Cecilia Fenerty

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.

The effectiveness of schemes that refine referrals between primary and secondary care--the UK experience with glaucoma referrals: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project.

Objectives A comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance. Design Retrospective multisite review. Setting The outcomes of clinical examinations by optometrists with a specialist interest in glaucoma (OSIs) were compared with optometrists with no specialist interest in glaucoma (non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, while Manchester and Gloucestershire reviewed OSI findings. Participants 1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham. Results The first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% compared with 36.1% from non-OSIs (difference 22%, CI 16.9% to 26.7%; p<0.001). The FVDR increased after the April 2009 National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines compared with pre-NICE, which was particularly evident when pre-NICE was compared with the current practice time period (OSIs 6.2–17.2%, difference 11%, CI −24.7% to 4.3%; p=0.18, non-OSIs 29.2–43.9%, difference 14.7%, CI −27.8% to −0.30%; p=0.03). Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%, respectively, of total referrals. The proportion of referrals for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs. Conclusions In terms of ‘demand management’, OSIs can reduce FVDR of patients reviewed in secondary care; however, in terms of ‘patient safety’ this study also shows that overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detect glaucomatous optic nerve features. It is recommended that referral letters from non-OSIs be stratified for risk, directing high-risk patients straight to secondary care, and low-risk patients to OSIs.

Patterns and rate of adherence to glaucoma therapy using an electronic dosing aid

Aims and purposeTo identify patterns and rates of adherence with travoprost eye drops using the Travatan dosing aid (TDA) and to present a method for graphically presenting adherence data.MethodsA prospective observational cohort study of patients on travoprost (prostaglandin) monotherapy. Patients were dispensed a TDA and followed up after approximately 3 months of usage. Data were downloaded from the TDA into a computer for analysis. Analysis used inter-dose intervals (the time between each dosing) to look at adherence between days 4 and 75.ResultsIn all, 100 patients were invited to participate, 53 agreed and complete TDA data sets were obtained from 37. In total 23 of the complete data sets showed good adherence (dosing within ±4 h of the agreed dosing time on >80% of occasions), 3 patients discontinued usage before 75 days, 4 showed frequent drug holidays (no dosing for ⩾8 days) and 7 frequently missed doses with adherence rates of <60%. Of the 16 patients for whom no TDA data was obtained, 5 were lost to follow-up, 4 had faulty/damaged TDAs, 3 changed medication, 3 preferred not to use the TDA, and 1 was hospitalized.ConclusionsThere were four easily defined patterns of adherence; (1) good adherence; (2) discontinued usage; (3) frequent drug holidays; and (4) frequent missed doses with low adherence rates. A new method for graphically presenting adherence data helps clinicians identify the pattern of usage and is a valuable aid to the overall management of patients on travoprost therapy.

The influence of socioeconomic and clinical factors upon the presenting visual field status of patients with glaucoma

PurposeTo investigate the relationship between socioeconomic status and the extent of visual field loss in POAG and treated OHT patients at their first presentation to Manchester Royal Eye Hospital.MethodsA cohort of 113 glaucoma patients seen between 1995 and 2005 was reviewed. The clinical parameters intraocular pressure, C : D ratio, family history of glaucoma, visual acuity, extent of visual field loss, and demographic parameters: age, gender, ethnicity, and residential postcode were extracted from hospital records. The socioeconomic status of each patient was estimated from the patients residential postcode with the ACORN index (group 1: affluent and group 2: socioeconomically deprived).ResultsIn comparison to group 1 (n=49), patients in group 2 (n=64) presented with more advanced field loss, lower educational attainment (18 vs 98% with no or unknown qualification), and were less aware of glaucoma in the family (27 vs 17%). Patients with a number of systemic health problems had worse vision, more severe visual field loss, and worse clinical attendance (P<0.05).ConclusionsThe extent of visual field loss in glaucoma patients at first presentation is related to a combination of clinical and socioeconomic factors including the patients postcode. This finding could be used to target future case-finding resources.

High-resolution hyperspectral imaging of the retina with a modified fundus camera

PURPOSE to examine the practical feasibility of developing a hyperspectral camera from a Zeiss fundus camera and to illustrate its use in imaging diabetic retinopathy and glaucoma patients. METHODS the original light source of the camera was replaced with an external lamp filtered by a fast tunable liquid-crystal filter. The filtered light was then brought into the camera through an optical fiber. The original film camera was replaced by a digital camera. Images were obtained in normals and patients (primary open angle glaucoma, diabetic retinopathy) recruited at the Manchester Royal Eye Hospital. RESULTS a series of eight images were captured across 495- to 720-nm wavelengths, and recording time was less than 1.6s. The light level at the cornea was below the ANSI limits, and patients judged the measurement to be very comfortable. Images were of high quality and were used to generate a pixel-to-pixel oxygenation map of the optic nerve head. Frame alignment is necessary for frame-to-frame comparison but can be achieved through simple methods. CONCLUSIONS we have developed a hyperspectral camera with high spatial and spectral resolution across the whole visible spectrum that can be adapted from a standard fundus camera. The hyperspectral technique allows wavelength-specific visualization of retinal lesions that may be subvisible using a white light source camera. This hyperspectral technique may facilitate localization of retinal and disc pathology and consequently facilitate the diagnosis and management of retinal disease.

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.

Outcomes and complications of trabeculectomy enhanced with 5-fluorouracil in adults with glaucoma secondary to uveitis.

Purpose:To analyze the long-term clinical outcomes of 5-fluorouracil (5FU)-enhanced trabeculectomy in patients with glaucoma secondary to uveitis (UG), to compare outcomes with those achieved elsewhere by primary mitomycin C-enhanced trabeculectomy and primary glaucoma drainage implant (GDI) surgery and to consider the optimal surgical approach in this group of patients. Methods:A retrospective analysis of a single-surgeon series of 31 eyes of 25 patients with UG attending the Manchester Uveitis Clinic who had undergone 5FU-enhanced trabeculectomy between October 2002 and August 2010. Main outcome measures were an intraocular pressure (IOP)<21 mm Hg with medications (unqualified success) and with medications (qualified success). Secondary outcome measures were IOP⩽66% of initial IOP. Other risk factors and postoperative complications were also examined. Results:The mean follow-up was 5.1 years. Qualified success for postoperative IOP control of <21 was achieved in 90.3% at 1 year and 76.5% at 5 years. IOP<66% of initial IOP was achieved in 93.5% at 1 year and 82.3% at 5 years. No patients developed long-term hypotony. Patients under 30 years of age at surgery were at a higher risk for bleb failure and 50% in this age group went on to require GDI surgery. Conclusions:This study demonstrates good long-term survival rates of 5FU-enhanced trabeculectomy in patients with UG, comparable with results for primary open-angle glaucoma. The results also compare favorably with those of mitomycin C-enhanced trabeculectomy and GDIs in patients with UG, with a lower risk of complications. We conclude that for patients over 30 years, 5FU-enhanced trabeculectomy is appropriate first-line surgery, whereas GDI surgery should be used as the primary procedure for those under 30 years.

Relationships between visual field sensitivity and spectral absorption properties of the neuroretinal rim in glaucoma by multispectral imaging.

PURPOSE To investigate the relationship between neuroretinal rim (NRR) differential light absorption (DLA, a measure of spectral absorption properties) and visual field (VF) sensitivity in primary open-angle glaucoma (POAG). METHODS Patients diagnosed with (n = 22) or suspected of having (n = 7) POAG were imaged with a multispectral system incorporating a modified digital fundus camera, 250-W tungsten-halogen lamp, and fast-tuneable liquid crystal filter. Five images were captured sequentially within 1.0 second at wavelengths selected according to absorption properties of hemoglobin (range, 570-610 nm), and a Beer-Lambert law model was used to produce DLA maps of residual NRR from the images. Patients also underwent VF testing. Differences in NRR DLA in vertically opposing 180° and 45° sectors either side of the horizontal midline were compared with corresponding differences in VF sensitivity on both decibel and linear scales by Spearmans rank correlation. RESULTS The decibel VF sensitivity scale showed significant relationships between superior-inferior NRR DLA difference and sensitivity differences between corresponding VF areas in 180° NRR sectors (Spearman ρ = 0.68; P < 0.0001), superior-/inferior-temporal 45° NRR sectors (ρ = 0.57; P < 0.002), and superior-/inferior-nasal 45° NRR sectors (ρ = 0.59; P < 0.001). Using the linear VF sensitivity scale significant relationships were found for 180° NRR sectors (ρ = 0.62; P < 0.0002) and superior-inferior-nasal 45° NRR sectors (ρ = 0.53; P < 0.002). No significant difference was found between correlations using the linear or decibel VF sensitivity scales. CONCLUSIONS Residual NRR DLA is related to VF sensitivity in POAG. Multispectral imaging may provide clinically important information for the assessment and management of POAG.

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.

Adherence to ocular hypotensive therapy: patient health education needs and views on group education

Background In this study the authors sought both to understand the health education needs of patients with glaucoma, with particular regard to adherence to glaucoma treatment, and to examine these patients’ views of group education. Methods Using a health promotion approach to health education, 27 qualitative interviews with new and established patients receiving glaucoma treatment were conducted. Health promotion is defined as a way of strengthening people’s capacities to control and optimize their own health. The interviews were transcribed and were then analyzed thematically Results Nine categories of health education needs were identified from the transcripts: (1) to understand glaucoma; (2) to understand their diagnosis or understand the difficulties in giving a diagnosis; (3) to understand the implications of eye drops, their side effects, and how to renew the eye drops; (4) to feel confident to put in eye drops; (5) to put the condition into perspective - to know how to manage their risk; (6) to be able to ask questions of clinicians; (7) to be able to navigate the health care system; (8) to understand and be able to manage own adherence behavior; and (9) to know where to access other sources of information. The majority of patients had something positive to say about group education, and about half of the patients said they would attend group education if they were offered the opportunity. Conclusion A health promotion approach identified a wide range of patient-centered health education needs regarding adherence to glaucoma treatment. Group education will be attractive to some patients. Clinicians could use the health education needs identified in this study to guide the development of either individual or group-based educational intervention to improve adherence to glaucoma treatment. However, clinicians need to be aware that when developing a group intervention, attention will need to be given to making the education relevant to the circumstances of each patient.