Therapeutic effect of 0.03% tacrolimus ointment for ocular graft versus host disease and vernal keratoconjunctivitis

Purpose

To determine whether topical tacrolimus might prove effective in the treatment of refractory anterior segment inflammatory diseases, and to evaluate its efficacy in eyes with ocular graft versus host disease (GVHD), and vernal keratoconjunctivitis (VKC).

Methods

Twenty-eight eyes of 14 patients with anterior segment inflammation refractory to steroid treatment were treated with 0.03% tacrolimus ointment at the Samsung Medical Center, Seoul, Korea from March 2008 through August 2009. Seven patients had ocular GVHD and seven had VKC. We evaluated the conjunctival and corneal inflammatory change at one, two, four, and eight weeks after treatment with a scoring system. Time to initial response of treatment and therapeutic effect between GVHD and VKC was also analyzed. After the eight-week treatment period, patients were divided into two groups (maintenance group and discontinuance group). Eight patients maintained the treatment for an additional four months, and six patients discontinued the treatments. Therapeutic effect was also compared between the groups at eight weeks and six months after treatment.

Results

The mean conjunctival and corneal inflammation score was reduced significantly at eight weeks after treatment (p < 0.0001). The therapeutic effect in conjunctival inflammation was first noted at week two after the initial treatment (p = 0.002); reduction in corneal inflammation was first noted at one week (p = 0.0009). When compared according to diagnosis, no therapeutic difference was detected between the groups (p > 0.05). Six months after treatment, we noted no therapeutic differences between the maintenance group and discontinuance group (p > 0.05).

Conclusions

0.03% tacrolimus ointment was safe and effective for use in anterior segment inflammatory disease refractory to steroid.     

Conjunctival pigmentation after 23-gauge microincisional vitrectomy surgery

Aim

To investigate cases with conjunctival pigmentation originating from sclerotomy sites after 23-gauge microincisional vitrectomy surgery (MIVS).

Methods

This is a retrospective study comprised of 185 eyes from 185 consecutive patients who underwent 23-gauge MIVS. The authors investigated the incidence and the clinical factors associated with conjunctival pigmentation, including indication of vitrectomy and surgical procedures.

Results

Eight eyes (4.3%) from 185 eyes showed conjunctival pigmentation after surgery within 7 days postoperatively. Light microscopic examination of excised tissue showed infiltration of abundant dark brownish colored melanophages with surrounding scattered, finely granular, melanin pigments. C3F8 gas tamponade (OR, 9.4; 95% CI, 1.9–44.5; P=0.005) was significantly associated with conjunctival pigmentation. The mean surface area (21.26±2.21 mm²) of three eyes with C3F8 tamponade was significantly larger than that of five eyes (2.51±0.73 mm²) without tamponade (P=0.025). Neither leakage nor hypotony was found.

Conclusions

Intraocular melanin pigments could prolapse through the sclerotomy site and cause conjunctival pigmentation after 23-gauge MIVS. Thus, preoperative warning is necessary in patients with 23-gauge MIVS.     

Force requirements in topical medicine use--the squeezability factor

Introduction

Patient compliance is essential to ensure efficacious treatment. The ease of topical drop delivery is of paramount importance. At least 50% of patients report difficulty in self-administration of topical ocular medicine. The two most frequently reported causes of difficulty include aiming the bottle and squeezing the bottle.

Purpose

The aims of this study were to identify (I) the force required to deliver a single drop from a bottle (the squeezability factor), (II) are some bottle designs easier to use than others? (III) Do compliance aids reduce the finger strength required to deliver an eye drop?

Method

We measured the force required to deliver a single drop from a variety of commonly used ophthalmic preparations. Force was slowly applied at the midpoint along the bottle until a drop fell from the tip. Compliance aids were also tested with this technique.

Results

We report a wide variation in the force requirements needed to use topical medicines. Three of the four compliance aids tested increased force requirements but may have had other beneficial effects by altering the grip on the medicine bottle.

Conclusion

This study highlights the large variability in force required to deliver a single drop using the ophthalmic preparations and compliance aids tested. We feel our results will be of interest and relevant to prescribing physicians and manufactures alike.     

Comparison of the SchirmerⅠtest with and without topical anesthesia for diagnosing dry eye

AIM: To determine the value of Schirmer Ⅰtest (SⅠt) without anesthesia and with topical anesthesia for diagnosing dry eye (DE). METHODS: Totally 220 eyes in 110 patients, male (44) and female (66), (39.56±12.67) years old diagnosed with DE were examined. SⅠt without anesthesia was performed firstly, and 15 minutes later, it was applied again in the same person after topical anesthesia with 0.5% proparacaine hydrochloride eye drops. The wetting strips counted <10mm per 5 minutes were defined positive, while ≤5mm per 5 minutes were defined strong positive. RESULTS: The wetting length in SⅠt after topical anesthesia was significantly lower than that in SⅠt without anesthesia (P<0.001). The positive rate and strong positive rate of SⅠt after topical anesthesia were significantly higher than that of SⅠt without anesthesia (P<0.001). The positive rate and strong positive rate of SⅠt without anesthesia and the strong positive rate of SⅠt after topical anesthesia in patients with aqueous-deficiency dry eye (ADDE) were significantly higher than those in total patients whereas those in patients with evaporative dry eye (EDE) were significantly lower than those in total patients (P<0.001). CONCLUSION: SⅠt after topical anesthesia with 0.5% proparacaine hydrochloride eye drops is more objective and reliable than that without anesthesia in reflecting the status of DE, and its diagnostic value in patients with ADDE was even higher, making itself a meaningful evidence for the diagnosis and treatment of DE.     

Eye drop instillation technique in patients with glaucoma

Aims

To evaluate the technique of eye drop instillation in patients with glaucoma and assess factors associated with a good technique.

Methods

A cross-sectional observational study of 85 participants using self-administered topical medication for glaucoma or ocular hypertension. Patients were asked to demonstrate how they normally instil eye drops using a 5-ml bottle of sterile artificial tear solution. The procedure was recorded and assessed by two masked graders. Whether the patient had been previously shown how to instil drops, the number of eye medications used, and self-perceived difficulty of using drops were also recorded. Univariable logistic regression was performed to relate each variable to drop technique and variables with P<0.2 were included in a multivariable logistic regression analysis.

Results

54.1% (46/85) of patients had a poor drop technique, 11.8% (10/85) missed the eye, 15.3% (13/85) touched the tip of the bottle to the bulbar conjunctiva or cornea, and 27.1% (23/85) touched the eyelid or lashes with the bottle tip. 81.2% (69/85) could not recall being shown how to instil eye drops. In the multivariable model, previous instruction regarding drop instillation technique was significantly associated with good technique (adjusted OR=8.17, 95% CI 2.02–33.05, P=0.003) and increasing age was associated with poor technique (adjusted OR=0.95, 95% CI 0.91–0.99, P=0.017).

Conclusions

Education relating to eye drop instillation technique is significantly associated with a patient''s ability to instil drops correctly. The assessment of a patient''s ability to instil eye drops correctly should be a routine part of the glaucoma examination.     

Cyclosporine a eye drop-induced elongated eyelashes: a case report

Purpose

The most common ocular adverse event following the use of cyclosporine A (CsA) 0.05% ophthalmic emulsion is ocular burning (17%). Other adverse effects that have been reported include conjunctival hyperemia (1-5%), discharge, epiphora, eye pain, foreign body sensation, pruritus, stinging and blurred vision. Here, we report a specific side effect of CsA, namely eye drop-induced eyelash elongation in a patient with refractory giant papillary conjunctivitis.

Design

Observational case report.

Methods

Case report and review of the literature.

Results

A 32-year-old female with giant papillary conjunctivitis on the left eye, who had undergone papillectomy 3 years previously and was refractory to topical steroid therapy, was treated with CsA 0.05% ophthalmic emulsion (Restasis) 4 times a day, preservative-frees artificial tears and gentamicin ophthalmic solution in the left eye. After 5 months of topical CsA treatment, elongated eyelashes of her left eye were observed without other adverse effects.

Conclusion

Although hypertrichosis and trichomegaly have been documented in the literature as side effects of systemic CsA, topical CsA 0.05% eye drop-induced elongated eyelashes have not been reported, and we believe ophthalmologists should be mindful and inform patients about this specific side effect.Key words: Cyclosporine A, Eyelash elongation, Giant papillary conjunctivitis, Side effect     

Pathological Findings of Pemphigus Vulgaris Showing Giant Cobblestone-Like Conjunctival Papillae

Purpose

To describe the pathophysiological findings of a patient with pemphigus vulgaris (PV) showing giant conjunctival papillae.

Methods

A 64-year-old man who had mucosal-dominant PV with giant conjunctival papillae, resembling those of vernal keratoconjunctivitis (VKC), underwent an ophthalmological workup. The clinical and pathological findings were investigated.

Results

Ophthalmic interventions were unable to provide the desired beneficial effects, and multiple excisions were necessary to remove the proliferative conjunctival lesions. Histopathological investigations of the excised tissues demonstrated acantholysis and a subconjunctival infiltration with numerous inflammatory cells such as lymphocytes, plasma cells, and neutrophils. However, in contrast to typical VKC, mast cells and eosinophils were rarely found in the subconjunctival tissues. Direct immunofluorescent staining showed a significant deposition of immunoglobulin G and complement component 3 in the epithelial intercellular substance, consistent with mucosal-dominant PV. Then, the patient was hospitalized because of oral erosion exacerbation and malnutrition. Because of the patient''s declining general condition, we administered an increasing dose of a systemic steroid with an intravenous immunoglobulin, after which his ocular lesions and symptoms improved.

Conclusions

The histological conjunctival papilla findings were quite different from those of VKC papillae. If PV causes a lesion in a patient, systemic immunosuppression might be more effective than topical ophthalmic treatment because of overall immunological involvement.Key words: Conjunctiva, Ocular surface, Pathology, Immunology     

The effect of pH,dilution, and temperature on the viscosity of ocular lubricants—shift in rheological parameters and potential clinical significance

Objective

To investigate the effect of temperature, dilution, and pH on the viscosity of ocular lubricants.

Design

Laboratory based investigation of viscosity.

Participants

No human subjects.

Methods

Hypromellose 0.3%, sodium hyaluronate 0.4%, carboxymethylcellulose sodium 0.5%/glycerin 0.9%, and carmellose sodium 0.5% were investigated. Ostwald capillary viscometers were utilised for viscosity measurements. The kinematic viscosity of each lubricant was tested quantitatively from 22 to 40 °C, and over a pH range of 5–8 under isothermal conditions. The kinematic viscosity of each eye drop was also tested under dilution by varying the mass fraction of each eye drop under isothermal conditions.

Main outcome measure

Changes in kinematic viscosity.

Results

Hypromellose 0.3% had an initial pH of 8.34, while the other lubricants had a pH close to neutral. From 22 to 35 °C, the kinematic viscosity of sodium hyaluronate 0.4 fell by 36% from 37.8 to 24.4 mm²/s, carboxymethylcellulose sodium 0.5%/glycerin 0.9% fell by 35% from 16.98 to 11.1 mm²/s, hypromellose fell by 37% from 6.89 to 3.69 mm²/s, and carmellose sodium 0.5% fell by 25% from 2.77 to 1.87 mm²/s. At 32 °C only sodium hyaluronate 0.4%, and carboxymethylcellulose sodium 0.5%/glycerin 0.9% retained sufficient kinematic viscosity to maintain precorneal residence. Kinematic viscosities of all the topical lubricants were unaffected by pH but decreased significantly with dilution.

Conclusions

This study suggests that currently used ocular lubricants have limited bioavailability due to reductions in viscosity by temperature and dilutional changes under physiological conditions. Developing lubricants with stable viscosities may maximise therapeutic efficacy.     

Comparison of trabeculectomy and Ex-PRESS implantation in fellow eyes of the same patient: a prospective, randomised study

Purpose

To compare intraocular pressure (IOP) over time after standard trabeculectomy vsEx-PRESS implantation in patients with bilateral primary open-angle glaucoma (POAG).

Design

Prospective, randomised study.

Patients and methods

This study included adult patients with bilateral POAG necessitating surgery. Each patient underwent trabeculectomy in one eye and Ex-PRESS implantation under a scleral flap in the other eye according to randomised contralateral allocations. Efficacy was assessed by IOP values and success rates (IOP threshold and/or need for topical glaucoma medication) during 30 months. Statistical analysis included Generalised Estimate Equation and Cox Survival models, and paired t-tests.

Results

Thirty eyes of 15 patients were studied for a mean of 23.6 months (SD, ±6.9). At the last follow-up visit, mean pre-operative IOP decreased from 31.1 (±14.2) to 16.2 (±1.5) mm Hg after trabeculectomy, and from 28.1 (±9.0) to 15.7 (±1.8) mm Hg after Ex-PRESS implantation (P=0.001). The mean number of anti-glaucoma medicines prescribed at the last follow-up decreased from 3.7 pre-operatively (both groups) to 0.9 after trabeculectomy vs0.3 after Ex-PRESS implantation (P=0.001). Complete success rates (5P=0.0024). Postoperative complications were more frequent after trabeculectomy (33%) compared with Ex-PRESS (20%), with four trabeculectomy eyes (27%) needing postoperative interventions, compared with none with Ex-PRESS.

Conclusions

Trabeculectomy and Ex-PRESS implantation provided similar IOP control, but the Ex-PRESS group had a lower rate of complications, fewer postoperative interventions, and needed less glaucoma medications.     

Optimizing evaluation of Lissamine Green parameters for ocular surface staining

Purpose

The recently published seminal dry eye workshop proceedings defined Lissamine Green (LG), an organic dye, as a gold standard for demonstrating ocular surface staining. The purpose of the current study was to determine the optimal parameters of 1% LG instillation for the ocular surface examination in dry eye patients.

Design

Prospective and observational quality improvement study.

Methods

A quality improvement study evaluated 16 eyes from eight dry eye patients with different levels of severity. LG (1%), in three volumes (5, 10, and 20 μl) was instilled into the conjunctival cul-de-sac, and four masked observers with different levels of clinical expertise examined the patients with and without red filter. The staining pattern of the conjunctiva and cornea was documented with the Oxford scale within 4 min of LG instillation. Optimal volume and inter-observer reliability were assessed.

Results

All dye volumes were tolerated well by all patients. Experienced observers preferred 10 μl volume because of the ease of examination and accuracy. Although instillation of 20 μl yielded similar scores as 10 μl, it resulted in overflow of the lid and facial skin staining. The use of red filter significantly improved reading scores (P<0.01). Inter-observer reliability was higher for conjunctival scores than for corneal scores for all patients. The highest reliability was demonstrated with 10 μl volume and increased with greater experience of the observer.

Conclusions

Ocular surface examination with instillation of 10 μl 1% LG has good inter-observer reliability and is well tolerated. Observation through a red filter facilitates the examination.     

Orbitofacial neurofibromatosis: clinical characteristics and treatment outcome

Purpose

To report clinical observations and surgical management in a large series of patients with orbitofacial neurofibromatosis type 1 (OFNF).

Patients and methods

Patients were identified and medical records reviewed for demographic data, ophthalmologic examinations, surgical interventions, and procedure outcome to create a retrospective, non-comparative case series of patients with OFNF seen at one medical centre over a 23-year period.

Results

Sixty patients with OFNF (31 females and 29 males; mean age, 14 years) were followed for an average of 5.7 years. Presenting signs and symptoms included eyelid swelling in all patients, ptosis in 56 (93.3%), proptosis in 34 (56.6%), dystopia or strabismus in 30 (50%), and decreased visual acuity in 50 (83.3%). Surgical intervention included ptosis repair in 54 (90% mean 1.6 surgical procedures), facial and orbital tumour debulking in 54 (90% mean 2.3 surgeries), and canthoplasty in 28 (46.6%) patients. Eleven patients required enucleation or exenteration of a blind eye.

Conclusion

Patients with OFNF often require multiple procedures to preserve vision, prevent additional disfigurement, and achieve cosmetic rehabilitation. Patients need regular ophthalmological monitoring given the potential for progressive visual and cosmetic consequences.     

Deep sclerectomy with mitomycin C in eyes with failed glaucoma surgery and pseudophakia

Purpose

To report outcomes of deep sclerectomy (DS) with intraoperative mitomycin C (MMC) application in eyes with previous failed glaucoma surgery (GS) and/or cataract extraction (CE).

Patients and methods

Single-surgeon case series of 82 eyes of 82 patients undergoing DS with MMC. The patients had previous CE with IOL and/or conjunctival GS and treated intraocular pressure (IOP) >18 mm Hg. MMC (0.2 mg/ml) was applied for 2–3 min before scleral flap dissection. Complete success was defined as IOP between 6 and 21 mm Hg or a reduction of 20% from baseline without medications. Reoperation for glaucoma or related complications, or loss of light perception vision was considered as failure.

Results

Mean follow-up was 57.7±22.4 months with 78% of patients completing the 3-year follow-up. Mean IOP decreased from 24.0 mm Hg (22.3–25.6, 95% confidence intervals) to 13.4 mm Hg (12.0–14.2) at 3 years after surgery (P<0.001). There was a significant decrease in the number of glaucoma medications from 2.0±1 preoperatively, to 0.3±0.7, 3 years after surgery. Kaplan–Meier cumulative success rates were 85.6% at 1 year, 80.0% at 2 years, and 76% at 3 years. At 3 years, IOP was maintained <19 and 15 mm Hg in 83 and 70% of eyes, respectively. Fourteen eyes (17.1%) had complications. Delayed hypotony (IOP <6 mm Hg) was the commonest complication in five eyes (6.1%).

Conclusion

DS with MMC appears to be a safe and effective surgical procedure for eyes with previous intraocular surgery.     

Accuracy of referrals for visual assessment in a stroke population

Purpose

To evaluate accuracy of referrals from multidisciplinary stroke teams requesting visual assessments.

Patients and methods

Multicentre prospective study undertaken in 20 acute Trust hospitals. Stroke survivors referred with suspected visual difficulty were recruited. Standardised screening/referral and investigation forms were used to document data on referral signs and symptoms, plus type and extent of visual impairment.

Results

Referrals for 799 patients were reviewed: 60% men, 40% women. Mean age at onset of stroke was 69 years (SD 14: range 1–94 years). Signs recorded by referring staff were nil in 58% and positive in the remainder. Symptoms were recorded in 87%. Diagnosis of visual impairment was nil in 8% and positive in the remainder. Sensitivity of referrals (on the basis of signs detected) was calculated as 0.42 with specificity of 0.52. Kappa statistical evaluation of agreement between referral and diagnosis of visual impairment was 0.428 (SE 0.017: 95% confidence interval of −0.048, 0.019).

Conclusion

More than half of patient referrals were made despite no signs of visual difficulty being recorded by the referring staff. Visual impairment of varying severity was diagnosed in 92% of stroke survivors referred for visual assessment. Referrals were made based predominantly on visual symptoms and because of formal orthoptic liaison in Trusts involved.     

Effects of corneal thickness on the intraocular penetration of travoprost 0.004%

Purpose

To determine whether the intraocular penetration of travoprost 0.004% is affected by central corneal thickness.

Methods

Sixty-four patients who were scheduled for cataract surgery without any other ophthalmologic pathology of significance were enroled in this study. At 120 min before surgery, one drop of travoprost 0.004% was instilled in the eye to be operated on. At the start of surgery, a sample of aqueous humour was extracted to subsequently determine its AL-5848 concentration. These concentrations were compared among three groups of patients established according to central corneal thickness measurements obtained by ultrasound pachymetry.

Results

Mean AL-5848 concentrations were 3.27±2.03 ng/ml in Group I (CCT<511 microns), 3.27±2.44 ng/ml in Group II (CCT≥511 and ≤574 microns), and 2.73±2.15 ng/ml in Group III (CCT>574 microns), indicating no significant differences among the groups.

Conclusions

We were unable to demonstrate the greater or lesser penetration of travoprost depending on corneal thickness, which could explain differences in patient responses to this drug.     

Clinical presentation, risk factors and treatment outcomes of first allograft rejection after penetrating keratoplasty in early and late postoperative period

Purpose

Corneal graft rejection is the most common reason for the failure of an allograft corneal transplant. We undertook this study to identify and compare risk factors and treatment outcomes for early and late corneal graft rejections after optical penetrating keratoplasty.

Methods

A retrospective case file analysis of 880 primary penetrating keratoplasties was performed at a tertiary ophthalmic care centre. Patients were divided into early rejectors (rejection episode within 6 months postoperatively) and late rejectors (rejection episode after 6 months postoperatively). Main parameters evaluated were demographics, preoperative diagnosis and clinical signs, donor tissue details, surgical technique, details of rejection episode, treatment, and outcome information.

Results

A total of 156 patients with rejection episodes were identified. Of these, 42 (26.9%) patients experienced early rejection episodes and 114 (73.1%) patients experienced late rejection episodes. Preoperative donor and recipient characteristics, surgical technique, and clinical presentation of graft rejection were found to be similar between both groups after a Bonferroni correction was applied (P>0.005). Treatment outcomes of graft rejections were not significantly different (P=0.46) between early and late rejectors, with 83% of patients responding to rejection treatment (80% early rejectors; 85% late rejectors).

Conclusion

Patients with early and late graft rejection have similar characteristics and both groups respond to treatment equally.     

Donor-recipient gender difference affects severity of dry eye after hematopoietic stem cell transplantation

Purpose

To determine whether the incidence rate and severity of dry eye after hematopoietic stem cell transplantation varies with donor vsrecipient gender.

Methods

We limited this study to patients received bone marrow transplantation (BMT). In all, 172 patients received BMT at Keio University School of Medicine between January 2000 and May 2007. Of them, 136 recipients who survived at least 70 days were studied prospectively. We classified the 136 patients according to the gender of the donor and the recipient (group I: female to female; group II: male to male; group III: male to female; group IV: female to male). The incidence and severity of chronic graft-vs-host disease-associated dry eye were determined for each group. The donor gender was masked when we assessed dry eye and calculate the incidence.

Results

The incidence of dry eye was 47.4% for group I, 37.5% for group II, 58.6% for group III, and 42.9% for group IV. The percentage of patients with severe dry eye was 44.4, 50.0, 35.3, and 77.8% respectively. There was a significant difference between the percent severe dry eye/total dry eye incidences in groups III and IV (P=0.0375) (odds ratio, 7.6; 95% confidence interval, 1.00–101.01).

Conclusions

Close attention must be paid to the development of dry eye in cases of female to male BMTs, because the ratio of severe/total dry eye is more common in cases of female to male BMTs than in other gender combination.     

The prevalence of ocular complications in leprosy patients seen in the United Kingdom over a period of 21 years

Objective

The objective of this study was to determine the prevalence of ocular complications and blindness among leprosy patients presenting in the United Kingdom.

Methods

Observational prospective study.

Results

A total of 126 consecutive leprosy patients attending their ophthalmic visit were examined, out of which 18 patients were blind in one eye (14.3%) and five patients were blind in both the eyes (4.0%). Visual acuity of ⩾6/18 was present in 96 patients (76.2%). A total of 65 patients (51.6%) had an ocular complication and 28 patients (22.2%) had a sight-threatening leprosy complication (lagophthalmos, severe corneal, or iris disease). The most common ocular complications were impaired lid closure (24 patients, 19%), impaired corneal sensation (20 patients, 15.9%), cataract (20 patients, 15.9%), mild corneal opacity (17 patients, 13.5%), and iris atrophy (17 patients, 13.5%). Impaired corneal sensation was associated with vision <6/18 (P<0.001, OR 13.5, 95% CI 5.14–35.44) and vision <3/60 (P=0.01 OR 6.42, 95% CI 2.15–19.15). Impaired lid closure was significantly associated with increasing age (P=0.029, OR 1.039, 95% CI 1.0–1.08) and vision <3/60 (P=0.03, OR 6.06, 95% CI 1.81–20.24).

Conclusion

There is a significant rate of ocular complications and blindness seen in leprosy patients in the United Kingdom, and over one in five had a potentially sight-threatening ocular complication. Health professionals and all leprosy patients, including those cured of the disease, need to be aware that new eye symptoms and signs require prompt ophthalmology review to prevent avoidable blindness, due to the life-long risk of sight-threatening ocular complications.     

Diabetic retinopathy equity profile in a multi-ethnic, deprived population in Northern England

Purpose

Equity profiles are an established public health tool used to systematically identify and address inequity within health and health services. Our aim was to conduct an equity profile to identify inequity in eye health across Leeds and Bradford. This paper presents results of findings for diabetic retinopathy in Bradford and Airedale.

Methods

A variety of routine health data were included and sub-analysed by measures of equity, including age, sex, ethnicity, and deprivation to identify inequity in eye health and healthcare. The Spearman Rank Correlation Coefficient was used to determine the association between variables.

Results

The prevalence of diagnosed diabetes in Bradford and Airedale district is 6.6% compared to 4.3% in nearby Leeds and 5.1% nationally. The age-standardised prevalence of diagnosed diabetic retinopathy within Bradford and Airedale is 2.21% (95% CI 1.54–2.26%), with a disproportionately high prevalence of disease in the Pakistani population and the most deprived parts of the population. There was a poorer uptake of diabetic retinopathy screening in more deprived parts of the district and the proportions with a higher rate of referral to ophthalmology following the screening in Black and Minority Ethnic populations compared with the white population (13.2% vs6.9%). Uptake of secondary care outpatient appointments is much lower in more deprived populations.

Conclusion

Inequalities are inherent in diabetic retinopathy prevalence, diagnosis, and treatment. The reasons for these inequities are multi-factorial and further investigation of reasons for poor uptake of services is required. Addressing the inequalities in eye health and healthcare requires cross-organisational collaboration.     

Evaluation of early and late presentation of patients with ocular mucous membrane pemphigoid to two major tertiary referral hospitals in the United Kingdom

Purpose

Ocular mucous membrane pemphigoid (OcMMP) is a sight-threatening autoimmune disease in which referral to specialists units for further management is a common practise. This study aims to describe referral patterns, disease phenotype and management strategies in patients who present with either early or established disease to two large tertiary care hospitals in the United Kingdom.

Patients and Methods

In all, 54 consecutive patients with a documented history of OcMMP were followed for 24 months. Two groups were defined: (i) early-onset disease (EOD:<3years, n=26, 51 eyes) and (ii) established disease (EstD:>5years, n=24, 48 eyes). Data were captured at first clinic visit, and at 12 and 24 months follow-up. Information regarding duration, activity and stage of disease, visual acuity (VA), therapeutic strategies and clinical outcome were analysed.

Results

Patients with EOD were younger and had more severe conjunctival inflammation (76% of inflamed eyes) than the EstD group, who had poorer VA (26.7%=VA<3/60, P<0.01) and more advanced disease. Although 40% of patients were on existing immunosuppression, 48% required initiation or switch to more potent immunotherapy. In all, 28% (14) were referred back to the originating hospitals for continued care. Although inflammation had resolved in 78% (60/77) at 12 months, persistence of inflammation and progression did not differ between the two phenotypes. Importantly, 42% demonstrated disease progression in the absence of clinically detectable inflammation.

Conclusions

These data highlight that irrespective of OcMMP phenotype, initiation or escalation of potent immunosuppression is required at tertiary hospitals. Moreover, the conjunctival scarring progresses even when the eye remains clinically quiescent. Early referral to tertiary centres is recommended to optimise immunosuppression and limit long-term ocular damage.     

Do topical ophthalmic corticosteroids suppress the hypothalmic-pituitary-adrenal axis in post-penetrating keratoplasty patients?

Purpose

To establish whether hypothalmic-pituitary-adrenal axis suppression is possible secondary to long-term topical ophthalmic corticosteroid use in patients who have undergone penetrating keratoplasty (PKP).

Methods

Patients who had undergone a PKP and had been using corticosteroid-based eye drops continuously for more than 6 months, with no history of concomitant steroid (oral, inhaled, or cutaneous) use, were included within the study. A low-dose short Synacthen (LDSST) test was performed in each patient followed later by a short Synacthen test (SST). The mean SST and LDSST after 30 min were calculated along with their corresponding 95% confidence intervals (CIs). Correlation between both baseline SST and baseline LDSST with duration of treatment was determined using Spearman''s correlation.

Results

In all, 20 patients were included within the study. The mean duration treatment was 28.2 months (range 11–96 months). All patients had normal baseline cortisol levels in both SST and LDSST tests. The mean 30 min SST was 753.8 nmol/l (95%CI: 696.6 nmol/l, 811.0 nmol/l) and no patients displayed inadequate adrenal response. The mean 30 min LDSST was 709.8 nmol/l (95%CI: 665.1 nmol/l, 754.5 nmol/l) and only one patient had an inadequate adrenal response. There was no correlation between baseline SST or LDSST and duration of treatment.

Conclusions

This study found no evidence that patients using continuous long-term corticosteroid eye drops after PKP experienced inadequate adrenal response. We did not find any evidence of a negative correlation between length of treatment and SST or LDSST measurements at baseline.