Andrei-Alexandru Szigiato

Trends in glaucoma surgical procedures in Ontario: 1992-2012.

OBJECTIVE To analyze trends in the surgical management of glaucoma in Ontario over the past 2 decades. DESIGN Retrospective analysis of health records. METHODS Ontario Health Insurance Plan billing service claims between 1992 and 2012 were analyzed for the yearly number of glaucoma laser and incisional surgical procedures. The yearly number of Ontarians with primary open-angle glaucoma (POAG) was estimated by applying composite prevalence curves to published population data and the yearly number of procedures per 1000 Ontarians with POAG was calculated. RESULTS Per 1000 people with POAG, laser trabeculoplasty (LT) rates increased nearly 2-fold (185%) from 1992 to 2012, with the rates stabilizing between 2008 and 2012, and total glaucoma filtration procedure (GFP) rates (trabeculectomy, aqueous shunts, and combined GFP and cataract extraction) in 2012 were similar to those in 1992, with a peak rate noted in 1996. Shunts represented 0.9% of GFP in 1992 and 33% in 2012. Data for combination codes billed on the same day for the same patient were available from 2000. From 2000 to 2012 the rates of trabeculectomy alone remained unchanged, the number of aqueous shunts alone increased more than 5-fold, combined trabeculectomy and cataract extraction decreased 81%, whereas combined shunts and cataract extraction increased from 6 in 2000 to 420 in 2012. Combined aqueous shunts and cataract extraction represented 0.4% of combined cataract extractions in 2000 and 26.3% in 2012. CONCLUSIONS Over the past 2 decades there was an overall increase in the rate of LT, no change in the rate of trabeculectomies, and a significant increase in aqueous shunt surgery.

INDUCTION OF MACULAR DETACHMENT FOR THE TREATMENT OF PERSISTENT OR RECURRENT IDIOPATHIC MACULAR HOLES.

Purpose: To analyze the efficacy of induced macular detachment for the treatment of persistent or recurrent idiopathic macular holes after treatment with one or more standard pars plana vitrectomies (PPVs) with internal limiting membrane peeling. Methods: This study is a retrospective consecutive case series of 10 patients who underwent a PPV with subretinal balanced salt solution injection from 2011 to 2014 to treat persistent or recurrent idiopathic macular holes. All patients had previously undergone PPV with internal limiting membrane peeling. Visual acuity, ocular examination findings, and optical coherence tomographic images were reviewed preoperatively and postoperatively to assess the anatomical and visual outcomes of this procedure. Results: Nine of the 10 patients who underwent the procedure had closure of their macular holes postoperatively (90%) and remained closed 6 months postoperatively. Most patients reported a subjective visual improvement. A mean objective visual improvement of 16 letters (Early Treatment Diabetic Retinopathy Study, 0.324 logMAR) was seen between preoperative and 6-month postoperative assessments of all patients (pre = 1.490, post = 1.166; P = 0.022). Subgroup analysis of patients with successful closure revealed 20 letters of improvement (0.398 logMAR) in visual acuity (pre = 1.491, post = 1.093; P = 0.004). There were no intraoperative or postoperative complications. Conclusion: In eyes with persistent or recurrent idiopathic macular holes after standard PPV with internal limiting membrane peeling, repeat PPV with subretinal balanced salt solution injection to create a macular detachment may be a viable surgical treatment option. Our results show improved anatomical and visual outcomes postoperatively that compare favorably to other case series describing various surgical treatments for these challenging cases.

Same-Day Bilateral Glaucoma Laser Treatments in Ontario: 2000 to 2013.

Objective:To analyze trends in bilateral, same-day laser iridotomies, and trabeculoplasties in Ontario over the last decade. Methods:Ontario Health Insurance Plan billing service claims between 2000 and 2013 were analyzed for the yearly number of glaucoma laser procedures. The annual number of Ontarians with primary open-angle glaucoma (POAG) was estimated by applying composite prevalence curves to published population data and the yearly number of procedures per 1000 Ontarians with POAG was calculated. Results:The volume of same-day bilateral trabeculoplasties increased from 15.3 per 1000 with POAG in 2000 to 74.7 in 2013 (4.9-fold). The proportion that were same-day bilateral procedures increased from 22.7% in 2000 to 40.2% in 2004 (76.9% increase) and remained stable from 2009 to 2013, reaching 38.5% in 2013. The number of same-day bilateral laser iridotomies increased from 3126 in 2000 to 11,716 in 2013 (3.75-fold). The proportion of iridotomies that were bilateral increased from 39% in 2000 to 54.6% in 2006 (40% increase) and remained stable from 2006 to 2013, reaching 56.7% in 2013. Conclusions:The increase in same-day bilateral trabeculoplasties coincided with the introduction of selective laser trabeculoplasty. The proportion of this practice remained constant for the last 3 years of the study period. In 2013, 56.7% of iridotomies and 38.5% of trabeculoplasties were performed as same-day bilateral procedures. We recommend comparison studies between same-day and sequential laser therapies to assess complication rates and patient satisfaction to provide an evidence-based treatment approach, as there are limited data to support this practice.

Wait times and volume of cataract surgery in Ontario: 2000—2012

OBJECTIVE To review cataract surgery trends and wait times in Ontario. DESIGN Retrospective analysis of health records. METHODS Ontario Health Insurance Plan billing service claims between 2000 and 2012 were analyzed for the yearly number of cataract surgeries, alone and in combination with other procedures. The number of Ontarians with cataracts was estimated by applying composite prevalence curves derived from published population data. This was then used to calculate the yearly number of procedures per 1000 Ontarians with cataracts. RESULTS Per 1000 people with cataract, the rate of cataract extraction increased 18.9% overall from 2000 to 2012, increasing by 38.3% from 2000 to 2006 and decreasing by 14.6% from 2006 to 2012. Mean wait times for cataract surgery decreased by 45.8% from 2006 to 2009 and increased 28.5% from 2009 to 2013. The proportion of surgeries that were same-day bilateral cataract extraction increased 2.21-fold from 2000 to 2012 but represented only 0.82% of total cataract surgeries in 2012. In 2000, 3% of cataract surgeries were combined with other procedures, and this decreased to 1.8% in 2012. Of these combinations, the rates of combined glaucoma filtration procedures decreased by 44.3%, anterior vitrectomy decreased by 32.5%, posterior vitrectomy increased by 58.3%, and corneal transplantation decreased by 10.7% during this time period. CONCLUSIONS The yearly rate of cataract surgery has decreased since 2006, and wait times have increased from 2009. Same-day bilateral cataract extraction represented less than 1% of the total cataract surgical volume. Rates of cataract combined with posterior vitrectomy have increased (58%), whereas anterior vitrectomy at the time of cataract surgery decreased (33%).

Trends in pediatric strabismus surgery in the new millennium: influence of funding and perceived benefits of surgery

OBJECTIVE The rate of strabismus surgery was previously reported to be decreasing in the United Kingdom and Ontario. Data on the influence of government funding on surgical trends and recent population trends for surgery in pediatric patients in Canada are limited. This study aims to analyze the trend in pediatric strabismus procedures in Ontario from 2000 to 2013. DESIGN A population based, retrospective data analysis. METHODS An analysis of the yearly volume of strabismus procedures in the pediatric population of Ontario was performed, subdivided by number of muscles repaired and repeat procedures. The number of ophthalmologists performing strabismus surgery on the pediatric population was analyzed, subdivided by high- and low-volume surgeons and career stage. RESULTS From 2000 to 2013, per 100,000 pediatric population, the number of total strabismus surgeries in Ontario increased 38.1%; rates of single-muscle surgery increased 12.8%, 2-muscle surgery increased 24.2%, and surgery of ≥3 muscles increased 135.4%. Repeat procedures increased 263.1% from 2000 to 2013 and represented 28.5% of all surgeries in 2013.The number of high-volume surgeons increased 33.3%, whereas low-volume surgeons decreased 61.4% during the same time span. CONCLUSION The number of pediatric strabismus procedures in Ontario has increased since 2000, and the practice has become increasingly subspecialized. This is likely due to changes in health care funding and increased parental and physician awareness of the functional and psychosocial benefits of strabismus surgery.

Sustained drug delivery for the management of glaucoma

ABSTRACT Introduction: New modalities for providing sustained drug delivery in glaucoma continue to be developed and aim to improve on the limitations inherent to topical eye drops. This article provides an update on recently published studies and clinical trials of topical, injectable, and other targeted drug delivery systems used to manage glaucoma and bleb fibrosis. Areas covered: Published peer-reviewed articles on sustained drug delivery in glaucoma from 2014 to present day were searched in PubMed and MEDLINE. Devices reviewed included punctal plugs, inserts, sustained release films, implants, and injectable sustained release formulations. We provide an overview of the areas that can be targeted for drug delivery in the eye, including the ocular surface, anterior chamber, subconjunctival space, and suprachoroidal space. Expert commentary: Promising results from preliminary clinical trials suggest that these devices may be a reasonable alternative to eye drops for treating glaucoma in the near future for patients that have difficulties administering drops or adhering to a complex medication schedule. The use of novel drug vehicles and combined therapies may also provide a more predictable outcome and increase the success of glaucoma filtration surgery. Large clinical trials are needed to determine the safety and efficacy of the sustained delivery devices described in this review.

Surgeon perspectives on learning ab-interno gelatin microstent implantation

OBJECTIVE To evaluate and compare the surgeons learning experience with an ab-interno gelatin microstent (XEN-45, Allergan) to other glaucoma surgeries. DESIGN Cross-sectional survey study. METHODS All surgeons in Canada who used the gelatin microstent were identified and given an anonymous online survey (FluidSurveys, Survey Monkey) designed to evaluate key factors associated with the device, including prior surgical experience, patient selection criteria, analysis of each surgical step, and postoperative care. The survey was validated using input from 3 experienced glaucoma surgeons. RESULTS Surgeons were in early to mid-career (11.8 ± 7.2 operating years) and experienced with filtration surgery (94.1% very comfortable). Surgeons would more commonly operate on patients who had moderate to advanced disease (88.2% and 76.5% of surgeons felt appropriate to operate, respectively); had a diagnosis of primary open angle glaucoma or pseudoexfoliative glaucoma (70.6%); were on 2, 3, or 4 glaucoma medications (70.6%, 75.5%, 70.6%, respectively); and had previously undergone microinvasive glaucoma surgery (83.3%). Creation of the scleral tunnel into the subconjunctival space was rated the most difficult step of the surgery. Most surgeons (52.9%) required 6-10 cases to be comfortable with the procedure and felt it was easier to gain proficiency with ab-interno microstent implantation than traditional filtration surgery (94.1% agree or strongly agree). CONCLUSION The group of glaucoma surgeons surveyed felt it was easier to gain proficiency with gelatin microstent implantation than with traditional filtration surgery.

Bilateral rhegmatogenous retinal detachment in spondyloepimetaphyseal dysplasia-Strudwick type

PURPOSE To document the diagnosis and repair of bilateral retinal detachments in a child with spondyloepimetaphyseal dysplasia-Strudwick type, a rare autosomal dominant genetic disorder involving abnormal production of Type II collagen. METHODS Case report. RESULTS A 13-year-old patient diagnosed with spondyloepimetaphyseal dysplasia-Strudwick type presented with a localized superior temporal retinal detachment in the right eye and a 180° giant retinal tear with an associated macula-off retinal detachment in the left eye. He was highly myopic and had a visual acuity of 20/80 in the right eye and counting fingers in the left eye. He underwent a pars plana vitrectomy in the left eye and laser retinoplexy in the right eye, achieving complete reattachment and/or stabilization of both retinae, with a visual acuity of 20/60 in the right eye and 20/100 in the left eye at 3 months postoperatively. CONCLUSION Patients with spondyloepimetaphyseal dysplasia-Strudwick type may be at a higher risk of developing myopia, vitreoretinal degeneration, and a subsequent retinal detachment, although the scientific literature provides a loose association between these conditions. Critically, we propose a temporal association between retinal detachment and the onset of puberty in these patients and suggest that a dilated retinal screening examination should be scheduled at around the time of puberty for patients with spondyloepimetaphyseal dysplasia-Strudwick type to detect any asymptomatic retinal pathology.