A review of fitness to practise referrals and investigations of ophthalmologists by the General Medical Council in the United Kingdom.

BACKGROUND: The General Medical Council (GMC) is a public body which regulates doctors in the United Kingdom (UK). One of its main roles is to investigate any concerns raised regarding a doctor. We aimed to study the current trends in referrals of ophthalmologists to the GMC. METHODS: A request was made to the GMC under the Freedom of Information Act 2000 for all complaints of ophthalmologists received by the GMC between 2007 and 2019, their outcomes and types of allegations. We have also calculated the annual incidences of suspension and erasure. RESULTS: There were 1032 complaints received by the GMC against ophthalmologists in 2007-2019. No actions were taken in 569 cases (55%). GMC investigations were carried out in 347 cases (34%). Sixty cases were referred to the Medical Practitioners Tribunal Service tribunal (6%), some of which cases resulted in suspension (28, 3%) and erasure (11, 1%). The commonest allegation types were Clinical Care, Knowledge, Skills and Performance, Maintaining Trust, Communication, Partnership and Teamwork and Probity. Annual incidences of complaints and serious outcomes between 2009 and 2017 were 30.54 (range 18.7-42.4) and 1.1 (range 0.8-2.0) per 1000 ophthalmologists respectively. CONCLUSION: There is an overall increase in the number of complaints to the GMC for ophthalmologists from 2007 to 2015 but since then there has been a gradual reduction. The annual incidences of complaints and serious outcomes have remained stable.

Impact of COVID-19 pandemic and lockdown on eye emergencies.

BACKGROUND: To characterise and compare ocular pathologies presenting to an emergency eye department (EED) during the COVID-19 pandemic in 2020 against an equivalent period in 2019. METHODS: Electronic patient records of 852 patients in 2020 and 1818 patients in 2019, attending the EED at a tertiary eye centre (University Hospitals of Leicester, UK) were analysed. Data was extracted over a 31-day period during: (study period 1 (SP1)) COVID-19 pandemic lockdown in UK (24th March 2020-23rd April 2020) and (study period 2 (SP2)) the equivalent 2019 period (24th March 2019-23rd April 2019). RESULTS: A 53% reduction in EED attendance was noted during lockdown. The top three pathologies accounting for >30% of the caseload were trauma-related, keratitis and uveitis in SP1 in comparison to conjunctivitis, trauma-related and blepharitis in SP2. The overall number of retinal tears and retinal detachments (RD) were lower in SP1, the proportion of macula-off RD's (84.6%) was significantly (p = 0.0099) higher in SP1 (vs 42.9% in SP2). CONCLUSION: COVID-19 pandemic related lockdown has had a significant impact on the range of presenting conditions to the EED. Measures to stop spread of COVID-19 such as awareness of hand hygiene practices, social distancing measures and school closures could have an indirect role in reducing spread of infective conjunctivitis. The higher proportion of macula-off RD and lower number of retinal tears raises possibility of delayed presentation in these cases. Going forward, we anticipate additional pressures on EED and other subspecialty services due to complications and associated morbidity from delayed presentations.

Correction: Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group.

.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group.

The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.

A comparative study of lens management in the United Kingdom and India with regard to rhegmatogenous retinal detachment surgery.

INTRODUCTION: Lens management in phakic patients with rhegmatogenous retinal detachments undergoing para plana vitrectomy surgery remains controversial among vitreoretinal surgeons. When combined phacovitrectomy is performed, the biometry decisions can be challenging both in the face of macula-off rhegmatogenous retinal detachments and previous refractive surgery. This study analyses current trends in practise. METHODS: A scenario-related survey was sent to all members of the British and Eire Association of Vitreoretinal Surgeons and to vitreoretinal surgeons in the northern Indian state of Punjab. RESULTS: In post-laser-assisted in situ keratomileusis patients with a visually significant cataract and a macula-on rhegmatogenous retinal detachment, the majority of British and Eire Association of Vitreoretinal Surgeons members (67.3%) and surgeons in Punjab (91.4%) would perform a stand-alone para plana vitrectomy and defer cataract surgery. When a combined phacovitrectomy is performed in this scenario, the majority of British and Eire Association of Vitreoretinal Surgeons (68%) would implant an intraocular lens (using either Haigis-L or European Society of Cataract and Refractive Surgeons/American Society of Cataract and Refractive Surgeons calculators), whereas the majority of Punjab surgeons (79.3%) would leave the patient aphakic. In a patient with a cataract and macula-off rhegmatogenous retinal detachment undergoing combined phacovitrectomy surgery, without any previous refractive surgery, the majority of British and Eire Association of Vitreoretinal Surgeons members (47.3%) would use the opposite eye biometry, whereas most Punjab surgeons (62.7%) would leave the patient aphakic. DISCUSSION: Vitreoretinal surgeons in both the United Kingdom and Punjab predominantly avoid combined surgery in rhegmatogenous retinal detachment cases, even when faced with a visually significant cataract. When combined phacovitrectomy is performed, most vitreoretinal surgeons preference using the opposite eye biometry for macula-off cases and Haigis-L (myope) or online calculators for post-laser-assisted in situ keratomileusis cases.

A Case Report of Conservative Management for a Roller-Coaster-Related Vitreous Haemorrhage.

The purpose of this report is to describe the case and management of an unexplained vitreous haemorrhage that occurred after repeated roller-coaster riding. The authors inadvertently demonstrate the value of observation over immediate surgery in certain situations and review the literature on vitreoretinal and other ocular complications after roller-coaster riding. A 26-year-old male presented 12 h after riding high-velocity roller-coasters with a left vitreous haemorrhage. A hazy view of the retina and B-scan revealed a bullous area of superior-temporal retinal lifting. A diagnosis of a presumed macula-on retinal detachment was made and the patient was listed for a pars plana vitrectomy retinal detachment repair. An abnormal clotting result, which was subsequently found out to be erroneous, ultimately delayed the procedure. During this delay the vision and retinal view improved to an extent whereby the diagnosis of a retinoschisis with an intraretinal cyst was made and surgery was avoided. The patient regained 6/6 vision, without the need to undergo surgery. Historically the management of an unexplained vitreous haemorrhage was observation with serial B-scans. The current evidence and practice for treating unexplained vitreous haemorrhage have since moved towards early surgical intervention. The authors highlight that despite the current trend, a place remains for conservative management for selected cases.

Probing the Aggregation and Signaling Behavior of Some Twisted 9,9'-Bianthryl Derivatives: Observation of Aggregation-Induced Blue-Shifted Emission.

With an aim to understand the photophysical behavior of twisted organic fluorescent molecules in their aggregated state, two twisted biaryl molecules, namely, 9,9'-bianthryl and 10,10'-dicyano-9,9'-bianthryl, have been synthesized and characterized by conventional spectroscopic methods. To understand the role of C-C bond twisting on the photophysical response of biaryl aggregates, monoaryl counterparts (anthracene and 9-anthracenecarbonitrile) of the biaryl systems are also investigated. Photophysical behaviors of these systems along with their monoaryl counterpart are investigated in both solution and aggregated state. Investigations reveal that fluorescence spectra of the biaryl compounds show blue-shifted emission upon aggregation. Interestingly, no blue shift of the emission has been observed for monoaryl aggregates. Photophysical data of biaryl systems compared to monoaryl unit reveal that change in geometry, during self-assembly process, disfavors the formation of charge-transfer state, which eventually causes blue shift in the emission upon aggregation. In addition to this, potential of these systems toward signaling of nitroaromatic explosive has also been explored. Among all of the nitroaromatics, the highest fluorescence quenching is observed for nitrophenols (say picric acid (PA)). The investigation also reveals that compared to monoaryl systems, biaryl systems are more responsive to fluorescence quenching by nitroaromatics. Perrin's model of quenching sphere action has been attributed to nitrophenol (PA) selective signaling behavior of biaryl systems.

Outcomes of switching treatment to aflibercept in patients with macular oedema secondary to central retinal vein occlusion refractory to ranibizumab.

PURPOSE: To assess the treatment outcome of switching from ranibizumab to aflibercept intravitreal injections in patients with macular oedema secondary to central retinal vein occlusion (CRVO). METHODS: A prospective interventional study was conducted in a tertiary retina service in Leicester Royal Infirmary, UK, where patients with CRVO and associated macular oedema were recruited. First-line treatment involved three monthly ranibizumab injections. Non-responders were defined as patients who despite a minimum of three consecutive injections had persistent intraretinal fluid one month after the last injection. In these cases, a treatment change to aflibercept injections on a per-needed basis was decided. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were measured before and after switching of treatment. Follow-up period lasted for a minimum of 24 weeks after switching. RESULTS: Twenty-nine eyes of 29 patients with refractory macular oedema secondary to CRVO were included. All eyes had an average of 4.5 ranibizumab intravitreal injections in a mean period of 6 months without reduction in intraretinal fluid and/or no visual acuity gain. A significant decrease in mean CRT from 633.67 ± 242.42 to 234.62 ± 78.28 µm and improvement in mean BCVA from 1.34 ± 0.66 log MAR to 0.91 ± 0.73 log MAR were noticed after switching treatment to aflibercept. The average number of aflibercept injections needed for oedema resolution was 2.19. CONCLUSIONS: Aflibercept is an effective alternative treatment for macular oedema secondary to CRVO refractory to ranibizumab. Good anatomical and functional result can be achieved with few injections. The maintenance of these results after 6 months is yet to be investigated.

Real-World Cost Savings Demonstrated by Switching Patients with Refractory Diabetic Macular Edema to Intravitreal Fluocinolone Acetonide (Iluvien): A Retrospective Cost Analysis Study.

INTRODUCTION: It is hypothesized that using fluocinolone acetonide (FAc) implants such as Iluvien for the treatment of diabetic macular edema (DME) may reduce the total number of intravitreal injections and clinic visits, resulting in an overall treatment cost reduction. The primary aim of this study is to identify the real-world cost savings achievable in a tertiary National Health Service (NHS) hospital. METHODS: A retrospective cost analysis study was conducted. The inclusion criteria were patients with refractory DME who were switched to Iluvien. The average yearly costs were calculated both before and after the switch to Iluvien. All costs including medicines, investigations, clinics, and management of raised intraocular pressure (IOP) were calculated. The cost differences over the 3 years' worth of Iluvien treatment were calculated and analyzed. To ensure non-inferiority of this treatment intervention, the best corrected visual acuity (BCVA) and central retinal thickness (CRT) were also analyzed. Statistical analysis was conducted with a Student t test where appropriate and statistical significance is identified where p < 0.05. RESULTS: Fourteen eyes of 13 patients met the inclusion criteria. Switching patients to Iluvien achieved on average a saving of £2606.17 per patient (p = 0.33) over the 3 years. However, seven cases (50%) had a rise in IOP after Iluvien that warranted medical treatment and two cases (14.3%) required glaucoma surgery. Incorporating the costs of glaucoma management reduced the overall savings over 3 years to £1064.66 per patient. The BCVA and CRT analysis showed a non-inferiority relationship between Iluvien and any previous treatment. CONCLUSIONS: The use of Iluvien in refractory DME patients represents a cost- and time-saving procedure, while showing non-inferiority in terms of efficacy.

Cytomegalovirus retinitis: an unusual presentation as vitreous hemorrhage.

PURPOSE: The purpose of this report is to describe an unusual presentation of vitreous hemorrhage (VH) in a patient with an immunosuppressive condition. METHODS: Retrospective case report. RESULTS: A 72-year-old woman with known T-cell prolymphocytic leukemia treated with a course of alemtuzumab presented to our department with a VH in her left eye after a fall. An initial diagnosis of hemorrhagic posterior vitreous detachment was made. However, as the VH was resolving, she was found to have underlying vitritis, occlusive vasculitis, and a pale optic nerve head. Vitreous biopsy confirmed cytomegalovirus retinitis. Despite treatment with intravenous foscarnet and oral valganciclovir, her vision continued to remain poor because of the severe damage from the retinal vasculitis and residual VH. CONCLUSION: As indications for immunosuppression increase, the incidence of cytomegalovirus retinitis in non-HIV-immunosuppressed patients is expected to rise. Therefore, in this subgroup of patients, we should be aware of any underlying retinitis especially in cases with an unusual presentation of VH.

Diagnosis and Monitoring of Choroidal Osteoma through Multimodal Imaging.

A 16-year-old Caucasian female with a 6-month history of decreased visual acuity and metamorphopsia in the left eye is reported. The fundus of the left eye revealed a well defined lesion in the macula region. Diagnosis of choroidal osteoma was established using spectral domain optical coherence tomography (OCT), fundus fluorescein angiography (FFA), indocyanine green angiography (ICG), and B-scan ultrasonography. Subretinal fluid (SRF) and retinal pigment epithelium (RPE) detachment were noted in the absence of obvious classic choroidal neovascularisation (CNV). The patient was followed up for over 13 months without any treatment in the interim and the lesion was noted to have enlarged but visual acuity and SRF had remained stable. We report an interesting case where subretinal fluid was noted in the absence of evident choroidal neovascularisation and provide an example of the imaging modalities application in the era of "optical biopsy."

Dexamethasone intravitreal implant for idiopathic retinal vasculitis, aneurysms, and neuroretinitis.

PURPOSE: To present the short-term favorable clinical results with the dexamethasone intravitreal implant in a patient with florid idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome (IRVAN).
 METHODS: A 26-year-old man presented with significant bilateral deterioration of vision due to vitreous hemorrhage and neuroretinitis with a background of vasculitis and neovascularization. The patient was initially treated with high doses of oral steroids (80 mg prednisolone), which were gradually tapered, and also received extensive argon laser photocoagulation in ischemic areas in both eyes. Despite vigorous treatment and an initial positive response to treatment, pars plana vitrectomy was eventually needed to address the recurrent vitreous hemorrhages in the left eye. Consequently, visual acuity improved from 0.1 to 0.2 (Snellen) and there was no relapse of vitreous hemorrhage. Persistent macular edema was noted, however, and it was decided to treat with a dexamethasone 0.7 mg intravitreal implant.
 RESULTS: Following the dexamethasone implant OS, visual acuity improved significantly from 0.2 to 0.5 (Snellen), the patient reported much less distortion, and there was marked reduction in central retinal thickness from 467 to 234 microns. The patient remains in remission without any exudation in the macula at 4 months follow-up.
 CONCLUSION: Dexamethasone 0.7 mg intravitreal implant appears to be a safe and effective solution in the treatment of macular edema in patients with IRVAN syndrome and could possibly be a treatment option for other cases of inflammatory induced macular edema.

Intravitreal ranibizumab in the treatment of butterfly-shaped pattern dystrophy associated with choroidal neovascularization: a case report.

PURPOSE: To present and document the effectiveness of intravitreal ranibizumab in the treatment of patients with choroidal neovascularization due to butterfly-shaped pattern dystrophy (PD) of the macula. METHODS: Three intravitreal ranibizumab injections of 0.5 mg/0.05 ml in monthly intervals were given to a patient with a previously diagnosed butterfly-shaped PD who subsequently developed subfoveal choroidal neovascularization on the right eye. The patient had previously received a combination of verteporfin/photodynamic therapy for a juxtafoveal choroidal neovascular membrane on the left eye. RESULTS: At the end of the treatment course, there was significant improvement of the patient's vision and the appearance of the macula on optic coherence tomography and fluorescein angiography. Best-corrected visual acuity improved from 6/12 to 6/6 and retinal thickness at the macula decreased from 323 to 247 µm. No subretinal fluid remained. The patient is clinically stable over a 12-month follow-up period. CONCLUSIONS: Intravitreal ranibizumab seems to be an effective and safe option for the treatment of subfoveal choroidal neovascularization in patients with butterfly-shaped PD.

Presumed bilateral branch retinal vein occlusions secondary to antiepileptic agents.

A 61-year-old man presented to the ophthalmology department having developed bilateral branch retinal vein occlusions. Baseline blood tests revealed no abnormality; however, subsequent investigations showed a raised plasma homocysteine (HC) level. The patient has been treated for refractory epilepsy for a number of years. Although antiepileptic medications have been shown to reduce folate levels and result in a raised HC level, this has not previously been shown to be to a level causing a retinal vascular event.

Densiron 68 as an intraocular tamponade for complex inferior retinal detachments.

INTRODUCTION: Densiron(®) 68 is a high-density liquid used to tamponade inferior retinal detachments. We present a case series of 12 patients treated with Densiron as an intraocular tamponade agent. METHODS: A retrospective analysis of 12 eyes in 12 patients was carried out. The primary endpoint was anatomic reattachment of the retina following removal of Densiron oil. RESULTS: All patients had inferior detachments; 33% had associated proliferative vitreoretinopathy (PVR). Densiron was utilized as a primary agent in five patients (42%); the remaining patients had prior unsuccessful surgery for retinal reattachment, including pars plana vitrectomy, cryotherapy, laser, encirclement, gas (C3F8 or C2F6), or silicone oil. Eleven patients (91%) had successful reattachment of the retina at 3 months following removal of Densiron; one patient had extensive PVR, total retinal detachment, preretinal macula fibrosis, and chronic hypotony, and surgical intervention was unsuccessful. Six patients (50%) had raised intraocular pressure (IOP), resolving in the majority of cases following Densiron removal; two patients had long-term raised IOP requiring topical or surgical therapy. Of the six phakic patients, 50% developed significant cataract in the operated eye. Of those with successful retinal reattachment, visual outcome was variable, with 36% patients gaining two to four lines on Snellen, 27% remaining objectively the same, and 36% losing one to two lines. CONCLUSION: The anatomic success rate is high (91%) in patients requiring Densiron tamponade for inferior retinal detachments with or without evidence of PVR either as a primary or secondary intervention. A common complication is raised IOP; however, this most often resolves following removal of the oil.

Face-down posturing after macular hole surgery: a meta-analysis.

AIMS To assess the effect that the duration of face-down posturing has on the outcome of macular hole surgery. METHODS A literature search was conducted to identify studies related to posturing duration following macular hole surgery. Where appropriate, studies were compared in a meta-analysis. The Mantel-Haenszel fixed-effect method was used to calculate the summary statistics. The main outcome measures were macular hole closure rate and visual acuity improvement. RESULTS 17 studies investigating the effect of face-down posturing time on the outcome of macular hole surgery were identified. 9 studies included a comparison group and were deemed suitable for inclusion in the meta-analysis. Studies were divided into two groups depending on the duration of face-down posturing investigated. The meta-analysis revealed an RR of anatomical failure of 1.34 (95% CI 0.66 to 2.72) with face-down posturing for 24 h or less compared with face-down posturing for 5-10 days, but this was not statistically significant (p=0.42). The study design was too dissimilar to allow a meaningful comparison of visual acuity outcomes. CONCLUSIONS Currently there is insufficient evidence to allow firm conclusions as to whether face-down posturing following macular hole surgery influences hole closure rates. Meta-analyses are limited by the quality of included studies; a well-conducted randomised control trial is needed.