Ponatinib Inducing a Panuveitis with Choroidal Effusions and Neurosensory Retinal Detachment in a Patient with Chronic Myeloid Leukaemia.

CASE SUMMARY: We present the case of a 50 year old male patient being treated for chronic myeloid leukemia by the tyrosine kinase inhibitor, Ponatinib. After 3 months of treatment, he developed a sight-threatening granulomatous panuveitis in both eyes, with choroidal effusions and neurosensory retinal detachments. Except for a positive interferon-gamma release assay suggesting previous Tuberculosis exposure, all uveitis investigations were normal. Discontinuation of the suspected causative drug led to resolution of signs and a consequent improvement in visual acuity. CONCLUSION: Ponatinib use may be associated with with a uveitic phenotype that is reminiscent of Harada's disease. We compare and contrast this rare ocular phenomenon with Vogt-Koyanagi-Harada syndrome and discuss a possible immunological basis.

"Cryoanalgesic preparation" before local anaesthetic injection for lid surgery.

INTRODUCTION: Lid surgery under local anaesthetic is commonplace in ophthalmic practise. The most distressing part of the surgery for the patient is often the injection of local anaesthetic into the sensitive lid skin. Various methods like pre-injection warming of the anaesthetic agent, buffering pH levels, varying agents used, and using thinner gauge needles have been tried to reduce pain levels. Cooling of tissue is known to have anaesthetic properties and has been proposed as a substitute to injection of local anaesthetic in certain surgical procedures. In this study we use the anaesthetic property of cooling, as a pre local anaesthetic injection procedure ("Cryo-preparation"). The anaesthetic injection induced discomfort with and without "cryo-preparation" was then assessed. METHODS: Thirty-nine patients aged 13-85 years (mean = 50, s.d. = 19) were randomly allocated and assessed. Twenty-two patients underwent local lid anaesthetic infiltration with "cryo-preparation," and 17 without. Pain monitoring was performed subjectively and objectively by scoring systems. Results were analysed using unpaired two tailed t-test on Microsoft Excel. RESULTS: Significant reduction in injection pain with cryo-preparation (24.6% reduction in score) was achieved (statistically significant p = 0.039). Surgical anaesthesia was complete in all cases. CONCLUSION: The study shows that "cryopreparation" by local ice application immediately prior to local anaesthetic injection reduces the sensitivity to the injection by a significant 24.6%. Thus while all the advantages of good analgesia are obtained from the injection, the distressing discomfort is reduced. This study serves as a pilot, in demonstrating a novel method of pain control for lid surgery.

Risk management strategies following analysis of cataract negligence claims.

INTRODUCTION: Clinical governance and risk management is very important in today's clinical practice. Cataract surgery is one of the most common procedures performed in the NHS, with around 200,000 operations per year. In order to help minimise the frequency of negligence claims, we performed a collaborative study to analyse claims relating to cataract surgery, dealt with by the defence organisations of England, Scotland, Wales, and Northern Ireland. MATERIALS AND METHODS: All claims dealt with by the Medical Defence Union, the Medical Protection Society, and the Medical and Dental Defence Union of Scotland from January 1990 to December 1999, were analysed by three ophthalmologists with at least 5 years' speciality experience. Recurrent themes were identified and claims were grouped by major causative factor. The findings were discussed by a panel compromising the authors in conjunction with the defence unions and risk management strategies were designed. RESULTS: There were 96 claims within the 10- year period analysed. Of these, the largest group (52) pertained to claims that related to accepted complications of cataract surgery. The remainder comprised two groups: 'Medical Errors' (anaesthetic, surgeon, and biometry) and 'Other Claims' comprising subjective complaints, pain and poor visual outcome. A total of 16 claims had been settled by May 2002, 45 are ongoing and 35 have closed without settlement. CONCLUSIONS: The majority of claims pertained to well-recognised complications of cataract surgery. If these risks are adequately explained to the patient before surgery and if the care provided reaches a standard acceptable to a responsible body of professional opinion, all such claims should be defensible. Good visual outcome does not protect against litigation.