247 QUALITY IMPROVEMENT IN DEMENTIA CARE: STREAMLINING CARE PATHWAYS IN A PSYCHIATRY OF OLD AGE SERVICE

Background

Dementia is increasingly considered a public health priority worldwide in the context of predicted increased prevalence. In Ireland, there are an estimated 67,000 persons living with dementia and by 2041 it is expected to rise to 145,000 persons. Challenges in dementia care have been highlighted in health services across Europe and the ineffective structure of dementia care with fragmented non-person-centred pathways has been identified.

Methods

An initial review of the existing cognitive impairment diagnostic pathways in our specialised Psychiatry of Old Age (POA) Service was undertaken. This included surveying the multidisciplinary team to identify challenges, clinical chart review and audit of physical examination equipment. Diagnostic pathway was updated based on findings and informed by the developing national ‘Model of Care for Dementia in Ireland’ and best practice.

Results

Review findings included lack of standardisation of memory assessment, delays in accessing neuroimaging and laboratory results, gaps in staff training. A care pathway document was developed detailing requirements for care from the point of referral through to cognitive impairment diagnosis. Staff training was completed to accompany the introduction of standardised dementia assessment scales. Access to laboratory/radiology booking was enhanced. A cognitive remediation group was developed by Occupational Therapy as part of post-diagnostic supports for service users. Preliminary data indicates improvements in satisfaction of those attending the group. Physical examination equipment audit resulted in quality improvements.

Conclusion

We demonstrate that a quality improvement approach can be implemented to enhance assessment, diagnosis and care provided to support diagnosis of cognitive impairment and dementia in POA service. The enhanced diagnostic care pathways will be assessed over time to assess impact on care of service users. Preliminary findings are positive and it is an approach that can be adopted in other services and inform development of national memory service developments.

Accuracy of toric intraocular lens implantation using automated vs manual marking

BACKGROUND

Accurate alignment of toric intraocular lens (TIOL) to steep corneal astigmatic axis is important to achieve effective postoperative results. The authors compare the accuracy of astigmatism correction using automated and manual marking in TIOL implantation during cataract surgery.

METHODS

One hundred thirty-two eyes with nuclear density from Grade 2 to 4 were randomly subdivided into 2 groups (automated and manual marking). All patients underwent manual marking and the steep axis was compared to SensoMotoric Instruments (SMI). After phacoemulsification, 62 patients underwent toric IOL implantation using the SMI and 70 patients underwent toric IOL implantation using manual marking. Intraoperative measurement was the steep axis difference. Clinical measurements included preoperative and postoperative best corrected visual acuity (BCVA), and TIOL axis.

RESULTS

The intraoperative steep axis difference between SMI and manual marking was 7.86 ± 6.4 degrees. The difference between the preoperative steep axis and the postoperative TIOL axis using SMI (3.63 ± 1.12 degrees) was significantly lower than that using manual marking (8.29 ± 2.23 degrees) (P < 0.05).

CONCLUSIONS

The steep axis measurements may be different when using SMI vs. manual marking. The SMI is more accurate than manual marking for TIOL implantation during cataract surgery.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12294725 , Retrospectively registered, on 20 July 2018.

Comparison of Anterior Capsule Stability Following Implantation of Three Single Piece Acrylic Intraocular Lenses with Different Haptic Design

Purpose

To compare the anterior capsule contraction and intraocular lens (IOL) decentration among three types of IOL to determine the influence of haptic design on anterior capsule stability.

Methods

One hundred fifty patients were enrolled in this prospective, randomized study and 260 eyes underwent implantation of one of the following IOLs: modified L-haptic IOL (n = 74), modified C-haptic IOL (n = 97), or a plate-haptic IOL (n = 89). The area of the anterior capsule opening, IOL decentration, and capsule overlap were measured using retroillumination photospot 1 day and 2 months after cataract surgery.

Results

The area of capsule opening at postoperative day 1 was significantly different between the three IOLs (p < 0.01). All IOLs showed reduction of the anterior capsule opening from 1 day to 2 months after surgery, and greater reduction was shown in the modified C-haptic IOL (p < 0.001). At postoperative month 2, IOL decentration was significantly different between the IOLs and showed a positive correlation with the mean area reduction during month 2.

Conclusions

The degree of anterior capsule contraction and IOL decentration in modified L-haptic IOLs were less than those in modified C-haptic IOLs and comparable to those in plate-haptic IOLs.

Comparison of Long-term Clinical Outcomes between Descemet's Stripping Automated Endothelial Keratoplasty and Penetrating Keratoplasty in Patients with Bullous Keratopathy

Purpose

To compare 2-year clinical outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) in patients with bullous keratopathy.

Methods

A retrospective chart review was performed to obtain 2 years of follow-up data of DSAEK or PK at a single center from March 2009 to September 2012. The study comprised 15 eyes of DSAEK and 11 eyes of PK. Outcome measures included best-corrected visual acuity (BCVA), spherical and keratometric changes, central corneal thickness, endothelial cell density, intraocular pressure, and postoperative complications. Graft survival rate was assessed by Kaplan-Meier survival analysis.

Results

There were no differences in patient baseline characteristics between the two groups. At postoperative 2 years, better BCVA of 0.69 ± 0.51 logarithm of the minimum angle of resolution (logMAR) was found after DSAEK compared to 0.88 ± 0.48 logMAR after PK. Refractive cylinder in DSAEK and PK was −2.60 ± 1.53 and −6.00 ± 1.05 diopters (D), respectively, and keratometric cylinder was 3.27 ± 3.70 and 6.34 ± 3.51 D, respectively, at postoperative 2 years. The difference of mean spherical equivalents between postoperative 1 month and 2 years was 0.84 D after DSAEK and 2.05 D after PK. A hyperopic shift of 1.17 D was present after 2 years of DSAEK. The mean endothelial cell density at postoperative 2 years was 1,548 ± 456 cells/mm² for DSAEK and 1,052 ± 567 cells/mm² for PK, with a cell loss of 19.96% vs. 52.38%, respectively when compared to postoperative 1 month. No significant difference in central corneal thickness was found between DSAEK and PK (592 ± 75 vs. 563 ± 90 µm, respectively). Finally, the 2-year survival rate did not differ significantly between DSAEK and PK (93.3% vs. 81.8%, respectively, p = 0.344).

Conclusions

Compared to PK, DSAEK provided more stable refractive errors with better visual outcome, lower endothelial cell loss, and a lower rate of graft rejection at postoperative 2 years in patients with bullous keratopathy.

Serologic Markers Are Associated With Ocular Staining Score in Primary Sjögren Syndrome

PURPOSE

To investigate the relationship between serologic markers and dry eye severity in subjects with primary Sjögren syndrome (SS).

METHODS

This study evaluated 64 patients diagnosed with primary SS according to the 2012 Sjögren's International Collaborative Clinical Alliance (SICCA) classification criteria. Serum anti-Ro/SSA, anti-La/SSB, rheumatoid factor (RF), and antinuclear antibody (ANA) levels, Ocular Surface Disease Index (OSDI), Schirmer I test values, tear film breakup time, and SICCA ocular staining score (OSS) were determined.

RESULTS

The conjunctival staining scores were 3.3 ± 1.9, 3.6 ± 2.0, 3.4 ± 1.9, and 3.5 ± 1.9 in the positive anti-Ro (≥25 EU), positive anti-La (≥25 EU), positive RF (≥20 IU/mL), and positive ANA (≥1:320) group, respectively. Subjects with positive anti-Ro, anti-La, RF, or ANA had significantly higher conjunctival staining scores compared with those with negative levels (P < 0.05). The total OSS in the positive ANA group was 5.5 ± 3.0, which was significantly higher than the total OSS (3.4 ± 2.1) in the negative ANA group (P = 0.005). Serum RF and ANA levels had strong correlations with conjunctival staining scores and the total OSS but not with corneal staining scores (r = 0.53, P < 0.001 and r = 0.382, P = 0.002). Other ocular parameters (OSDI, Schirmer I test values, and tear film breakup time) did not differ by the serologic marker level. Interestingly, the OSDI was positively correlated with the corneal staining score and total OSS (r = 0.646, P < 0.001 and r = 0.476, P < 0.001).

CONCLUSIONS

Serum RF and ANA levels are associated with conjunctival staining scores and the total OSS according to the SICCA OSS in primary SS.

Factors Affecting Long-term Myopic Regression after Laser In Situ Keratomileusis and Laser-assisted Subepithelial Keratectomy for Moderate Myopia

PURPOSE

High myopia is known to be a risk factor for long-term regression after laser refractive surgery. There have been few studies about the correction of moderate myopias that did not need retreatment after long-term follow-up. We evaluated 10 years of change in visual acuity and refractive power in eyes with moderate myopia after laser refractive surgery.

METHODS

We included patients that had undergone laser in situ keratomileusis (LASIK) or laser-assisted subepithelial keratectomy (LASEK) to correct their myopia and that had at least 10 years of follow-up. We evaluated the stability of visual acuity in terms of safety, efficacy, and refractive changes at examinations 6 months and 1, 2, 5, 7, and 10 years after surgery.

RESULTS

The study evaluated 62 eyes (36 eyes in LASIK patients and 26 eyes in LASEK patients). In both groups, the efficacy index tended to decrease, and it was consistently higher in the LASEK group compared to the LASIK group over the 10 years of follow-up. The safety index improved over 10 years and was always higher than 0.9 in both groups. The difference between the spherical equivalent at 6 months postoperatively and later periods was statistically significant after 5, 7, and 10 years in both groups (LASIK, p = 0.036, p = 0.003, and p < 0.001, respectively; LASEK, p = 0.006, p = 0.002, and p = 0.001, respectively). Ten years after surgery,26 eyes (66.7%) in the LASIK group and 19 eyes (73.1%) in the LASEK group had myopia greater than 1 diopter. In comparison with the thickness at 6 months postoperatively, central corneal thickness was significantly increased after 5, 7, and 10 years in both LASIK and LASEK groups (LASIK, p < 0.001, p < 0.001, and p < 0.001, respectively; LASEK, p = 0.01, p < 0.001, and p < 0.001, respectively).

CONCLUSIONS

Moderately myopic eyes showed progressive myopic shifting and corneal thickening after LASIK and LASEK during 10 years of follow-up. We also found that early refractive regression may indicate the long-term refractive outcome.

Objective assessment of nuclear cataract: comparison of double-pass and Scheimpflug systems

PURPOSE

To compare the objective assessment of lens density by 2 systems (double-pass Optical Quality Analysis System and Pentacam Scheimpflug) in eyes with age-related nuclear cataract.

SETTING

Department of Ophthalmology and Visual Science, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.

DESIGN

Cross-sectional study.

METHODS

In eyes with age-related nuclear cataract, the objective lens density (0 to 100 points) was determined using the Scheimpflug system while subjective grading was achieved using the Lens Opacities Classification System III (LOCS III). The objective scatter index (OSI) (0 to 25) was assessed using the double-pass system.

RESULTS

This study enrolled 47 patients (70 eyes). The mean OSI was 4.08 ± 2.22 (SD), and the mean Scheimpflug-measured lens density was 16.44 ± 4.36; the 2 parameters were correlated (r = 0.764, P<.01). There was a positive linear correlation between the OSI and LOCS III grading scores for nuclear opalescence and nuclear color (r = 0.772 and r = 0.752, respectively; P<.01). The cumulated dissipated energy (CDE) was strongly correlated with the OSI (r = 0.768) and Scheimpflug-measured lens density (r = 0.753).

CONCLUSIONS

The OSI based on the double-pass system was correlated with the Scheimpflug-measured lens density, subjective lens grading, and CDE. The OSI may improve the preoperative evaluation of nuclear cataract and help predict phacodynamics in cataract surgery.

Expression of p53 and caspase-8 in lens epithelial cells of diabetic cataract

PURPOSE

To determine expression of apoptotic factors p53 and caspase-8 in human lens epithelial cells (LECs) of cataract patients with or without diabetic retinopathy (DR), the duration of diabetes mellitus (DM), and the level of glycated hemoglobin (hemoglobin A1c [HbA1c]).

SETTING

St. Mary's Hospital, Catholic University of Korea, Seoul, South Korea.

DESIGN

Randomized prospective study.

METHODS

The LECs were isolated during cataract surgery. The isolated samples were classified into 4 groups as follows: patients without DM (Group 1), patients with DM but not DR (Group 2), diabetic patients with nonproliferative DR (Group 3), and diabetic patients with proliferative DR (Group 4). To explore the mechanism of apoptosis, the expressions of p53 and caspase-8 were measured by immunohistochemical staining and compared with the data according to the duration of DM, HbA1c levels, and severity of DR.

RESULTS

All groups comprised 15 eyes. The expressions of P53 and caspase-8 were higher in Groups 2, 3, and 4 than in Group 1 (P<.001). The expressions were statistically significantly increased with a longer duration of DM, higher HbA1c levels, and advanced DR.

CONCLUSIONS

The expressions of P53 and caspase-8 were strong in patients with DM and advanced DR. Knowledge of these relationships may lead to a better understanding of the development of diabetic cataract.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Optic neuritis in Singapore

INTRODUCTION

Optic neuritis (ON) is the commonest optic neuropathy encountered in the younger group of patients from the Singapore Neuro-Ophthalmology Study Group. Previous surveys in Asia and our study suggest that ON in Singapore differs from that in Western populations where the majority of cases are associated with multiple sclerosis (MS).

METHODS

Patients satisfying our entry criteria for ON seen between September 2002 and June 2004 were enrolled in the study. The data collected was recorded in a central database and analysed two years later.

RESULTS

The majority (60 percent) of our patients had anterior ON with optic disc swelling (papillitis), were idiopathic in 49.1 percent, and associated with MS in only 25.5 percent. Bilateral cases comprised 16.4 percent of our series and were usually of the anterior variety and mostly idiopathic, although it is still essential to rule out secondary causes. Recurrent ON is indicative of an underlying disease process.

CONCLUSION

The pattern of ON as seen in Singapore differs from that reported in Caucasian studies and from the seminal Optic Neuritis Treatment Trial. We found a higher incidence of optic disc swelling, i.e. anterior ON (papillitis), and a lesser association with MS; visual recovery is similarly good but our recurrence rate is lower.

Clinics in diagnostic imaging (120). Right rhinogenic optic neuritis secondary to mucocoele of the Onodi cell

Acute visual loss can be caused by retrobulbar optic neuritis, radiation optic neuropathy or ischaemic optic neuropathy. Sinusitis affecting the Onodi cell, a posterior ethmoidal air cell that has encroached on the adjacent sphenoid bone forming the optic canal, can present rarely with visual loss. We report a 60-year-old man, who developed a sudden ache on the nasal aspect of his right eye, and deterioration of the vision in his right eye. This case illustrates the typical radiological appearances of the Onodi cell on MR imaging and CT. The diagnosis of right rhinogenic optic neuritis secondary to mucocoele of the Onodi cell was confirmed at surgery. Functional endoscopic sinus surgery with decompression of the Onodi cell was performed. Physicians should be familiar with the presentation, performed. Physicians should be familiar with the presentation, diagnosis and management of this rare but important condition.

Polyurethane/poly(lactic-co-glycolic) acid composite scaffolds fabricated by thermally induced phase separation

In this study, we present a novel composite scaffold fabricated using a thermally induced phase separation (TIPS) process from poly(lactic-co-glycolic) (PLGA) and biomedical polyurethane (PU). This processing method has been tuned to allow intimate (molecular) mixing of these two very different polymers, giving rise to a unique morphology that can be manipulated by controlling the phase separation behaviour of an initially homogenous polymer solution. Pure PLGA scaffolds possessed a smooth, directional fibrous sheet-like structure with pore sizes of 0.1-200mum, a porous Young's modulus of 93.5kPa and were relatively brittle to touch. Pure PU scaffolds had an isotropic emulsion-like structure, a porous Young's modulus of 15.7kPa and were much more elastic than the PLGA scaffolds. The composite PLGA/PU scaffold exhibits advantageous morphological, mechanical and cell adhesion and growth supporting properties, when compared with scaffolds fabricated from PLGA or PU alone. This novel method provides a mechanism for the formation of tailored bioactive scaffolds from nominally incompatible polymers, representing a significant step forward in scaffold processing for tissue-engineering applications.

The presentation, aetiology, management and outcome of optic neuritis in an Asian population

PURPOSE

To analyse the presentation, aetiology, management and outcome of patients with optic neuritis (ON) in Singapore.

METHODS

This was a retrospective study involving consecutive patients with ON presentng at the Singapore National Eye Centre between January 1997 and May 1999. The presenting features, investigatons, treatment and visual outcome after 6 months were studied.

RESULTS

A total of 31 patents (39 eyes) presented with ON during this period, 17 of whom had anterior ON. No aetiology was found in 26 patients (83.9%), two patients (6.5%) had multiple sclerosis, one had active syphilis, one had rheumatoid arthritis and another had pan-sinusitis. Seventeen patients (54.8%) were treated with intravenous methyl-prednisolone followed by oral prednisolone. Within the follow-up period 26 of 31 eyes (83.9%) wth idiopathic ON attained visual acuity of 6/12 or better with 12 (38.7%) recovering to 6/6 or better and only one eye ending with less than 6/60 visual acuity. The one patient with syphilis recovered 6/6 visual acuity bilaterally. Both patients with multiple sclerosis also had good visual recovery at 6 months. The visual outcome in those cases of ON associated with rheumatoid arthritis and pan-sinusitis was poor with visual acuity of less than 6/60 at 6 months follow up in each instance.

CONCLUSION

The majority of the cases of ON in this study were idiopathic. There was a low association with multiple sclerosis. Most patients had good visual recovery within 6 months.

Ophthalmic manifestations in human immunodeficiency virus infection in Singapore

The paper retrospectively reviews the spectrum of ophthalmic manifestations in human immunodeficiency virus (HIV) infection in Singapore between May 1995 and October 1996. One hundred and eighteen patients were examined for ocular abnormalities. Criteria for examination were 1) visual complaints, 2) absolute CD4 count of less than 50 cells/ul, 3) patients with acquired immunodeficiency syndrome-defining illness or 4) any relevant systemic illnesses which may have ocular involvement. Only 25 patients (21.2%) had visual symptoms. Eighteen patients (15.3%) had abnormalities associated with microvasculature. Forty-four patients (37.3%) had opportunistic infection involving the eye of which 37 were that of cytomegalovirus retinitis (CMVR). Seven patients (5.9%) had neuro-ophthalmic disorders. One patient presented with proptosis due to orbital lymphoma. Four patients (3.4%) had episcleritis and 3 patients (2.5%) had symptomatic dry eyes. It is still not known if episcleritis and dry eyes are associated with HIV infection or are coincidental. Fifty-one patients (43.2%) had no ocular pathology and remained so throughout the period of study. Nine patients (7.6%) had more than one pathology. The major cause of visual loss was due to ocular infections, with CMVR being most prevalent. Recognising the ophthalmic signs in HIV patients will facilitate early diagnosis. Prompt treatment of eye involvement can prevent or delay blindness, which is psychologically and functionally important to these patients.