Anne Fiona Spencer

Cyclodiode: results of a standard protocol

AIMS To analyse the results of intraocular pressure (IOP) reduction in refractory glaucoma following diode laser cyclophotocoagulation with a repeatable standard protocol. METHODS 58 eyes of 53 patients were followed for 6–37 months (mean 19 months) after initial cyclodiode treatment. RESULTS Mean (SD) pretreatment IOP for the 58 eyes was 33.0 mm Hg (10.7) reducing at final index visit to 16.7 mm Hg (7.8) (p<0.0001). The mean antiglaucoma medication score per eye was significantly reduced from 2.4 (0.8) to 1.4 (1.0) at last index visit (p<0.0001) with 91% of patients able to stop oral acetazolamide. 45% of eyes required more than one treatment and the overall mean per eye was 1.6 (range 1–5). Of eyes with visual acuity 6/60 or better pretreatment, 12 (32%) lost more than two lines of Snellen acuity and two eyes with poorer acuity initially dropped to NPL. Poor visual outcome was associated with the presence of diabetic retinopathy. Hypotony (IOP <5 mm Hg) was noted in two eyes at the last index visit although neither had specific signs of the same. No phthisis was seen. CONCLUSION The simple treatment protocol, repeated if necessary, appears relatively safe and effective at lowering IOP in eyes with refractory glaucoma.

Individualised patient care as an adjunct to standard care for promoting adherence to ocular hypotensive therapy: an exploratory randomised controlled trial

PurposeTo evaluate the impact of individualised patient care, as an adjunct to standard care, on adherence to ocular hypotensive therapy.MethodsA two-arm, single-masked exploratory randomised controlled trial recruited patients newly prescribed ocular hypotensive therapy. The intervention involved an individual assessment of health-care needs and beliefs and a 1-year follow-up period according to need. The primary outcome was refill adherence, measured by collating prescription and dispensing data for 12 months. Secondary outcomes included self-reported adherence, glaucoma knowledge, beliefs about illness and medicines, quality of care, intraocular pressure (IOP) fluctuation, and changes in clinical management assessed at 12 months. The strength of the intervention was measured following withdrawal by reviewing clinical outcomes for a further 12 months.ResultsIn all, 127 patients were recruited (91% response rate). Intervention-arm patients collected significantly more prescriptions than control-arm patients. Self-report adherence was significantly better in the intervention-arm for patients who forgot drops and those who intentionally missed drops. The intervention group demonstrated significantly more glaucoma knowledge, expressed a significantly stronger belief in the necessity of eye drops and believed that they had more personal control over managing their condition. Control-arm patients had more IOP fluctuation and changes in clinical management. However, this finding only reached significance at 24 months.ConclusionModelling patient care according to health-care needs and beliefs about illness and medicines can have a significant impact on improving adherence to therapy for this patient group, with the potential benefit of improving clinical outcomes.

Agreement between specially trained and accredited optometrists and glaucoma specialist consultant ophthalmologists in their management of glaucoma patients

AimsOptometrists are becoming increasingly involved in the co-management of glaucoma patients as the burden on the Hospital Eye Service continues to escalate. The aim of this study was to assess the agreement between specially trained optometrists and glaucoma-specialist consultant ophthalmologists in their management of glaucoma patients.MethodsFour optometrists examined 23–25 patients each and the clinical findings, up to the point of dilation, were documented in the hospital records. The optometrist, and one of two consultant ophthalmologists, then independently examined and documented the optic-disc appearance before recording their decisions regarding the stability and management of the patient on a specially designed proforma. Percentage agreement was calculated together with kappa or weighted kappa statistics, where appropriate.ResultsAgreement between consultants and optometrists in evaluating glaucoma stability was 68.5% (kappa (κ)=0.42–0.50) for visual fields, 64.5% (weighted κ=0.17–0.31) for optic discs, and 84.5% (weighted κ=0.55–0.60) for intraocular pressures. Agreement regarding medical management was 96.5% (κ=0.73–0.81) and for other glaucoma management decisions, including timing of follow-up, referral to a consultant ophthalmologist, and discharge, was 72% (weighted κ=0.65). This agreement increased to 90% following a retrospective independent then consensus review between the two consultants and when qualified agreements were included. Of the 47 glaucoma and non-glaucoma queries generated during the study, 42 resulted in a change of management.ConclusionConfirming the ability of optometrists to make appropriate decisions regarding the stability and management of glaucoma patients is essential if their involvement is to continue to develop to meet the demand of an aging population.

Preliminary survey of educational support for patients prescribed ocular hypotensive therapy

PurposeTo establish the impact of educational support on patients’ knowledge of glaucoma and adherence, in preparation for an intervention study.MethodsStructured observation encapsulated the educational support provided during clinical consultations and patient interviews captured the depth of glaucoma knowledge, problems associated with glaucoma therapy, and adherence issues.ResultsOne hundred and thirty-eight patients completed the study. Education was didactic in nature, limited for many patients and inconsistent across clinics. Patients showed generally poor knowledge of glaucoma with a median score of 6 (range 0–16). A significant association was found between educational support and knowledge for newly prescribed patients (Kendalls tau=0.30, P=0.003), but no association was found for follow-up patients (Kendalls tau=0.11, P=0.174). Only five (6%) patients admitted to a doctor that they did not adhere to their drop regimen, yet 75 (94%) reported at interview that they missed drops.ConclusionsAlthough important, knowledge alone may not sufficiently improve adherence: a patient-centred approach based on ongoing support according to need may provide a more effective solution for this patient group.

A study to assess the feasibility of undertaking a randomized controlled trial of adherence with eye drops in glaucoma patients

Background Adherence with therapy could influence the progression of glaucoma and ultimately affect the onset of visual impairment in some individuals. This feasibility study evaluated the measures to be used for a future randomized controlled trial assessing the effects of group-based education on adherence with eye drops. Methods People diagnosed with glaucoma within the previous 12 months attending a regional ophthalmology clinic in the North West of England were recruited. A two-session education program delivered one week apart had been devised as part of a previous project. A combined adult learning and health needs approach to education was taken. Outcomes measured were knowledge of glaucoma, self-report of adherence, illness perception, beliefs about medicines, patient enablement, and general health (Short Form-12). Adherence was also measured objectively using a Medical Events Monitoring System device. Results Twenty-six participants consented to undertake the educational program and 19 produced analyzable data. Knowledge of glaucoma, illness perception, beliefs about medicine, and patient enablement all showed statistically significant improvements after education. Mean adherence with eye drops was maintained above 85% before and for 3 months after attendance at the educational program. Self-report exaggerated adherence by at least 10% when compared with the objective Medical Events Monitoring System data, and in fact the kappa agreement was zero. Conclusion All questionnaires other than the Short Form-12 were considered to be valuable measures and use of a Medical Events Monitoring System device was considered to be an objective surrogate measure for adherence with eye drops. A multicenter, randomized, controlled equivalence trial of group versus individualized education using adherence as the primary outcome is the next step.

Developing standards for the development of glaucoma virtual clinics using a modified Delphi approach

Purpose To obtain consensus opinion for the development of a standards framework for the development and implementation of virtual clinics for glaucoma monitoring in the UK using a modified Delphi methodology. Methods A modified Delphi technique was used that involved sampling members of the UK Glaucoma and Eire Society (UKEGS). The first round scored the strength of agreement to a series of standards statements using a 9-point Likert scale. The revised standards were subjected to a second round of scoring and free-text comment. The final standards were discussed and agreed by an expert panel consisting of seven glaucoma subspecialists from across the UK. A version of the standards was submitted to external stakeholders for a 3-month consultation. Results There was a 44% response rate of UKEGS members to rounds 1 and 2, consisting largely of consultant ophthalmologists with a specialist interest in glaucoma. The final version of the standards document was validated by stakeholder consultation and contains four sections pertaining to the patient groups, testing methods, staffing requirements and governance structure of NHS secondary care glaucoma virtual clinic models. Conclusions Use of a modified Delphi approach has provided consensus agreement for the standards required for the development of virtual clinics to monitor glaucoma in the UK. It is anticipated that this document will be useful as a guide for those implementing this model of service delivery.

Glaucoma, dementia, and the “precipice of care”: transitions between states of medication adherence

Purpose “She wouldn’t remember. Even when I go through, and she’s decided to go to bed, I’ll say I’ll come and do her drops. If I didn’t say that, they wouldn’t be done.” Dementia is widely considered as a key factor in whether patients take their medication as prescribed. However, few studies have examined the effect of dementia on medication management strategies for glaucoma including how patient and carer needs impact adherence and long-term prognosis. We report findings from a qualitative grounded theory study incorporating the views of patients, carers, and healthcare professionals. Methods Eighty-three semistructured interviews were conducted with 35 patients, 22 lay carers, and nine healthcare professionals across sites in Wales and Scotland. These explored understanding of eye drop regimens, barriers, and facilitators to drop administration, as well as attitudes toward glaucoma, dementia, and other comorbidities. Results Using Pound’s synthesis of adherence behavior, we identified categories of active and passive acceptance of medicines, alongside modification or rejection of eye drop regimens. In relation to dementia, participants highlighted transitions between such categories, with a shift from active to passive acceptance commonly reported. This loss of self-medicating capability was referred to as the precipice of care, where entwinement of multiple conditions (eg, heart disease, glaucoma, and dementia) and sociocultural influences (eg, living alone) contributed to accelerated health declines. That said, numerous factors mitigated this, with a key role being the lay carer. Spouses and family members often acted as the monitor of eye drops for patients, seeking intervention when any behavioral changes influenced their administration. Conclusion Though dementia was associated with progression toward the precipice of care, factors such as communication with healthcare professionals appeared to affect patient adherence. Recommendations for healthcare practice include better recording of dementia diagnoses and integrating eye drops into preexisting routines.

Long-Term Outcomes and Complications of Baerveldt Glaucoma Drainage Implants in Adults with Glaucoma Secondary to Uveitis

ABSTRACT Purpose: This study investigated the efficacy and safety of Baerveldt glaucoma implants (BGI) in adults with uveitic glaucoma (UG) at the Manchester Uveitis Clinic. Methods: This was a retrospective study of 42 patients with UG who underwent BGI implantation between 2006 and 2015. Primary outcome measures were intraocular pressure (IOP) reduction and number of medications at 5-year follow-up. Three IOP success criteria were chosen: 1.IOP ≤21 mmHg and ≥20% reduction from baseline 2.IOP ≤17 mmHg and ≥20% reduction from baseline and 3.IOP ≤14 mmHg. Results: The mean pre-operative IOP was 29.5 ± 9.5 mmHg on 3.9 antiglaucoma drops. At 5-year follow-up, IOP reduced to 14.4 ± 7.0 mmHg (p < 0.005) on 1.4 drops. The cumulative probability of failure at 5 years based on criteria 1, 2, and 3 was 24.3%, 39.6%, and 56.3%, respectively. Conclusion: This study demonstrated that BGI are safe and effective in refractory UG, especially in younger adults with complex uveitis.

Clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme

Background Glaucoma referral filtering schemes have operated in the UK for many years. However, there is a paucity of data on the false-negative (FN) rate. This study evaluated the clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme (GERS), estimating both the false-positive (FP) and FN rates. Method Outcome data were collected for patients newly referred through GERS and assessed in ‘usual-care’ clinics to determine the FP rate (referred patients subsequently discharged at their first visit). For the FN rate, glaucoma suspects deemed not requiring referral following GERS assessment were invited to attend for a ‘reference standard’ examination including all elements of assessment recommended by National Institute for Health and Care Excellence (NICE) by a glaucoma specialist optometrist. A separate 33 cases comprising randomly selected referred and non-referred cases were reviewed independently by two glaucoma specialist consultant ophthalmologists to validate the reference standard assessment. Results 1404 patients were evaluated in GERS during the study period; 651 (46.3%) were referred to the Hospital Eye Service (HES) and 753 (53.6%) were discharged. The FP rate in 307 assessable patients referred to the HES was 15.5%. This study reviewed 131 (17.4%) of those patients not referred to the HES through the GERS scheme; 117 (89.3%) were confirmed as not requiring hospital follow-up; 14 (10.7%) required follow-up, including 5 (3.8%) offered treatment. Only one patient (0.8%) in this sample met the GERS referral criteria and was not referred (true FN). There were no cases of missed glaucoma or non-glaucomatous pathology identified within our sample. Conclusion The Manchester GERS is an effective glaucoma filtering scheme with a low FP and FN rate.