Increasing access to cataract surgery in Counties Manukau by optimising the clinical pathway: a quality improvement report.

AIM: To streamline the cataract surgery pathway to improve the time from first specialist assessment (FSA) to surgery, while reducing the clinical priority assessment criteria (CPAC) score from 55 to 50. METHOD: A quality improvement project using Lean Six Sigma tools and the Model for Improvement. Most data were collected from the i.Patient Manager (iPM) system and analysed using statistical process control charts. Change interventions included combining FSA and pre-admission clinics (PAC); post-operative telephone review by non senior medical officers (SMO); and using our own surgeons in private theatres. RESULTS: The standard cataract pathway was reduced from 5 to 3 appointments. This removed 1,514 hours of appointments, released 113 SMO hours and saved patients NZ$156,000 in indirect costs over a year. The average waiting time from FSA to surgery decreased from 90 to 77 days (-13.5%). The number of overdue patients reduced from 127 to 44 (-35%). The average number of patients on the FSA waiting list dropped from 322 to 205 (-40%). There was no change to the proportions of surgeries or appointment attendance rates by ethnicity. Average monthly cataract surgeries increased from 192 to 215 (+12%), and the CPAC score threshold was decreased to 50 in February 2021. CONCLUSION: Despite significant demand pressures, and the disruptions of COVID-19, we were able to reduce the CPAC score for accessing cataract surgery by optimising the clinical pathway to better utilise staff capacity and maximise value for patients.

Use of Staurenghi lens angiography in the management of posterior uveitis.

PURPOSE: Retinal vasculitis is an important component of posterior uveitis. It may be difficult to detect either clinically or with conventional angiography. We assessed the role of Staurenghi lens angiography (SLA) in the diagnosis and management of patients with posterior uveitis. METHODS: A total of 26 patients attending the St Paul's Eye Unit uveitis clinic with posterior uveitis underwent wide-angle (150 degree) retinal angiography with the Heidelberg Retina Angiograph 2 Scanning Laser Ophthalmoscope using the Staurenghi SLO 230 contact lens. We determined the percentage of patients in whom this imaging modality assisted in diagnosing and quantifying the extent of vasculitis, planning treatment or monitoring disease activity. RESULTS: Staurenghi lens angiography assisted in diagnosing and quantifying the extent of vasculitis in 62% of patients, and in planning laser photocoagulation or immunosuppression titration in 62% of patients and enhanced disease monitoring in 35% of patients. In 31% of cases, SLA revealed vasculitis that was not evident clinically. CONCLUSION: Staurenghi lens angiography is a valuable tool in the management of patients with posterior uveitis and can be used for the diagnosis, treatment and follow-up of these patients.

Penetrating eye injuries from writing instruments.

PURPOSE: To consider the potential for ocular injury from writing implements by presenting four such cases, and to consider the incidence of such eye injuries from analysis of a national trauma database. METHODS: The Home and Leisure Accident Surveillance System was searched for records of eye injuries from writing instruments to provide UK estimates of such injuries. Four patients with ocular penetrating injury from pens or pencils (especially when caused by children), and examined by the authors, are described which illustrate mechanisms of injury. RESULTS: It is estimated that around 748 ocular pen injuries and 892 ocular pencil injuries of undetermined severity occurred annually in the UK during the database surveillance period 2000-2002. No eye injuries from swords, including toy swords and fencing foils, were reported. CONCLUSION: Ocular perforation sometimes occur from writing instruments that are thrown in the community, especially by children. Implications for policy and prevention are discussed. Non-specialists should have a low threshold for referring patients with eye injuries if suspicious of ocular penetration, even where caused by everyday objects, such as writing instruments.

Prospective study of surgical outcomes and bleb morphology using indocyanine green as a surgical dye in trabeculectomy with mitomycin C.

BACKGROUND: To investigate the effect of adding indocyanine green to mitomycin C in augmented trabeculectomy. DESIGN: A prospective, non-comparative interventional case series. PARTICIPANTS: A total of 37 eyes of 37 patients followed up for 1 year. METHODS: A solution containing 12.5 mg/mL of indocyanine green was added to mitomycin C, resulting in an mitomycin C concentration of 0.2-0.4 mg/mL, which was applied to bare sclera and Tenon's capsule for 3 min during trabeculectomy. MAIN OUTCOME MEASURES: Visual acuity, intraocular pressure, bleb morphology, Moorfields Bleb Grading System scores and complications. RESULTS: Indocyanine green could be visualized on clinical examination for all eyes on the first postoperative day. Mean intraocular pressure decreased from 22.9 ± 6.2 mmHg to 12.1 ± 4.4 mmHg postoperatively (P < 0.001) at 1 year. Thirty-four eyes (91.9%) achieved an intraocular pressure of less than 21 mmHg at final visit without additional topical intraocular pressure-lowering medications. Three eyes (8.1%) developed bleb failure and required Baerveldt device implantation. There were no cases of blebitis or late bleb leak. No adverse effects attributable to indocyanine green could be identified postoperatively. CONCLUSION: The addition of indocyanine green during trabeculectomy improves the visibility of antimetabolites intraoperatively and allows for the estimation of antimetabolite treatment area intraoperatively and postoperatively. It appears to have no adverse effect on surgical outcomes and complication rates, while improving safety of antimetabolite use.

Ocular and oral grading of mucous membrane pemphigoid.

BACKGROUND: A variety of methods have been described for grading ocular mucous membrane pemphigoid (MMP), each with their own limitations. In contrast, there are no reported grading systems for involvement of the oral mucosa. We wished to evaluate two ocular (one established and one proposed) and an oral mucosal grading system for MMP. METHODS: Patients with MMP were assessed by three ophthalmologists and two oral medicine physicians. Ocular disease was graded using the system described by Rowsey and a proposed system based on measurement of vertical depth and horizontal width measured from the bulbar conjunctival aspect. Oral assessment used a 'mucosal disease severity score' originally described for lichen planus, in which 17 areas of the mouth are scored for involvement, together with a pain score. Levels of agreement were evaluated using Fleiss' Kappa Statistic (k). RESULTS: Forty-four patients with MMP encompassing mild to severe disease were included. Good levels of agreement were observed between observers for both vertical (k:0.86) (upper 95% CI: 1.03 mm) and horizontal (k:0.80) (upper 95% CI: 3.01 mm) involvement for the proposed ocular system and the Rowsey system (k: 0.83) (upper 95% confidence interval: 3.19 mm). There was a high coefficient of determination (R(2)) between the ocular grading systems (0.81, p < 0.01). Oral grading showed excellent levels of agreement (k: 0.71) between observers. There was no significant association between the severity of oral and ocular disease using described grading systems. CONCLUSIONS: The proposed grading systems for both oral and ocular involvement in MMP are easy to use, and show good agreement between observers. The proposed ocular system correlates well with a currently used system, and overcomes some of the difficulties encountered with existing systems. For the individual patient, changes greater than 1.5 mm (vertical) and 3 mm (horizontal) are significant. This may increase our ability to detect change or disease progression. Although the risk of ocular involvement in patients with only oral involvement has been demonstrated, the severity of oral and ocular disease are not well-correlated, due in part to an absence of an ocular disease activity score.

A Bayesian approach to assessing the uncertainty in estimating bioconcentration factors in earthworms--the example of quinoxyfen.

BACKGROUND: Quinoxyfen is a fungicide of the phenoxyquinoline class used to control powdery mildew, Uncinula necator (Schw.) Burr. Owing to its high persistence and strong sorption in soil, it could represent a risk for soil organisms if they are exposed at ecologically relevant concentrations. The objective of this paper is to predict the bioconcentration factors (BCFs) of quinoxyfen in earthworms, selected as a representative soil organism, and to assess the uncertainty in the estimation of this parameter. Three fields in each of four vineyards in southern and northern Italy were sampled over two successive years. RESULTS: The measured BCFs varied over time, possibly owing to seasonal changes and the consequent changes in behaviour and ecology of earthworms. Quinoxyfen did not accumulate in soil, as the mean soil concentrations at the end of the 2 year monitoring period ranged from 9.16 to 16.0 µg kg⁻¹ dw for the Verona province and from 23.9 to 37.5 µg kg⁻¹ dw for the Taranto province, with up to eight applications per season. To assess the uncertainty of the BCF in earthworms, a probabilistic approach was used, firstly by building with weighted bootstrapping techniques a generic probabilistic density function (PDF) accounting for variability and incompleteness of knowledge. The generic PDF was then used to derive prior distribution functions, which, by application of Bayes' theorem, were updated with the new measurements and a posterior distribution was finally created. CONCLUSION: The study is a good example of probabilistic risk assessment. The means of mean and SD posterior estimates of log BCFworm (2.06, 0.91) are the 'best estimate values'. Further risk assessment of quinoxyfen and other phenoxyquinoline fungicides and realistic representative scenarios for modelling exercises required for future authorization and post-authorization requirements can now use this value as input.

Corneal confocal microscopy in Darier disease.

PURPOSE: We report ocular findings in a patient with Darier disease. In particular, we discuss the in vivo confocal images. METHOD: A retrospective noninterventional case report. RESULTS: Confocal microscopy revealed collections of intercellular material, separating the cells of the patient's basal corneal epithelium. Discrete foci of this material were scattered throughout the central corneal basal epithelium in both eyes. These deposits had a similar reflectance as corneal nerves, were 3-5-microm thick, and of note in places conformed to the cell borders. CONCLUSIONS: The findings of abnormal intercellular collections at the basal epithelial layer of the cornea correlate with the previously reported histological findings. They are consistent with the abnormal keratocyte-to-keratocyte adhesions that are described both in the skin and cornea of Darier disease. The abnormalities we describe occurred in the absence of other ocular signs of Darier disease. These findings on confocal microscopy may help with the diagnosis and monitoring of disease progression.

The effect of ICG on mitomycin C cytotoxicity in human tenon fibroblasts.

PURPOSE: To examine the effects of indocyanine green (ICG) with and without mitomycin C (MMC) on proliferation of cultured human Tenon fibroblasts. METHOD: Fibroblast monolayers were exposed to either MMC [0.4 mg/mL in phosphate buffered saline (PBS)] or PBS containing ICG (0.0625%, 0.125%, 0.25%, and 0.5% in 200 microL PBS) or a combination of MMC (0.4 mg/mL in PBS) and ICG (0.25% and 0.5%) for 5 minutes. Controls were exposed for 5 minutes to MMC, PBS, or culture medium containing no ICG. After treatment, the monolayers were washed and incubated in culture medium for 24, 48, 72 hours, and 1 week periods after which the number of viable cells was quantified. RESULTS: The presence of ICG alone, at concentrations ranging from 0.0625% to 0.5%, had no effect on the rate of fibroblast proliferation measured at any of the incubation periods. As expected, MMC treatment resulted in a significant reduction in viable fibroblast number (8.4+/-0.13x10(3)). ICG in combination with MMC did not significantly alter fibroblast numbers (8.5+/-0.05x10(3)) up to 1 week compared with MMC alone (8.4+/-0.12x10(3)). CONCLUSIONS: ICG at concentrations of 0.5% and below do not reduce proliferation of Tenon capsule fibroblasts. ICG did not potentiate or diminish the effect of MMC on Tenon capsule fibroblast proliferation.

Development of a highly detailed virtual model eye.

Using a three-dimensional modeling computer program, the authors created a three-dimensional, highly detailed computer-generated model of a normal eye to enhance the teaching of basic ophthalmic anatomy. The resulting model is a uniquely detailed virtual eye that can illustrate ocular anatomy clearly but realistically at many levels of magnification. Eye anatomy can be demonstrated from any viewpoint, with a choice of which structures are visible. The generation of video animations is also possible. The potential of this model for illustration of ocular disease will be the objective of further testing with medical students.

Deposition and dissipation of chlorpyrifos in surface water following vineyard applications in northern Italy.

Chlorpyrifos is an insecticide approved globally for use on a wide range of crops. Laboratory studies indicate that chlorpyrifos is toxic to fish and aquatic invertebrates, and so the adoption of practices that reduce aquatic exposure following use should be encouraged. This study assessed the exposure of surface water to the spray-drift of chlorpyrifos and the subsequent contamination of a realistic worst-case edge-of-field ditch in a vineyard in Northern Italy. Chlorpyrifos (DURSBAN 480 EC [Dow Elanco, Indianapolis, IN, USA]) was applied according to local Good Agricultural Practice (GAP) on two vineyard plots using atomizer equipment. Drift deposition and subsequent dissipation of chlorpyrifos were then monitored in an adjacent, common ditch, with an inherent buffer zone of approximately 7 m between the treated area and the ditch. The results showed that the drift loadings under the study conditions could reach predicted levels from standard spray-drift tables. However, the measured drift was highly variable due to physical factors such as the crop canopy and the distribution of vines within the rows. The amount of chlorpyrifos deposited onto the surface of the ditch water and intercepted by paper strips was approximately 2% of the applied amount after the two applications, with a maximum concentration of approximately 0.3 microg L(-1) immediately after the first application and 0.09 microg L(-1) after the second, which then dissipated from the water column within 12 to 24 h. The results showed that drift deposition spatially was variable and that chlorpyrifos residues dissipated rapidly from this surface water body. Both aspects are considered important in order to refine the aquatic risk assessment at a higher tier for both registration and management purposes.

Evidence of macrophage and lymphocyte, but not dendritic cell, infiltration in posterior uveal melanomas, whilst cultured uveal melanomas demonstrate pluripotency by expressing CD68 and CD163.

Although variation in the level of macrophage infiltration has been reported in uveal melanoma, little is known about the expression of other leucocyte markers. An immuno- histochemistry study of the levels of expression of macrophage and other leucocyte markers, in a series of 10 primary choroidal melanoma biopsies, was undertaken. Biopsies were either fixed immediately in formalin and embedded in paraffin wax or established as short-term cultures. Using single- and double-labelling immunohistochemistry, cultured cells and paraffin sections were analysed for a range of melanoma (HMB45, Melan A, S100 and tyrosinase) and immune cell (CD68, CD163, CD45 and CD1a) markers. All samples expressed at least two known melanoma markers. Infiltrating macrophages were present in the majority of sections. When cultured specimens were studied by double-labelling immunofluorescence, uveal melanoma cells were seen to express macrophage markers or have cross-reactivity with related proteins. Expression of the leucocyte antigen CD45 was observed in three tumours but was not present in any cultured cells, whilst the expression of the dendritic cell marker CD1a was absent from all samples.

Environmental fate of spinosad. 1. Dissipation and degradation in aqueous systems.

Spinosad is a bacterially derived insect control agent consisting of two active compounds, spinosyns A and D. The objective of this paper is to describe the environmental fate of spinosad in aquatic systems. To this end, several studies performed to meet regulatory requirements are used to study the fate and degradation in individual environmental media. Specifically, investigations of abiotic (hydrolysis and photolysis) and biotic (aerobic and anaerobic aquatic) processes are described. Understanding developed from the laboratory-based studies has been tested and augmented by an outdoor microcosm study. Understanding of aquatic fate is a building block for a complete environmental safety assessment of spinosad products (Cleveland, C. B.; Mayes, M. A.; Cryer, S. A. Pest Manag. Sci. 2001, 58, 70-84). From individual investigations, the following understanding of dissipation emerges: (1) Aqueous photolysis of spinosad is rapid (observed half-lives of <1 up to 2 days in summer sunlight) and will be the primary route of degradation in aquatic systems exposed to sunlight. (2) Biotic transformations contribute to spinosad's dissipation, but less so than photolysis; they will be of primary importance only in the absence of light. (3) Spinosad partitions rapidly (within a few days) from water to organic matter and soil/sediment in aquatic systems but not so rapidly as to replace sunlight as the primary route of dissipation. (4) Abiotic hydrolysis is relatively unimportant compared to other dissipation routes, except under highly basic (artificial) conditions and even then observed half-lives are approximately 8 months. Degradation pathways are understood are follows: (1) Degradation primarily proceeds by loss of the forosamine sugar and reduction of the 13,14-bond on the macrolide ring under aqueous photolytic conditions. (2) Degradation to several other compounds occurs through biotic degradation. Degradation under anaerobic conditions primarily involves changes and substitutions in the rhamnose ring, eventually followed by complete loss of the rhamnose ring. Degradation under aerobic conditions was more extensive (to smaller compounds) with the loss of both the forosamine and rhamnose sugars to diketone spinosyn aglycon degradates. (3) Hydrolytic degradation involves loss of the forosamine sugar and water and reduction on the macrolide ring to a double bond at the 16,17-position.