Determinants of non-attendance at face-to-face and telemedicine ophthalmic consultations

BACKGROUND/AIMS

Evaluation of telemedicine care models has highlighted its potential for exacerbating healthcare inequalities. This study seeks to identify and characterise factors associated with non-attendance across face-to-face and telemedicine outpatient appointments.

METHODS

A retrospective cohort study at a tertiary-level ophthalmic institution in the UK, between 1 January 2019 and 31 October 2021. Logistic regression modelled non-attendance against sociodemographic, clinical and operational exposure variables for all new patient registrations across five delivery modes: asynchronous, synchronous telephone, synchronous audiovisual and face to face prior to the pandemic and face to face during the pandemic.

RESULTS

A total of 85 924 patients (median age 55 years, 54.4% female) were newly registered. Non-attendance differed significantly by delivery mode: (9.0% face to face prepandemic, 10.5% face to face during the pandemic, 11.7% asynchronous and 7.8%, synchronous during pandemic). Male sex, greater levels of deprivation, a previously cancelled appointment and not self-reporting ethnicity were strongly associated with non-attendance across all delivery modes. Individuals identifying as black ethnicity had worse attendance in synchronous audiovisual clinics (adjusted OR 4.24, 95% CI 1.59 to 11.28) but not asynchronous. Those not self-reporting their ethnicity were from more deprived backgrounds, had worse broadband access and had significantly higher non-attendance across all modes (all p<0.001).

CONCLUSION

Persistent non-attendance among underserved populations attending telemedicine appointments highlights the challenge digital transformation faces for reducing healthcare inequalities. Implementation of new programmes should be accompanied by investigation into the differential health outcomes of vulnerable populations.

Tablet-based tests of everyday visual function in a diabetic macular oedema (DME) clinic waiting area: A feasibility study

PURPOSE

(1) To assess the feasibility of conducting tablet-based vision tests in hospital clinic waiting areas; (2) To test the hypothesis that increasing severity of diabetic macular oedema (DME) is associated with the performance of tablet-based surrogates of everyday tasks and self-reported visual function.

METHODS

Sixty-one people with mild (n = 28), moderate (n = 24) or severe (n = 9) DME performed two tablet-based tests of 'real-world' visual function (visual search and face recognition) while waiting for appointments in a hospital outpatient clinic. Participants also completed a tablet-based version of a seven-item, visual-functioning (VF-7) patient-reported outcome measure. Test performance was compared to previously published 99% normative limits for normally sighted individuals.

RESULTS

Thirty-four participants (56%; 95% confidence interval [CI] 43%-68%) exceeded normative limits for visual search, while eight (13%; 95% CI 65%-24%) exceeded normative limits for face discrimination. Search duration was significantly longer for people with severe DME than those with mild and moderate DME (p = 0.01). Face discrimination performance was not significantly associated with DME severity. VF-7 scores were statistically similar across DME severity groups. Median time to complete all elements (eligibility screening, both tablet-based tasks and the VF-7) was 22 (quartiles 19, 25) min. Further, 98% and 87% of participants, respectively, reported the search task and face discrimination task to be enjoyable, while 25% and 97%, respectively, reported finding the two tasks to be difficult.

CONCLUSIONS

Portable tablet-based tests are quick, acceptable to patients and feasible to be performed in a clinic waiting area with minimal supervision. They have the potential to be piloted in patients' homes for self-monitoring.

Transforming ophthalmology in the digital century-new care models with added value for patients

Ophthalmology faces many challenges in providing effective and meaningful eye care to an ever-increasing group of people. Even health systems that have so far been able to cope with the quantitative patient increase, due to their funding and the availability of highly qualified professionals, and improvements in practice routine efficiency, will be pushed to their limits. Further pressure on care will also be caused by new active substances for the largest group of patients with AMD, the so-called dry form. Treatment availability for this so far untreated group will increase the volume of patients 2-3 times. Without the adaptation of the care structures, this quantitative and qualitative expansion in therapy will inevitably lead to an undersupply.There is increasing scientific evidence that significant efficiency gains in the care of chronic diseases can be achieved through better networking of stakeholders in the healthcare system and greater patient involvement. Digitalization can make an important contribution here. Many technological solutions have been developed in recent years and the time is now ready to exploit this potential. The exceptional setting during the SARS-CoV-2 pandemic has shown many that new technology is available safely, quickly, and effectively. The emergency has catalyzed innovation processes and shown for post-pandemic time after that we are equipped to tackle the challenges in ophthalmic healthcare - ultimately for the benefit of patients and society.

Introducing the 'Benign Eyelid Lesion Pathway': 1 year experience of synchronous tele-oculoplastics in a tertiary hospital

BACKGROUND

Patients with benign eyelid lesions make up a large proportion of referrals to the oculoplastic service and lend themselves well to telemedicine with assessments heavily reliant on history, observation-based examination and photographs to enable management decision-making. Our tertiary unit set up tele-oculoplastics clinics for all new patients referred for benign eyelid lesions comprising tele-consultation with antecedent patient photograph: Benign Eyelid Lesion Pathway (BELP). One year on, we describe a retrospective analysis of 974 patients looking at distinct parameters of effectiveness.

METHODS

We retrospectively collected data from electronic patient records (EPR) for BELP patients from July 2020 to August 2021 (n = 974). We analysed time efficiency (referral time to treatment plan, consultation duration in minutes, average waiting times, number of patients seen per clinician and DNA rate), accessibility, safety (via video surveillance clinic) and theatre utilisation.

RESULTS

57.3% (n = 558) were listed for a surgical procedure direct from tele-consultation with 94.9% (n = 513) of these proceeding to surgery; 22.8% (n = 222) were discharged, 10.7% (n = 104) had further video follow-up and 6.7% (n = 65) required face-to-face follow-up. Our results showed efficient referral-to-treatment times, waiting times, consultation times and non-attendance rate. There was only a 2.57% non-attendance rate. There was no missed diagnosis of a malignancy of a presumed benign lesion.

CONCLUSION

Tele-oculoplastics provides a streamlined, safe, effective, and logistically convenient way to review benign eyelid lesions. With the increased waiting times for referral to biopsy of eyelid lesions, this clinic shows it is imperative to provide digital accessibility for patient assessment and booking to operating theatre.

System usability, user satisfaction and long-term adherence to mobile hyperacuity home monitoring-prospective follow-up study

PURPOSE

To evaluate the usability and long-term adherence to the mobile hyperacuity app Alleye in patients with retinal pathology.

METHODS

We enroled 72 patients (95 eyes) mainly treated for wet AMD (48/95; 50.5%). We calculated changes of clinical characteristics and the System Usability Score (SUS), and personal ratings of usefulness and number of tests performed per month at a follow-up visit of eighteen months.

RESULTS

At baseline, mean best corrected visual acuity (BCVA) was 74.9 letters (SD 14.8), mean age was 69.9 (SD 11.4) and 39/72 (54.2%) were female. Of included patients, 47/72 (65.2%) reported to use mobile devices daily. The retention rate until last follow-up was 73.6 % (53/72). The median SUS score at baseline was 90 (interquartile range (IQR) 82.5-95) and 92.5 (IQR 82.5-95) in the follow-up. No association between changes of SUS and clinical characteristics was seen. At baseline, 76.4% (55/72) stated that they would recommend the app to a friend, 83.3% (60/72) were very satisfied with the app and 58/72 (80.6%) of respondents said they trusted the app. These assessments remained similar among patients remaining on the program until the follow-up. Patients who dropped out of the study (n = 19) did not differ in age, gender, BCVA, and SUS at baseline, but stated that they did not use the mobile device daily (Odds Ratio 7.40 (95%CI: 2.32-23.65); p = 0.001).

CONCLUSIONS

The majority of users willing to perform home monitoring with the Alleye app are satisfied with the usability and have a positive attitude towards its trustworthiness and usefulness.

Expansion of patient eligibility for virtual glaucoma clinics: a long-term strategy to increase the capacity of high-quality glaucoma care

AIMS

The virtual glaucoma clinic (VGC) is a well-established diagnostic pathway for delivery of glaucoma care. Current UK national guidance recommends VGCs for patients with ocular hypertension, glaucoma suspects or early glaucoma. This study evaluates whether expanded eligibility criteria, including other glaucoma phenotypes and disease stages, can deliver safe and effective care with a positive patient experience.

METHODS

Records of over 8000 patients were reviewed in order to determine suitability for VGC attendance using expanded eligibility criteria. Patients with three prior consecutive visits within the glaucoma service were included. Follow-up interval, clinic type, visual acuity (VA), intraocular pressure (IOP) and visual field performance were recorded. Patient satisfaction was recorded for a sample of 118 patients.

RESULTS

2017 patients over 31 months were included. Two-thirds of eyes had ocular comorbidities, a fifth of eyes had undergone prior cataract surgery and 10% of eyes had undergone a prior laser treatment for glaucoma. After three visits, 32% of patients remained in the VGC, 42% were seen in face-to-face clinics and 25% were discharged. There were no clinically significant changes in VA, IOP and visual field performance during follow-up. 72% of patients expressed a preference to continue their care within VGCs.

CONCLUSIONS

This study demonstrates that VGCs with expanded patient eligibility criteria can deliver high-quality glaucoma care that is safe, effective and with high levels of patient satisfaction. This approach provides a long-term solution to adapt delivery of glaucoma care to our expanding and ageing population.

Practical implementation of a q4-q16 aflibercept treat-and-extend pathway for the treatment of neovascular age-related macular degeneration: Updated guidance from a UK expert panel

OBJECTIVES

This report, based on guidance from a panel of UK retina specialists, introduces a revised intravitreal aflibercept (IVT-AFL) treat-and-extend (T&E) pathway for the treatment of neovascular age-related macular degeneration (nAMD). The T&E pathway incorporates the updated IVT-AFL label (April 2021) allowing flexible treatment intervals of 4 weeks to 16 weeks, after three initiation doses and a further dose after 8 weeks. Practical guidance is provided on the clinical implementation of the revised pathway, with the aim of supporting clinical decision-making to benefit patients and addressing capacity issues in nAMD services.

METHODS

Three structured round-table meetings of UK retina specialists were held online on 19 May, 16 June and 13 October 2021. These meetings were organised and funded by Bayer.

RESULTS

The authors revised the previously published consensus pathway to reflect the changes to the IVT-AFL label and developed guidelines for the implementation of the pathway in UK clinical practice. The guidelines include topics such as recommendations for extending patients with 2- or 4-week adjustments, extending patients to 16-week treatment intervals, managing fellow eye involvement, and reducing treatment intervals for patients with particularly active disease.

CONCLUSIONS

The revised IVT-AFL T&E nAMD pathway offers guidance to clinicians seeking to increase the dosing flexibility of IVT-AFL, with 4- to 16-week treatment intervals, in line with the updated IVT-AFL label, to meet the continually evolving demands of nAMD service provision.

Paracentral acute middle maculopathy after uneventful ocular surgery with local anaesthetic blocks

OBJECTIVE

To describe the role of local anaesthetic blocks as a potential cause of paracentral acute middle maculopathy (PAMM) after uneventful ocular surgery.

METHODS

Retrospective, observational, international, multicentre case series. Nine cases of PAMM with associated visual loss following uneventful ocular surgery with local anaesthetic blocks were observed in a 9-year period (2011-2020). Demographic, ocular and systemic data, anaesthetic data and surgical details were collected. Visual acuity (VA), fundus photography, fluorescein angiography, optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) images were reviewed.

RESULTS

All nine cases were associated with decreased VA at 24 h postoperative check (ranging from hand movement to 20/200). A hyperreflective band within the middle retinal layers was observed in the structural OCT in the acute phase, evolving to thinning and atrophy of the inner retinal layers in sequential follow-up scans performed. Fluorescein angiography showed delayed perfusion in early arterial phase with normal perfusion in late venous phases. OCTA showed decreased perfusion in the deep capillary plexus. Visual recovery was variable between cases during follow-up (ranging from count fingers to 20/20).

CONCLUSIONS

A combination of a vasoconstrictive effect of the anaesthetic agent, an intraocular pressure spike and a mechanical effect of the volume of anaesthetic injected may result in decreased retinal artery perfusion and be evidenced as PAMM in OCT scans. PAMM may present as a potential complication of local anaesthetic blocks in cases of unexpected visual loss after uneventful ocular surgery.

Visual outcomes and treatment adherence of patients with macular pathology using a mobile hyperacuity home-monitoring app: a matched-pair analysis

OBJECTIVE

We compared patients with neovascular age-related macular degeneration (nvAMD), diabetic macular oedema (DMO) and other macular pathologies testing their vision with the hyperacuity home-monitoring app Alleye to patients not performing home-monitoring regarding clinical outcomes and clinical management.

DESIGN

Matched-pair analysis.

SETTING

Retina Referral Centre, Switzerland.

PARTICIPANTS

For each eye using Alleye, we matched 2-4 controls not using home-monitoring based on age, gender, number of previous intravitreal injections (IVI), best corrected visual acuity (BCVA) (Early Treatment Diabetic Retinopathy Study letters), central macular thickness (CRT) and time point of enrolment, using the Mahalanobis distance matching algorithm. We included 514 eyes (288 patients); 107 eyes with nvAMD using home monitoring and 218 controls not using home monitoring, 25 eyes with DMO (n=52 controls) and 40 eyes with miscellaneous conditions (n=72 controls). 173 eyes (33.7%) received no IVI during follow-up.

MAIN OUTCOME MEASURES

Improvement of ≥5 letters, number of injection visits and treatment retention after correcting for differences in baseline characteristics with multivariate analyses.

RESULTS

The mean follow-up duration was 809 days (range 147-1353) and the mean number of IVI/year among treated eyes was 6.7 (SD 3.1). Mean age at baseline was 70.4 years (SD 10.9), BCVA was 77.6 letters (SD 11.6) and CRT was 263.6 µm (SD 86.7) and was similar between patients using and not using home monitoring. In multivariate analyses, patients using home monitoring had a higher chance to improve visual acuity by ≥5 letters (OR 1.67 (95% CI 1.01 to 2.76; p=0.044)) than controls. Treated eyes using home monitoring had less injection visits/year (-0.99 (95% CI -1.59 to -0.40; p=0.001)) and a longer treatment retention +69.2 days (95% CI 2.4 to 136.0; p=0.042). These effects were similar across retinal pathologies.

CONCLUSIONS

This data suggest that patients capable of performing mobile hyperacuity home monitoring benefit in terms of visual acuity and discontinue treatment less often than patients not using home monitoring.

Enablers and Barriers to Deployment of Smartphone-Based Home Vision Monitoring in Clinical Practice Settings

Question

What are the enablers and barriers of patient engagement for app-based home vision monitoring at scale?

Findings

In this cohort and survey study including 417 adults, 258 patients were active users (61.9%) of whom 166 patients (64.3%) were compliant users. Engagement was positively associated with higher comfort with technology, White British ethnicity, visual acuity, neovascular age-related macular degeneration diagnosis, and the number of intravitreal injections and was negatively associated with increased age.

Meaning

These findings suggest effective smartphone app-based home vision monitoring should address the risk factors for low engagement and digital exclusion during clinical practice setting deployment.

Importance

Telemedicine is accelerating the remote detection and monitoring of medical conditions, such as vision-threatening diseases. Meaningful deployment of smartphone apps for home vision monitoring should consider the barriers to patient uptake and engagement and address issues around digital exclusion in vulnerable patient populations.

Objective

To quantify the associations between patient characteristics and clinical measures with vision monitoring app uptake and engagement.

Design, Setting, and Participants

In this cohort and survey study, consecutive adult patients attending Moorfields Eye Hospital receiving intravitreal injections for retinal disease between May 2020 and February 2021 were included.

Exposures

Patients were offered the Home Vision Monitor (HVM) smartphone app to self-test their vision. A patient survey was conducted to capture their experience. App data, demographic characteristics, survey results, and clinical data from the electronic health record were analyzed via regression and machine learning.

Main Outcomes and Measures

Associations of patient uptake, compliance, and use rate measured in odds ratios (ORs).

Results

Of 417 included patients, 236 (56.6%) were female, and the mean (SD) age was 72.8 (12.8) years. A total of 258 patients (61.9%) were active users. Uptake was negatively associated with age (OR, 0.98; 95% CI, 0.97-0.998; P = .02) and positively associated with both visual acuity in the better-seeing eye (OR, 1.02; 95% CI, 1.00-1.03; P = .01) and baseline number of intravitreal injections (OR, 1.01; 95% CI, 1.00-1.02; P = .02). Of 258 active patients, 166 (64.3%) fulfilled the definition of compliance. Compliance was associated with patients diagnosed with neovascular age-related macular degeneration (OR, 1.94; 95% CI, 1.07-3.53; P = .002), White British ethnicity (OR, 1.69; 95% CI, 0.96-3.01; P = .02), and visual acuity in the better-seeing eye at baseline (OR, 1.02; 95% CI, 1.01-1.04; P = .04). Use rate was higher with increasing levels of comfort with use of modern technologies (β = 0.031; 95% CI, 0.007-0.055; P = .02). A total of 119 patients (98.4%) found the app either easy or very easy to use, while 96 (82.1%) experienced increased reassurance from using the app.

Conclusions and Relevance

This evaluation of home vision monitoring for patients with common vision-threatening disease within a clinical practice setting revealed demographic, clinical, and patient-related factors associated with patient uptake and engagement. These insights inform targeted interventions to address risks of digital exclusion with smartphone-based medical devices.

Phenotyping of retinal neovascularization in ischemic retinal vein occlusion using wide field OCT angiography

BACKGROUND/OBJECTIVES

Abnormal retinal neovascularization caused by ischemic retinal vein occlusion (RVO) is a frequent cause of visually significant vitreous hemorrhage. The early detection of new vessels may be challenging and often requires the use of invasive tests such as fundus fluorescein angiography (FA). We demonstrate the use of wide-field optical coherence tomography angiography (WF-OCTA) in the detection and characterization of neovascularization secondary to ischemic RVO.

SUBJECTS/METHODS

We conducted a retrospective observational case series of patients diagnosed with ischemic RVO between August 2018 and March 2019, who underwent WF-SS-OCTA imaging (PLEX Elite 9000, Carl Zeiss Meditec). We performed real-life montage imaging, covering the involved area and compared the findings of WF-SS-OCTA to standard clinical examination and when available, ultrawide-field fluorescein angiography (UWF-FA, Optos 200TX).

RESULTS

In the included 39 eyes with ischemic RVO, neovascularization elsewhere (NVE) was encountered in 16 of 39 eyes (41%) on WF-OCTA and were characterized as sea-fan type vessels and nodular type vessels, based on their appearance and localization. NVE was identified in 4/39 eyes on standard clinical examination, equating to a detection rate of 10.3%. All were of a sea-fan morphology. In one case, NVE found on WF-OCTA was not observed on UWF-FA, which was a nodular type. Neovascularization of the disc (NVD) was detected in one eye.

CONCLUSIONS

WF-OCTA may become a useful noninvasive tool in the detection of neovascularization in patients with ischemic RVO. Furthermore, the characterization of different morphologies of neovascularization detected by WF-OCTA could be of clinical relevance.

Smartphone-based remote monitoring of vision in macular disease enables early detection of worsening pathology and need for intravitreal therapy

Background/aims

To assess the outcomes of home monitoring of distortion caused by macular diseases using a smartphone-based application (app), and to examine them with hospital-based assessments of visual acuity (VA), optical coherence tomography-derived central macular thickness (CMT) and the requirement of intravitreal injection therapy.

Design

Observational study with retrospective analysis of data.

Methods

Participants were trained in the correct use of the app (Alleye, Oculocare, Zurich, Switzerland) in person or by using video and telephone consultations. Automated threshold-based alerts were communicated based on a traffic light system. A ‘threshold alarm’ was defined as three consecutive ‘red’ scores, and turned into a ‘persistent alarm’ if present for greater than a 7-day period. Changes of VA and CMT, and the requirement for intravitreal therapy after an alarm were examined.

Results

245 patients performing a total of 11 592 tests (mean 46.9 tests per user) were included and 85 eyes (164 alarms) examined. Mean drop in VA from baseline was −4.23 letters (95% CI: −6.24 to −2.22; p<0.001) and mean increase in CMT was 29.5 µm (95% CI: −0.08 to 59.13; p=0.051). Sixty-six eyes (78.5%) producing alarms either had a drop in VA, increase in CMT or both and 60.0% received an injection. Eyes with persistent alarms had a greater loss of VA, −4.79 letters (95% CI: −6.73 to −2.85; p<0.001) or greater increase in CMT, +87.8 µm (95% CI: 5.2 to 170.4; p=0.038).

Conclusion

Smartphone-based self-tests for macular disease may serve as reliable indicators for the worsening of pathology and the need for treatment.

Digital technology, tele-medicine and artificial intelligence in ophthalmology: A global perspective

The simultaneous maturation of multiple digital and telecommunications technologies in 2020 has created an unprecedented opportunity for ophthalmology to adapt to new models of care using tele-health supported by digital innovations. These digital innovations include artificial intelligence (AI), 5th generation (5G) telecommunication networks and the Internet of Things (IoT), creating an inter-dependent ecosystem offering opportunities to develop new models of eye care addressing the challenges of COVID-19 and beyond. Ophthalmology has thrived in some of these areas partly due to its many image-based investigations. Tele-health and AI provide synchronous solutions to challenges facing ophthalmologists and healthcare providers worldwide. This article reviews how countries across the world have utilised these digital innovations to tackle diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration, glaucoma, refractive error correction, cataract and other anterior segment disorders. The review summarises the digital strategies that countries are developing and discusses technologies that may increasingly enter the clinical workflow and processes of ophthalmologists. Furthermore as countries around the world have initiated a series of escalating containment and mitigation measures during the COVID-19 pandemic, the delivery of eye care services globally has been significantly impacted. As ophthalmic services adapt and form a "new normal", the rapid adoption of some of telehealth and digital innovation during the pandemic is also discussed. Finally, challenges for validation and clinical implementation are considered, as well as recommendations on future directions.

Impact and Challenges of Integrating Artificial Intelligence and Telemedicine into Clinical Ophthalmology

ABSTRACT

Aging populations and worsening burden of chronic, treatable disease is increasingly creating a global shortfall in ophthalmic care provision. Remote and automated systems carry the promise to expand the scale and potential of health care interventions, and reduce strain on health care services through safe, personalized, efficient, and cost-effective services. However, significant challenges remain. Forward planning in service design is paramount to safeguard patient safety, trust in digital services, data privacy, medico-legal implications, and digital exclusion. We explore the impact and challenges facing patients and clinicians in integrating AI and telemedicine into ophthalmic care-and how these may influence its direction.

Telemedicine in oculoplastic and adnexal surgery: clinicians' perspectives in the UK

BACKGROUND/AIMS

The COVID-19 has facilitated a paradigm shift in the sphere of ophthalmic telemedicine: its utility is no longer limited to providing care to remote regions, rather it is expeditiously being adopted as the new standard of care. The aim of our paper is to explore the current attitudes of oculoplastic surgeons towards telemedicine and its utility in the present landscape and its prospects in the future.

METHODS

A 39-item questionnaire was distributed to consultant oculoplastic surgeons practising across the UK and anonymised responses were collected and analysed.

RESULTS

The COVID-19 pandemic has allowed rapid implementation of telemedicine services in oculoplastic departments across the UK with 86.6% of the respondents incorporating telemedicine into the routine clinical practice. Clinicians reported a statistically significant increase in utility of telemedicine, confidence in using telemedicine and quality of infrastructure available to employ telemedicine following the COVID-19 outbreak. The greatest utility of telemedicine is in triaging, postoperative assessment and eyelid lesion assessment. Main barriers to implementation of telemedicine included difficulties in conducting clinical examinations, lack of administrative support and poor access to digital technologies for patients. Overall, most clinicians were satisfied with the impact of telemedicine services and almost all experts foresee themselves continuing to use telemedicine in the future.

CONCLUSIONS

Telemedicine has become an integral part of the oculoplastic service delivery since the COVID-19 pandemic its use is likely to continue. Further development of digital infrastructure and improvement of clinical examination capabilities are required to enable its wider adoption.

Insights From Survival Analyses During 12 Years of Anti-Vascular Endothelial Growth Factor Therapy for Neovascular Age-Related Macular Degeneration

Importance

Although multiple imputation models for missing data and the use of mixed-effects models generally provide better outcome estimates than using only observed data or last observation carried forward in clinical trials, such approaches usually cannot be applied to visual outcomes from retrospective analyses of clinical practice settings, also called real-world outcomes.

Objective

To explore the potential usefulness of survival analysis techniques for retrospective clinical practice visual outcomes.

Design, Setting, and Participants

This retrospective cohort study covered a 12-year observation period at a tertiary eye center. Of 10 744 eyes with neovascular age-related macular degeneration receiving anti-vascular endothelial growth factor (VEGF) therapy between October 28, 2008, and February 1, 2020, 7802 eyes met study criteria (treatment-naive, first-treated eyes starting anti-VEGF therapy). Eyes were excluded from the analysis if they received photodynamic therapy or macular laser, any previous anti-VEGF therapy, treatment with anti-VEGF agents other than ranibizumab or aflibercept, or had an unknown date or visual acuity (VA) value at first injection.

Main Outcomes and Measures

Kaplan-Meier estimates and Cox proportional hazards modeling were used to consider VA reaching an Early Treatment Diabetic Retinopathy Study (ETDRS) letter score of 70 (Snellen equivalent, 20/40) or better, duration of VA sustained at or better than 70 (20/40), and VA declining to 35 (20/200) or worse.

Results

A total of 7802 patients (mean [SD] age, 78.7 [8.8] years; 4776 women [61.2%]; and 4785 White [61.3%]) were included in the study. The median time to attaining a VA letter score greater than or equal to 70 (20/40) was 2.0 years (95% CI, 1.87-2.32) after the first anti-VEGF injection. Predictive features were baseline VA (hazard ratio [HR], 1.43 per 5 ETDRS letter score or 1 line; 95% CI, 1.40-1.46), baseline age (HR, 0.88 per 5 years; 95% CI, 0.86-0.90), and injection number (HR, 1.12; 95% CI, 1.10-1.15). Of the 4439 of 7802 patients (57%) attaining this outcome, median time sustained at an ETDRS letter score of 70 (20/40) or better was 1.1 years (95% CI, 1.1-1.2).

Conclusions and Relevance

In this cohort study, patients with neovascular age-related macular degeneration beginning anti-VEGF therapy were more likely to experience positive visual outcomes within the first 2.0 years after treatment, typically maintaining this outcome for 1.1 years but then deteriorating to poor vision within 8.7 years. These findings demonstrate the potential usefulness of the proposed analyses. This data set, combined with the statistical approach for retrospective analyses, may provide long-term prognostic information for patients newly diagnosed with this condition.

Safety of video-based telemedicine compared to in-person triage in emergency ophthalmology during COVID-19

BACKGROUND

the need for social distancing midst the COVID-19 pandemic has forced ophthalmologists to innovate with telemedicine. The novel process of triaging emergency ophthalmology patients via videoconsultations should reduce hospital attendances. However, the safety profile of such services were unknown.

METHODS

in this retrospective cohort study, we reviewed case notes of 404 adults who used our videoconsultation service from 20/04/2020 to 03/05/2020. We compared these to 451 patient who attended eye casualty in person at the same time who were deemed not to require same day ophthalmic examination.

FINDINGS

patients seen by videoconsultations tended to be younger (Median = 43 years, Inter-quartile range = 27 vs Median= 49 years, Inter-quartile range = 28)'. More males used the face-to-face triage (55%) while more females used videoconsultation (54%)%. Fewer patients seen by videoconsultations required specialist review compared to face-face triage [X ² (1, N = 854) = 128.02, p<0.001)]. 35.5% of the patients initially seen by videoconsultation had unplanned reattendance within 1 month, compared to 15.7% in the group initially seen in person. X ² (1, N = 234) = 7.31, p = 0.007). The rate of actual harm was no different (at 0% for each method), with perfect inter-grader correlation when graded independently by two senior ophthalmologists. 97% of patients seen on the video platform surveyed were satisfied with their care.

INTERPRETATION

we demonstrate comparable patient safety of videoconsultations at one-month follow-up to in person review. The service is acceptable to patients and reduces the risk of COVID-19 transmission. We propose that videoconsultations are effective and desirable as a tool for triage in ophthalmology.

FUNDING

the research supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology who fund PT and DS's time to conduct research. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

Emerging therapies and their delivery for treating age-related macular degeneration

Age-related macular degeneration (AMD) is the most common cause of blindness in the Western world and is characterised in its latter stages by retinal cell death and neovascularisation and earlier stages with the loss of parainflammatory homeostasis. Patients with neovascular AMD (nAMD) are treated with frequent intraocular injections of anti-vascular endothelial growth factor (VEGF) therapies, which are not only unpopular with patients but carry risks of sight-threatening complications. A minority of patients are unresponsive with no alternative treatment available, and some patients who respond initially eventually develop a tolerance to treatment. New therapeutics with improved delivery methods and sustainability of clinical effects are required, in particular for non-neovascular AMD (90% of cases and no current approved treatments). There are age-related and disease-related changes that occur which can affect ocular drug delivery. Here, we review the latest emerging therapies for AMD, their delivery routes and implications for translating to clinical practice.

Paracentral acute middle maculopathy after uneventful ocular surgery with local anaesthetic blocks

OBJECTIVE

To describe the role of local anaesthetic blocks as a potential cause of paracentral acute middle maculopathy (PAMM) after uneventful ocular surgery.

METHODS

Retrospective, observational, international, multicentre case series. Nine cases of PAMM with associated visual loss following uneventful ocular surgery with local anaesthetic blocks were observed in a 9-year period (2011-2020). Demographic, ocular and systemic data, anaesthetic data and surgical details were collected. Visual acuity (VA), fundus photography, fluorescein angiography, optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) images were reviewed.

RESULTS

All nine cases were associated with decreased VA at 24 h postoperative check (ranging from hand movement to 20/200). A hyperreflective band within the middle retinal layers was observed in the structural OCT in the acute phase, evolving to thinning and atrophy of the inner retinal layers in sequential follow-up scans performed. Fluorescein angiography showed delayed perfusion in early arterial phase with normal perfusion in late venous phases. OCTA showed decreased perfusion in the deep capillary plexus. Visual recovery was variable between cases during follow-up (ranging from count fingers to 20/20).

CONCLUSIONS

A combination of a vasoconstrictive effect of the anaesthetic agent, an intraocular pressure spike and a mechanical effect of the volume of anaesthetic injected may result in decreased retinal artery perfusion and be evidenced as PAMM in OCT scans. PAMM may present as a potential complication of local anaesthetic blocks in cases of unexpected visual loss after uneventful ocular surgery.

Accuracy of periocular lesion assessment using telemedicine

Objectives

To assess the agreement in diagnosis and management plans reached between clinicians reviewing eyelid lesions remotely and in face-to-face clinics.

Methods

In this single-centre observational case series, data were prospectively collected on 50 consecutive adults referred with eyelid lesions suitable to be seen by a nurse. A proforma was completed to gather salient information. A nurse specialist saw patients in face-to-face clinics and collected information using the proforma, devising a diagnosis and management plan. Photographs of the eyelid lesions were taken by a medical photographer. A subsequent remote review was completed by an oculoplastic consultant using the proforma information and photographs in the absence of the patient. The diagnosis and management plan constructed by the nurse specialist were compared with those reached by the consultant.

Results

Complete data were available for 44 consecutive cases. There was an overall 91% agreement (40 cases out of 44) between the diagnoses reached by the nurse specialist, and the remote reviewer; kappa coefficient 0.88 (95% CI 0.76 to 0.99). There was an overall 82% agreement (36 out of 44 cases) in the management plans devised by the nurse-led clinic and remote reviewer; kappa coefficient 0.74 (95% CI 0.58 to 0.90). The average time taken for a remote reviewer to reach a diagnosis and management plan was 1 min and 20 s.

Conclusions

This study evaluated the feasibility of assessing eyelid lesions using asynchronous telemedicine. There was overall a high rate of concordance in the diagnosis reached, and management devised between the clinic and remote review.

A virtual-clinic pathway for patients referred from a national diabetes eye screening programme reduces service demands whilst maintaining quality of care

Aim

To evaluate the potential of an integrated virtual medical retina clinic in secondary care for diabetic patients screened and referred by the UK National Diabetic Eye Screening Program (DESP).

Methods

This retrospective cohort study included diabetic patients referred by the DESP to either a virtual or a traditional doctor’s appointment (face-to-face, F2F) at the Moorfields Eye Hospital NHS Foundation Trust (London, UK) between January 2015 and December 2018. The primary outcome was the proportion of patients that qualified for a virtual-clinic appointment according to hospital guidance. Secondary outcomes included the rate of attendance, mean time from DESP referral to initial hospital appointment, mean time-to-discharge and -to-treatment of either panretinal photocoagulation or intravitreal injection of anti-vascular endothelial growth factor.

Results

We included 12,563 patients in this study. While 8833 patients (70.7%) would have qualified for a virtual appointment according to local triage guidance, only 2306 (18.4%) were referred to a virtual consultation due to capacity constraints. For routine referrals, mean time to the first hospital appointment was 66.9 days with a standard deviation of ±35.9 and 80.9 ± 44.4 days for a virtual and a F2F consultation, respectively. The mean time from referral to discharge to community was 71.7 ± 30.8 and 86.3 ± 37.0 days for a virtual and a F2F consultation, respectively. We did not observe a statistically significant difference in the mean time-to-treatment in the sub-cohort that required intravitreal therapy for maculopathy (virtual clinics: 220.7 ± 84.8; F2F: 178.0 days ± 80.7; p value > 0.05). Moreover, we observed a non-inferior attendance rate in virtual as compared to F2F clinics.

Conclusion

A significant proportion of diabetic patients referred to a F2F clinic could initially be managed in a virtual clinic. Increasing the adoption of virtual clinics in the management of diabetic patients that do not need long-term management or monitoring in secondary services may help alleviate service demands without diminishing quality of clinical care. Collectively, our analyses suggest that virtual consultations are a faster and clinically appropriate alternative for a substantial proportion of diabetic patients.

Creating the Moorfields' virtual eye casualty: video consultations to provide emergency teleophthalmology care during and beyond the COVID-19 pandemic

Background

The COVID-19 crisis forced hospitals in the UK dramatically to reduce outpatient activity. To provide continuity of care and to assist patients reluctant or unable to leave their homes, video consultations were rapidly implemented across routine and emergency ophthalmology services.

Objective

To describe the deployment and scaling to a large volume of teleophthalmology using a video consultation platform ‘Attend Anywhere’ in Moorfields Eye Hospital’s accident and emergency (A&E) department (London, UK).

Method

Patient satisfaction, waiting time, consultation duration, outcome and management were audited following the launch of the new virtual A&E service.

Results

In the 12 days following the service launch, 331 patients were seen by video consultation. 78.6% of patients (n=260) were determined not to need hospital A&E review and were managed with advice (n=126), remote prescription (n=57), general practitioner referral (n=27), direct referral to hospital subspecialty services (n=26) or diversion to a local eye unit (n=24). Mean patient satisfaction was 4.9 of 5.0 (n=62). The mean consultation duration was 12 min (range 5–31 min) and the wait time was 6 min (range 0–37 min).

Conclusion

Video consultations showed greater than expected usefulness in the remote management of eye disease and supported a substantial reduction in the number of people visiting the hospital.

The Evolution of Diabetic Retinopathy Screening Programmes: A Chronology of Retinal Photography from 35 mm Slides to Artificial Intelligence

As a third of people with diabetes mellitus (DM) will suffer the microvascular complications of diabetic retinopathy (DR) and therapeutic options can effectively prevent visual impairment, systematic screening has substantially reduced disease burden in developed countries. In an effort to tackle the rising incidence of DM, screening programmes have modernized in synchrony with technical and infrastructural advancements. Patient evaluation has shifted from face-to-face ophthalmologist-based review delivered through community grassroots to asynchronous store-and-forward modern telemedicine platforms commissioned on a nationwide scale. First pioneered with primitive 35-mm slide film retinal photography, the last decade has seen an emergence of high resolution and widefield imaging devices, which may reveal extents of DR indiscernible to the clinician but with implications of potential earlier identification. Similar progress has been seen in image analysis approaches - automated image analysis of retinal photographs of DR has evolved from qualitative feature detection to rules-based algorithms to autonomous artificial intelligence-powered classification. Such models have, relatively rapidly, been validated and are now receiving approval from health regulation authorities with deployment into the clinical sphere. In this review, we chart the evolution of global DR screening programmes since their inception highlighting major milestones in healthcare infrastructure, telemedicine approaches and imaging devices that have shaped the robust and effective frameworks recognised today. We also provide an outlook for the future of DR screening in the context of recent technological advancements with respect to their limitations in current times.

Psychological, social and everyday visual impact of diabetic macular oedema and diabetic retinopathy: a systematic review

AIMS

To synthesize the evidence on the impact of diabetic retinopathy and diabetic macular oedema from the patient perspective.

METHODS

A systematic literature review was conducted using MEDLINE Complete, PsycINFO, EMBASE and AMED. We included articles investigating the impact of the condition on quality of life, symptoms, visual functioning, activities of daily living, well-being, social functioning, and financial status. The studies evaluated were observational, including cross-sectional, prospective cohort and retrospective cohort designs. Outcome data were extracted and synthesized.

RESULTS

Searches yielded 5114 publications. After screening, 85 studies were included, measuring the following outcomes: visual functioning (n=46); quality of life (n=22); well-being (n=16); functional status (n=5); work (n=4); and visual task performance (n=2). Diabetic retinopathy has a considerable impact on visual functioning and this is greater in people with greater disease severity. Diabetic retinopathy significantly limits activities including working, driving, walking and reading, and has the potential to have a negative impact on psychological well-being.

CONCLUSIONS

Diabetic retinopathy is associated with poor self-reported visual functioning, well-being, and health-related quality of life. Ability to perform basic everyday tasks appears to diminish with disease severity. Some studies suggest impaired mobility and problems with work, but there are gaps in this evidence.

Health Economic and Safety Considerations for Artificial Intelligence Applications in Diabetic Retinopathy Screening

Systematic screening for diabetic retinopathy (DR) has been widely recommended for early detection in patients with diabetes to address preventable vision loss. However, substantial manpower and financial resources are required to deploy opportunistic screening and transition to systematic DR screening programs. The advent of artificial intelligence (AI) technologies may improve access and reduce the financial burden for DR screening while maintaining comparable or enhanced clinical effectiveness. To deploy an AI-based DR screening program in a real-world setting, it is imperative that health economic assessment (HEA) and patient safety analyses are conducted to guide appropriate allocation of resources and design safe, reliable systems. Few studies published to date include these considerations when integrating AI-based solutions into DR screening programs. In this article, we provide an overview of the current state-of-the-art of AI technology (focusing on deep learning systems), followed by an appraisal of existing literature on the applications of AI in ophthalmology. We also discuss practical considerations that drive the development of a successful DR screening program, such as the implications of false-positive or false-negative results and image gradeability. Finally, we examine different plausible methods for HEA and safety analyses that can be used to assess concerns regarding AI-based screening.

Widefield optical coherence tomography angiography for early detection and objective evaluation of proliferative diabetic retinopathy

PURPOSE

To evaluate the utility of widefield optical coherence tomography angiography (WF-OCTA) compared with clinical examination in grading diabetic retinopathy in patients diagnosed clinically with proliferative diabetic retinopathy (PDR) or severe non-proliferative diabetic retinopathy (NPDR).

DESIGN

This retrospective observational case series included patients diagnosed clinically with PDR or severe NPDR. Patients underwent standard clinical examination and WF-OCTA imaging (PLEX Elite 9000, Carl Zeiss Meditec AG) using 12×12 montage scans between August 2018 and January 2019. Two trained graders identified neovascularisation at the disc (NVD) and neovascularisation elsewhere (NVE) on WF-OCTA which were compared with the clinical examination, and to ultra-widefield fluorescein angiography (UWFA) when available.

RESULTS

Seventy-nine eyes of 46 patients were evaluated. Of those, 57 eyes were diagnosed clinically with PDR, and 22 with severe NPDR. NVD was detected on OCTA-B scan as preretinal hyperreflective material (PRHM) in 39 eyes (100%) with evident flow signals in 79.5% compared with 51.3% detected clinically. We further classified NVD on OCTA into four subtypes and found that subtypes 1 and 2 could not be seen on clinical examination alone. WF-OCTA detected NVE in 81% of the cases compared with 55.7% detected clinically. Using WF-OCTA resulted in a higher percentage of PDR grading (88.6%) than on clinical examination (72.2%). When available, UWFA confirmed the WF-OCTA diagnosis in the majority of cases.

CONCLUSION

This study demonstrates that WF-OCTA has a higher detection rate of PDR than clinical examination. This suggests that this modality could be used non-invasively for the purpose of early detection and characterisation of neovascularisation.

Intravenous indocyanine green dye is insufficient for robust immune cell labelling in the human retina

It is not currently possible to reliably visualise and track immune cells in the human central nervous system or eye. Previous work demonstrated that indocyanine green (ICG) dye could label immune cells and be imaged after a delay during disease in the mouse retina. We report a pilot study investigating if ICG can similarly label immune cells within the human retina. Twelve adult participants receiving ICG angiography as part of routine standard of care were recruited. Baseline retinal images were obtained prior to ICG administration then repeated over a period ranging from 2 hours to 9 days. Matched peripheral blood samples were obtained to examine systemic immune cell labelling and activation from ICG by flow cytometry with human macrophage cultures as positive controls. Differences between the delayed near infrared ICG imaging and 488 nm autofluorescence was observed across pathologies, likely arising from the retinal pigment epithelium (RPE). Only one subject demonstrated ICG signal on peripheral blood myeloid cells and only three distinct cell-sized signals appeared over time within the retina of three participants. No significant increase in immune cell activation markers were detected after ICG administration. ICG accumulated in the endosomes of macrophage cultures and was detectable above a minimum concentration, suggesting cell labelling is possible. ICG can label RPE and may be used as an additional biomarker for RPE health across a range of retinal disorders. Standard clinical doses of intravenous ICG do not lead to robust immune cell labelling in human blood or retina and further optimisation in dose and route are required.

A Clinician's Guide to Artificial Intelligence: How to Critically Appraise Machine Learning Studies

In recent years, there has been considerable interest in the prospect of machine learning models demonstrating expert-level diagnosis in multiple disease contexts. However, there is concern that the excitement around this field may be associated with inadequate scrutiny of methodology and insufficient adoption of scientific good practice in the studies involving artificial intelligence in health care. This article aims to empower clinicians and researchers to critically appraise studies of clinical applications of machine learning, through: (1) introducing basic machine learning concepts and nomenclature; (2) outlining key applicable principles of evidence-based medicine; and (3) highlighting some of the potential pitfalls in the design and reporting of these studies.

Anterior Segment Optical Coherence Tomographic Angiography Assessment of Acute Chemical Injury

PURPOSE

To compare routine clinical examination with optical coherence tomography angiography (OCTA) for the assessment of limbal conjunctival ischemia following a chemical burn.

SETTING

Validity analysis.

METHODS

We assessed 10 participants (15 eyes) with an acute chemical injury. Clinical photographs were used to determine the extent of any limbal conjunctival epithelial defect and ischemia. These were compared with the extent of limbal ischemia identified on OCTA images of the ocular surface. Quantitative and longitudinal analysis using the OCTA software were also performed. Correlations with visual outcome were sought using clinical and OCTA-derived variables.

RESULTS

The extent of clinically determined limbal ischemia was less than that identified with OCTA (2.3±3.6 clock hours vs 5.1±4.2 clock hours, P = .003), which in turn was less than the size of limbal conjunctival epithelial defect (7.3±5.1 clock hours, P = .03). Longitudinal OCTA analysis showed that mean vessel area increased by 0.2%±0.1% during the study, corresponding to a rate of vascular recovery of 0.9 mm²/d. Significant correlations were found between visual outcome at 3 months and limbal conjunctival fluorescein staining (r = 0.67, P = .006), and limbal conjunctival ischemia on OCTA (r = 0.76, P = .001).

CONCLUSIONS

OCTA can objectively identify and monitor the recovery of limbal ischemia following an acute ocular chemical injury. OCTA confirms that limbal ischemia is usually more extensive than is suggested by clinical examination, and the former is highly correlated with visual outcome. OCTA therefore is a useful tool in the management of ocular chemical injury.

Implementation of a cloud-based referral platform in ophthalmology: making telemedicine services a reality in eye care

BACKGROUND

Hospital Eye Services (HES) in the UK face an increasing number of optometric referrals driven by progress in retinal imaging. The National Health Service (NHS) published a 10-year strategy (NHS Long-Term Plan) to transform services to meet this challenge. In this study, we implemented a cloud-based referral platform to improve communication between optometrists and ophthalmologists.

METHODS

Retrospective cohort study conducted at Moorfields Eye Hospital, Croydon (NHS Foundation Trust, London, UK). Patients classified into the HES referral pathway by contributing optometrists have been included into this study. Main outcome measures was the reduction of unnecessary referrals.

RESULTS

After reviewing the patient's data in a web-based interface 54 (52%) out of 103 attending patients initially classified into the referral pathway did not need a specialist referral. Fourteen (14%) patients needing urgent treatment were identified. Usability was measured in duration for data input and reviewing which was an average of 9.2 min (median: 5.4; IQR: 3.4-8.7) for optometrists and 3.0 min (median: 3.0; IQR: 1.7-3.9) min for ophthalmologists. A variety of diagnosis was covered by this tool with dry age-related macular degeneration (n=34) being most common.

CONCLUSION

After implementation more than half of the HES referrals have been avoided. This platform offers a digital-first solution that enables rapid-access eye care for patients in community optometrists, facilitates communication between healthcare providers and may serve as a foundation for implementation of artificial intelligence.

United Kingdom Diabetic Retinopathy Electronic Medical Record (UK DR EMR) Users Group: report 4, real-world data on the impact of deprivation on the presentation of diabetic eye disease at hospital services

AIM

To assess the impact of deprivation on diabetic retinopathy presentation and related treatment interventions, as observed within the UK hospital eye service.

METHODS

This is a multicentre, national diabetic retinopathy database study with anonymised data extraction across 22 centres from an electronic medical record system. The following were the inclusion criteria: all patients with diabetes and a recorded, structured diabetic retinopathy grade. The minimum data set included, for baseline, age and Index of Multiple Deprivation, based on residential postcode; and for all time points, visual acuity, ETDRS grading of retinopathy and maculopathy, and interventions (laser, intravitreal therapies and surgery). The main  outcome measures were (1) visual acuity and binocular visual state, and (2) presence of sight-threatening complications and need for early treatment.

RESULTS

79 775 patients met the inclusion criteria. Deprivation was associated with later presentation in patients with diabetic eye disease: the OR of being sight-impaired at entry into the hospital eye service (defined as 6/18 to better than 3/60 in the better seeing eye) was 1.29 (95% CI 1.20 to 1.39) for the most deprived decile vs 0.77 (95% CI 0.70 to 0.86) for the least deprived decile; the OR for being severely sight-impaired (3/60 or worse in the better seeing eye) was 1.17 (95% CI 0.90 to 1.55) for the most deprived decile vs 0.88 (95% CI 0.61 to 1.27) for the least deprived decile (reference=fifth decile in all cases). There is also variation in sight-threatening complications at presentation and treatment undertaken: the least deprived deciles had lower chance of having a tractional retinal detachment (OR=0.48 and 0.58 for deciles 9 and 10, 95% CI 0.24 to 0.90 and 0.29 to 1.09, respectively); in terms of accessing treatment, the rate of having a vitrectomy was lowest in the most deprived cohort (OR=0.34, 95% CI 0.19 to 0.58).

CONCLUSIONS

This large real-world study suggests that first presentation at a hospital eye clinic with visual loss or sight-threatening diabetic eye disease is associated with deprivation. These initial hospital visits represent the first opportunities to receive treatment and to formally engage with support services. Such patients are more likely to be sight-impaired or severely sight-impaired at presentation, and may need additional resources to engage with the hospital eye services over complex treatment schedules.

Clinically applicable deep learning for diagnosis and referral in retinal disease

The volume and complexity of diagnostic imaging is increasing at a pace faster than the availability of human expertise to interpret it. Artificial intelligence has shown great promise in classifying two-dimensional photographs of some common diseases and typically relies on databases of millions of annotated images. Until now, the challenge of reaching the performance of expert clinicians in a real-world clinical pathway with three-dimensional diagnostic scans has remained unsolved. Here, we apply a novel deep learning architecture to a clinically heterogeneous set of three-dimensional optical coherence tomography scans from patients referred to a major eye hospital. We demonstrate performance in making a referral recommendation that reaches or exceeds that of experts on a range of sight-threatening retinal diseases after training on only 14,884 scans. Moreover, we demonstrate that the tissue segmentations produced by our architecture act as a device-independent representation; referral accuracy is maintained when using tissue segmentations from a different type of device. Our work removes previous barriers to wider clinical use without prohibitive training data requirements across multiple pathologies in a real-world setting.

Implementation of medical retina virtual clinics in a tertiary eye care referral centre

BACKGROUND

The increasing incidence of medical retinal diseases has created capacity issues across UK. In this study, we describe the implementation and outcomes of virtual medical retina clinics (VMRCs) at Moorfields Eye Hospital, South Division, London. It represents a promising solution to ensure that patients are seen and treated in a timely fashion METHODS: First attendances in the VMRC (September 2016-May 2017) were included. It was open to non-urgent external referrals and to existing patients in a face-to-face clinic (F2FC). All patients received visual acuity testing, dilated fundus photography and optical coherence tomography scans. Grading was performed by consultants, fellows and allied healthcare professionals. Outcomes of these virtual consultations and reasons for F2FC referrals were assessed.

RESULTS

A total number of 1729 patients were included (1543 were internal and 186 external referrals). The majority were diagnosed with diabetic retinopathy (75.1% of internal and 46.8% of external referrals). Of the internal referrals, 14.6% were discharged, 54.5% continued in VMRC and 30.9% were brought to a F2FC. Of the external referrals, 45.5% were discharged, 37.1% continued in VMRC and 17.4% were brought to a F2FC. The main reason for F2FC referrals was image quality (34.7%), followed by detection of potentially treatable disease (20.2%).

CONCLUSION

VMRC can be implemented successfully using existing resources within a hospital eye service. It may also serve as a first-line rapid-access clinic for low-risk referrals. This would enable medical retinal services to cope with increasing demand and efficiently allocate resources to those who require treatment.

Assessment of retinal vascular calibres as a biomarker of disease activity in birdshot chorioretinopathy

PURPOSE

Birdshot chorioretinopathy (BCR) is a potentially blinding ocular disorder involving the retinal vasculature and choroid without any systemic manifestations. The objective of the study was to describe vascular calibre changes in BCR and analyse the possibility of this optical biomarker for staging and monitoring disease activity in BCR.

METHODS

This retrospective case-control study at a tertiary referral eye centre in the UK included 33 eyes from 21 patients with BCR and equal number of eyes from control subjects. Diagnosis of BCR was confirmed on fundus fluorescein and indocyanine green angiography. Vascular calibres were measured using validated semiautomated software.

RESULTS

Patients with BCR had smaller retinal venular calibres central retinal venular equivalent (CRVE) than controls (211.3 versus 227.9 μm, p = 0.008). After adjusting for variables, the difference between the two groups for CRVE at baseline was statistically significant based on two different analysis methods. Central retinal venular equivalent (CRVE) was lower at the 6-month follow-up visit (206.2 versus 213.8 μm, p-value = 0.03), and arteriole-to-venule ratio was larger (0.74 versus 0.71, p = 0.04) in subjects with BCR. Arteriolar calibre (CRAE) remained the same.

CONCLUSION

This study provides novel insight into the pattern of vascular involvement in BCR. There was significant difference in the CRVE in patients with BCR. More studies are needed to correlate this data with visual function and treatment outcome and to validate the findings.

Neuropilin 1 Involvement in Choroidal and Retinal Neovascularisation

PURPOSE

Inhibiting VEGF is the gold standard treatment for neovascular age-related macular degeneration (AMD). It is also effective in preventing retinal oedema and neovascularisation (NV) in diabetic retinopathy (DR) and retinal vein occlusions (RVO). Neuropilin 1 (Nrp1) is a co-receptor for VEGF and many other growth factors, and therefore a possible alternative drug target in intra ocular neovascular disease. Here we assessed choroidal and retinal NV in an inducible, endothelial specific knock out model for Nrp1.

METHODS

Crossing Nrp1 floxed mice with Pdgfb-CreERT2 mice produced tamoxifen-inducible, endothelial specific Nrp1 knock out mice (Nrp1ΔEC) and Cre-negative, control littermates. Cre-recombinase activity was confirmed in the Ai3(RCL-EYFP) reporter strain. Animals were subjected to laser-induced CNV (532 nm) and spectral domain-optical coherence tomography (SD-OCT) was performed immediately after laser and at day 7. Fluorescein angiography (FA) evaluated leakage and postmortem lectin staining in flat mounted RPE/choroid complexes was also used to measure CNV. Furthermore, retinal neovascularisation in the oxygen induced retinopathy (OIR) model was assessed by immunohistochemistry in retinal flatmounts.

RESULTS

In vivo FA, OCT and post-mortem lectin staining showed a statistically significant reduction in leakage (p<0.05), CNV volume (p<0.05) and CNV area (p<0.05) in the Nrp1ΔEC mice compared to their Cre-negative littermates. Also the OIR model showed reduced retinal NV in the mutant animals compared to wild types (p<0.001).

CONCLUSION

We have demonstrated reduced choroidal and retinal NV in animals that lack endothelial Nrp1, confirming a role of Nrp1 in those processes. Therefore, Nrp1 may be a promising drug target for neovascular diseases in the eye.

Natural history and effect of therapeutic interventions on subretinal fluid causing foveal detachment in macular telangiectasia type 2

AIM

To report the natural history of subretinal fluid (SRF) causing foveal detachment in macular telangiectasia type 2 (MacTel) and our experience of therapeutic intervention with intravitreal steroids or antivascular endothelial growth factor inhibitor (anti-VEGF) agents in some cases.

METHODS

Retrospective case series. Three of the MacTel study's largest registries were searched to identify eyes with foveal detachment.

RESULTS

We identified 7 eyes from 6 exclusively female patients. The prevalence of foveal detachment was low, present in 1.4% of the assessed MacTel population. Age at presentation ranged from 50 to 66 years. Follow-up ranged from 2 to 8 years. There was late-phase leakage on fluorescein angiography from what was presumed to be ectatic capillaries. The SRF fluctuated without a rapid decline in visual acuity in cases that were not treated. When they were, intravitreal anti-VEGF and steroid therapy in general reduced SRF, at least temporarily, but did not halt the gradual long-term decrease in visual acuity. In one case, optical coherence tomography angiography showed significant reduction in the extent of the predominantly deep intraretinal vascular complex 1 month after anti-VEGF therapy.

DISCUSSION AND CONCLUSIONS

As the natural history of this unusual MacTel phenotype is not characterised by rapid visual decline, intervention with intravitreal anti-VEGF or steroid therapy may not be necessary.

Evaluation of Nonperfused Retinal Vessels in Ischemic Retinopathy

Purpose

Retinal ischemia has been traditionally assessed by fluorescein angiography, visualizing perfused vessels. However, this method does not provide any information about nonperfused vessels, and although it is often assumed that vessels in ischemic areas regress, we know little about how nonperfused retinal vessels change over time. Here, we aim to learn more about the long-term fate of nonperfused vessels in the retinal vasculature.

Methods

Optical coherence tomography (OCT) was used to visualize perfusion as well as structural properties of the retinal vasculature in patients suffering from retinal vascular occlusions. In addition, postmortem tissue from a patient with long standing (6 years) central retinal vein occlusion (CRVO) was investigated, using immunohistochemistry on whole-mount retina and paraffin sections to visualize blood vessel components.

Results

Comparing OCT angiography with enface OCT images revealed that in ischemic areas of the retina, nonperfused, larger vessels could be detected as hyperreflective structures in enface OCT images. Furthermore, analysis of a postmortem tissue sample from a CRVO patient with a large nonperfused region in the macula, revealed preservation of the basement membrane from all retinal vessels, including nonperfused, acellular vessels of all calibers.

Conclusions

Our data suggests long-term preservation of vascular basement membrane in ischemic retina. This has implications for therapeutic approaches aiming to alleviate retinal ischemia via the regeneration of damaged vessels.

The Evaluation of Diabetic Macular Ischemia Using Optical Coherence Tomography Angiography

PURPOSE

The purpose of this study was to compare optical coherence tomography (OCT) angiography to standard fluorescein angiography (FA) in the grading of diabetic macular ischemia.

METHODS

In our study, OCT angiography and traditional FA images were acquired from 24 diabetic patients. The level of diabetic macular ischemia in the superficial capillary plexus was graded with standard Early Treatment Diabetic Retinopathy Study (ETDRS) protocols and a comparison between conventional FA and OCT angiography was performed. The deep vascular plexus and choriocapillaris were also graded for macular ischemia. Additionally, flow indices were analyzed for all OCT angiography images.

RESULTS

We identified moderate agreement between diabetic macular ischemia grades for conventional FA and OCT angiography (weighted κ of 0.53 and 0.41). In addition, the intergrader agreement for the superficial, deep, and choriocapillaris scores was substantial (weighted κ of 0.65, 0.61, and 0.65, respectively). Finally, the parafoveal flow indices were shown to have a statistically significant relationship with diabetic macular ischemia grades for the superficial capillary plexus (P = 0.04) and choriocapillaris (P = 0.036), with a trend toward significance for the deep capillary plexus (P = 0.13).

CONCLUSIONS

We demonstrated moderate agreement between diabetic macular ischemia grading results for OCT angiography and conventional FA using standard ETDRS protocols. We also showed that OCT angiography images could be graded for diabetic macular ischemia with substantial intergrader agreement.

Quantitative analysis of vitreous inflammation using optical coherence tomography in patients receiving sub-Tenon's triamcinolone acetonide for uveitic cystoid macular oedema

BACKGROUND/AIMS

To evaluate the vitreous signals obtained on spectral domain optical coherence tomography (SD-OCT) in patients with uveitic cystoid macular oedema (CMO) and compare these signals before and after sub-Tenon's triamcinolone acetonide injection.

METHODS

Retrospective study with standardised longitudinal imaging preintervention and postintervention. The study cohort comprises 22 patients (22 eyes) with uveitic CMO receiving a sub-Tenon's triamcinolone acetonide (STTA) injection. Post hoc analysis of SD-OCT images using custom software provided an 'absolute' measurement of vitreous signal intensity, which was expressed as a ratio to the retinal pigment epithelium intensity ('VIT/RPE-relative intensity') in arbitrary units.

MAIN OUTCOME MEASURE

Difference in VIT/RPE-relative intensity before and after treatment.

RESULTS

Treatment with STTA resulted in a significant reduction in VIT/RPE-relative intensity, which was associated with both a reduction in central retinal thickness (CRT) and improvement in visual acuity. Mean (SD) VIT/RPE-relative intensity pretreatment was 0.139 (0.074) versus 0.053 (0.028) post-treatment (p=3×10^-5). Mean (SD) CRT was 581 μm (119 μm) pretreatment versus 333 μm (95 μm) post-treatment (p=2×10^-8); the mean reduction in CRT was 248 (95% CI 189 to 306). The correlation coefficient between VIT/RPE-relative intensity and CRT was 0.534 (p=0.011) and between VIT/RPE-relative intensity and visual acuity was 0.702 (p=0.0001).

CONCLUSIONS

This study provides evidence that the OCT-derived VIT/RPE-relative intensity may be useful as a quantitative and objective marker of disease activity and treatment response in uveitis complicated by CMO. This first longitudinal study of this novel OCT parameter is an encouraging step in the development of sensitive objective OCT-based endpoints for trials of efficacy in uveitis.

The Evolution of Teleophthalmology Programs in the United Kingdom: Beyond Diabetic Retinopathy Screening

Modern ophthalmic practice in the United Kingdom is faced by the challenges of an aging population, increasing prevalence of systemic pathologies with ophthalmic manifestations, and emergent treatments that are revolutionary but dependent on timely monitoring and diagnosis. This represents a huge strain not only on diagnostic services but also outpatient management and surveillance capacity. There is an urgent need for newer means of managing this surge in demand and the socioeconomic burden it places on the health care system. Concurrently, there have been exponential increases in computing power, expansions in the strength and ubiquity of communications technologies, and developments in imaging capabilities. Advances in imaging have been not only in terms of resolution, but also in terms of anatomical coverage, allowing new inferences to be made. In spite of this, image analysis techniques are still currently superseded by expert ophthalmologist interpretation. Teleophthalmology is therefore currently perfectly placed to face this urgent and immediate challenge of provision of optimal and expert care to remote and multiple patients over widespread geographical areas. This article reviews teleophthalmology programs currently deployed in the United Kingdom, focusing on diabetic eye care but also discussing glaucoma, emergency eye care, and other retinal diseases. We examined current programs and levels of evidence for their utility, and explored the relationships between screening, teleophthalmology, disease detection, and monitoring before discussing aspects of health economics pertinent to diabetic eye care. The use of teleophthalmology presents an immense opportunity to manage the steadily increasing demand for eye care, but challenges remain in the delivery of practical, viable, and clinically proven solutions.