James F Kirwan

Trabeculectomy in the 21st century: a multicenter analysis.

OBJECTIVE To evaluate the efficacy and safety of current trabeculectomy surgery in the United Kingdom. DESIGN Cross-sectional, multicenter, retrospective follow-up. PARTICIPANTS A total of 428 eyes of 395 patients. METHODS Consecutive trabeculectomy cases with open-angle glaucoma and no previous incisional glaucoma surgery from 9 glaucoma units were evaluated retrospectively. Follow-up was a minimum of 2 years. MAIN OUTCOME MEASURES Surgical success, intraocular pressure (IOP), visual acuity, complications, and interventions. Success was stratified according to IOP, use of hypotensive medications, bleb needling, and resuturing/revision for hypotony. Reoperation for glaucoma and loss of perception of light were classified as failures. RESULTS Antifibrotics were used in 400 cases (93%): mitomycin C (MMC) in 271 (63%), 5-fluorouracil (5-FU) in 129 (30%), and no antifibrotic in 28 (7%). At 2 years, IOP (mean ± standard deviation) was 12.4 ± 4 mmHg, and 342 patients (80%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP without IOP-lowering medication, whereas 374 patients (87%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP overall. An IOP ≤18 mmHg and 20% reduction of preoperative IOP were achieved by 337 trabeculectomies (78%) without IOP-lowering treatment and by 367 trabeculectomies (86%) including hypotensive medication. Postoperative treatments included suture manipulation in 184 patients (43%), resuturing or revision for hypotony in 30 patients (7%), bleb needling in 71 patients (17%), and cataract extraction in 111 of 363 patients (31%). Subconjunctival 5-FU injection was performed postoperatively in 119 patients (28%). Visual loss of >2 Snellen lines occurred in 24 of 428 patients (5.6%). A total of 31 of the 428 patients (7.2%) had late-onset hypotony (IOP <6 mmHg after 6 months). In 3 of these, visual acuity decreased by >2 Snellen lines. Bleb leaks were observed in 59 cases (14%), 56 (95%) of which occurred within 3 months. Two patients developed blebitis. Bleb-related endophthalmitis developed in 1 patient within 1 month postoperatively and in 1 patient at 3 years. There was an endophthalmitis associated with subsequent cataract surgery. CONCLUSIONS This survey shows that good trabeculectomy outcomes with low rates of surgical complications can be achieved, but intensive proactive postoperative care is required.

Portsmouth visual field database: an audit of glaucoma progression.

AimTo explore visual field (VF) progression in a cohort of secondary care-treated glaucoma and ocular hypertensive (OHT) patients.MethodsWe extracted VFs from our database drawn from our normal clinical practice. VF series from 4177 eyes from 2208 patients who had five or more VFs were obtained, the ‘better’ eye was selected and the rate of VF progression was calculated using mean deviation (MD) data.ResultsThe median rate of progression for the whole sample was −0.1 dB/year (interquartile range (IQR) −4 to 0 dB/year) over a median of 6.7 years (IQR 4.9–8.7). Of 2208 patients, 477 (21.2%) progressed at >−0.5 dB/year; 46 (2.1%) progressed at >−2.0 dB/year. Of those with a ‘final MD’ of worse than −10 dB (N=244) in their better eye; 14.0% were ‘fast progressors’ (>−2 dB/year), 33.7% ‘moderate progressors’ (−1 to −2 dB/year), and 28.8% ‘slow progressors’ (−0.3 dB to −1 dB/year). Of those with ‘initial MD’ better than −3 dB and those with worse than −3 dB, 31/1679 (1.8%) and 213/529 (40.3%) respectively, had a final MD of worse than −10 dB.ConclusionFast progressors, while important, are relatively rare. Moderate and slow progressors make up the majority of the progressing population within this data set. The risk of significant visual loss is much higher in those with initial damage. With increasing life expectancy, moderate and slow progressors may become increasingly clinically important.

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.

Shorter Axial Length and Increased Astigmatic Refractive Error are Associated With Socio-Economic Deprivation in an Adult UK Cohort

Purpose: To evaluate whether socio-economic deprivation is associated with ocular axial length and refractive error in a British cohort. Methods: The study population consisted of 7,652 individuals who provided data to the prospective cataract database at Portsmouth Eye unit, UK over a 4 year period (January 2004 to June 2008). Indices of multiple deprivation (IMD) scores measuring both social and economic domains for each patient’s locality were calculated. The association of these measures of deprivation with axial length and refractive error (astigmatic and spherical) were evaluated using regression analyses after adjusting for age and sex. Results: Socio-economically deprived areas (higher IMD scores) were inversely associated with axial lengths and astigmatic refraction. After controlling for age and sex, an inverse linear association was observed between axial length and IMD scores (-0.24mm in highest quintile compared to lowest; 95% confidence intervals: -0.33 to -0.15) and between astigmatic refraction and IMD scores (-0.12 dioptres in highest quintile compared to lowest; 95% confidence intervals: -0.21 to -0.03). There was no association between spherical refraction and IMD scores. Conclusions: Axial length and astigmatic refraction were inversely associated with socio-economic deprivation in this population. Identification of the environmental exposures involved may identify reversible risk factors for impaired vision.

Risk stratification for posterior capsule rupture and vitreous loss during cataract surgery.

Risk stratification for posterior capsule rupture and vitreous loss during cataract surgery

Bleb compression and autologous blood for relief of bleb dysaesthesia. Does it work

1. Takahashi M, Omodaka K, Maruyama K, et al. Simulated visual fields produced from macular RNFL data in patients with glaucoma. Curr Eye Res 2013; 38: 1133–41. 2. Jampel HD, Friedman DS, Quigley H, et al. Correlation of the binocular visual field with patient assessment of vision. Invest Ophthalmol Vis Sci 2002; 43: 1059–67. 3. Crabb DP, Viswanathan AC, McNaught AI, et al. Simulating binocular visual field status in glaucoma. Br J Ophthalmol 1998; 82: 1236–41. 4. Gracitelli CPB, Abe RY, Tatham AJ, et al. Association between progressive retinal nerve fiber layer loss and longitudinal change in quality of life in glaucoma. JAMA Ophthalmol 2015; 133: 384–90.

Author Response: Predicting and Preventing Visual Impairment and Blindness by Incorporating Individual Progression Velocity in Glaucoma Care

We thank Wesselink and Jansonius for their thoughtful letter and for emphasizing some important points that help in framing our study results. Our modeling exercise broadly attempted to make predictions about the proportion of treated patients, in glaucoma clinics in England, progressing at a rate of loss that could lead to long-term visual disability. The results were intriguing from a ‘‘real world’’ glaucoma service delivery perspective and show the positive consequence of treatment. We fully acknowledge that our findings relate to a population rather than informing clinical practice on an individual patient level. We now take the opportunity to expand on this and other important points. Our data were comprised solely of patients already in clinical care and who were undergoing treatment. We do not suggest that treatment should be delayed or tapered in early glaucoma. Patients who are diagnosed early on with glaucoma likely will be treated earlier, therefore, reducing the likelihood of reaching a stage of visual impairment within their lifetime. Figure 2 in the study of Wesselink and Jansonius supports this argument, with the majority of eyes predicted to progress to blindness as those with advanced visual field loss from the outset, reflecting the important point that early diagnosis and detection will make the most profound difference to reducing blindness from glaucoma—this has been discussed elegantly elsewhere. Wesselink and Jansonius further make the important point that an individual patient with minimal field loss in their first visit still can be at risk of blindness. We agree. Progression rates and patterns vary greatly between patients and are unknown before follow-up. As a result, it is extremely difficult to predict if a given individual, at the point of diagnosis, will become visually impaired in their lifetime. Of course it is important to treat patients from the outset and establish progression speed to identify which patients are most at risk of impairment and adjust treatment accordingly. Still, our predictions suggest only a minority of elderly treated patients with early visual field loss at the point of diagnosis are at high risk of blindness in their lifetime. We still speculate that monitoring resources (not treatment resources) might be better concentrated on those with more damaged visual fields at diagnosis. The tool described by Wesselink and Jansonius has real clinical utility: Experienced clinicians know that life expectancy should be an important consideration in treatment, but this chart could help with the calculation and illuminate this important point. We wonder if the authors could develop a chart that considers both eyes when evaluating patient prognosis, especially as looking at one eye alone often can underestimate a patient’s visual function. In summary, it is essential to treat glaucoma patients on an individual level and monitor them with life expectancy in mind. At the moment, certainly in England, there is a tendency to have a ‘‘one size fits all’’ approach to monitoring visual field loss in the diagnosed patient. We hope our reports motivate thoughts about optimizing the use of monitoring resources in glaucoma, especially in those patients who present with more advanced disease compared to those with little visual loss at diagnosis, or those with ocular hypertension only. We thank Wesselink and Jansonius for their interest in our article and providing us with the opportunity to reiterate these important messages.

Acute suprachoroidal haemorrhage post-tenecteplase thrombolysis for myocardial infarction: management considerations.

We report a case of a 63-year-old man who received intravenous tenecteplase as thrombolytic therapy for an inferior ST elevation myocardial infarction. Three hours later he complained of blurred vision in the right eye and on examination had sustained a suprachoroidal haemorrhage. With conservative treatment the haemorrhage resolved, leading to a normalisation of visual acuity. To the authors’ knowledge, no case reports exist of this rare complication following intravenous tenecteplase. We discuss implications for further thrombolysis and anticoagulation.