Manchester Royal Eye Hospital Research Articles

Adalimumab (ADA) in Pediatric Non-infectious Uveitis: An Observational Study.

Pediatric uveitis is a rare but sight-threatening condition. Prompt and adequate treatment is crucial to preserve vision and avoid long-term complications. In cases that are resistant to corticosteroids and disease-modifying anti-rheumatic drugs (DMARDs), anti-tumor necrosis (anti-TNF) biologic agents are usually added. In this study, we report our experience with adalimumab (ADA) anti-TNF use in this group of patients. This is a retrospective observational study conducted in a tertiary pediatric uveitis clinic, in Manchester Royal Eye Hospital. All patients were pediatric patients (aged 2-18 years old) under follow-up during the period of six months. The patients' data were analyzed according to the diagnosis, age of onset of uveitis, systemic medications used before and concomitantly withADA, duration of uveitis before starting ADA, its effect, and time to notice the therapeutic effect in controlling inflammation. Finally, cases were reviewed for the development of anti-drug antibodies. Forty-two patients were included in the study. Idiopathic uveitis was diagnosed in 47.6% of patients and 40.5% of patients were associated with juvenile idiopathic arthritis (JIA). Most (97.6%) of patients were using topical steroids before starting ADA and 95.2% continued using steroids after established ADA use, but systemic steroid use was reduced from 33.3% to 14.3%. The most common non-biologic DMARD used before ADA was methotrexate (MTX) (90.5%). One-third of the patients started ADA between 6 and 12 months after the diagnosis of uveitis, while this percentage dropped to 9.5% the year after diagnosis. Seventy-eight percent of patients acquired complete clinical control of inflammation on ADA use. Almost 78.6% of patients showed a full response in less than six months. In eight patients who were not controlled or were transiently controlled on ADA, three patients had positive anti-drug antibodies. In one patient, antidrug antibodies were identified after 12 years of ADA use, and in another, after 4 years. Adalimumab is an effective, well-tolerated drug in children with uveitis refractory to non-biologic DMARD therapy. DMARDs were usually used alongside ADA in this cohort and few patients had confirmed ADA antibodies.

Be mindful of the blood glucose measurement: The relevance of blood glucose in the eye emergency department

Aims/Purpose: Diabetic eye disease is a leading cause of blindness worldwide and diabetes‐related eye conditions are frequent presentations in Eye Emergency Departments (EEDs). Early detection and intervention of inadequate blood glucose control in the EED could be sight‐saving.The aims of this study are to determine the: prevalence of pre‐existing diabetes mellitus (DM) in the EED. prevalence of suboptimal (HbA1c 53–70 mmol/mol) or poor (HbA1c >70 mmol/mol) glycaemic control in the EED. proportion of diabetes patients with this diagnosis documented in the EED. proportion of EED patients at risk of undiagnosed diabetes. number of EED patients that had a capillary blood glucose measurement (BgM). Methods: A retrospective review of 683 patients attending the EED over 10 consecutive weekdays at Manchester Royal Eye Hospital, Manchester, United Kingdom. The following parameters were assessed: EED documentation: patient age, gender, presentation, diagnosis, management plan and whether a BgM was done. General Practitioner records: diabetes diagnosis cross‐referenced with EED documentation. If diabetes patients: diabetes type, duration, and glycaemic control. Potentially undiagnosed diabetes. Results: The prevalence of diabetes patients was 9.5%–64.6% of these patients had diabetes documented in EED and 1 had a capillary BgM. 70.7% of diabetes patients had pre‐existing suboptimal [33.8%] or poor [36.9%] glycaemic control. 8.5% of patients were considered high‐risk for undiagnosed diabetes of which 1 had a BgM.Conclusions: There is a high prevalence of diabetes patients in the EED, and most have inadequate glycaemic control. This makes the EED an important setting to detect patients at high risk of diabetes‐related ocular disease and complications. BgM testing for all suspected patients is a quick test to allow earlier detection and intervention of inadequately controlled diabetes and reduce the risk of diabetes‐related vision loss.

Morphological Changes of Corneal Keratocytes following Surface Ablation Laser Surgery: An Observational Study from the United Kingdom

Introduction: Laser Subepithelial Keratomileusis (LASEK) is a type of surface ablation laser surgery that offers a solution to patients for correcting their ametropia. In rare instances, LASEK has been associated with complications such as the development of postoperative haze, infection, and poor visual outcomes. Imaging features detected within the patient’s cornea using In-Vivo Confocal Microscopy (IVCM) have aided in identifying the cellular basis of complications like these. Aim: To observe and describe the morphological changes seen on IVCM in patients following LASEK surgery. Materials and Methods: This observational study aimed to assess the quantity and morphology of anterior and posterior keratocytes in adults aged 18 years and older. Five participants (9 eyes) who presented for follow-up appointments following LASEK surgery at Manchester Royal Eye Hospital (MREH), United Kingdom, from July to December 2018 were recruited for the study. The cell counts of the anterior and posterior keratocytes were calculated using the Heidelberg Eye Explorer software. The images were analysed with the Image J program (National Institutes of Health, Bethesda, USA). Nerve fibers were assessed using the ACCMetrics program (University of Manchester, UK). The t-test was used to establish the statistical association between variables. Results: Morphological changes, such as zones of hyperreflectivity beneath the epithelium, were observed in all the recruited participants. Immune cells and sub-basal nerve abnormalities were detected in several participants. The number of keratocytes in the anterior stroma of all the participants was found to be much lower compared to that of the control. Only participant number 3 had a greater number of keratocytes in the anterior stromal layer (454 and 514 cells/mm2 ) compared to the other participants, who had a cell count ranging between 156 to 262 cells/mm2. Conclusion: It is evident that visible changes are noted both quantitatively and morphologically in both the anterior and posterior keratocytes postoperatively. More research is required with larger controlled studies to investigate the IVCM imaging biomarkers and morphological features that represent the wound healing process and the factors influencing visual outcomes, ensuring that postoperative complications can be minimised.

Impact of First Healthcare Provider on Acanthamoeba Keratitis Course: How to Overcome Poor Prognosis in Acanthamoeba Keratitis Treatment? A Single Tertiary Center, Observational Study.

To assess the difference in course and final visual outcome of Acanthamoeba keratitis (AK) patients based on the first healthcare provider (HCP) seen. Retrospective observational cohort study of AK patients admitted to the Manchester Royal Eye Hospital between 2003 and 2017. HCPs were grouped (Group 1: Optometrists, Opticians; Group 2: General Practitioners (GPs); Group 3: Ophthalmologists) and the data analyzed on demographics, risk factors, clinical history, clinical features, and Acanthamoeba subspecies. Forty-one patients with unilateral culture-proven AK were included. Median time to consultation with first HCP was 7 days (IQR 4-14 days), while mean time to the correct diagnosis of AK was 15 days (IQR 7-29 days). Patients saw an optician, optometrist or ophthalmologists significantly earlier than GPs (median 4 days, vs 15 or 5 days, respectively, p = 0.04). Bacterial keratitis was the most common initial clinical diagnosis (43%). The shortest time to making the AK diagnosis (median 11 days) and the highest rate of initiating AK treatment started at the first visit (38%) were both in the ophthalmologists' group. No significant differences were observed in initial and final visual acuity between HCP groups (p = 0.36). AK patients often seek ocular help earlier from optometrists and opticians than medical doctors. Final clinical outcomes did not significantly differ based on the first HCP seen, but ophthalmologists were more likely to make the diagnosis of AK and initiate anti-amoebal therapy faster than other HCPs. Greater education and collaboration between ophthalmologists and other HCPs to increase awareness of AK are needed.

Providing capacity in glaucoma care using trained and accredited optometrists: A qualitative evaluation

IntroductionThe role of optometrists in glaucoma within primary and secondary care has been well described. Whilst many studies examined safety and clinical effectiveness, there is a paucity of qualitative research evaluating enablers and barriers for optometrists delivering glaucoma care. The aims of this study are to investigate qualitatively, and from a multi-stakeholder perspective whether optometric glaucoma care is accepted as an effective alternative to traditional models and what contextual factors impact upon their success.MethodsPatients were recruited from clinics at Manchester Royal Eye Hospital and nationally via a Glaucoma UK registrant database. Optometrists, ophthalmologists, and other stakeholders involved in glaucoma services were recruited via direct contact and through an optometry educational event. Interviews and focus groups were recorded and transcribed anonymously, then analysed using the framework method and NVivo 12.ResultsInterviews and focus groups were conducted with 38 participants including 14 optometrists and 6 ophthalmologists (from all 4 UK nations), and 15 patients and 3 commissioners/other stakeholders. Themes emerging related to: enablers and drivers; challenges and barriers; training; laser; professional practice; the role of other health professionals; commissioning; COVID-19; and patient experience.ConclusionSuccess in developing glaucoma services with optometrists and other health professionals is reliant on multi-stakeholder input, investment in technology and training, inter-professional respect and appropriate time and funding to set up and deliver services. The multi-stakeholder perspective affirms there is notable support for developing glaucoma services delivered by optometrists in primary and secondary care, with caveats around training, appropriate case selection and clinical responsibility.

Retinal Microvasculature Image Analysis Using Optical Coherence Tomography Angiography in Patients with Post-COVID-19 Syndrome.

Several optical coherence tomography angiography (OCT-A) studies have demonstrated retinal microvascular changes in patients post-SARS-CoV-2 infection, reflecting retinal-systemic microvasculature homology. Post-COVID-19 syndrome (PCS) entails persistent symptoms following SARS-CoV-2 infection. In this study, we investigated the retinal microvasculature in PCS patients using OCT-angiography and analysed the macular retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL) thickness via spectral domain-OCT (SD-OCT). Conducted at the Manchester Royal Eye Hospital, UK, this cross-sectional study compared 40 PCS participants with 40 healthy controls, who underwent ophthalmic assessments, SD-OCT, and OCT-A imaging. OCT-A images from the superficial capillary plexus (SCP) were analysed using an in-house specialised software, OCT-A vascular image analysis (OCTAVIA), measuring the mean large vessel and capillary intensity, vessel density, ischaemia areas, and foveal avascular zone (FAZ) area and circularity. RNFL and GCL thickness was measured using the OCT machine's software. Retinal evaluations occurred at an average of 15.2 ± 6.9 months post SARS-CoV-2 infection in PCS participants. Our findings revealed no significant differences between the PCS and control groups in the OCT-A parameters or RNFL and GCL thicknesses, indicating that no long-term damage ensued in the vascular bed or retinal layers within our cohort, providing a degree of reassurance for PCS patients.

Impact of the junior doctors' industrial action on the emergency eye department in a large tertiary ophthalmic hospital: the Manchester experience.

To assess the impact of the junior doctors' industrial action on one of the largest emergency eye departments (EED) in the United Kingdom. We compared staff allocation, patient presentation, time in streaming, time in the department, the Manchester Triage System (MTS) score, number of eye emergencies and follow-up care of patients who attended the EED in the Manchester Royal Eye Hospital (MREH) during the 3-day industrial action (13-15 March 2023) compared with control periods 2weeks before and 2weeks after the industrial action. During the industrial action, there were almost 1.5 times more staff allocated to EED with a near doubling of the senior workforce. There was no difference in patient presentation, MTS score, number of eye emergencies or patient follow-up during the industrial action. However, patients had significantly less time in streaming (p < 0.001) and in the department (p < 0.001) during the industrial action compared to control periods. Emergency ophthalmic patient care was not compromised during the industrial action due to the reallocation of the workforce to EED. The results of this study may help in the planning of ophthalmic eye-care services in the event of future industrial actions.

The PAUL® glaucoma implant: 1-year results of a novel glaucoma drainage device in a paediatric cohort.

The PAUL® glaucoma implant (PGI) is a novel glaucoma drainage device, which has not been previously reported in paediatric glaucoma management. This study aims to evaluate the safety and effectiveness of the PGI in a paediatric cohort. A retrospective evaluation of 25 cases of paediatric PGI surgery (age 8months to 16years) wasperformed at Manchester Royal Eye Hospital between September 2019 and July 2020. Primary outcome measures included failure (intraocular pressure (IOP) > 21mmHg or < 20% reduction of IOP, removal of the implant, further glaucoma intervention or visual loss. Secondary outcomes included mean IOP, mean number of medications, logMAR visual acuity and complications. Eleven eyes (48%) had a complete success and achieved an unmedicated IOP < 21mmHg, and 21 eyes (84%) had a qualified success (with or without medications). Four failures were observed, 2 due to hypotony and 2 underwent further surgery (gonioscopy-assisted transluminal trabeculotomy). The mean preop IOP was 30.9 ± 5.9mmHg (n = 25), falling to 13.5 ± 6.8mmHg at 1month, 17.9 ± 7.2mmHg at 3months, 13.4 ± 5.1mmHg at 6months, 13.2 ± 4.9mmHg at 12months and 11.8 ± 4.6mmHg at 24months. The mean change in IOP from the preoperative visit to the last visit was a reduction of 19.1 ± 7.7mmHg. A significant reduction in the number of medications and IOP was demonstrated after PGI (p < 0.0001). Nine patients required removal of the intraluminal Prolene stent from the PGI for further pressure lowering. The one- to two-year results demonstrate paediatric PGI has high qualified success rates and effectively reduces IOP and the need for glaucoma medical therapy.

Impact of the COVID-19 Pandemic on the Incidence and Characteristics of Culture-Positive Microbial Keratitis at a Tertiary Eye Hospital in the UK.

PurposeThe COVID-19 pandemic has led to drastic changes to the daily lives of those living in the United Kingdom. We hypothesized that the effect of the imposed lockdown on both behaviour and social interaction has the potential to influence the characteristics of microbial keratitis presenting locally to Manchester Royal Eye Hospital — a major tertiary eye centre in the UK.MethodsWe conducted a retrospective case-note review of all positive corneal scrape cultures identified by our local microbiology laboratory during the year since the announcement of lockdown measures in the UK (23 March 2020 to 23 March 2021). Culture results were compared with previously collated, published “baseline” data from prior to the onset of the COVID-19 pandemic (2004–2019). Statistical analysis was undertaken, predominantly looking at the incidence of microbial keratitis and the variety of cultured pathogens.ResultsA total of 6243 corneal scrape results were reviewed. Comparison of data between the COVID-19 pandemic and subsequent lockdown did not show a significant change in the incidence of culture-positive microbial keratitis: mean annual positive samples during 2004–2019 were 128 (35%) vs 91 (29%) during lockdown (P=0.096). No statistically significant shifts in the incidence of organism subtypes — fungi, acanthamoeba, Gram-positive bacteria, or Gram negative bacteria — were identified (P=0.196, 1, 0.366, and 0.087, respectively).ConclusionContrary to our hypothesis, our results suggest that the COVID-19 pandemic did not alter the incidence or characteristics of microbial keratitis presenting to Manchester Royal Eye Hospital in the year following the implementation of lockdown measures in the UK.

Outcomes of screening for hydroxychloroquine retinopathy at the Manchester Royal Eye Hospital: 2 years' audit.

The Royal College of Ophthalmologists has produced guidelines for screening for hydroxychloroquine retinopathy. New imaging modalities had suggested an increased prevalence of retinopathy compared with previous reports. The aim of this study is to identify the real-life prevalence of hydroxychloroquine retinopathy in patients attending Manchester Royal Eye Hospital screening service over a 2-year period using The RCOphth diagnostic criteria. Data were collected prospectively from all patients attending Manchester Royal Eye Hospital hydroxychloroquine screening service over the audit period. Results of Humphrey visual field tests, spectral-domain optical coherence tomography and fundus autofluorescence were collected as well as data on dose, indication, duration of treatment, and additional risk factors. Cases were identified as having definite, possible, or no retinopathy based on the 2018 RCOphth criteria. The data are not publicly available due to information that could compromise research participant privacy and confidentiality but are available upon request from the corresponding author. 910 patients attended for screening. 566 were identified as being at risk of retinopathy (543 had been on treatment >5 years, 10 had renal impairment, 12 were on doses of >5 mg/kg/day, and one was concurrently on tamoxifen). The prevalence of HCQ retinopathy was 10/910 (1.09%) of all those screened, and 1.76% of those at risk (10/566). Six patients of those deemed at risk were identified as having definite hydroxychloroquine retinopathy, while four had possible retinopathy. Our results show a prevalence of retinopathy largely consistent with reports from regional audits yet reveal a far lower estimate compared to previously reported figures.

A British gentleman, a man with a vision Emanuel Saul Rosen MD, FRCSEd September 23, 1936-November 20, 2021.

The field of ophthalmology lost a huge asset in November 2021. Emanuel Rosen was not only an innovator, pioneer, and driving force who helped shape the field of cataract and refractive surgery as we know it today, but he was also a wonderful colleague and kind friend. His successful career in the UK was lengthy and varied, but I would like to highlight the tremendous ways Emanuel helped shape the ESCRS and this journal. A more in-depth look at his career can be found on the ESCRS EuroTimes website (www.eurotimes.org). In 1973, a time when intraocular implants, phacoemulsification, and corneal refractive surgery were all met with hostility and reluctance by the medical/surgical establishment, Emanuel performed his first intraocular lens implantation after removing a cataract. Recognizing that this was the future, he assembled a group of young, passionate surgeons from around the world who were eager to develop new methods to help improve the vision of their patients. This group formed the Manchester Cataract Centre at the Manchester Royal Eye Hospital, UK, with the express purpose of surgical teaching and training. Emanuel's partnership with the hospital continued for nearly 30 years. In 1981, after years of networking, he was an inaugural member of the European IntraOcular Implant Council (EIIC). The society's membership grew quickly, and in 1988, the EIIC changed its name to the ESCRS.1 Emanuel was a key player in this transition and served as the first ESCRS President from 1988 to 1993. Some historical context puts the amazement of these achievements into perspective. During the time that the Manchester Cataract Centre and these European societies were founded and developing, the Cold War was ongoing, Europe was not unified in currency, borders or governing policy, and Germany was still divided by East and West. Today, the ESCRS is a society with 6730 members and 3086 trainees. Emanuel's desire to connect people and expand ideas was complimented by his commitment to move knowledge forward through publishing. In 1969, he published the first English-language textbook on retinal disorders and angiography. By 1986, he was the Editor of the English language version of Implant, the monthly journal of the EIIC. In 1996, as the EIIC continued to expand and changed its name to ESCRS, and in the advent of an internet-connected world, Dr. Stephen Obstbaum from the ASCRS and Emanuel Rosen from the ESCRS envisioned a collective journal for both societies.2 From this vision emerged the Journal of Cataract & Refractive Surgery. Emanuel served as the JCRS European Editor from 1996 to 2014 and Case Report Editor from 2014 to 2020.2–4 Emanuel was a direct link to surgical pioneers who introduced what are now standard ideas, including intraocular lenses, phakic lenses, phacoemulsification, and corneal refractive laser surgery. He set a high bar of achievement, collegial cooperation, and commitment. I was lucky to have been able to work with him for so many years. He will be greatly missed, and his achievements will be remembered for decades to come. We extend our most sincere sympathy to his wife, Barbara, and 3 children, Caroline, William, and Edward.

Impact of COVID-19-associated anxiety on the adherence to intravitreal injection in patients with macular diseases a year after the initial outbreak

Background:As the primary burden of treating COVID-19 patients began to ease in the United Kingdom, ophthalmology clinic volume within the National Health Service has since recovered. Alarmingly, the rate of non-attendance remains higher than the pre-pandemic level.Purpose:The purpose was to assess how the perceived risk of contracting coronavirus disease 2019 (COVID-19) influences the willingness of individuals with sight-threatening macular conditions to attend intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection appointments during the second wave of the pandemic.Methods:This prospective cross-sectional survey was conducted at the Macular Treatment Centre, Manchester Royal Eye Hospital. Patients who missed their appointment in January 2021 were invited to complete an anonymous survey over the telephone. The survey consisted of two parts: (1) a 23-item questionnaire aiming to assess fear of contracting COVID-19 in different hospital-related settings; and (2) the validated COVID-19 Anxiety Syndrome Scale (C-19ASS) to evaluate COVID-19-related anxiety.Results:A total of 104 patients agreed to participate in the survey. Only a small proportion of patients believed COVID-19 vaccination (23 out of 88, 26.1%) had influenced their willingness to attend injection appointments. Majority of patients felt concerned about contracting COVID-19 during hospital appointments (n = 63, 60.6%). Only a minority of patients (n = 36, 34.6%) agreed with the hospital guidance on minimising clinical examinations during clinic visit. The C-19ASS was significantly higher in female patients, those older than 70 years and those with mobility issues. Higher C-19ASS, older age and living alone were predictors of clinic nonattendance.Conclusion:COVID-19 anxiety and fear of viral exposure could adversely affect patient adherence to clinic appointments during the pandemic. Particular attention should be provided to older patients, those who live alone and patients with impaired mobility. This is particularly relevant as hospital eye services across the world are in the process of restarting.

Environmental Effect of Fluorinated Gases in Vitreoretinal Surgery: A Multicenter Study of 4,877 Patients

To investigate the direct contribution to carbon emissions of fluorinated gases used in all vitreoretinal (VR) procedures utilizing gas tamponade and assess the respective carbon footprint of the three different gas delivery systems. A multicenter, retrospective, environmental impact study. All VR procedures using fluorinated gases between 2017 to 2020 at the Manchester Royal Eye Hospital (MREH) and Birmingham and Midland Eye Centre (BMEC) (the second and third largest VR centers in the UK), and between 2019 to 2020 at the University Hospitals Coventry and Warwickshire (UHCW) were included. CO2 equivalent mass (CO2EM) was calculated from the mass of each gas used, according to the Intergovernmental Panel on Climate Change. A total of 4877 (1883 SF6 [38.6%], 2096 C2F6 [43.0%], and 897 C3F8 [18.4%]) procedures were analyzed. UHCW and BMEC utilized single-use 30 mL and 75 mL cannisters, respectively. MREH used four cylinders of each gas over 4 years (2 kg SF6, 1 kg C2F6, 1 kg C3F8). Mean CO2EM per patient was: MREH 111.8 kg, BMEC 7.5 kg, and UHCW 2.7 kg. For MREH and BMEC, the CO2EM was 73.4 metric tons annually (if all cases were performed with i) 30 mL: 3.7 tons and ii) cylinders: 148.0 tons, x 40-fold difference), equating to 599,400 (30,500-1.2 million) km travelled by a passenger car. The current use of SF6 in VR surgery accountsfor 0.11% of total SF6 use; if 30 mL cylinders were exclusively used in the UK, this could be lowered to 0.01%. This study highlights the significant waste associated with large gas cylinders and demonstrated that 30 mL cannisters can lead to a marked reduction in carbon emissions, even after accounting for the increased carbon footprint involved in their manufacture and disposal.

Complete manuscript title: Neurological complications from sinugenic orbital cellulitis.

This study was undertaken with an aim to identify any common factors or trends among patients of orbital cellulitis that developed neurological complications. A 24-month retrospective review of patients was undertaken to include those showing clinical deterioration and neurological complications on radiological imaging, after being treated for orbital cellulitis at Manchester Royal Eye Hospital. The study specifically looked at the site of orbital collection, sinus involvement, types of neurological complications and whether these were detected at initial presentation, surgical input and microbiology findings. Nine patients (9/26) developed associated neurological complications during the study period. (February 2018 and January 2020) This included subdural empyema in six patients; leptomeningeal enhancement in two and septic emboli in one patient. All the patients had associated significant pan-sinusitis at initial presentation. Neurological complications were detected in three patients at the time of admission and after clinical deterioration and further investigations in the rest. A superior orbital abscess and Streptococcus mileri infection had higher risk of neurological complications. It is worth debating whether patients with chronic sinusitis who develop orbital cellulitis need earlier surgical input rather than a conservative treatment. Patients who fail to improve clinically need to be re-imaged to look for possible neurological complications.

The Accuracy of GP Referrals into Manchester Royal Eye Hospital Orthoptic Department

Background:There is little research that examines the accuracy of paediatric referrals into secondary and tertiary care, particularly those from general practicioners (GPs) to ophthalmology and orthoptic departments. Inaccurate referrals could have a detrimental effect on service delivery and NHS funding as well as patient experience. Available evidence shows GP referral accuracy to range between 39% and 90% across different areas of medicine with accuracy of GP referral to ophthalmology between 56% and 66%.Methods:A retrospective case note analysis was carried out on 99 case notes to examine the accuracy of paediatric GP referrals (including those via the community optometrist) into the Orthoptic Department at Manchester Royal Eye Hospital (MREH).Results:GP referral accuracy was found to be 63% for strabismus cases, 50% for reduced vision/amblyopia cases, 45% for NAD cases, 100% of nystagmus cases and 92% of “other” cases. GPs were significantly less accurate than community optometrists (p = 0.01). Referrals from GPs alone had an accuracy rate of 65% compared to 87% of GP referral via community optometrist. Accuracy of referral appeared to improve with age, however this was not found to be statistically significant (p = 0.06).Conclusion:This study found orthoptic referral accuracy for GPs in Manchester to be similar to other areas of medicine. While acceptable compared to other areas of medicine, improving referral accuracy is essential to improve NHS spending, service delivery, and patient experience. To aid with this the aim is to design and implement a virtual training package that focuses on detection of strabismus to improve referral accuracy.

Outcomes of Primary Trabeculectomy From Two Same-centre Cohorts 10 Years Apart.

Trabeculectomy can effectively lower intraocular pressure (IOP). A more junior surgeon profile is emerging. Mitomycin C (MMC) has replaced 5-fluorouracil (5-FU) intraoperatively with comparable success rates and a decrease in postoperative antimetabolite administration. We compare 2-year outcomes for primary trabeculectomy in 2 cohorts, 10 years apart, performed at a large UK teaching hospital. Consecutive case series of trabeculectomies at Manchester Royal Eye Hospital between 2004-2005 (Cohort 1/C1) and 2014-2015 (Cohort 2/C2). Preoperative and postoperative data was collected for IOP outcomes and complications. Success was defined as IOP ≥6 and ≤21, ≤18, ≤16, ≤14, or ≤12 mm Hg with/without a ≥20% decrease from preoperative IOP. The need for and absence of postoperative antihypertensive medication defined qualified and complete success, respectively. A total of 186 cases were analyzed [52 (C1), 134 (C2)]. Mean preoperative IOP was 24±10 mm Hg (C1) and 21±7 mm Hg (C2) (P=0.01). Overall, 34 (79%), 33 (77%), 33 (77%), 29 (67%), and 25 (58%) patients in C1 and 88 (70%), 82 (65%), 73 (58%), 64 (51%), and 40 (32%) patients in C2 achieved complete success for IOP ≤21 mm Hg (P=0.33), ≤18 mm Hg (P=0.22), ≤16 mm Hg (P=0.04), ≤14 mm Hg (P=0.09), or ≤12 mm Hg (P=0.004). Similarly, 43 (93%), 40 (87%), 40 (87%), 35 (76%), and 27 (59%) in C1 and 123 (98%), 116 (92%), 106 (84%), 87 (69%), and 58 (49%) in C2 achieved qualified success (P=0.34, 0.37, 0.83, 0.48, and 0.19). In all, 32 (74%), 31 (72%),31 (72%), 28 (65%), and 24 (56%) in C1 and 64 (51%), 63 (50%), 61 (48%), 54 (43%), and 39 (31%) in C2 achieved complete success with ≥20% reduction from preoperative IOP and IOP of ≤21 mm Hg (P=0.01), ≤18 mm Hg (P=0.02), ≤16 mm Hg (P=0.01), ≤1 mm Hg (P=0.02), or ≤12 mm Hg (P=0.006). By same definition, 37 (80%), 36 (78%), 36 (78%), 33 (72%), and 26 (57%) in C1 and 94 (75%), 93 (74%), 90 (71%), 75 (60%), and 58 (46%) in C2 achieved qualified success (P=0.55, 0.69, 0.48, 0.20, and 0.30). Mean IOP at 2 years was 13±5 mm Hg (C1) and 13±4 mm Hg (C2) (P=0.35). Overall, 62% had intraoperative 5-FU in C1; only MMC was used in C2 (P<0.0001). Postoperative 5-FU was administered in 54% versus 22% in C1 and C2, respectively (P<0.0001). Needling rates were not statistically different [42% (C1), 54% (C2)] (P=0.22). Trabeculectomy is effective in lowering IOP with success comparable across various definitions. MMC replaced 5-FU as intraoperative antimetabolite resulting in reduced need for postoperative antimetabolite but not increased complications.

Virtual clinics for glaucoma care - Patients' and clinicians' experiences and perceptions: a qualitative evaluation.

BackgroundThe role of glaucoma virtual clinics has developed to help meet demand for capacity within busy glaucoma services. There is limited research of patient and clinician experiences and perceptions of these clinics and the aim of this study is to provide further information to help improve patient experience and guide service delivery.MethodsA mixed methods research design was employed comprising of a patient satisfaction survey, and patient and clinician interviews. Consultant ophthalmologists were recruited from throughout the UK, and patients and data gathering clinical staff recruited from the Manchester Royal Eye Hospital and Bristol Eye Hospital.ResultsWe received a total of 148 patient satisfaction questionnaires with an overall response rate of 55.4%. Most respondents were diagnosed with primary open angle glaucoma (33.9%) at Manchester and glaucoma suspect status at Bristol (50.6%). Patients had high levels of confidence in the person conducting the tests (94.8% Manchester, 98.8% Bristol), and most were likely to recommend the service to family or friends (94.8% Manchester, 92.6% Bristol). We interviewed 10 consultant ophthalmologists, 10 data gathering staff and 20 patients. A number of key themes emerged from the transcribed interviews including: patient experience, clinician perception of patient experience, service delivery, staffing and staff experience, and patient safety.ConclusionsGlaucoma virtual clinics can be acceptable to both clinicians and patients, including those with a varied complexity of glaucoma and glaucoma-related disease. Dissatisfaction seemed to relate to poor communication or processes and systems within the service rather than complexity of disease.

Statistical Modelling of the Visual Impact of Subretinal Fluid and Associated Features.

IntroductionThe aim of this study was to develop a statistical model to determine the visual significance of subretinal fluid (SRF) in combination with other constructed optical coherence tomography (OCT) features in patients with wet age-related macular degeneration.MethodsThe project used labelled data from 1211 OCTs of patients with neovascular macular degeneration (nAMD) attending the macular treatment centre of Manchester Royal Eye Hospital to build a statistical model to determine vision for any virtual, constructed OCT. A four-dimensional plot was created to represent the visual impact of SRF in OCTs in the context of the associated OCT characteristics of atrophy and subretinal hyperreflective material (SHRM).ResultsThe plot illustrates that at levels of SRF below 150 µm, the impact of SRF on vision is very low. Increasing the amount of fluid to 200 µm and beyond increases the impact on vision, but only if there is little atrophy or SHRM.ConclusionsThis study suggests that levels of SRF up to around 150 µm thickness on OCT have minimal impact on vision. Greater levels of SRF have greater impact on vision, unless associated with significant amounts of atrophy or SHRM, when the additional effect of the SRF on vision remains low.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-020-00327-w.

Changing clinical patterns of Rhegmatogeneous Retinal Detachments during the COVID19 pandemic lockdown in the North West of the UK.

The UK Government imposed a COVID19 lockdown (LD) restricting all but essential activities from 24th March 2020. Subsequently, there has been a significant reduction in casualty attendances nationwide including for ophthalmic emergencies. We aim to study the presentation of rhegmatogenous retinal detachments (RRD) and significant vitreous haemorrhage caused by posterior vitreous detachment (PVD-VH) in three tertiary centres covering most of the North West of England in the 6 weeks before and during the lockdown. A retrospective multicenter non-randomised consecutive case series study was designed to collect information on all cases of RRD and PVD-VH requiring surgery presenting to the vitreoretinal departments of Manchester Royal Eye Hospital, East Lancashire NHS Foundation Trust and the Lancashire NHS Foundation Trust from 11th February to 4th May 2020. A total of 137 eyes of 137 patients were identified between the three centres of which 132 eyes were operated for RRD. Of these, 86 (64.7%) were operated pre-LD compared with 46 eyes (34.8%) during LD. Forty-five out of 86 eyes (52.3%) were macula-off pre-LD compared with 31 out of 46 eyes (67.3%) during LD (p = 0.06). There was lower proportion of non-PVD related RRD during LD (11 pre-LD to 1 during LD, p = 0.05). PVR was present in four cases during LD compared to 2 before (p = 0.19). There was a clinically significant reduction in the overall incidence of RRD in our centres with an increase in the proportion of macula-off and proliferative vitreoretinopathy during the LD period compared to a similar period before.

Prospective validation of a virtual clinic pathway in the management of choroidal naevi: the NAEVUS study Report no. 1: safety assessment

BackgroundChoroidal naevi are a common incidental finding prompting specialist referrals to ocular oncology. Rarely, such lesions have sufficient suspicious features to diagnose a small melanoma. The aim of the study...