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Objective The purpose of this report is to develop a consensus for Canadian national guidelines specific to a tele-medicine approach to screening for diabetic retinopathy (DR) using evidence-based and clinical data. Methods Canadian Tele-Screening Grading Scales for DR and diabetic macular edema (DME) were created primarily based on severity grading scales outlined by the International Clinical Diabetic Retinopathy Disease Severity Scale (ICDR) and the Scottish DR Grading Scheme 2007. Other grading scales used in international screening programs and the clinical expertise of the Canadian Retina Research Network members and retina specialists nationwide were also used in the creation of the guidelines. Results National Tele-Screening Guidelines for DR and DME with and without optical coherence tomography (OCT) images are proposed. These outline a diagnosis and management algorithm for patients presenting with different stages of DR and/or DME. General guidelines detailing the requirements for imaged retina fields, image quality, quality control, and follow-up care and the role of visual acuity, pupil dilation, OCT, ultra-wide-field imaging, and artificial intelligence are discussed. Conclusions Tele-retina screening can help to address the need for timely and effective screening for DR, whose prevalence continues to rise. A standardized and evidence-based national approach to DR tele-screening has been proposed, based on DR/DME grading using two 45° image fields or a single widefield or ultra-wide-field image, preferable use of OCT imaging, and a focus on local quality control measures.

Purpose: The purpose of this study was to determine the efficacy of pneumatic vitreolysis in the treatment of symptomatic focal vitreomacular traction (VMT). Methods: Patients choosing intravitreal gas injection as their preferred treatment for symptomatic VMT were invited to participate in this prospective study; 0.3 mL of perfluoropropane gas was injected. Optical coherence tomography was performed pre-and postprocedure to determine the proportion of eyes showing release of VMT. Results: Nine eyes of nine participants were included in the study, with a mean follow-up of 5.0±1.8 months. Gas injection resulted in the release of VMT in 7 of 9 eyes (78%) during the course of the study. Both eyes in which the VMT failed to release also showed an improvement in central macular anatomy. Mean visual acuity improved from logarithm of the minimum angle of resolution (logMAR) 0.33±0.14 (Snellen equivalent, ∼20/42) to logMAR 0.24±0.21 (Snellen, ∼20/35) at final follow-up ( P = .03); 8 of 9 patients (89%) reported a subjective improvement in their presenting symptoms and/or vision during the study period. The mean maximum foveal thickness of 480 ± 22 μm at baseline reduced to 282 ± 94 μm by the time of the final visit ( P = .002). Two patients had retinopexy for retinal breaks/suspect breaks. Conclusions: Pneumatic vitreolysis is an effective treatment for symptomatic VMT and may offer cost savings for patients and/or health services.

Objective: To identify primary surgical success rates for retinal detachment repair in Alberta and compare functional outcomes of methods of repair. Methods: Data was retrospectively extracted from the Alberta Health Services Discharge Abstract Database and the National Ambulatory Care Reporting System for all patients diagnosed with retinal detachment and vitreoretinal procedures during the 2008/09 to 2012/13 fiscal years. Results: Of the 5,433 surgeries for retinal detachment identified, 279 were excluded due to invalid provincial health numbers, unidentified procedure location, and/or treating physician other than an Alberta retina surgeon. The final analysis included 4,336 detachments in 4,020 patients. The average primary retinal detachment success rate was 84.9% (3,680/4,336). Primary success rates varied between vitrectomy only (84.9%, 2,149/2,532), vitrectomy and scleral buckle (85.5%, 818/957), and scleral buckle (84.4%, 702/832). Conclusions: Alberta retina surgeons have an average primary success rate of 84.9% (3,680/4,336) for repair of retinal detachments. This result is in keeping with other published retinal detachment success rate studies.

Purpose To characterize the presentation of Terson syndrome, the occurrence of a vitreous hemorrhage in association with intracranial hemorrhage, and report on the outcomes of vitrectomy at two major centers in Canada. Methods Retrospective chart review of consecutive patients with Terson syndrome undergoing vitrectomy by retina specialists over the last 10 years. Primary outcome was the change in best-corrected visual acuity (BCVA) at 3 months from baseline. Secondary outcomes included the association between baseline BCVA and final BCVA, and the association between final BCVA and timing of surgery (early vs. later than 90 days). Results A total of 14 eyes of 11 patients were included. The mean time between observation of intraocular hemorrhage and vitrectomy was 160 days. Baseline preoperative BCVA was logarithm of the minimum angle of resolution 1.57 ± 1.03 (Snellen 20/740), which improved to logarithm of the minimum angle of resolution 0.53 ± 0.82 (Snellen 20/70) at the final postoperative follow-up, P = 0.01. Baseline BCVA was not significantly correlated with final BCVA, Spearman's rho = 0.016, P = 0.957. Final BCVA did not significantly differ between those who had surgery before 90 days compared with after 90 days, P = 0.087. Conclusion Vitrectomy is safe and effective and should be considered for nonclearing vitreal bleeding due to Terson syndrome. Ocular hemorrhaging in Terson syndrome can be observed conservatively for spontaneous improvement without the risk of reduced visual potential. Ophthalmic evaluation should be considered promptly after intracranial hemorrhage.

Background Monocular vision loss, attributed to either central retinal artery occlusion ( CRAO ), branch retinal artery occlusion ( BRAO ), or ocular ischemic syndrome ( OIS ), is thought to be associated with an increased prevalence of cerebral infarcts. However, there is a paucity of data substantiating this. We aimed to investigate this relationship in a Canadian center and further understand the importance of associated internal carotid artery stenosis in potential clinical decision making. Methods and Results We performed a retrospective cohort study at a comprehensive stroke center of patients presenting initially with CRAO , BRAO , or OIS to a centralized ophthalmology center over a 5‐year period. Patients were followed for 3 years for the occurrence of a hemispheric stroke. We identified 83 affected eyes, with 31 CRAO , 35 BRAO , and 17 OIS patients. Before ocular diagnosis, 32.3%, 11.4%, and 41.2% of CRAO , BRAO , and OIS patients, respectively, experienced a symptomatic stroke. Of the remaining patients, 4.8%, 12.9%, and 40%, respectively, suffered a hemispheric stroke within 3 years of ocular diagnosis. Logistic regressions suggested that for CRAO and BRAO patients together, the degree of ipsilateral internal carotid artery stenosis is unable to predict the occurrence of a stroke ( P =0.18), whereas our model correctly predicted a stroke in 82.4% of OIS patients ( P =0.005). Conclusions CRAO , BRAO , and OIS are associated with significantly increased symptomatic stroke rates. Degree of ipsilateral internal carotid artery stenosis may not be useful in risk stratification for these patients, suggesting that they should be triaged appropriately for stroke risk‐factor management, independent of internal carotid artery stenosis.

Topic: An international, expert-led consensus initiative to develop systematic, evidence-based recommendations for the treatment of noninfectious uveitis in the era of biologics. Clinical relevance: The availability of biologic agents for the treatment of human eye disease has altered practice patterns for the management of noninfectious uveitis. Current guidelines are insufficient to assure optimal use of noncorticosteroid systemic immunomodulatory agents. Methods: An international expert steering committee comprising 9 uveitis specialists (including both ophthalmologists and rheumatologists) identified clinical questions and, together with 6 bibliographic fellows trained in uveitis, conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review of the literature (English language studies from January 1996 through June 2016 ; Medline [OVID], the Central Cochrane library, EMBASE, CINAHL, SCOPUS, BIOSIS, and Web of Science). Publications included randomized controlled trials, prospective and retrospective studies with sufficient follow-up, case series with 15 cases or more, peer-reviewed articles, and hand-searched conference abstracts from key conferences. The proposed statements were circulated among 130 international uveitis experts for review. A total of 44 globally representative group members met in late 2016 to refine these guidelines using a modified Delphi technique and assigned Oxford levels of evidence. Results: In total, 10 questions were addressed resulting in 21 evidence-based guidance statements covering the following topics: when to start noncorticosteroid immunomodulatory therapy, including both biologic and nonbiologic agents ; what data to collect before treatment ; when to modify or withdraw treatment ; how to select agents based on individual efficacy and safety profiles ; and evidence in specific uveitic conditions. Shared decision-making, communication among providers and safety monitoring also were addressed as part of the recommendations. Pharmacoeconomic considerations were not addressed. Conclusions: Consensus guidelines were developed based on published literature, expert opinion, and practical experience to bridge the gap between clinical needs and medical evidence to support the treatment of patients with noninfectious uveitis with noncorticosteroid immunomodulatory agents.

PURPOSE To evaluate the efficacy of pars plana vitrectomy for congenital optic disk pit maculopathy with various adjuvant techniques, including gas tamponade, internal limiting membrane peel, and temporal optic disk endolaser in a multicenter study with long-term follow-up. METHODS A retrospective chart review was performed to identify eyes that underwent surgical repair for congenital optic disk pits and serous macular detachment with or without macular retinoschisis from four retinal centers across Canada from 2003 to 2013. Data collected included surgeries performed, preoperative and postoperative vision, central retinal thickness, and presence or absence of subretinal fluid. Optical coherence tomography was used to define anatomical success (i.e., foveal reattachment). RESULTS Thirty-two eyes of 32 patients with optic disk pits and serous macular detachments were identified that had undergone surgical repair. All eyes underwent pars plana vitrectomy and induction of posterior vitreous detachment if one was not present. Additional procedures performed on occasion included internal limiting membrane peel (n = 8), temporal optic disk pits endolaser (n = 7), and gas tamponade (air, C3F8 or SF6; n = 31). After vitrectomy surgery, foveal attachment was achieved in 26 of 32 eyes (81.3%). The average number of surgeries required was 1.4 ± 0.6, with a maximum of 3 vitrectomies (n = 2). Mean change in best-corrected visual acuity was -0.47 ± 0.54 logMAR units, which corresponds to approximately 5 lines of visual improvement (P < 0.001). Median time to reattachment was 416 days. Preoperative vision, preoperative symptom days, and age were not associated with postoperative reattachment. Similarly, internal limiting membrane peel and temporal endolaser were not associated with postoperative reattachment, nor was there a difference between air and SF6 and C3F8 gas tamponade. Elevated preoperative central retinal thickness was associated with a lower chance of postoperative reattachment (P = 0.007) and was also the best prognostic indicator of success (P = 0.039). CONCLUSION Vitrectomy for macular detachment due to optic disk pit has good long-term success and results in an improvement in visual acuity. However, adjuvant techniques such as internal limiting membrane peel and temporal endolaser may not improve outcomes, nor does there seem to be a difference between short- and long-acting gases. Patients should be made aware that it can take more than a year and multiple surgeries to achieve foveal reattachment and that increased baseline central retinal thickness is a poor prognostic sign.

Wai-Ching Lam,1 David A Albiani,2 Pradeepa Yoganathan,3 John Chanchiang Chen,4 Amin Kherani,5 David AL Maberley,6 Alejandro Oliver,7 Theodore Rabinovitch,3 Thomas G Sheidow,8 Eric Tourville,9 Leah A Wittenberg,10 Chris Sigouin,11 Darryl C Baptiste12 1Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, 2West Coast Retinal Consultants, Vancouver, BC, 3North Toronto Eye Care, North York, ON, 4Department of Ophthalmology, McGill University, Montreal, QC, 5Southern Alberta Eye Center, Calgary, AB, 6Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, 7Timmins and District Hospital, Timmins, ON, 8Ivey Eye Institute, London, ON, 9Center Oculaire de Quebec, Quebec City, QC, 10Retina Surgical Associates, New Westminster, BC, 11Clinwest Research Inc, Burlington, ON, 12Allergan Inc., Markham, ON, Canada Background: The purpose of this study was to evaluate the real-world use, efficacy, and safety of one or more dexamethasone intravitreal implant(s) 0.7 mg (DEX implant) in patients with macular edema (ME).Methods: This was a retrospective cohort study of patients with ME secondary to retinal disease treated at ten Canadian retina practices, including one uveitis center. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure (IOP), glaucoma and cataract surgery, and safety data were collected from the medical charts of patients with ≥3 months of follow-up after the initial DEX implant.Results: One hundred and one patient charts yielded data on 120 study eyes, including diagnoses of diabetic ME (DME) (n=34), retinal vein occlusion (RVO, n=30; branch in 19 and central in 11), and uveitis (n=23). Patients had a mean age of 60.9 years, and 73.3% of the study eyes had ME for a duration of ≥12months prior to DEX implant injection(s). Baseline mean (± standard error) BCVA was 0.63±0.03 logMAR (20/86 Snellen equivalents) and mean CRT was 474.4±18.2 µm. The mean number of DEX implant injections was 1.7±0.1 in all study eyes; 44.2% of eyes had repeat DEX implant injections (reinjection interval 2.3–4.9months). The greatest mean peak changes in BCVA lines of vision occurred in study eyes with uveitis (3.3±0.6, P0.05). Significant decreases in CRT were observed: -255.6±43.6 µm for uveitis, -190.9±23.5 µm for DME, and -160.7±39.6 µm for RVO (P

Background/aimsTo describe an alternative technique for avoiding contact with the lids and lashes, without the use of a lid speculum, during intravitreal anti-vascular endothelial growth factor injections.MethodsRetrospective case series of all patients undergoing intravitreal injections of bevacizumab and ranibizumab, with the lid splinting retraction technique from January 2010 to December 2015. Injections performed by six vitreoretinal specialists were included. The key preinjection ocular surface preparation includes topical anaesthetic, 5% povidone-iodine and a subconjunctival injection of 2% lidocaine with epinephrine. A second instillation of 5% povidone-iodine is given and the intravitreal injection is then performed. No lid speculum is used. A search of the electronic medical records identified patients diagnosed with postinjection endophthalmitis and charts were reviewed to ensure inclusion criteria were met. The main outcome measure was incidence of postinjection endophthalmitis.ResultsA total of 78 009 consecutive intravitreal injections were performed, of which 22 207 were bevacizumab and 55 802 were ranibizumab. In this cohort of patients (n=6320), 12 cases of endophthalmitis developed, corresponding to a rate of 0.015%.ConclusionsThe technique of eyelid retraction for intravitreal injection has a low rate of endophthalmitis, similar to the reported rates using a metal lid speculum. This is beneficial for both the physician and the patient as it minimises patient discomfort as well as the duration of the procedure. To our knowledge, this is one of the largest studies performed to date evaluating intravitreal injection-related endophthalmitis.

Objective We describe the case of a boy with a TUBA1A mutation presenting with microphthalmia and congenital cataracts in addition to microcephaly and severe brain malformation. Methods A boy presented in early infancy with microphthalmia, congenital cataracts, and microcephaly. His neurological course included severe hypotonia and drug-resistant epilepsy. Magnetic resonance imaging of the brain revealed a complex malformation that included agenesis of the corpus callosum, severely hypoplastic cerebellar vermis, mildly hypoplastic and dysplastic cerebellar hemispheres, mildly hypoplastic brainstem, mild posterior simplified cerebral gyral pattern, dysplastic basal ganglia and thalami, hypoplastic optic nerves, and absent olfactory bulbs. Results TUBA1A genetic testing was conducted and revealed a previously unreported heterozygous 808G>T missense mutation. Parental genetic testing was negative, indicating that the child's mutation was de novo . Conclusion The TUBA1A gene encodes tubulin alpha-1A, a protein with an important role in microtubule function and stability. Human mutations can result in a wide spectrum of brain malformations including lissencephaly, microlissencephaly, cerebellar hypoplasia, agenesis of the corpus callosum, pachygyria and polymicrogyria. Although TUBA1A is expressed in both developing brain and retinal tissue, there are no reported cases of TUBA1A mutations in association with major developmental ophthalmologic abnormalities.

There is currently a widespread use of intravitreal triamcinolone acetonide (IVTA) for age-related macular degeneration, diabetic macular edema, cystoid macular edema secondary to retinal vein occlusions, and uveitis. The aim of this investigation was to assess the rates of various complications associated with this treatment and to determine which factors are associated with the development of these complications.A retrospective interventional case series of all patients from one retina specialist undergoing IVTA was conducted in a clinical setting from 2002 to 2005. All disease entities were included. Patients were followed for a mean of 9.5 months after receiving 4 mg (0.1 mL) of nonfiltered triamcinolone acetonide (TA). All complications associated with the injection procedure or with the TA were noted.Two hundred and twenty-three (223) eyes of 192 patients received a total of 336 IVTA injections between 2002 and 2005. The mean age was 73.3 years and mean follow-up was 9.5 months. A single injection was performed in 144 eyes (64.6%); 2 IVTAs in 55 eyes (24.7%); 3 IVTAs in 16 eyes (7.2%), and 3.6% of eyes had more than 3 injections at a minimal interval of 3 months. The only immediate complication was a single injection (0.3%) associated with a temporary occlusion of the central retinal artery, which opened immediately following anterior paracentesis. Late complications included endophthalmitis in 1 of 336 (0.3%) injections and a steroid response requiring glaucoma medication in 60 of 192 patients (31.3%). In patients with preexisting glaucoma, 58.8% required additional glaucoma medication. Glaucoma-filtering surgery was required in 2 of 192 patients (1.0%).In the study center, the IVTA is extremely safe in patients without a history of glaucoma. However, patients with preexisting glaucoma with progressive optic neuropathy must be treated with great caution.

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

To the authors' knowledge, there is a paucity of published accounts of management of radiation-induced optic neuropathy (RION) by optic nerve sheath fenestration (ONSF) in the conventional medical literature. With higher doses of radiation being given by using conformal techniques, more radiation-induced optic neuritis and neuropathy will be identified. We report here the successful use of ONSF to restore vision to three consecutive patients with pending anterior RION, and the importance of early identification and intervention in these potentially reversible cases.

Xanthomonas maltophilia (originally Pseudomonas maltophilia and subsequently Stenotrophomonas maltophilia) is a ubiquitous free-living gram-negative bacillus that can be isolated from soil, water, and var­ ious plants and animals.' It has become an increasing­ ly important cause of nosocomial infection, especially in immunocompromised patients.2 X. maltophilia has only rarely been reported as a pathogen in ocular infections. In a series of 15 exter­ nal infections, it was the predominant isolate in 5 cases and part of a polymicrobial infection in 10 cases. l These included eight cases of bacterial keratitis, two cases of acute conjunctivitis, two infected scleral buckles, two cases of infantile dacryocystitis and one case of preseptal cellulitis. X. maltophilia endophthalmitis has been reported following implantation of a su stained-release ganci­ clovir pellet in a patient with the acquired immunode­ ficiency syndrome,3 after cataract surgery in seven immunocompetent patients4-6 and following injury in two immunocompetent patients,?,8

Background: This study aimed to describe and measure the health results of a Category 3 teleophthalmology screening project for diabetic retinopathy (DR). Implemented through mobile screening imaging units located within pharmacies, the project had the goal of reaching unscreened diabetic patients in urban communities while lowering barriers to screening and saving medical resources. Methods: Image capture of both eyes of 3505 known diabetic individuals was performed in the provinces of Quebec, British Columbia, Alberta, Manitoba, and Saskatchewan. A photographer performed fundus imaging, and a nurse used mild pupil dilation only when necessary to secure image quality. Screening was provided free of cost in the context of DR health days for DR screening. Through teleophthalmology, ophthalmologists proceeded with data and image interpretation, and timely referral when indicated. Results: This project allowed the resumption of screening of over 38% of the cohort of known diabetics who reported never having undergone any eye examination with pupil dilation, and an additional 30% who reported not having been examined for over 2 years. All known diabetics were under the care of a general physician, and their mean diabetes duration, when known, was 8 years. DR pathology was found in 22.5% (20%–28%) of the cohort, 1.8% requiring urgent referral (within 30 days) as a result of the severity of the DR and 0.6% (0%–l.8%) requiring urgent referral for other reasons. An additional 8.7% (8.1%–19.5%) required ophthalmologic attention within 6 months because of DR and another 2.0% (0%–6.3%) between 6 months and I year. Incidental findings were found in 23%, the majority of which were related to cataract and dry macular degeneration. Urgent or significant incidental findings were found in 0.6% of the screened eyes. Pupil dilation with tropicamide 1% was deemed useful or necessary in 33.7% of the cohort. For 0.7% of the cohort, the images could not be interpreted because of poor image quality and for that reason had to be referred for a traditional dilated eye examination. Ophthalmologists were relieved of the examination of 85.6% of the screened diabetic individuals who benefited from screening without requiring a traditional ophthalmologic examination. On the other hand, ophthalmologists were required to provide urgent (within 30 days) services to 2% of the cohort, either because of threatening DR or because of incidental findings requiring rapid ophthalmologic attention. Interpretation: This screening strategy for DR through mobile teleophthalmology imaging units efficiently lowered barriers to screening and created new screening opportunities for a large number of known diabetic individuals who were lost to the traditional health system. It has the potential to provide better outreach to diabetic populations while identifying individuals truly in need of the services of an ophthalmologist; at the same time it maximizes the use of limited ophthalmologic resources while favouring multidisciplinary collaborations. The significant incidental findings associated with screening highlight the need for ophthalmologic competencies during DR screening within a teleophthalmology approach. Further involvement of government health authorities is pivotal in embracing the opportunities provided by emerging technologies such as teleophthalmology and translating them into better outreach services to diabetic populations and thus better visual health results.