Testing the reliability of an eye-dedicated triaging system: the RESCUE.

PURPOSE: To calculate the reliability of an eye-dedicated triaging system named Rome Eye Scoring System for Urgency and Emergency (RESCUE). METHODS: There were four coding parameters: pain, redness, loss of vision, and risk of open globe. Each parameter is assigned a score, the sum of which allows color coding. There were 1000 consecutive patients divided into urgent (U) or non-urgent (NU) based upon diagnosis, need for treatment, hospitalization, and/or follow-up visit. Correlation between RESCUE triage scoring as assigned by the nurse on presentation and urgency as estimated retrospectively was calculated. Accuracy, sensitivity, and specificity have been calculated. False positives (FP) have been defined as patients assigned a RESCUE green or yellow code while retrospectively judged NU and false negatives (FN) have been defined as patients assigned a white code despite being considered U. RESULTS: Of 1000 patients, 332 (33.2%) were classified as U and 668 (66.8%) NU. The difference in RESCUE scoring between U and NU patients was significant (p<0.001), as well as the correlation between RESCUE scoring and urgency status. Accuracy was 95% with 9.3% FP and 2.7% FN. Sensitivity was 90.7% and specificity 97.2%. Positive predictive value was 94.6%, and negative predictive value was 95.2%. All 32 hospitalized patients and 147/198 (74.2%) patients given a return appointment properly received a yellow or green code. CONCLUSIONS: RESCUE accuracy, sensitivity, and specificity yield encouraging results, confirming the system''s ability to properly spot the most urgent cases. The concept of urgency in ophthalmology can be difficult to establish; nonetheless, an eye-dedicated triage can help in properly prioritizing urgent patients.

Triaging and coding ophthalmic emergency: the Rome Eye Scoring System for Urgency and Emergency (RESCUE): a pilot study of 1,000 eye-dedicated emergency room patients.

PURPOSE: Ophthalmic emergency (OE) triage is essential for prompt recognition of urgent cases. To date, no formal eye-dedicated triaging system has been widely accepted. The purpose of the present study is to propose a fast, accurate, and reproducible coding scale called the Rome Eye System for Scoring Urgency and Emergency (Rescue). METHODS: Phase 1 of the study is a retrospective analysis of electronic medical records (EMR); phase 2 is a prospective consecutive series. Phase 1 included 160,936 patients. Phase 2 included 1000 consecutive patients referred to the emergency department (ED) of our institution. In phase 1, the authors retrospectively analyzed EMRs of patients presenting to the ED, listing signs and symptoms most frequently associated with hospitalization. Redness, pain, loss of vision, and the risk for an open eye were identified and assigned a score ranging from 0 to 12. Color coding was assigned based on increasing scoring: 0-3 white, 4-7 green, 8-12 yellow code. In phase 2, 1000 consecutive ED patients were enrolled and prospectively coded according to RESCUE. After diagnosis and proper treatment, EMRs were retrospectively reviewed by a masked physician and patients recoded (Retro coding) according to clinical course. Correlation between Rescue and Retro coding was calculated. MAIN OUTCOME MEASURES: Prospective and retrospective ED color coding correlation. RESULTS: A total of 160,936 EMR were retrospectively analyzed; 2407 (1.4%) patients required hospitalization. Loss of vision (90%), redness (76%), and pain (47%) were the most frequent complaints. Rescue significantly correlated to Retro coding (p<0.01): 841/1000 patients coded exactly the same color, 45/1000 were overestimated by one color class, none by two, 107/1000 underestimated by one, and 6/1000 by two classes. The 32/1000 hospitalized patients in the prospective cohort had a Rescue score significantly higher than non-admitted patients (p<0.01) and color coding among admitted and dismissed patients was significantly different as well (p<0.01). CONCLUSIONS: The Rescue system seems promising in terms of usefulness and ease of implementation. The high correlation between Rescue code assigned prospectively and the post-diagnosis coding, as well as the prompt discrimination of cases that eventually required hospitalization, may lead to a wider use of the Rescue system. Further testing on larger samples and different institutions is warranted.

In vivo detection of monosomy 3 in eyes with medium-sized uveal melanoma using transscleral fine needle aspiration biopsy.

PURPOSE: Cytogenetic prognostication of choroidal melanoma, particularly monosomy 3 detections, is limited to enucleated eyes or resected tumors. The authors developed an in vivo technique to detect monosomy 3 using transscleral fine needle aspiration biopsy (FNAB). METHODS: Eight eyes with medium-sized choroidal melanoma were included in this prospective study. A 25-gauge transscleral FNAB was performed during surgical procedure for brachytherapy, just before applying the radioactive plaque over the tumor base. Sampled material underwent fluorescence in situ hybridization (FISH) with centromeric probes for chromosome 3. Follow-up was >12 months. RESULTS: Transscleral FNAB yielded sufficient material in 7 of 8 eyes (87.5 %). Five of seven eyes had monosomy 3. No early or late complications were detected. CONCLUSIONS: This study demonstrates that medium choroidal melanomas may be safely sampled by intraoperative transscleral FNAB to detect monosomy 3 in vivo.

Long-term prognosis after removal of silicone oil.

PURPOSE: To investigate surgical and functional results six or more months after silicone oil (SiO) removal in patients undergoing pars plana vitrectomy (PPV) and tamponade for various reasons. METHODS: Retrospective chart review. Inclusion criteria were recurrent retinal detachment with PVR grade C (R-RD), primary PVR grade C longer than 9 hours, recurrent vitreous hemorrhage in PDR (PDR-RVH) with traction RD, giant retinal tears (GRT) with PVR grade C and total RD with vitreous hemorrhage and hypotony in penetrating traumas (PT). Indications for removal of SiO included attached retina and intra-ocular pressure (IOP) more than 10 mmHg after 60 days or IOP more than 30 mmHg despite medication. RESULTS: Of the 212 patients undergoing PPV and SiO tamponade between 1994-1997, 91 met the inclusion criteria, 8 had incomplete charts so 83 eyes were included in the study. The mean interval between PPV and SiO removal was 163.1 +/- 111.0 days and follow-up was 351.5 +/- 148.6 days. At the time of SiO removal, 30.6% of phakic eyes had cataract, 14.4% keratopathy and 8.4% IOP more than 30 mmHg. At the last visit after SiO removal, 43.5% had cataract, 12.0 keratopathy, 6.0% IOP > 30 mmHg and 3.6% IOP < 5 mmHg. After SiO removal, 6.0% eyes developed R-RD. There was no significant difference in SiO duration for patients with and without R-RD. VA was more than 5/200 in 16.8% of eyes preoperatively, 79.5% at the time of SiO removal (p<0.05) and 78.3% at the last visit (n.s.) and better than 20/400 in respectively 2.4%, 51.8% (p<0.05) and 53% (n.s.). There was a tendency for VA to improve after SiO removal (p = 0.011). CONCLUSIONS: SiO is an effective tamponade for complex RD, although its possible benefits must always be weighted carefully against the complications and the need for further intervention. The present series compares favorably with the current literature in terms of complication rates. The optimal timing of SiO removal and precise screening and decision-making guidelines before removal are still the main issues and need careful consideration.

Repair of scleral rupture and total retinal detachment in a self-injuring psychotic patient under local anesthesia: a case report.

PURPOSE: Ocular self-injury by psychotic patients is an uncommon cause of ocular morbidity that poses peculiar problems. This report describes a schizophrenic self-injuring patient with scleral rupture and retinal detachment (RD), treated under loco-regional anesthesia. CASE REPORT: A 65-year-old man presented with scleral rupture, hyphema, traumatic lens luxation, vitreous prolapse, vitreous hemorrhage and total RD after deliberately hitting his head. The fellow eye had been successfully operated with scleral buckle surgery for the same reason two years earlier. The patient underwent a two-step surgical procedure under local anesthesia, with repositioning and resection of the uveal prolapse and scleral rupture repair and, separately, lens removal pars plana vitrectomy (PPV), membrane peeling, retinotomy, laser treatment and SiO tamponade. RESULTS: Twelve months after PPV, the cornea was clear, IOP was 16 mmHg, the retina was attached and VA was 20/200. The fellow eye maintained 20/30 VA. CONCLUSIONS: In psychotic patients the intrinsic difficulty of a traumatic RD is combined with systemic illness, no compliance and the risk of recurrence. Although ocular traumas usually require general anesthesia, this patient underwent both interventions under local anesthesia with sedation, because of his psychotic condition and chronic liver failure. Local anesthesia and sedation proved effective in controlling pain and intra-operative compliance even in such a difficult patient. Although it is reasonable to question operating on such patients, we nonetheless believe that every attempt should always be made at gaining useful vision in both eyes since these patients are at a high risk of recurrent ocular trauma.

Nanophthalmic uveal effusion syndrome after prophylactic laser treatment.

PURPOSE: We report a case of nanophthalmic uveal effusion syndrome (NUES) with total exudative retinal detachment (RD) after prophylactic argon laser (AL) treatment. The RD subsided and eventually resolved with i.v. steroid therapy. METHODS: A 45-year-old woman was referred to us with NUES and total exudative RD after prophylactic AL treatment for retinoschisis performed elsewhere. The patient had been scheduled for surgical intervention and was given i.v. prednisolone. RESULTS: Two days after starting i.v. prednisolone, the subretinal fluid partially resolved. Intervention had therefore been postponed. After 15 days the RD almost disappeared and vision improved to 20/400. Ten days later the macula was flat and vision was 20/200. At the six-month follow-up visit vision was 20/40. CONCLUSIONS: To our knowledge this is the first report of NUES and total exudative RD following AL treatment that resolved with i.v. steroid therapy alone. Since the AL treatment clearly seemed to play a role in the pathogenesis of the NUES and associated RD we strongly advise careful assessment of the risk/benefit ratio of prophylactic laser treatment in nanophthalmic patients. Although sclerectomy and vortex vein decompression are well-established techniques, we believe steroid therapy might be tried before proceeding to surgery.