New NICE Interventional procedures guidance [IPG612] Microinvasive subconjunctival insertion of a trans-scleral gelatin stent for primary open-angle glaucoma

New NICE Interventional procedures guidance [IPG612] Microinvasive subconjunctival insertion of a trans-scleral gelatin stent for primary open-angle glaucoma


Published date: April 2018  Next review: April 2021


Evidence-based recommendations on microinvasive subconjunctival insertion of a trans-scleral gelatin stent for primary open-angle glaucoma in adults. This involves putting a tiny gelatin tube (stent) under the skin at the base of the eye to create a new drainage channel for excess fluid.


For full guidance https://www.nice.org.uk/guidance/ipg612

New NICE Interventional procedures guidance IPG605: Ab interno supraciliary microstent insertion with phacoemulsification for primary open-angle glaucoma

Ab interno supraciliary microstent insertion with phacoemulsification for primary open-angle glaucoma



Evidence-based recommendations on ab interno supraciliary microstent insertion with phacoemulsification for primary open-angle glaucoma in adults. This involves inserting a tiny tube just below the surface of the eye to create a drainage channel.
Published February 2018
Next review: this guidance will be reviewed if there is new evidence or safety concerns.


Full guidance available at: https://www.nice.org.uk/guidance/ipg605

UHCW publication: Secondary Glaucoma due to Iridescent Crystalline Particles Masquerading as Refractory Hypertensive Uveitis in an Eye With Irradiated Iris Melanoma

Secondary Glaucoma due to Iridescent Crystalline Particles Masquerading as Refractory Hypertensive Uveitis in an Eye With Irradiated Iris Melanoma.
Chahal R, Mohite AA, Heimann H, Bansal A.

Journal of Glaucoma: February 01, 2018 Publish Ahead of Print
doi: 10.1097/IJG.0000000000000891

Abstract
Purpose: We report a previously unrecognised mechanism of secondary glaucoma due to iridescent crystalline particles released from an irradiated iris melanoma. It masqueraded as refractory hypertensive uveitis following uncomplicated phacoemulsification.
Methods: A 58-year-old gentleman had an iris melanoma that underwent successful regression following irradiation with proton beam radiotherapy (PBRT). Three years later an uncomplicated phacoemulsification with intraocular lens implant was performed and subsequently the patient presented with apparently “refractory hypertensive uveitis”. Closer examination identified unique iridescent crystalline particles originating from a disintegrating tumour and dispersing within the anterior chamber and drainage angle. The patient developed a unilateral secondary open angle glaucoma attributable to these particles. Ultrasound biomicroscopy (UBM) of the anterior segment confirmed absence of tumour recurrence or intra-scleral spread and systemic investigations ruled out distant metastases.
Results: The intra-ocular pressure (IOP) was refractory to maximal medical treatment, but was eventually controlled with trans-scleral diode laser cyclo-photocoagulation.
Conclusions: This is the first report of a secondary glaucoma attributable to trabecular blockage with iridescent crystalline particulate material released from a disintegrating, previously irradiated, iris melanoma. . PBRT and possibly phacoemulsification may have played a role in triggering the release of these previously undescribed particles from the atrophied tumour surface. This unique mechanism of secondary glaucoma needs to be kept in mind in such rare cases. Trans-scleral cyclodiode laser may be used as a good initial option in such cases to minimise potential risk of tumour seeding with incisional glaucoma surgery.


Full text available from Ovid (UHCW Athens login required) at http://ovidsp.ovid.com/athens/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=ovft&AN=00061198-900000000-98515&PDF=y

Age-related macular degeneration [NG 82]

New:  NICE guideline

1.1 Classifying age-related macular degeneration

1.2 Information and support

1.3 Risk factors

1.4 Diagnosis and referral

1.5 Pharmacological management of AMD

1.6 Non-pharmacological management of AMD

1.7 Monitoring AMD

Terms used in this guideline

Child vision screening guidance updated

Public Health England has updated its guidance on child vision screening. The resources for commissioners and providers include a service specification, competencies, leaflets and template letters.

2018 Clinical Excellence Awards

The 2017 Clinical Excellence Awards Round results were announced in late December 2017. ACCEA have now announced that the 2018 round will open on Tuesday 13 February 2018 and will close on Thursday 12 April 2018.

Diabetic eye screening: approved cameras and settings

This document from Public Health England sets out the NHS diabetic eye screening (DES) programme's recommended cameras and settings for digital DES.

RCOphth Safety Announcement: BSS and Open Systems for Injectable Medicines

Following reported errors of drug misidentification in other specialties causing serious harm, when an injectable medication was decanted into an ‘open system’, e.g. a gallipot, before administration, NHS Improvement has expressed concerns to RCOphth about the widespread practice during cataract surgery of decanting BSS (balanced salt solution) from the infusion bag into a gallipot at the start of the procedure which may then be drawn up and used to re-inflate the eye later in the operation. In addition, concern was raised that BSS kept in a gallipot might pose a risk of potential bacterial contamination.

In response, the College has replied that given the short duration that BSS typically remains in a sterile gallipot during cataract surgery, it does not consider that this practice poses a sterility issue. However there is a potential risk for drug misidentification although no other drug would commonly be placed into a gallipot during cataract surgery. RCOphth has pointed out that BSS is not currently available as a pre-filled syringe and that preparing and labelling of several syringes of BSS at the beginning of each case would be both impractical and potentially wasteful.

New ways to avoid wrong IOLs

The Royal College of Ophthalmologists is aware that never events relating to the insertion of wrong intraocular lenses (IOLs) is an ongoing problem and that members continue to have concerns about how best to avoid such incidents, and about how to ensure there is no unhelpful blame or punitive measures which lead to financial penalties or inhibit reporting and learning.

IMCgp100 for the Treatment of Advanced or Metastatic Uveal Melanoma

There are currently few effective treatments available for advanced or metastatic uveal melanoma, including surgery to remove the cancer, radiotherapy or chemotherapy.  IMCgp100 is a drug under development that would enable the body’s own immune system to recognise and specifically target and kill cancer cells. IMCgp100 is given by intravenous infusion and is currently being studied in patients with advanced/ metastatic uveal melanoma. It will offer a new treatment option if licenced.

From the NIHR Innovation Observatory.

Lenadogene Nolparvovec (GS-010) for Vision Loss from Leber’s Hereditary Optic Neuropathy Due to Mutation of the ND4 Gene

There are currently very few treatment options for LHON. Most treatment methods are used to support the patient rather than cure them. Lenadogene nolparvovec is a new gene-targeted treatment intended for vision loss caused by LHON due to an alteration in a specific gene. As a genetic medicine, lenadogene nolparvovec could be a promising option to treat LHON and if licensed, could provide a new treatment option for those with LHON.

From the NIHR Innovation Observatory

Eye Care in the Intensive Care Unit (ICU)

Produced in collaboration with the Intensive Care Society, the Eye Care in Intensive Care Unit guidance provides advice for clinical staff involved in eye care in the ICU. It is primarily intended to help non-ophthalmic ICU staff to:

• protect the eye in vulnerable patients, thus preventing ICU-related eye problems
• identify disease affecting the eye in ITU patients, and specifically those which might need ophthalmic referral
• deliver treatment to the eye when it is prescribed

It concentrates on the common problems of the eye surface but also touches on other less common conditions. As such, it should also be helpful to those ophthalmologists asked for advice about ICU patients.

NEW Defined Guidance for the use of Serum Eye Drops

Ocular Surface Disease with dry eye is a global public-health problem with significant impact on quality of life. Serum Eye Drops (SED) contain many nutritional factors that aid therapeutics. 

Across the NHS there is variation in practice, inequality of access to SED service and no regulated monitoring of outcome. This guideline sets out defined guidance for the use of Serum Eye Drops, monitoring of clinical and patient-reported outcomes to improve patient morbidity and standards of care.

RCOphth and NIHR launch Researcher of the Year Awards 2018

The Royal College of Ophthalmologists and The National Institute for Health Research are pleased to announce the opening for applications of the 2018 RCOphth / NIHR Researcher of the Year awards.

Eyes Right!

New RCN guidance, Eyes Right!, helping non-ophthalmic health care professionals deliver quality care safely.

Cataract rationing survey reveals 66% of responding eye units have some restrictions to access surgery

The Royal College of Ophthalmologists (RCOphth) has undertaken a survey of ophthalmic clinical leads to understand how the current situation of visual acuity thresholds and other imposed restrictions are affecting access to cataract surgery. Of 140 leads contacted in England and Northern Ireland, 87 replied, a response rate of 62%.

Download a summary of the key findings: Cataract surgery: current limitations to patients accessing treatment

RCOphth welcomes EU Court of Justice Advocate General’s new opinion on the use of ‘off-label’ drug Avastin

The Royal College of Ophthalmologists (RCOphth) believes that ophthalmologists should have the discretion to prescribe Bevacizumab (Avastin) or alternatives such as Ranibizumab (Lucentis) or Aflibercept (Eylea), whichever is the most appropriate treatment of age related macular degeneration (AMD) for the patient, and provided the patient gives informed consent.

The RCOphth has long petitioned a review on Bevacizumab being available for wider use for AMD in the NHS. Not only does this cheaper alternative to Ranibizumab or Aflibercept potentially save the NHS over £100million a year, as identified by the IVAN study in 2012 but is clinically proven as safe and as effective by two major studies, CATT and IVAN, and the Cochrane review in 2014.

RCOphth Statement on Ethambutol Toxicity

NHS Improvement has highlighted two recent incidents of severe visual loss due to delayed diagnosis of optic neuropathy from ethambutol.

In 2015, 5758 cases of tuberculosis were notified in England and ethambutol is frequently prescribed in its initial phase of treatment

Although ethambutol optic neuropathy is rare, members are strongly reminded of the possibility of this cause of preventable sight loss and to ensure that current guidance is followed.

Netarsudil plus latanoprost (Roclatan) for glaucoma or ocular hypertension

Glaucoma describes a group of disorders characterised by sight loss. Glaucoma is generally associated with high pressure in the liquids inside the eye but it can happen when the pressure level is normal. Individuals with consistently high eye pressure are at risk of developing glaucoma. Glaucoma does not normally cause any symptoms but once eye sight is lost it cannot be recovered. Approximately one in every ten blindness registrations is due to glaucoma. There are approximately half a million people living with glaucoma in England.
Current treatment options include a number of different eye drop formulations to stop internal eye pressure raising. If the eye drops do not work and glaucoma is diagnosed, laser therapy or eye surgery can also be used to stop sight loss. Roclatan is a fixed dose combination of two drugs, netarsudil and latanoprost, which is widely used to treat eye pressure. Individually, both drugs act in different and unique ways to lower the pressure in the eye. When used in combination, both drugs have a potential to produce a stronger and more sustained effect. If licenced, Roclatan has the potential to be more effective at lowering eye pressure when compared to current treatment options.


From the NIHR Innovation Observatory

Glaucoma: diagnosis and management [NG81]

New guidance from NICE:

This guideline covers diagnosing and managing glaucoma in people aged 18 and over. It includes recommendations on testing and referral (case-finding) for chronic open angle glaucoma and ocular hypertension, and on effective diagnosis, treatment and reassessment to stop these conditions progressing.

This guideline covers diagnosing and managing glaucoma in people aged 18 and over. It includes recommendations on testing and referral (case-finding) for chronic open angle glaucoma and ocular hypertension, and on effective diagnosis, treatment and reassessment to stop these conditions progressing.