Amin Kherani

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.

Long-term Outcomes For Optic Disk Pit Maculopathy After Vitrectomy

Purpose: To evaluate the efficacy of pars plana vitrectomy for congenital optic disk pit maculopathy with various adjuvant techniques, including gas tamponade, internal limiting membrane peel, and temporal optic disk endolaser in a multicenter study with long-term follow-up. Methods: A retrospective chart review was performed to identify eyes that underwent surgical repair for congenital optic disk pits and serous macular detachment with or without macular retinoschisis from four retinal centers across Canada from 2003 to 2013. Data collected included surgeries performed, preoperative and postoperative vision, central retinal thickness, and presence or absence of subretinal fluid. Optical coherence tomography was used to define anatomical success (i.e., foveal reattachment). Results: Thirty-two eyes of 32 patients with optic disk pits and serous macular detachments were identified that had undergone surgical repair. All eyes underwent pars plana vitrectomy and induction of posterior vitreous detachment if one was not present. Additional procedures performed on occasion included internal limiting membrane peel (n = 8), temporal optic disk pits endolaser (n = 7), and gas tamponade (air, C3F8 or SF6; n = 31). After vitrectomy surgery, foveal attachment was achieved in 26 of 32 eyes (81.3%). The average number of surgeries required was 1.4 ± 0.6, with a maximum of 3 vitrectomies (n = 2). Mean change in best-corrected visual acuity was −0.47 ± 0.54 logMAR units, which corresponds to approximately 5 lines of visual improvement (P < 0.001). Median time to reattachment was 416 days. Preoperative vision, preoperative symptom days, and age were not associated with postoperative reattachment. Similarly, internal limiting membrane peel and temporal endolaser were not associated with postoperative reattachment, nor was there a difference between air and SF6 and C3F8 gas tamponade. Elevated preoperative central retinal thickness was associated with a lower chance of postoperative reattachment (P = 0.007) and was also the best prognostic indicator of success (P = 0.039). Conclusion: Vitrectomy for macular detachment due to optic disk pit has good long-term success and results in an improvement in visual acuity. However, adjuvant techniques such as internal limiting membrane peel and temporal endolaser may not improve outcomes, nor does there seem to be a difference between short- and long-acting gases. Patients should be made aware that it can take more than a year and multiple surgeries to achieve foveal reattachment and that increased baseline central retinal thickness is a poor prognostic sign.

Real-world assessment of intravitreal dexamethasone implant (0.7 mg) in patients with macular edema: the CHROME study.

Background The purpose of this study was to evaluate the real-world use, efficacy, and safety of one or more dexamethasone intravitreal implant(s) 0.7 mg (DEX implant) in patients with macular edema (ME). Methods This was a retrospective cohort study of patients with ME secondary to retinal disease treated at ten Canadian retina practices, including one uveitis center. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure (IOP), glaucoma and cataract surgery, and safety data were collected from the medical charts of patients with ≥3 months of follow-up after the initial DEX implant. Results One hundred and one patient charts yielded data on 120 study eyes, including diagnoses of diabetic ME (DME) (n=34), retinal vein occlusion (RVO, n=30; branch in 19 and central in 11), and uveitis (n=23). Patients had a mean age of 60.9 years, and 73.3% of the study eyes had ME for a duration of ≥12 months prior to DEX implant injection(s). Baseline mean (± standard error) BCVA was 0.63±0.03 logMAR (20/86 Snellen equivalents) and mean CRT was 474.4±18.2 μm. The mean number of DEX implant injections was 1.7±0.1 in all study eyes; 44.2% of eyes had repeat DEX implant injections (reinjection interval 2.3–4.9 months). The greatest mean peak changes in BCVA lines of vision occurred in study eyes with uveitis (3.3±0.6, P<0.0001), followed by RVO (1.3±0.5, P<0.01) and DME (0.7±0.5, P>0.05). Significant decreases in CRT were observed: −255.6±43.6 μm for uveitis, −190.9±23.5 μm for DME, and −160.7±39.6 μm for RVO (P<0.0001 for all cohorts). IOP increases of ≥10 mmHg occurred in 20.6%, 24.1%, and 22.7% of DME, RVO, and uveitis study eyes, respectively. IOP-lowering medication was initiated in 29.4%, 16.7%, and 8.7% of DME, RVO, and uveitis study eyes, respectively. Glaucoma surgery was performed in 1.7% of all study eyes and cataract surgery in 29.8% of all phakic study eyes receiving DEX implant(s). Conclusion DEX implant(s) alone or combined with other treatments and/or procedures resulted in functional and anatomic improvements in long-standing ME associated with retinal disease.

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus.

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Acute intraocular inflammation following intravitreal injection of bevacizumab--a large cluster of cases.

attended our clinic for routine control. Visual acuity of the right eye had decreased from 20 ⁄ 20 to 25 ⁄ 30 over the last year, the left eye was 20 ⁄ 20. Funduscopy revealed moderate NPDR and retinal thickening originating from the upper vessel arcade extending into the macular region. On fluorescein angiograpy, significant exudation was present in this area. Therefore, focal macular laser photocoagulation for clinically significant macular oedema was performed on the right eye utilizing Navilas. Treatment was preplanned on the software system based on colour fundus imaging (Fig. 2A). Navigated, semi-automatic pattern laser application was conducted without complications (laser settings: spot size: 100 lm, time 100 ms, energy 80–100 mW). One week after treatment, Navilas fundus imaging and spectral-domain optical coherence tomography of the treated areas were conducted, and confirmed laser application to the preplanned area (Fig. 2B and C). A 69-year-old man with a longstanding history of type 2 diabetes and NPDR presented with a decrease of vision of his right eye. Visual acuity had decreased from 20 ⁄ 30 to 10 ⁄100 during the last month; visual acuity on the left eye was 25 ⁄ 30. Clinical examination revealed PDR with multiple areas of peripheral retinal neovascularisation and a mild vitreous haemorrhage on the right and moderate NPDR on the left eye. Panretinal full scatter photocoagulation (usually applied over 3–4 sessions at our institution) was suggested as a treatment for the right eye. However, the first treatment session using a conventional 532 -nm slitlamp-based laser and a standard contact lens (‘TransEquator’ by Volk, USA) had to be aborted after 50 laser spots. The patient did not agree to continue treatment, as he could not tolerate the contact lens and felt significant pain from retinal laser application. One week later, panretinal pattern photocoagulation using the Navilas laser device was conducted. Because of the optical design of the device, laser treatment can be applied either with or without the use of a contact lens. Although currently not recommended by the manufacturer in selected cases, such as in patients with corneal irritations or blepharospasm, it might be advantageous to not apply a contact lens. In the current case – without a contact lens – during one session, 59 times a 5 · 5-spot pattern, resulting in 1475 single laser effects, could be applied to the peripheral retina (laser settings, 5 · 5-squared laser patterns; spot size, 200 lm; time, 30 ms; energy, 220 mW; overall treatment time, 7 min 24 second). During and after treatment, the patient reported no significant pain and tolerated treatment well. One week after treatment, widefield fundus imaging of the treated areas was conducted and confirmed laser application and clearing of vitreous haemorrhage (Fig. 2D).

Bilateral progressive necrotizing retinochoroiditis in an immunocompromised patient: histopathological diagnosis

history of splenic B-cell lymphoma and Pneumocystis carinii pneumonia presented with floaters and photopsia in the right eye. The fundus exam showed a few retinal haemorrhages with vitritis (Fig. 1A and 1B). The diagnosis of cytomegalovirus (CMV) retinitis was made. The patient was treated with topical steroids, atropine, brimonidine, repeated injections of intravitreal gancyclovir and a short course of oral valganciclovir 900 mg twice daily. The patient’s right eye stabilized and vision improved to 20 ⁄25. After 1 month, he presented with similar lesions on the left eye accompanied by anterior chamber haemorrhage (Fig. 1C). The left eye received treatment similar to the right eye. Despite treatment, the disease in his left eye progressed and vision deteriorated to counting fingers. A diagnostic vitrectomy was performed in his left eye and, despite negative cultures and polymerase chain reaction (PCR) for viruses and lymphoma, the patient continued treatment for CMV retinitis based on clinical suspicion and apparent response to treatment in his right eye. He then received a higher dosage of intravitreal ganclovir (1 mg). However, there was no improvement and even perception of light was lost in his left eye. A diagnostic enucleation was performed and the specimen showed large areas or retinal necrosis and extensive inflammatory infiltrate within the choroid (Fig. 1D). A few retinal toxoplasma cysts could be seen (Fig. 1E), confirmed by immunohistochemistry (Fig. 1F). Also, eosinophilic deposits under the retinal pigment epithelium (RPE) corresponding to necrosis of Bruch’s membrane were present (Fig. 1E). Based on the histopathological findings, the diagnosis of ocular toxoplasmosis was made. Unfortunately, because of complications of his systemic disease, the patient died soon after the diagnosis was made. Ocular toxoplasmosis is caused by the protozoa Toxoplasma gondii, and can be acquired congenitally or by ingesting uncooked infected meat or contaminated vegetables and water (Silveira et al. 1988). In immunocompetent patients it usually presents as a unilateral granulomatous uveitis with retinochoroiditis and moderated to severe vitritis. Recurrences are usually observed as an active retinal lesion adjacent or near to a retinochoroidal scar. In immunocompromised patients, the presentation of toxoplasmosis can be atypical. Multiple lesions, bilaterality, retinal vasculitis, retinal vascular occlusions, retinal detachments, pigmentary retinopathy mimicking retinitis pigmentosa, neuroretinitis, optic neuropathy (Kallenbach & Frederiksen 2008) and scleritis are some of the unusual presentations (Smith & Cunningham 2002). CMV retinopathy is an opportunistic infection that usually affects immunocompromised patients. It typically presents with retinal necrosis accompanied by haemorrhage and little inflammatory response. Ocular toxoplasmosis in immunodeficient patients might present in a very similar clinical picture. Although for most patients the distinction can be made on clinical grounds, histopathology is occasionally required to distinguish between the two aetiologies. Pathological diagnosis of Diagnosis ⁄ Therapy in Ophthalmology

TUBA1A Mutation Associated With Eye Abnormalities in Addition to Brain Malformation.

OBJECTIVE We describe the case of a boy with a TUBA1A mutation presenting with microphthalmia and congenital cataracts in addition to microcephaly and severe brain malformation. METHODS A boy presented in early infancy with microphthalmia, congenital cataracts, and microcephaly. His neurological course included severe hypotonia and drug-resistant epilepsy. Magnetic resonance imaging of the brain revealed a complex malformation that included agenesis of the corpus callosum, severely hypoplastic cerebellar vermis, mildly hypoplastic and dysplastic cerebellar hemispheres, mildly hypoplastic brainstem, mild posterior simplified cerebral gyral pattern, dysplastic basal ganglia and thalami, hypoplastic optic nerves, and absent olfactory bulbs. RESULTS TUBA1A genetic testing was conducted and revealed a previously unreported heterozygous 808G>T missense mutation. Parental genetic testing was negative, indicating that the childs mutation was de novo. CONCLUSION The TUBA1A gene encodes tubulin alpha-1A, a protein with an important role in microtubule function and stability. Human mutations can result in a wide spectrum of brain malformations including lissencephaly, microlissencephaly, cerebellar hypoplasia, agenesis of the corpus callosum, pachygyria and polymicrogyria. Although TUBA1A is expressed in both developing brain and retinal tissue, there are no reported cases of TUBA1A mutations in association with major developmental ophthalmologic abnormalities.

Commercial Air Travel With a Small Intravitreous Gas Bubble

tute for Computational Biomedicine (Dr Gracia, Ms Borcherding, and Mr Banfelder), Weill Cornell Medical College, New York, New York. Correspondence: Dr Kiss, Department of Ophthalmology, Weill Cornell Medical College, 1305 York Ave, 11th Floor, New York, NY 10021 (szk7001@med.cornell .edu). Author Contributions: Mr Aaker and Dr Gracia contributed equally to this work and are considered co–first authors. Financial Disclosure: Weill Cornell Medical College, Drs Gracia and Kiss, and Mr Banfelder have intellectual property rights to some of the material presented in this article. Funding/Support: This work was supported by Research to Prevent Blindness. Role of the Sponsor: The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; and in the preparation, review, or approval of the manuscript. Previous Presentation: This paper was presented at the 27th Meeting of the Club Jules Gonin; November 4, 2010; Kyoto, Japan. Online-Only Material: The video is available at http: //www.archophthalmol.com.

Diabetic retinopathy screening

We would like to thank Greve and Tennant for their comments in the editorial accompanying our article in the December 2008 issue of the Candian Journal of Ophthalmology. Although diabetic retinopathy is a treatable eye disease, it remains a leading cause of blindness in industrialized countries. Despite efforts to educate both patients and physicians about the importance of routine diabetic screening and despite the publication of Canadian screening guidelines, a large percentage of the diabetic population continues to receive inadequate retinopathy screening. This has led to the search for strategies to better detect vision-threatening retinopathy and reduce the incidence of complications and blindness from diabetic retinopathy. Diabetic retinopathy is an important public health concern requiring targeted examinations to obtain improved vision outcomes. Although new developments in technology make comprehensive teleophthalmology possible, the best strategy for diabetic retinopathy may or may not require a comprehensive eye examination. A screening strategy specifically designed for diabetic retinopathy in a public health context may not need to provide a complete eye examination, just as screening for colon cancer does not entail a comprehensive gastrointestinal workup. Screening must be separated from diagnosis, treatment, and followup where a more sophisticated setup and technology are probably necessary. Screening for diabetic retinopathy addresses a very specific public health need and results in better awareness, education, and access to reliable screening. In addition, such a screening strategy for diabetic retinopathy is supported by international scientific literature. The screening strategy and methods used in our study are in accordance with published literature and public screening programs in other parts of the world, such as the U.K. Greve and Tennant have expressed some concern about using pharmacies as an entry point for a screening program, and suggest the use of family doctors and endocrinology offices as a more sustainable option, a strategy that has until now failed to reach diabetics efficiently. Our intent was not to dictate a single program for teleophthalmology diabetic retinopathy screening, but to demonstrate the significant health results that can be obtained when screening is provided for these patients with diabetes. The use of pharmacies as an entry point is only one possible solution to the problem of accessibility. Physicians are very effective at providing care to a captive patient population in a health care setting, but in order for a screening program to be beneficial, we need to target the population outside traditional medical settings. Different populations and regions may require different solutions, and we need to be creative in our outreach methods to maximize the general population’s exposure to timely screening. We believe that efforts to improve screening rates need to be multifaceted and that better access to rigorous, reliable, and timely screening services for diabetic retinopathy offers the best chance of preventing disease and preserving the vision of our diabetic population. We are adamant that government health authorities need to become more involved many external reviewers before it is ultimately reviewed and endorsed by the society itself. I am proud of the guidelines that the COS committee produced and am happy to praise them rather than bury them.

Lid splinting eyelid retraction technique: a minimised sterile approach for intravitreal injections

Background/aims To describe an alternative technique for avoiding contact with the lids and lashes, without the use of a lid speculum, during intravitreal anti-vascular endothelial growth factor injections. Methods Retrospective case series of all patients undergoing intravitreal injections of bevacizumab and ranibizumab, with the lid splinting retraction technique from January 2010 to December 2015. Injections performed by six vitreoretinal specialists were included. The key preinjection ocular surface preparation includes topical anaesthetic, 5% povidone-iodine and a subconjunctival injection of 2% lidocaine with epinephrine. A second instillation of 5% povidone-iodine is given and the intravitreal injection is then performed. No lid speculum is used. A search of the electronic medical records identified patients diagnosed with postinjection endophthalmitis and charts were reviewed to ensure inclusion criteria were met. The main outcome measure was incidence of postinjection endophthalmitis. Results A total of 78 009 consecutive intravitreal injections were performed, of which 22 207 were bevacizumab and 55 802 were ranibizumab. In this cohort of patients (n=6320), 12 cases of endophthalmitis developed, corresponding to a rate of 0.015%. Conclusions The technique of eyelid retraction for intravitreal injection has a low rate of endophthalmitis, similar to the reported rates using a metal lid speculum. This is beneficial for both the physician and the patient as it minimises patient discomfort as well as the duration of the procedure. To our knowledge, this is one of the largest studies performed to date evaluating intravitreal injection-related endophthalmitis.