De novo choroidal osteoma after laser photocoagulation of a peripapillary choroidal neovascular membrane.

We describe the case of a 76-year-old man who developed an asymptomatic choroidal osteoma in the left eye 10 years after receiving retinal laser photocoagulation for treatment of a peripapillary choroidal neovascular membrane. The choroidal osteoma presented as a progressively enlarging, well-circumscribed yellow lesion adjacent to the region of retinal fibrosis. Optical coherence tomography showed a choroidal lesion with superficial lamellations and ultrasonography demonstrated increased echogenicity. The choroidal osteoma was not encroaching on the fovea and is currently being monitored. This is only the third report of a de novo choroidal osteoma developing subsequent to retinal laser photocoagulation.

Choroidal effusion as a manifestation of central serous chorioretinopathy: A case report.

PURPOSE: To report a case of bullous central serous chorioretinopathy presenting with large choroidal effusions. OBSERVATIONS: A patient presented with typical features of bullous central serous chorioretinopathy with large choroidal effusions. He had a previous history of bullous central serous chorioretinopathy in his other eye. The condition worsened after a short course of oral prednisolone, consistent with central serous chorioretinopathy. Surgical management with sclerectomies resulted in resolution of serous retinal detachment, choroidal effusions and subfoveal fluid. CONCLUSIONS: We report choroidal effusions as a potential manifestation of central serous chorioretinopathy which may aid in our understanding in the pathogenic mechanisms of this condition. Furthermore, we demonstrate that surgical sclerectomies as a potential treatment option for serous retinal detachment and choroidal effusions in this condition.

Task sharing: situation analysis about capacity and resources for management of diabetic retinopathy in Pakistan.

AIM: To assess the capacity and resources of eye care facilities, using the WHO Health Systems Framework, to manage diabetic retinopathy (DR) through task sharing. METHODS: Using purposive sampling, four participants (administrators) from four selected hospitals in two provinces in Pakistan were recruited for this cross-sectional study. A survey, to assess the capacity and resources of the selected eye care facilities for the feasibility to adopt task sharing in management of DR to prevent vision loss, was emailed to participants who were asked to complete. Responses to open-ended questions were entered into a Microsoft Excel spread sheet and inductive approach was applied for analysis. RESULTS: All the surveyed eye care facilities offer eye care services for people with diabetes and DR. All surveyed eye care facilities have a shortage in the number of human resources across all cadres. Optometrists and mid-level eye care workers did not have active roles in DR screening and management in all four hospitals. All the hospitals surveyed did not have a computerized record management system for patients who visit ophthalmologists for eye examinations. Equipment for detection and management of DR were short in number and main users were ophthalmologists. There was no policy for population-based screening program for detection of DR in any of the surveyed hospitals. CONCLUSION: A system-based approach to manage DR is needed. The capacity of eye care facilities and the potential to improve access of people with diabetes to eye care services can be enhanced through implementation of task sharing.

Task sharing in the eye care workforce: Screening, detection, and management of diabetic retinopathy in Pakistan. A case study.

PURPOSE: Diabetic retinopathy (DR) is a preventable cause of vision loss. Reducing vision loss due to DR and providing access to eye care services for people with diabetes have been severely constrained by a shortage in the number of ophthalmologists. This study aimed to explore the potential for task sharing in the eye care workforce for screening, detection, and management of DR. METHODS: Using purposive sampling, 24 participants were recruited from four selected hospitals in 2 provinces in Pakistan. Face-to-face interviews were conducted to explore the potential for task sharing in DR management. RESULTS: Amongst 24 participants recruited, 22 (91.7%) including administrators (n = 3), ophthalmologists (n = 10), optometrists (n = 3), mid-level eye care workers (n = 4), and endocrinologist (2) participated in the study. All participants indicated the need for an organised screening program for DR detection through task sharing. Participants suggested that people with diabetes can be sent directly to an optometrist for initial eye exams, rather than making them wait to be examined by an ophthalmologist. Factors favouring task sharing included the name task sharing rather than task shifting and a high demand for eye care services. Major barriers to implementation of task sharing included the lack of a trained eye care workforce in the healthcare system and the lack of coordination amongst health professionals and policy makers. CONCLUSION: Participants were accepting task sharing approach and believed that task sharing could improve access to eye care services for people with diabetes and better utilise the services of eye and healthcare providers.

Roles of the eye care workforce for task sharing in management of diabetic retinopathy in Cambodia.

AIM: To identify the current roles of eye and health care workers in eye care delivery and investigate their potential roles in screening and detection for management of diabetic retinopathy (DR) through task sharing. METHODS: Purposive sampling of 24 participants including health administrators, members from non-government organizations and all available eye care workers in Takeo province were recruited. This cross sectional mixed method study comprised a survey and in-depth interviews. Data were collected from medical records at Caritas Takeo Eye Hospital (CTEH) and Kiri Vong District Referral Hospital Vision Centre, and a survey and interviews with participants were done to explore the potential roles for task sharing in DR management. Qualitative data were transcribed into a text program and then entered into N-Vivo (version 10) software for data management and analysis. RESULTS: From 2009 to 2012, a total of 105 178 patients were examined and 14 030 eye surgeries were performed in CTEH by three ophthalmologists supported by ophthalmic nurses in operating and eye examination for patients. Between January 2011 and September 2012, 151 patients (72 males) with retinal pathology including 125 (83%) with DR visited CTEH. In addition 170 patients with diabetes were referred to CTEH for eye examinations from Mo Po Tsyo screening programs for people with diabetes. Factors favouring task sharing included high demand for eye care services and scarcity of ophthalmologists. CONCLUSION: Task sharing and team work for eye care services is functional. Participants favor the potential role of ophthalmic nurses in screening for DR through task sharing.

Attitudes and perceptions of eye care workers and health administrators regarding task sharing in screening and detection for management of diabetic retinopathy in Pakistan.

PURPOSE: The shortage of ophthalmologists in many countries is a major barrier to timely provision of eye care. A team work approach to screen, detect and manage diabetic retinopathy (DR) could achieve greater screening coverage of people with diabetes to prevent vision loss. This study aimed to assess the attitudes and perceptions of eye care workers and health administrators regarding task sharing for management of DR. METHODS: Using purposive sampling, 121 eye and health care workers in five selected hospitals in two provinces in Pakistan were recruited. A cross-sectional survey explored the possibility for involvement of optometrists and mid-level eye care workers to share tasks with ophthalmologists for DR management and the potential outcomes of task sharing, through multiple choice and open-ended questions. RESULTS: Ninety-six (79%) participants-doctors (n = 56), optometrists (n = 29) and mid-level eye care workers (n = 11) responded to the survey. All participants supported task sharing in screening and detection for management of DR. There was no significant difference among the groups with respect to their positive attitude towards task sharing (p = 0.22). The majority in each group believed that the task sharing would not degrade the quality of care (p = 0.48). Two potential major outcomes of task sharing in the eye care system included the benefits for people with diabetes and potential DR and the strengthening of the health care system. CONCLUSION: Task sharing among various cadres of eye care workers has the potential to improve screening coverage of people with diabetes to prevent visual loss from DR.

Solar retinopathy in children.

PURPOSE: To describe the visual acuity, fundus appearance, and spectral domain optical coherence tomography (SD-OCT) findings in 5 eyes of 3 children with foveal damage from solar retinopathy. METHODS: This was a prospective, observational case series of children who presented to the emergency department at the Royal Victorian Eye and Ear Hospital after having directly viewed the Sun during the transit of Venus on June 6, 2012, or the partial eclipse of the Sun on November 14, 2012. All patients underwent visual acuity testing, dilated fundus examination, and SD-OCT imaging. RESULTS: The 3 patients' ages at presentation were 8, 10, and 11 years. Best-corrected visual acuity in the affected eyes ranged from 20/20 to 20/40 on presentation. Significant foveal pathology was identified on SD-OCT in all 5 eyes, even when visual acuity was normal. At presentation, all eyes showed disruption of the photoreceptor ellipsoid zone and the interdigitation zone on SD-OCT. Additionally, in those eyes with decreased visual acuity, there was disruption of the outer nuclear layer and/or external limiting membrane. At 3-5 months' follow-up, the outer nuclear layer and external limiting membrane lesions had resolved; however, in some eyes the ellipsoid and interdigitation zone abnormalities persisted at 5 months' follow-up, even in the presence of best-corrected visual acuity as good as 20/12.5. CONCLUSIONS: Solar retinopathy in children can cause persistent damage to multiple retinal layers despite recovery of good visual acuity.

Cardiovascular Adverse Effects of Phenylephrine Eyedrops: A Systematic Review and Meta-analysis.

IMPORTANCE: Topical phenylephrine hydrochloride is routinely administered with few safety precautions, but evidence regarding its systemic safety to date is controversial. As even short-term variations in 24-hour blood pressure (BP) and heart rate (HR) can adversely affect cardiovascular health, better evidence on phenylephrine's effects on HR and BP is required. OBJECTIVE: To perform a meta-analysis of available evidence regarding cardiovascular adverse effects of topical phenylephrine. DATA SOURCES: PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews and Clinical Trials were searched for relevant literature from January 1, 1970, to January 1, 2014, using a combination of the following search terms: topical, ocular, ophthalmic, phenylephrine, tropicamide, cardiovascular effect, side effect, blood pressure, heart rate, mydriatic, and eye drops. A total of 70 articles related to the topic were identified and all full texts were retrieved. STUDY SELECTION: Randomized clinical trials reporting change in BP and HR for adults were included in this review. All studies reporting results for neonates or infants, not reporting standard deviations, or not specifying the time of measurement or the concentration of phenylephrine used were excluded. DATA EXTRACTION AND SYNTHESIS: Data from randomized clinical trials that reported BP and/or HR as well as the time following administration of topical phenylephrine at which measurements were obtained by concentration of phenylephrine as a mean change and its standard deviation were extracted. Data were synthesized by concentration of phenylephrine and time of measurement following topical application using random-effects models with inverse variance weighting to account for heterogeneity across studies. MAIN OUTCOMES AND MEASURES: Difference in BP and HR after topical administration of phenylephrine. RESULTS: Eight RCTs with a total of 916 participants were included. Data were available for phenylephrine, 2.5%, at 20 to 30 minutes and 60 minutes or longer after administration, and neither BP nor HR changed at either time. Following application of phenylephrine, 10%, BP increased at 5 and 10 minutes (mean difference for both, +15 mm Hg; 95% CI, 11.94-18.54; P < .001) but decreased at 20 to 30 minutes and 60 minutes or longer with no changes detected against baseline. A mean increase in HR by 4.48 beats/min (95% CI, 1.09-7.88; P = .01) was present at 20 to 30 minutes following application of phenylephrine, 10%, and HR decreased by 60 minutes or longer with no changes detected compared with baseline. CONCLUSIONS AND RELEVANCE: Phenylephrine, 2.5%, leads to no clinically relevant change in BP or HR, and the changes in BP and HR seen with phenylephrine, 10%, are short lived. Thus, phenylephrine, 2.5%, is safe to use in clinical routine.

Accuracy of diabetic retinopathy screening by trained non-physician graders using non-mydriatic fundus camera.

INTRODUCTION: We compared the agreement of diabetic retinopathy (DR) assessment between trained non-physician graders (NPGs) and family physicians (FPs) in a primary healthcare setting. METHODS: This was a cross-sectional study conducted retrospectively over a period of one month. The participants were diabetic patients from two primary healthcare clinics (polyclinics) in Singapore. Single-field digital retinal images were obtained using a non-mydriatic 45-degree fundus camera. Retinal images were graded for the presence or absence of DR by FPs at the polyclinics and by NPGs at a central ocular grading centre. The FPs' and NPGs' assessments of DR were compared with readings by a single retinal specialist (reference standard). RESULTS: A total of 367 diabetic patients (706 eyes) were included in the study. The mean age of the patients was 63 years, and the majority were Chinese (83.8%). For DR assessment, the agreement between NPGs and the retinal specialist was substantial (ĸ = 0.66), while the agreement between FPs and the retinal specialist was only fair (ĸ = 0.40). NPGs' assessment showed higher sensitivity (70% vs. 45%) and comparable specificity (94% vs. 92%) as compared to FPs' assessment. The area under the receiver operating characteristic curve of NPGs' assessment of DR was greater than that of the FPs' (0.82 vs. 0.69, p < 0.001). CONCLUSION: This study has demonstrated that trained NPGs are able to provide good detection of DR and maculopathy from fundus photographs. Our findings suggest that DR screening by trained NPGs may provide a costeffective alternative to FPs.

Shared care for chronic eye diseases: perspectives of ophthalmologists, optometrists and patients.

OBJECTIVE: To report the perspectives of optometrists, ophthalmologists and patients on a model of shared care for patients with chronic eye diseases. DESIGN, SETTING AND PARTICIPANTS: Qualitative study of a model of shared care between optometrists and ophthalmologists for patients with stable age-related macular degeneration, diabetic retinopathy and glaucoma, trialled by the Royal Victorian Eye and Ear Hospital in Melbourne during 2007­2009. Semi-structured interviews were conducted with optometrists, ophthalmologists and patients at completion of the project to obtain their perspectives on this model. RESULTS: Seventeen optometrists submitted expressions of interest to participate, and 12 completed web-based training modules and clinical observerships and adhered to specified examination and reporting protocols. All five participating ophthalmologists and 11 of the optometrists were interviewed. Ninety-eight patients participated and 37 were interviewed. Optometrists not only met ophthalmologists' expectations but exceeded them, appropriately detecting and referring patients with additional, previously undetected conditions. Patients reported savings in travel time and were satisfied with the quality of care they received. Optometrists, ophthalmologists and patients indicated a general acceptance of shared care arrangements, although there were some issues relating to interprofessional trust. CONCLUSIONS: Shared care between local optometrists and hospital-based ophthalmologists can help to reduce patient waiting time for review and offers an opportunity for these two groups of eye care professionals to collaborate in providing localised care for the benefit of patients. However, trust and relationship building need to be further developed.

Increased serum kallistatin levels in type 1 diabetes patients with vascular complications.

BACKGROUND: Kallistatin, a serpin widely produced throughout the body, has vasodilatory, anti-angiogenic, anti-oxidant, and anti-inflammatory effects. Effects of diabetes and its vascular complications on serum kallistatin levels are unknown. METHODS: Serum kallistatin was quantified by ELISA in a cross-sectional study of 116 Type 1 diabetic patients (including 50 with and 66 without complications) and 29 non-diabetic controls, and related to clinical status and measures of oxidative stress and inflammation. RESULTS: Kallistatin levels (mean(SD)) were increased in diabetic vs. control subjects (12.6(4.2) vs. 10.3(2.8) µg/ml, p = 0.007), and differed between diabetic patients with complications (13.4(4.9) µg/ml), complication-free patients (12.1(3.7) µg/ml), and controls; ANOVA, p = 0.007. Levels were higher in diabetic patients with complications vs. controls, p = 0.01, but did not differ between complication-free diabetic patients and controls, p > 0.05. On univariate analyses, in diabetes, kallistatin correlated with renal dysfunction (cystatin C, r = 0.28, p = 0.004; urinary albumin/creatinine, r = 0.34, p = 0.001; serum creatinine, r = 0.23, p = 0.01; serum urea, r = 0.33, p = 0.001; GFR, r = -0.25, p = 0.009), total cholesterol (r = 0.28, p = 0.004); LDL-cholesterol (r = 0.21, p = 0.03); gamma-glutamyltransferase (GGT) (r = 0.27, p = 0.04), and small artery elasticity, r = -0.23, p = 0.02, but not with HbA1c, other lipids, oxidative stress or inflammation. In diabetes, geometric mean (95%CI) kallistatin levels adjusted for covariates, including renal dysfunction, were higher in those with vs. without hypertension (13.6 (12.3-14.9) vs. 11.8 (10.5-13.0) µg/ml, p = 0.03). Statistically independent determinants of kallistatin levels in diabetes were age, serum urea, total cholesterol, SAE and GGT, adjusted r2 = 0.24, p < 0.00001. CONCLUSIONS: Serum kallistatin levels are increased in Type 1 diabetic patients with microvascular complications and with hypertension, and correlate with renal and vascular dysfunction.

Association of retinal vessel calibre with diabetic retinopathy in an urban Australian indigenous population.

PURPOSE: To assess the relationship of retinal vessel diameter and diabetic retinopathy (DR) in a subgroup of participants recruited through the Darwin Region Urban Indigenous Diabetes study. METHODS: Participants were examined as part of the Darwin Region Urban Indigenous Diabetes study. All participants with gradable fundus photographs were included in the current analysis. Assessment of retinal vascular diameter, including arteriolar diameter (central retinal arteriolar equivalent) and venular diameter (central retinal venular equivalent), was undertaken using a semi-automated retinal vascular imaging program. DR was graded according to the modified Early Treatment DR Study scale. RESULTS: A total of 110 participants, 25 men and 85 women, with a mean age of 50.8 years were included in the analysis. The odds ratio for having DR for each standard deviation increase in central retinal venular equivalent was as high as 1.62 (95% confidence intervals 0.94, 2.80); however, this did not reach statistical significance (P = 0.08). Moreover, individuals with severe non-proliferative DR and proliferative DR were found to have narrower arteriolar diameters compared with those with no DR, but this was not statistically significant (-8.1 microm, 95% confidence intervals, -39.3 microm, 23.1 microm; P = 0.612). CONCLUSION: Our data indicate a trend for narrower arteriole diameter and wider venular diameter with DR in this high-risk ethnic group, which concurs with overall trends seen in non-indigenous populations.

Acute retinal arteriolar emboli after cardiac catheterization.

BACKGROUND AND PURPOSE: There are concerns that cardiac catheterization may cause retinal embolization, a risk marker for cerebrovascular emboli and stroke. We describe the incidence of acute retinal embolism after cardiac catheterization. METHODS: One hundred unselected patients attending a tertiary referral center for diagnostic cardiac catheterization were recruited. Digital retinal photography (optic disc and macular fields) was performed precatheterization and within 3 hours postcatheterization. New retinal emboli were identified by a senior researcher and confirmed by a retinal specialist. RESULTS: There was one case of retinal embolus precatheterization. Two patients (incidence 2.02%; 95% CI, 0.25 to 7.11) developed new retinal arteriolar emboli after catheterization. No patient developed clinically apparent visual or neurological changes. CONCLUSIONS: The risk of acute retinal embolism immediately after cardiac catheterization is 2%. This finding indicates that the retinal, and possibly the cerebral circulation, may be compromised more frequently than is clinically apparent as a complication of cardiac catheterization.