Redesigning services for the management of vitreomacular traction and macular hole

Vitreomacular traction (VMT) and VMT with macular hole (MH) are serious conditions, being associated with visual disturbance, for example, metamorphopsia, and diminished visual acuity (VA). Pars plana vitrectomy is the routine treatment for symptomatic VMT and VMT+MH. However, ocriplasmin has demonstrated favourable efficacy and safety in specific patient groups with VMT/MH and is now recommended as a treatment option for certain patients by the National Institute of Health and Care Excellence. This means that services for managing patients with VMT/MH may need to be revised, as patients can now potentially receive treatment earlier in the course of the disease. VMT triage clinics could provide a more efficient way of managing VMT/MH patients. Patient assessment should always include high-definition optical coherence tomography, as this is the most accurate means of assessing abnormalities in the vitreoretinal (VR) interface, and an accurate measurement of best-corrected VA. It has been proposed that patients with VMT+MH be managed as a routine 6-week referral, with the complete patient journey—from initial referral to treatment—taking no longer than 6 months. It is important that patients are entered onto VR surgical lists so that there is no delay if ocriplasmin treatment is unsuccessful. Patients will need appropriate counselling about the expected outcomes and possible side effects of ocriplasmin treatment. One-year follow-up data should be collected by treatment centres in order to evaluate the new VMT service.

Optical coherence tomography for the diagnosis of neovascular age-related macular degeneration: a systematic review

The purpose is to study the diagnostic performance of optical coherence tomography (OCT) and alternative diagnostic tests for neovascular age-related macular degeneration (nAMD). Methods employed are as follows:systematic review and meta-analysis;

INDEX TEST

OCT including time-domain (TD-OCT) and the most recently developed spectral domain (SD-OCT); comparator tests: visual acuity, clinical evaluation (slit lamp), Amsler chart, colour fundus photographs, infra-red reflectance, red-free images/blue reflectance, fundus autofluorescence imaging (FAF), indocyanine green angiography (ICGA), preferential hyperacuity perimetry (PHP), and microperimetry; reference standard: fundus fluorescein angiography. Databases searched included MEDLINE, MEDLINE In Process, EMBASE, Biosis, SCI, the Cochrane Library, DARE, MEDION, and HTA database. Last literature searches: March 2013. Risk of bias assessed using QUADAS-2. Meta-analysis models were fitted using hierarchical summary receiver operating characteristic (HSROC) curves. Twenty-two studies (2 abstracts and 20 articles) enrolling 2124 participants were identified, reporting TD-OCT (12 studies), SD-OCT (1 study), ICGA (8 studies), PHP (3 studies), Amsler grid, colour fundus photography and FAF (1 study each). Most studies were considered to have a high risk of bias in the patient selection (55%, 11/20), and flow and timing (40%, 8/20) domains. In a meta-analysis of TD-OCT studies, sensitivity and specificity (95% CI) were 88% (46-98%) and 78% (64-88%), respectively. There was insufficient information to undertake meta-analysis for other tests. TD-OCT is a sensitive test for detecting nAMD, although specificity was only moderate. Data on SD-OCT are sparse. Diagnosis of nAMD should not rely solely on OCT.

Ranibizumab for the treatment of choroidal neovascularisation secondary to pathological myopia: interim analysis of the REPAIR study

AIMS

To evaluate the efficacy and safety of intravitreal ranibizumab in patients with choroidal neovascularisation secondary to pathological myopia (myopic CNV). Data are from a pre-planned, 6-month interim analysis.

METHODS

Phase II, open-label, single arm, multicentre, 12-month study, recruiting patients (aged ≥18 years) with active primary or recurrent subfoveal or juxtafoveal myopic CNV, with a best-corrected visual acuity (BCVA) score of 24-78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the study eye and a diagnosis of high myopia of at least -6 dioptres. Patients received 0.5 mg ranibizumab administered intravitreally to the study eye, followed by monthly injections given as needed (based on a predefined algorithm) for up to 11 months.

RESULTS

At 6 months, mean BCVA improved from baseline by 12.2 letters, as did central macular thickness (in this interim analysis defined as a measure of either central subfield macular thickness or centre point macular thickness) from baseline by 108 μm in the 48 study eyes of 48 patients. Fewer patients had centre-involving intraretinal oedema (13.0% vs 91.5%), intraretinal cysts (10.9% vs 57.4%), or subretinal fluid (13.0% vs 66.0%) at 6 months than at baseline. Patients received a mean of 1.9 retreatments, were satisfied with ranibizumab treatment, and well being was maintained. No new safety signals were identified.

CONCLUSIONS

Results from the planned interim analysis support the role of ranibizumab in the treatment of myopic CNV, with excellent efficacy achieved with a low number of injections and few serious adverse events.

Ranibizumab for the treatment of choroidal neovascularisation secondary to pathological myopia: interim analysis of the REPAIR study

AIMS

To evaluate the efficacy and safety of intravitreal ranibizumab in patients with choroidal neovascularisation secondary to pathological myopia (myopic CNV). Data are from a pre-planned, 6-month interim analysis.

METHODS

Phase II, open-label, single arm, multicentre, 12-month study, recruiting patients (aged ≥18 years) with active primary or recurrent subfoveal or juxtafoveal myopic CNV, with a best-corrected visual acuity (BCVA) score of 24-78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the study eye and a diagnosis of high myopia of at least -6 dioptres. Patients received 0.5 mg ranibizumab administered intravitreally to the study eye, followed by monthly injections given as needed (based on a predefined algorithm) for up to 11 months.

RESULTS

At 6 months, mean BCVA improved from baseline by 12.2 letters, as did central macular thickness (in this interim analysis defined as a measure of either central subfield macular thickness or centre point macular thickness) from baseline by 108 μm in the 48 study eyes of 48 patients. Fewer patients had centre-involving intraretinal oedema (13.0% vs 91.5%), intraretinal cysts (10.9% vs 57.4%), or subretinal fluid (13.0% vs 66.0%) at 6 months than at baseline. Patients received a mean of 1.9 retreatments, were satisfied with ranibizumab treatment, and well being was maintained. No new safety signals were identified.

CONCLUSIONS

Results from the planned interim analysis support the role of ranibizumab in the treatment of myopic CNV, with excellent efficacy achieved with a low number of injections and few serious adverse events.

Action on AMD. Optimising patient management: act now to ensure current and continual delivery of best possible patient care

In recent years, there have been significant advances in the clinical management of patients with wet age-related macular degeneration (wet AMD)—a rapidly progressing and potentially blinding degenerative eye disease. Wet AMD is responsible for more than half of registered severe sight impairment (blindness) in the United Kingdom, and patients who are being treated for wet AMD require frequent and long-term follow-up for treatment to be most effective. The clinical workload associated with the frequent follow-up required is substantial. Furthermore, as more new patients are diagnosed and the population continues to age, the patient population will continue to increase. It is thus vital that clinical services continue to adapt so that they can provide a fast and efficient service for patients with wet AMD. This Action on AMDdocument has been developed by eye health-care professionals and patient representatives, the Action on AMDgroup. It is intended to highlight the urgent and continuing need for change within wet AMD services. This document also serves as a guide for eye health-care professionals, NHS commissioners, and providers to present possible solutions for improving NHS retinal and macular services. Examples of good practice and service development are considered and can be drawn upon to help services meet the recommended quality of care and achieve best possible outcomes.

Microperimetric changes in neovascular age-related macular degeneration treated with ranibizumab

PURPOSE

To assess the value of microperimetry in eyes with neovascular age-related macular degeneration previously treated with ranibizumab and now in the maintenance phase of therapy.

METHODS

A total of 21 eyes (14 patients) were included. Microperimetry was performed using the Macular Integrity Assessment Device on at least three occasions for each eye. Intravitreal ranibizumab was administered if visual acuity (VA) or optical coherence tomography (OCT) showed signs of active disease.

RESULTS

Five eyes showed no change in VA or OCT findings, and required no intravitreal injections. In these eyes, mean threshold sensitivity (TS) decreased by 13% (paired t-test, P=0.05) during the study period, but fixation stability (FS) was unchanged. In all, 16 eyes showed signs of disease activity, and therefore required ranibizumab injections during the study. In these eyes, VA, central retinal thickness (CRT), FS, and TS remained unchanged during follow-up. Peak TS was noted when CRT was 210 μm; above or below 210 μm, there was a gradual reduction in TS.

CONCLUSION

This study has provided novel information on the relationship between macular sensitivity, CRT, and VA in the maintenance phase of ranibizumab therapy. Patients with stable VA and CRT may still have deteriorating retinal sensitivity. This is usually a late manifestation and may indicate subclinical CNV activity.

Barriers to cataract surgical uptake in the upper East region of ghana

SUMMARY BACKGROUND

The Upper East Region has one of the highest cataract surgical rates in Ghana. Notwithstanding this, cataract blindness is still a major problem.

AIM

To determine patient-related barriers to cataract services in the region and their resolution.

METHODS

Focus Group Discussion (FGD) and In-depth interviews were used to explore the opinions of 66 cataract patients resident in the region between July and August 2003. Purposeful sampling was used in selecting 24 patients in the hospital while a Snowball sampling method was employed on 42 respondents resident in the village communities

RESULTS

Average age of the respondents was 67.6 years with equal proportions of males and females (0.9:1). Twelve and fifteen percent of respondents respectively cited fear and lack of escort as barriers to service up-take while 8% and 9% pointed to sociocultural beliefs and the fact that they were able to cope satisfactorily with their disability. Only 1.5% of respondents gave lack of awareness as a barrier with none citing geographical barrier as a problem. Cost of surgery, however, stood out clearly as a very significant barrier with 91% of respondents attesting to it.

CONCLUSION

It is concluded that further expansion of outreach services, coupled with a more intensive health education is needed to overcome these barriers.

Performance in the Duke-Elder ophthalmology undergraduate prize examination and future careers in ophthalmology

AIMS

Cognitive factors (eg, academic achievement) have had a significant role in selecting postgraduate surgical trainees in the past. This project sought to determine the role of a national undergraduate ophthalmology prize examination (Duke-Elder examination) in the selection of postgraduate ophthalmology trainees. This would also serve as a quality assurance exercise for the assessment, in which the ultimate aim is to encourage trainees into ophthalmology.

METHODS

A retrospective analysis of the top 20 ranked candidates in the Duke-Elder examination from 1989 to 2005 (except 1995) was carried out to determine which of them subsequently entered the ophthalmic training and General Medical Council Specialist Registers.

RESULTS

Out of the top 20 candidates in the exam, 29.5% went into specialist training in ophthalmology. Some appeared in the top 20 more than once, with 56% of them going into ophthalmic training, but they had a similar median time to enter training as those who appeared in the top 20 once. There was no significant evidence to suggest that the overall median ranking scores between the UK medical schools differed (P=0.23; Kruskal-Wallis test). However, there was a marked difference in frequency of top 20 candidates from each medical school, which could not be explained by the size of the medical school alone.

CONCLUSION

It is difficult to conclude from these findings the importance that the Duke-Elder examination has in the selection of trainees into ophthalmology. The role of cognitive factors in selection into postgraduate medical/surgical training is discussed, along with the potential academic criteria, which may influence interview scores.

Epidemiology of hospitalized ocular injuries in the upper East region of ghana

Summary

AIM OF STUDY

The Upper East is the poorest and most rural region in Ghana and ocular injuries are a major public health problem. This study aims at providing epidemiologic data on the burden of this problem in order to facilitate the provision of integrated eye care and safety strategies for the prevention of such injuries in the region.

DESIGN

A retrospective case series.

METHODS

Computerized records of all eye injuries admitted to the clinic between January and December 2004 were retrieved and analyzed using the Epi-Info software. Injuries were classified using the Birmingham Eye Trauma Terminology while Snellen visual acuities were classified/banded using the WHO categories of visual impairments.

RESULTS

Ninety six eyes of 96 patients were admitted over the study period. Seventy five percent of the patients were males and 82.3% below the age of 30 years. Half of the patients had to travel beyond 100 km to get ophthalmic assistance. Only one third of the cases reported within 24 hours while 21% reported after one week of their injuries. These delayed periods of reporting showed no statistically significant relationship with the distances travelled to the hospital (p=0.76; chi2 test), nor the eventual visual outcome achieved following treatment. Open-globe injuries were by far the most common (60/96) and were 4.7 times more likely (Chi squared test) to produce poor visual outcome (p=0.02 CL 1.75-12.63).

CONCLUSION

Current eye care strategies do not adequately address the issue of eye injuries in the region. There is the need to provide integrated approach by incorporating primary eye care strategies into the existing primary health care system.

Outcome of trabeculectomies without adjunctive antimetabolites

SUMMARY BACKGROUND

The effectiveness of trabeculectomy in the management of glaucoma is well known. It is the most common intervention for most glaucoma cases treated in the Upper East region. In this region trabeculectomies are, however, performed without adjunctive antimetabolites.

OBJECTIVE

To report on the outcome of trabeculectomy without adjunctive antimetabolites in controlling the intraocular pressures of eyes with Primary Open Angle and Normal Tension Glaucomas.

DESIGN

Retrospective, non-comparative interventional case study

METHOD

Records of 191 eyes of 164 patients who had undergone standard trabeculectomy were retrospectively analyzed.

OUTCOME MEASURE

Successful intraocular pressure control defined as IOP less than 22 mmHg or a reduction of 30% if pre-operative pressure was already less than 22mmHg.

RESULTS

There were 185 (96.8%) eyes with Primary Open Angle glaucoma and 6 (3.2%) with the Normal Tension variant. Mean age of patients was 50.6 years (Range 17-85) with 22% aged below 40 years. There was a statistically significant difference between the mean pre-op and post-op intraocular pressures (38.09, SD=6.11 versus 18.97, SD=7.28 mmHg respectively); p=0.0001. The procedure was effective in controlling the intraocular pressures to below 22mmHg in 88.46% and below 18mmHg in 67.95% of OAG eyes at six months. In eyes with NTG only one out of six (16.7%) achieved a successful 30% target pressure reduction.

CONCLUSION

Trabeculectomy alone was effective in controlling IOPs to less than 22 mmHg in POAG. Lower IOP levels needed to control progressive visual field loss may require the use anti-metabolites.

Alternate eye care services in a ghanaian district

OBJECTIVE

To determine eye care services sought outside the regular hospital system and their providers.

STUDY SETTING

Akwapim South district

METHOD

Questionnaire survey and in depth interviews.

RESULTS

We recruited 1,537 persons with a previous history of eye disease and alternate service providers (21 chemical shop attendants and 55 herbalists). There was no significant difference between patronage of the regular and the alternative providers (p value 0.78). Most of the herbalists were trained by relations; parents (29/55) and grandparents (10/55). Two thirds had some formal education and 96% practiced part-time. Over 75% claimed they treated cataracts, eye injuries, and "kooko" and 28% also treated red eyes. Chemical shop attendants were all literates, sold only antibiotic eye drops, and 64% practiced full time.

CONCLUSIONS

Herbalists and chemical sellers provided substantive eye care along the regular hospital services but some of their practices may be harmful.

Inherited retinal telangiectasia with glial proliferation

We describe five patients from a family of Pakistani origin with inherited retinal telangiectasia and glial proliferation. Characteristics of this condition include: variable visual loss; peripapillary retinal telangiectasia with vascular incompetence on fluorescein angiography; glial proliferation; cystoid macular edema or altered macular pigment; retinal hemorrhage; and abnormal electroretinopathy. We discuss the similarities with and distinguishing features from other documented conditions and the mode of inheritance.