Changing Trends in Uveitis in the United Kingdom: 5000 Consecutive Referrals to a Tertiary Referral Centre.

PURPOSE: To demonstrate changes in the demography and diagnosis of uveitis in a specialist clinic in the United Kingdom. METHODS: Retrieval of data including all new referrals to Manchester Uveitis Clinic from 1991 to 2020. The incidence and proportions of diagnoses between 4 quartiles was compared. RESULTS: 5000 patients with uveitis were seen. Referral rates trebled over time. Highly significant increases in referrals were seen for multiple evanescent white dot syndrome-spectrum disorders, syphilis and tuberculosis; increases were also seen for herpetic retinitis, vitreoretinal lymphoma and sarcoidosis. Highly significant decreases were seen for Fuchs' uveitis, Behçet's uveitis and ocular toxoplasmosis. CONCLUSIONS: Subspecialisation and de-skilling has changed referral patterns to specialist clinics; changes cannot be entirely attributed to disease incidences, which also vary between countries. International data are non-comparable. There are clear changes in referral patterns and disease incidence in this population, influenced by evolving diagnosis. Local data should steer care planning.

Detection of Pre-clinical Involvement of the Second Eye in Viral Acute Retinal Necrosis Using Optical Coherence Tomography.

PURPOSE: To report the detection of retinitis in the second eye of a patient with viral acute retinal necrosis (ARN), before the appearance of clinical change, using swept-source optical coherence tomography. RESULTS: A 63 year-old male developed right-sided varicella-zoster virus (VZV) ARN, confirmed with aqueous sampling. High-dose intravenous aciclovir caused renal impairment and was suspended for two-days. One day later, left eye macular SS-OCT revealed focal retinal thickening and disruption of retinal architecture without clinically detectable retinitis. The patient was asymptomatic. Aqueous sampling was VZV PCR positive. He received bilateral foscarnet injections and renal adjusted dose of aciclovir. The left OCT signs improved with full restoration of retinal layers. CONCLUSIONS: We report for the first time the use of OCT to detect pre-clinical second eye retinitis during ARN. Prompt diagnosis and combined systemic and intensive local antiviral therapy resulted in a favourable structural and functional outcome.

Management of subluxed and dislocated intraocular lenses in patients with uveitis: a practical approach.

Purpose: To describe practical approaches to the management of subluxed or dislocated intraocular lenses (IOL) in patients with uveitis.Patients and methods: Retrospective case series from a specialist uveitis clinicResults: Fifteen IOLs in 13 patients were subluxed inferiorly (12) or dislocated into anterior chamber (2) or vitreous (1) at a mean delay of 12 years after cataract surgery. Six eyes required vitrectomy and seven IOL explantation. A dislocated IOL was repositioned by scleral fixation in one, and a new IOL was implanted in three (two scleral-sutured, one iris-claw). Eight were observed without surgery and 7 were left functionally aphakic (4 corrected with contact lens). The mean final best-corrected visual acuity was 0.6 LogMAR.Conclusions: There are several management choices for IOL dislocation which should take into account the degree of uveitis, patient age and expectations. We present a pragmatic approach: surgery can often be avoided in this high-risk group.

Management of Ganciclovir Resistant Cytomegalovirus Retinitis in a Solid Organ Transplant Recipient: A Review of Current Evidence and Treatment Approaches.

Purpose: Cytomegalovirus retinitis (CMVR) is a serious and potentially sight-threatening infection in immunocompromised individuals. Strategies for the management of drug-resistant CMVR are described. Methods: A case of severe bilateral CMVR in a single lung transplant patient, with UL97 mutation conferring ganciclovir-resistance, is presented. Treatment with standard antiviral agent and adjuvant leflunomide, immunosuppression modifications (calcineurin inhibitors and corticosteroid), intravitreal antiviral therapy and novel use of CMV-immunoglobulin is described. A literature review to support drug-resistant CMVR management is presented. Results: Severe and progressive CMV retinitis was refractory to intravitreal foscarnet and systemic leflunomide. Drug-toxicity restricted systemic antiviral therapy options. The use of combined leflunomide and CMV-immunoglobulins, in the absence of viremia, has not been previously reported. Loss of ganciclovir-resistance was eventually observed permitting successful treatment with systemic and intravitreal ganciclovir. Conclusions: Drug-resistant CMVR is a complex clinical challenge. Multiple systemic and local treatment strategies may be necessary but toxicity, resistance, and co-morbidities may severely restrict available options.

Retinal burns from laser pointers: a risk in children with behavioural problems.

OBJECTIVE: To explore self-inflicted retinal burns from laser pointers in children. METHODS: Literature review of laser pointer retinal injuries in childhood and online survey of UK Consultant Ophthalmologists. A cohort of local children with self-inflicted injury is described. The matter is topical. We review progress in recent legislation and policy change in the UK. RESULTS: Four of 77 case reports of laser burns in childhood analysed reported psychological or behavioural issues. Three of four children in our cohort had such issues. Delay in diagnosis occurred in two of our patients. Structural retinal damage persisted for over 12 months in all four children (seven eyes). Our survey of UK ophthalmologists found 159 cases of injury (85% male), 80% under 20 years of age. The majority of the laser pointers were purchased online. Many patients (36%) suffered moderate vision loss (6/18 to 6/60 Snellen), while 17% (at least 11 patients) suffered severe vision loss (<6/60 Snellen). CONCLUSION: We highlight the risk of macular damage and vision loss from handheld lasers specifically in children with behavioural, learning or mental health issues. The diagnosis may be difficult or delayed in such children. In children with uncertain macular changes, ophthalmologists should explore the history for possible instances of exposure to handheld lasers pointers. Regulatory authorities and manufacturers of handheld lasers need to be aware of the risk to children. Furthermore, there is a need to better inform parents, carers and teachers of the risk of ocular self-injury from such lasers pointers.

Deep sclerectomy for uveitic glaucoma: long-term outcomes.

PurposeTo report long-term outcomes of deep sclerectomy (DS) in eyes with raised intraocular pressure (IOP) and glaucoma secondary to uveitis.Patients and methodsRetrospective consecutive case series of 43 eyes of 43 patients with uveitic glaucoma. Mitomycin C (MMC) 0.2-0.4 mg/ml was applied sub-conjunctivally prior to scleral flap dissection for 2-3 min in 35 eyes (81%). Combined phacoemulsification and DS was done in 4 cases (9%).ResultsMean follow-up was 68.5±33.5 months. In total, 23 eyes (53.5%) had previous intraocular surgery. Pre-operative IOP was 33.6±12.0 mm Hg. Mean IOP at one, three and five years after surgery was 15.5±5.0 mm Hg, 16.9±6.7 mm Hg and 16.4±5.2 mm Hg, respectively.The probability of IOP <22 and <19 mm Hg was 69 and 62% at 3 years and 60 and 51% at 5 years, respectively. This included eyes that had undergone needle revision and/or laser goniopuncture within that period but had not needed glaucoma medication or further glaucoma procedures. The overall number of glaucoma medications decreased from 3.0±1.2 to 0.8±1.2 by last follow-up (P<0.001). Serious complications included hypotony with macular folds in two eyes and occlusion of the trabeculo-Descemet's membrane (TDM) by iris in two eyes. Recurrence of uveitis was observed in 16 eyes. Seven eyes (16.3%) had subsequent procedures including trabeculectomy with MMC in one eye, DS with MMC in two eyes and Baerveldt tube implantation in five eyes.ConclusionsDS is a safe and effective procedure to lower IOP in uveitic glaucoma. However, as with other glaucoma procedures, a significant proportion of patients will require another IOP-lowering procedure in the long-term.

Wrong intraocular lens events-what lessons have we learned? A review of incidents reported to the National Reporting and Learning System: 2010-2014 versus 2003-2010.

PurposeTo identify the causal factors in wrong intraocular lens (IOL) events from a national data set and to compare with similar historical data (2003-2010) prior to mandatory checklist use, for the purpose of developing strategies to prevent never events.MethodsData from wrong IOL patient safety incidents (PSIs) submitted to the National Reporting and Learning System (2010-2014) were reviewed by thematic analysis and compared with the data previously collected by the group using the same methodology.ResultsOne hundred and seventy eight wrong IOL PSIs were identified. The contributory factors included: transcription errors (n=26); wrong patient biometry (n=21); wrong IOL selection (n=16); changes in planned procedure (n=16); incorrect IOL brought into theatre (n=11); left/right eye selection errors (n=9); communication errors (n=9); and positive/negative IOL power errors (n=9). In 44 PSIs, no causal factor was reported, limiting the learning value of such reports. Compared with the data from previous years, biometry errors were much reduced but IOL transcription and documentation errors were greater, particularly if further checks did not refer to the original source documentation. IOL exchange surgery was reported in 45 cases.ConclusionsThe selection and implantation of the correct IOL is a complex process which is not adequately addressed by existing checking procedures. Despite the introduction of surgical checklists, wrong IOL incidents continue to occur and are probably under-reported. Human or behavioural factors are heavily implicated in these errors and need to be addressed by novel approaches, including simulation training. There is also scope to further improve the quality and detail of incident reporting and analysis to enhance patient safety.

Staphylococcal endogenous endophthalmitis in association with pyogenic vertebral osteomyelitis.

PURPOSE To describe pyogenic vertebral osteomyelitis as a rare infection associated with endogenous endophthalmitis.METHODS A retrospective review of three patients with endogenous endophthalmitis and sepsis due to underlying Staphylococcal vertebral osteomyelitis presenting during a 21-month time period. The ophthalmic and systemic features and management and outcomes are presented.RESULTS One patient developed unilateral endophthalmitis with cervical spine osteomyelitis, Staphylococcus aureus being isolated from blood cultures. The second presented with bilateral endophthalmitis with disseminated Methicillin-resistant S. aureus (MRSA) infection, with thoracic and lumbar discitis and para-spinal abscesses. MRSA was cultured from vitreous, blood, and synovial fluid. Both patients received prolonged courses of intravenous antibiotics. Intravitreal antibiotic therapy was used in the second patient. Excellent visual and systemic outcomes were achieved in both cases with no ocular complications. The third patient developed lumbar osteomyelitis following spinal surgery and presented with disseminated S. aureus sepsis including unilateral endogenous endophthalmitis. Despite systemic antibiotics and intensive care the patient died.CONCLUSIONS Endogenous endophthalmitis should be suspected in septic patients developing eye symptoms. Endogenous endophthalmitis with staphylococcal bone infection is a rare but serious condition. Osteomyelitis should be considered as an infective source in any such patient reporting bone pain or reduced spinal mobility. Prompt investigation and treatment can achieve favourable visual and systemic outcomes.

Microincision cataract surgery combined with vitrectomy: a case series.

AIM: The objective of this study was to present the results of combined phacovitrectomy using 1.8 mm microincision cataract surgery (MICS) with special emphasis on the anterior segment complications in this group. METHODS: Retrospective, single-centre case series involving consecutive patients undergoing phacovitrectomy in a single centre in the United Kingdom during a 6-month period. RESULTS: A total of 52 eyes underwent combined MICS and pars plana vitrectomy. Intraoperative complications included posterior capsule rupture (n=2), minor iris trauma during phacoemulsification (n=1), iatrogenic retinal tears (n=2), and entry site break (n=1). Postoperatively two cases had significant inflammation, one of which resulted in 360° posterior synaechiea, iris bombe, and raised intraocular pressure. Other complications included mild posterior synaechiae (n=2), posterior capsular opacification (n=3), cystoid macular oedema (n=1), and hyphaema (n=1), which spontaneously resolved. There were no cases of intraocular lens decentration. Two patients who underwent surgery for retinal detachment repair subsequently redetached. Among those having surgery for macular hole, non-closure was seen in one patient and one patient developed a retinal detachment. CONCLUSION: In conclusion, sub-2 mm MICS is a safe and effective technique in dealing with vitreoretinal disorders necessitating cataract surgery at the same time.

Surgical checklist for cataract surgery: progress with the initiative by the Royal College of Ophthalmologists to improve patient safety.

PURPOSE: The World Health Organisation (WHO) identified patient safety in surgery as an important public health matter and advised the adoption of a universal peri-operative surgical checklist. An adapted version of the WHO checklist has been mandatory in the National Health Service since 2010. Wrong intraocular lens (IOL) implantation is a particular safety concern in ophthalmology. The Royal College of Ophthalmologists launched a bespoke checklist for cataract surgery in 2010 to reduce the likelihood of preventable errors. We sought to ascertain the use of checklists in cataract surgery in 2012. PATIENTS AND METHODS: A survey of members of the Royal College of Ophthalmologists seeking views on the use of checklists in cataract surgery. Four hundred and sixty-nine completed responses were received (18% response rate). RESULTS: Respondents worked in England (75%), Scotland (11%), Wales (5%), Northern Ireland (2%), the Republic of Ireland (1%), and overseas (6%). Ninety-four per cent of respondents support the use of a checklist for cataract surgery and 85% say that they always use a checklist before cataract surgery. Sixty-seven per cent of cataract surgeons stated they undertake a pre-operative team brief. Thirty-six per cent use a cataract surgery checklist developed locally, 18% use the college's bespoke cataract surgery checklist, 39% use a generic surgical checklist, and 4% reported that they do not use a checklist. CONCLUSION: Ninety-three per cent of cataract surgeons responding to the questionnaire report using a surgical checklist and 67% use a team brief. However, only 54% use a checklist, which addresses the selection of the correct intraocular implant. We recommend wider adoption of checklists, which address risks relevant to cataract surgery, in particular the possibility of selection of an incorrect IOL.

Consent for cataract surgery training: a national trainers' survey.

AIMS: To evaluate current trainers' attitudes and practices for informing patients about the trainee participation in cataract surgery within the United Kingdom. METHODS: An anonymous online survey was distributed to current cataract surgery trainers via all Royal College of Ophthalmologists' tutors within the United Kingdom. Trainers were asked specific questions about their current consent practice regarding trainee participation in the cataract surgery. Questions also targeted experiences of patient complaints about training. RESULTS: One hundred and twenty-three trainers completed the survey. Ninety-three percent (n=114) of responders were consultants and 7% (n=8) were non-consultant career-grade doctors or other grades. A total of 34% (n=42) of responders stated that consent was usually taken by themselves or the trainee assigned to the list, whereas 26% (n=32) always took consent themselves. Sixty percent of responders (n=74) stated that consent is taken on the day of surgery; 59% (n=73) indicated consent is taken where listing takes place. Thirty-three percent (n=41) of trainers indicated that they had experienced patient dissatisfaction or complaints. Surgical complications, length of surgery, and discussions during surgery were the leading causes of complaints. Thirty-nine percent (n=48) would operate themselves if patients requested no trainee participation. CONCLUSIONS: There is a wide variety in the current practice of disclosure and level of information given regarding trainee participation in surgery. This will influence patients' expectations, experiences, and satisfaction.

Deep anterior lamellar keratoplasty on a previously failed full-thickness graft.

PURPOSE: To report a case of deep anterior lamellar keratoplasty (DALK) on a previously failed full-thickness graft in a case of herpetic keratitis. METHODS: A 70-year-old patient with a history of penetrating keratoplasty for herpetic keratitis performed 30 years ago presented with blurry vision in her left eye. She had corneal stromal scarring secondary to herpetic keratitis. The endothelium was spared. We performed a DALK with big-bubble technique. RESULTS: Postoperatively, corneal edema was noticed initially, which resolved in 3 months. Her best-corrected visual acuity is 6/12 in her left eye. CONCLUSION: DALK on a previous penetrating keratoplasty is a technical possibility when there is a functioning endothelium.