Clinical operational considerations and responses to lockdown and reopening in the Covid-19 pandemic: experience of a tertiary ophthalmology centre in Singapore.

BACKGROUND: Much has been written on infection control and clinical measures for ophthalmic institutions and departments to cope with the COVID-19 pandemic. However, few articles have detailed implementation plans to manage lockdowns and subsequent re-openings. In this article, specific operational responses and their outcomes in a large tertiary ophthalmology centre are described. METHOD: Through a concerted effort led by a dedicated task force, the Singapore National Eye Centre (SNEC) planned and executed an operational transformation to respond to the restrictions imposed on healthcare delivery during a national lock down. A carefully calibrated re-starting of services was carried out with the subsequent phased reopening of the country, taking into consideration unique constraints faced at that time. Strategies for operating in the new normal environment were also developed. RESULTS: Outpatient attendances were safely and expediently reduced by 70% (8749 vs. 29,311) and 82% (5164 vs. 29,342) in April and May 2020, respectively, compared to the corresponding months in 2019. A correspondingly large reduction in surgical load was also achieved through a similar triaging and prioritization system. Through optimizing the center's use of space and time, as well as expanding on new models of care, a return to pre-pandemic patient load was achieved 3 months into the phased reopening of the country, and subsequently exceeded in the following months. CONCLUSION: The lessons gleaned from SNEC's experience may be useful for institutions currently facing the same challenges, and for future responses to COVID-19 resurgences or other pandemics.

Submacular integration of hESC-RPE monolayer xenografts in a surgical non-human primate model.

BACKGROUND: Human pluripotent stem cells (hPSCs) provide a promising cell source for retinal cell replacement therapy but often lack standardized cell production and live-cell shipment logistics as well as rigorous analyses of surgical procedures for cell transplantation in the delicate macula area. We have previously established a xeno- and feeder cell-free production system for hPSC differentiated retinal pigment epithelial (RPE) cells, and herein, a novel immunosuppressed non-human primate (NHP) model with a disrupted ocular immune privilege is presented for transplanting human embryonic stem cell (hESC)-derived RPE on a scaffold, and the safety and submacular graft integration are assessed. Furthermore, the feasibility of intercontinental shipment of live hESC-RPE is examined. METHODS: Cynomolgus monkeys were systemically immunosuppressed and implanted with a hESC-RPE monolayer on a permeable polyester-terephthalate (PET) scaffold. Microscope-integrated intraoperative optical coherence tomography (miOCT)-guided surgery, postoperative follow-up incorporated scanning laser ophthalmoscopy, spectral domain (SD-) OCT, and full-field electroretinography (ERG) were used as outcome measures. In addition, histology was performed after a 28-day follow-up. RESULTS: Intercontinental cell shipment, which took >30 h from the manufacturing to the transplantation site, did not alter the hESC-RPE quality. The submacular hESC-RPE xenotransplantation was performed in 11 macaques. The miOCT typically revealed foveal disruption. ERG showed amplitude and peak time preservation in cases with favorable surgical outcomes. Histology confirmed photoreceptor preservation above the grafts and in vivo phagocytosis by hESC-RPE, albeit evidence of cytoplasmic redistribution of opsin in photoreceptors and glia hypertrophy. The immunosuppression protocol efficiently suppressed retinal T cell infiltration and microglia activation. CONCLUSION: These results suggest both structural and functional submacular integrations of hESC-RPE xenografts. It is anticipated that surgical technique refinement will further improve the engraftment of macular cell therapeutics with significant translational relevance to improve future clinical trials.

Real-World Treatment Outcomes of Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy in Asians.

PURPOSE: To describe the 12-month outcomes of treatment-naïve eyes with choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) after initiation of intravitreal anti-vascular endothelial growth factor (VEGF) monotherapy or combination therapy with verteporfin photodynamic therapy (PDT). DESIGN: A 12-month single-center, retrospective, comparative, nonrandomized cohort study. PARTICIPANTS: Patients with AMD or PCV who initiated intravitreal anti-VEGF therapy during 2015. METHODS: Demographics, visual outcomes, OCT, and treatment data were collected at baseline and months 1, 3, 6, and 12 after treatment initiation. Multivariate analysis was performed to identify baseline features predictive of visual maintenance and improvement after 12 months of treatment. MAIN OUTCOME MEASURES: Primary end point was visual acuity (VA) change from baseline to month 12. Secondary end points were treatment exposure and change in central subfield thickness on OCT. RESULTS: A total of 364 patients (165 AMD and 199 PCV) were included. Baseline vision was 41 and 43 logarithm of the minimum angle of resolution (logMAR) letters for AMD and PCV patients, respectively. Patients with AMD and PCV received 5.5 and 5.3 injections (5.0 monotherapy vs. 5.6 combination therapy; mean, 1.2 PDT sessions), respectively. Patients with AMD gained 4.7 logMAR letters after 12 months (P = 0.002), whereas PCV patients gained 6.6 logMAR letters (P = 0.001) and 10.8 logMAR letters (P < 0.001) for monotherapy and combination therapy, respectively. Only patients with presenting VA of fewer than 35 letters (Snellen equivalent, 6/60) achieved significant visual improvement (10.4 letters for AMD, 17.1 letters for PCV with monotherapy, and 35.5 letters for PCV with combination therapy). Predictors of VA gain included number of intravitreal injections (AMD and PCV adjusted odds ratio, 12.1 [P = 0.001] and 12.5 [P = 0.004] for ≥7 injections, respectively) and baseline VA of 20 logMAR letters or fewer (adjusted odds ratio, 3.8 and 10.6 for AMD and PCV, respectively). Age, gender, race, use of PDT or focal laser therapy, and central subfield thickness were not predictive of significant visual gain at 12 months. CONCLUSIONS: In Asian patients, treatment of AMD with anti-VEGF therapy yielded 12-month visual outcomes comparable with those of other real-world studies from Western populations but poorer than those of controlled trials. In contrast, for PCV eyes, anti-VEGF monotherapy and combination therapy with PDT yielded comparable outcomes as those of controlled clinical trials.

25-years Trends and Risk factors related to Surgical Outcomes of Giant Retinal Tear-Rhegmatogenous Retinal Detachments.

To describe the 25-year surgical trends, long-term outcomes and risk factors affecting the outcomes of giant retinal tear-related rhegmatogenous retinal detachments (GRT-RRD). Patients' demographics, pre-operative characteristics, risk factors, operative procedures and post-operative outcomes were collected and divided into three groups - Group A: 1991 to 2015 (overall); Group B: 1991 to 2005, and Group C: 2006 to 2015. Functional and anatomical successes were monitored over a 5-year period. Multivariate logistic regression analysis was performed to identify the risk factors related to functional and anatomical success.127 eyes of 127 patients were included in the study. At 5th year, 69.4% patients had visual acuity (VA) < logMAR 1.0 with 87.5% primary anatomical success rate. While the functional outcome remained the same between group B and C, there was an increase in the anatomical success from 89.7% to 100%, albeit not statistically significant. Patients with worse presenting VA, 150 degrees or more of giant retina tear, macula-detached status and presence of PVR were associated with VA of> logMAR 1.0 (all p < 0.05). The types of surgery (TPPV vs combined SB/TPPV), number of breaks, lens extraction and additional cryotherapy were not associated with the functional or anatomical success. In conclusion, the GRT-RRD functional and structural outcomes were comparable between 1991-2005 and 2006-2015, albeit a statistically insignificant improvement of anatomical outcome over the past 25 years. Worse presenting VA, 150 degrees or more of giant retinal tear, detached macula and presence of PVR were associated with poorer visual outcome.

Surgical management of late dislocated lens capsular bag with intraocular lens and endocapsular tension ring.

A case of late spontaneous dislocation of the lens capsular bag (CB) with foldable acrylic intraocular lens (IOL) and endocapsular tension ring (CTR) and its surgical management is reported in a 52-year-old man. The dislocation occurred 2 years 3 months after phacoemulsification cataract surgery in which a CTR was used for zonular instability. A 3-port pars plana vitrectomy was performed. Because it was not possible to grasp the IOL-CTR-CB complex, perfluorocarbon liquid was used to attempt to float it up. This was unsuccessful, so a scleral indenter was used to apply external pressure on the sclera to tilt the IOL-CTR-CB complex into a position where it could be grasped with a forceps and removed through a corneal section. A scleral-fixated IOL was placed, and the patient achieved a best corrected visual acuity of 6/9. The procedure was safe and effective without intraocular complications.

Goniosurgery for glaucoma complicating chronic childhood uveitis.

OBJECTIVES: To describe the safety and efficacy of goniotomy in medically uncontrolled glaucoma complicating chronic uveitis and the factors affecting its outcome. METHODS: All goniotomies performed by a single surgeon for refractory childhood uveitic glaucoma were retrospectively reviewed. Success was defined as final intraocular pressure (IOP) of no greater than 21 mm Hg without medications and qualified success as IOP of no greater than 21 mm Hg with medications. Unless otherwise indicated, data are expressed as mean +/- SD. RESULTS: Fifty-four goniotomies were performed in 40 eyes of 31 patients. Juvenile rheumatoid arthritis-associated uveitis was the diagnosis in 30 eyes (75%). Eleven eyes (28%) were aphakic. Mean follow-up was 98.9 months (range, 2-324 months). Mean age at surgery was 10.3 +/- 4.7 years (range, 4-22 years). Mean preoperative IOP was 36.7 +/- 6.4 mm Hg while receiving a mean of 2.9 +/- 1.1 medications. Overall surgical success was achieved in 29 eyes (72%), including success in 22 (55%) and qualified success in 7 (18%) while receiving a mean of 1.6 +/- 1.1 medications. Mean postoperative IOP in the success and qualified-success groups were 14.3 +/- 2.8 and 15.7 +/- 3.1 mm Hg, respectively. Kaplan-Meier survival probabilities (95% confidence interval) at 1, 5, and 10 years were 0.92 (0.82-1.00), 0.81 (0.65-0.97), and 0.71 (0.49-0.92), respectively. Phakic eyes, eyes with fewer peripheral anterior synechiae, patients younger than 10 years, and eyes with no prior surgery had significantly better outcomes. Hyphema, typically mild and transient, occurred in 43 procedures (80%). CONCLUSIONS: Goniosurgery is low risk and effective for refractory glaucoma complicating chronic childhood uveitis. It should be considered the surgical procedure of choice for this condition. Surgical outcome is adversely affected by increased age, peripheral anterior synechiae, prior surgeries, and aphakia.

Effect of diode laser contact transscleral pars plana photocoagulation on intraocular pressure in glaucoma.

PURPOSE: To evaluate the efficacy of diode laser contact transscleral pars plana photocoagulation (CTPPP) for intraocular pressure (IOP) control in glaucoma and its clinical application. METHOD: A prospective, non-randomized hospital-based pilot study was conducted. Fourteen patients with poor visual acuity (VA worse than 6/60) and medically uncontrolled, refractory glaucoma were recruited, and CTPPP was performed after informed consent. RESULTS: Mean preoperative IOP was 41.0 mmHg (SD 12.6, range 27-70, n = 14). At 1 week postoperatively, IOP was reduced in 12 of 14 (86%) patients to a mean of 28.6 mmHg (SD 15.8, range 3-55, n = 14). This represented a mean decrease of 12.4 mmHg. Mean IOP was 34.0 mmHg (SD 17.4, range 5-71, n = 14) and 31.6 mmHg (SD 13.4, range 5-22, n = 12) at 4 and 12 weeks, respectively. The IOP reduction was significant at 1 week (P = 0.001, paired t-test) and at 12 weeks (P = 0.04, paired t-test). The two patients with preoperative pain reported abolition of pain after the procedure. Seven of 13 patients on preoperative antiglaucoma eye drops did not require eye drops postoperatively. CONCLUSION: Diode laser CTPPP was found to significantly reduce IOP in the majority of patients at 1 week postoperatively, with less but still significant effect at 12 weeks. Its potential application as a procedure for short-term IOP reduction in medically uncontrolled glaucoma requiring filtering surgery needs to be further investigated.