Pushing the envelope: the feasibility of using a mailed contrast sensitivity test to prioritise cataract waiting lists.

BACKGROUND: Cataract waiting lists are growing globally. Pragmatic, cost-effective methods are required to prioritise the most urgent cases. Here we investigate the feasibility of using a third-party pen-and-paper contrast sensitivity, CS, test (SpotChecksTM), delivered by mail, and performed by patients at home unsupervised, to flag eyes requiring surgery. METHODS: Pen-and-paper CS tests were mailed to 233 people waiting for a cataract assessment, along with a prepaid return envelope (cross-sectional study). Response rates were tabulated (stratified by age, sex and socioeconomic status), and test scores analysed to see how well the home tests predicted which eyes were listed subsequently for surgery. A subset of patients (N = 39) also underwent in-person follow-up testing, to confirm the accuracy of the home data. RESULTS: Forty-six percent of patients responded (216 eyes). No gross differences were observed between respondents and non-respondents, either in terms of age, sex, socioeconomic status, or geographic location (all P > 0.05). The home-test CS scores predicted which eyes were subsequently listed for surgery, with an AUROC {±CI95%} of 0.69 {0.61-0.76}. Predictive performance was further-improved when machine learning was used to combine CS scores with letter acuity, extracted from patients' medical records (AUROC {±CI95%} = 0.77 {0.70-0.83}). Among 39 patients who underwent follow-up testing, home CS scores were correlated with various measures made in clinic: biometry signal-to-noise (P = 0.032), LogMAR acuity, Pelli-Robson CS and SpotChecks CS (all P < 0.001). CONCLUSIONS: Mailing patients pen-and-paper CS tests may be a feasible, 'low-tech' way of prioritising patients on cataract waiting lists.

Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 11, techniques and complications of local anesthesia for cataract surgery in the United Kingdom.

PURPOSE: To describe variation in local anesthesia techniques and complications over a 10-year period for cataract surgery in the United Kingdom. SETTING: Reporting centers to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD). DESIGN: Retrospective cross-sectional register-based study. METHODS: Data from the RCOphth NOD were used. Eligible for analysis were 1 195 882 cataract operations performed using local anesthesia between April 1, 2010, and March 31, 2020, in 80 centers. RESULTS: Overall, topical anesthesia alone was used in 152 321 operations (12.7%), combined topical and intracameral in 522 849 (43.7%), sub-Tenon in 461 175 (38.6%), and peribulbar/retrobulbar in 59 537 (5.0%). In National Health Service (NHS) institutions, 48.3% of operations were topical with/without intracameral vs 88.7% in independent sector treatment centers (ISTCs). 45.9% were sub-Tenon in NHS vs 9.6% in ISTCs. 5.8% were peribulbar/retrobulbar in NHS vs 1.7% in ISTCs. Anesthetic complication rates decreased from 2.7% in the 2010 NHS year to 1.5% in the 2019 NHS year (overall, 2.1% for NHS; 0.2% for ISTCs). Overall anesthetic complication rates were 0.3%, 0.3%, 3.5%, and 3.1% for topical alone, combined topical/intracameral, sub-Tenon, and peribulbar/retrobulbar, respectively. Complication rates were higher for sharp-needle anesthesia (peribulbar/retrobulbar) in patients taking warfarin rather than direct oral anticoagulants (4.8% vs 3.1%; P = .024). Considerable variation was observed between centers on anesthetic choices and anesthetic complication rates. CONCLUSIONS: Combined topical and intracameral is the most common choice of anesthesia for cataract surgery in the United Kingdom and is associated with lower anesthetic-related complication rates than sub-Tenon and peribulbar/retrobulbar anesthesia. Variation in the anesthetic choice exists between centers and between NHS and ISTC sectors.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of Cataract Surgery: Report 12, Risk factors for suprachoroidal haemorrhage during cataract surgery.

OBJECTIVE: To establish the incidence of acute intraoperative suprachoroidal haemorrhage (AISH) during cataract surgery and identify the risk factors for this complication. METHODS: Data from the Royal College of Ophthalmologists' National Ophthalmology Database was analysed. During the 11-year study period, from 01/04/2010 to 31/03/2021, 709 083 operations performed on 498 170 patients from 65 centres were eligible for inclusion. RESULTS: AISH occurred in 0.03% (204/709 083, approximately 1 in 3 500) of eligible cataract operations performed during the study period. Posterior capsule rupture was the risk factor most strongly associated with AISH (OR: 17.6, 95% CI: 12.4-24.9, p < 0.001). Other ocular risk factors identified were raised intraocular pressure (IOP) preoperatively (OR: 3.7, 95% CI: 2.5-5.5, p < 0.001), glaucoma (OR: 1.7, 95% CI: 1.2-2.4, p = 0.004). Risk increased with age and patients aged over 90 years were at greatest risk (OR: 6.7, 95% CI: 3.5-12.8, p < 0.001). The addition of intracameral anaesthetic when performing surgery under topical anaesthetic appears to be protective (OR: 0.5, 95% CI: 0.3-0.8, p = 0.003), compared to topical anaesthetic alone. There was a 16-fold increase in the incidence of vision loss when AISH occurred. CONCLUSIONS: The risk of AISH during modern cataract surgery is approximately 1 in 3 500 and is associated with a significant increase in the risk of vision loss should it occur. Posterior capsule rupture is the risk factor most strongly associated with AISH. Preoperative IOP control is a modifiable risk factor. The use of intracameral anaesthesia may reduce the risk of AISH.

Systematic Literature Review of Clinical, Economic, and Humanistic Outcomes Following Minimally Invasive Glaucoma Surgery or Selective Laser Trabeculoplasty for the Treatment of Open-Angle Glaucoma with or Without Cataract Extraction.

Introduction: Selective laser trabeculoplasty (SLT) and minimally invasive glaucoma surgery (MIGS) are increasingly used options for mild-to-moderate open-angle glaucoma (OAG) care. While most MIGS devices are indicated for use in combination with cataract surgery only, with phacoemulsification playing a role in lowering IOP, newer technologies can also be used as standalone glaucoma surgery. Methods: This systematic literature review (SLR) aimed to assess the clinical, economic, and humanistic outcomes of MIGS and SLT for the treatment of OAG and was conducted according to PRISMA guidelines. Studies that assessed MIGS or SLT in at least one treatment arm versus any other glaucoma treatment in adults with mild-to-moderate OAG were included. Clinical, humanistic (health-related quality of life [HRQoL] and patient burden), and economic data were extracted, and the methodological quality of included studies was evaluated. Results: A total of 2720 articles were screened, and 81 publications were included. Fifty-eight reported clinical outcomes. The majority assessed iStent or iStent inject (n=41), followed by OMNI (n=9), gonioscopy-assisted transluminal trabeculotomy (GATT) or the Kahook Dual Blade (KDB) (n=7), Hydrus (n=6), SLT (n=5), Xen Gel Stent (n=2), PreserFlo (n=1), and iTrack (n=1). IOP reduction was observed across prospective studies, varying from -31% to -13.7% at month 6 and from -39% to -11.4% at year 1 versus baseline. Most adverse events were transient and non-serious. Limited humanistic and economic data were identified. Conclusion: Given their established efficacy and safety, there is a rationale for wider use of MIGS in mild-to-moderate OAG. Of the MIGS devices, iStent and OMNI have the largest clinical evidence base supporting their sustained effectiveness.

Using an open-source tablet perimeter (Eyecatcher) as a rapid triage measure for glaucoma clinic waiting areas.

BACKGROUND: Glaucoma services are under unprecedented strain. The UK Healthcare Safety Investigation Branch recently called for new ways to identify glaucoma patients most at risk of developing sight loss, and of filtering-out false-positive referrals. Here, we evaluate the feasibility of one such technology, Eyecatcher: a free, tablet-based 'triage' perimeter, designed to be used unsupervised in clinic waiting areas. Eyecatcher does not require a button or headrest: patients are simply required to look at fixed-luminance dots as they appear. METHODS: Seventy-seven people were tested twice using Eyecatcher (one eye only) while waiting for a routine appointment in a UK glaucoma clinic. The sample included individuals with an established diagnosis of glaucoma, and false-positive new referrals (no visual field or optic nerve abnormalities). No attempts were made to control the testing environment. Patients wore their own glasses and received minimal task instruction. RESULTS: Eyecatcher was fast (median: 2.5 min), produced results in good agreement with standard automated perimetry (SAP), and was rated as more enjoyable, less tiring and easier to perform than SAP (all p<0.001). It exhibited good separation (area under receiver operating characteristic=0.97) between eyes with advanced field loss (mean deviation (MD) < -6 dB) and those within normal limits (MD > -2 dB). And it was able to flag two thirds of false-positive referrals as functionally normal. However, eight people (10%) failed to complete the test twice, and reasons for this limitation are discussed. CONCLUSIONS: Tablet-based eye-movement perimetry could potentially provide a pragmatic way of triaging busy glaucoma clinics (ie, flagging high-risk patients and possible false-positive referrals).

Recommendations for the management of elevated intraocular pressure due to bleb fibrosis after XEN gel stent implantation.

Surgical management of glaucoma offers a means of effective disease control. A gel stent that facilitates drainage to the subconjunctival space offers intraocular pressure (IOP) reduction similar to traditional glaucoma filtering surgeries in a less invasive manner. However, like all subconjunctival filtering procedures that result in a bleb, fibrosis can present as a cause of elevated IOP. The following proposed techniques and recommendations for managing elevated IOP due to bleb fibrosis after gel stent implantation are based on the clinical experience of the authors. The goal of this paper is to improve outcomes following gel stent surgery by providing guidance on assessment of bleb function and strategies for bleb enhancement.

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.

Ocular Features of Cerebro-Costo-Mandibular Syndrome.

Cerebro-costo-mandibular syndrome (CCMS) is a rare hereditary disorder characterized by micrognathia, posterior rib gaps, and secondary developmental delay. Patients often require ventilation and feeding support throughout life. We describe the first reported ophthalmic findings of CCMS and propose that defects in choroidal permeability lead to chronic macular edema and refractory aqueous misdirection syndrome. Here we discuss the medical and surgical management concerns of recurrent angle closure and raised intraocular pressure in a CCMS patient.

Glaucoma Surgery in Scleromalacia: Using Endoscopic Cyclophotocoagulation where Conventional Filtration Surgery or Angle Procedures are contraindicated.

AIM: To describe the surgical management of glaucoma in a patient with severe scleromalacia, and secondary angle closure. INTRODUCTION: The management of glaucoma with coexisting scleromalacia plus secondary angle closure is challenging as most commonly performed incisional glaucoma surgery as well as minimally invasive glaucoma surgery (MIGS), which targets the drainage angle are all contraindicated. CASE REPORT: Medically refractory glaucoma in a 60-year-old male with a 30-year history of granulomatosis with polyangiitis resulting in extensive severe scleromalacia, cicatricial lower lid retraction with significant conjunctival exposure, and widespread synechial angle closure from chronic anterior uveitis was managed with combined phacoemulsification cataract surgery, and endoscopic cyclophotocoagulation (ECP). Careful postoperative management with intensive immunosuppression was used to successfully prevent complications related to the surgery, which resulted in improved visual acuity, and control of intraocular pressure (IOP). CONCLUSION: The ECP is a minimally invasive procedure that targets inflow of aqueous, and can be safely and successfully used to control IOP in challenging patients with complex secondary glaucoma, where the use of traditional incisional surgery, and other MIGS procedures are all contraindicated. CLINICAL SIGNIFICANCE: The choice of surgical treatment for medically refractory glaucoma needs to be selected based on the circumstances of individual patients, and take into consideration the condition of the sclera, conjunctiva and drainage angle, against the safety and efficacy of possible treatments. HOW TO CITE THIS ARTICLE: Rodrigues IAS, Lindfield D, Stanford MR, Goyal S. Glaucoma Surgery in Scleromalacia: Using Endoscopic Cyclophotocoagulation where Conventional Filtration Surgery or Angle Procedures are contraindicated. J Curr Glaucoma Pract 2017;11(2):73-75.

The "Pull-Through" Suture; Facilitating Watertight Anterior Chamber Entry and Minimizing Early Hypotony in Glaucoma Tube Surgery.

Tube procedures are increasing world wide. One failing of all tube procedures is early hypotony; most commonly attributable to entry site leak as ligature and stent sutures become standard surgical practice. The tube versus trabeculectomy and primary tube versus trabeculectomy study protocols employ 21 G anterior chamber entry; however, entry site leaks can still occur often requiring suturing. Twenty-three-gauge entry produces a reliably watertight seal but can be technically challenging. The "Pull-Through" suture facilitates efficient and reproducible tube insertion while avoiding entry site trauma.

Teaching referral skills to medical students.

BACKGROUND: Referrals are an important and frequent part of a junior doctor's work. Difficulty with making successful referrals is also very common. Despite this, training in referral skills is not routinely carried out in medical schools. RESULTS: We designed and delivered a 1-h interactive lecture to final year medical students to teach referral skills. The lecture was delivered on six occasions to up to 70 students at each session. 191 students attended and provided evaluation. 68% of students had no previous training in referral skills and 99% felt that referral skills should be included in the undergraduate curriculum. 90% reported that the lecture had improved their understanding of referral techniques and 83 and 80% felt that the lecture had improved their ability and confidence, respectively. CONCLUSIONS: Referral skills can be successfully taught in a large group lecture setting. We recommend that the teaching of referral skills is incorporated into all medical schools' curricula.

Dexamethasone implants in retinal vein occlusion: 12-month clinical effectiveness using repeat injections as-needed.

OBJECTIVE: To report the 12-month outcomes of the dexamethasone intravitreal implant in retinal vein occlusion (RVO), using an as-needed repeat injection protocol. DESIGN: Retrospective consecutive case series of 51 eyes of 49 patients with macular oedema as a result of RVO that received an intravitreal dexamethasone implant and were followed up for at least 12 months. RESULTS: 70% of patients responded to dexamethasone implant injection with an improvement in visual acuity (VA) and macular oedema within 3 months of injection, but only 30% of eyes gained ≥15 letters. The mean change in VA letter score at 12 months compared with baseline for branch RVO (BRVO) and central RVO (CRVO) was 5.7±2.3 and 11.5±11.0 EDTRS letters, respectively. 56% of patients relapsed, with the median time to relapse being 17 weeks for patients with branch RVO and 18 weeks for patients with CRVO. Repeat injections achieved similar VA gains, but the duration of effect of repeat dexamethasone implants was much shorter at 10 weeks. 14 eyes (27%) developed a significant rise in intraocular pressure, and three of these required treatment with oral acetazolamide. Four eyes with CRVO developed neovascular glaucoma during the study. CONCLUSIONS: The intravitreal dexamethasone implant does not last the 6 months implied by the retreatment protocol in the GENEVA trial, and improved results can be achieved with an as-needed retreatment protocol, particularly in CRVO. However, visual outcomes remain similar to those previously seen with triamcinolone in the SCORE study and neovascular complications remain a feature of CRVO.

'Phaco-ECP': combined endoscopic cyclophotocoagulation and cataract surgery to augment medical control of glaucoma.

OBJECTIVES: Does phaco-ECP reduce intraocular pressure? Is phaco-ECP safe? DESIGN: Retrospective case note review of all patients undergoing phaco-ECP between June 2008 and June 2009. All glaucoma subtypes were included. SETTING: Single District General Hospital Ophthalmology Department within the UK. PARTICIPANTS: 58 participants case notes reviewed. Mean age 79.0 years (SD ±9.8). INTERVENTIONS: All patients received combined cataract surgery and endoscopic cyclophotocoagulation. OUTCOME MEASURES: Follow-up was 1 day, 1 week, 1, 3, 6, 12, 18 and 24 months for intraocular pressure (IOP) measurement. Number of medications, visual acuity and presence of complications were also assessed. RESULTS: Of the 58 cases performed, 56 case notes (97%) were available for analysis. Mean age 79.0 years (SD ±9.8). Mean pre-procedural IOP was 21.54 mm Hg (95% CI 19.86 to 23.22, n=56). Mean IOP was 14.43 mm Hg (95% CI 13.65 to 15.21, n=53) at 18 months and 14.44 mm Hg (95% CI 13.63 to 15.25, n=41) at 24 months. The mean drop from baseline to 18 and 24 months was 7.1 mm Hg. Statistically significant decrease in IOP was demonstrated at all time points (p<0.001). Mean medication usage was 1.97 agents (95% CI 1.69 to 2.25) at baseline, 1.96 agents (95% CI 1.70 to 2.22) at 18 months and 2.07 agents (95% CI 1.76 to 2.38) at 24 months. No statistically significant change throughout. CONCLUSIONS: This study confirms the safety of phaco-ECP. In this case series, the IOP-lowering effect was significant at all time points; however, the effect of cataract surgery alone was not controlled. A randomised controlled trial is required to draw efficacy conclusions. The authors proposed endoscopic cyclophotocoagulation's main role is to optimise control of low-risk glaucoma of low-risk patients at the time of cataract surgery. However, the authors do not propose that phaco-ECP is a substitute for filtration surgery in high-risk eyes or when low target pressures (<14 mm Hg) are indicated.