Eduardo Normando’s research while affiliated with Imperial College Healthcare NHS Trust and other places


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Publications (83)


Comparison of glaucoma drainage devices with plate areas given below in blue.
Comparison of eyePlate-300 on the left side with the Baerveldt 350 on the right. The grey double-ended arrows highlight the maximum base to height distance which is greater in the Baerveldt plate (Arrows: plate height, dotted lines show difference in plate heights between eyePlate-300 and Baerveldt-350) (image courtesy of Faisal Ahmed).
Intraoperative view of eyePlate-300 by Rheon Medical with 3/0 prolene stent inserted.
Kaplan–Meier survival analysis. Curve (left) shows failure, as defined by an IOP > 18 mmHg or <5 mmHg on two consecutive visits or NLP vision, and Curve (right) shows failure as defined by an IOP > 15 mmHg or <5 mmHg on two consecutive visits.
Violin plot showing mean IOP and IOP variations over the period of observation. Each symbol represents a single data point within the respective time period: ○ (circle): Represents an individual data point at Baseline. ■ (block): Represents an individual data point at 1 Month. ▲ (triangle): Represents an individual data point at 3 Months. ▼ (inverted triangle): Represents an individual data point at 6 Months. ♦ (diamond): Represents an individual data point at 12 Months. Statistical significance is indicated by asterisks, where * p < 0.05; ** p < 0.01; ****p < 0.0001.

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Evaluating the Safety and Efficacy of a Novel Glaucoma Drainage Device in High-Risk Adult Glaucoma Patients: A One-Year Pilot Study
  • Article
  • Full-text available

August 2024

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32 Reads

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1 Citation

Journal of Clinical Medicine

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Eduardo Normando

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Syed Ahmed

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[...]

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Ahmed Al-Nahrawy

Background: We report on the 12-month safety and efficacy outcomes of a new non-valved glaucoma drainage device, the eyePlate-300 (Rheon Medical, Lausanne, Switzerland), in managing refractory glaucoma. Methods: A retrospective review was conducted on consecutive patients over 18 who underwent glaucoma drainage device (GDD) surgery with the eyePlate-300 after a single glaucoma consultation between February 2020 and April 2021, with at least 12 months of documented post-op follow-up. Results: A total of 16 eyes from 15 patients were included. Complete success was observed in 47% of patients and overall success in 83%. The mean IOP decreased from 31.5 mm Hg to 10.7 mm Hg (67% reduction from baseline), and the number of IOP-lowering drops was reduced from 3.1 to 0.7 at one year. The mean BCVA remained stable. No additional IOP-lowering surgeries were required, and no severe sight-threatening complications were noted. Conclusions: The initial one-year results suggest that the eyePlate could be a safe and effective device for reducing IOP in an ethnically diverse refractory glaucoma population. Further follow-up is necessary to determine the long-term safety and efficacy.

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Fig. 1: Flow diagram of Dora R1's call with patients undergoing routine cataract surgery.
Fig. 2: Logic diagram of the clinical study.
Fig. 3: Participant flow diagram.
Fig. 4: Flowchart for study recruitment.
Missing data.
Accuracy and safety of an autonomous artificial intelligence clinical assistant conducting telemedicine follow-up assessment for cataract surgery

July 2024

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17 Reads

EClinicalMedicine

Background Artificial intelligence deployed to triage patients post-cataract surgery could help to identify and prioritise individuals who need clinical input and to expand clinical capacity. This study investigated the accuracy and safety of an autonomous telemedicine call (Dora, version R1) in detecting cataract surgery patients who need further management and compared its performance against ophthalmic specialists. Methods 225 participants were recruited from two UK public teaching hospitals after routine cataract surgery between 17 September 2021 and 31 January 2022. Eligible patients received a call from Dora R1 to conduct a follow-up assessment approximately 3 weeks post cataract surgery, which was supervised in real-time by an ophthalmologist. The primary analysis compared decisions made independently by Dora R1 and the supervising ophthalmologist about the clinical significance of five symptoms and whether the patient required further review. Secondary analyses used mixed methods to examine Dora R1's usability and acceptability and to assess cost impact compared to standard care. This study is registered with ClinicalTrials.gov (NCT05213390) and ISRCTN (16038063). Findings 202 patients were included in the analysis, with data collection completed on 23 March 2022. Dora R1 demonstrated an overall outcome sensitivity of 94% and specificity of 86% and showed moderate to strong agreement (kappa: 0.758–0.970) with clinicians in all parameters. Safety was validated by assessing subsequent outcomes: 11 of the 117 patients (9%) recommended for discharge by Dora R1 had unexpected management changes, but all were also recommended for discharge by the supervising clinician. Four patients were recommended for discharge by Dora R1 but not the clinician; none required further review on callback. Acceptability, from interviews with 20 participants, was generally good in routine circumstances but patients were concerned about the lack of a ‘human element’ in cases with complications. Feasibility was demonstrated by the high proportion of calls completed autonomously (195/202, 96.5%). Staff cost benefits for Dora R1 compared to standard care were £35.18 per patient. Interpretation The composite of mixed methods analysis provides preliminary evidence for the safety, acceptability, feasibility, and cost benefits for clinical adoption of an artificial intelligence conversational agent, Dora R1, to conduct follow-up assessment post-cataract surgery. Further evaluation in real-world implementation should be conducted to provide additional evidence around safety and effectiveness in a larger sample from a more diverse set of Trusts. Funding This manuscript is independent research funded by the 10.13039/501100000272National Institute for Health Research and NHSX (Artificial Intelligence in Health and Care Award, AI_AWARD01852).


Comparison of intraocular pressure profiles during the water drinking test and the modified diurnal tension curve

March 2024

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57 Reads

Eye (London, England)

Objectives To compare intraocular pressure (IOP) during the water drinking test (WDT) and modified diurnal tension curve (mDTC) in open-angle glaucoma (OAG) patients, using multimodal, observer-masked tonometry. Methods Open-angle glaucoma subjects were prospectively enroled, excluding those who had undergone glaucoma filtration or laser surgery. Two-hourly mDTC Goldmann applanation (GAT) and rebound tonometry (RT) was performed between 8:00 and 16:00, and every 15 min for 45 min after ingestion of 800mls of water. Blood pressure, heart rate, pupillometry measurements, and optical coherence tomography (AS-OCT) were also recorded. Results Forty-two subjects’ right eyes were included. 48% were using topical glaucoma medication. Mean baseline IOP was 14.9 ± 4.52 mmHg, with mean visual field mean deviation (±SD) −5.05 ± 5.45 dB. Strong association was found between maximum IOP during mDTC and WDT ( r = 0.90, 95% CI 0.82–0.95 p < 0.0001) with agreement (mDTC-WDT) bias −0.82 mmHg, 95% LoA −1.46 to −0.18. During the WDT, mean systolic blood pressure (±SD) increased from 140.0 ± 20.0 to 153.3 ± 24.0 mmHg (p < 0.0001), mean heart rate ( ± SD) reduced from 69.5 ± 11.3 bpm to 63.6 ± 10.0 bpm ( p < 0.0001), and temporal iridocorneal angle increased from 29.2 ± 6.0° to 29.6 ± 5.2° ( p = 0.04). Conclusion This study presents repeated, observer-masked IOP data showing strong correlation between maximum IOP during mDTC and WDT using multimodal tonometry. This supports WDT as a meaningful alternative to mDTC when investigating diurnal IOP characteristics in clinic, with reduced time requirements and associated costs.


Fig. 1 IOP and average number of glaucoma medications after CW-TSCP and MPTLT. A The effect of CW-TSCP (white circle) and MPTLT (black circle) on IOP. B The effect of CW-TSCP (white bar) and MPTLT (black bar) on the average number of glaucoma medications required. Vertical error bars represent SEM. *p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001, ****p ≤ 0.0001-Wilcoxon matched pairs signed-rank test comparing preoperative vs follow-up IOP after CW-TSCP (grey asterisks)/MPTLT (black asterisks). Paired t-test used for day-1, 3-months, 6-months MPTLT (parametric). Mann-Whitney U test comparing pre-operative and follow-up average number of medications after CW-TSCP (grey asterisks)/MPTLT (black asterisks). CW-TSCP continuous wave transscleral cyclophotocoagulation, MPTLT micropulse transscleral laser therapy, IOP intraocular pressure, n number of eyes at follow-up.
Fig. 2 Kaplan-Meier analysis using cumulative probability of overall treatment success. Overall success: success at the last available followup. Success at follow-up: ≥ 20% IOP reduction AND IOP 6-18 mmHg, with the same or fewer glaucoma medications. Failure: an inability to reach either success criteria at 2 successive visits/an increased number of glaucoma medications/a need for an additional laser treatment/a need for alternative glaucoma surgery. 85 eyes underwent CW-TSCP, 173 eyes underwent MPTLT. Vertical bars represent SEM. Mantel-Cox test was used to test for significance between two curves (p = 0.94). CW-TSCP continuous wave transscleral cyclophotocoagulation, MPTLT micropulse transscleral laser therapy, IOP intraocular pressure.
Baseline characteristics of CW-TSCP and MPTLT patients.
Cyclodiode vs micropulse transscleral laser treatment

January 2024

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68 Reads

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3 Citations

Eye (London, England)

Background Continuous-wave transscleral cyclophotocoagulation (CW-TSCP) is usually reserved for advanced/refractory glaucoma. Micropulse transscleral laser therapy (MPTLT) utilises short energy pulses separated by ‘ off ’-periods. MPTLT is postulated to have fewer complications, but its relative efficacy is not known. The National Institute for Health and Care Excellence (NICE) has deemed the evidence supporting MPTLT use of inadequate quality, limiting its use to research. This study aims to evaluate MPTLT efficacy and safety compared to CW-TSCP. Methods This 24-month follow-up retrospective audit included 85 CW-TSCP and 173 MPTLT eyes at a London tertiary referral centre. Primary outcome was success rate at the last follow-up; defined as at least 20% intraocular pressure (IOP) reduction with the same/fewer medications, and IOP between 6 and 18 mmHg. Secondary outcomes were acetazolamide use and success rates per glaucoma type. Safety outcomes were reported as complication rates. Results By 24-months, mean IOP reduced from 34.6[±1.4]mmHg to 19.0[ ± 3.0]mmHg post-CW-TSCP ( p < 0.0001); and from 26.1[±0.8]mmHg to 19.1[±2.2]mmHg post-MPTLT ( p < 0.0001). Average IOP decreased by 45.1% post-CW-TSCP, and 26.8% post-MPTLT. Both interventions reduced medication requirements ( p ≤ 0.05). More CW-TSCP patients discontinued acetazolamide ( p = 0.047). Overall success rate was 26.6% for CW-TSCP and 30.6% for MPTLT ( p = 0.83). Only primary closed-angle glaucoma saw a significantly higher success rate following CW-TSCP ( p = 0.014). CW-TSCP complication rate was significantly higher than MPTLT ( p = 0.0048). Conclusion Both treatments significantly reduced IOP and medication load. CW-TSCP had a greater absolute/proportionate IOP-lowering effect, but it carried a significantly greater risk of sight-threatening complications. Further prospective studies are required to evaluate MPTLT compared to CW-TSCP.



Retinal Vascular Changes in Response to Hypoxia: A High-Altitude Expedition Study

November 2023

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30 Reads

High Altitude Medicine & Biology

Westwood, Jessica, India Mayhook-Walker, Ciaran Simpkins, Andrew Darby-Smith, Dan Morris, and Eduardo Normando. Retinal vascular changes in response to hypoxia: a high-altitude expedition study. High Alt Med Biol 00:000-000, 2023. Background: Increased tortuosity and engorgement of retinal vasculature are recognized physiological responses to hypoxia. This can lead to high-altitude retinopathy (HAR), but incidence reports are highly variable, and our understanding of the etiological mechanisms remains incomplete. This study quantitatively evaluated retinal vascular changes during an expedition to 4,167 m. Methods: Ten healthy participants summited Mount Toubkal, Morocco. Fundus images were taken predeparture, daily throughout the expedition, and 1 month postreturn. Diameter and tortuosity of four vessels were assessed, in addition to vessel density and features of HAR. Results: Significant (p ≤ 0.05) increases in tortuosity and diameter were observed in several vessels on high-altitude exposure days. There was a strong correlation between altitude and supratemporal retinal artery diameter on days 2, 3, and 6 of the expedition (r = 0.7707, 0.7951, 0.7401, respectively; p < 0.05). There was a significant increase in median vessel density from 6.7% at baseline to 10.0% on summit day. Notably there were no incidences of HAR. Conclusion: Physiological but not pathological changes were seen in this cohort, which gives insight into the state of the cerebral vasculature throughout this expedition. These results are likely attributable to relatively low altitude exposure, a conservative ascent profile, and the cohort's demographic. Future study must include daily retinal images at higher altitudes and take steps to mitigate environmental confounders. This study is relevant to altitude tourists, patients with diabetic retinopathy or retinal vein occlusion, and critically ill patients.


How latanoprost changed glaucoma management

June 2023

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25 Reads

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5 Citations

Acta Ophthalmologica

Glaucoma is currently considered one of the leading causes of severe visual impairment and blindness worldwide. Topical medical therapy represents the treatment of choice for many glaucoma patients. Introduction of latanoprost, 25 years ago, with an entirely new mechanism of action from that of the antiglaucoma drugs used up to that time was a very important milestone. Since then, due mainly to their efficacy, limited systemic side effects and once daily dosing, prostaglandin analogues (PGAs) have become as the first-choice treatment for primary open-angle glaucoma. PGAs are in general terms well tolerated, although they are associated with several mild to moderate ocular and periocular adverse events. Among them, conjunctival hyperemia, eyelash changes, eyelid pigmentation, iris pigmentation and hypertrichosis around the eyes are the most prevalent. The objective of this paper is to review the role of PGAs in the treatment of glaucoma over the 25 years since the launch of Latanoprost and their impact on clinical practice outcomes.



Paired analysis of pre-and post-COVID visual acuity and glaucoma variables
Effects of COVID-19 pandemic on glaucoma appointment scheduling in a tertiary hospital in London, UK

April 2023

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184 Reads

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3 Citations

European Journal of Ophthalmology

Purpose: To investigate the impact of the delay in patient appointments caused by the COVID-19 pandemic and the triage system on the glaucomatous disease of patients in a London tertiary hospital. Methods: Observational retrospective study that randomly selected 200 glaucoma patients with more than 3 months of unintended delay for their post-COVID visit and other inclusion and exclusion criteria. Demographic information, clinical data, number of drugs, best-corrected visual acuity (BCVA), intraocular pressure (IOP), visual field (VF) mean deviation (MD), and global peripapillary retinal nerve fibre layer (pRNFL) thickness were obtained from the pre- and post-COVID visit. At the post-COVID visit, the clinical outcomes subjective clinical concern and change of treatment or need for surgery were also annotated. The variables were stratified by glaucoma severity (according to the MD into early, moderate and advanced) and by delay time (more and less than 12 months) and analysed using SPSS. Results: We included 121 eyes (from 71 patients). The median patient age was 74 years (interquartile range -IQR- 15), 54% were males and 52% Caucasians. Different glaucoma types and all glaucoma severities were included. When data was stratified for glaucoma severity, at the pre-COVID visit, significant differences in BCVA, CCT and IOP were observed and there were significantly higher values in the early glaucoma group. The median follow-up delay was 11 months (IQR 8), did not differ between the glaucoma severity groups and did not correlate to the glaucoma severity. At the post-COVID visit, significant differences in BCVA, IOP, and Global pRNFL thickness were observed between the glaucoma severity groups, as lower BCVA and higher IOP and pRNFL thickness were observed in the early glaucoma group. At the post-COVID visit there was cause for concern in 40 eyes: 5 were followed more closely, 22 had a change of treatment and 13 were booked for surgery (3 for cataract and 10 for glaucoma surgery). However, the number of eyes with causes for concern were similar between the glaucoma severity groups and there was no correlation between these clinical outcomes and the delay of the post-COVID visit. The number of topical hypotensive medications increased significantly after the post-COVID visit, higher number of medications were observed in the advanced glaucoma group. When differences of IOP, MD and pRNFL thickness between the pre and post-COVID visit, only the MD difference was significantly different between the glaucoma severity groups because it was higher in the severe group. When data was stratified for delay longer or shorter than 12 months, no differences were observed between the groups except at the pre-COVID visit, when the numbers of patients with MD deviation >-6 dB had longer delay time. When differences in IOP, MD and RNFL thickness were calculated, only the pRNFL thickness showed significant differences between the delay groups, because it was higher in the longer delay group. Finally, when paired analysis of the variables at the pre- and post-COVID visits, stratified by glaucoma severity and delay were conducted, although there were no significant differences in IOP in any group, the BCVA decreased significantly in the overall group and in the longer delay groups, the number of hypotensive drugs increased significantly overall and in the moderate and advanced glaucoma, the MD of the VF worsened significantly in the overall group and in the early glaucoma and longer delay groups and the pRNFL thickness decreased significantly in all groups. Conclusions: We document that delayed care impacts negatively on the glaucomatous disease of our patients because at the post-COVID visit there were reasons for clinical concern in a third of eyes that resulted in change of treatment or surgery. However, these clinical consequences were not related to IOP, glaucoma severity or delay time and reflect that the triage methods implemented worked adequately. The most sensitive parameter to indicate progression in our sample was the pRNFL thickness.


Intraocular pressure changes at high altitude

December 2022

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16 Reads

Acta Ophthalmologica

Purpose: The effect of altitude on Intraocular Pressure has been debated for decades. The literature is unclear, encompassing exertional and non-exertional ascents, as well as simulated ascents, with most finding a decrease in IOP, but some finding no change or an increase. Additionally, several papers have previously corrected IOP for Central Corneal Thickness, further confounding efforts to draw conclusions from the literature. The Imperial Remote Medicine BSc's Morocco expedition aimed to assess changes in IOP and CCT during an exertional winter ascent of Mount Toubkal (4167 m) which to our knowledge is the first exertional study conducted partially in sub-zero temperatures. Methods: IOP, CCT, clinical parameters and Lake Louise Score (LLS) were recorded daily in 9 participants before, 1 month after and during the expedition. Participants flew into Marrakesh, ascended to Imlil (1886 m) by car, and ascended from there on foot, stayed at the Nelter refuge for 3 nights (3037 m). All measurements were taken in the evening. IOP was measured using an iCare ic200 tonometer. Total IOP and CCT per participant per day was used to assess more fully the overall change in IOP and CCT across the expedition. Differences between eyes were also assessed. Results: No significant change in IOP was seen. CCT increased significantly at altitude. IOP was significantly positively correlated with LLS and headache, and significantly negatively correlated with SpO2. In line with current clinical practice, IOP was not adjusted for CCT. There was no difference in IOP or CCT between contact users and non-contact users. Conclusions: The increase in CCT is in line with the existing literature. The lack of significant change in IOP has precedence, and we propose that it is the interplay of physiological changes at altitude, alongside other factors such as exertion and temperature that alter IOP rather than IOP changes simply being a function of altitude.


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Citations (42)


... We describe a novel method of the minimally invasive tube surgery (MITS) technique for implanting a GDD with the use of the eyePlate-300 from Rheon Medical [6]. Our novel method vastly reduces the need for a large limbal conjunctival peritomy, preserving corneal limbal anatomy, reducing tissue trauma, and potentially reducing surgical time. ...

Reference:

Minimally Invasive Tube Surgery (MITS)—A Novel Method in Glaucoma Drainage Device Implantation
Evaluating the Safety and Efficacy of a Novel Glaucoma Drainage Device in High-Risk Adult Glaucoma Patients: A One-Year Pilot Study

... Most authors prefer performing TSCPC with a 810-nm diode laser, whereas others advocate for 1064-nm Nd:YAG laser [6,7]. Discussion is still going on the advantages of different types of laser for TSCPC, efficacy of techniques for the transscleral laser exposure, and laser energy settings for performing transscleral cyclodestructive procedures. ...

Cyclodiode vs micropulse transscleral laser treatment

Eye (London, England)

... Moreover, a variety of clinical examinations are necessary for the diagnosis of glaucoma, such as measurement of intraocular pressure (IOP), examination of the optic nerve, testing of the visual field, and structural imaging of the optic nerve and retina. Although these diagnostic techniques are essential for detecting glaucomatous damage, their sensitivity and specificity are naturally limited [17][18][19][20]. For instance, an IOP measurement by itself might not adequately indicate the likelihood that glaucoma will worsen because optic nerve injury can occur in some people with normaltension glaucoma even though their IOP levels are normal [21]. ...

Evaluating primary treatment for people presenting with advanced glaucoma: 5-year results of the Treatment of Advanced Glaucoma Study
  • Citing Article
  • January 2024

Ophthalmology

... Lowering intraocular pressure has proven to be the only proven way to treat the disease effectively. Glaucoma medications, usually in the form of eye drops, are often the first treatment option as they reduce aqueous humor production or improve drainage (Cordeiro et al. 2023). Other approaches, such as laser therapy and surgery, may also be options. ...

How latanoprost changed glaucoma management
  • Citing Article
  • June 2023

Acta Ophthalmologica

... The proportion of patients stratified into the highest level of risk (red) at follow-up is striking and indicative of significant decline in vision between clinic visits. These findings are similar to previous research examining MD change between pre and post pandemic which suggested a higher proportion of patients with early glaucoma progressing between appointments, whereas those with moderate or advanced glaucoma did not progress [33]. It is noteworthy that the sample used in our study may not be wholly representative of the national trends across glaucoma clinics during the pandemic. ...

Effects of COVID-19 pandemic on glaucoma appointment scheduling in a tertiary hospital in London, UK

European Journal of Ophthalmology

... Individual RCT risk of bias appraisal is reported in the Online Resource 1, as shown there was no significant high risk of bias. Nine non-randomized studies matched intervention and control patients according to baseline characteristics [16][17][18][19][20][21][22][23][24]. Individual appraisals of non-randomized studies are reported in Online Resource 2. All the studies were considered at low risk, except one study that was considered at moderate risk of bias due to possible selection and confounding bias. ...

MicroShunt versus Trabeculectomy for Surgical Management of Glaucoma: A Retrospective Analysis

... This makes its follow-up assessment an ideal target for automation, which could provide a safety net for patients and free up clinicians' time for skilldemanding tasks. 12 In the UK, the most common follow-up practice is face-to-face (F2F) review, usually at 4 weeks; however, some NHS Trusts have adopted telephone follow-up and found it to be a viable option (although the rates of telephone follow-up are poorly reported) and a number of Trusts only review if symptoms dictate (e.g. patient-initiated follow up). ...

Safety and Acceptability of a Natural Language Artificial Intelligence Assistant to Deliver Clinical Follow-up to Cataract Surgery Patients: Proposal

JMIR Research Protocols

... The condition affects the central vision and causes a decline in vision, characterized by blurring and blindness. It is mainly triggered by the inability of the fluid to permeate the retinal vasculature [19]. The WHO estimated that half of the 15 million people with DME are undiagnosed and 50\% of the 8 million people affected do not have eye care. ...

Recent advances in imaging technologies for assessment of retinal diseases
  • Citing Article
  • September 2020

... Similar to their success in diagnosing glaucoma, CNNs have been particularly effective in analyzing OCT images and fundus photography to predict glaucomatous progression [50]. These models have achieved accuracies of up to 93.7% with sensitivities and specificities of 0.91 and 0.97, respectively, in binary glaucoma diagnosis tasks using either OCT or fundus photography [51][52][53]. One longitudinal study developed models to predict glaucoma incidence and progression using color fundus photographs from 17,497 eyes of 9346 patients [54]. ...

A CNN-aided method to predict glaucoma progression using DARC (Detection of Apoptosing Retinal Cells)
  • Citing Article
  • April 2020

... The efficacy and the safety of SL-TSCPC treatment in primary open-angle glaucoma (POAG) [14][15][16] seem to be favourable, and the results in secondary glaucoma cases have also been promising [17,18]. The delivered treatment energy shows large variations in power, duration, and duty cycle [19][20][21][22][23]. Sweep velocity and the resulting fluence are also paramount factors to be considered, as higher fluence is associated with greater efficacy [24]. ...

Micropulse transscleral cyclophotocoagulation: initial results using a reduced energy protocol in refractory glaucoma

Graefe's Archive for Clinical and Experimental Ophthalmology