Purpose: Wrong lens implants have been associated with the highest frequency of medical errors in cataract surgery. The purpose of this paper is to explore the use of the Systems Engineering Initiative for Patient Safety (SEIPS) framework to sustainably reduce wrong intraocular lens (IOL) implants in cataract surgery. Design/methodology/approach: In this mixed-methods study, the SEIPS framework was used to analyse a series of (near) misses of IOL implants in a national tertiary specialty hospital in Singapore. A series of interventions was developed and applied in the case hospital. Risk assessment audits were done before the interventions (2012; n=6,111 surgeries), during its implementation (n=7,475) and in the two years post-interventions (2013-2015; n=39,390) to compare the wrong IOL-rates. Findings: Although the absolute number of incidents was low, the incident rate decreased from 4.91 before to 2.54 per 10,000 cases after. Near miss IOL error decreased from 5.89 before to 3.55 per 1,000 cases after. The number of days between two IOL incidents increased from 35 to an initial peak of 385 before stabilizing on 56. The large variety of available IOL types and vendors was found as the main root cause of wrong implants that required reoperation. Practical implications: The SEIPS framework seems to be helpful to assess components involved and develop sustainable quality and safety interventions that intervene at different levels of the system. Originality/value: The SEIPS model is supportive to address differences between person and system root causes comprehensively and thereby foster quality and patient safety culture.

This review provides an overview of conventional and novel retinal imaging modalities for hydroxychloroquine (HCQ) retinopathy. HCQ retinopathy is a form of toxic retinopathy resulting from HCQ use for a variety of autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus. Each imaging modality detects a different aspect of HCQ retinopathy and shows a unique complement of structural changes. Conventionally, spectral-domain optical coherence tomography (SD-OCT), which shows loss or attenuation of the outer retina and/or retinal pigment epithelium–Bruch’s membrane complex, and fundus autofluorescence (FAF), which shows parafoveal or pericentral abnormalities, are used to assess HCQ retinopathy. Additionally, several variations of OCT (retinal and choroidal thickness measurements, choroidal vascularity index, widefield OCT, en face imaging, minimum intensity analysis, and artificial intelligence techniques) and FAF techniques (quantitative FAF, near-infrared FAF, fluorescence lifetime imaging ophthalmoscopy, and widefield FAF) have been applied to assess HCQ retinopathy. Other novel retinal imaging techniques that are being studied for early detection of HCQ retinopathy include OCT angiography, multicolour imaging, adaptive optics, and retromode imaging, although further testing is required for validation.

Purpose: While diabetes is a chronic disease, in many health care systems patients with diabetes at risk of diabetic retinopathy (DR) are managed in hospital settings. Aim of this feasibility study is to assess the quality of care and economic benefits of a shared care model managing patients at risk of DR in a primary eye care clinic (PEC) compared with a current tertiary specialist outpatient clinic (SOC).Methods: A randomized trial was performed, to compare a PEC with a SOC in Singapore. The trial patients included those previously seen at the SOC, and having no DR or stable mild non proliferative (NPDR) with no macular edema, no visual and DR deterioration. Primary outcomes were clinical management. Secondary outcomes were patient satisfaction and cost of consultation. Differences analysis used equivalence testing and generalized odds ratios (GOR).Results: The trial included 231 patients, 83.1% classified as no DR (PEC: 79.1%; SOC: 87.1%) and 16.9% as stable mild NPDR (PEC: 20.9%; SOC: 12.9%). DR management at PEC was significantly equivalent to that received at the SOC (rate difference 2.56%; CI: (−1.61% to 6.74%)) and 4.29%; CI: (0.14%–8.45%), respectively. Patient satisfaction at the PEC was equally high when compared to SOC (GOR: 1.71; CI: (0.50–2.00)). Direct costs per patient visit was 45% lower at PEC compared to SOC.Conclusions: Our feasibility trial showed that patients with diabetes with no or stable DR receive similar clinical care and management at a lower-cost PEC setting, are equally satisfied with the service compared to tertiary eye care. A follow-up study is necessary to validate these findings. Managing patients with diabetes at risk of DR at a PEC may be a safe and effective shared care model to improve accessibility for patients while enhancing professional collaboration between hospital and community settings.

(1) Purpose: ABCA4-associated retinal degeneration (ABCA4-RD) is a phenotypically diverse disease that often evades diagnosis, even by experienced retinal specialists. This may lead to inappropriate management, delayed genetic testing, or inaccurate interpretation of genetic testing results. Here, we illustrate the phenotypic diversity of ABCA4-RD using a series of representative cases and compare these to other conditions that closely mimic ABCA4-RD. (2) Methods: Genetically confirmed ABCA4-RD cases with representative phenotypes were selected from an inherited retinal disease cohort in Singapore and compared to phenocopies involving other retinal diseases. (3) Results: ABCA4-RD phenotypes in this series included typical adolescent-onset Stargardt disease with flecks, bull’s eye maculopathy without flecks, fundus flavimaculatus, late-onset Stargardt disease, and severe early-onset Stargardt disease. Phenocopies of ABCA4-RD in this series included macular dystrophy, pattern dystrophy, cone dystrophy, advanced retinitis pigmentosa, Leber congenital amaurosis, drug toxicity, and age-related macular degeneration. Key distinguishing features that often suggested a diagnosis of ABCA4-RD were the presence of peripapillary sparing, macular involvement and centrifugal distribution, and a recessive pedigree. (4) Conclusions: ABCA4-RD demonstrates a remarkable phenotypic spectrum that makes diagnosis challenging. Awareness of the clinical spectrum of disease can facilitate prompt recognition and accurate diagnostic testing.

Purpose: To characterize and evaluate differences in fundus autofluorescence (FAF) alteration in polypoidal choroidal vasculopathy (PCV) and typical neovascular age-related macular degeneration (tAMD). Methods: The authors used multimodal imaging to delineate the area of macular neovascularization (MNV) and extent of subretinal fluid (SRF). Macular FAF alteration was categorized to those limited to the area of the neovascular lesion (Zone 1), area beyond Zone 1 affected by subretinal fluid or pigment epithelial detachment (Zone 2), and area beyond Zone 2 (Zone 3). Loss of FAF signal that correlated with complete outer retina and RPE loss (c-RORA) was documented. Results: The authors included 94 eyes from 94 patients (48 with diagnosis of PCV; 46 with diagnosis of tAMD). The PCV eyes had greater subfoveal choroidal thickness (250 ± 92 vs. 178 ± 86 µm, P < 0.001) compared with tAMD. FAF alteration was seen in all eyes in Zone 1 and 2. Polypoidal lesion(s) appear as hyper-AF, iso-AF, or hypo-AF round lesions. The FAF alteration extending to Zone 3 was observed in 41.7% of PCV eyes and 19.6% of tAMD eyes (P = 0.02), in which hyper-AF pattern was predominant. Furthermore, Zone 3 FAF alteration was associated with choroidal vascular hyperpermeability in eyes with PCV but not in tAMD (40% vs. 0%, P = 0.03). Conclusion: These findings highlight that retinal pigment epithelium dysfunction may affect widespread areas in PCV and may be the effect of choroidal congestion.