Clinical negligence in ophthalmology: fifteen years of national health service litigation authority data.

OBJECTIVE: To categorize and understand the reasons behind ophthalmic clinical negligence claims in the National Health Service and how such claims can be avoided. DESIGN: Retrospective analyses of all ophthalmic clinical negligence claims between 1995 and 2009 were carried out. Data were obtained from the National Health Service Litigation Authority through the Freedom of Information Act. Claims were classified according to ophthalmic subspecialty, mean payment per subspecialty, severity, paid-to-closed ratio, and cost. PARTICIPANTS: One thousand two hundred fifty-three ophthalmology-related claims occurring from 1995 through 2009. Of these, 963 claims were closed over the 15-year period. Eighty-four were excluded because of insufficient case data. INTERVENTION: Retrospective analysis of all public sector ophthalmology litigation claims over a 15-year period in England. MAIN OUTCOME MEASURES: Subspecialty pertaining to claim, mean payment per claim, and severity of outcome of clinical incident. RESULTS: Nine hundred sixty-three claims were closed over a 15-year period, of which 67% resulted in payment. The total cost of claims was £32.1 million ($50.3 million), with a mean payment per claim of £33 300 ($52 300). The specialties with the highest mean payment per claim were neuro-ophthalmology and pediatric ophthalmology. Cataract subspecialty had the highest number of claims, accounting for 34% of all claims. CONCLUSIONS: Overall, the number of litigation claims in ophthalmology is low, relative to the high volume of outpatient and surgical workload.

Recombinant tissue plasminogen activator (r-TPA) in fibrin dissolution due to postoperative endophthalmitis.

INTRODUCTION: The aim of this paper was to describe the use of r-TPA for fibrin clot dissolution following endophthalmitis. CLINICAL PICTURE: A 74-year-old man presented with painful loss of vision following routine uncomplicated cataract surgery. TREATMENT: He underwent standard treatment for postoperative endophthalmitis but despite this, developed a dense fibrin clot. He underwent further intracameral injection of r-TPA. OUTCOME: Following the injection, he had complete clot dissolution within 2 hours without any complications. CONCLUSION: R-TPA may be used effectively in the treatment of fibrin clots secondary to endophthalmitis following cataract surgery.

Safety Profile of Stromal Hydration of Clear Corneal Incisions with Cefuroxime in the Mouse Model.

PURPOSE: The use of sutureless clear corneal incisions (CCIs) for phacoemulsification is an established surgical technique, but the dynamic morphology of the wound and poor construction can lead to an increased risk of postoperative endophthalmitis. Stromal hydration with balanced salt solution (BSS) can improve the self-sealing status. Intracameral cefuroxime has reduced endophthalmitis rates. This study investigates the safety profile of stromal hydration with cefuroxime, as sequestering antibiotic at the wound may potentially provide added protection against infection. METHODS: MF-1 mice underwent bilateral CCI, followed by stromal hydration with 5 µL of 10 mg/mL cefuroxime, cefuroxime-texas red conjugate (for detection using confocal microscopy), or BSS. Corneas were harvested from 1 h to 12 weeks postoperatively; gross morphology, histology, and apoptotic cell death levels were investigated to determine the safety profile. Bactericidal activity of cefuroxime was assayed using homogenized whole cornea following stromal hydration at 1 h, 24 h, and day 7 against gram-negative Escherichia coli. RESULTS: Cefuroxime stromal hydration did not alter corneal morphology, with no evidence of corneal scarring or vascularization. Corneal histology and levels of apoptosis were minimal and comparable to the BSS groups up to 12 weeks. Confocal microscopy detected cefuroxime-texas red up to 1 week surrounding the corneal wound. Whole corneal tissue homogenates displayed bactericidal activity up to 24 h postoperatively. CONCLUSIONS: Stromal hydration of CCI with cefuroxime is safe in mouse corneas. A reservoir of antibiotic at the wound can potentially act as a barrier of defense against infection following cataract and associated ocular surgery.

The scotogenic contact lens: a novel device for treating binocular diplopia.

Binocular diplopia is a debilitating visual symptom requiring immediate intervention for symptomatic control, whether or not definitive treatment is eventually possible. Where prismatic correction is infeasible, the current standard is occlusion, either by a patch or an opaque contact lens. In eliminating one problem-diplopia-occlusive techniques invariably create another: reduced peripheral vision. Crucially, this is often unnecessary, for the reduced spatial resolution in the periphery limits its contribution to the perception of diplopia. Here, we therefore introduce a novel soft contact lens device that instead creates a monocular central scotoma inversely mirroring the physiological variation in spatial acuity across the monocular visual field, thereby suppressing the diplopia with minimal impact on the periphery. We compared the device against standard eye patching in 12 normal subjects with prism-induced binocular diplopia and 12 patients with binocular diplopia of diverse causes. Indexed by self-reported scores and binocular perimetry, the scotogenic contact lens was comparably effective in eliminating the diplopia while significantly superior in acceptability and its impact on the peripheral visual field. This simple, inexpensive, non-invasive device may thus be an effective new tool in the treatment of a familiar but still troublesome clinical problem.

Familial Bell's palsy in females: a phenotype with a predilection for eyelids and lacrimal gland.

The authors report a family with familial Bell's palsy affecting seven individuals, six of whom are females. This is a distinct subtype of Bell's palsy with a predilection for juvenile females, previously reported only very rarely. In conjunction with a review of the literature, this case suggests that this phenotype carries with it a greater risk of serious complications affecting the eyelids and lacrimal gland. These carry significant functional and cosmetic implications owing to aberrant regeneration of the seventh, sixth and possibly third cranial nerves, chronicity and relapses. Clinical features include synkinesis of the eyelids with the orbicularis oris causing synkinetic ptosis, recurrent paralytic ectropion, paralysis of facial muscles of expression with dry eye, hyperlacrimation (crocodile tears), and transient strabismus. Clinically, the decision to offer surgery in place of conservative treatment should consider the natural history of chronicity and relapses often seen with this subtype of familial Bell's palsy. Botulinum toxin injections are especially versatile in managing the complications associated with this phenotype.