Sir, Utilisation of orthoptists to give intravitreal injections-a multidisciplinary approachWe read with interest the study conducted by the Medical Retina Intravitreal (IVT) Service at Moorfields Eye Hospital reporting the use of nurses to give IVT injections, and wish to report the utilisation of orthoptists at Frimley Park Hospital (FPH) and Oxford Eye Hospital (OEH) to deliver injections as part of their macular services. 1 With the exponential growth in numbers of patients requiring IVT injections of antivascular endothelial growth factor (antiVEGF) agents for neovascular age-related macular degeneration (nAMD), and for macular oedema in diabetic retinopathy and retinal vein occlusions, there has been a massive increase in the required capacity for clinic appointments and IVT injections.The IVT Service at FPH utilises both orthoptists and nurses, and the orthoptist also is involved in the outpatient assessment and management of AMD cases. FPH adapted the Moorfields Nurse-Led IVT policy to include orthoptists after obtaining support from the British and Iris Orthoptic Society (BIOS), and then submitted the policy to their Trust and obtained local approvals.The Guidelines for AMD assessment and IVT policy are currently with the BIOS Professional Development Committee to obtain approval to roll out the training programme to all orthoptists and will be available on the BIOS Special Interest Group for Retinal Disease website.The OEH is currently training orthoptists based on the FPH model to carry out IVT injections, as well as work in the AMD clinic. Orthoptists and optometrists work alongside specialist medical staff in the clinics to assess and manage AMD.Both centres have significantly increased their capacity to see and assess patients. At FPH an orthoptist and three nurses are trained, and the OEH has both orthoptists and nurses in training. As this is a relatively new initiative, careful planning, a targeted training programme, specific operating procedures, continuous audit and quality assurance, with robust processes are all mandatory. In the current era, with increasing numbers of patients requiring assessment and IVT intervention, centres using a multidisciplinary approach can address this workload with appropriate training and support. FPH and OEH wish to highlight here the potential of utilising orthoptist AHPs for IVT and AMD clinical services. Conflict of interestGeeta Menon has attended the Ad boards for Novartis, Allergan, Bayer, Alcon, and Alimera. Research grants have been awarded by Novartis, Bayer, Allergan, and Alcon to Frimley Park Hospital. Mrs Menon has also received travel grants from Bayer and Novartis. Susan Downes has received honoraria in the past for lectures from Bayer and Novartis, and has been a prinicipal investigator on the trials for both Bayer and Novartis. Oxford Eye Hospital has received funding for research personnel and equipment and for educational meetings from Bayer and Novartis. The remaining authors declare no conflict of interest.

BackgroundWith increasing availability of toric intraocular lenses (IOL) for cataract surgery, real-world refractive outcome data is needed to aid the counselling of patients regarding lens choice. We aim to assess the outcomes of toric intraocular lens use in the non-specialist environment of a typical United Kingdom NHS cataract service.MethodsA retrospective cohort study conducted at the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, UK. All patients who received a toric IOL implant over a 10 months period. Patients underwent pre-operative corneal marking, phacoemulsification and toric IOL implantation. Biometry was obtained using a Zeiss IOLMaster 500 and the toric IOLs were selected using the manufacturers’ online calculators. Post-operative refractions were obtained from optometrist’s manifest refraction or by autorefraction. The outcome measures were post-operative unaided visual acuity (UVA), spherical equivalent refraction, cylindrical correction and all complications.ResultsThirty-two eyes of 24 patients aged 21–86 years (mean 66.4, SD 14.5) were included. UVA was superior to pre-operative best-corrected visual acuity (BCVA) in 81% of eyes, same in 16% and inferior in 3%, resulting in a median improvement of 0.20 LogMAR (IQR 0.10 to 0.30). 56%, 81%, 94% and 100% of eyes were within ±0.5, ±1.0, ±1.5 and ±2.0 D of predicted spherical equivalent, respectively. Three (9%) eyes required further surgery to rectify significant IOL rotation.ConclusionsReduced cylindrical correction and improved UVA could be expected in the majority of patients undergoing toric IOL implantation. Patients should be counselled about the risk of lens rotation.

This report describes a case of unilateral pigmented paravenous retinochoroidal atrophy (PPRCA) in a patient with low-grade unilateral intermediate uveitis. A 31-year-old woman, previously diagnosed with intermediate uveitis in the right eye (OD) presented to the clinic. Best-corrected visual acuity was 20/20 OD. Fundus examination, fluorescein angiography, autofluorescence, and optical coherence tomography OD were in keeping with a phenotypic diagnosis of PPRCA. Electrophysiology showed severe photoreceptor dysfunction of both the rod and the cone systems OD. Systemic workup revealed QuantiFERON-gold positive. This is the first report of unilateral PPRCA secondary to presumed ocular tuberculosis. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:345-349.].

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Retinal vein occlusion is associated with ocular morbidity and blindness as a result of macular oedema, macular ischaemia and neovascular glaucoma. New treatment options have become available, particularly for the management of the associated macula oedema; however, there is no consensus as to the best therapeutic option. ongoing trials will provide further evidence to aid decision-making as to the most cost-effective treatment option with the best visual outcome. We present a synopsis of the most recent trial data for the management of retinal vein occlusion. at present it is recommended that treatment choices are tailored to individual patient needs. KeywordsRetinal vein occlusion, ranibizumab, dexamethasone implant, aflibercept, laser Retinal vein occlusion (RVo) is a common retinal vascular disease second only to diabetic retinopathy, affecting the elderly population.1 Blockage of the retinal venous circulation has the potential to cause significant loss of vision. The introduction of newly approved anti-vascular endothelial growth factor (anti-VEGF) agents such as ranibizumab (lucentis; Novartis, Switzerland) and aflibercept (Eylea; Bayer, Germany), and the slow-release dexamethasone implant (ozurdex; allergan, uS) offer more treatment options to improve the potential for visual recovery. The remit of this article is to present a summary of the latest evidence on the ophthalmic management for RVo. Epidemiology and Pathophysiologya recent study on the prevalence of RVo has shown an age and sex standardised prevalence of 5.20 per 1,000 for any form of RVo.This was a large study of 68,751 individuals, ranging from 30 to 101 years of age. The prevalence of branch RVo (BRVo) was higher than central RVo (cRVo) (4.42 versus 0.80 per 1,000), increased with age and there was no difference between the sexes.2 over 50 % of cases of RVo occur in patients older than 65 years of age.3 it has also been shown that the chance of developing an RVo in the contralateral eye within 4 years of the first occlusion to be around 7 %.3 The exact pathogenesis of RVo still remains ill-defined. it is thought to occur due to a combination of venous stasis, degenerative changes of the vessel wall and blood hypercoagulability. This is known as Virchow's triad. The risk of RVo is higher in patients with hypertension, diabetes and hypercholesterolaemia.4 o'Mahoney et al. 4 performed a meta-analysis that showed that the prevalence of hypertension in RVo patients was 63.6 % compared with 36.2 % in controls. hyperlipidaemia was twice as common among patients with RVo (35.1 %) compared with controls (16.7 %). diabetes was slightly more prevalent among patients with RVo (14.6 %) than unaffected controls (11.1 %).Rarer associations include thrombophilia, 5 oral contraceptive pill, 6 optic disc vasculitis, 7 myeloproliferative 8 and systemic inflammatory disorders. 5Myeloproliferative disorders cause increased blood viscosity and systemic vasculitides, such as BehÇets and polyarteritis nodosa, cause retinal vasculitis leading to RVo, espec...