Proportion of Angle Closure Glaucoma in Tamale, Ghana.

PRCIS: In the largest clinic-based study to date, our review of 588 patients presenting with glaucoma in Northern Ghana revealed 36% of these had primary angle closure glaucoma (PACG). OBJECTIVE: Glaucoma is the second leading cause of blindness worldwide. In Africa, glaucoma is an established public health problem, and PACG is not commonly discussed. Recognizing it is important because of its negative impact on visual morbidity, and also because its treatment is different from primary open angle glaucoma. In response to the observation of many PACG cases at the Northern Community Eye Hospital in Tamale, Ghana, we investigated the proportion of those attending with a first diagnosis of glaucoma who had PACG. PATIENTS AND METHODS: Using the electronic records, we identified 976 patients who attended with a first diagnosis of glaucoma between January 2021 and October 2022. Of these, 588 met the inclusion criterion of a clear glaucoma subtype diagnosis. RESULTS: Of these 316 (53.7%) had primary open angle glaucoma, 210 (35.7%) PACG, and 62 (10.5%) secondary glaucoma. Thus, over a third of presenting glaucomas had PACG. CONCLUSION: This study highlights that PACG is present in about a third of patients presenting to our clinic in North Ghana. Our study demonstrates the importance of a clear diagnostic pathway including gonioscopy in the assessment of glaucoma patients and the consideration of wider training on angle closure glaucoma diagnosis and management.

Long-Term Safety and Outcomes of ß-radiation for Trabeculectomy.

PRCIS: ß-radiation is a neglected antiscarring therapy with past concerns for safety. This report found it safe and efficacious when used as an adjuvant to trabeculectomy surgery in 101 people (135 eyes) over 20 years. PURPOSE: ß-radiation has been used as an adjunct to prevent scarring in trabeculectomy surgery for many decades. Safety concerns were raised with the use of high doses on the bare sclera. Moorfields Eye Hospital has a large cohort of patients who have received ß-radiation therapy. We report a review of the long-term safety and efficacy. METHODS: Cases undertaken between August 1992 and August 1996 were reviewed. Those with records available for postoperative review of more than 5 years were included. Failure (reintervention/>21 mm Hg on 2 successive occasions) and any complication previously reported in association with ß-radiation were the primary outcomes. RESULTS: In total, 292 operations using ß-radiation were recorded and 101 people (135 eyes) with trabeculectomy surgery and postoperative follow-up for over 4.5 years were included. The median follow-up period was 22.5 years. At the final follow-up, 48 (48%) single eyes per person had failed and 20/51 (51%) eyes with primary open angle glaucoma had cataract surgery. Other complications were rare and associated with copathology. CONCLUSION: In glaucoma patients at risk of scarring and failure after trabeculectomy, as an antiscarring adjuvant, a 750 cGY dose of ß-radiation was found to be safe and efficacious in the long term.

Antifibrinolytic Drugs for the Prevention of Bleeding in Pediatric Cardiac Surgery on Cardiopulmonary Bypass: A Systematic Review and Meta-analysis.

BACKGROUND: Bleeding is one of the commonest complications affecting children undergoing cardiac surgery on cardiopulmonary bypass. Antifibrinolytic drugs are part of a multifaceted approach aimed at reducing bleeding, though sufficiently sized pediatric studies are sparse, and dosing algorithms are heterogeneous. Our objective was to evaluate the efficacy and safety of antifibrinolytic agents as well as the effectiveness of different dosing regimens in pediatric cardiac surgery using cardiopulmonary bypass. METHODS: We performed a systematic review and meta-analysis evaluating randomized controlled trials published between 1980 and 2019, identified by searching the databases MEDLINE, EMBASE, PubMed, and CENTRAL. All studies investigating patients <18 years of age without underlying hematological disorders were included. The primary outcome was postoperative bleeding; secondary end points included blood product transfusion, mortality, and safety (thromboses, anaphylaxis, renal or neurological dysfunction, and seizures). Different dosing regimens were compared. Studies were dual appraised, outcomes were reported descriptively and, if appropriate, quantitatively using the Review Manager 5 (REVMAN 5) software (The Cochrane Collaboration). RESULTS: Thirty of 209 articles were included, evaluating the following drugs versus control: aprotinin n = 14, tranexamic acid (TXA) n = 12, and epsilon-aminocaproic acid (EACA) n = 4. The number of participants per intervention group ranged from 11 to 100 (median, 25; interquartile range [IQR], 20.5) with a wide age span (mean, 13 days to 5.8 years) and weight range (mean, 3.1-26.3 kg). Methodological quality was low to moderate.All agents reduced mean 24-hour blood loss compared to control: aprotinin by 6.0 mL/kg (95% confidence interval [CI], -9.1 to -3.0; P = .0001), TXA by 9.0 mL/kg (95% CI, -11.3 to -6.8; P < .00001), and EACA by 10.5 mL/kg (95% CI, -21.1 to 0.0; P = .05). Heterogeneity was low for TXA (I2 = 29%; P = .19), moderate for aprotinin (I2 = 41%; P = .11), and high for EACA (I2 = 95%; P < .00001). All agents also reduced 24-hour blood product transfusion. There was no clear dose-response effect for TXA nor aprotinin. Studies were underpowered to detect significant differences in mortality, thromboses, anaphylaxis, and renal or neurological dysfunction. CONCLUSIONS: The available data demonstrate efficacy for all 3 antifibrinolytic drugs. Therefore, the agent with the most favorable safety profile should be used. As sufficient data are lacking, large comparative trials are warranted to assess the relative safety and appropriate dosing regimens in pediatrics.

Glaucoma and glare.

PURPOSE: To determine whether a purpose-built glare tester, in combination with new glare-specific questions, can better assess glaucoma patients' experience of glare and visual disability than visual acuity (VA) or visual fields alone. PATIENTS AND METHODS: Consecutive patients attending for visual fields in a single glaucoma clinic from 03/06/2019-01/11/2019 underwent VA assessment using a Brightness Acuity Tester as a glare source, examination for media opacities, and completed the VFQ-25 with four additional glare-related questions. One hundred and sixteen eyes (64 patients) were included for analysis. The amount of disability glare (VA reduction due to glare) was compared according to presence/absence of media opacity and glaucoma severity. Subjective glare symptoms were compared with objective disability glare measurement using a Bland-Altman plot. RESULTS: Patients with advanced-severe glaucoma had significantly worse disability glare than those with mild-moderate glaucoma. VA reduction due to glare from mild-moderate to acute-severe glaucoma (mean -3.4 letters, P = 0.01, CI -0.8, -6.0) was of almost identical magnitude to that due to presence of any media opacity (mean -3.3 letters, P = 0.03, CI -0.4, -6.2). There was a trend towards greater disability glare in more symptomatic patients, with good agreement between subjective and objective glare measurements for those with few glare signs or symptoms, but progressively more variation either side of agreement as either measurement worsened. CONCLUSIONS: Glaucoma is associated with objective and subjective acuity reduction in the presence of glare. We demonstrated an increase in disability glare in patients with more severe glaucoma. The worse the glare symptoms or signs, the more variable the agreement between objective and subjective assessments.

Initial experience in self-monitoring of intraocular pressure.

BACKGROUND/AIMS: Diurnal variation in intraocular pressure (IOP) is a routine assessment in glaucoma management. Providing patients the opportunity to perform self-tonometry might empower them and free hospital resource. We previously demonstrated that 74% of patients can use the Icare® HOME tonometer. This study further explores Icare® HOME patient self-monitoring. METHODS: Patients were trained by standard protocol to use the Icare® HOME rebound tonometer. Patient self-tonometry was compared to Goldmann applanation tonometry (GAT) over one clinical day. Following this, each patient was instructed to undertake further data collection that evening and over the subsequent two days. RESULTS: Eighteen patients (35 eyes) participated. Good agreement was demonstrated between GAT and Icare® HOME for IOPs up to 15 mm Hg. Above this IOP the Icare® tended to over-read, largely explained by 2 patients with corneal thickness >600 um. The mean peak IOP during 'clinic hours' phasing was 16.7 mm Hg and 18.5 mm Hg (p = 0.24) over three days. An average range of 5.0, 7.0 and 9.8 mm Hg was shown during single day clinic, single day home and three day home phasing respectively (p =<0.001). The range of IOP was lower in eyes with prior trabeculectomy (6.1 mm Hg vs 12.2 mm Hg). All patients undertook one reading in the early morning at home with an average of 4.8 readings during, and 3.1 readings after office hours. CONCLUSIONS: This small study shows that self-tonometry is feasible. The findings from home phasing demonstrated higher peak and trough IOPs, providing additional clinical information. Home phasing is a viable alternative. The cost-effectiveness of this approach has yet to be addressed.

The cost and quality of life impact of glaucoma in Tanzania: An observational study.

AIMS: To determine the cost and quality of life impact imposed by glaucoma in Tanzania, East Africa. METHODS: An expert panel of eye health professionals was convened to agree current glaucoma practice in Tanzania. In addition a structured patient survey was developed and administered. Supplemental cost and quality of life information was collected using cost questionnaires and validated quality of life measures, including the EQ5D and VFQ-25. RESULTS: Key findings include following. Non-adherence is a major issue, especially in rural settings where over 50% of the patients may fail to return for review. Whilst medical therapy is overwhelmingly the first line treatment, the cost of maintaining this represents up to 25% of a patient's income. There is an impact of glaucoma on patients general well-being as determined by the EQ-5D and more tellingly on visual function with particular impact on role limitations as determined by the VF25. Despite our sample being taken in a private clinic and thus containing a much larger proportion of professionals than the general population, one third of the population earned Tanzanian Shillings (TZS) 170,000 per month which is below the minimum wage. CONCLUSION: These findings are of great importance for health care planners seeking to determine cost-effective, acceptable methods of both identifying and treating this major cause of preventable blindness.

Adherence with Medical Therapy for Primary Open-Angle Glaucoma in Kenya - A Pilot Study.

BACKGROUND/OBJECTIVES: Adherence is a major challenge in topical glaucoma therapy, particularly in an African context. We report a pilot study assessing adherence independently for the first time in an African context. SUBJECTS/METHODS: Participants with newly diagnosed open-angle glaucoma received a weighed bottle of Lumigan 0.01% with counselling on therapy. The bottles were returned monthly for renewal and weighed on return to estimate drops taken during the period. Data collection was for one year with a short compliance questionnaire. RESULTS: 11 patients participated. 5 (45%) failed to complete one full year of topical therapy. The overall mean number of drops per eye per day was 1.74 (SD 0.69) for the 6 with one year of monthly returned bottles and controlled IOPs at each visit. Self-perception of compliance in these patients was good. CONCLUSION: The signs of poor adherence based on both self-report (previous literature), and in this small-scale study of an objective measure suggest medication may not be the first-line treatment of choice in this environment. Our report does, however, raise the possibility that those patients who return for repeat prescriptions and review are indeed adhering to their treatment regimens.

Perceptions of training in gonioscopy.

PURPOSE: To evaluate ophthalmology trainees' perception of their gonioscopy learning experience in the Ophthalmology Specialty Training programme. MATERIALS AND METHODS: A cross-sectional electronic survey was conducted amongst ophthalmology trainees across London Deaneries. The ten questions survey collected parameters, including training grade, previous level of gonioscopy training, confidence in performing the procedure, level of satisfaction with the training formats received, potential barriers and improvements to the training programme. The respondents were also invited to express any additional comments. RESULTS: Fifty-seven complete responses were analysed. The respondents included 25 junior trainees (ST1-3) and 32 senior trainees (ST4-7 and fellows). One-fifth of the respondents (11/57) were unconfident in performing gonioscopy, the majority being junior trainees (9/11). Over a quarter of the respondents were dissatisfied with the quantity of the gonioscopy training received. Teaching formats, such as consultant teaching (mean 8.0 ± 0.50), self-directed learning (mean 8.0 ± 0.38) and small-group tutorials (mean 7.6 ± 1.6) were all well received. Overall, lack of clinical time was considered as the major barrier to gonioscopy training; however, lack of training was considered as the major barrier in the low-confidence group. CONCLUSIONS: This study highlighted ophthalmology trainees' dissatisfaction in the current gonioscopy training curriculum and a lack of confidence in performing the procedure. Appropriate modifications to the Ophthalmology Specialty Training programme could enhance trainees' gonioscopy learning experience.

A Survey of Emergency Department Quality Improvement Activities: Effective Fast Track Waiting Area Management.

This article describes the quality improvement process used to implement a waiting area within fast track. Staff and patient survey data indicated a significant decrease in workload, with a subsequent high satisfaction of both groups following the redesign process.

Long-term follow-up of phacotrabeculectomy surgery in Tanzania.

INTRODUCTION: The glaucomas often co-exist with cataract. We previously reported a large trial of anti-scarring treatment in combined phacotrabeculectomy surgery. Long-term outcomes in an African population are extremely rarely reported. We present here the outcomes in IOP, acuity, bleb morphology and patient perceptions at 3-5-years post surgery. METHODS: Tanzanian patients with glaucoma and visually significant cataract underwent combined phacotrabeculectomy surgery. In November 2015 an attempt was made to contact all participants in the study inviting them for a repeat examination. All who attended were given a detailed examination. A semi-structured interview in Swahili was administrated to determine patient experience and satisfaction with the surgery. RESULTS: Sixty-eight (23%) attended for repeat review in 2015. The mean time from original surgery was 4.5-years (range 2.3-6.6-years). Overall 53 (78%) had IOP < 21 mm Hg and 29 (43%) an IOP < 16 mm Hg at final follow-up. A flat bleb at 26 and 100 days was associated with failure by IOP criteria at 4.5-years post-operatively. A vascular bleb at those time points was not any more associated with late failure than a non-vascular bleb. A majority of patients were pleased with the surgery. The cost of surgery is high but it is a price patients were willing to pay. Nearly all patients (95%) would recommend the service to family and friends. DISCUSSION: Owing to the small proportion reviewed, our conclusions are severely limited. Phacotrabeculectomy worked well in a majority of the reviewed population long-term and is accepted by a majority of these patients as worthwhile.

Correction: How do paper and electronic records compare for completeness? A three centre study.

Following the publication of the above article the authors noted an error in the author list, 2 authors were mistakenly omitted. Zena Rodrigues and Faisal Ahmed have now been added to the author list and the PDF and HTML versions of the paper have been corrected.

Success of trabeculectomy surgery in relation to cataract surgery: 5-year outcomes.

AIMS: To compare success proportions at 5 years in three surgical groups: group 1, trabeculectomy alone; group 2, trabeculectomy followed by cataract surgery within 2 years; and group 3, trabeculectomy performed on a pseudophakic eye. METHODS: A retrospective cohort study. 194 eyes of 194 patients were identified with at least 5 years' follow-up post trabeculectomy (N=85, 60 and 49 in groups 1, 2 and 3, respectively). MAIN OUTCOME MEASURES: 1. PRIMARY OUTCOME MEASURE: intraocular pressure (IOP) at 5 years post-trabeculectomy surgery, 2.Secondary outcome measure: change in visual acuity at 5 years. RESULTS: At 5 years, the mean IOP (SD) was 12.9 (3.5), 12.5 (4.8) and 12.7 (4.8) mm Hg in groups 1, 2 and 3, respectively. Overall success was almost identical, 58%, 57% and 59% in groups 1, 2 and 3, respectively. There was no significant difference between the groups in terms of percentage IOP reduction, number of medications, proportion restarting medication and reoperation rates at 5 years. Logistic regression for an outcome of failure showed men to be at increased risk of failure OR 1.97 (95% CI 1.10 to 3.52, p=0.02). Nearly 80% of patients retained or improved their vision following their initial trabeculectomy. CONCLUSIONS: The sequence in which surgery is carried out does not appear to affect trabeculectomy function at 5 years, success being similar to trabeculectomy alone. In our study, men may be at increased risk of failure.

Directed Evolution of Saccharomyces cerevisiae for Increased Selenium Accumulation.

Selenium-enriched yeast (selenium yeast) are one of the most popular sources of selenium supplementation used in the agriculture and human nutritional supplements industries. To enhance the production efficiency of selenium yeast, we sought to develop a method to identify, and ultimately select for, strains of yeast with enhanced selenium accumulation capabilities. Selenite resistance of four genetically diverse strains of Saccharomyces cerevisiae was assayed in various conditions, including varying carbon sources, nitrogen sources, and phosphate amounts, and they were correlated with selenium accumulation in a commercially relevant selenium-containing growth medium. Glycerol- and selenite-containing media was used to select for six yeast isolates with enhanced selenite resistance. One isolate was found to accumulate 10-fold greater selenium (0.13 to 1.4 mg Se g-1 yeast) than its parental strain. Glycerol- and selenium-containing medium can be used to select for strains of yeast with enhanced selenium accumulation capability. The methods identified can lead to isolation of industrial yeast strains with enhanced selenium accumulation capabilities that can result in greater cost efficiency of selenium yeast production. Additionally, the selection method does not involve the construction of transgenic yeast, and thus produces yeasts suitable for use in human food and nutrient supplements.

Glaucoma Control Strategies in Sub-Saharan Africa: A Review of the Clinical and Health Economic Evidence.

PURPOSE: A review of the effectiveness, costs, and cost-effectiveness of detection and treatment strategies for glaucoma control in Sub-Saharan Africa (SSA) was conducted. METHODS: Detailed searches were performed using the Ovid Medline, Ovid Embase, The Cochrane Library, Web of Science, Scopus, and LILACS databases up to September 2016. The key Medical Subject Heading search terms used included glaucoma, diagnosis, treatment, effectiveness, costs, cost-effectiveness, and Sub-Saharan Africa. Effectiveness was measured as the proportion of study participants with an intra-ocular pressure less than or equal to 22 mmHg. RESULTS: A total of 5658 records were examined with 48 papers identified. The sensitivity and specificity of portable instruments or smartphone technologies to detect glaucomatous changes ranged from 58.3% to 93.8% and from 82.4% to 96.8%, respectively. The overall effect size for various glaucoma interventions was: 0.39 (95% confidence interval (CI) 0.27-0.54, I2 = 64.85, p = 0.036) for laser trabeculoplasty; 0.56 (95% CI 0.23-0.84, I2 = 85.74, p = 0.001) for drainage implant devices; 0.66 (95% CI 0.61-0.71, I2 = 0.00, p = 0.402) for medical management; and 0.73 (95% CI 0.65-0.80, I2 = 93.25, p = 0.000) for all other non-drainage tube surgical interventions, including trabeculectomy surgery and the use of anti-metabolites. The mean annual cost of anti-glaucoma drugs across SSA was USD 394, with a mean direct non-medication cost per year of USD 54, and a mean surgical cost per year of USD 283. CONCLUSIONS: While effective glaucoma control interventions exist, their widespread use and diffusion across SSA remain challenging principally due to low per capita income levels and high glaucoma treatment costs.

How do paper and electronic records compare for completeness? A three centre study.

OBJECTIVES: Medical records are legal documentation of patients' care hence must be accurate and complete for both medical and legal purposes. Electronic patient record (EPR) systems aim to improve the accuracy of documentation, provide better organisation and access of data. This study compares the completeness of traditional note records and EPR in glaucoma patients. METHODS: Using criteria from the April 2009 National Institute for Health and Care Excellence (NICE) guidelines completeness of data entry was compared between EPR and paper notes in three units. Moorfields Eye Hospital (City Road) uses the Openeyes EPR. Bedford Hospital (Moorfields Eye Centre) and Western Eye Hospital use the Medisoft EPR. The standard was set at 100% compliance for predetermined parameters. RESULTS: One hundred seventy paper notes and 270 electronic records were analysed. With the exception of central corneal thickness (p = 0.31), all other key parameters were more consistently recorded in the paper records than in the EPR. Intraocular pressure (p = 0.004), anterior chamber configuration and depth assessments using gonioscopy (p < 0.001), fundus examination (p = 0.015), past medical history (p < 0.001), medication including glaucoma medication (p < 0.001) and drug allergies (p < 0.001). CONCLUSIONS: Our results show that paper records are significantly more complete than EPR. This is the case for two different EPRs and three separate sites. We propose additional training to aid data-collection; improving the design of EPRs by investigating factors such as layout and use of forced choice fields.

Strategies for Prevention and Management of Bleeding Following Pediatric Cardiac Surgery on Cardiopulmonary Bypass: A Scoping Review.

OBJECTIVE: We aimed to systematically describe, via a scoping review, the literature reporting strategies for prevention and management of mediastinal bleeding post pediatric cardiopulmonary bypass surgery. DATA SOURCES: MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL Register. STUDY SELECTION: Two authors independently screened publications from 1980 to 2016 reporting the effect of therapeutic interventions on bleeding-related postoperative outcomes, including mediastinal drain loss, transfusion, chest re-exploration rate, and coagulation variables. Inclusions: less than 18 years, cardiac surgery on cardiopulmonary bypass. DATA EXTRACTION: Data from eligible studies were extracted using a standard data collection sheet. DATA SYNTHESIS: Overall, 299 of 7,434 screened articles were included, with observational studies being almost twice as common (n = 187, 63%) than controlled trials (n = 112, 38%). The most frequently evaluated interventions were antifibrinolytic drugs (75 studies, 25%), blood products (59 studies, 20%), point-of-care testing (47 studies, 16%), and cardiopulmonary bypass circuit modifications (46 studies, 15%). The publication rate for controlled trials remained constant over time (4-6/yr); however, trials were small (median participants, 51; interquartile range, 57) and overwhelmingly single center (98%). Controlled trials originated from 22 countries, with the United States, India, and Germany accounting for 50%. The commonest outcomes were mediastinal blood loss and transfusion requirements; however, these were defined inconsistently (blood loss being reported over nine different time periods). The majority of trials were aimed at bleeding prevention (98%) rather than treatment (10%), nine studies assessed both. CONCLUSIONS: Overall, this review demonstrates small trial sizes, low level of evidence, and marked heterogeneity of reported endpoints in the included studies. The need for more, higher quality studies reporting clinically relevant, comparable outcomes is highlighted. Emerging fields such as the use of coagulation factor concentrates, goal-directed guidelines, and anti-inflammatory therapies appear to be of particular interest. This scoping review can potentially guide future trial design and form the basis for therapy-specific systematic reviews.

A Case of Bilateral Pigment Dispersion Syndrome Following Many Years of Uninterrupted Treatment With Atropine 1% for Bilateral Congenital Cataracts.

PURPOSE: Describe an unusual case of bilateral pigment dispersion syndrome (PDS) following years of uninterrupted treatment with atropine 1% for bilateral congenital cataracts, speculate on potential mechanisms leading to this condition. DESIGN: This is a case report. CASE: A 45-year-old white patient on long-term treatment with atropine 1% ointment since his infancy for bilateral congenital cataracts developed PDS with secondary ocular hypertension. RESULTS: The patient showed all the hallmarks of PDS with secondary ocular hypertension. An anterior segment Swept-Source optical coherence tomography was obtained to review the iris profile. The patient showed good pressure response to topical prostaglandin therapy. CONCLUSIONS: This is the second case report of PDS in a patient with chronic use of topical atropine. The proposed mechanisms for pigment dispersion are discussed and the possibility raised of dispersion being a potential side effect of the drug.