Prevalence of age-related macular degeneration in an elderly UK Caucasian population-The Bridlington Eye Assessment Project: a cross-sectional study.

ImportanceThere is paucity of data on prevalence and disease asymmetry of age-related macular degeneration (AMD), particularly the earlier stages, in the UK population.Objective and PurposeTo determine the prevalence of age-related macular degeneration in an elderly Caucasian UK population.DesignCross-sectional population study, 2002-2006.ParticipantsResidents in the study area of Bridlington aged 65 years and older.MethodsFull-ophthalmic examination was undertaken in 3549 participants, of eligible 6319 Caucasian population (response rate of 56%). Non-stereoscopic Colour fundus photographs (30°) were graded masked using a modified Rotterdam Classification for 3475 (98%) participants with gradable images. Prevalence for different AMD grades were calculated. Demographic details were analysed then integrated with the AMD gradings for full analysis. Prevalence rates for the different AMD Grades were calculated, as well as the age-specific prevalences.ResultsAMD prevalence in the worst eye were 38.5% grade 0, 41.4% grade 1, 12.8% grade 2, 2.8% grade 3, and 4.6% grade 4. Geographic atrophy (grade 4a) occurred in 2.5%, and neovascular AMD (grade 4b) in 1.8%. Prevalence increased with age such that grade 4 (advanced) AMD was 2.2% in the 65-69 years group, 15.8% for the 85-90, and 21.2% for over 90 years. There was significant asymmetry between the two eyes of individuals with advanced AMD (P<0.001), such that vision loss was unilateral. Persons with more advanced AMD grades were more likely to be dissatisfied with their vision.ConclusionsAdvanced AMD occurs more commonly in the UK Caucasian population than previously reported. Significant asymmetry between the two eyes occurs in individuals with unilateral advanced AMD so that visual impairment statistics do not represent true prevalence of advanced AMD. Persons with more advanced AMD were more likely to be dissatisfied with their vision.

Is the 1-day postoperative IOP check needed post uncomplicated phacoemulsification in patients with glaucoma and ocular hypertension?

PURPOSE: To determine whether the 1-day postoperative intraocular pressure (IOP) check following routine uncomplicated phacoemulsification is necessary in patients with pre-existing glaucoma and ocular hypertension (OHT), if acetazolamide prophylaxis is used. To investigate the practice of U.K. glaucoma specialists in IOP rise prophylaxis and follow-up regimes. PATIENTS AND METHODS: The IOP 1-day postoperatively was analysed against the last recorded IOP before phacoemulsification in a cohort of patients with glaucoma or OHT who underwent uncomplicated phacoemulsification cataract surgery between December 2009 and September 2012, where it was routine practice to give acetazolamide postoperatively. U.K. and Eire Glaucoma Society members were surveyed via an online questionnaire to analyse practice among U.K. glaucoma specialists. RESULTS: One hundred and seven eyes were studied: 99 with glaucoma and 8 with OHT. The mean IOP change was -0.8 mm Hg with only two eyes measuring >30 mm Hg postoperatively (2%). Both these eyes received 750 mg acetazolamide. Eighteen (17%) eyes had an IOP rise of at least 30%. In the survey of practice there were 65 respondents. Twenty-one (32%) respondents did not use IOP prophylaxis. Only 17 (26%) of respondents routinely reviewed their patients 1-day postoperatively. CONCLUSION: Our prophylactic acetazolamide regime does not completely eliminate the risk of an IOP >30 mm Hg on day 1 post routine phacoemulsification in glaucoma/OHT patients. Patients with pre-existing glaucoma, despite acetazolamide prophylaxis, will require IOP management decisions on the first postoperative day after uncomplicated phacoemulsification surgery. U.K. expert practice is non-uniform with regard to IOP prophylaxis, and the 1-day review, and further discussion and formulation of consensus appears necessary.

Socio-demographic inequalities in stage of cancer diagnosis: evidence from patients with female breast, lung, colon, rectal, prostate, renal, bladder, melanoma, ovarian and endometrial cancer.

BACKGROUND: Understanding socio-demographic inequalities in stage at diagnosis can inform priorities for cancer control. PATIENTS AND METHODS: We analysed data on the stage at diagnosis of East of England patients diagnosed with any of 10 common cancers, 2006-2010. Stage information was available on 88 657 of 98 942 tumours (89.6%). RESULTS: Substantial socio-demographic inequalities in advanced stage at diagnosis (i.e. stage III/IV) existed for seven cancers, but their magnitude and direction varied greatly by cancer: advanced stage at diagnosis was more likely for older patients with melanoma but less likely for older patients with lung cancer [odds ratios for 75-79 versus 65-69 1.60 (1.38-1.86) and 0.83 (0.77-0.89), respectively]. Deprived patients were more likely to be diagnosed in advanced stage for melanoma, prostate, endometrial and (female) breast cancer: odds ratios (most versus least deprived quintile) from 2.24 (1.66-3.03) for melanoma to 1.31 (1.15-1.49) for breast cancer. In England, elimination of socio-demographic inequalities in stage at diagnosis could decrease the number of patients with cancer diagnosed in advanced stage by ∼5600 annually. CONCLUSIONS: There are substantial socio-demographic inequalities in stage at diagnosis for most cancers. Earlier detection interventions and policies can be targeted on patients at higher risk of advanced stage diagnosis.

Community optometrist referral of those aged 65 and over for raised IOP post-NICE: AOP guidance versus joint college guidance--an epidemiological model using BEAP.

BACKGROUND/AIMS: To identify the percentage of those aged 65 and over who might be referred by community optometrists as ocular hypertensive suspects in the post-NICE era when differing guidance is followed by community optometrists. METHOD: The authors constructed an epidemiologically based model utilising Bridlington Eye Assessment Project (BEAP) data. Ocular hypertensive suspects' data were subjected to two algorithms (Association of Optometrists (AOP) and Joint College) to determine referral of suspects if community optometrists followed either algorithm. RESULTS: 85 of 1643 people (5.2%) tested by BEAP, with normal acuity and visual fields, recorded Goldmann IOPs of >21 mm Hg in either or both eyes. Without pachymetric information, all 85 would be referred under the AOP algorithm, decreasing to 31 (1.9%) under the joint College algorithm (63% reduction). If central corneal thickness readings influenced referral, 39 (2.4%) would be referred under the AOP algorithm and 13 (0.8%) under the joint College algorithm. CONCLUSION: If community optometrists use Goldmann tonometry and pachymetry, following the joint College guidelines, referrals of OHT suspects could be reduced to a fifth of those under the original AOP guidance. Community optometrists should be encouraged to use GAT and pachymetry in order to refine referrals when another examination is normal. Potential savings to the NHS are considerable.

Transscleral diode laser cycloablation in patients with good vision.

PURPOSE: To investigate the effect of diode laser cyclophotocoagulation for glaucoma on central visual function in patients with good visual acuity (VA). PATIENTS AND METHODS: Patients with preoperative VA 20/60 or better who had undergone cyclodiode treatment according to a standard protocol were evaluated retrospectively. The primary outcome variable was a recorded loss of two or more Snellen lines of best corrected VA during follow-up. Successful intraocular pressure (IOP) control was defined as being between 6 and 21 mmHg inclusive without oral acetazolamide or other glaucoma surgery. RESULTS: 49 eyes of 43 patients with a median pretreatment acuity of 20/30 were included (range 20/16-20/60). After a mean duration of follow-up of 5.0 years, median VA was 20/60 with a line loss of two or more recorded in 15 eyes (30.6%) (mean survival time 7.7 years). 67.3% (33/49) retained VA 20/60 or better, but VA deteriorated by one Snellen line or more in 31 (63.2%), and in 16.3% (8/49), final VA was <20/200. In cases experiencing a two-line loss in acuity, the main causes were glaucoma progression (nine cases) and macula oedema (four cases). Visual loss was unrelated to total treatment dose (mean 99.7 J), initial acuity or initial IOP level. IOP was controlled at final follow-up in 39/49 (79.6%) with no cases of hypotony. CONCLUSIONS: Most of these eyes with difficult to manage glaucoma retained their good VA over long-term follow-up after undergoing diode laser cyclophotocoagulation. The proportion losing two Snellen lines is in line with that reported after trabeculectomy or tube surgery. These results suggest a possible role for the use of transscleral cyclodiode in selected eyes with significant visual potential. Further controlled prospective studies are required to better define this role.

Shared care in glaucoma: a national study of secondary care lead schemes in England.

PURPOSE: To determine the number and nature of shared care schemes for glaucoma and glaucoma suspects operating in England. METHODS: A two-stage investigational process targeting all secondary-care ophthalmic departments with junior medical staff. An initial telephone contact for basic data (March 2006) was followed by a detailed questionnaire for completion by the scheme lead (May 2006). RESULTS: The telephone contact showed that of the 131 eligible ophthalmic departments, 76 claimed to be operating a glaucoma-based shared care scheme. Questionnaires were returned from 74 of the 76 departments claiming to run a scheme, showing that there were only 66 schemes operating in mid 2006 in association with 62 departments. Of these, 14 were community-based (predominantly run by trained optometrists) and 52 operated 'in-house' (predominantly involving nurses and optometrists). Most schemes were <6 years old and of the 30 schemes seeing new patients, 14 (47%) did not use gonioscopy as part of the assessment. In 8 schemes (12%), the shared care staff members were able to prescribe medication for glaucoma. CONCLUSION: In England, even before the outcome of the Department of Health shared care pilots had been published, approximately 50% of ophthalmic departments were running shared care schemes for glaucoma. However, most schemes contributed only modestly to the overall volume of glaucoma care, indicating that the majority of glaucoma-related consultations still occur directly with ophthalmologists. The Royal College of Ophthalmologists guidelines on gonioscopy are not being followed in almost half of the schemes seeing new patients.

Long-term review of driving potential following bilateral panretinal photocoagulation for proliferative diabetic retinopathy.

AIM: To determine the necessity for repeated Driver and Vehicle Licensing Agency (DVLA) visual field testing in people with diabetes who have had bilateral panretinal photocoagulation (PRP) for proliferative diabetic retinopathy. METHODS: A questionnaire survey was conducted of driving history in a cohort of people with diabetes who had been treated with bilateral PRP for proliferative retinopathy between 1988 and 1990. In addition, all similarly eligible subjects attending the diabetic retinal review clinic over a 12-month period who had had laser between 1991 and 2000 were questioned as to their driving status. RESULTS: Forty-five surviving patients from the 1988-1990 cohort were eligible and 25 returned the questionnaire (55%). Eight had never driven and 15 (13 with Type 1 diabetes) still held a valid licence, having passed the DVLA field test on a number of occasions. Neither of the two patients who had stopped driving reported failing the DVLA field test as the reason for stopping. All 12 of the patients directly questioned in the clinic were still driving and had passed at least one repeat DVLA test. CONCLUSIONS: People with Type 1 diabetes who have no further laser treatment for proliferative diabetic retinopathy can expect to retain their UK driving licence for at least 15 years following small-burn PRP, provided they maintain sufficient acuity.

The relationship between central corneal thickness and the optic disc in an elderly population: the Bridlington Eye Assessment Project.

PURPOSE: To determine population-based normative CCT data for elderly white subjects, with and without diabetes, and to explore the relationship between CCT and IOP and HRT2 measurements in such subjects with normal visual fields. METHODS: All eligible subjects were consecutive in a population screened for eye disease. CCT was measured by ultrasound pachymetry, and the optic disc was morphometrically defined using Heidelberg retinal tomography (HRT2). Inclusion criteria were: (1) normal visual field on suprathreshold testing and (2) corrected logMAR acuity of at least 0.3 in both eyes. Subjects with significant corneal pathology, previous corneal surgery, or known history of glaucoma or treatment for raised intraocular pressure were excluded. One eye was randomly selected from each subject for analysis. RESULTS: In all, 983 eyes of 983 subjects were included with 690 HRT images deemed acceptable for the analysis. The mean age (414 men and 569 women) was 73.3 years (minimum 65 years). Mean (SD) CCT was 544.1 (36.5) microm, with a normally distributed range of 429-633 microm. There was no significant difference in CCT between men and women (mean CCT 546.1 and 542.7 microm, respectively, P=0.15, Student's t-test), though CCT was correlated weakly and negatively with age (Pearson's r=-0.063, P=0.047). Diabetic patients (n=103) had a greater mean CCT than non-diabetic patients (551.9 and 543.0 microm respectively, P=0.02). No significant correlation was found between any global optic disc parameter and CCT in the 690 eyes analysed. CONCLUSION: Elderly white eyes with normal fields have CCTs that are normally distributed, with those from diabetic persons having greater CCTs. No clear evidence of a relationship between CCT and HRT2 optic disc parameters used in glaucoma diagnosis was found.

Peripapillary retinal nerve fibre layer thickness in highly myopic Caucasians as measured by Stratus optical coherence tomography.

AIMS: To assess peripapillary retinal nerve fibre layer (RNFL) thickness distribution in a group of non-glaucomatous Caucasian subjects with a high degree of myopia and to evaluate the relationship between RNFL thickness, both global and sectoral, and other variables including axial length and optic disc size. METHOD: 31 eyes of 31 healthy Caucasian subjects with spherical equivalent >or=-6 dioptres (D) were recruited from a community optometric practice. RNFL thickness was measured using the Stratus optical coherence tomography (OCT) Fast RNFL 3.4 mm scan protocol. Optic disc area was measured using the Heidelberg Retinal Tomograph II and axial length using the IOL Master. Associations between RNFL measurements and axial length, spherical equivalent and optic disc area were evaluated by linear regression analysis. RESULTS: The sample had a mean age of 48.1 years, mean spherical equivalent of -7.7 D, and mean axial length of 26.5 mm. The mean (SD) RNFL thickness was 81.4 (13.7) microm. In comparison with the Status OCT normative database, the distribution of RNFL thickness was substantially lower in the study group. The greatest disparity was around 7 clock hours centred on the nasal meridian in which 26/31 (83.9%) had one or more clock hours in which RNFL thickness was below normal at the 5% probability level in comparison with the Stratus normative database. No statistically significant associations between mean RNFL thickness and age (p = 0.12), gender (p = 0.76), spherical equivalent (p = 0.80), cup:disc area ratio (p = 0.88), optic disc area (p = 0.14) or axial length (p = 0.18) were identified in this group. However, RNFL thickness from vertical quadrants and in particular the superior sector correlated strongly with axial length, age and optic disc area. CONCLUSIONS: The Stratus OCT normative database may be misleading in highly myopic eyes from Caucasians resulting in a substantial proportion of false positive errors. Particular caution is needed when the RNFL appears to be below the normative database normal limit at the upper or lower poles or on the nasal side of the disc. Stratified normal databases are required for accurate diagnosis of conditions resulting in nerve fibre loss such as chronic glaucoma.

Anticoagulation therapy in glaucoma surgery.

PURPOSE: To identify the practices of ophthalmologists when undertaking glaucoma surgery on patients concurrently using warfarin or acetylsalicylic acid (aspirin). METHODS: A questionnaire was designed to examine perioperative management of patients being treated with warfarin and aspirin prior to and during glaucoma surgery. The questionnaire was posted with stamped self-addressed envelopes to all glaucoma specialists registered on a glaucoma shared care scheme database. RESULTS: Of the 93 eligible participants, 64 returned a completed questionnaire, representing a response rate of 68.8%. Twenty-one surgeons (32.8%) routinely stopped warfarin before surgery. Mean time prior to surgery of drug cessation was 4 days (range 2-7). Three surgeons (14.3%) routinely commenced heparin if they stopped warfarin. Ten (47.6%) never used heparin, while the remaining eight (38.1%) would use heparin depending upon the indication for anticoagulation. Forty-two surgeons (81.25%)were happy to operate only at an INR < or =3 at the time of surgery. The remainder (18.75%) were happy to operate at higher INRs, including two surgeons (3.1%) who would operate at any level. Twenty surgeons (31.2%) routinely stopped aspirin before surgery, while the rest did not. Of those who stopped aspirin, the mean time prior to surgery was 7.1 days (range 4-14 days). CONCLUSIONS: The majority of surgeons do not stop warfarin or aspirin prior to glaucoma surgery. There is a great diversity in current practice with regard to the management of anticoagulant therapy prior to glaucoma surgery amongst glaucoma surgeons in England. Currently there is little information available to offer definitive guidance.

Patients' attitudes towards trainee surgeons performing cataract surgery at a teaching hospital.

AIM: To evaluate patients' preferences of surgeon to perform their cataract surgery if given a choice between consultant and trainee. METHODS: A questionnaire based patient satisfaction survey was conducted in a large University Teaching Hospital in the UK. One hundred and eighty patients undergoing first eye cataract surgery between January and March 2006 were asked a number of set questions on their preferences regarding the surgeon performing the operation. Primary outcome measure was the patient's preference for who would perform their cataract surgery (consultant or trainee). RESULTS: Overall, 126 (70%) accepted that trainee surgeons should operate as part of their training. Only 102 (81%) of these (57% of the total) would be happy to be operated on themselves by a supervised surgical trainee. Ninety-eight (78%) patients objected to being operated on by a trainee if they were to be unsupervised. One hundred and forty-two (79%) patients stated they would choose to wait longer for their surgery if it meant that a consultant would perform their operation. This preference was held significantly more strongly among patients who had been listed for surgery from a consultant's clinic rather than from the pooled 'cataract clinic' (P=0.048). One hundred and forty-four (80%) patients thought they should be told the name and designation of the surgeon who was to perform their operation. CONCLUSIONS: Patients undergoing their first cataract procedure appear to have a preference for their named consultant to perform their surgery. If 'patient choice' extends to the choice of operating surgeon, then there are clear implications for the training of future UK ophthalmologists.

Mean deviation fluctuation in eyes with stable Humphrey 24-2 visual fields.

AIM: To describe the expected fluctuation in the mean deviation (MD) scores on a large, long-term series of stable visual field reports for particular grades of defect in order to give clinicians an aid to the correct diagnosis of glaucomatous progression. METHOD: Visual field reports of subjects with five reliable consecutive Humphrey 24-2 visual fields, recorded over a period of at least 3 years, were scored using the Advanced Glaucoma Intervention Study (AGIS) system. The AGIS scores of the first and last visual fields were required to be identical. RESULTS: A total of 202 eyes from 202 patients were used in the study, with a total of 1010 visual fields being used in the analysis. Visual fields with no defect (AGIS score 0) had a 99% confidence interval (CI) of 0.3 dB, mild defects 0.4 dB, moderate defects 0.8 dB, severe 1 dB, and 1.3 dB for end-stage defects when considering variation of MD scores. Using a one-way ANOVA incorporating all stages showed very little fluctuation throughout the series (P=0.96). The correlation between the CI and grade of field defect showed a good positive correlation (r=0.7, P=0.0003) indicating an increase in CI as field defects worsen. CONCLUSION: When considering a series of reliable visual fields in a stable eye, one should expect only very little fluctuation in the MD, indicating that an increase in the MD beyond that of the 99% CI described may suggest progression. The reliability indices of the visual field test should be regarded as a primary consideration when assessing visual fields.

Intravitreal triamcinolone will cause posterior subcapsular cataract in most eyes with diabetic maculopathy within 2 years.

PURPOSE: To determine the incidence of cataract following intravitreal triamcinolone (IVTA) for diabetic macular oedema. METHODS: Prospective, non-randomised, interventional cohort case series. A total of 27 eyes of 27 patients with diabetic macular oedema received an intravitreal injection of 4 mg (0.1 ml) of triamcinolone acetonide inferotemporally through the pars plana under direct vision. In 20 patients the fellow eye served as control, whereas seven patients had both eyes injected (not simultaneously). Seven patients had a repeat (second) injection in the same eye. The main outcome measures were cataract and intraocular pressure (IOP) rise of at least 5 mmHg (IOP responder). RESULTS: The mean follow-up time was 18.9 months (range 13-29 months). A total of 22 (81%) of 27 eyes developed cataract during the follow-up period, of which 20 (74%) were posterior subcapsular in nature. None of the 20 uninjected fellow eyes developed posterior subcapsular cataract. Mean time to cataract formation was 16.2 months. In the seven patients who had both eyes injected, mean time to cataract formation was 16.5 and 17.1 months in the first and second eye, respectively. Mean time to cataract formation in seven eyes receiving a repeat second injection was 17.9 months. There was no significant difference in cataract formation between IOP responders (85%) and non-responders (79%) (P=1.00, Fisher's exact test). Uneventful cataract surgery was performed in six eyes of five patients. CONCLUSION: This study demonstrates that given appropriate long-term follow-up, the majority of patients, even after a single IVTA injection, will go on to develop cataract, of which posterior subcapsular will be by far the most common.

The -174G/C interleukin-6 promoter polymorphism influences the development of macular oedema following uncomplicated phacoemulsification surgery.

AIM: To determine whether the functional -174 G/C interleukin-6 gene polymorphism is a risk factor for the development of cystoid macular oedema (CMO) following routine uncomplicated phacoemulsification surgery in patients with no established risk factors. METHODS: A total of 40 patients who underwent routine phacoemulsification surgery as part of a randomised controlled trial comparing the use of postoperative steroid drops against a single sub-tenon injection of triamcinolone were genotyped for the IL-6 -174G/C polymorphism. All patients underwent fluorescein angiography at 30 days and anterior chamber flare measurements pre-operatively and at day 1, 7, and 30. RESULTS: Angiographic CMO developed in 14 patients of the 40 studied. 9 out of the 14 patients carried the GG genotype (Fisher's exact test P=0.05, Hazard ratio for GG genotype; 4.05 (1.02-16.00)). There was no difference in flare measurements between the GG and Non-GG (GC/CC) group. The two groups were otherwise well matched in terms of age, sex, phacoemulsification energy used intraoperatively, and proportion of patients receiving postoperative triamcinolone or steroid drops. CONCLUSION: The -174G/C interleukin-6 promoter gene variant appears to modulate the response to phacoemulsification surgery and to influence the development of postoperative CMO. These data suggest a genetic predisposition to this complication.

Detecting glaucoma with RADAAR: the Bridlington Eye Assessment Project.

AIMS: To develop a diagnostic algorithm using rim/disc area asymmetry ratio (RADAAR) to discriminate between normal and glaucomatous eyes using the Heidelberg retina tomograph (HRT). METHODS: RADAAR was calculated by dividing rim/disc area ratio of the larger disc by that of the smaller disc. RADAAR normal tolerances in each disc sector were generated using 611 population based normal elderly individuals (mean age 72.5 years). Overall status for each individual was equal to the worst disc sector. Sensitivity was assessed in 45 patients with open angle glaucoma. RESULTS: RADAAR variance was significantly greater in glaucoma compared with normality in all disc sectors (p<0.001). Normal RADAAR limits were not dependent on age or sex. Overall, at the 99th percentile limit, the diagnostic algorithm's specificity was 95.1% with a sensitivity of 55.6%. Males with glaucoma showed greater RADAAR variance than females. Corresponding sensitivity of the diagnostic algorithm was 63.0% and 44.4% in males and females respectively, although this difference was not statistically significant (p = 0.43). CONCLUSION: The RADAAR diagnostic algorithm detected glaucoma with moderate sensitivity but was limited by significant numbers of glaucoma patients with symmetrical optic disc changes. RADAAR may have greater sensitivity in males than in females although this requires confirmation in further studies.