Results From the First Teleglaucoma Pilot Project in Addis Ababa, Ethiopia.

PRECIS: A teleglaucoma case-finding model was utilized in Ethiopia using a high-risk case identification approach. An overall 7.9% of patients had definite glaucoma, and 13.8% were glaucoma suspects. Most cases could be managed medically. BACKGROUND: This study was carried out to analyze disease prevalence and clinical referral pathways for high-risk patients assessed through a hospital-based teleglaucoma case-finding program. METHODS: Patients over the age of 35 years were referred from outpatient diabetic and hypertensive clinics. Through a teleglaucoma consultation, a glaucoma specialist provided remote diagnosis and management recommendations. Patient referral pathways were analyzed. Part way through the program, frontline ophthalmic nurses and optometrists were empowered to refer patients to be seen by general ophthalmologists within a week if patients met high-risk criteria. Qualitative stakeholder feedback was also obtained. RESULTS: A total of 1002 patients (53% female) were assessed with a mean age of 51.0±11.7 years. The prevalence of glaucoma and glaucoma suspects was 7.9% (79 cases) and 13.8% (138 cases), respectively. Retinopathy was found in 9.1%, with hypertensive retinopathy (2.7%) and diabetic retinopathy (2.5%) representing the majority of cases. Age-related macular degeneration was present in 1.5% and cataract in 16%. An overall 63% of cases were without organic eye disease. 35% of patients were referred to a general ophthalmologist, 0.7% to a glaucoma specialist (for surgery), 1.5% to a retina specialist, and 17.7% to an optometrist for further care. Qualitative analysis revealed that stakeholders felt the value of teleglaucoma would be in triaging patients requiring more urgent management and in identifying disease at an earlier stage. CONCLUSIONS: There is a high prevalence of glaucoma in Ethiopian patients assessed through this teleglaucoma program. This model and study have also demonstrated various principles behind telemedicine, such as the development of an intelligent triage system, case-finding for a variety of diseases, and consideration of optimal patient flow/referral pathways.

Efficacy and safety of ab interno trabeculectomy in juvenile open-angle glaucoma.

OBJECTIVE: To determine the efficacy and safety of ab interno trabeculectomy with Trabectome in juvenile open-angle glaucoma (JOAG) patients. DESIGN: Prospective cohort study. METHODS: Evaluation of the 12-month results of 2 patient groups receiving ab interno trabeculectomy: group 1, eyes with no prior incisional surgery; group 2, eyes that had prior incisional cataract or glaucoma surgery. RESULTS: Group 1, 40 eyes (average age 31 ± 7 years), had a significant reduction in intraocular pressure (IOP) of 10.6 mm Hg at 12 months from a baseline of 27.4 mm Hg (p = 0.01), and the number of glaucoma medications reduced by 0.4 (p = 0.80). Four eyes (10%) within the study period required a secondary glaucoma surgery. Group 2, 20 eyes (average age 27 ± 8 years), had a significant reduction in IOP of 8.8 mm Hg from a baseline of 27.1 mm Hg (p = 0.06), and the number of glaucoma medications reduced by 1.4 (p = 0.36). Five eyes (25%) from this group underwent a secondary glaucoma surgery within 12 months. CONCLUSION: After 1 year of follow-up, ab interno trabeculectomy appears to be an effective and safe intervention for patients with JOAG; however, a reduction in use of topical medications may not be observed in those receiving ab interno trabeculectomy as a primary procedure.

Association of pseudoexfoliation syndrome with cardiovascular and cerebrovascular disease: a systematic review and meta-analysis.

OBJECTIVE: Pseudoexfoliation syndrome (PEX) is a systemic disease, but evidence of its association with cardiovascular disease (CVD) and cerebrovascular disease (CVA) is controversial. A quantitative systematic review will provide an accurate summary of the current body of the literature. DESIGN: Meta-analysis. PARTICIPANTS: Not applicable. METHODS: A comprehensive literature search of published and unpublished English-language studies was performed. Summary statistics were calculated using inverse variance weighting and are presented in forest plots. Sources of variance were evaluated statistically. RESULTS: After screening 4547 studies, 47 articles were reviewed, and 25 eligible studies were selected that reported patients from around the world. Twenty studies enrolling 9583 individuals with PEX evaluated CVD, providing a summary odds ratio (OR) of 1.61 (95% CI 1.37-1.90). Eleven studies, enrolling 1308 PEX patients, evaluated CVA and generated a summary OR of 1.76 (1.40-2.22). For any vascular event (AVE) using all 25 studies, there were 9716 PEX patients and 363,312 control patients, yielding a summary OR of 1.64 (95% CI 1.39-1.92). Analysis for publication bias with the Egger's test was not significant for studies reporting CVD and AVE (p = 0.92 and 0.64, respectively) but was significant for CVA (p = 0.03). Asymmetry of Begg's funnel plot was noted for the CVA and AVE analyses. Multiple sensitivity analyses were performed, including assessment of study quality; the OR for all 3 outcomes varied minimally and remained significant in all analyses. CONCLUSION: There is strong evidence that PEX is significantly associated with both CVD and CVA.

Compressed 3D and 2D digital images versus standard 3D slide film for the evaluation of glaucomatous optic nerve features.

SYNOPSIS: Clinicians can feel confident compressed three-dimensional digital (3DD) and two-dimensional digital (2DD) imaging evaluating important features of glaucomatous disc damage is comparable to the previous gold standard of stereoscopic slide film photography, supporting the use of digital imaging for teleglaucoma applications. BACKGROUND/AIMS: To compare the sensitivity and specificity of 3DD and 2DD photography with stereo slide film in detecting glaucomatous optic nerve head features. METHODS: This prospective, multireader validation study imaged and compressed glaucomatous, suspicious or normal optic nerves using a ratio of 16:1 into 3DD and 2DD (1024×1280 pixels) and compared both to stereo slide film. The primary outcome was vertical cup-to-disc ratio (VCDR) and secondary outcomes, including disc haemorrhage and notching, were also evaluated. Each format was graded randomly by four glaucoma specialists. A protocol was implemented for harmonising data including consensus-based interpretation as needed. RESULTS: There were 192 eyes imaged with each format. The mean VCDR for slide, 3DD and 2DD was 0.59±0.20, 0.60±0.18 and 0.62±0.17, respectively. The agreement of VCDR for 3DD versus film was κ=0.781 and for 2DD versus film was κ=0.69. Sensitivity (95.2%), specificity (95.2%) and area under the curve (AUC; 0.953) of 3DD imaging to detect notching were better (p=0.03) than for 2DD (90.5%; 88.6%; AUC=0.895). Similarly, sensitivity (77.8%), specificity (98.9%) and AUC (0.883) of 3DD to detect disc haemorrhage were better (p=0.049) than for 2DD (44.4%; 99.5%; AUC=0.72). There was no difference between 3DD and 2DD imaging in detecting disc tilt (p=0.7), peripapillary atrophy (p=0.16), grey crescent (p=0.1) or pallor (p=0.43), although 3D detected sloping better (p=0.013). CONCLUSIONS: Both 3DD and 2DD imaging demonstrates excellent reproducibility in comparison to stereo slide film with experts evaluating VCDR, notching and disc haemorrhage. 3DD in this study was slightly more accurate than 2DD for evaluating disc haemorrhage, notching and sloping.

Phaco-trabectome versus phaco-iStent in patients with open-angle glaucoma.

OBJECTIVE: To investigate efficacy and safety of phaco-trabectome (PT) versus phaco-iStent (Pi) for intraocular pressure (IOP) control in open-angle glaucoma (OAG). DESIGN: Retrospective comparative case series. PARTICIPANTS: A total of 70 eyes of 55 patients with OAG underwent either PT surgery by a single surgeon or Pi (insertion of 2 stents) by another surgeon in Canada between January 2010 and December 2012. METHODS: The medical records of consecutive adult patients who underwent either PT or Pi surgery were reviewed. All patients who satisfied both the inclusion and exclusion criteria were included in the outcomes analyses. IOP reduction, reduction in glaucoma medication, safety profile, and best-corrected visual acuity were evaluated. RESULTS: Thirty-six eyes of 30 patients had PT and 34 eyes of 25 patients had Pi. Baseline IOP was higher in the PT group (20.92 ± 5.07 mm Hg) than in the Pi group (17.47 ± 4.87 mm Hg; p = 0.026). At 12 months there was no significant difference between groups in relative reduction of mean IOP (PT -5.09 ± 5.73, 24% relative reduction vs. Pi -3.84 ± 3.80, 22% relative reduction; p = 0.331) or glaucoma medication use (PT -0.49 ± 1.17 vs. Pi -0.26 ± 0.73; p = 0.168) from baseline. However, Pi had significantly fewer individual complications (PT 20 vs. Pi 5; p < 0.0001) throughout the postoperative period. CONCLUSION: At 12 months of follow-up, both techniques significantly lowered IOP, but fewer complications were observed in the Pi group.

Porcine cataract creation using formalin or microwave treatment for an ophthalmology wet lab.

OBJECTIVE: Wet labs are an important part of ophthalmology residency training in order to develop intraocular surgical proficiency. The purpose of this study was to compare the effectiveness of formalin versus microwave treatment to produce porcine cadaveric cataracts. DESIGN: This study was a comparative observational study at a single centre. METHODS: Cataracts were created through the injection of 0.1 mL of 100% ethanol into the anterior chamber followed by the infiltration of 0.1 mL of 37% formalin using a short 30-gauge needle into the lens by introduction through the pars plana. The comparison group investigated porcine eyes treated with a microwave for 5-13 seconds using a 700 W power setting. Two observers used a validated nuclear opalescence and corneal clarity scale to independently grade the treated eyes. RESULTS: In total, 70 eyes were treated with either formalin or by microwave. The formalin eyes had an average lens opacity score of 0.04 ± 0.03 and 1.91 ± 01.10 pre- and post-treatment (p < 0.001). Microwaved eyes had an average pretreatment lens opacity of score 0.10 ± 0.31, which increased to 2.86 ± 0.1.08 post-treatment (p < 0.001). Post-treatment lens opacity was significantly greater in microwave eyes than in formalin-treated eyes (p = 0.003). Pretreatment corneal clarity was 3.65 ± 0.73 in the formalin group, and 3.70 ± 0.93 in the microwave group. After treatment, there was a significant reduction in corneal clarity within the formalin (3.01 ± 1.04, p = 0.0012) and microwave groups (3.03 ± 1.07, p < 0.001). CONCLUSIONS: Porcine eye models provide a realistic way to simulate cataracts and so residents can practice the basics of cataract surgery. Both microwave and formalin-based treatments are able to opacify the porcine lens with acceptable reductions in corneal clarity.

Implantation of 2 trabecular microbypass stents in a patient with primary open-angle glaucoma refractory to previous glaucoma-filtering surgeries.

UNLABELLED: A 77-year-old woman with primary open-angle glaucoma was referred for surgical evaluation after failing to achieve target intraocular pressure (IOP) despite previous combined phacotrabeculectomy and Ahmed valve implantations. The IOP prior to surgery was 28 mm Hg on topical dorzolamide-timolol, latanoprost, and brimonidine. Trabecular bypass surgery with implantation of 2 iStents was performed. The IOP decreased by 11 mm Hg to 17 mm Hg after surgery and has remained stable for 2 years. This is the first published case reporting this magnitude of IOP reduction sustained for more than 2 years following insertion of 2 trabecular microbypass stents in a patient who had previous glaucoma-filtering surgeries. Further prospective studies are needed to establish expanded surgical indications for implantation of trabecular microbypass stents. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Optic nerve gray crescent can confound neuroretinal rim interpretation: review of the literature.

The optic nerve gray crescent can be of clinical significance if unrecognized during assessment for glaucoma. It has a characteristic appearance of a slate gray area of pigmentation within the disc margins and commonly appears along the inferotemporal or temporal neuroretinal rim areas. This type of disc rim pigmentation can create the impression of neuroretinal rim thinning, and thus lead to the misdiagnosis of glaucoma or "glaucoma suspect" with attendant implications for overtreatment or unnecessary close monitoring of such patients. The gray crescent is more common in African Americans than whites (prevalence rate 27% vs 7%) and is bilateral in at least 58% of cases. It has been reported in association with Kjer optic atrophy type 1. Suggested causes of the gray crescent include an accumulation of melanocytes, or retinal pigment epithelium cells partially located in the optic nerve head region if Bruch's membrane extends internal to the peripapillary scleral ring. Other causes of pigmentation that may resemble gray crescent are conus pigmentosus and variations of peripapillary atrophy. When a gray crescent is present, clinicians should endeavour to identify the true anatomical disc margins via the scleral lip and, if necessary, evaluate the patient further with imaging and visual field studies.

Northern Alberta remote teleglaucoma program: clinical outcomes and patient disposition.

OBJECTIVE: To review the diagnostic outcomes and clinical referral pathways of patients assessed and managed through a collaborative care patient-centred teleglaucoma program. STUDY DESIGN: Retrospective cohort study. METHODS: Eligible patients were those assessed by the referring optometrist or ophthalmologist to be open-angle glaucoma suspects or to have definite early open-angle glaucoma. A glaucoma specialist graded each case through virtual consultation. Clinical referral pathways were noted: in-person consultation with glaucoma specialist, repeat teleconsultation, collaborative glaucoma management with optometrist, or referral for nonglaucomatous ophthalmic pathology. RESULTS: A total of 247 patients were referred to the program from 2008 to 2012. Of all teleconsults, 31.1% were diagnosed with glaucoma, 42.1% were suspects, and 26.7% were unaffected. Of all patients, 27% were referred for in-person glaucoma evaluation; 69% of patients could be managed by their referring optometrist, with 48% of patients requiring repeat teleconsultation. Treatment was initiated before being seen for 87% of patients with definite glaucoma and 28% of glaucoma suspects. CONCLUSIONS: Of all patients seen through the remote teleglaucoma program, most did not require an in-person consultation with an ophthalmologist and could be managed through distance collaboration. For the approximately one third who were diagnosed with glaucoma based on virtual assessment, medication was started in the majority of cases and in-person consultation was arranged. Further studies to validate and consider cost-effectiveness of this system are under way.

Improved access and cycle time with an "in-house" patient-centered teleglaucoma program versus traditional in-person assessment.

BACKGROUND: To compare access time and cycle time between an "in-house" teleglaucoma program and in-person glaucoma consultation. PATIENTS AND METHODS: This was a prospective comparative study of 71 patients seen through the teleglaucoma program (eligible patients were glaucoma suspects or early-stage open-angle glaucoma) and 63 patients seen via a traditional in-person exam with a physician present. Access time was calculated as the time from the patient being referred to the date of a booked visit for either a teleglaucoma or in-person exam. Cycle time was defined as the time from registration until departure during the visit to the hospital; it was calculated for the subset of patients from each study group who completed activity logs on the day of their visit. RESULTS: The mean access time was significantly shorter for patients seen through teleglaucoma compared with in-person exam: 45±22 days (range, 13-121 days) (n=68) versus 88±47 days (range, 27-214 days) (n=63), respectively (p<0.0001). The cycle time was also reduced for patients seen through teleglaucoma, compared with in-person assessment: 78±20 min (range, 40-130 min) (n=39) versus 115±44 min (range, 51-216 min) (n=39), respectively (p<0.001). The mean percentage time spent in the waiting room was also significantly reduced for patients seen through teleglaucoma versus in-person assessments: 19±13% versus 41±24% (n=39), respectively (p<0.01). CONCLUSIONS: Teleglaucoma improves access to care and is a more efficient way of managing glaucoma suspects and patients with early-stage glaucoma compared with in-person assessment.

Probing without irrigation in children with congenital nasolacrimal duct obstruction.

PURPOSE: The purpose of this study was to evaluate the results of probing, without fluorescein irrigation, as a primary treatment for epiphora and/or mucous discharge, secondary to congenital nasolacrimal duct obstruction (CNLDO) METHODS: The medical records of nine-two children (127 eyes) with CNLDO who underwent a single probing without the use of fluorescein irrigation between January 2006 and December 2011 were reviewed retrospectively. Inclusion criteria were no prior nasolacrimal surgical procedure, history of epiphora and/or discharge since birth or shortly after birth in one or both eyes and at least one of the following clinical signs: epiphora, muco-purulent discharge and increased tear meniscus height. Children were investigated in two sub-groups based on age at time of probing; group 1 (51 eyes/40 children) included children who underwent probing at age ≤ 2 years and group 2 (76 eyes/52 children) included children who underwent probing at age > 2years. The primary outcome was the complete disappearance of symptoms and signs in the affected eye(s), assessed at 3 months after surgery. RESULTS: The success rate for the overall sample was 83.5 % (106/127 eyes), in group 1 was 90.2% (46/51) and in group 2 was 78.9% (60/76). There was no significant difference in success rate between groups (p=0.094). Gender (p=0.292), affected eye (p=0.647) and bilateral cases (p=0.739) were not associated with successful elimination of symptoms. CONCLUSION: Probing without fluorescein irrigation for CNLDO beyond 1 year of age is highly successful and comparable to the published efficacy rates of the traditional probing with fluorescein irrigation.

Phenotypic features of Chinese family members with primary angle closure.

OBJECTIVE: To describe ocular phenotypic features in Chinese families with primary angle closure (PAC). DESIGN: Prospective cohort study. PARTICIPANTS: 428 individuals of 103 eligible families. METHODS: Probands identified in clinic and their relatives were examined. Measurements included intraocular pressure, anterior chamber depth, lens thickness, axial length, and gonioscopic features related to the anterior chamber angle. Electroretinogram (ERG) testing for dark and light adaptation on both eyes of each individual examined was also obtained. RESULTS: There were 144 PAC affected patients (33.7%), 60 suspects (14%), and 224 unaffected individuals (52.3%). There were more than 2 affected members in 51 families (49.5%). Compared with unaffected individuals, affected individuals were more likely to be female, have shallower peripheral and central anterior chamber depths, narrower angles, thicker lenses, and shorter axial lengths (p<0.001). Affected patients and suspects had similar axial lengths (p>0.05). Compared with unaffected individuals, affected and suspect individuals showed ERG adaptation abnormalities (p<0.05). Of 45 unaffected individuals with mean axial length ≤ 22.00 mm (10.51%), 20 individuals (4.67%) showed ERG adaptation abnormalities similar to affected patients and suspects (p> 0.05). CONCLUSIONS: Patients with PAC were significantly more likely to be female, have shorter axial length, and have thicker lenses compared with unaffected individuals. PAC suspects showed similar axial lengths to affected individuals. ERG abnormalities mainly occurred in affected patients and suspects, but also occurred in unaffected individuals with short axial length.

Dismantling sociocultural barriers to eye care with tele-ophthalmology: lessons from an Alberta Cree community.

PURPOSE: There are significant disparities in access to health care amongst Aboriginal Canadians. The purpose of this study was to determine whether tele-ophthalmology services, provided to Aboriginal Canadians in a culturally-sensitive community-based clinic, could overcome social and cultural barriers in ways that would be difficult in the traditional hospital-based setting. METHODS: The Aboriginal Diabetes Wellness Program of Alberta incorporates culturally-sensitive health-related activities and rituals as a component of a diabetic retinopathy tele-ophthalmology screening program. Metrics of program attendance were collected while stakeholders participated in a survey to identify barriers to healthcare delivery. RESULTS: Aboriginal patients, cultural liaison, nurses and program administrators revealed economic, geographic, social and cultural barriers to healthcare faced by Aboriginal people. It was found that the introduction of culturally-sensitive programs led to increased appointment attendance; from 25% to 85%. Involvement of Aboriginal nurses, inclusion of culturally-sensitive activities and participation in spiritual ceremonies led to qualitative accounts of increased patient satisfaction, trust towards the healthcare team and communication amongst participants. CONCLUSIONS: A culturally-sensitive model of healthcare delivery in a community-based health clinic improved access to tele-ophthalmology services. This was demonstrated by increased attendance at appointments and increased satisfaction amongst patients.

Incidence of retinopathy of prematurity and risk factors among premature infants at a neonatal intensive care unit in Canada.

PURPOSE: To study the incidence of retinopathy of prematurity (ROP) in a neonatal intensive care unit and obtain information on risk factors associated with ROP. METHODS: Four hundred twenty-three infants were screened for ROP between July 2006 and July 2010. Demographic information, clinical data, and risk factors were reviewed. RESULTS: The incidence was 40.4% (171 infants) for ROP, 9.2% (39 infants) for severe ROP, and 5.67% (24 infants) for laser treatment. Mean gestational age and birth weight were significantly lower among infants with ROP versus those without ROP (26 ± 0.13 vs 28.55 ± 0.12 weeks, P < .0001 and 840.5 ±17.49 vs 1,190.24 ± 20.20 g, P < .0001, respectively). Birth weight (P < .001), gestational age (P < .001), mechanical ventilation therapy (P = .039), and necrotizing enterocolitis (P = .019) were independent risk factors for ROP. CONCLUSION: Gestational age and birth weight were the most significant risk factors for developing ROP. The study population had an elevated percentage of infants with birth weight less than 1,000 g (extremely low birth weight), yet there was no corresponding increase in severe ROP incidence and treatment when compared to other studies.

Incidence and severity of retinopathy of prematurity in extremely premature infants.

OBJECTIVE: To analyze incidence and severity of retinopathy of prematurity (ROP) among extremely premature infants. DESIGN: Retrospective, longitudinal study. PARTICIPANTS: We studied the data concerning 207 infants whose gestational ages (GAs) were equal to 27 weeks or fewer and who were admitted to a neonatal intensive care unit between July 2006 and July 2010. METHODS: Data were extracted from the Canadian Neonatal Network, which maintains clinical information about neonates, and were confirmed by reviewing medical charts. Infants were classified into 2 groups: the GAs of the infants in group 1 were ≤ 25 weeks; those in group 2 had GAs between 26 and 27 weeks. The incidence and severity of ROP were assessed in the total screened population and between groups. RESULTS: The overall incidence of any ROP was 64.7%; 88% of infants in group 1 had any ROP compared to 48% infants in group 2. The overall incidence of type 1 ROP was 11.6%; in group 1 it was 24.4%, compared to 2.5% in group 2. Type 1 ROP was significantly associated with birth weight in grams (p < 0.001; OR = 8.20) and GA (p < 0.001; OR = 2.46). There was no difference in mean postmenstrual age at first ROP onset between group 1 and group 2 (33.5 vs 33.9 weeks, respectively). PMA at time of ROP diagnosis was not associated with development of type 1 ROP (p = 0.75; OR = 0.94; CI 0.62-1.41). CONCLUSIONS: Extremely premature infants with lower GA had a higher incidence of type 1 ROP. Earlier presentation of ROP did not predict development of type 1 ROP. No infant with a GA > 26 weeks at birth or birth weight > 1000 g had type 1 ROP.

Success rates of primary probing for congenital nasolacrimal obstruction in children.

PURPOSE: To determine the success rate of nasolacrimal duct probing for the treatment of congenital nasolacrimal duct obstruction and to identify the age at which the success rate decreases. METHODS: Records for probing procedures from 2005 to 2010, over a 56-month period, were reviewed. Successful probing was defined as complete resolution of epiphora 3 months after treatment. Success rates were compared between children <3 years of age and children ≥3 years of age at the time of the procedure. RESULTS: A total of 168 eyes (128 children, mean age 32.2 ± 23.8 months) had undergone a probing procedure, and the overall success rate was 72%. Children aged <36 months had a success rate of 78%; children aged ≥36 months had a success rate of 50%. Multivariate analysis demonstrated that age at the time of procedure was a significant risk factor for failed probing (P = 0.035; OR, 1.67; 95% CI, 1.04-2.69), whereas sex and bilateral surgery were not. CONCLUSIONS: The success rate of primary probing for congenital nasolacrimal duct obstruction was significantly reduced when performed on children ≥3 years of age.