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.

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.

Direct costs of glaucoma and severity of the disease: a multinational long term study of resource utilisation in Europe.

BACKGROUND: Resource utilisation and direct costs associated with glaucoma progression in Europe are unknown. As population progressively ages, the economic impact of the disease will increase. METHODS: From a total of 1655 consecutive cases, the records of 194 patients were selected and stratified by disease severity. Record selection was based on diagnoses of primary open angle glaucoma, glaucoma suspect, ocular hypertension, or normal tension glaucoma; 5 years minimum follow up were required. Glaucoma severity was assessed using a six stage glaucoma staging system based on static threshold visual field parameters. Resource utilisation data were abstracted from the charts and unit costs were applied to estimate direct costs to the payer. Resource utilisation and estimated direct cost of treatment, per person year, were calculated. RESULTS: A statistically significant increasing linear trend (p = 0.018) in direct cost as disease severity worsened was demonstrated. The direct cost of treatment increased by an estimated 86 for each incremental step ranging from 455 euro per person year for stage 0 to 969 euro per person year for stage 4 disease. Medication costs ranged from 42% to 56% of total direct cost for all stages of disease. CONCLUSIONS: These results demonstrate for the first time in Europe that resource utilisation and direct medical costs of glaucoma management increase with worsening disease severity. Based on these findings, managing glaucoma and effectively delaying disease progression would be expected to significantly reduce the economic burden of this disease. These data are relevant to general practitioners and healthcare administrators who have a direct influence on the distribution of resources.

Defining response to anti-VEGF therapies in neovascular AMD.

The introduction of anti-vascular endothelial growth factor (anti-VEGF) has made significant impact on the reduction of the visual loss due to neovascular age-related macular degeneration (n-AMD). There are significant inter-individual differences in response to an anti-VEGF agent, made more complex by the availability of multiple anti-VEGF agents with different molecular configurations. The response to anti-VEGF therapy have been found to be dependent on a variety of factors including patient's age, lesion characteristics, lesion duration, baseline visual acuity (VA) and the presence of particular genotype risk alleles. Furthermore, a proportion of eyes with n-AMD show a decline in acuity or morphology, despite therapy or require very frequent re-treatment. There is currently no consensus as to how to classify optimal response, or lack of it, with these therapies. There is, in particular, confusion over terms such as 'responder status' after treatment for n-AMD, 'tachyphylaxis' and 'recalcitrant' n-AMD. This document aims to provide a consensus on definition/categorisation of the response of n-AMD to anti-VEGF therapies and on the time points at which response to treatment should be determined. Primary response is best determined at 1 month following the last initiation dose, while maintained treatment (secondary) response is determined any time after the 4th visit. In a particular eye, secondary responses do not mirror and cannot be predicted from that in the primary phase. Morphological and functional responses to anti-VEGF treatments, do not necessarily correlate, and may be dissociated in an individual eye. Furthermore, there is a ceiling effect that can negate the currently used functional metrics such as >5 letters improvement when the baseline VA is good (ETDRS>70 letters). It is therefore important to use a combination of both the parameters in determining the response.The following are proposed definitions: optimal (good) response is defined as when there is resolution of fluid (intraretinal fluid; IRF, subretinal fluid; SRF and retinal thickening), and/or improvement of >5 letters, subject to the ceiling effect of good starting VA. Poor response is defined as <25% reduction from the baseline in the central retinal thickness (CRT), with persistent or new IRF, SRF or minimal or change in VA (that is, change in VA of 0+4 letters). Non-response is defined as an increase in fluid (IRF, SRF and CRT), or increasing haemorrhage compared with the baseline and/or loss of >5 letters compared with the baseline or best corrected vision subsequently. Poor or non-response to anti-VEGF may be due to clinical factors including suboptimal dosing than that required by a particular patient, increased dosing intervals, treatment initiation when disease is already at an advanced or chronic stage), cellular mechanisms, lesion type, genetic variation and potential tachyphylaxis); non-clinical factors including poor access to clinics or delayed appointments may also result in poor treatment outcomes. In eyes classified as good responders, treatment should be continued with the same agent when disease activity is present or reactivation occurs following temporary dose holding. In eyes that show partial response, treatment may be continued, although re-evaluation with further imaging may be required to exclude confounding factors. Where there is persistent, unchanging accumulated fluid following three consecutive injections at monthly intervals, treatment may be withheld temporarily, but recommenced with the same or alternative anti-VEGF if the fluid subsequently increases (lesion considered active). Poor or non-response to anti-VEGF treatments requires re-evaluation of diagnosis and if necessary switch to alternative therapies including other anti-VEGF agents and/or with photodynamic therapy (PDT). Idiopathic polypoidal choroidopathy may require treatment with PDT monotherapy or combination with anti-VEGF. A committee comprised of retinal specialists with experience of managing patients with n-AMD similar to that which developed the Royal College of Ophthalmologists Guidelines to Ranibizumab was assembled. Individual aspects of the guidelines were proposed by the committee lead (WMA) based on relevant reference to published evidence base following a search of Medline and circulated to all committee members for discussion before approval or modification. Each draft was modified according to feedback from committee members until unanimous approval was obtained in the final draft. A system for categorising the range of responsiveness of n-AMD lesions to anti-VEGF therapy is proposed. The proposal is based primarily on morphological criteria but functional criteria have been included. Recommendations have been made on when to consider discontinuation of therapy either because of success or futility. These guidelines should help clinical decision-making and may prevent over and/or undertreatment with anti-VEGF therapy.

Effects of GH, prolactin and cortisol on hepatic heat shock protein 70 expression in a marine teleost Sparus sarba.

Heat shock protein 70 (HSP70) expression was assessed in hepatic tissue of a marine teleost Sparus sarba after exogenous hormone administration. Using a PCR-amplified, homologous HSP70 cDNA clone, as a probe in Northern analysis, we detected a 2.3 kb transcript which was elevated after exposure to a temperature 7 degrees C above the ambient. For our studies on hormonal effects on HSP70 expression, groups of fish were administered recombinant bream GH (rbGH), ovine prolactin (oPRL) or cortisol daily over a 7-day period. Quantification of hepatic HSP70 transcript revealed that the administration of GH and PRL significantly reduced HSP70 mRNA abundance by 42% and 54% from saline-injected fish respectively. Also hepatic HSP70 levels were reduced by 76% and 64% as determined by immunoblotting after rbGH and oPRL treatment respectively. The administration of exogenous cortisol did not alter hepatic HSP70 mRNA or protein levels in S. sarba. The results obtained in this study are the first evidence for hormonal modulation of heat shock protein expression in fish. The significance of these results is discussed within the context of current knowledge on the roles of these hormones in teleostean stress response.

Serious eye injury in badminton players.

Serious eye injury can occur in badminton players and may become more frequent. The causes and nature of such injuries in this sport in six patients are discussed. All were playing competitive doubles matches. Penetrating eye injury due to a shattered glass spectacle lens occurred. Players should be advised not to wear spectacles with glass lenses. Ocular protection in this sport is desirable, and the forward player should hold the racket in front of the face.

Chickenpox chorioretinitis.

Chickenpox infection in an adult was complicated by peripheral chorioretinitis and treated with oral acyclovir. Similarities of this case to the recently proposed mild type of acute retinal necrosis syndrome are discussed.

Effect of the calcium antagonist nifedipine on intraocular pressure in normal subjects.

We studied the effects of nifedipine, a calcium antagonist, given intravenously and orally, on intraocular pressure in six normal volunteers. Nifedipine had no effect on intraocular pressure. Nifedipine is not contraindicated for the treatment of cardiovascular disease in glaucomatous patients and may have theoretical advantages in this situation, which are discussed.

Microcornea associated with retinopathy of prematurity.

Eight children with retinopathy of prematurity (ROP) in whom the corneal diameters were abnormally small in one or both eyes are reported. The mechanisms for microcornea in ROP are discussed. The differential diagnosis of microphthalmos is briefly considered.

Retinochoroiditis in acute Epstein-Barr virus infection.

The case is reported of a 17-year-old male with secondary glaucoma and retinochoroiditis complicating acute clinical infectious mononucleosis. The diagnosis was confirmed by Epstein-Barr virus specific serology. Toxoplasmic infection was initially suspected. The differential diagnosis and relevant literature are discussed.

Convulsion following intravenous fluorescein angiography.

Tonic-clonic seizures followed intravenous fluorescein injection for fundus angiography in a 47-year-old male. Despite precautions this adverse reaction recurred on re-exposure to intravenous fluorescein.

Solitary extramedullary plasmacytoma of the maxillary antrum and orbit presenting as acute bacterial orbital cellulitis.

Orbital involvement by plasma cell tumours is rare. Orbital tumours do not generally present as an acute orbital inflammatory disease in adults, though tumours such as rhabdomyosarcoma may cause clinical signs similar to an acute orbital cellulitis in children. We describe a patient with bacterial orbital cellulitis and sinusitis who was found to have an extra-medullary plasmacytoma of the maxillary antrum and orbit and coexisting testicular seminoma.

Hypercortisolemia does not affect the branchial osmoregulatory responses of the marine teleost Sparus sarba.

The effect of cortisol treatment on branchial Na(+)-K(+)-ATPase subunit mRNA abundance, enzyme activity, chloride cell number/morphometrics and serum electrolyte levels were investigated for the marine teleost Sparus sarba. Groups of fish received intraperitoneal injections of cortisol at a concentration of 4 micrograms/g body weight, daily, over a seven-day period. This dose of cortisol was sufficiently high enough to maintain a condition of hypercortisolemia as serum cortisol levels in treated fish were eleven fold higher than controls at time of sacrifice. By using branchial Na(+)-K(+)-ATPase alpha- and beta-subunit cDNA clones we were able to demonstrate that cortisol administration to S. sarba caused a significant elevation in the abundance of alpha-mRNA whereas the levels of beta-mRNA were unchanged. In addition Na(+)-K(+)-ATPase activity remained unaltered by cortisol administration. Branchial chloride cell number, exposure, apical area as well as serum Na+ and Cl- levels remained unchanged after cortisol administration. The results of this study suggest that elevated cortisol level may not necessarily translate into modulated branchial Na(+)-K(+)-ATPase activity and chloride cell function in hypo-osmoregulating marine fish.

Hormonal modulation of branchial Na+-K+-ATPase subunit mRNA in a marine teleost Sparus sarba.

The effect of hormone treatment on the abundance of Na+-K+-ATPase alpha- and beta-subunit mRNA in Sparus sarba branchial tissue was investigated. Groups of seawater (33/1000) and hypo-osmotic (6/1000) acclimated fish were injected daily, with either saline, cortisol, recombinant bream growth hormone (rbGH) or ovine prolactin (oPRL). Total RNA from branchial tissue was analyzed by Northern blotting using PCR amplified Na+-K+-ATPase alpha- and beta-subunit cDNA clones. Na+-K+-ATPase alpha- and beta- subunit transcripts of 3.3kb and 2.4kb respectively, were detected and their abundance, after hormone treatment was assessed using RNA dot blots. The abundance of subunit mRNAs increased 1.4-1.9 fold, relative to controls, after cortisol treatment. The alpha:beta mRNA ratio also increased in cortisol treated seawater acclimated fish. Growth hormone treatment did not cause any significant changes in Na+-K+-ATPase subunit mRNA, whereas prolactin significantly reduced alpha-subunit mRNA levels by approximately 0.5 fold in both seawater and hypo-osmotic conditions. The data from this study add further support to the generally accepted roles that cortisol and prolactin have in the modulation of Na+-K+-ATPase activity. It can be concluded from this study that S. sarba branchial Na+-K+-ATPase subunit expression is multihormonally regulated.

Stimulation of macrophage phagocytosis and lymphocyte count by exogenous prolactin administration in silver sea bream (Sparus sarba) adapted to hyper- and hypo-osmotic salinities.

Juvenile silver sea bream (Sparus sarba) were adapted to hyper- (33 ppt) and hypo-osmotic (6 ppt) salinities for 3 weeks and injected daily with ovine prolactin (1 microg/g body weight i.p.) during the last 7 days of the adaptation period. Fish injected with prolactin exhibited significant increases in percent phagocytosis and phagocytic index of both pronephric and splenic macrophages regardless of salinity. Prolactin injection also resulted in elevated blood lymphocyte counts in both hyper- and hypo-osmotically adapted sea bream. The present results provide further evidence for the existence of a neuroendocrine-immune link in teleosts.

Larval development of silver sea bream (Sparus sarba): ontogeny of RNA-DNA ratio, GH, IGF-I, and Na(+)-K(+)-ATPase.

To ascertain some of the important biochemical and molecular events that take place during early larval development of silver sea bream (Sparus sarba), we undertook a study of changes in the morphology as well as the ontogeny of the RNA-DNA ratio, growth hormone (GH), insulin-like growth factor I (IGF-I) messenger RNA abundance, Na(+)-K(+)-ATPase subunit mRNA abundance, and Na(+)-K(+)-ATPase enzyme activity. Larvae samples were collected at 1 to 46 days posthatch (dph). At 7 dph the yolk sac was fully absorbed, and from 28 dph onward larvae underwent rapid developmental changes to the juvenile stage. The RNA-DNA ratio was highest at 1 dph, decreased to low levels between 7 and 21 dph, then increased by 28 dph, and then again by 46 dph. The ontogenetic profiles of GH, IGF-I, and Na(+)-K(+)-ATPase alpha1 and beta1 subunits were studied using reverse transcriptase polymerase chain reaction, coupled with radioisotope hybridization of immobilized DNA. Growth hormone abundance reached a constant and high level from 35 dph onward, whereas the IGF-I level reached a peak at 35 dph and then significantly decreased. Both Na(+)-K(+)-ATPase alpha1 and beta1 subunit mRNAs increased up to 35 dph, however, at 46 dph the alpha1 subunit remained high whereas the beta1 subunit decreased. Na(+)-K(+)-ATPase activity was low in 1-dph larvae but increased rapidly as development progressed. The importance of these findings is discussed within the context of larval development.

Intravitreal bevacizumab injection in unrecognised early pregnancy.

PURPOSE: The use of intravitreal vascular endothelial growth factor (VEGF) inhibitor medications has widened considerably to include indications affecting females of reproductive age. PATIENTS AND METHODS: We present our experiences following intravitreal injection of bevacizumab during the first trimester of unrecognised pregnancies in four women. RESULTS: All our patients were inadvertently exposed to bevacizumab within the first trimester when placental growth and fetal organogenesis take place. There were three cases of pregnancy without complication and one case of complicated pregnancy in which there was a significant past obstetric history. CONCLUSION: This case series provides further insights into intravitreal injection of bevacizumab in early pregnancy. There is insufficient information to suggest that such use is safe, nor is there definitive evidence to suggest that it causes harm. We advise that ophthalmologists discuss pregnancy with women of childbearing age undergoing intraocular anti-VEGF injections. Should a woman become pregnant, counselling is needed to explain the potential risks and benefits, and the limited available data relating to the use of these agents in early pregnancy.

'Toy' laser macular burns in children.

PURPOSE: Laser 'toys' can be purchased online and imported with relative ease; the variety of such devices is a potential public safety concern. We describe five children with maculopathy following exposure to laser 'toys'. METHODS: Case series of maculopathy following exposure to laser 'toys'. RESULTS: Five children were seen in our Ophthalmic Unit with macular injuries following exposure to laser 'toys'. Clinically, three children had an acute vitelliform-like maculopathy which resolved to leave sub-foveal retinal pigment epithelium changes with reduced vision. One case was complicated by a choroidal neovascular membrane. CONCLUSION: Laser 'toys', which resemble laser pointers, are increasingly available over the internet. Such 'toys' may not meet safety standards. Retinal injury in childhood following exposure to laser 'toys' is a public safety concern.

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.

Generation of the VESPA response to rapid contrast fluctuations is dominated by striate cortex: evidence from retinotopic mapping.

The VESPA (visual-evoked spread spectrum analysis) method derives an impulse response function of the visual system from scalp electroencephalographic (EEG) data using the controlled modulation of some feature of a visual stimulus. Recent research using VESPA responses to modulations of stimulus contrast has provided new insights into both early visual attention mechanisms and the specificity of visual-processing deficits in schizophrenia. To allow a fuller interpretation of these and future findings, it is necessary to further characterize the VESPA in terms of its underlying cortical generators. To that end, we here examine spatio-temporal variations in the components of the VESPA as a function of stimulus location. We found that the first two VESPA components (C1/P1) each have a posterior dorsal midline focus and reverse in polarity across the horizontal meridian, consistent with retinotopic projections to calcarine cortex (V1) for the stimulus locations tested. Furthermore, the focal scalp topography of the VESPA was strikingly constant across the entire C1-P1 timeframe (50-120 ms) for each stimulus location, with negligible global scalp activity visible at the zero-crossing dividing the two. This indicates a common focal source underpinning both components, which was further supported by a significant correlation between C1 and P1 amplitudes across subjects (r=0.54; p<0.05). These results, along with factors implicit in the method of derivation of the contrast-VESPA, lead us to conclude that these responses are dominated by activity from striate cortex. We discuss the implications of this finding for previous and future research using the VESPA.