Diabetic Disease of the Eye in Canada: Consensus Statements from a Retina Specialist Working Group.

Despite advances in systemic care, diabetic disease of the eye (DDE) remains the leading cause of blindness worldwide. There is a critical gap of up-to-date, evidence-based guidance for ophthalmologists in Canada that includes evidence from recent randomized controlled trials. Previous guidance has not always given special consideration to applying treatments and managing DDE in the context of the healthcare system. This consensus statement aims to assist practitioners in the field by providing a spectrum of acceptable opinions on DDE treatment and management from recognized experts in the field. In compiling evidence and generating consensus, a working group of retinal specialists in Canada addressed clinical questions surrounding the four themes of disease, patient, management, and collaboration. The working group reviewed literature representing the highest level of evidence on DDE and shared their opinions on topics surrounding the epidemiology and pathophysiology of diabetic retinopathy and diabetic macular edema; diagnosis and monitoring; considerations around diabetes medication use; strategic considerations for management given systemic comorbidities, ocular comorbidities, and pregnancy; treatment goals and modalities for diabetic macular edema, non-proliferative and proliferative diabetic retinopathy, and retinal detachment; and interdisciplinary collaboration. Ultimately, this work highlighted that the retinal examination in DDE not only informs the treating ophthalmologist but can serve as a global index for disease progression across many tissues of the body. It highlighted further that DDE can be treated regardless of diabetic control, that a systemic approach to patient care will result in the best health outcomes, and prevention of visual complications requires a multidisciplinary management approach. Ophthalmologists must tailor their clinical approach to the needs and circumstances of individual patients and work within the realities of their healthcare setting.

Risk factors for epiretinal membrane formation and peeling following pars plana vitrectomy for primary rhegmatogenous retinal detachment, an OCT guided analysis.

BACKGROUND: To evaluate the rate and risk factors of epiretinal membrane (ERM) formation and need for ERM peeling after pars plana vitrectomy (PPV) for uncomplicated primary rhegmatogenous retinal detachment (RRD). METHODS: Retrospective, single-center, cohort study of 119 consecutive patients (119 eyes) that underwent RRD repair using PPV. The primary outcomes were ERM formation, classified using an optical coherence tomography grading system, and the rate of ERM peeling. Visual acuity, postoperative complications, and risk factors for ERM formation and peeling were also identified. RESULTS: Postoperative ERM formation occurred in 69 eyes (58.0%); 56 (47.1%) were stage 1, 9 (7.6%) stage 2, 3 (2.5%) stage 3, and 1 (0.8%) stage 4. Only 6 (5.0%) eyes required secondary PPV for a visually significant ERM, with a mean time to reoperation of 488 ± 351 days. Risk factors for ERM formation included intraoperative cryotherapy, more than 1000 laser shots, 360° laser photocoagulation, and choroidal detachment (p < 0.01). Eyes with more than 3 tears had a trend towards increased ERM surgery (p = 0.10). CONCLUSIONS: Visually significant ERM formation following PPV for primary RRD was uncommon in this cohort (5%). Half of the ERMs were detected after the first post-operative year, indicating that this complication may be underreported in studies with only 1-year follow-up.

ENDOPHTHALMITIS IN A PATIENT TREATED WITH BACILLUS CALMETTE-GUÉRIN IMMUNOTHERAPY.

BACKGROUND: Intravesical Bacillus Calmette-Guérin (BCG) instillation has become one of the mainstays of adjunctive therapy in the treatment of superficial bladder cancer. Ophthalmologic complications are rare, but few cases are reported in the literature. METHODS: Retrospective observational case report. RESULTS: The authors report a case of unilateral Mycobacterium bovis BCG endophthalmitis after intravesical BCG instillations. Despite appropriate systemic antituberculous and corticosteroid therapy, the patient almost completely lost sight in the affected eye. This is the fourth case in the literature of proven M. bovis endophthalmitis suggesting a direct choroidal mycobacterial infection and not only a hypersensitivity immunologic reaction as previously suggested. CONCLUSION: This case highlights the direct choroidal mycobacterial infection of the disease after BCG instillations for bladder cancer and failure of treatment despite culture-proven drug sensitivity, thus suggesting the need to revaluate adequate treatment to avoid loss of vision.

Primary rhegmatogenous retinal detachment with inferior retinal breaks postoperative prone positioning results: 1 day versus 7 days.

BACKGROUND: To compare the primary anatomical outcome of pars plana vitrectomy, 360° peripheral endolaser, and 15% octafluoropropane C3F8 gas tamponade in patients with uncomplicated rhegmatogenous detachment and inferior retinal breaks, after 24-h postoperative prone positioning to similar patients with 1 week postoperative prone positioning. METHODS: Records of 5500 patients who underwent pars plana vitrectomy between 2008 and 2015 were retrieved. Collected data included age, gender, number of retinal quadrants with retinal breaks, number of retinal breaks, macula status on presentation (attached or detached), phakic status (phakic, pseudophakic, or aphakic), and primary anatomical outcome (at 1 and 3 months post-operative). RESULTS: 270 patients met the study inclusion criteria (78 females, and 192 males). In the 24-h positioning arm (183 patients), the overall anatomical success rate was 96.2% at 1 month and 83.6% at 3 months. In the 1-week positioning group (87 patients), the overall anatomical success rate was 93% at 1 month and 79% at 3 months. Both positioning groups did not show statistical difference in outcome at 1 month (p-value = 0.7) or at 3 months (p-value = 0.39). Logistic regression analysis found that the number of retinal breaks correlates with the postoperative anatomical success at 3 months (odd ratio 0.8, p-value = 0.016). CONCLUSION: This short term retrospective study demonstrated that patients with uncomplicated rhegmatogenous retinal detachment due to inferior retinal breaks, who underwent pars plana vitrectomy, 360° endolaser, 15% C3F8 gas, and limited (24-h) prone positioning did not show statistical difference in the anatomical outcome (at 1, and 3 months) when compared with 1 week postoperative positioning. Larger prospective studies are warranted to further elucidate positioning role.

Self-care tools to treat depressive symptoms in patients with age-related eye disease: a randomized controlled clinical trial.

BACKGROUND: Depression is very common in people with age-related eye disease. Our goal was to determine if self-care tools plus limited telephone support could reduce depressive symptoms in patients with age-related macular degeneration or diabetic retinopathy. DESIGN: A single-blind randomized controlled clinical trial was conducted at Maisonneuve-Rosemont Hospital in Montreal, Canada. PARTICIPANTS: Eighty participants were recruited. METHODS: To be eligible, participants must have had either late stage age-related macular degeneration or diabetic retinopathy, at least mild depressive symptoms, and visual acuity better than 20/200. Half were randomized to the intervention arm and half to delayed intervention/usual care. The intervention consisted of large print written and audio tools incorporating cognitive-behavioral principles plus three 10-minute telephone calls from a lay coach. Eight-week follow-up data were collected by telephone. MAIN OUTCOME MEASURES: The primary outcome was the 8-week change in depressive symptoms as measured by the Patient Health Questionnaire-9. Secondary outcomes included anxiety, life space and self-efficacy. RESULTS: The baseline mean logMAR visual acuity was 0.37 (SD = 0.20), and the baseline mean Patient Health Questionnaire-9 score was 9.5 (SD = 3.9) indicating moderate depressive symptoms. After adjusting for baseline imbalances in visual acuity, the intervention reduced depressive symptoms by 2.1 points more than usual care (P = 0.040). The intervention was not associated with the secondary outcomes (P > 0.05). CONCLUSIONS: Self-care tools plus telephone coaching led to a modest improvement in depressive symptoms in patients with age-related eye disease. Additional research on how to maximize their effect is necessary.

The effect of surface properties of polycrystalline, single phase metal coatings on bacterial retention.

In the food industry microbial contamination of surfaces can result in product spoilage which may lead to potential health problems of the consumer. Surface properties can have a substantial effect on microbial retention. The surface characteristics of chemically different coatings (Cu, Ti, Mo, Ag, Fe) were defined using white light profilometry (micro-topography and surface features), atomic force microscopy (nano-topography) and physicochemical measurements. The Ag coating had the greatest topography measurements and Fe and Mo the least. Mo was the most hydrophobic coating (lowest γAB,γ(+), γ(-)) whilst Ag was the most hydrophilic (greatest γAB,γ(+), γ(-)). The physicochemical results for the Fe, Ti and Cu coatings were found to lie between those of the Ag and Mo coatings. Microbiological retention assays were carried out using Listeria monocytogenes, Escherichia coli and Staphylococcus aureus in order to determine how surface properties influenced microbial retention. It was found that surface chemistry had an effect on microbial retention, whereas the shape of the surface features and nano-topography did not. L. monocytogenes and S. aureus retention to the surfaces were mostly affected by surface micro-topography, whereas retention of E. coli to the coatings was mostly affected by the coating physicochemistry. There was no trend observed between the bacterial cell surface physicochemistry and the coating physicochemistry. This work highlights that different surface properties may be linked to factors affecting microbial retention hence, the use of surface chemistry, topography or physicochemical factors alone to describe microbial retention to a surface is no longer adequate. Moreover, the effects of surface parameters on microbial retention should be considered individually for each bacterial genus.

Factors associated with outcomes of pneumatic retinopexy for rhegmatogenous retinal detachments: a retrospective review of 422 cases.

BACKGROUND: To determine the factors associated with anatomical and visual outcomes, and complications when using pneumatic retinopexy in the management of rhegmatogenous retinal detachments. METHODS: On a whole, 406 patients having undergone 422 primary pneumatic retinopexies for the management of rhegmatogenous retinal detachment at a tertiary care hospital, between January 2004 and December 2009, with a minimum follow-up of 3 months were included in this case series. Multivariate logistic regression was used to estimate associations of demographic and clinical factors with anatomical and visual outcomes. RESULTS: The single operation success rate was 60.7%, and final anatomical success was 99.5%. Male gender and the presence of complications were associated with single operation failure, whereas age over 65 years, poor preoperative visual acuity, the presence of complications were associated with poorer visual outcomes. Better preoperative visual acuity and absence of complications were associated with obtaining both a good visual outcome and anatomical success after a single intervention. The most common complications included new or missed tears (16.3%), delayed subretinal fluid reabsorption (12.1%), and epiretinal membrane (10.2%). CONCLUSION: Several factors are associated with pneumatic retinopexy outcomes for rhegmatogenous retinal detachments. These factors should be taken into consideration when identifying patients who would benefit from pneumatic retinopexy and those who are at risk of requiring additional interventions.

The effect of intravitreal injection of bevacizumab on retinal circulation in patients with neovascular macular degeneration.

PURPOSE: Intravitreal (ITV) injection of anti-VEGFs like bevacizumab are widely used to treat neovascular AMD. However, VEGF is essential for biologic functions such as blood pressure regulation. Indeed, anti-VEGF intravenous administration is associated with hypertension. Therefore, the effect of ITV bevacizumab on retinal circulation was examined. METHODS: Twenty-three patients with neovascular AMD treated with three repeat ITV injections of bevacizumab were recruited. Blood arteriolar diameter and flow measurements were performed with a bidirectional laser Doppler flowmeter at baseline, 1 week after the first injection, just before the second injection, and 5 weeks after the third injection. Scanning laser Doppler flowmetry was used to assess the effect of bevacizumab on tissue perfusion at the first and fourth visits. RESULTS: Arteriolar diameter significantly decreased from 122.5 ± 14.5 µm to 118.9 ± 14.0 µm (P = 0.03) during the first week to reach a mean value of 117.2 ± 13.7 µm at the end of the study (P < 0.01). Arterial blood flow did not change significantly. Neuroretinal rim perfusion decreased from 181.1 ± 84.1 arbitrary flow units to 167.7 ± 76.5 arbitrary flow units, which was borderline significant (P = 0.06). No significant change was observed in the peripapillary retina. CONCLUSIONS: Arteriolar diameter decreased significantly after the first injection and persisted until the end of the study suggesting a long-term effect of bevacizumab on vascular tone. However, the blood flow change is not significant. A borderline significant decrease in neuroretinal rim perfusion was observed and suggests that the neuroretinal rim may be more sensitive than the peripapillary retina to the effects of bevacizumab.

Intravitreal bevacizumab (avastin) for choroidal neovascularization associated with deferoxamine retinopathy.

PURPOSE: To report the effect of antivascular endothelial growth factor therapy for choroidal neovascularisation associated with deferoxamine toxicity. METHOD: In an interventional case report, intravitreal antivascular endothelial growth factor therapy was used for the treatment of a choroidal neovascularization in a patient with deferoxamine retinopathy. RESULTS: A 54-year-old woman with beta-thalassemia intermedia and known deferoxamine toxicity presented with recent vision loss to the left eye secondary to a choroidal neovascular membrane. Visual acuity had decreased from 20/30 to 20/80 in the left eye. Funduscopic examination and fluorescein angiography revealed diffuse retinal pigment epithelial mottling and a choroidal neovascular membrane. Treatment with three doses of intravitreal bevacizumab led to a good structural outcome and improvement of the visual acuity. The patient later developed a choroidal neovascular membrane in the right eye. Similar treatment with intravitreal bevacizumab also led to a rapid structural resolution of the lesion, albeit with a more modest improvement in the visual acuity. CONCLUSION: Therapy with intravitreal bevacizumab might be an option for the treatment of choroidal neovascularization in the context of deferoxamine toxicity.

Teleophthalmology screening for diabetic retinopathy through mobile imaging units within Canada.

BACKGROUND: This study aimed to describe and measure the health results of a Category 3 teleophthalmology screening project for diabetic retinopathy (DR). Implemented through mobile screening imaging units located within pharmacies, the project had the goal of reaching unscreened diabetic patients in urban communities while lowering barriers to screening and saving medical resources. METHODS: Image capture of both eyes of 3505 known diabetic individuals was performed in the provinces of Quebec, British Columbia, Alberta, Manitoba, and Saskatchewan. A photographer performed fundus imaging, and a nurse used mild pupil dilation only when necessary to secure image quality. Screening was provided free of cost in the context of DR health days for DR screening. Through teleophthalmology, ophthalmologists proceeded with data and image interpretation, and timely referral when indicated. RESULTS: This project allowed the resumption of screening of over 38% of the cohort of known diabetics who reported never having undergone any eye examination with pupil dilation, and an additional 30% who reported not having been examined for over 2 years. All known diabetics were under the care of a general physician, and their mean diabetes duration, when known, was 8 years. DR pathology was found in 22.5% (20%-28%) of the cohort, 1.8% requiring urgent referral (within 30 days) as a result of the severity of the DR and 0.6% (0%-1.8%) requiring urgent referral for other reasons. An additional 8.7% (8.1%-19.5%) required ophthalmologic attention within 6 months because of DR and another 2.0% (0%-6.3%) between 6 months and 1 year. Incidental findings were found in 23%, the majority of which were related to cataract and dry macular degeneration. Urgent or significant incidental findings were found in 0.6% of the screened eyes. Pupil dilation with tropicamide 1% was deemed useful or necessary in 33.7% of the cohort. For 0.7% of the cohort, the images could not be interpreted because of poor image quality and for that reason had to be referred for a traditional dilated eye examination. Ophthalmologists were relieved of the examination of 85.6% of the screened diabetic individuals who benefited from screening without requiring a traditional ophthalmologic examination. On the other hand, ophthalmologists were required to provide urgent (within 30 days) services to 2% of the cohort, either because of threatening DR or because of incidental findings requiring rapid ophthalmologic attention. INTERPRETATION: This screening strategy for DR through mobile teleophthalmology imaging units efficiently lowered barriers to screening and created new screening opportunities for a large number of known diabetic individuals who were lost to the traditional health system. It has the potential to provide better outreach to diabetic populations while identifying individuals truly in need of the services of an ophthalmologist; at the same time it maximizes the use of limited ophthalmologic resources while favouring multidisciplinary collaborations. The significant incidental findings associated with screening highlight the need for ophthalmologic competencies during DR screening within a teleophthalmology approach. Further involvement of government health authorities is pivotal in embracing the opportunities provided by emerging technologies such as teleophthalmology and translating them into better outreach services to diabetic populations and thus better visual health results.

Using the CanMEDS roles when interviewing for an ophthalmology residency program.

BACKGROUND: To improve the admissions process for the Université de Montréal (UdeM) ophthalmology residency program, the interview structure was modified to encompass the seven CanMEDS roles introduced by the Royal College of Physicians and Surgeons of Canada (RCPSC). These roles include an applicant's abilities as a communicator, collaborator, manager, health advocate, professional, scholar, and medical expert. METHODS: In this retrospective pilot study, the records of all applicants were reviewed by 8 members of the admissions committee, with a high intraclass correlation coefficient of 0.814. Four 2-person interview teams were then formed. The first 3 groups asked the applicants specific questions based on 2-3 of the CanMEDS roles, marking their impressions of each candidate on a visual analogue scale. The last group answered candidates' questions about the program but assigned no mark. RESULTS: The intraclass correlations for the teams were 0.900, 0.739, and 0.585, demonstrating acceptable interrater reliability for 2 of the teams. Pearson correlation coefficients between groups of interviewers were considered adequate at 0.562, 0.432, and 0.417 (p < 0.05). For each interviewer, the Pearson correlation coefficient between record marking and interview scoring was either not statistically significant or very low. INTERPRETATION: By basing the 2006 interview process on the CanMEDS roles defined by the RCPSC, information was obtained about the candidates that could not have been retrieved by a review of the medical students' records alone. Reliability analysis confirmed that this new method of conducting interviews provided sound and reliable judging and rating consistency between all members of the admissions committee.

Subretinal recombinant tissue plasminogen activator injection and pneumatic displacement of thick submacular hemorrhage in Age-Related macular degeneration.

OBJECTIVE: To evaluate the anatomic and visual outcomes after a surgical procedure for displacement of thick submacular hemorrhage in patients with age-related macular degeneration. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Twenty-nine consecutive eyes of 28 patients with thick submacular hemorrhage secondary to age-related macular degeneration. INTERVENTION: The procedure consisted of a pars plana vitrectomy with subretinal recombinant tissue plasminogen activator injection (125 micrograms/ml) through a translocation microcannula, followed by fluid-air exchange and postoperative prone positioning [correction]. MAIN OUTCOME MEASURES: Intraoperative and postoperative surgical complications, preoperative and postoperative best-corrected visual acuities, postoperative fluorescein angiography results, and additional postoperative treatments. RESULTS: Total subfoveal blood displacement was achieved in 25 eyes, with subtotal displacement in the others. Based on fluorescein angiography results, 8 eyes were eligible for additional postoperative treatments. At 3 months, 17 eyes had gained more than 2 lines of visual acuity, whereas 3 had lost more than 2 lines. The difference between preoperative and 3-month postoperative visual acuity was statistically significant (P = 0.0167). Complications consisted of 2 cases of vitreous hemorrhage that cleared within 4 weeks. CONCLUSIONS: This surgical technique seems useful in displacing thick submacular hemorrhage secondary to age-related macular degeneration, allowing postoperative fluorescein angiography testing and, potentially, subsequent treatments. No significant complication from the procedure was identified. However, further controlled studies will be required to assess its efficacy in the management of this difficult clinical problem.

Effectiveness and safety of screening for diabetic retinopathy with two nonmydriatic digital images compared with the seven standard stereoscopic photographic fields.

BACKGROUND: The use of nonmydriatic cameras, which offer ease of screening and 45 degrees immediate imaging of the fundus, is gaining increasing acceptance for screening programs tailored to diverse conditions. We performed a study to evaluate the effectiveness and safety of screening for diabetic retinopathy with two nonmydriatic camera images compared with the seven standard stereoscopic 30 degrees fields (7SF). We also wished to determine whether safe screening guidelines could be established to identify patients needing referral to an ophthalmologist. METHODS: In this prospective masked cross-sectional study, we evaluated agreement in the assessment of the severity of diabetic retinopathy by means of two 45 degrees images centred on the optic disc and on the macula obtained with the Topcon CRW6 nonmydriatic camera and by means of 7SF photography and ophthalmologic slit-lamp biomicroscopy, both performed with pupil dilation. Between November 2000 and June 2001, 98 adult patients known to have type 1 or 2 diabetes mellitus who presented for the first time to the diabetic retinopathy clinic of a tertiary care centre in Montreal were enrolled consecutively. Thus, patient recruitment was weighted toward more severe retinopathy to ensure sufficient representation of less frequent but more severe levels. Each patient underwent nonmydriatic fundus photography of both eyes, followed by a complete ophthalmologic examination with pupil dilation by a single retina specialist and 7SF photography of both eyes with pupil dilation. The level of retinopathy was graded independently in each eye from the 7SF photographs according to the Early Treatment Diabetic Retinopathy Study (ETDRS) scale by two graders; an independent retina specialist adjudicated the rare instances of interreader disagreement in a masked fashion. Two months later, two graders independently graded the nonmydriatic images in a blinded fashion according to the ETDRS scale; a third observer adjudicated the rare instances of interreader disagreement. We measured concordance between grading results with the various screening techniques using the weighted and unweighted kappa statistic. We used sensitivity and specificity indices to determine safe screening guidelines to identify patients needing referral to an ophthalmologist. RESULTS: There was substantial agreement in the grading of retinopathy with nonmydriatic camera imaging and with 7SF photography, both for all eyes (kappa = 0.626 [standard deviation (SD) 0.045]) and for the eye with more severe disease (kappa = 0.654 [SD 0.063]). With nonmydriatic camera imaging, screening thresholds for patient referral to an ophthalmologist of very mild retinopathy (ETDRS grade 20), mild retinopathy (ETDRS grade 35) and moderate retinopathy (EDTRS grade 43) had sensitivity values of 97.9%, 97.1% and 53.3% respectively and specificity values of 81.3%, 95.5% and 96.9% respectively. Screening thresholds of very mild or mild retinopathy both correctly identified 100% of eyes with severe nonproliferative or proliferative retinopathy. With a screening threshold of mild retinopathy, screening with the nonmydriatic camera would lead to referral to an ophthalmologist of 37.8% of patients because of detected disease and of an additional 17.3% because of insufficient image quality in at least one eye, for a total of 55.1%. The overall sensitivity and specificity of a two-field nonmydriatic screening strategy with a threshold of mild retinopathy for referral of patients with insufficient image quality in at least one eye are 97.7% and 84.0% respectively. INTERPRETATION: Our results suggest that two-field nonmydriatic camera imaging is a safe screening strategy that may identify the patients with diabetes most in need of ophthalmologic care.

Comparison of two, three and four 45 degrees image fields obtained with the Topcon CRW6 nonmydriatic camera for screening for diabetic retinopathy.

BACKGROUND: The use of the nonmydriatic camera is gaining increasing acceptance for the detection of diabetic retinopathy when integrated into a community-tailored program. We performed a study to evaluate the optimal number and positioning of photographic fields necessary to screen for diabetic retinopathy with the Topcon CRW6 nonmydriatic camera. METHODS: In this prospective masked cross-sectional comparative study, we compared the assessment of diabetic retinopathy using two, three or four 45 degrees fundus images (centred respectively on the disc and the macula; on the disc, on the macula and temporal to the macula; and on the disc, on the macula, temporal to the macula and superotemporal to the macula, including the superior temporal vein) acquired with the Topcon CRW6 nonmydriatic camera, with the grading of the seven standard stereoscopic 30 degrees field photographs (7SF). The study population consisted of 98 consecutive adult patients known to have type 1 or 2 diabetes mellitus who presented for the first time to the diabetic retinopathy clinic of a tertiary care centre in Montreal. All patients underwent four nonmydriatic fundus photography sessions of both eyes, 7SF photography with pupil dilation and a complete ophthalmologic examination with pupil dilation by a retina specialist. RESULTS: Compared to the 7SF, the sensitivity and specificity of screening for any retinopathy (Early Treatment Diabetic Retinopathy Study [ETDRS] grade greater than 10) using the two central fields were 95.7% and 78.1% respectively. The corresponding values with three image fields were 97.6% and 71.9%, and with four image fields, 97.6% and 65.6%. The sensitivity and specificity of screening for mild or worse disease (ETDRS grade 35 or greater) using the two central fields were 87.5% and 92.3%. The corresponding values with three image fields were 88.9% and 94.6%, and with four image fields, 88.9% and 91.9%. Poor image quality occurring with the addition of extra fields resulted in an increase of 6.2% in the rate of referral to an ophthalmologist. The use of two image fields missed no cases of retinopathy. INTERPRETATION: The use of image fields in addition to the two 45 degrees images centred on the disc and the macula on imaging with the Topcon CRW6 nonmydriatic camera did not significantly increase the sensitivity or specificity of screening for diabetic retinopathy. Contrary to the desired effect, the addition of fields resulted in diminished utility and cost-effectiveness of this screening approach.