, and associations in an elderly UK population. METHODS: Masked grading of colour fundus photographs from 3549 participants in the cross-sectional study of Bridlington residents aged ≥65 years. GA size, shape and foveal involvement were correlated with demography and vision. RESULTS: GA was detected in 130 eyes (101 individuals) of 3480 participants with gradable images (prevalence 2.90%; 95% CI 2.39-3.52 either eye), was bilateral in 29/3252 subjects (0.89%, 95% CI 0.62-1.28) with bilateral gradable photos, with mean age of 79.26 years (SD 6.99, range 67-96). Prevalence increased with age, from 1.29% (95% CI 0.69-2.33) at 65-69 to 11.96% (95% CI 7.97-17.50) at 85-90 years. Mean GA area was 4.51 mm2 (SD 6.48, 95% CI 3.35-5.66); lesions were multifocal in 47/130 eyes (36.2%; 95% CI 28.4-44.7). Foveal involvement occurred in 41/130 eyes (31.5%; 95% CI 24.2-40.0). In eccentric GA, mean distance from circumference to fovea was 671µm (SD 463; 95% CI 570-773). Older age (OR 1.10/year increase; 95% CI 1.06-1.14), RPD (OR 1.87; 95% CI 1.10-3.19) and large drusen/RPD ≥ 125 µm (OR 6.16; 95% CI 3.51-10.75) were significantly associated with GA in multivariate analysis. GA lesions (18/31 eyes; 58%; 95% CI 40.7-73.6) had U-shape configuration more frequently in RPD subjects than those without (9/99 eyes, 9.1%; 95% CI 4.66-16.6) (p = 0.0001). CONCLUSION: GA, commonly solitary and eccentric, occurred in the perifovea. However, one third of GA eyes had foveal and bilateral involvement. Possible association of RPD with GA phenotype exists. Population multimodal imaging studies may improve understanding further.

First postoperative day review in eyes undergoing pars plana vitrectomy, encirclement and endotamponade to check intraocular pressure: Is it necessary?

PURPOSE: To assess the proportion of patients with raised intraocular pressure (IOP) (≥ 30 mmHg) on the first postoperative day following pars plana vitrectomy (PPV), encirclement and endotamponade and assess the number requiring alteration in management to address elevated IOP. To establish whether review on day one is required. METHODS: Retrospective case note review of consecutive patients who underwent 23-gauge PPV, 276-encirclement and endotamponade under the care of a single surgeon. All patients as standard received prophylactic anti-glaucoma medication post-surgery (eye drops) to take home but initiate only after day-one review. Statistical analysis was carried out using student t tests and Fisher's exact tests. RESULTS: Sixty-six patients were examined over a 2-year period. Mean day-one IOP was 22.2 mmHg (SD 7.3, 95% CI 20.4-24.0). Eleven patients (16.7%) had IOP ≥ 30 mmHg. Five patients (7.6%) had management changing decisions made at the day-one postoperative visit. Lens status, endotamponade, preoperative IOP, surgeon grade, cryopexy versus laser retinopexy or preoperative administration of once only 500 mg dose of intravenous acetazolamide did not influence IOP, with no significant difference between these subgroups. No cases of hypotony occurred. CONCLUSIONS: A significant minority of patients had elevation of IOP above 30 mmHg, a number of whom required treatment changes to address this. No preoperative risk factors were identified indicating those at risk of high IOP. It is important to identify these potentially harmful IOP elevations, and therefore day-one review is imperative and should be continued.

Natural course of adult-onset vitelliform lesions in eyes with and without comorbid subretinal drusenoid deposits.

PURPOSE: Adult vitelliform lesions (AVL) are associated with age related macular degeneration (AMD) and subretinal drusenoid deposits (SRDD). We evaluated the natural course of AVL, assessing the influence of SRDD on disease progression, visual function and incidence of macular atrophy (MA) and choroidal neovascular membranes (CNVM). METHODS: A retrospective cohort study was conducted between January 2011 and March 2016. Demographic, clinical and imaging data from 26 consecutive AVL patients were analysed following case note review. Optical coherence tomography images were graded for SRDD and patients divided into those with/without SRDD. Outcomes included presenting/changes in best corrected visual acuity (BCVA) and incidence of MA/CNVM. RESULTS: Mean age was 78.6 ± 7.6 years. Mean follow-up was 51.5 ± 25.6 months. Twelve patients (46.2%) had SRDD at presentation with 3 more (11.5%) developing them. Subjects with SRDD were older (mean 81.7 ± 6.1 years vs 74.3 ± 7.6 years, p = 0.010). Mean presenting BCVA was worse in SRDD eyes (0.39 ± 0.31 logMAR vs 0.19 ± 0.18 logMAR, p = 0.017). Eight of 15 patients with SRDD (53.3%) developed incident MA or CNVM; higher than those with no SRDD (1/11, 9.1%; p = 0.036). Two patients (7.7%) developed full thickness macular holes. CONCLUSIONS: Patients with AVL and SRDD likely represent an advanced pathological stage or phenotype with worse visual outcome and higher risk of MA/CNVM. Possible overlap with AMD exists. Follow-up, counselling and provisions for early detection/treatment of complications should be made. Better classification including improved understanding of phenotypic and genetic variations with reference to comorbid diseases including AMD is required. Presence of SRDD in AVL offers a dichotomous classification, indicating risk of future MA/CNVM formation.

Biofeedback fixation training method for improving eccentric vision in patients with loss of foveal function secondary to different maculopathies.

PURPOSE: Fixation stability (FS) of the preferred retinal locus (PRL) may be improved by biofeedback fixation training (BFT) with microperimetry. Such training can be done on the patient's PRL or in different retinal loci with better functional characteristics. We studied both options and compared the outcomes. METHODS: Sixty-seven consecutive patients with bilateral central vision loss, poor FS and visual acuity (VA) lower than 0.3 LogMAR were recruited for BFT with microperimeter. Patients were assigned into 2 groups. In group A, BFT was performed on the patient's spontaneous PRL. In group B, PRL was located between 2 adjacent loci with the highest light sensitivity and the lowest distance from the fovea. Two sets of 12 weekly BFT sessions were performed. Primary outcomes were: FS, VA and reading speed. RESULTS: Outcomes were statistically significantly better in group B. Mean percentage of FS at therapy end improved from 32 to 35% for group A and from 40 to 55% in group B. Mean VA improved from 1 to 0.86 in group A and from 1 to 0.84 in group B. Reading speed (wpm) improved from 56 to 58 in group A and from 63 to 89 in group B. CONCLUSIONS: This study describes a reliable methodology of improving eccentric fixation stability using BFT in microperimetry, when the fixation training locus is individualized as the retinal area with best functional characteristics. Further studies are needed to validate its value in a larger scale of patients, at different stages of the disease, and its persistence over time.

Prevalence of optic disc haemorrhages in an elderly UK Caucasian population and possible association with reticular pseudodrusen-the Bridlington Eye Assessment Project (BEAP): a cross-sectional study (2002-2006).

AIMS: To determine disc haemorrhage (DH) prevalence in an elderly UK population-the Bridlington Eye Assessment Project (BEAP). METHODS: Thirty-degree fundus photographs (3549 participants ≥65 years) were graded for DH/macula changes. Glaucoma evaluation included Goldmann tonometry, 26-point suprathreshold visual-fields and mydriatic slit-lamp assessment for glaucomatous optic neuropathy. RESULTS: In all, 3548 participants with photographs in at least one eye. DHs were present in 53 subjects (1.49%), increasing from 1.17% (65- to 69-year age group) to 2.19% (80- to 84-year age group), p = 0.06. DH was found in 9/96 (9.38%) right eyes (RE) with open-angle glaucoma (OAG). Two of twelve RE (16.67%) with normal-tension glaucoma (NTG) had DH. Prevalence in eyes without glaucoma was lower (32/3452, [0.93%]). Reticular pseudodrusen (RPD) occurred in 170/3212 (5.29%) subjects without DH, and 8/131 subjects (6.11%) with OAG. Twenty eyes had NTG, two of whom had RPD (10%) (p = 0.264). Within a logistic regression model, DH was associated with glaucoma (OR 10.2, 95% CI 5.32-19.72) and increasing age (OR 1.05, 95% CI 1.00-1.10, p = 0.03). DH was associated with RPD (p = 0.05) with univariate analysis but this was not statistically significant in the final adjusted model. There was no significant association with gender, diabetes mellitus (DM), hypertension treatment or Age-related Macular Degeneration (AMD) grade. CONCLUSION: DH prevalence is 1.5% in those over 65 years old and significantly associated with glaucoma and increasing age. There appears to be increased RPD prevalence in eyes with DH and NTG with age acting as a confounding factor. Larger studies are required to fully assess the relationship and investigate a possible shared aetiology of choroidal ischaemia.