The older surgical patient - to operate or not? A state of the art review.

The increasing age and subsequent medical complexity of patients presenting for surgery grants the opportunity to examine the processes and delivery of peri-operative care. There is a need to redesign peri-operative pathways allowing room for shared decision making and personalised, evidence-based care. In times of financial constraint, this is no easy task. However, neglecting to transform services now may lead to challenges in the sustainability of the provision of peri-operative care in the long-term. Challenges in redesigning peri-operative care pathways include identification and optimisation of those at highest peri-operative risk to inform the difficult conversations surrounding the appropriateness of surgery. The moral burden of these conversations on patient and professionals alike is increasingly recognised and managing this issue requires innovative models of collaborative, multidisciplinary and interprofessional working. To operate or not can be a challenging question to answer with a number of different perspectives to consider; not least that of the patient.

Management of thyroid eye disease in the United Kingdom: A multi-centre thyroid eye disease audit.

This article aims to provide baseline data and highlight any major deficiencies in the current level of care provided for adult patients with thyroid eye disease (TED). We undertook a prospective, nonrandomized cross-sectional multicenter observational study. During a 3-month period June-August 2014, consecutive adult patients with TED who presented to nominated specialist eye clinics in the United Kingdom, completed a standardized questionnaire. Main outcome measures were: demographics, time from diagnosis to referral to tertiary centre, time from referral to review in specialist eye clinic, management of thyroid dysfunction, radioiodine and provision of steroid prophylaxis, smoking, and TED classification. 91 patients (mean age 47.88 years) were included. Female-to-male ratio was 6:1. Mean time since first symptoms of TED = 27.92 (73.71) months; from first visit to any doctor with symptoms to diagnosis = 9.37 (26.03) months; from hyperthyroidism diagnosis to euthyroidism 12.45 (16.81) months. First, 13% had received radioiodine. All those with active TED received prophylactic steroids. Seven patients who received radioiodine and did not have TED at the time went on to develop it. Then, 60% patients were current or ex-smokers. 63% current smokers had been offered smoking cessation advice. 65% patients had active TED; 4% had sight-threatening TED. A large proportion of patients (54%) were unaware of their thyroid status. Not enough patients are being provided with smoking cessation advice and information on the impact of smoking on TED and control of thyroid function.

Impact of stereoacuity on simulated cataract surgery ability.

BACKGROUND AND OBJECTIVES: There exists a long-standing perception that diminished stereoacuity has a detrimental effect on microsurgical ability and skills acquisition. This has potential implications on the enrolment of surgical trainees into ophthalmology and other microsurgery specialities. However, strong evidence in this area is lacking. This case-control study aims to establish the exact level of stereopsis impairment at which a statistical drop in surgical performance occurs. METHODS: Fifty participants were enrolled from the University of Dundee Medical School and the NHS Tayside Foundation Doctor programme. Participants were assessed for their stereopsis level before completing an orientation module on an ophthalmic surgical simulator. They were then required to repeat a task four times. Automated and objective performance levels were recorded and analysed. RESULTS: Nineteen (38%) had stereopsis lower than the defined normal of 60 seconds of arc (arcsec). Statistical analysis found no correlation between visual acuity and surgical performance. No statistical difference was found between performance scores and stereoacuities of 30, 60 and 120 arcsec. A statistically significant difference was discovered in the surgical performance of participants with a stereoacuity worse than 120 arcsec (total score = -69.85) as compared to the ones with a stereoacuity of 120 arcsec or better (total score = -42.23) with p = 0.010. CONCLUSIONS: This study provides evidence of a specific level of stereopsis where statistical degradation of surgical performance occurs. The findings of this work may help formulate policy on stereoacuity standards required to commence microsurgical training.

Screening for diabetic retinopathy: a comparative trial of photography and scanning laser ophthalmoscopy.

AIMS: To evaluate the sensitivity and specificity of wide-field scanning laser ophthalmoscopy (WSLO) in the detection of referable diabetic eye disease, and to compare its performance with digital retinal photography. METHODS: Patients enrolled into the study underwent non-mydriatic WSLO imaging, then single- and dual-field mydriatic digital retinal photography, and examination with slit lamp biomicroscopy, the reference standard. Grading of retinopathy was performed in a masked fashion. RESULTS: A total of 380 patients (759 eyes) were recruited to the study. Technical failure rates for dilated single-field retinal photography, dual-field retinal photography and undilated WSLO were 6.3, 5.8 and 10.8%, respectively (0.005 < p < 0.02 for photography vs. WSLO). The respective indices for screening sensitivity were 82.9, 82.9 and 83.6% (p > 0.2). Specificity was 92.1, 91.1 and 89.5%, respectively (p > 0.2). CONCLUSIONS: Sensitivity and specificity for WSLO were similar to retinal photography. The technical failure rate was greater for the WSLO used in this study.

Eye injuries in sport.

Most ocular injuries involve only the external eye. However, in approximately one-third of cases the intraocular structures are damaged with potentially sight threatening consequences. A small number of sports, such as soccer, rugby, hockey and the racquet sports are responsible for most injuries. Sport is responsible for between 25-40% of all eye injuries severe enough to require hospital admission. Most of these are recognised as being largely preventable and methods of reducing the number and severity of such injuries are of prime importance.

The ophthalmo-meningeal foramen masquerading as an intraocular foreign body.

Although the diagnosis of intraocular foreign body is primarily a clinical one, radiographic imaging is often used to clarify the diagnosis and to localise the foreign body. For this case the radiographic findings served to confuse the diagnosis.

The variable expression of keratoconus within monozygotic twins: dundee University Scottish Keratoconus Study (DUSKS).

INTRODUCTION: As part of a longitudinal observational prospective study (Dundee University Scottish Keratoconus Study, DUSKS) a caucasian female subject was identified with keratoconus affecting both corneas. Of interest was that the subject's mother was a monozygotic twin, however, the mother was reportedly unaffected by keratoconus, although her sister (the subject's aunt) had been diagnosed with keratoconus. METHOD: Computer video-keratoscopy (CVK) was undertaken was on this family to clarify this apparent discordance. RESULTS: CVK demonstrated the variable expression of the keratoconic phenotype, by identifying evidence of subclinical keratoconus in the 'unaffected' twin. CONCLUSION: So far only one set of monozygotic twins with keratoconus have been reported within the UK, this paper reports a second. Since CVK has been available the majority agree on concordance of keratoconus expression but not all, including this study. If monozygotic twin studies demonstrate heterogeneity of keratoconus this may at least explain the contradictory data that exists within the literature and why the inheritance pattern of keratoconus is still unclear in 2005.

Flexible trainees in Scotland.

INTRODUCTION: Demand for flexible training is increasing. The contribution of such trainees to the trained medical workforce is not clear. METHODS: All full time and flexible trainees in Scotland were 'tracked' at the completion of training. RESULTS: 80% of flexible trainees took up a consultant post of which 93% were in Scotland. 82% of full time trainees took up a consultant post of which 80% were in Scotland. DISCUSSION: Flexible trainees become consultants at the same rate as their full time counterparts. They are commonly geographically tied and are therefore more likely to remain in Scotland and contribute to retention of doctors in this country.

Vision screening in children: a retrospective study of social and demographic factors with regards to visual outcomes.

BACKGROUND: Amblyopia and its risk factors have been demonstrated to be more common among children from low socioeconomic backgrounds. We sought to investigate this association in a region with orthoptic-delivered screening and whole population coverage, and to also examine the association of the Health Plan Indicator (HPI) with screening outcome. METHODS: Screening examination outcomes, postcodes and HPIs were extracted from the community child health database for every child who underwent preschool vision screening between March 2010 and February 2011 Tayside. We obtained the Scottish Index of Multiple Deprivation score for every child as a measure of area-based deprivation. We assessed the vulnerability/needs of the individual family through the HPI-'Core' (children and families receiving universal health visiting service), 'Additional' (receiving additional health/social support) and 'Intensive' (receiving high levels of support). The outcomes from follow-up examinations for those who failed screening were extracted from the orthoptic department database. RESULTS: 4365 children were screened during the year 2010-2011 of whom 523 (11.9%) failed. The odds of children from the least deprived socioeconomic group passing the visual screening test was 1.4 times higher than those from the most deprived socioeconomic group (OR 1.4, 95% CI 1.07 to 1.89, p=0.01). The odds of a child from a family assigned as 'Intensive' failing the preschool visual screening test was three times greater than the odds of a child from a family assigned as 'Core' (OR 3.59, 95% CI 1.6 to 7.8, p=0.001). CONCLUSIONS: We found that children from the most deprived backgrounds and those from unstable homes were more likely to fail preschool vision screening.

Atypical unilateral superior keratoconus in young males.

Generally in keratoconus the corneal apex displacement is inferior in position and bilateral in expression. Two young male keratoconic subjects enrolled in the Dundee University Scottish Keratoconus Study (DUSKS) demonstrated with corneal topography the presence of unilateral superior keratoconus. Successful visual rehabilitation of a superior cone with contact lens fitting represents a particular challenge to the contact lens practitioner. This report discusses the management of two such cases.

Trends in serious ocular trauma in Scotland.

PURPOSE: To report trends in serious, sight-threatening ocular trauma in Scotland. METHODS: A prospective, population-based, observational study of patients with ocular trauma admitted to hospital in Scotland during a 12-month period (2008-2009), conducted through the British Ophthalmic Surveillance Unit. Data on circumstances of the injuries and visual outcomes were collected using protocols standardised to those from an earlier study (1991-1992) to allow direct comparisons over time. RESULTS: In all, 0.3% of all emergency admissions in Scotland were for ocular trauma. Significant differences were observed between the time periods in where an injury occurred (P=0.009): a reduction of those occurring in a sports/leisure facility (8.2%) and an increase in those occurring on the street (21.4%). Assaults remained the most common cause of injury (31%). Gender differences persisted with females more likely to have an injury from falls (OR=8.67; 95% CI: 2.41-31.49; P=0.002), or in the home (OR=5.40; 95% CI: 1.69-17.16; P=0.009 ), and less likely to have one in the workplace (P=0.06). Poor visual outcome was associated with injuries occurring in the home (OR=4.33, P=0.047), in a public place (OR=6.25, P=0.047), and those caused by a fall (OR 42.75, P<0.001); or assault (OR 7.29, P=0.019). Half of those with a poor outcome have no perception of light. CONCLUSION: Serious ocular trauma remains an infrequent, sight-threatening event, associated with significant monocular visual morbidity. The findings suggest a shift from corporate to personal responsibility for risk awareness, health, and safety.

Oxidative effects of laser photocoagulation.

Diabetic proliferative retinopathy is a common and sight-threatening condition. Oxidative stress is an integral and possibly causative part of the pathogenesis. Although laser photocoagulation is usually a beneficial treatment it remains unclear how it works. The possibility that it induces a sudden, temporary increase in free radical activity either by direct thermal damage or by oxygen reperfusion is explored in this clinical study by measuring the oxidative status in the peripheral blood of 13 patients undergoing panretinal photocoagulation. There were significant increases at one hour in malondialdehyde-like material (MDA-LM), 8.1 (6.9-9.6) nmol/mL, to 9.1 (7.6-9.8) nmol/mL, (less than 0.005); plasma thiols (PSH), 423 (352-457) microns/L, to 444 (382-478) microns/L, (p less than 0.005) and red cell reduced glutathione (GSH), 1357 (1295-1655) microns/L, to 1480 (1305-1760) microns/L, (p less than 0.01). Diene conjugates rose over the first hour 0.55 (0.36-0.79) od/mL, to 0.58 (0.34-0.85) od/mL falling to 0.56 (0.36-0.79) od/mL at 2 h but these changes were not significant. At 2 h, MDA-LM 8.4 (6.7-9.6) nmol/mL and PSH 404 (379-462) microns/L had returned to baseline but GSH remained significantly elevated 1500 (1325-1675) microns/L, (p less than 0.005 compared to baseline). This is a new observation and in some circumstances such generation of free radicals could explain the mechanism behind the complications of photocoagulation by direct or indirect damage to vascular endothelium leading to increased vascular permeability manifest as macular oedema or choroidal effusions.

Epidemiology and implications of ocular trauma admitted to hospital in Scotland.

OBJECTIVES: To describe the current epidemiology of serious ocular trauma which necessitates admission to hospital so that health and safety strategies for the prevention of ocular injuries and their role within the national health strategy, The Health of the Nation, can be better informed. DESIGN: A prospective observational study of all patients with ocular trauma admitted to hospital under the care of a consultant ophthalmologist between 1 November 1991 and 31 October 1992. SETTING: All ophthalmic department in Scotland. SUBJECTS: All patients with ocular trauma admitted to hospital in Scotland. The population of Scotland represented the population at risk of injury. MEASURES AND MAIN RESULTS: Measures included the type and cause of injury, the place where it occurred, and awareness of risk and safety. All ophthalmic departments in Scotland participated and 428 admissions were reported. The home was the most common place for a serious injury to occur (30.2%), followed by the workplace (19.6%) and a sports or leisure facility (15.8%). The home was the single most frequent place of injury for the 0-15 year and 65 year and over age groups. Tools or machinery, either at home (13.9%) or at work (10.3%), were collectively (24.2%) the most frequent cause of injury, followed by assault (21.8%) and sports-related activities (12.5%). The most frequent type of injury was a blunt injury (54.4%). Six per cent (n = 25) of all injuries were bilateral. Only 13.2% of patients were aware of any risk of injury, with 5.6% aware of any risk at home. When applicable, protective eye wear was only available to 48.6% of patients and only 19.4% of these used it. CONCLUSION: Serious ocular trauma frequently occurs at home and the young and the elderly are particularly at risk. This represents a significant change in the epidemiology of serious ocular trauma and has important implications for prevention. Health and safety strategies specifically aimed at preventing eye injury should now include the home as a high risk environment in addition to the work-place and sports/leisure facilities. The target groups for accident prevention in The Health of the Nation strategy include those at risk of serious ocular trauma with potentially sight threatening sequelae. Those involved in implementing the national accident prevention strategy should be aware of this, for in this process it is possible that some serious eye injuries may also be prevented.

Sport associated eye injury: a casualty department survey.

A survey was performed of all patients attending the combined Glasgow Eye Infirmary and Western Infirmary Eye Casualty Department with sports injuries. During an 18-month period a total of 246 patients presented with such injuries. Football was responsible for 110 (44.7%), rugby for 24 (9.8%), squash for 19 (7.7%), badminton for 16 (6.5%), and skiing for 9 (3.7%), and 68 (27.6%) were caused by other sports. One hundred and sixty-two patients (65.8%) had superficial or surrounding soft tissue injuries, 54 (22%) had more severe anterior segment damage in the form of hyphaema or traumatic uveitis, 17 (6.9%) had retinal damage manifest as oedema or retinal tear with or without detachment, and two (0.8%) suffered severe disruption of the globe with subsequent loss of the eye in each case. Forty-six (18.7%) required inpatient care and 200 (81.3%) were treated as outpatients, of whom 104 required at least one follow-up appointment (42.3% of the total). I conclude that with increasing time available for leisure activities there has been a parallel increase in sport associated eye trauma.

Eye injuries: a prospective survey of 5671 cases.

5671 patients with injuries presenting to a busy eye casualty department were examined prospectively to determine the incidence, aetiology, and severity of the injury. Of these cases 69.9% occurred at work, 18.3% during leisure and domestic activities (excluding recognised sport), 2.3% during sport, and 1.9% were due to assaults; contact lens injury occurred in a further 2.3%, and the cause was unknown in 5.3%. One hundred and two (1.8%) patients required admission to hospital, and of their injuries 13.7% occurred at work, 22.6% during leisure and domestic activities, 42.2% at sport, 18.6% during assault, and 2.9% from an unknown cause. Children under 10 years of age accounted for 4% of the total patients presenting, but for more than 18% of those admitted and 26% of ocular penetrations. 98.3% of all injuries involved periorbital or superficial ocular structures only. The remainder involved intraocular structures. The majority of serious injuries were contusional. There was only one case of intraocular foreign body. This indicates that, while most injuries still occur in the workplace, sport and leisure activities account for the majority of serious injuries. While most injuries do not threaten sight, they do so disproportionately in children.

Why is squint surgery in children in decline?

BACKGROUND: /aims: Paediatric squint surgery appears to be declining. This study aims to identify if this is so and, if so, why. METHODS: Retrospective review of (1) episodes of paediatric squint surgery in Scotland and Tayside, 1986-2001, (2) presentations to orthoptists (Tayside) during 1986 and 1996. RESULTS: (1) Overall, a 58% fall in surgery in Scotland and 59% in Tayside. For esotropia, a reduction of 63% (Scotland) and 69% (Tayside). (2) Incidence of esotropia was unchanged; surgery for these esotropes fell (from 55% to 30%) (p = 0.013). More children received maximum hypermetropic correction (p <0.001) and more developed stereopsis (p = 0.003). CONCLUSION: Childhood strabismus surgery, particularly for esotropia, is declining. The maximum hypermetropic correction has improved the functional results.

A penetrating orbitocranial stab wound.

An unusual case of intracranial penetration of a bread knife through the orbit is described. Despite the proximity of the blade to the internal carotids, the optic nerves and chiasm, and the pituitary the patient survived with only a minimal field defect affecting the eye opposite to the entry site; otherwise no neurological or endocrine deficit was evident.

Aetiology and management of the 'detached' rectus muscle.

The clinical features and management of 17 cases of detached extraocular muscles are described. They are classified into four groups: (1) the muscle which is cut and lost during squint surgery, (2) the muscle which breaks during squint surgery, (3) the muscle which slips following squint surgery, and (4) the muscle which is damaged during facial or orbital trauma. The prognosis for group 1 is poor whereas groups 2-4 have a good chance of successful muscle relocation.

Eye injuries in children: the current picture.

AIMS: To investigate the current causes and outcomes of paediatric ocular trauma. METHODS: A prospective observational study of all children admitted to hospital with ocular trauma in Scotland over a 1 year period. RESULTS: The commonest mechanism of injury was blunt trauma, accounting for 65% of the total. 60% of the patients were admitted with a hyphaema. Injuries necessitating admission occurred most frequently at home (51%). Sporting activities were the commonest cause of injury in the 5-14 age group. There were no injuries caused by road traffic accidents or fireworks. Patients were admitted to hospital for a mean of 4.2 days (range 1-25 days). One (1%) child had an acuity in the "visually impaired" range (6/18-6/60) and one (1%) was "blind" (6/60) in the affected eye. No child was bilaterally blinded by injury and none required blind or partial sight registration. CONCLUSION: This study has shown that the incidence of eye injuries affecting children has fallen. The outcome of ocular trauma has improved significantly, and for the first time paediatric injuries appear to have a better prognosis than injuries affecting adults.

Factors influencing visual outcome in anisometropic amblyopes.

AIM: To identify which factors influence the final visual acuity in children with anisometropic amblyopia. METHODS: A retrospective analysis of 112 children with anisometropic amblyopia, identified from examining all case notes of children who had failed preschool or school screening. RESULTS: The age at presentation had no effect on the final visual outcome (p=0.804). Both the degree of refractive error and the degree of anisometropia at presentation correlated with final visual acuity (p<0.001 and p=0.001). Those with strabismus had a poorer final outcome. CONCLUSIONS: The age at presentation of a child with anisometropic amblyopia appears to have no significant effect on the final visual acuity. The amount of refractive error and degree of anisometropia at presentation do correlate strongly with final visual acuity. This would suggest, firstly, that children with poorer visual acuity at presentation and higher degrees of anisometropia should be treated more aggressively and that, secondly, children with anisometropic amblyopia should be treated regardless of age.