Real-world experience of using stereotactic radiotherapy combined with anti-vascular endothelial growth factor to treat neovascular AMD.

INTRODUCTION: Adjunctive treatment or longer-acting drugs are required to treat nAMD to help ease burdens for patients and hospital clinics alike. Stereotactic therapy is one such option, providing a reduction in the number of injections over time. OBJECTIVE: To determine the clinical outcomes in a cohort of patients with nAMD receiving a combination therapy of stereotactic radiotherapy (SRT) with intravitreal anti-VEGF injections (IVI). METHOD: A retrospective analysis of 74 patients with nAMD, who had received IVI and SRT (16 Gray maximum dose to the macula) at a large tertiary university eye hospital, between March 2018 and September 2019 was performed. The number of IVIs, visual acuity (VA), and central retinal thickness (CRT) were evaluated at 12, 24, and 36 months after patients received SRT and compared to the same time interval prior to SRT. RESULTS: Follow-up data at 12, 24, and 36 months following and prior to SRT was available for 74, 48, and 22 patients respectively. Overall there was a significant reduction in the number of injections post-SRT. Twelve months following SRT, the median number of IVI was reduced by 1 (p < 0.05). The reduction in the median number of IVI was significantly reduced by 3 and 6 injections at 24- and 36-month follow-up respectively (p < 0.05). The CRT was significantly reduced post-SRT compared to the baseline values at all time periods. There was no statistically significant difference in VA at 12-month follow-up compared to baseline. The VA, however, significantly decreased at 24- and 36-month follow-up (p < 0.05). CONCLUSION: A therapy combining SRT with IVI has shown an overall reduction in the number of injections required in nAMD patients at 12, 24, and 36 months following SRT compared to IVI treatment alone. These real-world outcomes are comparable to other studies while also confirming the maintenance of the reduced frequency of required IVI for patients with nAMD.

Scope of practice of optometrists working in the UK Hospital Eye Service: Second national survey.

PURPOSE: As the landscape in ophthalmology and related commissioning continues to change, there is a pressing need to re-evaluate the current scope of practice of hospital optometrists working within secondary care in the UK. We aim to establish if the skills or services delivered by optometrists have changed to meet varying demands, and to better understand what changes in practice may have arisen as a result of COVID-19. METHOD: A survey developed from that used in 2015 was disseminated to 129 optometry Hospital Eye Service (HES) leads in September 2020, including questions on department workforce; core services; extended roles; procedures undertaken within extended roles; level of autonomy; arrangements for prescribing; training and accreditation, and service changes in response to COVID-19. RESULTS: Ninety responses were received (70% response rate) from within England (76%), Scotland (22%) and Northern Ireland (2%). Whole time equivalents within units ranged from 0.4-79.2 (median of 2.5). In comparison to the 2015 survey, there was an increase in the proportion of units delivering extended roles, with glaucoma (88%) remaining the most common extended role, and new areas of practice in uveitis (21%) and vitreoretinal (13%) services. There was increased use of independent prescribing (67%) in comparison to 18% in 2015 and there was an increase in optometrists delivering laser interventions. In response to COVID-19, optometrists were increasingly delivering telephone consultations and there were new collaborations between primary and secondary care. CONCLUSIONS: Optometrists' scope of practice continues to develop in the HES with an increased variety of roles and an apparent increase in the number of units employing optometrists, often working in roles historically performed by medical practitioners. Such changes appear necessary in recovery and transformation within ophthalmology, alongside wider optometry changes arising at the interface of primary and secondary care.

Treatment decisions of UK hospital optometrists and ophthalmologists in patients with nAMD: a vignette study.

PURPOSE: A vignette study to examine treatment decisions made by UK hospital optometrists in patients with neovascular age-related macular degeneration (nAMD) and the effect of optometrists' experience on agreement. METHODS: Patients with nAMD attending Manchester Royal Eye Hospital, Manchester, UK were identified as potential candidates for the case series of vignettes. The cases were chosen to reflect a varied case-mix with respect to difficulty as well as ensuring good quality of the images. Each vignette included a history summary consisting of the number of previous injections given and visual acuity measurements at baseline, the previous visit, and the current visit. Images were compiled to show baseline fundus photographs and ocular coherence tomography (OCT) images with the current visit images on which the treatment decision was to be made along with the images from the previous visit. Hospital optometrists were recruited and asked to complete the series of vignettes, deciding if treatment was required at that visit and how confident they felt with that decision. Their responses were compared to the reference standard created by a consensus of consultant ophthalmologists with a sub-speciality interest in medical retina. RESULTS: Regarding treatment decision for optometrists, the percentage correct value was 75% with the sensitivity being 75.6% (95% CI 70.1-80.3) and the specificity as 75.1% (95% CI 72.1-77.8). No statistically significant difference was found between differing levels of experience. However, there was a significant difference in confidence levels between groups. Potentially sight threatening decisions accounted for 6.4% of the optometrists' decisions, 3.5% were made with a high confidence rating suggesting no discussion with an ophthalmologist was required. CONCLUSIONS: Although the optometrists showed modest agreement with the reference standard in a series of cases that have higher than average complexity, the optometrists showed a similar amount of variability within their treatment decisions compared to the reference standard. The optometrists were therefore not inferior in their performance compared to the ophthalmologists and this can be seen as supporting evidence for their extended role within this clinical area. Experience did not have an effect on 'correct' treatment decisions although there was a statistically significant effect on increasing confidence of treatment decision.

Scope of practice of optometrists working in the UK Hospital Eye Service: a national survey.

PURPOSE: The role of the optometrist in the Hospital Eye Service (HES) has undergone significant development in recent years to include extended areas of clinical practice more traditionally undertaken by ophthalmologists, commensurate with a growing demand for increased capacity in ophthalmic services. In this report, we present the findings from a national survey of the scope of practice of optometrists working in the UK HES. METHODS: A survey was designed to incorporate questions on the provision of core services before seeking detailed information on the scope of practice within extended roles to include: ophthalmic sub-specialist areas where optometrists currently practice; the undertaking of specific procedures within these services; the relative autonomy of practice within these extended roles; and the training and accreditation requirements for working within extended roles. SurveyMonkey was used to disseminate the survey to the head of optometry in 79 HES units throughout the UK. RESULTS: Responses were received from 70 of the 79 (89%) survey invitations. A substantial majority of respondents (N = 67/70, 96%) indicated that optometrists undertook extended roles. Glaucoma is the leading extended role service provided by optometrists (92% of respondents providing extended role services), with roles in macula (71%), medical retina/diabetes (67%), cataract (55%) and corneal services (55%) also being relatively common. A wide variety of clinical procedures or interventions are undertaken as part of these services, which for a small number of optometrists now also includes the undertaking of specific laser procedures. There is evidence for a significant degree of autonomy within these extended roles. The primary mode of training is an 'apprentice' model, incorporating sessions worked under supervision in ophthalmology clinics. Methods of accreditation for optometric participation in extended role services are varied. CONCLUSIONS: While optometrists working within the UK HES continue to undertake the traditional clinical roles of refraction, clinically necessary contact lenses, and low vision rehabilitation, it is clear that these professionals now undertake a wide range of extended clinical roles, with a transformed scope of practice now incorporating diverse roles traditionally undertaken by medical practitioners.

An international collaborative family-based whole-genome linkage scan for high-grade myopia.

PURPOSE: Several nonsyndromic high-grade myopia loci have been mapped primarily by microsatellite markers and a limited number of pedigrees. In this study, whole-genome linkage scans were performed for high-grade myopia, using single nucleotide polymorphisms (SNPs) in 254 families from five independent sites. METHODS: Genomic DNA samples from 1411 subjects were genotyped (Linkage Panel IVb; Illumina, San Diego, CA). Linkage analyses were performed on 1201 samples from 10 Asian, 12 African-American, and 221 Caucasian families, screening for 5744 SNPs after quality-control exclusions. Two disease states defined by sphere (SPH) and spherical equivalence (SE; sphere+cylinder/2) were analyzed. Parametric and nonparametric two-point and multipoint linkage analyses were performed using the FASTLINK, HOMOG, and MERLIN programs. Multiple stratified datasets were examined, including overall, center-specific, and race-specific. Linkage regions were declared suggestive if they had a peak LOD score >or= 1.5. RESULTS: The MYP1, MYP3, MYP6, MYP11, MYP12, and MYP14 loci were replicated. The novel region q34.11 on chromosome 9 (max NPL= 2.07 at rs913275) was identified. Chromosome 12, region q21.2-24.12 (36.59 cM, MYP3 locus) showed significant linkage (peak HLOD = 3.48) at rs337663 in the overall dataset by SPH and was detected by the Duke, Asian, and Caucasian subsets as well. Potential shared interval was race dependent-a 9.4-cM region (rs163016-rs1520724) driven by the Asian subset and a 13.43-cM region (rs163016-rs1520724) driven by the Caucasian subset. CONCLUSIONS: The present study is the largest linkage scan to date for familial high-grade myopia. The outcomes will facilitate the identification of genes implicated in myopic refractive error development and ocular growth.

Myocilin polymorphisms and high myopia in subjects of European origin.

PURPOSE: Three previous studies have tested for an association between high myopia and polymorphisms in the open angle glaucoma gene, myocilin (MYOC), all in subjects of Chinese ethnicity. In two of the studies, a significant association was found while in the third, there was no association. We sought to investigate the association between high myopia and polymorphisms in MYOC in subjects of European ethnicity. METHODS: Subjects were recruited from two sites, Cardiff University in the UK and Duke University in the United States. The Cardiff University cohort was comprised of 164 families with high myopia (604 subjects) plus 112 unrelated, highly myopic cases and 114 emmetropic controls. The Duke University cohort was comprised of 87 families with high myopia (362 subjects) plus 59 unrelated, highly myopic cases. Subject DNA was genotyped with a panel of MYOC single nucleotide polymorphisms (SNPs) including those found previously associated with high myopia. The Cardiff cohort was also genotyped for two flanking microsatellite markers analyzed in prior studies. Association between high myopia and MYOC polymorphisms was assessed using the Unphased program. RESULTS: Since there was no evidence of heterogeneity in genotype frequencies between families and singleton samples or between cohorts, both subject groups (families and unrelated subjects) from both recruitment sites were analyzed jointly for those SNPs genotyped in common. Two variants showed significant association before correction for multiple testing. These two variants were rs16864720 (p=0.043) and NGA17 (p=0.026). However, there was no significant association after Bonferroni correction. The estimated relative risk (RR) conferred by each of the MYOC variants was low (RR<1.5). CONCLUSIONS: Our results suggest that MYOC polymorphisms have a very low, or possibly negligible, influence on high myopia susceptibility in subjects of European ethnicity.

Postnatal refractive development in the Brown Norway rat: limitations of standard refractive and ocular component dimension measurement techniques.

PURPOSE: The genetic tractability of the rat and its larger eye size as compared to the mouse make it an attractive model for studies of ocular development and emmetropisation. This study aimed to provide normative data in the strain of rat being used for the rat genome sequencing project whilst also evaluating standard measurement techniques. METHODS: Ocular refraction (retinoscopy, Hartinger coincidence optometry) and ocular component dimensions (keratometry, A-scan ultrasonography, calliper measures, eye weight) were measured at intervals from eye-opening to adulthood. RESULTS: There was no convincing evidence of visually guided emmetropisation during normal development. Key measurement techniques such as high-resolution A-scan ultrasonography, which work effectively in several other animal species, were unusable or inaccurate in the rat. CONCLUSIONS: This study found no evidence of emmetropisation during normal development in rat. As in mice, technical difficulties prevent accurate measurement of ocular refraction and vitreous chamber depth and may complicate tests of emmetropisation to imposed blur.