Macular Hole Surgery and Face-down Posturing

We have recently demonstrated that non-posturing macular hole surgery is just as effective as posturing – this has created real interest among our colleagues in the UK and USA.

Macular Hole Surgery and Face-down Posturing
Is it really necessary in FTMH patients?

BY JERRY HELZNER

Noting that the need for face-down posturing following surgery for full-thickness macular holes (FTMH) larger than 400 µm) remains “the focus of debate,” researchers from Southampton University Hospital in the United Kingdom conducted a retrospective analysis of 220 consecutive patients with FTMH.

All patients underwent vitrectomy, internal limiting membrane peel, and isovolumetric gas tamponade. Phakic patients underwent phacoemulsification and IOL, even in the absence of visually significant cataract. Patients were not asked to posture but were to avoid lying supine for a week. Demographics, as well as preoperative and postoperative complications, were recorded. The size of the hole and postoperative closure were assessed using OCT.

The mean age of patients was 70 years old (range 45-93), and 162 patients (74%) were female. Macular hole size was small (<250 mm) in 36 patients (16%), medium (250-400 mm) in 77 patients (35%), and large (>400 mm) in 107 patients (49%). Primary success (macular hole closed at 3 months after a single procedure) was achieved in 93.5% of patients. Primary success rate was significantly higher in holes <400 µm (97%) compared with holes >400 µm (90%). Success rate did not vary according to age or gender.

The researchers concluded that macular hole surgery is highly successful without face-down posturing. Even in holes larger than 400 mm, “primary success rates in our study are comparable to surgery with posturing.”

The researchers presented their findings at the recent ARVO meeting under the title “Posturing is not required after macular hole surgery.”

Presentation on what can be seen with the OCT

Click here to download the presentation – OCT update

Oxford Eye Meeting..

Just attended the Oxford Congress of Ophthalmology http://www.oxford-ophthalmological-congress.org.uk– my favorite annual meeting.

Around 300 attend ophthalmologists a series of lectures / discussions on various hot topics. Particularly interesting this year was a morning on ocular inflammation and its treatment, also Russell Foster’s(http://en.wikipedia.org/wiki/Russell_G._Foster) Doyne lecture on the third type of photo-receptor (not rods / cones but a ganglion cell photoreceptor). This photoreceptor controls our wake / sleep cycle, and pupil functions but cannot be detected by our conscious brain. Fascinating stuff. You can see a similar lecture at http://www.ted.com/talks/russell_foster_why_do_we_sleep

Also heard great talks by James Talks and Rob Johnstone on the effect of anti-VEGF treatments on AMD in real life patients. Real life data is very different to reported Trials. Important implications for NICE decisions regarding new treatments.

Hope you enjoy.

Pure Joy – The Mercy Vision Programme

Here is a short video showing some of the patients I had the privilege of looking after in Congo last November.

The patients were so brave and so grateful it was a delight to be part of a team bringing real hope to many people in that country. I hope you enjoy the video and pass it on to your friends so they can get a sense of the difference Mercy Ships is doing throughout West Africa.

Richard Newsom

Can food supplements prevent blindness?

Age-related macular degeneration (AMD) is a common eye disease. It affects around 25% of people over the age of 75 in the UK to some extent, and presents with gradual deterioration and distortion of central vision. Although in the early stages most have no symptoms (when the condition is termed age-related maculopathy), late AMD that significantly impairs vision affects 2.4% of people over the age of 65 (Owen, Jarrar, Wormald et al, 2012).

Wet and dry AMD

A detailed review of AMD can be found in a previous issue of InnovAiT (Newsom and Simon, 2008). All patients start with dry (or ‘geographic’) AMD. It is caused by a reduction in blood flow to the macula and release of free radicals. The cells of the macula break down resulting in drusen formation (yellowish lipid deposits – Figure 1). As the number and size of the drusen increase, central vision deteriorates.

Retinal photographs of AMD

Figure 1: Retinal photographs of AMD

 

Wet AMD is much less common than dry AMD but is much more likely to cause blindness. In patients with dry AMD, drusen may lift the retinal pigment epithelium away from its blood supply. New blood vessels then grow from the choroid (choroidal neovascularisation) and these new vessels may bleed forming scars and leading to irreversible loss of central vision.

How can vitamin supplements help?

The Age-Related Eye Disease Study (AREDS) run by the US-based National Eye Institute reported in 2001 (Age Related Eye Disease Study Group, 2001). It involved 4,757 participants aged between 55-80 years, in 11 clinical centres across the US. Participants in the study were given food supplements containing different combinations of antioxidants (500 mg of vitamin C; 400 international units of vitamin E; 15 mg of beta-carotene) and zinc (80mg of zinc oxide and 2mg of copper as cupric oxide to prevent the copper deficiency associated with zinc supplementation). Participants were randomised to one of four treatments:

  • Zinc alone
  • Antioxidants alone
  • A combination of antioxidants and zinc, or
  • A placebo formulation

The trial was double-blinded with neither participants nor investigators knowing which preparation each individual was receiving. The study found that the combination of antioxidants and zinc reduced the risk of developing advanced dry AMD or wet AMD and its accompanying visual loss (odds ratio (OR) 0.72; 99% confidence interval (CI) 0.52-0.98). This equates to a risk reduction of around 20% overall. The risk reduction was most pronounced (up to 30%) for those with more advanced AMD with little or no visual loss, and those who already had advanced dry or wet AMD in one eye (with loss of vision in that eye) but preserved vision in the other eye. This reduction in risk was maintained after 10 years follow up (Chew, Clemons, Agral et al, 2013).

However, there were ongoing concerns that the beta-carotene component of the AREDS formula was associated with an increased risk of lung cancer in smokers and former smokers, and suggestions that other antioxidants might be at least as effective (or even more effective) than those used in the AREDS formula. In addition, the high doses of zinc used in the AREDS formula caused gastrointestinal upset and made the formula unpalatable for some.

In 2006, a new five-year study was started (AREDS2). It explored whether the AREDS formulation could be improved by adding omega-3 fatty acids and/or the carotenoids lutein and zeaxanthin, or by removing beta-carotene and/or reducing zinc content (Age Related Eye Disease Study  2 Research Group, 2013).

Participants were aged 50-85 years and were all at risk for progression to advanced AMD with bilateral large drusen, or large drusen in one eye and advanced AMD in the other eye. In total there were 4203 participants. The study used a double-blinded factorial randomised controlled trial design in which participants were randomised into groups taking:

  • The original AREDS formulation unchanged
  • The original AREDS formulation with no beta-carotene
  • The original AREDS formulation with reduced zinc (25mg), and
  • The original AREDS formulation with no beta-carotene and low zinc.

Within each of these four groups, participants were further randomised into groups taking additional supplements:

  • Lutein 10mg and zeaxanthin 2mg
  • Omega-3 fatty acids (1g)
  • Lutein, zeaxanthin and omega-3 fatty acids, or
  • Placebo.

Analysis of the results from the 16 different treatment groups showed that reducing the dose of zinc did not change the effectiveness of the preparation but did reduce side effects. Addition of omega-3 fatty acids also made no difference to outcomes. Substitution of lutein and zeaxanthin for beta-carotene into the formulation was at least as effective (and up to 18% more effective amongst those with low dietary intake of green.leafy vegetables) without increasing the risk of lung cancer.

What do these studies mean for GPs?

In the GP surgery, patients with AMD usually present with slowly progressive loss of vision. This causes problems with reading and face recognition first and is worse with changes in lighting. A dark patch that rapidly fades may be noticed on waking. This can be interpreted as ‘seeing a shadowy figure’ and be very frightening. With severe visual loss patients may see visual hallucinations, usually of faces or stars. These can also be very frightening and patients may need considerable reassurance.

With the equipment available in the GP surgery, it is often difficult to visualise any changes at the back of the eye in patients with AMD, even if the pupil is dilated. Further slit-lamp assessment (with or without retinal photography if available) may be helpful from a community-based optician.

An Amsler grid (Figure 2) can be a useful test for AMD in the GP surgery. Each eye should be tested separately with the other eye covered. Patients with AMD affecting their vision may find that when fixing their gaze on the dot in the middle of the chart (with reading glasses on if worn), the straight lines appear wavy or missing. The defect can be marked on the chart. Once a diagnosis is established any change in the area of the defect may represent a progression and warrants further assessment by an eye specialist. It is worth finding out what your local referral pathways are.

Amsler Grid

Figure 1: Amsler Grid

Refer any patient with progressive loss of vision with either no obvious cause, or a suspicion of AMD, to ophthalmology for confirmation of diagnosis. Refer urgently if the loss of vision is of recent onset or there is rapid reduction in vision.

Once AMD is confirmed, patients are usually followed up at least annually according to local protocols. However, there is an ongoing role for GPs in their care. Risk factors for development and progression of AMD include age, family history, smoking, hypertension and diet. Whilst age and family history are not modifiable, GPs have a role in:

  • promoting smoking cessation for all patients with AMD
  • helping to control blood pressure to within current national targets
  • promoting a healthy diet rich in green, leafy vegetables and
  • recommending AREDS2 formula antioxidant and zinc supplementation

Of note, it is impossible to obtain the required levels of antixidants and zinc to reduce progression of AMD with diet alone.

Referral for treatment of other coexisting conditions that affect vision (e.g. cataract) can also help. Finally, provision of visual aids, registration of blindness and social support are important for those with significant visual loss.

Conclusion

The AREDS and AREDS2 trials show that dietary factors are important to prevent progression of AMD both in the short and longer term. Several companies are now producing AREDS2 food supplements for patients with AMD to purchase. In addition to control of blood pressure and promotion of smoking cessation, GPs should include dietary advice for patients with AMD whenever they are seen in primary care to eat more green, leafy vegetables, and recommend that they take AREDS2 formulation food supplements, check their vision regularly on the Amsler grid, and report any changes in vision.

References and further information

Age Related Eye Disease Study  2 Research Group (2013). Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. Journal of the American Medical Association 309(19):2005-15.

Age Related Eye Disease Study Group. (2001). A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol, 119(10), 1417-36.

Chew EY, Clemons TE, Agron E, Sperduto RD, Sangiovanni JP, Kurinii N, Davis MD; Age Related Eye Disease Study Research Group (2013) Long-Term Effects of Vitamins C, E, Beta-Carotene and Zinc on Age-Related Macular Degeneration. Ophthalmology. DoI: 10.1016/j.ophtha.2013.01.021 (ePub ahead of print)

Newsom R, Simon C (2008) Age-related macular degeneration. InnovAiT (10): 710-713

Owen CG, Jarrar Z, Wormmald R, Cook DG, Fletcher AE, Rudnicka AR (2012). The estimated prevalence and incidence of late stage age related macular degeneration in the UK. British Journal of Ophthalmology 96 (5): 752-6

Simon C, Everett H, van Dorp F, Burkes M (2013). Oxford Handbook of General Practice (4th Edition): Chapter 26: Ophthalmology. Oxford University Press.

Social media first for Spire Southampton Hospital

Mr Richard NewsomLeepeckgroup has helped Spire Southampton Hospital create a social media first by live tweeting a cataract operation from one of the hospital’s state of the art operating theatres.

During National Eye Health Week, Mr Richard Newsom, consultant ophthalmic surgeon at Spire Southampton Hospital removed a cataract from LPG Chairman Lee Peck’s right eye, while the whole procedure was reported through @spiresoton, the hospital’s official Twitter feed.

The ten-minute operation was also recorded and uploaded to Youtube to show the incredible advances in eye surgery and how these life-changing procedures are now open to anyone.

Lee was photographed talking about what lay ahead with Mr Newsom just an hour before entering the operating theatre, and having undertaken the procedure with just a local anaesthetic, was able to leave the hospital the same afternoon.

Lee Peck said: “The operation was a complete success and my vision is now absolutely brilliant. From my perspective the biggest plus is that I’ve been able to return to work within five days of the procedure.”

Mr Newsom said: “Advances in new diagnostics and surgical equipment mean that 95% of patients enjoy good vision following cataract surgery. Lee was a model patient and now enjoys 20/20 vision in both eyes.”

It is the first time that Spire Southampton Hospital have used social media to demonstrate the work of their surgeons and the ground-breaking procedures that are available to patients in the area.

Mr Richard Newsom during the operation

Jane Whitney-Smith, Spire Southampton Hospital director said: “Communicating what we do is so important to give confidence to patients. Spire Southampton Hospital offers comprehensive private hospital treatments, procedures, tests and scans to patients from across the region and this was an excellent opportunity to show people just one of the many treatments available.”

The operation was followed by @myvisionmatters the Twitter feed of National Eye Health Week and widely praised by followers within the eye health sector. The photography was by Innes Marlow

Traffic nightmare drives Fiona to pioneering operation

Fiona HutchingsIt took a terrifying night drive for Fiona Hutchings to ultimately discover a state-of-the-art procedure to restore her rapidly deteriorating vision. Unaware as to how bad her eyesight had actually become, petrified Fiona found she could barely see past the glare being created by the headlights of the oncoming traffic during her drive back to her home in Holbury near Southampton, Hampshire.

She was so frightened she felt if she had pulled over to allow the line of traffic built up behind her to pass, she would never have had the courage to continue driving back to the home she shares with her beloved husband Derrick.

“It really affected my confidence,” explains the normally happy-go-lucky 50-year-old. “I hadn’t driven on my own for a good few months and it was such a shock that my vision had become so bad. I was so scared I didn’t drive again after that — not even in the day!”

However, she is now safely back behind the wheel after being one of the first people in Hampshire to have her impaired vision corrected by state-of-the art implantable lenses.

“I can now see the definition on things and that has given me my confidence back”

Fiona was suffering from the onset of cataracts — the leading cause of treatable blindness worldwide — and presbyopia, the natural ageing process that makes people dependent on reading spectacles as they reach their forties.

“I was shocked when I was told I had cataracts by the optician as I had always thought they were something you got when you’re older,” says Fiona, who works in the finance department of a local scaffolding company.

“Up until a few years ago I had perfect vision so it was quite a surprise to discover I had cataracts. I was obviously just putting up with my eyesight and making adjustments.”

Fiona’s life has been brought back into bright, crisp and clear focus thanks to the expertise of highly respected consultant ophthalmologist Richard Newsom and a ground-breaking implantable lens known as the ReSTOR.

Mr Newsom, who has private practices at both the Wessex Nuffield Hospital, Chandlers Ford and BUPA Hospital Southampton, is one of a select group of the UK’s leading ophthalmic surgeons who are offering the ReSTOR, which utilises ground-breaking patented technology to provide patients excellent distance and near vision.

Pioneered and manufactured by world-leading eye care company Alcon, the ReSTOR has proved so successful in allowing cataract patients to see clearly at all distances that it has just received European CE approval to treat other, more simple, vision disorders.

“The possibilities for the ReSTOR are immense because in addition to offering high-quality near and distance vision to people with cataracts, it now offers the millions of people suffering from just presbyopia a genuine alternative to spectacles,” adds Mr Newsom.

“Presbyopia is caused by an age-related loss in the elasticity of the natural crystalline lens,” he explains. “A young crystalline lens has elastic properties making it very malleable and easily moulded to enable clear near vision. As we get older the consistency of the lens changes. It becomes harder and thicker, making it increasingly difficult to adjust the shape of the lens, which affects its focusing ability and results in problems with near vision.

“In the past we were unable to correct presbyopia with more traditional techniques such as laser eye surgery so the benefits of the ReSTOR are likely to be far reaching — particularly among those people who have been fortunate to have perfect vision until their forties and don’t want to become dependent on spectacles in later life.”

Fiona says: “I was shocked that I needed treatment as I had always considered I was ageing well! But it is amazing. As soon as I had it done I realised how bad my vision had become. It was like I was looking through net curtains. I can now see the definition on things and that has given me my confidence back.”

Her eyes were treated in two separate day-case operations that were performed nearly two weeks apart at BUPA Hospital Southampton. “It is just fascinating,” says Fiona. “I purposely didn’t ask too much about the procedure in advance, but it was great. It seemed to be over very quickly.”

And the results have made a huge difference to her life. Being able to read without the aid of glasses has rekindled Fiona’s passion for literature. “I had been put off reading because it had become a hassle, but since the treatment I’ve become quite a little bookworm. The only downside of the operation is that I can now see all the dirt in my house! It’s been a bit of an eye-opener as before I obviously couldn’t see all of the dust and cob webs.”

Fiona Hutchings (538 downloads)

New website launch

I am pleased to announce the launch of my new website. The aim of the new site is to make it easy to find information about eye conditions and to be able to contact me to arrange an appointment.

I will be adding new information to the site over the next few weeks. If you or know someone who is suffering from a retinal disease, please do contact me to enquire as to the ways I can help.