Harmonizing ophthalmic residency surgical training across Europe: A proposed surgical curriculum.

BACKGROUND: One of the core aims of the European Union of Medical Specialists is to harmonize training across Europe by creating European Training Requirements for all medical specialties including Ophthalmology. The theoretical part is already defined by the EBO, however as ophthalmology also includes surgical skills, we herein propose a surgical minimum curriculum for ophthalmology residents in Europe. METHODS: National and international ophthalmic training curricula which are publicly available in English were reviewed and compared. The final proposal was created from 5 criteria: 1. Disease prevalence; 2. Patient safety; 3. Case-trainee ratio; 4. Skill transfer; and 5. Technical difficulty. RESULTS: In total 7 different training curricula from across the world were compared. Among the surgical procedures, cataract surgery has the highest median number of procedures required to be completed during residency: 86 procedures (50-350). Followed by oculoplastics: 28 procedures (10-40) and panretinal photocoagulation: 27.5 procedures (10-49) Full procedural competence is proposed in 9 surgical skills, including YAG laser posterior capsulotomy, retinal argon laser, intravitreal injection, corneal foreign body removal, removal of corneal sutures, facial and periocular laceration repair, eyelid laceration repair, minor eyelid procedures, and punctal occlusion. These procedures are deemed essential and feasible for all ophthalmology residents in Europe to perform independently upon completion of their training. CONCLUSION: This proposal should be regarded as a recommendation based on comparable surgical curricula in use worldwide to establish standards across European countries and may serve as valuable insight to those responsible for compiling ETRs for ophthalmology, or their national curriculums.

Radiotherapy for nasopharyngeal carcinoma: Effect on the eye 10 years later: A case report.

A patient who had previously received radiotherapy for a nasopharyngeal carcinoma was rightfully discharged from otorhinolaryngology and oncology once treatment was completed. After 10 years, the patient presented with visual loss in one eye and was found to have radiation retinopathy. This case highlights the importance of recognising the effects that radiation administered to structures near the eye can have on vision. The latency of this case demonstrates the need for routine eye tests in patients who have undergone radiotherapy near the orbit. Prompt recognition and referral to ophthalmologists is necessary for all suspected cases to best manage visual loss.

Bilateral posterior scleritis due to giant cell arteritis.

A woman aged mid 70s with mild learning difficulty presented with eye symptoms, headache and shoulder pains. She was found to have bilateral posterior scleritis secondary to giant cell arteritis. Posterior scleritis is a potentially blinding condition, with ambiguous symptoms and signs, therefore diagnosis is commonly delayed. This patient was seen in General Practice as well as in Accident and Emergency, where diagnoses of acute angle closure glaucoma as well as iritis were rightfully considered. Her symptoms persisted for 11 days before ophthalmic opinion was sought. Thorough assessment of a painful red eye as well as knowledge of these red-flag signs may allow early treatment and a better outcome for patients. The Royal College of Ophthalmologists has published guidance on how to assess and manage visual loss in people with learning difficulties, including recognising 'symptoms' such as hesitancy on steps, eye rubbing and loss of interest in activities.

Phacoemulsification combined with micropulse cyclodiode laser in glaucoma patients: efficacy and safety.

OBJECTIVE: To evaluate the safety and efficacy of phacoemulsification combined with Micropulse transscleral cyclophotocoagulation (MP-TSCPC) in glaucoma patients. METHODS: This is a retrospective case-note review. The participants were adult patients with diagnoses of glaucoma and cataract who required a further reduction in IOP or a reduction in the number of glaucoma drops. All consecutive patients who underwent cataract surgery (CS) combined with MP-TSCPC laser between October 2018 and July 2019 were included in the study. The effect on visual acuity (VA), intraocular pressure (IOP) and number of anti-glaucoma drops were evaluated at 6 and 12 months in addition to any complications that occurred during any time point of the study. RESULTS: 42 eyes were included in the study. Mean IOP was reduced from 19.5 ± 5.4 mmHg by 22.5% to 15.1 ± 4.6 at 6 months post-operatively and by 19.5% to 15 ± 6.6 mm Hg at 12 months (p < 0.001 at both time points). The number of anti-glaucoma medications also reduced significantly from 2.8 ± 1.3 to 1.6 ± 1.2 at 6 months and to 2.2 ± 1.3 at 12 months (p < 0.001 at both time points). The success rate was 56% at 6 months and 54% at 12 months. 54.7% of our patients who completed 12 months follow up had an improvement or unchanged vision at the last visits. CONCLUSION: This is the first study evaluating the effect of cataract surgery combined with MP-TSCPC in glaucoma patients. We demonstrated that this led to a reduction in IOP and the number of anti-glaucoma medications at 6 and 12-month postoperatively. The majority of patients had either stable or better vision at 12 months follow-up.

Lessons of the month 2: A case of Behçet's disease: 70% have ophthalmic involvement.

A 34-year-old man presented to the emergency department with acute painless loss of vision of the left eye. Past medical history included painful lumps in the legs and frequent mouth ulcers, which were undiagnosed. The patient's visual acuity was 6/5 and counting fingers in the right and left eye, respectively. There were extensive intraretinal haemorrhages and venous sheathing in the superior quadrant of the left eye with associated disc oedema. The case was discussed in a multidisciplinary team meeting in the presence of ophthalmology, dermatology and immunology and a diagnosis of Behçet's disease was reached. The patient was commenced on intravenous methylprednisolone for 3 days followed by a switch to oral prednisolone. Due to recalcitrant uveitis, an intravitreal dexamethasone implant was administered. Eventually, systemic azathioprine and infliximab were commenced with frequent review by ophthalmology and immunology. The macular oedema improved but, unfortunately, the patient's visual acuity did not recover. Behçet's disease is a complex vasculitis involving multiple organ systems. Ocular manifestations can occur in 70% of patients, comprising retinal vasculitis, anterior uveitis, iridocyclitis, chorioretinitis, scleritis, keratitis, vitreous haemorrhage, optic neuritis, conjunctivitis, retinal vein occlusion and retinal neovascularisation. A tailored multidisciplinary approach is required, with corticosteroids being the mainstay of treatment.

Lesson of the month 2: A case of Behçet's disease: 70% have ophthalmic involvement.

A 34-year-old man presented to the emergency department with acute painless loss of vision of the left eye. Past medical history included painful lumps in the legs and frequent mouth ulcers, which were undiagnosed. The patient's visual acuity was 6/5 and counting fingers in the right and left eye, respectively. There were extensive intraretinal haemorrhages and venous sheathing in the superior quadrant of the left eye with associated disc oedema. The case was discussed in a multidisciplinary team meeting in the presence of ophthalmology, dermatology and immunology and a diagnosis of Behçet's disease was reached. The patient was commenced on intravenous methylprednisolone for 3 days followed by a switch to oral prednisolone. Due to recalcitrant uveitis, an intravitreal dexamethasone implant was administered. Eventually, systemic azathioprine and infliximab were commenced with frequent review by ophthalmology and immunology. The macular oedema improved but, unfortunately, the patient's visual acuity did not recover. Behçet's disease is a complex vasculitis involving multiple organ systems. Ocular manifestations can occur in 70% of patients, comprising retinal vasculitis, anterior uveitis, iridocyclitis, chorioretinitis, scleritis, keratitis, vitreous haemorrhage, optic neuritis, conjunctivitis, retinal vein occlusion and retinal neovascularisation. A tailored multidisciplinary approach is required, with corticosteroids being the mainstay of treatment.

A multi-centre interventional case series of 259 ab-interno Xen gel implants for glaucoma, with and without combined cataract surgery.

AIMS: To assess the efficacy of Xen in reducing intraocular pressure (IOP) in varying glaucoma subtypes. To assess the effect of combined phacoemulsification. To determine the frequency of complications and explore further bleb management needed. METHODS: Retrospective case note review of all patients undergoing Xen implantation across four centres from August 2015 to May 2017. RESULTS: In total, 259 consecutive surgeries of 226 patients were reviewed. IOP reduced from 19.3 (SD ± 6.0) mmHg preoperatively to 14.2 (SD ± 4.4) at month 12 and 13.5 (SD ± 3.3) at month 18 (p < 0.0001). Medication usage reduced from 2.6 (±1.1) preoperatively to 0.8 (±1.0) at month 12 (p < 0.0001) and 1.1 (±1.3) medications at month 18 (p < 0.0001). Simultaneous phacoemulsification did not alter outcomes as Xen IOP was 14.3 (SD ± 4.7) mmHg and Phaco-Xen was 13.8 (SD ± 2.6) mmHg at month 12 (p = 0.5367). Xen appears to be effective in previous failed filtration surgery. Adverse events included: IOP spikes of ≥30 mmHg in 33 (12.7%) cases, secondary filtration surgery required in 24 (9.3%) cases; implant exposure in 6 (2.3%) cases; persistent hypotonous maculopathy in 5 (1.9%) cases; persistent choroidal effusions in 4 (1.5%) cases; a cyclodialysis cleft secondary to implant insertion in 1 (0.5%) case; and 1 (0.5%) case of endophthalmitis post-implant bleb resuturing. In all, 40.9% of cases required postoperative bleb needling or antimetabolite injection. CONCLUSIONS: Xen reduces IOP and medications at 18 months. Adverse events are uncommon. Careful postoperative surveillance and low threshold for bleb management is needed. Xen is safe and effective in mild to moderate glaucoma.

Is a Day 1 postoperative review following ab interno Xen gel stent surgery for glaucoma needed?

PURPOSE: To assess whether a first day review is needed following Xen surgery in glaucoma patients. PATIENTS AND METHODS: We performed a retrospective case note review of all Xen surgeries performed across four centers between August 2015 and May 2017. Intraocular pressure (IOP), number of medications, complications, and all further procedures were recorded. RESULTS: Two hundred and fifty-nine cases from 226 patients were analyzed, 78 of 259 cases (30.1%) had numerical hypotony (<6 mmHg) on Day 1, but 60 had resolved by Week 1. Zero cases of hypotony required intervention at Day 1. Two of 259 cases (0.8%) had transient IOP of ≥20 mmHg due to air bubble/iris blockage on Day 1 with one case (0.4%) requiring iris manipulation at the slit-lamp. One case (0.4%) required IOP lowering medications at Day 1. All other complications and interventions in our series occurred at 1 week or beyond. Day 1 IOP was not shown to be a reliable indicator for outcomes at Week 1 (r2=0.2155), Month 1 (r2=0.0574), or Month 12 (r2=0.1580). CONCLUSION: The presence of significant complications requiring intervention at Day 1 was 0%. Only one case (0.4%) required topical IOP lowering medication and one case (0.4%) needed stent manipulation at Day 1. Day 1 IOP is not a reliable indicator of long-term outcomes in Xen surgeries. Removing Day 1 follow-up would have been safe in our series and it may be more effective to perform the first postoperative review of Xen surgery at Week 1.

Efficacy and Safety of the Ab-interno Xen Gel Stent After Failed Trabeculectomy.

AIMS: To assess the efficacy and safety of the Xen gel stent in reducing intraocular pressure (IOP) in eyes with prior failed trabeculectomy and to determine the frequency of complications and further intervention. METHODS: Retrospective case note review of all patients with prior trabeculectomy undergoing Xen surgery across 5 centers from August 2015 to May 2017. RESULTS: In total, 17 surgeries were reviewed. IOP reduced from 21.5 (±2.4) mm Hg preoperatively to 13.6 (±3.4) mm Hg at month 12 (P<0.05). Medication usage reduced from 2.8 (±0.6) preoperatively to 1.0 (±1.3) at month 12 (P<0.05). Adverse events included: numerical hypotony (IOP<6 mm Hg) in 4 cases (23.5%) that all resolved spontaneously, IOP spike of ≥30 mm Hg in 2 (11.8%) cases and transient occlusion of the implant by iris in 1 (5.9%) case. Secondary filtration surgery (Baerveldt tube implantation) was required in 2 (11.8%) cases. Postoperative bleb intervention was required in 9 cases (52.9%), usually in the first month after surgery. CONCLUSIONS: Xen reduces IOP and number of medications in eyes with failed trabeculectomy. Detailed preoperative conjunctival assessment and targeted stent placement is required. Prospective data and follow-up beyond 12 months are required but Xen seems a viable, effective, and safe option after failed trabeculectomy.

3D culture of human pluripotent stem cells in RGD-alginate hydrogel improves retinal tissue development.

No treatments exist to effectively treat many retinal diseases. Retinal pigmented epithelium (RPE) and neural retina can be generated from human embryonic stem cells/induced pluripotent stem cells (hESCs/hiPSCs). The efficacy of current protocols is, however, limited. It was hypothesised that generation of laminated neural retina and/or RPE from hiPSCs/hESCs could be enhanced by three dimensional (3D) culture in hydrogels. hiPSC- and hESC-derived embryoid bodies (EBs) were encapsulated in 0.5% RGD-alginate; 1% RGD-alginate; hyaluronic acid (HA) or HA/gelatin hydrogels and maintained until day 45. Compared with controls (no gel), 0.5% RGD-alginate increased: the percentage of EBs with pigmented RPE foci; the percentage EBs with optic vesicles (OVs) and pigmented RPE simultaneously; the area covered by RPE; frequency of RPE cells (CRALBP+); expression of RPE markers (TYR and RPE65) and the retinal ganglion cell marker, MATH5. Furthermore, 0.5% RGD-alginate hydrogel encapsulation did not adversely affect the expression of other neural retina markers (PROX1, CRX, RCVRN, AP2α or VSX2) as determined by qRT-PCR, or the percentage of VSX2 positive cells as determined by flow cytometry. 1% RGD-alginate increased the percentage of EBs with OVs and/or RPE, but did not significantly influence any other measures of retinal differentiation. HA-based hydrogels had no significant effect on retinal tissue development. The results indicated that derivation of retinal tissue from hESCs/hiPSCs can be enhanced by culture in 0.5% RGD-alginate hydrogel. This RGD-alginate scaffold may be useful for derivation, transport and transplantation of neural retina and RPE, and may also enhance formation of other pigmented, neural or epithelial tissue. STATEMENT OF SIGNIFICANCE: The burden of retinal disease is ever growing with the increasing age of the world-wide population. Transplantation of retinal tissue derived from human pluripotent stem cells (PSCs) is considered a promising treatment. However, derivation of retinal tissue from PSCs using defined media is a lengthy process and often variable between different cell lines. This study indicated that alginate hydrogels enhanced retinal tissue development from PSCs, whereas hyaluronic acid-based hydrogels did not. This is the first study to show that 3D culture with a biomaterial scaffold can improve retinal tissue derivation from PSCs. These findings indicate potential for the clinical application of alginate hydrogels for the derivation and subsequent transplantation retinal tissue. This work may also have implications for the derivation of other pigmented, neural or epithelial tissue.

An evaluation of two heavier-than-water internal limiting membrane-specific dyes during macular hole surgery.

PURPOSE: To evaluate the staining characteristics and effect on internal limiting membrane (ILM) histology of two heavier-than-water ILM-specific dyes during macular hole surgery: acid violet 17 combined with 5 % mannitol (AV17-M) and brilliant blue G with 4 % polyethylene glycol (BBG-P). METHODS: Single-centre observational comparative cohort study. The ILM of consecutive patients undergoing surgery for idiopathic macular hole were stained with BBG-P and AV17-M for 10 s each. The ILMs were retrieved and examined with electron microscopy. The extent of retinal and vitreous side debris was scored. Surgical videos were used to assess the staining contrast effect by measuring the Euclidean distance in the CIELAB colour space between stained and unstained retinas after peeling. RESULTS: 51 consecutive patients were studied with 25 in the AV17-M group and 26 in the BBG-P group. The mean age was 71 years with no significant difference between the groups. The amount of retinal side tissue was greater on the BBG-P-stained ILMs compared to the AV17-M-stained ILMs (30.2 versus 19.6 %, p < 0.001). There was a difference in the CIELAB colour space separation distance between stained and peeled retinas (5.89 versus 3.97, p = 0.01) in favour of BBG-P. Visual outcomes between the two groups were similar (logMAR visual acuity 0.40 versus 0.38, p = 0.74). CONCLUSION: Both stains were successfully used to peel the ILM with comparable outcomes. AV17-M resulted in less retinal debris than BBG-P, suggesting an altered and potentially beneficial ILM cleavage plane from the retina but with lowered staining contrast than BBG-PEG.