Resource Planning in Glaucoma: A Tool to Evaluate Glaucoma Service Capacity

Background: The National Patient Safety Agency (2009) publication advising timely follow-up of patients with established glaucoma followed several reported instances of visual loss due to postponed appointments and patients lost to follow-up. The Royal College of Ophthalmologists Quality Standards Development Group stated that all hospital appointments should occur within 15% of the intended follow-up period.

Aim: To determine whether:

1. Glaucoma follow-up appointments at a teaching hospital occur within the requested time

2. Appointments are requested at appropriate intervals based on the NICE Guidelines

3. The capacity of the glaucoma service is adequate

Methods: A two-part audit was undertaken of 98 and 99 consecutive patients respectively attending specialist glaucoma clinics. In the first part, the reasons for delayed appointments were recorded. In the second part the requested follow-up was compared with NICE guidelines where applicable. Based on the findings, changes were implemented and a re-audit of 100 patients was carried out. Results: The initial audit found that although clinical decisions regarding follow-up intervals were 100% compliant with NICE guidelines where applicable, 24% of appointments were delayed beyond 15% of the requested period, due to administrative errors and inadequate capacity, leading to significant clinical deterioration in two patients. Following the introduction of an electronic appointment tracker and increased clinical capacity created by extra clinics and clinicians, the re-audit found a marked decrease in the percentage of appointments being delayed (9%). Conclusions: This audit is a useful tool to evaluate glaucoma service provision, assist in resource planning for the service and bring about change in a non-confrontational way. It can be widely applied and adapted for use in other medical specialities.     

青光眼住院病人的构成比变化特点

目的:了解住院青光眼病人的内部构成比变化,为青光眼的防治研究提供新的流行病学资料。方法:青光眼病区1990年7月～1996年6月住院患者3156人,按出院诊断、性别及年龄分组,分析其内部构成及变化趋势,并与1977年7月～1982年7月的资料比较。结果:闭角型青光眼占青光眼总数的55.86％,40岁以上女性患者居多,原发性开角型青光眼和糖皮质激素诱发开角型青光眼的比重增大,分别为19.25％和4.35％,患病对象集中在年轻男性。结论:我国原发性开角型青光眼的患病率并不低,在作好闭角型青光眼防治工作的同时,必须加强原发性开角型青光眼和糖皮质激素诱发开角型青光眼的防治,重点对象为年轻的男性患者。眼科学报1997;13:96～99。     

Eye Care Disparities and Health-Related Consequences in Elderly Patients with Age-Related Eye Disease

ABSTRACT

The elderly population in the United States (age 65 and older) is growing rapidly, estimated by the U.S. Census Department to reach 83.7 million by 2050.¹ Visual impairment increases with age among all racial and ethnic groups.² In the elderly, the most common culprits for vision loss are cataract, glaucoma, and age-related macular degeneration (AMD).² In the developed world, vision loss from cataract has been dramatically reduced by increased access to cataract surgery. However, AMD and glaucoma lead to irreversible vision loss without early diagnosis and intervention. In the U.S., cases of AMD are expected to double by 2050, reaching 17.8 million among patients age 50 or older.³ Similarly, cases of glaucoma are expected to reach 5.5 million by 2050, an increase of over 90% from 2014.³ The visually impaired elderly face disparities in access to eye care, and subsequent general medical and psychosocial complications.     

The Multi—channel VEP Topographies in Patients with Late—stage Glaucoma

Purpose: To study the clinical application of multi-channel VEP topographies in patients with late-stage glaucoma.Methods: The multi- channel checkerboard reversal VEP waves of 25 normal persons and 15 patients with late-stage gloucoma were recorded and analyzed, All patients were examined using Humphrey Field Analyzer. The VEP topographies of multi-channel VEP waves were shown by computer processing system.Results: In normal subjects , the topographies showed symmetric distribution to full-field pattern stimulation . In all patients with late-stage glaucoma, even whose visual field was severely damaged, multi-channel VEP could be recorded, All channels showed simple 'NPN' wave form, N1,N2 waves were not conspicuous, even both were lost, all channels showed the reduced amplitudes of PI waves, and longer latency. The multi-channel VEP topographies showed irregular distribution, Some showed amplitude asymmetry, other limited or widespread, lateralized.Conclusions : Despite the severely damaged visual fiel     

Awareness and Use of Eye Care Services in Fiji

Purpose: To determine the awareness, use, and barriers to use of eye services in Fiji's Central Province. Methods: A cross-sectional survey study design with random clusters of households was used. Semi-structured interviews were conducted (152 females and 22 males). For 267 household members, presenting distance and near visual acuities were measured, and the perception of and satisfaction with their vision were recorded. Results: Most (86%; 150/174) respondents were aware of at least one conventional eye care service. However, only 66% (121/183) of household members with previous eye problems had consulted one of these; the proportion was even lower for those in the older age groups (p < 0.01). Rural dwellers expressed satisfaction with their vision, despite being more likely to regard it as limiting their activities and being less likely to seek conventional care. A higher proportion of females were reported to have (or have had) eye problems (60:40) and were found to have bilateral visual impairment (60:40). Despite this, females and males attended the hospital eye clinic (47:53) or sought treatment from conventional services (51:49) nearly equally. The reasons given for not seeking conventional care were “fatalistic attitude” (“did not bother”, “could manage”, or accepted the condition: 57%), expense (12%), and fear (8%). Conclusion: Central Province Fijians, particularly the old, rural, and female, under-utilise conventional eye care services. As in developing countries elsewhere, fatalistic attitudes to visual impairment are a significant contributor to this. To improve eye health, planning and implementation of eye care services must overcome under-utilisation by addressing local barriers to uptake through community participation in education and affirmative action.     

Lens Implantation in Patients with Glaucoma

Lens implantation can be performed successfully in patients with glaucoma, but the hazards include not only postoperative problems but also technical problems at the time of surgery. Glaucoma remains a relative contraindication to lens implantation.     

The Management of Secondary Glaucoma in Nanophthalmic Patients

Purpose:To investigate the clinical characteristcs,management of secondary glaucoma in nanophthalmos,and the prevention of its compications.Methods:Retrospectively,9 cases(17eyes)with nanophthalmic glaucoma were studied.Results:The axial length of the eyes ranged(14.36-19.33)mm;All of the cases combined with hyperopia ranged( 7.00- 16.00)D.All 17 eyes had the manifestation like angle-closure glaucoma.The glaucoma was controlled in 9 of 17 eyes at the early stage,which underwent laser iridotomy(4 of 9 eyes also underwent laser iridoplasty).1 eye underwent ciliary photocoagulation because its visual acuity was lost and the patient complained of pain.The other 7 eyes underwent filtration surgery and 3 of them had permanent loss of vision caused by disastrous complications after the surgery.Conclusions:Management of secondary glaucoma in nanophthalmos is complicated.The laser iris surgery is safe and effective in glaucoma at the early stage.Vortex vein decompression,sclerotectomy or anterior sclerotomy may be performed to reduce disastrous complications.     

Healthcare Utilization by Glaucoma Patients in a Team Care Model

Purpose: To determine the effect of a glaucoma team care model on resource utilization and efficiency in glaucoma management.

Methods: Retrospective cohort study of 358 patients diagnosed and treated for glaucoma. Analysis included number of patient visits, diagnostic tests, and glaucoma procedures performed before (2005–2007) and after (2008–2010) implementation of a team care model in 2008. Patients not involved in the model served as controls.

Results: Number of patient visits did not change significantly after model implementation (p > .05). Diagnostic tests significantly increased in comprehensive ophthalmologist and glaucoma subspecialist groups 25 months after diagnosis (p = .03 and p = .001). Procedures increased for glaucoma subspecialists but was not statistically significant (p = .06). Optometrists used billing codes with significantly lower reimbursement than other providers (p < .001).

Conclusions: Team care model had neutral effect on patient visits and increased testing. Continued evaluation of this model is required to determine its effect on disease progression and outcomes.     

Clinical Manifestations of Strabismus in Patients with Primary Congenital Glaucoma

Purpose: To determine the clinical manifestations and risk factors of developing strabismus in primary congenital glaucoma (PCG) patients who underwent glaucoma surgery.

Methods: A retrospective case-series study of 54 PCG patients who were followed for at least 3 years after glaucoma surgery. The subjects were divided into 2 groups based on the occurrence of strabismus. Age at glaucoma diagnosis and surgery, visual acuity, intraocular pressure, amblyopia, cup-disc ratio, and orthoptic status were compared between the 2 groups.

Results: Twenty of 54 patients (37.0%) developed strabismus after glaucoma surgery. The mean ages at the time of glaucoma diagnosis and surgery were 3.2 ± 2.7 months and 3.4 ± 2.8 months in the strabismus group and 24.3 ± 19.1 months and 26.4 ± 18.9 months in the non-strabismus group, respectively (p < .05). In addition, the mean logMAR visual acuities were 0.87 ± 0.38 in the strabismus group and 0.24 ± 0.21 in the non-strabismus group (p < .05). The proportion of patients experiencing amblyopia was 90.0% in the strabismus group. Low visual acuity and young age at glaucoma surgery were significant predictors of developing strabismus. Kaplan-Meier survival analysis demonstrated that the probability of developing strabismus after glaucoma surgery was 50.6% at 10 years post-surgery.

Conclusions: PCG patients who developed strabismus after glaucoma surgery were diagnosed with glaucoma and underwent surgery at a younger age, exhibited a worse mean best corrected visual acuity, and exhibited a higher amblyopia incidence than did patients in the non-strabismus group.     

Glaucoma screening in the health care setting

Glaucoma surveys are an important means of detecting early cases of glaucoma. Traditionally, most such surveys have been conducted in the community, while the health care setting has been underutilized as a screening location. We reviewed studies on surveys conducted in community and health care settings, using tonometry and ophthalmoscopy, and presented data from a study we carried out in the outpatient department of a hospital. Results of our review indicate that over 11 times as many people were screened in the community studies as in the health care studies, but the latter had the higher percentage of referrals. Data from the literature review, as well as from our own study, suggest that the high number of referrals is related to the characteristics of the population available for screening in a health care facility. In such a population there is a higher percentage of individuals at risk for development of glaucoma. Risk factors for the disease include age, sex (males more at risk than females), race, (blacks more at risk than whites), family history of glaucoma, and presence of diabetes and vascular diseases. It was also found that ophthalmoscopy is an effective, but underutilized, method of screening. We recommend an increase in use of health care facilities as sites of glaucoma screening surveys. We also suggest that physicians employ ophthalmoscopy to screen for glaucoma as part of the routine funduscopic examination.     

Evaluation of Visual Field Test Parameters after Artificial Tear Administration in Patients with Glaucoma and Dry Eye

Purpose: To examine the effect of a single dose of artificial tear administration on automated visual field (VF) testing in patients with glaucoma and dry eye syndrome. Material and Methods: A total of 35 patients with primary open-angle glaucoma experienced in VF testing with symptoms of dry eye were enrolled in this study. At the first visit, standard VF testing was performed. At the second and third visits with an interval of one week, while the left eyes served as control, one drop of artificial tear was administered to each patient’s right eye, and then VF testing was performed again. The reliability parameters, VF indices, number of depressed points at probability levels of pattern deviation plots, and test times were compared between visits. Results: No significant difference was observed in any VF testing parameters of control eyes (P>0.05). In artificial tear administered eyes, significant improvement was observed in test duration, mean deviation, and the number of depressed points at probability levels (P?0.5%, P?1%, P?2) of pattern deviation plots (P?0.05). The post-hoc test revealed that artificial tear administration elicited an improvement in test duration, mean deviation, and the number of depressed points at probability levels (P?0.5%, P?1%, P?2%) of pattern deviation plots from first visit to second and third visits (P?0.01, for all comparisons). The intraclass correlation coefficient for the three VF test indices was found to be between 0.735 and 0.85 (P<0.001, for all). Discussion: A single dose of artificial tear administration immediately before VF testing seems to improve test results and decrease test time.     

原发性开角型青光眼患者一级亲属青光眼患病率调查

目的：了解成都地区原发性开角型青光眼（POAG）患者≥40 岁的一级亲属青光眼患病情况,研究家族史这一危险因素在POAG发病中的作用。方法：病例对照研究。选取2014 年2 月至2015 年10 月期间在华西医院确诊的99 例POAG患者为先证者,其≥40 岁的一级亲属290 例作为病例组。同期来院行白内障手术（无其他合并眼部疾病）的105 例患者,其≥40 岁的一级亲属355 例作为对照组。分别进行问卷调查和青光眼筛查。采用t 检验、卡方检验,多元Logistic回归等进行统计学分析。结果：①病例组总患病率高于对照组（10.7% vs . 1.4%,χ2=26.090,P ＜0.001）。②病例组女性青光眼患病率高于对照组女性青光眼患病率（11.7% vs . 1.6%,χ2=15.203,P ＜0.001）,病例组男性青光眼患病率也高于对照组男性青光眼患病率（9.8% vs . 1.2%,χ2=11.098,P ＜0.001）。③按年龄（＜50 岁、50～59岁、60～69岁、≥70岁）分层,在＜50岁、50～59岁、≥70岁这3个年龄亚组,病例组青光眼患病率均明显高于对照组（χ2=14.328、4.919、6.959,P ＜0.05）。④在调整年龄和性别的影响后,病例组患病风险是对照组的8.45倍（95%CI：3.24～22.06）,其中病例组中子女患病风险为对照组的11.53倍（95%CI：2.45～54.26）。⑤92.1%的POAG患者一级亲属无青光眼筛查意识。结论：POAG患者≥40岁以上的一级亲属患病风险明显高于其他人群,绝大多数POAG患者一级亲属缺乏进行青光眼筛查的意识。     

The Preliminary Study of Glucocorticoid Receptor Gene in Chinese Patients with Glucocorticoid—induced Glaucoma^#

Background: To study the glucocorticoid receptor (GR) and the associated gene regulation in the pathogenesis of glucocorticoid- induced glaucoma (GIG) in Chinese patients.Methods: The trabecular cells of normal individuals and patients with GIG were cultured in vitro. By using polymerase chain reaction (PCR),gene fragments on GR DNA binding sites of trabecular cells were amplified. The product was detected by gel electrophoresis.Results: The trabecular cells were cultured successfully in normal individuals and patients with GIG in vitro. A single PCR product was obtained in both two groups with the same size of 545 base pairs.Conclusion: There is not any difference in gene on the GR DNA binding sites between normal individuals and patients with GIG. The results suggest the difference in mRNA or other functional genes. Eye Science 1999 ; 15 ; 46 - 50.     

超声乳化摘除白内障治疗葡萄膜炎继发性青光眼的疗效观察

目的初步评价白内障超声乳化摘除联合人工晶体植入术治疗合并有葡萄膜炎引起的继发性青光跟和并发性白内障的疗效.方法对13例(15眼)同时患有葡萄膜炎、继发性青光眼和并发性白内障的患者行连续环形撕囊的白内障超声乳化摘除联合人工晶体植入术,观察术后并发症、眼压和视力的变化情况.结果所有患者术中、术后都没有出现严重的并发症;术后3个月的视力平均为0.34±0.19,明显好于术前0.05±0.07(P＜0.05);术后3个月跟压和使用抗青光眼药物的种类分别为2.03±0.31kPa(15.21±2.36mmHg)和0.83±0.32种,较手术前的2.33±0.14kPa(17.5±1.03mmHg)和2.7±0.21种减少(P＜0.05).结论白内障超声乳化摘除联合人工晶体植入术是治疗葡萄膜炎引起的继发性青光眼和并发性白内障的又一种新的理想的选择.     

Perceptions of Eye Health and Eye Health Services among Adults Attending Outreach Eye Care Clinics in Papua New Guinea

Abstract

Purpose: To determine how people attending outreach eye care clinics in Papua New Guinea (PNG) perceive eye health and eye health services.

Methods: An interview-based questionnaire was administrated to a convenience sample of 614 adult participants across four provinces and perceptions of eye health and eye health services were recorded. Presenting and near visual acuity were measured and cause of visual impairment (VI) determined.

Results: In this sample, 113/614 participants (18.4%) presented with distance VI, 16 (2.6%) with distance blindness, and 221 (47.6%) with near VI. Older participants and those with near VI were more likely to indicate that it is hard to have an eye examination due to travel time, lack of transport and transport costs. Female participants and those from underserved areas were more likely to report shame and fear of jealousy from others when asked about their attitudes towards spectacles. Participants reporting that they were willing to pay higher amounts for testing and spectacles/treatment also reported higher education levels, higher household incomes and were more likely to be male. A quarter of participants (25.9%) indicated that they did not like having an eye examination because their reading and writing was poor.

Conclusions: People attending outreach eye care clinics in PNG reported finding it difficult to attend eye health services due to transport difficulties and anticipated high costs. Negative attitudes towards spectacles were also prevalent, and negative perceptions appeared more frequently among older participants and those with less education.     

Phacoemulsification in Patients with Secondary Glaucoma Caused by Uveitis

Purposes: To evaluate the effect of phacoemulsification in the patients with uveitis,secondary glaucoma and complicated cataract.Methods: Phacoemulsification and implantation of a foldable intraocular len wasperformed in 12 patients(13 eyes) with uveitis, secondary glaucoma and complicatedcataract. The complications, intraocular pressures (IOP), and visual acuity wereobserved postoperatively.Results: No severe complication was found in the patients postoperatively or within theoperation procedure. The visual acuity was improved after the operation ( P < 0. 05) .The intraocular pressures and/or the number of antiglaucoma medications reduced in 3months of the follow-up time.Conclusion: phacoemulsification is the best way to treat the patients with secondaryglaucoma and complicated cataract caused by uveitis.     

Characterization of Glucocorticoid Receptor on Lymphocytes in Chinese Patients with Glucocorticoid-induced Glaucoma

Purpose : We studied the pathogenesis of glucocorticoid-induced glucoma (GIG) through characterization of glucocorticoid receptor (GR) on lymphocytes in Chinese patients with GIG.Methods:By radioligand receptor binding followed by Scatchard analysis, the specific binding sites were characterized and quantitated for glucocorticoid receptors on peripheral blood lymphocytes obtained from patients with GIG and the control group.Results:The binding sites we detected were as follows; 12.7 ± 1.47 × 103 receptors per cell with a KD of 3.02 ± 0.62nmol/L in patients with GIG, 7.26 ± 0.45 × 103 receptors per cell with a KD of 3.03 ± 0.56nmol/L in the control group. The statistical difference of receptors per cell is significant between two groups (p < 0.05), patients with GIG having more GR binding sites, while the difference of Kd is not significant ( p > 0.05 ) . Conclusion: The preliminary findings suggest that patients with GIG are more sensitive to glucocorticoid and the increase of binding sites of GR     

微信干预对青光眼患者体力活动量的影响

观察利用微信干预增加青光眼患者体力活动的效果。方法：前瞻性随机对照研究。选择2018年 6-12月于温州医科大学附属眼视光医院门诊确诊的青光眼患者102例作为研究对象。利用Excel生成的随机数随机分为对照组和干预组。对照组患者仅在门诊入组时进行运动宣教,并告知其可增加每天的运动步数;干预组患者入组时进行运动宣教,告知其可增加每天的运动步数的同时,加入微信群进行运动提醒干预。所有患者均需利用运动监测仪器完成基线1周和随访1个月的体力活动监测。采用卡方检验、独立样本t检验、Mann-Whitney U检验、配对t检验及Wilcoxon符号秩检验进行数据分析。结果：排除30例基线运动量较大（步数>12 000步/d）、依从性不好及其他原因失访的患者,最终纳入72例（对照组42例,干预组30例）。干预组患者干预后的步数（t=4.94,P<0.001）,运动消耗的卡路里（Z=-2.87,P=0.004）,代谢当量（Z=-3.30,P=0.001）,中等强度体力活动时间（Z=-2.89, P=0.004）,高强度体力活动时间（t=2.57,P=0.016）及中高强度体力活动时间（Z=-3.01,P=0.003）均较基线增加;轻度体力活动时间（t=-2.14,P=0.041）和久坐静止不动次数较干预前减少（t=-2.76, P=0.022）。对照组随访的步数也较基线增加（t=3.29,P<0.001）,轻度体力活动时间较基线减少（t=-2.57,P=0.014）。另外,干预组的高强度体力活动时间增加量（随访-基线）（Z=-3.04,P=0.002）和超高强度体力活动时间增加量（Z=-2.06,P=0.040）明显高于对照组,差异均有统计学意义。结论：微信干预可以增加青光眼患者的每天运动步数和中高强度体力活动时间,减少患者的轻度体力活动时间和久坐静止次数。