No abstract

Background Annually 2.7 million individuals are offered screening for diabetic retinopathy (DR) in England. Spectral-Domain Optical Coherence Tomography (SD-OCT) has the potential to relieve pressure on NHS services by correctly identifying patients who are screen positive for maculopathy on two-dimensional photography without evidence of clinically significant macular oedema (CSMO), limiting the number of referrals to hospitals. We aim to assess whether the addition of SDOCT imaging in digital surveillance clinics is a cost-effective intervention relative to hospital eye service (HES) follow-up. Methods We used patient-level data from the Gloucestershire Diabetic Eye Screening Service linked to the local digital surveillance programme and HES between 2012 and 2015. A model was used to simulate the progression of individuals with background diabetic retinopathy (R1) and diabetic maculopathy (M1) following DR screening across the clinic pathways over 12 months. Results Between January 2012 and December 2014, 696 people undergoing DR screening were found to have screen-positive maculopathy in at least one eye for the first time, with a total of 766 eyes identified as having R1M1. The mean annual cost of assessing and surveillance through the SD-OCT clinic pathway was £101 (95% CI: 91–139) as compared with £177 (95%CI: 164–219) under the HES pathway. Surveillance under an SD-OCT clinic generated cost savings of £76 (95% CI: 70–81) per patient. Conclusions Our analysis shows that SD-OCT surveillance of patients diagnosed as R1M1 at DR screening is not only cost-effective but generates considerable cost savings.

MRCP(UK), 4 on behalf of the EMERALD Study Group Purpose: The increasing diabetes prevalence and advent of new treatments for its major visual-threatening complications (diabetic macular edema [DME] and proliferative diabetic retinopathy [PDR]), which require frequent lifelong follow-up, have increased hospital demands markedly. Subsequent delays in patient's evaluation and treatment are causing sight loss. Strategies to increase capacity are needed urgently. The retinopathy (EMERALD) study tested diagnostic accuracy, acceptability, and costs of a new health care pathway for people with previously treated DME or PDR. Design: Prospective, multicenter, case-referent, cross-sectional, diagnostic accuracy study undertaken in 13 hospitals in the United Kingdom. Participants: Adults with type 1 or 2 diabetes previously successfully treated DME or PDR who, at the time of enrollment, had active or inactive disease. Methods: A new health care pathway entailing multimodal imaging (spectral-domain OCT for DME, and 7field Early Treatment Diabetic Retinopathy Study [ETDRS] and ultra-widefield [UWF] fundus images for PDR) interpreted by trained nonmedical staff (ophthalmic graders) to detect reactivation of disease was compared with the current standard care (face-to-face examination by ophthalmologists). Main Outcome Measures: Primary outcome: sensitivity of the new pathway. Secondary outcomes: specificity; agreement between pathways; costs; acceptability; proportions requiring subsequent ophthalmologist assessment, unable to undergo imaging, and with inadequate images or indeterminate findings. Results: The new pathway showed sensitivity of 97% (95% confidence interval [CI], 92%e99%) and specificity of 31% (95% CI, 23%e40%) to detect DME. For PDR, sensitivity and specificity using 7-field ETDRS images (85% [95% CI, 77%e91%] and 48% [95% CI, 41%e56%], respectively) or UWF images (83% [95% CI, 75%e89%] and 54% [95% CI, 46%e61%], respectively) were comparable. For detection of high-risk PDR, sensitivity and specificity were higher when using UWF images (87% [95% CI, 78%e93%] and 49% [95% CI, 42%e56%], respectively, for UWF versus 80% [95% CI, 69e88%] and 40% [95% CI, 34%e47%], respectively, for 7-field ETDRS images). Participants preferred ophthalmologists' assessments; in their absence, they preferred immediate feedback by graders, maintaining periodic ophthalmologist evaluations. When compared with the current standard of care, the new pathway could save £1390 per 100 DME visits and between £461 and £1189 per 100 PDR visits. Conclusions: The new pathway has acceptable sensitivity and would release resources. Users' suggestions should guide implementation. Ophthalmology 2020;-:1e13

The outcomes of supervised trainee trabeculectomy compare favourably with consultant cases after 2 year follow up. Trainee cases had higher complication rates than consultant cases. Bleb leaks are a common complication of trainee cases, where closer supervision may be required. There is potential for surgical simulation to help increase the success of such cases. These findings may encourage trainee participation in glaucoma surgery.