Long-term visual outcomes of intravitreal ranibizumab treatment for wet age-related macular degeneration and effect on blindness rates in south-east Scotland.

AIMS: To evaluate patient visual acuity outcomes and blindness rates attributable to wet AMD with a potential 5-year follow-up from intravitreal ranibizumab treatment (IVTR) in south-east Scotland. METHODS: Data was analysed from 104 eyes of 96 patients who initiated treatment prior to September 2008. The main outcome measures were LogMAR visual acuity, number of clinic visits and the number of injections. Annual blind registration data in south-east Scotland were analysed using blind certifications recorded by the Royal National Institute of Blind People. RESULTS: Patients had a mean clinical follow-up of 4 years and 1 month and a mean loss of 5.5 letters over the study period. Of the treated eyes 9.6% gained ≥ 15 letters whilst 24.0% lost ≥ 15 letters during this period. An average of 9.56 injections were administered per patient. The age-sex standardised incidence of legal blindness attributable to wet AMD in south-east Scotland peaked at 9.1 cases per 100,000 of the population in 2006 in either eye. Following the introduction of IVTR there were annual decreases in the incidence of blindness attributable to AMD falling to a trough of 4.8 cases per 100,000 of the population in 2011. CONCLUSIONS: This study demonstrates that the majority of patients in a south-east Scotland maintain their vision following IVTR in wet AMD in the real-world setting. Our study also suggests that the introduction of IVTR has had population wide benefits in reducing the blindness attributable to wet AMD in the south-east Scotland population.

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.

Glaucoma surgery: trainee outcomes and implications for future training: southeast Scotland.

AIM: Postoperative outcome of trainee glaucoma surgery compared with glaucoma specialist consultant surgery. Survey of Scottish consultant ophthalmologists' views on trainee surgery. METHOD: Retrospective analysis of 128 trainee and 176 consultant trabeculectomies, with minimum postoperative follow-up of 2 years. Prospective postal survey of 80 Scottish consultant ophthalmologists. RESULTS: Trainees operated mainly on cases of chronic open angle glaucoma, while consultants operated on significantly more complicated glaucomas (P=0.0004). Trainee cases had more bleb leaks (P=0.01), hypotony (P=0.05), early (P=0.01) and late (P=0.03) return to theatre, and bleb interventions (P=0.01). Trainee mitomycin trabeculectomies were associated with higher rates of return to theatre (P=0.002), and cataract extraction within the first postoperative year (P=0.002). Trainee cases of pseudoexfoliation had more early complications (P=0.024), and trainee cases of low tension required more bleb interventions (P=0.05). There was no significant difference (P>0.05) between average intra-ocular pressure control (IOP) at postoperative visit year 1 between consultant (14.3 mm Hg) and trainee (13.9 mm Hg) cases. More than 50% of the 80 Scottish ophthalmology consultants surveyed, indicated that glaucoma surgery training requirements should be retained. CONCLUSIONS: Trainee trabeculectomy cases showed significantly higher rates of early complications, return to theatres, and bleb interventions compared with consultant cases. Satisfactory IOP control was achieved in both groups at postoperative year 1. Trainee cases require careful preoperative selection, avoiding complicated glaucomas including pseudoexfoliation and low tension, and those that require mitomycin. The majority of Scottish consultants wish to retain glaucoma surgery within the remit of generic training.

Haemorrhagic pigment epithelial detachment as a predictive feature of polypoidal choroidal vasculopathy in a Chinese population.

PURPOSE: To determine the frequency of haemorrhagic pigment epithelial detachment (PED) among patients presenting with either polypoidal choroidal vasculopathy (PCV) or choroidal neovascularization (CNV) and calculate the degree to which the presence of a haemorrhagic PED can be used to predict the diagnosis of PCV. METHODS: A retrospective review of 290 eyes of 253 patients presenting to the Singapore National Eye Centre with serosanguineous maculopathy. Patients underwent ophthalmologic examination including digital colour fundus photography and stereoscopic fluorescein angiography and indocyanine green angiography (ICGA). Classification into PCV or CNV was based on ICGA findings, and presence or absence of haemorrhagic PED was documented. RESULTS: In total, 138 eyes of 123 patients were diagnosed with PCV and 152 eyes of 130 patients with CNV. A haemorrhagic PED was a significantly more common (P<0.001) presenting feature in PCV eyes (63, 45.7%) than CNV eyes (6, 3.9%) (odds ratio (OR) 20.4, 95% confidence interval (CI) 8.5-49.4). Age-related maculopathy was found significantly more frequently (P<0.001) in the unaffected fellow eye of CNV patients (57, 52.8%) than PCV patients (28, 22.8%) (OR 3.2, 95% CI 1.8-5.7). CONCLUSIONS: In patients of Chinese ethnicity, a haemorrhagic PED is significantly more likely to be the presenting feature of PCV than CNV. Patients presenting with this clinical feature should make the clinician suspicious of an underlying diagnosis of PCV.

Education, socio-economic status and age-related macular degeneration in Asians: the Singapore Malay Eye Study.

BACKGROUND/AIMS: Low socio-economic status is increasingly being identified as a risk marker for chronic diseases, but few studies have investigated the link between socio-economic factors and age-related macular degeneration (AMD). The present study aimed to assess the association between socio-economic status and the prevalence of AMD. METHODS: A population-based cross-sectional study of 3280 (78.7% response rate) Malay adults aged 40-80 years residing in 15 south-western districts of Singapore. AMD was graded from retinal photographs at a central reading centre using the modified Wisconsin AMD scale. Early and late AMD signs were graded from retinal photographs following the Wisconsin grading system. Socio-economic status including education, housing type and income were determined from a detailed interview. RESULTS: Of the participants, 3265 had photographs of sufficient quality for grading of AMD. Early AMD was present in 168 (5.1%) and late AMD in 21 (0.6%). After adjusting for age, gender, smoking, hypertension, diabetes and body mass index, participants with lower educational levels were significantly more likely to have early AMD (multivariate OR 2.2, 95% CI 1.2 to 4.0). This association was stronger in persons who had never smoked (multivariate OR 3.6, 95% confidence CI 1.4 to 9.4). However, no association with housing type or income was seen. CONCLUSIONS: Low educational level is associated with a higher prevalence of early AMD signs in our Asian population, independent of age, cardiovascular risk factors and cigarette smoking.

South-East Scotland trabeculectomy survey.

AIM: Assessment of trabeculectomy in South-East Scotland (SESTS) with comparison to National Survey of Trabeculectomy (NST) and outcomes of consultant and trainee surgery. METHOD: A retrospective study of 304 consecutive, primary trabeculectomies, in two Scottish centres (Edinburgh and Dunfermline) with two glaucoma specialists and higher surgical trainees, was performed. The study group had primary open angle glaucoma (65.5%), pseudoexfoliation (6.9%), normal tension glaucoma (7.6%), pigment dispersion syndrome (1.6%), and other complicated glaucoma (18.4%). All patients underwent trabeculectomy by the glaucoma specialist (57.6%) and higher surgical trainee (42.4%) with close scrubbed supervision. RESULTS: Compared to the NST, the waiting time for surgery (<3 months) was significantly less in the SESTS (P<0.001). There was also significantly more use of intraoperative antimetabolites (P<0.01), bleb intervention (P<0.001), and a higher rate of early complications (P<0.025). There was no significant difference in outcome at intraocular pressure (IOP)<2/3 listing IOP (qualified and unqualified) between the SESTS and the NST. Significantly, more patients achieved an unqualified success of IOP<21 mmHg (P<0.01) and an unqualified success of IOP<16 mmHg in the SESTS than the NST (P<0.05). At 1 year post surgery, visual loss of greater than one Snellen line was more common in the NST (P<0.01) as was the use of anti-glaucoma medication (P<0.001). Trainee cases returned to theatre more frequently (P<0.025) and merited more bleb intervention (P<0.01) than consultant cases, but the long-term outcome was similar. CONCLUSION: Our study highlights significant changes in the practice and outcome of trabeculectomy compared to the national survey conducted a decade ago.

Isolated conjunctival lymphoma metastasis from previous low grade non-Hodgkin's lymphoma.

Ocular involvement of systemic non-Hodgkin's lymphoma is rare. This report describes the unusual occurrence of a biopsy confirmed low grade lymphoma recurring in the conjunctiva, three years after initial diagnosis of systemic disease. The tumour was surgically resected and the patient remains disease free four years later. After the diagnosis of lymphoma, long term follow up is advised as recurrences in unusual sites can occur.