Search

Objective: The Eye Institute of Alberta Emergency Eye Clinic (EIA EEC) is a tertiary eye care centre that provides emergency eye services to a population of more than 1 million. The purpose of this study was to describe the epidemiology of ocular emergencies at the EIA EEC., Design: Prospective epidemiologic study based on secondary use of patient data., Participants: All patients seen in the EIA EEC on weekdays between July 2020 and June 2021., Methods: Charts were reviewed to obtain patient demographics, referral details, final diagnoses, need for imaging, emergency procedures, or further referrals. SPSS Statistics was used for data analysis., Results: A total of 2586 patients were seen over the study period. Most of the referrals (58%) were from emergency physicians. Optometrists and general physicians contributed 14% and 11% of referrals, respectively. Most referral diagnoses were related to inflammation (32%), and trauma (22%). Of all the cases of inflammation, 41% involved infection of the eye and 8% involved infection of ocular adnexa. In addition, 44% and 7% of cases involved noninfectious inflammation of the eye and adnexa, respectively. Frequently preformed emergency procedures were corneal or conjunctival foreign-body removal (39%) and corneal scraping (14%)., Conclusions: Continuing education related to emergency eye care may be most beneficial to emergency physicians, general practitioners, and optometrists. Educational opportunities could focus on most frequently seen diagnostic categories such as inflammation and trauma. Targeted public education aimed at preventing ocular trauma and infection, such as promoting wearing eye protection and practicing contact lens hygiene, may be beneficial., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: In Canada, there is a recognized underrepresentation of women in the field of surgery. However, the extent to which this trend applies across various surgical specialties is not well delineated. The aim of this study is to identify existing disparities and trends over time to inform the need for future interventions to make the match process more equitable for applicants., Methods: Data regarding surgical specialty applicants was extracted from the Canadian Resident Matching Service (CaRMS)'s 2003 to 2022 reports., Results: A total of 9,488 applicants ranked surgical specialties as their first choice from 2003-2022. Increases in the proportion of women applicants comparing periods 2003-2007 to 2018-2022 were significant for cardiac surgery (22% to 43%, p = 0.03), general surgery (46% to 60%, p<0.001), orthopedic surgery (23% to 35%, p<0.001), urology (23% to 38%, p<0.001), and all aggregated surgical specialties ('all surgery') (45% to 55%, p<0.001). An increase in the proportion of women applicants who matched over the same periods was observed for general surgery (+47% to 60%, p<0.001), orthopedic surgery (24% to 35%, p<0.01), urology (21% to 34%, p<0.001), and all surgery (46% to 54%, p<0.001). From 2003-2022, a lower match rate for women compared to men was observed for otolaryngology (0.60 v 0.69, p = 0.008), urology (0.61 v 0.72, p = 0.003), and all surgery (0.71 v 0.73, p = 0.038), while higher match rates were observed for ophthalmology (0.65 v 0.58, p = 0.04). No statistically significant differences in match rate were observed from 2018-2022., Conclusions: While the proportion of women applicants to surgical specialties in Canada has been increasing, women remain underrepresented in several surgical specialties. This underrepresentation cannot be solely attributed to fewer women applying to these specialties, as women experience lower success rates when matching to specific surgical specialties. Further research is essential to identify and address the underlying causes of these disparities., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Bondok et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To create a standardized undergraduate medicine ophthalmology curriculum for Canadian medical schools., Design: Two-stage modified Delphi technique., Participants: Undergraduate ophthalmology leads at all the medical schools in Canada and 6 nonophthalmologist physicians with medical education expertise., Methods: In stage 1, a preliminary list of curricular objectives was developed using the 2018 Association of University Professors in Ophthalmology's list of curricular objectives as a foundation. Subsequently, an online survey was sent to 24 individuals (18 ophthalmology undergraduate curriculum leads and 6 non-ophthalmology medical educators) at 17 institutions to evaluate the objectives using a 5-point Likert-type scale. In stage 2, the ophthalmology curriculum leads were invited to participate in a virtual meeting during which the list of curricular objectives was discussed and finalized by consensus., Results: In stage 1, a preliminary list of 76 learning objectives organized into 10 overarching topics was developed. A total of 21 survey responses were received (87.5% response rate), allowing for the creation of a revised list. In stage 2, five participants from four schools met, achieving consensus following one round of feedback. The final undergraduate ophthalmology curriculum contained 10 topics and 75 objectives; it covered common presentations of a variety of acute and chronic eye diseases that were felt to be relevant to a wide medical audience., Conclusions: The consensus obtained on a comprehensive list of undergraduate medicine ophthalmology curricular objectives identified in this study is the first of its kind in Canada. These objectives can be used by medical schools across Canada to standardize undergraduate ophthalmology teaching., (Copyright © 2023 Canadian Ophthalmological Society. All rights reserved.)

Background: Applicants to ophthalmology have high rates of going unmatched during the CaRMS process, but how this compares to other competitive or surgical specialties remains unclear. Our research aims to examine this phenomenon by identifying trends and comparing match data with other specialties, to identify disparities that may inform the need for future interventions to improve the match process for applicants., Methods: We used a cross-sectional analysis of data provided by CaRMS on the residency match from 2013 to 2022., Results: We obtained data from 608 ophthalmology, 5,153 surgery, and 3,092 top five (most competitive) specialty first choice applicants from 2013-2022. Ophthalmology applicants were more likely to go unmatched (18.9% [120/608]) than applicants to the top five (11.9% [371/3,092]) and surgical (13.5% [702/5,153]) specialties (p<0.001) and were twice as likely to rank no alternate disciplines (31.8%, p < 0.001) over the study period. In the first iteration, when alternate disciplines were ranked, the match rate to alternate disciplines was highest for ophthalmology applicants (0.41, p < 0.001). The majority (57.8%) of unmatched ophthalmology applicants do not participate in the second iteration., Conclusion: Compared to other competitive specialties, first choice ophthalmology applicants were more likely to go unmatched, rank no alternate disciplines, and choose not to participate in the second iteration. Ophthalmology applicant behaviours should be further studied to help explain these study findings., Competing Interests: The authors have no financial or proprietary interest in any materials discussed in this article., (© 2024 Bondok, Bondok, Law, Nathoo, Damji; licensee Synergies Partners.)

Objective: Lengthy wait times for cataract surgery can negatively affect patients' quality of life and increase the incidence of falls and depression. The COVID-19 pandemic has presented significant challenges to the delivery of elective cataract surgeries. The effects of the COVID-19 pandemic on cataract surgery wait times in the Alberta Health Services' Edmonton zone were studied by examining the wait times before and during the pandemic., Methods: This study was conducted based on a retrospective population-based design. Data were compiled from a centralized database related to hospital-based cataract surgery (Royal Alexandra, Fort Saskatchewan, and WestView Health Centre) between April 2019 and March 2022 (i.e., 3 fiscal years)., Results: The average wait time for cataract surgery increased from 14.4 ± 1.4 weeks in 2019-2020 to 18.2 ± 2.7 weeks in 2020-2021 (p = 0.005) and then decreased to 11.5 ± 1.3 in 2021-2022 (p < 0.001). The number of completed surgeries decreased from 13,103 in 2019-200 to 9,308 (p = 0.09) and 10,365 (p = 0.1) during the next 2 years. The annual operating room time for scheduled cases was reduced to 4463 hours (p = 0.42) and 4552 hours (p = 0.15) during the pandemic compared with 5541 hours before the pandemic. However, the average waitlist size decreased from 6629 at the end of 2019-200 to 6122 (p = 0.029) and 4011 (p < 0.001) during the next 2 years., Conclusion: The COVID-19 pandemic resulted in significantly increased average wait times for elective cataract surgery during the first year of the pandemic. Because of a reduction of the waitlist size, the wait times decreased during the second year of the pandemic., (Copyright © 2022 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: Post-stroke visual impairment (VI) is a common but under-recognized care challenge. Common manifestations of post-stroke VI include: diplopia, homonymous hemianopia, oscillopsia secondary to nystagmus, and visual inattention or neglect. In acute care settings, post-stroke VI recognition and treatment are often sub-optimal as emphasis is placed on survival. Stroke survivors with VI often face inconsistencies when accessing care out of hospital because variable availability and subsidization of visual rehabilitation. We sought to identify gaps in care experienced by stroke survivors with VI from stroke survivors' and care providers' perspectives., Methods: We conducted a qualitative description study across 12 care sites in Alberta, Canada, using semi-structured interviews. Survivor interviews focused on the health system experience. Provider interviews discussed approaches to care, perceived gaps, and current resources. Interviews were audio-recorded and transcribed. Iterative content analysis was completed using NVivo 12. We promoted rigour through an audit trail, open-ended questions, thick description, and collaborative coding., Results: We completed 50 interviews: 19 survivor interviews and 31 provider interviews. The majority of survivors were male (n = 14) and recruited from community settings (n = 16). Providers varied in profession and location within the care continuum. Two key themes emerged from the provider and survivor interviews pertaining to (a) facets of visual rehabilitation (sub-themes: access, resources, and multidisciplinary professional interaction); and (b) functioning with post-stroke VI (sub-themes: early experiences post-stroke and living with VI in the real world)., Conclusions: The visual rehabilitation model needs to be optimized to ensure transparent inter-disciplinary communication and efficient referral pathways. Future research will focus on evaluating the effectiveness of post-stroke care from multiple perspectives in Alberta., (© 2023. The Author(s).)

Exfoliation syndrome presents as an accumulation of insoluble fibrillar aggregates that commonly correlates with age and causes ocular complications, most notably open-angle glaucoma. Despite advances in understanding the pathogenesis and risk factors associated with exfoliation syndrome, there has been no significant progress in curative pharmacotherapy of this disease. It is thought that the ability to target the fibrillar aggregates associated with exfoliation may offer a new therapeutic approach, facilitating their direct removal from affected tissues. Phage display techniques yielded two peptides (LPSYNLHPHVPP, IPLLNPGSMQLS) that could differentiate between exfoliative and non-affected regions of the human lens capsule. These peptides were conjugated to magnetic particles using click chemistry to investigate their ability in targeting and removing exfoliation materials from the anterior human lens capsule. The behavior of the fibrillar materials upon binding to these magnetic particles was assessed using magnetic pins and rotating magnetic fields of various strengths. Ex vivo studies showed that the magnetic particle-peptide conjugates could generate enough mechanical force to remove large aggregates of exfoliation materials from the lens capsule when exposed to a low-frequency rotating magnetic field (5000 G, 20 Hz). Biocompatibility of targeting peptides with and without conjugated magnetic particles was confirmed using MTT cell toxicity assay, live/dead cell viability assay, and DNA fragmentation studies on primary cultured human trabecular meshwork cells. This is a novel, minimally invasive, therapeutic approach for the treatment of exfoliation glaucoma via the targeting and removal of exfoliation materials that could be applied to all tissues within the anterior segment of the eye., (© 2022. The Author(s).)

Objective: To compare costs between two different eye drop delivery modalities: multidose bottles and single-use minims., Design: Retrospective cohort study., Methods: Monthly dilating eye drop costs and quantities (tropicamide 1%, phenylephrine 2.5%, cyclopentolate 1%) were studied over a 2-year period between April 2013 and March 2015 at 2 tertiary ophthalmic centres (Royal Alexandra Hospital [RAH, Edmonton] and Rockyview General Hospital [RGH, Calgary]). In April 2014, RAH switched its dilating eye drop practice from predominantly multidose bottles to single-use minims, whereas RGH continued using predominantly multidose bottles. Eye drop volume and total and per-patient eye drop costs were quantified at RAH before switching (pre-intervention) and after (post-intervention) using an interrupted time-series analysis with RGH as a control. A counterfactual analysis was also performed. Significance was obtained using independent t-testing., Results: After switching to single-use minims, RAH experienced changes in the following: an increase in single-use minims as a proportion of total eye drop utilization (from 5.6% to 89.1%; p = 0.001), an increase in total eye drop cost by $2117 per month (95% confidence interval [CI], $1354-$2880; p < 0.001), an increase in per-patient costs by $984 per 1000 patients per month (95% CI, $674-$1293). Contrastingly, RGH did not experience similar changes. Ultimately, the cost of switching to single-use minims was $22 481 (95% CI, $7830-$31 336) over a 12-month period., Conclusions: If safe eye drop practices are enforced via proper protocols, the use of multidose bottles may be a more cost-effective option than single-use minims for routine clinical practice., (Copyright © 2021 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the incidence and risk factors for steroid response in patients undergoing combined phacoemulsification cataract extraction (PCE) and microinvasive glaucoma surgery with either trabecular microbypass stent implantation (iStent) or ab interno trabeculectomy (Trabectome)., Design: Retrospective, noncomparative, single-institutional observational chart review., Participants: Consecutive patients with open-angle glaucoma who underwent PCE with iStent or Trabectome with 3 months of follow-up., Methods: Data were collected from patient charts, including pre- and postoperative intraocular pressure (IOP) following application of topical corticosteroid on postoperative visits for at least 3 months. A steroid response was defined as an IOP rise of greater than 5 mm Hg beginning at least 3 days after surgery with no other obvious explanation and with IOP < 20 mm Hg following rapid tapering or withdrawal of the steroid., Results: A total of 118 eyes from 89 patients, average age of 71.4 ±12.1 years, were included. Overall, a steroid response was seen in 12.7% of eyes (n = 15), and no difference was noted between Trabectome (11.8%) and iStent (13.6%, p = 0.782) eyes. Axial length (AL; p = 0.01), younger age (p = 0.009), traumatic glaucoma (p = 0.004), and normal-tension glaucoma (NTG; p = 0.0048) were significant predictors of steroid response in a multivariate analysis. In eyes with AL ≥ 25 mm, the steroid response rate was 40%, in contrast to eyes with AL < 25 mm, where it was 10.2%., Conclusion: A steroid response develops in approximately 1 in 8 patients undergoing PCE with Trabectome or iStent. Young age, AL > 25 mm, traumatic glaucoma, and NTG were found to be significant predictors of steroid response., (Copyright © 2021 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors have no proprietary or commercial interest in any materials discussed in this article.

Purpose: The purpose of this paper is to evaluate leadership training in the Sandwich Glaucoma Fellowship (SGF), a program in which fellows learn skills in a developed world institution and their home country to become leaders in glaucoma care., Design/methodology/approach: This paper is a retrospective, qualitative and quantitative evaluation. Participants of the SGF between 2007 and 2019 were provided a survey eliciting demographic information, leadership training exposure, development of leadership competencies and feedback for the fellowship program., Findings: Seven of nine alumni responded. The fellowship strongly impacted leadership competencies including integrity (8.8, 95% CI 7.8-9.8), work ethic (8.64, 95% CI 7.7-9.6) and empathy (8.6, 95% CI 7.7-9.5). A total of 85% of alumni indicated positive changes in their professional status and described an increasing role in mentorship of colleagues or residents as a result of new skills. Lack of formal leadership training was noted by three respondents. Informal mentorship equipped fellows practicing in regions of Sub Saharan Africa with competencies to rise in their own leadership and mentoring roles related to enhancing glaucoma management. Suggested higher-order learning objectives and a formal curriculum can be included to optimize leadership training catered to the individual fellow experience., Originality/value: Leadership is necessary in health care and specifically in the context of low- and middle-income countries to bring about sustainable developments. The SGF contains a unique "Sandwich" design, focusing on the acquisition of medical and leadership skills. This evaluation outlines successes and challenges of this, and similar fellowship programs. Other programs can use a similar model to promote the development of skills in partnership with the fellows' home country to strengthen health-care leaders., (© Emerald Publishing Limited.)

Precis: A teleglaucoma (TG) case-finding model was used in Kenya. Of the patients, 3.46% had definite glaucoma and 4.12% were glaucoma suspects. Most cases were of moderate to advanced stage and referred for further assessment., Purpose: The aim was to evaluate glaucoma prevalence in a high-risk population using a TG model., Methods: Patients aged 35 or over were referred to the TG program from the outpatient diabetic and hypertensive clinics at Nyamira District Hospital (NDH) and from community awareness programs. Comprehensive ophthalmic examination included structured history, visual acuity, intraocular pressure, central corneal thickness, stereoptic nerve, and macular images. A glaucoma specialist provided diagnosis and management recommendation through virtual consultation. Glaucoma diagnosis and staging were based on at least 1 eye meeting the optic nerve criteria as specified by the Canadian glaucoma guidelines., Results: In all, 1206 participants were seen and 19 of these could not complete the examination. Of 1187 patients, 56% were women and the mean age was 56.60±12.36 years. Of the patients, 11.8% had images that were ungradable in at least 1 eye. The prevalence of glaucoma and glaucoma suspects was 3.46% (n=42) and 4.12% (n=50), respectively. The proportion of patients with early, moderate, advanced, and absolute glaucoma was 2.4%, 33.3%, 52.4%, and 2.4%, respectively. Other diagnoses (pathology in at least 1 eye) included cataract in 13.2%, diabetic retinopathy in 1.48%, and optic atrophy in 1.98%. Of the patients, 28.2% were referred to the Innovation Eye Centre, Kisii, for further assessment., Conclusion: A structured TG program detected glaucoma in 3.46% of a rural Kenyan population. Timely patient referral was also initiated., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Exfoliation syndrome is largely considered an age-related disease that presents with fibrillar aggregates in the front part of the eye. A growing body of literature has investigated structural diversity of amyloids and fibrillar aggregates associated with neurodegenerative disease. However, in case of exfoliation syndrome, there is a dearth of information on the biophysical characteristics of these fibrils and structural polymorphisms. Herein, structural diversity of fibrils isolated from the anterior lens capsule of patients was evaluated using transmission electron microscopy techniques. It was apparent that, despite having a low sample number of different patients, there exists a wide range of fibril morphologies. As it is not precisely understood how these fibrils form, or what they are composed of, it is difficult to postulate a mechanism responsible for these differences in fibril structure. However, it is apparent that there is a wider range of fibril structure than initially appreciated. Moreover, these data may suggest the variance in fibril structure arises from patient-specific fibril composition and/or formation mechanisms.

Background: Selective laser trabeculoplasty (SLT) is a safe and effective treatment modality for lowering intraocular pressure (IOP)., Purpose: To determine the efficacy and safety of SLT among Ethiopian patients with primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PXG), and ocular hypertension (OHT)., Method: A prospective, nonrandomized interventional study was conducted at Menelik II Hospital, Ethiopia. Patients on antiglaucoma medication with uncontrolled IOP and those patients treated for the first time with 360 degrees of SLT were included. Success was defined as an IOP lowering of > 20% from baseline without repeat treatment., Result: A total of 95 eyes of 61 patients with a diagnosis of OAG and OHT were enrolled. The diagnosis was POAG in 55 (57.9%) eyes, PXG in 22 (23.2%) eyes, and OHT in 18 (18.9%) eyes. Seventy (73.7%) eyes were on medications, and 25 (26.3%) eyes were treated with laser as primary therapy. The mean (SD) baseline IOP and medication were 24.3 ± 2.5 mmHg and 1.29 ± 1.01, respectively. The one-year mean (SD) IOP reduction was 6.7 ± 4.2 mmHg and medication reduction was 0.26 ± 1.34. The overall IOP reduction at 12 months was 27.6%, and the success rate was 60%. The mean IOP (SD) reduction for patients who were treated for the first time with laser and on antiglaucoma medication was 6.5 ± 3.1 mmHg and 6.8 ± 2.8 mmHg, respectively. Post-SLT, patients experienced transient ocular pain, brow ache, headache, and/or blurring of vision in 31.6%, anterior chamber reaction in 36.8%, and IOP spike ≥ 6 mmHg in 11.6%., Conclusion: SLT is an effective and safe treatment modality for OHT, POAG, and PXG among Ethiopian patients either as a first-line treatment or as an adjunct to topical glaucoma treatment., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2020 Jibat Gemida Soboka et al.)

Purpose: This study compares a web-based teleophthalmology assessment with a clinical slit lamp examination to screen for diabetic retinopathy (DR) and age-related macular degeneration (AMD) among diabetic patients in a rural East African district., Methods: Six hundred and twelve eyes from 306 diabetic patients underwent both a clinical slit lamp examination and a teleretina (TR) assessment by an experienced ophthalmologist. Both assessments were compared for any DR and AMD using the early treatment diabetic retinopathy study and age-related eye disease study grading scales, respectively., Results: Of the 612 TR assessment photos, 74 (12%) were deemed ungradable due to media opacities, poor patient cooperation, or unsatisfactory photographs. The ability to detect DR and AMD showed a fair agreement (kappa statistic 0.27 and 0.23, respectively) between the TR and clinical slit lamp examination. Relative to a clinical slit lamp evaluation, a positive TR diagnosis carried a 75.0% positive predictive value when diagnosing DR and a 27.3% positive predictive value when diagnosing AMD. A negative TR diagnosis carried a 97.2% negative predictive value for the diagnosis of DR and a 98.1% negative predictive value for the diagnosis of AMD., Conclusion: When comparing TR assessments to clinical slit lamp examinations to diagnose DR and AMD, there was a fair agreement. Although further validation is needed, the TR approach provides a promising method to diagnose DR and AMD, two major causes of ocular impairment worldwide., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Middle East African Journal of Ophthalmology.)

Objective: This study was done to determine the validity of amsler grid test black on white (BOW), as well as white on black (WOB) for identifying central visual field (VF) defects in patients with advanced glaucoma., Design: Prospective study., Participants: We prospectively included 100 consecutive eyes of 88 adult patients with advanced glaucoma and 100 eyes of 100 normal individuals. We used a lottery method to choose the side of the eye for the control groups., Methods: All participants had reliable Humphrey 10-2 Swedish Interactive Threshold Algorithm (SITA) standard VF. Both the BOW and WOB amsler grid tests were done for each group. Sensitivity, specificity, and positive and negative predictive values of the amsler grid scotoma area were calculated with the 10-2 VF as the reference standard., Results: The mean ± standard deviation (SD) of age and the 10-2 VF mean deviation (MD) of advanced glaucoma eyes were 59.8 ± 11.8 (range 34-84) years and -19.94 ± 9.8(range -34.98--0.52) respectively. Among 108 eyes with normal 10-2 VF test, 103 had a normal BOW amsler grid test and 5 had an abnormal BOW test. Among 92 eyes with an abnormal 10-2 VF test, 74 had an abnormal and 18 had normal BOW amsler grid test. Sensitivity, specificity, and positive and negative predictive values of the BOW amsler grid test were 80.4%, 95.4%, 93% and 85.1% respectively whereas that of the WOB amsler grid test were 71.7%, 95.4%, 93% and 72.8% respectively., Conclusion: The sensitivity and specificity of both BOW and WOB amsler grid tests were high in detecting VF defects in advanced glaucoma., Competing Interests: The authors have declared that no competing interest exist.

Exfoliation syndrome is generally considered a progressive age-related systemic disorder of the extracellular matrix, which is clinically characterized through the observation of flaky white aggregates on ocular tissues. Exfoliation syndrome is directly linked to exfoliative glaucoma in elderly patients, where it is known as the most common identifiable cause of open-angle glaucoma. Despite the identification of various risk factors associated with exfoliation syndrome, the exact pathogenesis of this syndrome has not been fully elucidated. There is a growing number of genome-wide association studies in different populations around the world to identify genetic factors underlying exfoliation syndrome. Besides variants in LOXL1 and CACNA1A genes, new loci have been recently identified which are believed to be associated with exfoliation syndrome. Among different genetic factors, functional variants might help to better understand mechanisms underlying this systemic disorder. Besides genetic factors, epigenetic regulation of different gene expression patterns has been thought to play a role in its pathogenesis. Other factors have been also considered to be involved in the development of exfoliation syndrome at cellular organelles level where mitochondrial impairment and autophagy dysfunction have been suggested in relation to exfoliation syndrome. This review addresses the most recent findings on genetic factors as well as cellular and molecular mechanisms involved in both the development and progression of exfoliation syndrome., (© 2019 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Objective: To describe a teaching model for aqueous tube shunt surgery using freshly enucleated pig eyes., Design: A descriptive methods report, containing a small prospective noncomparative interventional case series., Participants: Six ophthalmology residents from the University of Alberta program., Methods: A descriptive report outlines the materials and methods required for creating a surgical wet lab that teaches aqueous draining device implantation. Residents practiced each step associated with the insertion of plated aqueous tube shunt devices in porcine eyes., Results: The porcine model worked well to demonstrate and perform steps associated with tube implant surgery. Trainee comfort improved in all surgical steps practiced during the session when reassessed at 3-month follow-up: priming and anchoring the drainage device (p = 0.042), inserting the tube into the eye (p = 0.025), creating and securing a scleral patch graft (p = 0.034), and closure of the conjunctiva (p = 0.034). Overall confidence in performing tube shunt surgery also remained above baseline at follow-up (p = 0.042)., Conclusions: Implantation of tube shunt devices in the porcine model closely resembles surgery in human eyes. Practicing each step associated with tube shunt surgery on porcine eyes in a supervised wet-lab environment improves trainee confidence in the procedure., (Copyright © 2019 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Precis: A teleglaucoma case-finding model was utilized in Ethiopia using a high-risk case identification approach. An overall 7.9% of patients had definite glaucoma, and 13.8% were glaucoma suspects. Most cases could be managed medically., Background: This study was carried out to analyze disease prevalence and clinical referral pathways for high-risk patients assessed through a hospital-based teleglaucoma case-finding program., Methods: Patients over the age of 35 years were referred from outpatient diabetic and hypertensive clinics. Through a teleglaucoma consultation, a glaucoma specialist provided remote diagnosis and management recommendations. Patient referral pathways were analyzed. Part way through the program, frontline ophthalmic nurses and optometrists were empowered to refer patients to be seen by general ophthalmologists within a week if patients met high-risk criteria. Qualitative stakeholder feedback was also obtained., Results: A total of 1002 patients (53% female) were assessed with a mean age of 51.0±11.7 years. The prevalence of glaucoma and glaucoma suspects was 7.9% (79 cases) and 13.8% (138 cases), respectively. Retinopathy was found in 9.1%, with hypertensive retinopathy (2.7%) and diabetic retinopathy (2.5%) representing the majority of cases. Age-related macular degeneration was present in 1.5% and cataract in 16%. An overall 63% of cases were without organic eye disease. 35% of patients were referred to a general ophthalmologist, 0.7% to a glaucoma specialist (for surgery), 1.5% to a retina specialist, and 17.7% to an optometrist for further care. Qualitative analysis revealed that stakeholders felt the value of teleglaucoma would be in triaging patients requiring more urgent management and in identifying disease at an earlier stage., Conclusions: There is a high prevalence of glaucoma in Ethiopian patients assessed through this teleglaucoma program. This model and study have also demonstrated various principles behind telemedicine, such as the development of an intelligent triage system, case-finding for a variety of diseases, and consideration of optimal patient flow/referral pathways.

Objective: To evaluate preoperative testing for cataract surgery, implement stakeholder-driven change, and increase the number of patients who arrived for surgery with complete preoperative requirements, for the purpose of delivering safe, high-quality, and cost-effective care for patients., Design: Quality improvement., Participants: Cataract surgery patients, health care staff in Ophthalmology Day Surgery, an Ophthalmology improvement team, the Clinical Section Heads of Ophthalmology and Anaesthesia, Quality Consultants, and members of the Quality Council participated in this study., Methods: A lean quality improvement approach was used to define and build understanding of the problem. Between July and November 2016, a chart-based reporting system captured all patients who arrived for cataract surgery with expired or incomplete preoperative requirements. A cost analysis was completed, and evidence was reviewed to ensure alignment with best practice preoperative recommendations., Results: On average, 25% (619/2451 over a 17-week period) of patients per day arrived at the Ophthalmology Day Surgery for cataract surgery with incomplete and/or expired physical history forms and ECGs. An improvement team worked to implement a radical improvement idea and relied on an existing questionnaire to ensure patient safety preoperatively., Conclusions: Based on the literature, best practice guidelines, and a cost analysis, it was decided that patients undergoing routine cataract surgery in Edmonton Zone Hospitals under regional anaesthesia would no longer require physician history and physicals and ECGs. Elimination of the preoperative requirements for all but select high-risk patients meant that 100% of patients who arrived for cataract surgery would not have outstanding presurgery requirements., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: The effectiveness of selective laser trabeculoplasty (SLT) was compared with argon laser trabeculoplasty (ALT) in a randomized clinical trial for patients with medically uncontrolled open-angle glaucoma who have previously received 360° SLT., Design: An active equivalence parallel armed randomized control trial., Participants: Patients with open-angle glaucoma including pigmentary dispersion syndrome and pseudoexfoliation syndrome were enrolled into the study from 7 different sites across Canada., Methods: One setting of 180° of either SLT or ALT was assigned randomly and applied to each participant., Main Outcome Measures: The change in intraocular pressure (IOP) from baseline to 12 months was compared between the 2 groups., Results: A total of 132 patients were recruited, 2 of which dropped out early in the study, leaving 130 patients who completed the study as per protocol. For those, the study's primary outcome was calculated. The IOP change at 1 year in comparison to baseline for SLT vs. ALT was found to be different by 0.33 mmHg between the 2 groups (3.16 for SLT and 2.83 for ALT) and was not statistically significant (P = 0.71) Further analysis, though, showed that SLT had a significantly lower IOP reduction at early time points: 1 week and 1 month, but this effect was lost by 3 months. Corresponding to this finding was the strong trend for ALT to fail more quickly than SLT. Although repeatable, the first repeat SLT reduced IOP to only about half compared with initial SLT treatment., Conclusions: The comparison at 12 months following the laser therapy showed that both modalities lowered the IOP with approximately 3 mmHg, yet essentially all of the time-to-failure analyses favored SLT over ALT. The repeat SLT effect was found to be half of the initial treatment., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the efficacy and safety of ab interno trabeculectomy with the Trabectome combined with cataract surgery (phaco-AIT) versus Trabeculectomy with mitomycin C combined with cataract surgery (phaco-Trab) in open-angle glaucoma., Methods: A prospective randomized controlled trial with a single surgeon and surgical center was undertaken. Patients were recruited from July 2009 to October 2014. Primary outcomes were mean intraocular pressure (IOP) at 6 months and surgical complications. Secondary outcomes were mean IOP at 12 months, achievement of target IOP, number of glaucoma medications, and rate of secondary surgery., Results: The trial was ended early before achieving our intended sample size due to difficulties in recruitment and lack of clinical equipoise over time. Nineteen patients were enrolled, 10 phaco-AIT and 9 phaco-Trab. Baseline IOP was 20.0 ± 5.3 in phaco-AIT and 23.1 ± 6.4 mm Hg in phaco-Trab (p = 0.22). IOP decreased to 17.5 ± 3.8 and 16.0 ± 6.0 mm Hg at 6 months (p = 0.54), and 16.8 ± 2.7 and 17.1 ± 5.0 mm Hg at 1 year (p = 0.57), respectively. Mean number of glaucoma medications at baseline was 1.8 ± 1.3 in phaco-AIT and 1.4 ± 1.1 in phaco-Trab (p = 0.59). Mean number of glaucoma medications decreased to 0.78 ± 1.39 and 0.38 ± 0.74 at 6 months (p = 0.68), and 0.44 ± 0.88 and 0.75 ± 0.89 at 1 year (p = 0.41), respectively. Mild and moderate complications were seen in both treatment groups, but severe complications were seen only in phaco-Trab. One secondary glaucoma procedure was required in the phaco-AIT group., Conclusions: Phaco-AIT achieved similar IOP lowering at 6 and 12 months compared with phaco-Trab with a similar number of glaucoma medications required at 1 year, and no serious complications were identified in the Phaco-AIT group., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background/aims: Teleophthalmology is well positioned to play a key role in screening of major chronic eye diseases. Economic evaluation of cost-effectiveness of teleophthalmology, however, is lacking. This study provides a systematic review of economic studies of teleophthalmology screening for diabetic retinopathy (DR), glaucoma and macular degeneration., Methods: Structured search of electronic databases and full article review yielded 20 cost-related articles. Sixteen articles fulfilled the inclusion criteria and were retained for a narrative review: 12 on DR, 2 on glaucoma and 2 on chronic eye disease., Results: Teleophthalmology for DR yielded the most cost savings when compared with traditional clinic examination. The study settings varied among urban, rural and remote settings, community, hospital and health mobile units. The most important determinant of cost-effectiveness of teleophthalmology was the prevalence of DR among patients screened, indicating an increase of cost savings with the increase of screening rates. The required patient pool size to be screened varied from 110 to 3500 patients. Other factors potentially influencing cost-effectiveness of teleophthalmology were older patient age, regular screening and full utilisation of the equipment. Teleophthalmology for glaucoma was more cost-effective compared with in-person examination. Similarly, increasing number of glaucoma patients targeted for screening yielded more cost savings., Conclusions: This economic review provides supportive evidence of cost-effectiveness of teleophthalmology for DR and glaucoma screening potentially increasing screening accessibility especially for rural and remote populations. Special selection of the targeted screening population will optimise the cost-effectiveness of teleophthalmology., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To determine the efficacy and safety of ab interno trabeculectomy with Trabectome in juvenile open-angle glaucoma (JOAG) patients., Design: Prospective cohort study., Methods: Evaluation of the 12-month results of 2 patient groups receiving ab interno trabeculectomy: group 1, eyes with no prior incisional surgery; group 2, eyes that had prior incisional cataract or glaucoma surgery., Results: Group 1, 40 eyes (average age 31 ± 7 years), had a significant reduction in intraocular pressure (IOP) of 10.6 mm Hg at 12 months from a baseline of 27.4 mm Hg (p = 0.01), and the number of glaucoma medications reduced by 0.4 (p = 0.80). Four eyes (10%) within the study period required a secondary glaucoma surgery. Group 2, 20 eyes (average age 27 ± 8 years), had a significant reduction in IOP of 8.8 mm Hg from a baseline of 27.1 mm Hg (p = 0.06), and the number of glaucoma medications reduced by 1.4 (p = 0.36). Five eyes (25%) from this group underwent a secondary glaucoma surgery within 12 months., Conclusion: After 1 year of follow-up, ab interno trabeculectomy appears to be an effective and safe intervention for patients with JOAG; however, a reduction in use of topical medications may not be observed in those receiving ab interno trabeculectomy as a primary procedure., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Exfoliation syndrome (XFS) is a systemic disease with significant ocular manifestations, including glaucoma and cataract. The disease impacts close to 70 million people globally and is now recognised as the most common identifiable cause of open-angle glaucoma. Since the discovery of XFS 100 years ago by Dr John G. Lindberg, there has been considerable advancement in understanding its pathogenesis and resulting clinical implications. The purpose of this paper is to summarise information regarding the epidemiology, pathophysiology, ocular manifestations and systemic associations of XFS with the objective of sharing clinical pearls to assist in early detection and enhanced management of patients., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To compare the intraocular pressure-lowering efficacy and complication rate of ab interno trabeculectomy with the Trabectome between African American (AA) and Caucasian patients with open-angle glaucoma., Methods: A total of 164 patients (82 AA and 82 Caucasian) who underwent ab interno trabeculectomy over an 8-year period were included in this prospective, case-control study. The Neomedix database was used to look for AA or Caucasian patients with open-angle glaucoma who underwent Trabectome with or without phacoemulsification., Results: The average IOP of AA patients was reduced from 21.2 ± 6.8 mm Hg to 16.1 ± 4.1 mm Hg at 12 M (p < 0.01), and the mean number of glaucoma medications was reduced from 2.4 ± 1.3 to 2.0 ± 1.4 (p = 0.13). Among Caucasians, the mean IOP was reduced from 21.2 ± 6.8 mm Hg to 15.7 ± 4.2 mm Hg at 12 M (p < 0.01), and the number of medications dropped from 2.4 ± 1.2 to 1.7 ± 1.3 (p < 0.01). No statistically significant difference was found between these 2 race groups in IOP, number of medications, and complications. For complications with Trabectome alone, 13% of AA and 9% of Caucasian patients needed secondary surgery. There was only 1 case of hypotony which was in the AA group. For complications with Trabectome combined with phacoemulsification, 4% of AA as well as 4% of Caucasian patients required secondary surgery. There was only 1 case of hypotony which was in the Caucasian group., Conclusion: Ab interno trabeculectomy with Trabectome is associated with a reduction in IOP in both race groups with a similar complication and survival profiles., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objective: Pseudoexfoliation syndrome (PEX) is a systemic disease, but evidence of its association with cardiovascular disease (CVD) and cerebrovascular disease (CVA) is controversial. A quantitative systematic review will provide an accurate summary of the current body of the literature., Design: Meta-analysis., Participants: Not applicable., Methods: A comprehensive literature search of published and unpublished English-language studies was performed. Summary statistics were calculated using inverse variance weighting and are presented in forest plots. Sources of variance were evaluated statistically., Results: After screening 4547 studies, 47 articles were reviewed, and 25 eligible studies were selected that reported patients from around the world. Twenty studies enrolling 9583 individuals with PEX evaluated CVD, providing a summary odds ratio (OR) of 1.61 (95% CI 1.37-1.90). Eleven studies, enrolling 1308 PEX patients, evaluated CVA and generated a summary OR of 1.76 (1.40-2.22). For any vascular event (AVE) using all 25 studies, there were 9716 PEX patients and 363,312 control patients, yielding a summary OR of 1.64 (95% CI 1.39-1.92). Analysis for publication bias with the Egger's test was not significant for studies reporting CVD and AVE (p = 0.92 and 0.64, respectively) but was significant for CVA (p = 0.03). Asymmetry of Begg's funnel plot was noted for the CVA and AVE analyses. Multiple sensitivity analyses were performed, including assessment of study quality; the OR for all 3 outcomes varied minimally and remained significant in all analyses., Conclusion: There is strong evidence that PEX is significantly associated with both CVD and CVA., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Argon laser trabeculoplasty as well as selective laser trabeculoplasty can be used in patients with exfoliation syndrome with similar safety and efficacy. However, treatment effect may abruptly reverse and patients need to be followed regularly to monitor intraocular pressure control. Newer laser treatment modalities including micropulse laser trabeculoplasty, titanium sapphire laser trabeculoplasty and pattern scanning trabeculoplasty show promising results but need to be studied in exfoliation patients. For exfoliation patients with angle closure, peripheral iridectomy, iridoplasty or cataract extraction can be very helpful. For refractory exfoliation glaucoma, transscleral diode laser cyclophotocoagulation offers a reasonable option to lower intraocular pressure. Other approaches to cyclophotocoagulation such as micropulse transcleral diode laser need to be studied further in exfoliation patients.

Background: To synthesize high-quality evidence to compare traditional in-person screening and tele-ophthalmology screening., Methods: Only randomized controlled trials (RCTs) were included in this systematic review and meta-analysis. The intervention of interest was any type of tele-ophthalmology, including screening of diseases using remote devices. Studies involved patients receiving care from any trained provider via tele-ophthalmology, compared with those receiving equivalent face-to-face care. A search was executed on the following databases: Medline, EMBASE, EBM Reviews, Global Health, EBSCO-CINAHL, SCOPUS, ProQuest Dissertations and Theses Global, OCLC Papers First, and Web of Science Core Collection. Six outcomes of care for age-related macular degeneration (AMD), diabetic retinopathy (DR), or glaucoma were measured and analyzed., Results: Two hundred thirty-seven records were assessed at the full-text level; six RCTs fulfilled inclusion criteria and were included in this review. Four studies involved participants with diabetes mellitus, and two studies examined choroidal neovascularization in AMD. Only data of detection of disease and participation in the screening program were used for the meta-analysis. Tele-ophthalmology had a 14% higher odds to detect disease than traditional examination; however, the result was not statistically significant (n = 2,012, odds ratio: 1.14, 95% confidence interval (CI): 0.52-2.53, p = 0.74). Meta-analysis results show that odds of having DR screening in the tele-ophthalmology group was 13.15 (95% CI: 8.01-21.61; p < 0.001) compared to the traditional screening program., Conclusions: The current evidence suggests that tele-ophthalmology for DR and age-related macular degeneration is as effective as in-person examination and potentially increases patient participation in screening.

Synopsis: Clinicians can feel confident compressed three-dimensional digital (3DD) and two-dimensional digital (2DD) imaging evaluating important features of glaucomatous disc damage is comparable to the previous gold standard of stereoscopic slide film photography, supporting the use of digital imaging for teleglaucoma applications., Background/aims: To compare the sensitivity and specificity of 3DD and 2DD photography with stereo slide film in detecting glaucomatous optic nerve head features., Methods: This prospective, multireader validation study imaged and compressed glaucomatous, suspicious or normal optic nerves using a ratio of 16:1 into 3DD and 2DD (1024×1280 pixels) and compared both to stereo slide film. The primary outcome was vertical cup-to-disc ratio (VCDR) and secondary outcomes, including disc haemorrhage and notching, were also evaluated. Each format was graded randomly by four glaucoma specialists. A protocol was implemented for harmonising data including consensus-based interpretation as needed., Results: There were 192 eyes imaged with each format. The mean VCDR for slide, 3DD and 2DD was 0.59±0.20, 0.60±0.18 and 0.62±0.17, respectively. The agreement of VCDR for 3DD versus film was κ=0.781 and for 2DD versus film was κ=0.69. Sensitivity (95.2%), specificity (95.2%) and area under the curve (AUC; 0.953) of 3DD imaging to detect notching were better (p=0.03) than for 2DD (90.5%; 88.6%; AUC=0.895). Similarly, sensitivity (77.8%), specificity (98.9%) and AUC (0.883) of 3DD to detect disc haemorrhage were better (p=0.049) than for 2DD (44.4%; 99.5%; AUC=0.72). There was no difference between 3DD and 2DD imaging in detecting disc tilt (p=0.7), peripapillary atrophy (p=0.16), grey crescent (p=0.1) or pallor (p=0.43), although 3D detected sloping better (p=0.013)., Conclusions: Both 3DD and 2DD imaging demonstrates excellent reproducibility in comparison to stereo slide film with experts evaluating VCDR, notching and disc haemorrhage. 3DD in this study was slightly more accurate than 2DD for evaluating disc haemorrhage, notching and sloping., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To develop a standardized process for reviewing daily patient lists and identifying potential risks of misidentification. Our goal was to develop a proactive approach to identify and eliminate risks of patient misidentification., Methods: Assessment of current patient identification practices took place over a period of 4 weeks. Using a process map, a patient survey was developed to determine the encounter points when patient identification was confirmed. This information was used to develop a standardized protocol for review of daily appointment lists., Results: Review of daily appointment lists was completed to identify potential similar/same name risks. A standardized manual process of chart review, flagging, and tracking was developed., Conclusions: The name alert process resulted in a simple manual process for identifying which patients have a higher name risk and allowed care providers to take preventative action to decrease potential risk of incorrect diagnostic testing, procedure, or medication administration., (Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Crystallins are a major family of proteins located within the lens of the eye. Cataracts are thought to be due to the formation of insoluble fibrillar aggregates, which are largely composed of proteins from the crystallin family. Today the only cataract treatment that exists is surgery and this can be difficult to access for individuals in the developing world. Development of novel pharmacotherapeutic approaches for the treatment of cataract rests on the specific targeting of these structures. βB2-crystallin, a member of β-crystallin family, is a large component of the crystallin proteins within the lens, and as such was used to form model fibrils in vitro. Peptides were identified, using phage display techniques, that bound to these fibrils with high affinity. Fibrillation of recombinantly expressed human βB2-crystallin was performed in 10% (v/v) trifluoroethanol (TFE) solution (pH 2.0) at various temperatures, and its amyloid-like structure was confirmed using Thioflavin-T (ThT) assay, transmission electron microscopy (TEM), and X-ray fiber diffraction (XRFD) analysis. Affinity of identified phage-displayed peptides were analyzed using enzyme-linked immunosorbent assay (ELISA). Specific binding of a cyclic peptide (CKQFKDTTC) showed the highest affinity, which was confirmed using a competitive inhibition assay., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose: To compare the efficacy and safety of endoscopic cyclophotocoagulation (ECP) versus trabeculectomy with mitomycin C (trab) in combination with cataract surgery., Materials and Methods: We evaluated the 6-month results of patients undergoing phacoemulsification (phaco) with either ECP or trab. The primary outcome was mean intraocular pressure (IOP) at 6 months; secondary outcomes were change in glaucoma medications, visual acuity, intraocular inflammation, and postoperative complications. Complete success was a target IOP of <21 mmHg and >6 mmHg without glaucoma medications. Qualified success was target IOP achieved through glaucoma medications., Results: We evaluated 53 eyes of 53 patients; 24 (45.3%) eyes were treated with ECP-phaco and 29 (54.7%) with trab-phaco. At 6 months, there was no significant difference in mean IOP of the two groups (ECP-phaco 14.2 ± 3.6 mmHg; trab-phaco 13.0 ± 2.5 mmHg; P = 0.240). Six (25.0%) ECP-phaco eyes and 20 (69.0%) trab-phaco eyes achieved complete success ( P = 0.002). Qualified success was achieved in 18 (75.0%) ECP-phaco eyes and 9 (31.0%) trab-phaco eyes ( P = 0.002). The mean reduction of medication from baseline was significant (ECP-phaco 1.2 ± 1.1; trab-phaco 2.1 ± 1.5; P = 0.020). ECP-phaco resulted in more IOP spikes on the 1 st postoperative day ( P = 0.040) and more anterior cellular reaction at 1 week and 1 month compared to trab-phaco ( P < 0.05). The rate of postoperative complications was not significantly different between groups., Conclusion: At 6 months, ECP-phaco demonstrated similar improvements in IOP and visual acuity compared to trab-phaco. However, ECP-phaco patients had higher incidences of immediate postoperative IOP spikes and anterior chamber inflammation as well as requiring additional medications postoperatively., Competing Interests: There are no conflicts of interest.