Irish Journal of Medical Science (1971 -) (2018) 187 (Suppl 2):S11–S16 https://doi.org/10.1007/s11845-018-1762-9

ABSTRACTS

Proceedings of the RAMI Section of Ophthalmology Meeting, Friday 24th November 2017 in the Chartered Accountants House, Pearse Street, Dublin 2

# Royal Academy of Medicine in Ireland 2018

Outcomes of Trabeculectomy in a single centre with focus on efficacy of bleb needling in failing or failed trabeculecomy C McCloskey, S Quinn Sligo University Hospital Aim: To determine outcomes of patients who underwent a trabeculectomy and specifically the efficacy of subsequent bleb needling. Methods: A retrospective case series of 63 trabeculectomies performed by a single surgeon between February 2008 and Janury 2017. Inclusion criteria: Any patient at least three months post trabeculectomy surgery for any aetiology. Outcomes measured: IOP (intra-ocular pressure) pre and post trabeculectomy, number of IOP lowering medications pre and post trabeculectomy, number requiring subsequent Type 1 or 2 bleb needling, IOP pre and post bleb needling and number of IOP lowering medications pre and post needling. Results: A total of 52 trabeculectomy procedures performed (43 patients) met the inclusion criteria. Mean age was 68 +/-13years. Mean length of follow up since trabeculectomy was 1076 days +/-797 (2.9 years). Mean IOP pre-trabeculectomy was 24.46 mmHg+/-7.17 and the mean number of IOP lowering medications was 3.59+/-1.28. Mean final IOP was 12.32mmHg+/-4.03 (p<0.0001) and the mean number of IOP lowering medications at end of follow-up was 0.44+/-0.9 (p<0.0001). Eighteen of the 52 trabeculectomy patients underwent subsequent Type 1 or 2 bleb needling at a mean of 407 days +/- 633 (13 months) post initial surgery due to failed or failing bleb defined as increasing IOP and flat or vascularised blebs. Mean IOP preneedling was 26.03mmHg +/-5.74 and the mean number of IOP lowering medications was 0.66+/-0.98. The mean number of needlings per eye was 1.88+/-1.02. Mean length of follow-up post initial needling was 843 days +/- 647 (2.3 years). The mean final IOP of the 18 trabeculectomies which underwent bleb needling was 13.92mmHg+/-4.92 (p<0.0001) and the mean number of IOP lowering medications as end of follow-up was 1.06+/-1.21 (p<0.22). Conclusion: There are statistically significant reductions in IOP and the number of IOP lowering medications post trabeculectomy. There are also statistically significant reductions in IOP with bleb needling and a non significant increase in the number of IOP lowering medications post needling compared with pre needling.

An unusual case of sudden onset unilateral proptosis T Murphy, Q Pilson, R Khan, A Doyle Royal Victoria Eye and Ear Hospital, Dublin Case: A 29-year-old man presented to RVEEH with a 1-day history of sudden onset left severe proptosis and double vision after blowing his nose. On examination he had ophthalmoplegia, complete mechanical ptosis, and inferotemporal globe displacement. He had a past medical history of sarcoidosis. The patient was evaluated by computed tomography and magnetic resonance imaging. This demonstrated intra-orbital air collection with a fluid level in the superomedial sub-periosteal space. There was no evidence of sinus collection. The patient was treated as presumptive orbital cellulitis and received intravenous antibiotics. The left orbital collection was drained. However, this did not yield any bacterial growth or cells. Conclusion: Despite the clinical appearance of orbital cellulitis on presentation, this case demonstrates the importance of complete evaluation and clinical suspicion for unusual causes of proptosis.

Introduction of Intravitreal Injection Booklet in University College Hospital Galway C Ern Hui Fang, P Murtagh, F Kinsella Department of Ophthalmology University College Hospital Galway, Galway Introduction: Intravitreal injections are a safe and efficient method for drug delivery to the posterior segment of the eye. Their use has sky-rocketed in recent years since the advent of intravitreal anti-VEGF which is used for neovascular age related macular degeneration, diabetic macular oedema and oedema associated with central retinal vein occlusions. Many of these patients are on treatment regimens which may continue indefinitely. This has led to frustration among doctors with regards patient’s notes making it difficult to ascertain quickly and clearly how many injections they have had, which type of injection they have received and what their diagnosis is.

S12 Objective: To highlight the safety concens among doctors administrating injections in our department and to assess the difficulty in retrieving information from the patient’s notes quickly and effectively and if this was a concern to patient safety. Methods: A survey was undertaken by the doctors in the Ophthalmology Department on their opinion of the ease of access of patient information when carrying out intravitreal injections and the potential effect on patient safety. Results: Unanimously all the doctors believed that it was time consuming and a risk to patient safety to quickly retrieve pertinent information from the paper laden charts. Our proposal is to introduce an “Intravitreal Injection Booklet” akin to the warfarin booklet. This would be a passport sized document which the patient would need to bring with them at each appointment. It would contain information on the injections themselves including side effects and emergency details should a problem arise. It would also be a record of number and type of injections they received and the indication. We will demonstrate the layout and benefits of such a booklet. Conclusion: There is an increasing burden on ophthalmology departments across the country to perform more and more intravitreal injections. The introduction of a booklet will make this process more efficient and safer from a patient’s perspective. We aim to re-audit the booklet a few months after its introduction to determine if it would be beneficial for nationwide use.

Ir J Med Sci (2018) 187 (Suppl 2):S11–S16 can cause significant visual loss. Prompt and effective treatment modalities should be undertaken to limit any visual loss.

Recurrent endophthalmitis requiring evisceration T Butler Ophthalmology Dept, University Hospital Galway Endophthalmitis is an uncommon but potentially blinding complication of intravitreal injections. We report the case of an 8o year old immunosuppressed diabetic patient with multiple co-morbidities who developed recurrent endophthalmitis following intravitreal bevacizumab. He presented acutely with endophthalmitis which was treated with intravitreal and topical antibiotics, as well as early vitrectomy. Five months following initial presentation, the patient presented again with signs and symptoms of endophthalmitis. Evisceration was carried out at this time revealing an intraocular abscess. The same unusual organism was seen on microbiological DNA analysis on both occasions. Endophthalmitis is a potentially devastating ophthalmic disease, and even with successful initial treatment it may recur, particularly in immunecompromised patients.

An Unusual Case of a Retinal Detachment in a Young Male D Minasyan, T McSwiney, J Doris, N Horgan

Feasibility and safety of triaging eye emergency department referrals from GPs for outpatients review

Waterford Regional Hospital, Royal Victoria Eye and Ear Hospital

C Quigley, S Moran, T Fulcher

Introduction: We report an unusual case of a retinal detachment in young myopic male. A 26-year-old male presented to a regional eye centre in September 2017 complaining of shadow in his superior visual field, progressing over a two week period. He did not state any floaters nor flashing lights prior to onset of shadow. On examination his visual acuity with glasses was: right eye 6/9, left eye 6/24 improving to 6/12 with pinhole. Anterior segments were unremarkable. Dilated fundal examination revealed inferior retinal detachment, with no PVD (posterior vitreous detachment), and no tobacco dust in vitreous. No holes, breaks, tears or lesions were noted on indented retinal examination. He did not have any medical or surgical history of note although a port wine stain noted on his face. Diagnoses of exudative retinal detachment was made, and patient underwent 25 gauge pars plana vitrectomy. Preoperatively, after drainage of fluid, diffuse choroidal haemangioma was discovered. He underwent subsequent further evaluation, including ICG and FFA and B-Scan ultrasound which demonstrated findings consistent with diagnosis of a diffuse choroidal haemangioma. Photodynamic therapy was undertaken with standard settings and a 6400um spot size. Overview: Choroidal haemangioma is an uncommon benign vascular tumour of the choroid, which can be circumscribed or diffuse. The diffuse form is usually part of Sturge-Weber syndrome. They are usually diagnosed between the second and fourth decade of life when they cause visual disturbance because of exudative retinal detachment. The aim of treatment is to limit the visual effect caused by subretinal fluid. Various treatment modalities have been tried for the treatment of choroidal haemangioma with varying degrees of success and photodynamic therapy has become a new treatment option. Conclusion: We present an unusual but important cause of retinal detachment in the younger population. Although rare, choroidal haemangiomas

Mater Misericordiae University Hospital, Dublin Introduction: Currently there is no triaging system of referrals to our eye emergency department (EED). Consequently, some patients with non-acute problems are seen there. This results in an overburdened service with long waiting times. We retrospectively triaged referral letters, and then reviewed outcomes, to investigate if instituting a triaging system would significantly and safely reduce numbers needing to be seen. Methods: The Mater EED attendances during desk hours, 08.00 to 16.00, Monday to Friday, from 4th September to 15th September 2017, were included. Retrospective triage of GP referral letters of newly attending patients was carried out separately, and independently by a specialist registrar and an SHO. Outcomes of those patients who were selected for review in outpatients were assessed. Results: There were n=429 patients in total registered in the EED, of whom n=258 (60.1%) patients were new attendances with a GP letter. The SpR selected n=71 (16.6%) of these patients for review in OPD, and the SHO selected n=26 (6.1%) patients. Of those patients who were selected for review in OPD, the outcomes for all patients were reviewed- mild inflammatory conditions including blepharitis and conjunctivitis were the majority, n=24, followed by cataract, n=10, followed by other outcomes, n=43. Of those triaged as refer to OPD, n=3 were found to have been referred for management of wet age related macular degeneration (AMD), and the outcome was unknown for n=4. Discussion: Triaging of referrals to the EED would variably reduce the volume of patients attending, depending on the triager. Triage may be problematic, as we found that patients who had wet AMD could be selected for review in outpatients, this risk could be reduced with greater detail in referral letters.

Ir J Med Sci (2018) 187 (Suppl 2):S11–S16 The importance of distinguishing between cytomegalovirus retinitis and central retinal vein occlusion in a patient with a diagnosis of Human Immunodeficiency Virus E O’Neill, P Murtagh, G Fahy Ophthalmology Department, Galway University Hospital, Newcastle Rd, Co. Galway Purpose: To report a case of central retinal vein occlusion in patient with a new diagnosis of HIV with a CD4 count of 100, and the importance of outruling cytomegalovirus (CMV) retinitis in this patient Methods: Case report Result: A 55-year-old man presented to eye casualty with a 3-day history of blurred vision in the left eye on a background of a new diagnosis of HIV. He had no previous ocular history. He had been admitted to the hospital with cerebellar signs and symptoms of sore throat and unintentional weight loss 10 days previously, with a subsequent diagnosis of HIV infection and a CD4 count of 100. On fundal exam, there were peripheral cotton wool spots in all quadrants bilaterally, while the right eye showed a haemorrhagic swollen disc, flame haemorrhages and tortuous vessels. OCT was performed and showed gross macular oedema. Though the appearance of the fundus seemed consistent with a left eye central retinal vein occlusion, senior opinion was sought in eye casualty as it was felt that CMV retinitis could not be outruled as a cause of fundal changes in this patient. There was discussion between senior house officers and specialist registrars as to which was more consistent with the changes seen. Consultant opinion was sought and it was decided fundal changes were more in keeping with a CRVO. The patient was listed for a course of 3 anti-VEGF injections and measures were taken to optimise cardiovascular health. Conclusion: This case demonstrates that CRVO and CMV retinitis may have similar features on ocular examination. In a patient with HIV, it is essential to know the CD4 count to attempt to out rule CMV as a cause of fundal changes. Where the CD4 count is less than 100, there should be a high index of suspicion of reactivation of CMV as cause of fundal changes, and thorough investigation and treatments should be instigated to preserve vision. However, while CMV retinitis should remain high in the differential, the more commonly occurring CRVO should also be considered as a cause of fundal changes. Where there is any doubt as to which entity the patient is presenting with, expert opinion should be sought.

A case of spontaneous resolution of a refractive surprise following cataract surgery on a patient with a history of LASIK corrective surgery E Greenan, E O’Connell Cork University Hospital Introduction: A case of spontaneous resolution of a refractive surprise following cataract surgery on a patient with a history of LASIK corrective surgery. Description/case report: A 71-year-old female attended The South Infirmary Victoria University Hospital for elective cataract surgery. Her background ocular history was reported as being significant only for a retinal detachment with macula off, occurring four months before. This was successfully repaired with a vitrectomy involving endolaser, cryotherapy and gas tamponade with C3F8 under local anesthetic. The patient had also had prior LASIK surgery, which was undisclosed preoperatively. At the patient’s preoperative evaluation, her right visual acuity measured 6/18 unaided on the Snellen chart, with no notable improvement with pin

S13 hole assistance, and her left visual acuity was 6/6. Based on her right biometry readings, using the SKR/T formula, a Rayner –Flex 570C IOL +21.00D was chosen for a predicted refractive outcome of -0.17D. Four weeks post-op, right visual acuity was 6/24-1 unaided, correcting to 6/36 with pin hole and her left vision was again measured 6/6. OCT was performed and was normal. The patient’s autorefraction measured a sphere of -2.75D and a cylinder of +0.50D to equate to a SE of -2.50, and thus confirming her refractive surprise. With further questioning it transpired that the patient had previous LASIK correction in 1999. Two weeks later the patient returned to clinic. Her vision had improved slightly, right eye visual acuity was 6/18 unaided, and 6/12 with pinhole aid. A further three months later, and just shy of the eight month after her initial cataract extraction the patient was seen in again in our outpatient clinic. Despite having forgotten her distance correction glasses her RVA had improved to 6/12+1 unaided, 6/9 with pinhole. Her autorefraction on that day was a sphere of -1.00 D, cylinder of +1.25D and SE of -0.50D Discussion/Conclusion: A ‘refractive surprise’ can be defined as an unintended post-operative refractive outcome after cataract surgery than what had been predicted preoperatively. In the case of previous corneal refractive surgery, the SRK/T is insufficient to calculate the required IOL power due to the change in relationship between the anterior and posterior corneal surface. Over the past number of years various formulations have been produced to overcome the challenge of IOL calculation in eyes with previous laser vision correction. One of the most reliable is the Haigis, which compares more favorably than that of the Double-K Method. Using the Haigis formula, an IOL power of 21.00D would have potentially produced a refractive outcome of -0.45 D in our patient. Over the eight-month post-operative period our patient’s visual acuity gradually improved from 6/24 to 6/9, and her refractive error from -2.50 to -0.50 D, spherical equivalent (SE) with conservative management alone. The documented resolution over time suggests that there were secondary reasons for the patients’ refractive error, such as capsular bag syndrome. This case highlights the need to fully investigate all the possible causes of post-operative refractive surprise before making and instigating a management plan.

Clinical features of multiple sclerosis in a regional hospital in North West Ireland E Hegazy, L Kobayter, S Chetty Sligo University Hospital Introduction: Multiple Sclerosis (MS) is one of the most prevalent diseases of the central nervous system. It affects approximately 2.5 million people worldwide, an estimated 9000 people in Ireland and 1 in 400 people in North West Ireland. Aim: To characterise the clinical features, radiological and laboratory findings, treatment modalities and hospital admissions of patients with a new diagnosis of clinically isolated syndrome (CIS) or MS in a 5- year period, presenting to a large regional hospital in North West Ireland. Methods: A retrospective chart review was conducted, with data collected on patients who had a contrast-MRI brain for suspected demyelinating disease between the period 01/01/2012 to 31/12/2016. Information regarding age, gender, presenting complaint, MS category, laboratory investigations, treatment, hospital stay, Vitamin D levels and supplementation was collected. Results: Ninety patients received a contrast-MRI brain for suspected demyelinating disease in the 5-years. 57 patients had evidence of demyelination on imaging: 74% female, 26% male. The median age at presentation was 37 years (age range: 15-71). 58% were classified as relapsing remitting MS (RRMS), 33% as CIS, 7% as primary progressive MS and 2% as Neuromyelitis Optica.

S14 The most common presenting complaint was weakness and paraesthesia (40%) and optic neuritis (40%), followed by ataxia 9%, diplopia 5%, vertigo 2%, nystagmus 2% and cognitive decline 2%. Laboratory investigations included cerebrospinal fluid analysis for all patients, anti- aquaporin4 antibodies, anti-myelin oligodendrocyte glycoprotein (MOG) antibodies, a coeliac screen and vitamin D levels. 66% who had vitamin D levels measured at presentation were deficient. 2% were positive for anti-aquaporin4 antibodies, no patients were positive for anti-MOG antibodies/coeliac disease. 63% of patients received IV steroid treatment at presentation; 54% over 5 days and 46% over 3 days. 58% of patients were admitted, with the mean number of inpatient days 4, (+5)days. Mean MRI brain performed to date since diagnosis was 3, (+1)and mean MRI spine was 3, (+- 1). 60% are on disease modifying agents: Interferon B1a 25%, Glatiramir 14%, Fingolimod 11%, Natalizumab 4%, Dimethyl Fumarate 4% and Teriflunomide 2%. Vitamin D supplements were taken by 90% of patients. Conclusion: MS has a high incidence and prevalence in North West Ireland. A significant proportion of patients presented with ocular symptoms. A considerable number of patients were diagnosed with RRMS and required IV steroids along with hospital admission in the acute setting. The majority of patients also had deficient vitamin D levels at presentation. This may be a factor accounting for the increased incidence in the North West of Ireland where there is limited sunlight exposure.

Acute Intraocular Haemorrhage in a Young Healthy Male K Curtin, E Mahmoud, A Cullinane Ophthalmology Department, Cork University Hospital Objective: Here we report a case of a healthy male who presents with severe bilateral intravitreal, subhyaloid and intraretinal haemorrhage. Method: Case Report and literature review. Results: We report this case of a 38 year-old male who presented to A&E with a two week history of worsening left sided, throbbing headache and associated neck pain following minor head trauma. During his assessment he had an episode of vomiting followed by loss of consciousness lasting approximately one minute. There were no localizing neurological signs and initial computed tomography with contrast showed no cerebral lesion. Lumbar puncture, CSF, serology and infectious workup including blood cultures were unremarkable. The following day he was referred to eye casualty for assessment of his vision. Best- corrected visual acuity was 6/9 in the right eye and hand motion in the left eye. Fundal examination revealed bilateral intraocular haemorrhage involving multiple retinal layers. A large, prominent subhyaloid macular haemorrhage of approximately five disc diameters was noted in the left eye. There was no history or features of diabetic, hypertensive or anemic retinopathy. Discussion: The differential diagnosis, investigative findings, pathogenesis and treatment will be discussed.

Clinical outcomes of Zeiss toric intraocular lens implantation for correction of corneal astigmatism after cataract K Kamel, E Dervan Ophthalmology Dept. - Mater Misericordiae University Hospital – Dublin High corneal astigmatism is a main contributing factor in poor unaided visual outcomes after cataract removal surgery. Toric intraocular lens

Ir J Med Sci (2018) 187 (Suppl 2):S11–S16 (IOL) can be an effective alternative for these patients in comparison to a monofocal lens. This is a retrospective study of clinical outcomes of Zeiss toric IOL (AT TORBI 709M/MP) implantation post cataract removal for corneal astigmatism >1.5 diopters (D) under the care of one consultant in the Mater Misericordiae University Hospital from June 2016 until June 2017. Incision location, lens position, post-operative uncorrected distance visual acuity (UCDVA) and best corrected (BCDVA) has been recorded. Surgically induced astigmatism (SIA) has been calculated for each of the three surgeons included in this study. 28 patients underwent 29 procedures. 22 eyes had a temporal incision, while 7 had on axis incision. 4 patients did not attend for post op review. Post op lens position was checked after 3-4 weeks in 10 eyes, 8 had their lenses within 5 degrees of planned position while 2 had them more than 10 degrees rotated. 6 patients had other ocular pathologies explaining poor visual outcomes. Excluding these patients, 4/19 (21.2%) patients achieved 6/6 UCDVA (all had temporal incisions). 14/19 (73.6%) achieved 6/12 or better. 15 patients had post op subjective refraction. Excluding other ocular pathologies, the BCDVA was 6/9 or better for the other 11 eyes. SIA was mostly <1.00D for temporal incisions and >1.00D for non-temporal incisions regardless of the surgeon. Our 6/6 and 6/12 UCDVA achievement rate were within the international standards, ranging between (12-40.7%) & (68-97%) respectively. In conclusion, Zeiss toric IOLs are effective in treating cataract patients with high corneal astigmatism. Pre-operative marking, precise IOL calculation and positioning are essential. Temporal incisions induce less astigmatism and thus offer better refractive predictability when planning for toric IOL implantation.

Analysis of non-attendance of the diabetic retina screening patients at the diabetic retinopathy clinic in Limerick University Hospital M Mohamed, M Hickey Dwyer, AM Mongan, O Klis Department of Ophthalmology University Hospital Limerick, Dooradoyle Introduction: Non-attendance at diabetic retinopathy clinics (DRC) has a negative impact on the efficiency of health service provision, resulting in longer waiting lists that affect not only the non attendant patients themselves but all DRC appointments. Objectives: To measure the percentage of non-attendees, and to determine their demographics, clinical characteristics, and geographic distributions. Study design: A retrospective audit of all patients who failed to attend the DRC in Limerick University Hospital between 1st August 2016 and 31st August 2017. Methods: Optomize ® software was used to identify characteristics of people who failed to attend the DRC following referral from diabetic retina screening (DRS). Results: In the 12-month period the percentage of non-attendant patients was 13.9 % (n=137); most were male 66.4 %. Non-attendant patients had a mean age of 65.8 years (range 21-95 years). The majority of the nonattendees (46.7%) lived in County Limerick while the rest were from County Clare 29.2 %, County Tipperary 19.7%, County Kerry 0.7% and 3.6% unknown. 58.4% of patients did not attend their DRC once while 41.6 % did not attend on two occasions. Although 12.4 % of DRS referrals were urgent; 35.3% of these did not attend two consecutive appointments. Most DRS referrals (73.7%, n=101) were due to diabetic eye disease.

Ir J Med Sci (2018) 187 (Suppl 2):S11–S16 Conclusion: This study showed an attendance rate to DRC of 86.2 % in a one year period. Detailed analysis of these results will be presented and the visual consequences of non-attendances will be discussed.

An Audit of Referrals to Ophthalmology Casualty Service University Hospital Limerick R Ellard, O Klis, I Tuwir University Hospital Limerick Aims: The objective of this audit was to evaluate the presentations to the ophthalmology service and to make appropriate recommendations to improve the service. Methods: A prospective audit was carried out over a 24 day period in October 2017. Data was collected regarding the patient demographics, who the referral was made by, the duration of symptoms, the reason for referral, diagnosis and outcome. Results: A total of 220 patients attended the ophthalmology casualty service during the period of the study. 52.7% of these were referred by general practitioners. The majority of presentations were non-urgent referrals. Over 73% were non-painful conditions and 75% were non-sight threatening. Conclusion: There is a high rate of number of non-urgent referrals and there is a need for improved triaging. There is a role for an eye casualty nurse specialist to triage the presentations and liaise with general practitioners. The use of a standard GP referral form as used in other institutions may aid the appropriate triaging.

A case series of hypotony maculopathy after CYPASS insertion which resolved with supraciliary stenting

S15 Conclusion: MIGs for glaucoma surgery is based on a one-size fits all principle, which might not be without complications in patients with variations in their eye anatomy and physiology. Most studies involving CYPASS were carried out on patients with mean age of 70 and above, where the supraciliary space was found to be less efficient.Myopia has also been linked to having a higher risk of developing hypotony maculopathy. Our case series demonstrate CYPASS could cause hypotony maculopathy in younger myopic patients and supraciliary stenting is an efficient management method. References: 1. Vold S, Ahmed II, Craven ER, et al Two-year COMPASS trial results: Supraciliary microstenting with phacoemulsification in patients with open-angle glaucoma and cataracts. Ophthalmology. 2016;123(10): 2103–2112. 2. Pillunat LE, Erb C, Jünemann AG, et al. Micro-invasive glaucoma surgery (MIGS): a review of surgical procedures using stents. Clin Ophthalmol. 2017 Aug 3. Hoeh H, Vold SD, Ahmed IK, et al Initial clinical experience with the CyPass micro-stent: safety and surgical outcomes of a novel supraciliary microstent. J Glaucoma. 2016;25(1):106–112. 4. Hoeh H, Ahmed II, Grisanti S, et al. Early postoperative safety and surgical outcomes after implantation of a suprachoroidal micro-stent for the treatment of open-angle glaucoma concomitant with cataract surgery. J Cataract Refract Surg. 2013;39:431e7 5. Ho¨h H, Grisanti S, Grisanti S, et al. Two-year clinical experience with the CyPass micro-stent: safety and surgical outcomes of a novel supraciliary micro-stent. Klin Monatsbl Augenheilkd. 2014;231:377e81 6. Fannin, L. A., Schiffman, J. C. & Budenz, D. L. 2003. Risk factors for hypotony maculopathy. Ophthalmology, 110, 1185-1191.

Lateral Canthopexy for patients with lid laxity and epiphora L Bourke, P Lee, N Rahman, A Altenburg

S Sii, L Perucho Gonzalez, K Barton Moorfields Eye Hospital, London

Ophthalmology Department, Occuloplastic Division, St. Vincent's University Hospital, Dublin

Background: The CyPass Micro-Stent is a type of minimally invasive glaucoma surgery (MIGS) which functions by creating an artificial channel in the supraciliary space, enabling augmentation of aqueous drainage to lower intraocular pressure(IOP). Studies examining the efficacy and safety of this device had only reported low rates of transcient hypotony. Case Studies: We report 2 patients with hypotony maculopathy following CYPASS insertion in Moorfields Eye Hospital, London. The first patient is a female, high myope of (-12.00D on right and – 8.00D on left) in her late thirties who was referred for specialist input on bilateral advanced glaucoma refractory to maximal medical treatment and bilateral Baerveldt tubes. Baseline IOP was 24mmHg OD. The second patient is another female in her mid-forties, myopic (-4.00 D) with a history of Possner-Sclossman Syndrome in her right eye. She was counselled for CYPASS insertion after failure of IOP control with trabeculectomy. IOP was 40mmHg OD. In both cases, CYPASS insertion was carried by the same senior surgeon using standard techniques. Post-operatively, hypotony persistent more than 1 month and progressed into hypotony maculopathy. The first patient was initially managed with ligature sutures and advancement of supramid in the Baerveldt tube. Subsequently, the option of CYPASS revision was explored. The second patient was initially managed unsuccessfully with Healon GV, subsequently she was offered revision of CYPASS. On subsequent follow ups, hypotony maculopathy had resolved with IOPs being stable at 10-12mmHg for both patients.

Background: Lateral canthopexy is a canthal tendon tightening procedure that is performed with the insertion of a suture and does not involve reconstruction of the lateral canthal tendon (canthoplasty). A small eyelid incision is made and the suture is passed through the incision to tighten the lateral canthal tendon to the orbital rim. It is a minimally invasive and time-efficient procedure with low risk of morbidity. The procedure is mainly performed for patients who have recurrent watering (epiphora) due to lid laxity but no ectropion or entropion. Methods: Twelve patients were identified, through retrospective chart analysis, who had received lateral canthopexy surgery in the occuloplastic department over the previous 18 months. A 12-part questionnaire was created, using the Likert scale for the majority of questions, to assess patient’s resolution of symptoms/satisfaction with the surgery. Initial improvement in presenting symptoms was classified as a resolution of symptoms for 2 weeks after surgery. We planned to perform phone interviews to gather patient responses and incorporate our findings into improving practice going forward. Results: Ten patients participated in our phone interview from the identified cohort of 12 (20 eyes in total). Verbal consent was obtained from all participants for their answers to be used in this audit. Seven patients presented with the initial symptom of epiphora only. Two patients presented with epiphora, recurrent redness and itch, and foreign body sensation. 1 patient present with epiphora, recurrent redness

S16 and itch, foreign body sensation, and photophobia. Two patients reported a complete resolution of symptoms. 8 patients reported reoccurrence of initial symptoms. Of the 8 patients with reoccurrence, 2 patients said they had no immediate improvement in epiphora. Six reported improvement in symptoms, 3 patients saying it was 20% improved and 1 patient reporting a 60% improvement. Reoccurrence of symptoms occurred at various time-points after surgery, but all reoccurrence of symptoms occurred within 12 weeks of the procedure. Conclusions: Lateral canthopexy is a quick and minimally invasive day procedure with low morbidity. However, our results indicate

Ir J Med Sci (2018) 187 (Suppl 2):S11–S16 that this procedure is ineffective in curing epiphora in 80% of our patients, with reoccurrence occurring immediately for some patients, but within 12 weeks for all with reoccurrence. This is valuable information and will alter the way in which we manage these patients going forward, with a view to possibly performing more invasive procedures such as lateral tarsal strip and wedge procedures.