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.

Does strabismus surgery improve quality and mood, and what factors influence this?

AimsTo establish the impact of adult strabismus surgery on clinical and psychosocial well-being and determine who experiences the greatest benefit from surgery and how one could intervene to improve quality of life post-surgery.MethodsA longitudinal study, with measurements taken pre-surgery and at 3 and 6 months post-surgery. All participants completed the AS-20 a disease specific quality of life scale, along with measures of mood, strabismus and appearance-related beliefs and cognitions and perceived social support. Participants also underwent a full orthoptic assessment at their preoperative visit and again 3 months postoperatively. Clinical outcomes of surgery were classified as success, partial success or failure, using the largest angle of deviation, diplopia and requirement for further therapy.Results210 participants took part in the study. Strabismus surgery led to statistically significant improvements in psychosocial and functional quality of life. Those whose surgery was deemed a partial success did however experience a deterioration in quality of life. A combination of clinical variables, high expectations, and negative beliefs about the illness and appearance pre-surgery were significant predictors of change in quality of life from pre- to post-surgery.ConclusionsStrabismus surgery leads to significant improvements in quality of life up to 6 months postoperatively. There are however a group of patients who do not experience these benefits. A series of clinical and psychosocial factors have now been identified, which will enable clinicians to identify patients who may be vulnerable to poorer outcomes post-surgery and allow for the development of interventions to improve quality of life after surgery.

Which factors are associated with quality of life in patients with Graves' orbitopathy presenting for orbital decompression surgery?

PURPOSE: Graves' orbitopathy (GO) is associated with changes in the appearance of the eyes and visual dysfunction. Patients report feeling socially isolated and unable to continue with day-to-day activities. This study aimed at investigating the demographic, clinical, and psychosocial factors associated with quality of life in patients presenting for orbital decompression surgery. METHODS: One-hundred and twenty-three adults with GO due for orbital decompression at Moorfields Eye Hospital London were recruited prospectively. Clinical measures including treatment history, exophthalmos, optic neuropathy, and diplopia were taken by an ophthalmologist. Participants completed psychosocial questionnaires, including the Graves' Ophthalmopathy Quality of Life Scale (GO-QOL), the Hospital Anxiety and Depression Scale, and the Derriford Appearance Scale. Hierarchical multiple regression analyses were used to identify predictors of quality of life. RESULTS: Higher levels of potential cases of clinical anxiety (37%) and depression (26%) were found in this study sample than in patients with other chronic diseases or facial disfigurements. A total of 55% of the variance in GO-QOL visual function scores was explained by the regression model; age, asymmetrical GO and depressed mood were significant unique contributors. In all, 75% of the variance in GO-QOL appearance scores was explained by the regression model; gender, appearance-related cognitions and depressed mood were significant unique contributors. CONCLUSION: Appearance-related quality of life and mood were particularly affected in this sample. Predominantly psychosocial characteristics were associated with quality of life. It is important when planning surgery for patients that clinicians be aware of factors that could potentially influence outcomes.

Mechanisms and management of vision loss following orbital and facial trauma.

PURPOSE OF REVIEW: To examine the proposed mechanisms of vision-threatening injuries occurring secondary to orbital and facial trauma: traumatic optic neuropathy (TON), retrobulbar haemorrhage (RBH) and penetrating eye injury. To evaluate the evidence supporting different management options for traumatic vision-threatening injury. RECENT FINDINGS: Despite considerable debate over the roles of surgical decompression and systemic steroid therapy for TON, these interventions have not been proved to be more effective than conservative management and there is limited evidence that the use of steroids may be associated with an adverse outcome. Lateral canthotomy and inferior cantholysis have been proven to be effective treatments for RBH. Orbital exploration and surgical evacuation of haematoma remains a second line intervention. Open globe injuries require immediate primary surgical exploration and repair. Irretrievable devastating globe injuries require either enucleation or evisceration. There is no consensus as to which is the best treatment with recent surveys indicating that enucleation is preferred in the USA and evisceration in the United Kingdom. SUMMARY: Conservative management is the first line treatment for TON. The evidence strongly supports lateral canthotomy and inferior cantholysis as best treatment for RBH. There is no consensus as to whether enucleation or evisceration is the best treatment for irretrievable devastating globe injury. The choice of management is currently determined by surgeon preference.

Appearance concerns in ophthalmic patients.

AIMS: This study aimed to determine the psychosocial and appearance-related concerns of a sample of ophthalmic patients by measuring a range of psychological, social, and demographic factors. METHODS: Standardized psychological measures including anxiety, depression, appearance-related distress, self-discrepancy, appearance salience and valence were administered to 98 participants attending ophthalmic outpatient clinics in either London, Bristol, Sheffield or Bradford. Differences between groups were explored using t-tests and ANOVA, relationships between all variables were investigated using Pearson's correlation coefficient. RESULTS: Although mean scores for psychological adjustment were within the normal range, some participants were experiencing considerable levels of generalized anxiety. Being older, male, and married or living with a partner was related to significantly better adjustment. Better adjustment was also related to a less visible area of concern, greater disguisability of the affected area, a more positive evaluation of their own appearance, less engagement in comparing themselves with others, greater feelings of being accepted by others, appearance being less important to their self-concept, and a smaller discrepancy between the persons ideal and actual appearance. CONCLUSIONS: A majority of ophthalmic patients adjust positively to the demands placed on them. By identifying the variables that are associated with successful adaptation, the specific psychological interventions and appropriate systems of support can be put in place to help those who are adversely affected.

Higher surgical training in ophthalmology: trends in cumulative surgical experience 1993-2008.

INTRODUCTION: Recent years have seen significant changes in the provision surgical training for ophthalmology. The aim of this study is to establish the patterns in long-term trends of cumulative surgical experience of ophthalmology trainees in the United Kingdom. MATERIALS AND METHODS: Data were obtained from the department of training and education at the Royal College of Ophthalmologists (RCOphth). The cumulative surgical experience of all ophthalmology higher surgical trainees attaining accreditation, CCST, or CCT between 1993-2001 and 2005-2008 was included for descriptive analysis. RESULTS: Cumulative cataract surgical experience per trainee has been relatively stable at levels between 500 and 600 for most years. The cumulative experience vitreoretinal and corneal graft surgery have historically been low with a large outlier effect, although trends demonstrate a decrease in the median numbers of procedures. Squint surgery has seen a downward trend with a decrease in the median numbers from 121 in 1993 to 43 in 2008. Oculoplastics procedures demonstrate a decrease in overall numbers from 46 in 1993 to 15 in 2001. A jump from 2005 coincides with changes in the definition of what is counted as an oculoplastics procedure. The role of the RCOphth in legislating minimum levels of experience has had an impact on the data distribution manifest by the truncation of the inferior quartile of many of the dataspreads. DISCUSSION: These data demonstrate that although the cumulative experience of cataract surgery for trainees has remained stable, there has been a reduction in the median numbers of subspecialty procedures performed over the past 15 years.

Towards a better understanding of patient perspectives of clinical teaching in ophthalmology.

OBJECTIVE: To investigate of the perspectives of ophthalmology patients involved in clinical teaching. METHODS: In all, 26 patients attending a revision course for postgraduate Membership of the Royal College of Ophthalmologists examination were recruited. Every patient was examined by each of 36 residents who were present on this course making a total of 936 clinical examinations. Patient perspectives on their experience were investigated using a questionnaire. Four domains were investigated: interpersonal aspects, information exchange, discomfort, and overall perceptions. RESULTS: Four different examinations were carried out: neurological, orthoptic and slit-lamp examination of the anterior or posterior segment. The overwhelming proportion of patients learned much about their condition and felt that their contribution towards the training was valuable. Patients found the experience to be positive and satisfying, and all of the patients expressed a desire to reattend. No significant difference in patient discomfort (P=0.36) or perceptions of rough handling by doctors (P=0.62) between patients undergoing slit-lamp examination or non-slit-lamp examination was evident. CONCLUSIONS: Patients are willing to participate in clinical teaching and assessment, and they gain from the experience. Patients undergoing examinations using high luminance light sources were no more affected by discomfort than those undergoing eye movement or neurological examinations. Our data demonstrate the argument for a greater role of patient-based teaching as a training and assessment tool for fundoscopy.

Topical anaesthesia alone versus topical anaesthesia with intracameral lidocaine for phacoemulsification.

BACKGROUND: Cataract is defined as loss of transparency of the natural lens and is usually an age-related phenomenon. The only recognized treatment available for cataract involves surgery. An ideal anaesthetic should allow for pain-free surgery with no systemic or local complications. It should be cost effective and should facilitate a stress-free procedure for surgeon and patient alike. Topical anaesthesia involves applying anaesthetic eye drops to the surface of the eye prior to and during surgery. This has found large acceptance especially in the USA where it is used by 61% of cataract surgeons. Many surgeons who perform cataract surgery under topical anaesthesia also use intraoperative supplementary intracameral lidocaine (injected directly into the anterior chamber of the eye). The benefits and possible risks of intracameral lidocaine have been assessed by a number of randomized controlled trials, but the results have been conflicting and many of the endpoints have been heterogeneous. OBJECTIVES: The primary objective of this systematic review was to assess pain during surgery and patient satisfaction with topical anaesthesia alone compared to topical anaesthesia with intracameral anaesthesia for phacoemulsification. The secondary objectives were to assess adverse effects and complications attributable to choice of anaesthesia and the need for additional anaesthesia during surgery. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006) and LILACs (1982 to 3 May 2006). We also searched the reference lists of the identified studies and the Science Citation Index. We did not have any language restriction. SELECTION CRITERIA: We included only randomized controlled trials (RCTs) comparing topical anaesthesia alone to topical anaesthesia with intracameral lidocaine. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. For dichotomous outcomes data were presented as odds ratios. For continuous outcomes the weighted mean difference was employed. A random-effects model was used unless there were fewer than three trials in a comparison, where a fixed-effect model was used. We explored heterogeneity between trial results using a chi-squared test. MAIN RESULTS: A total of eight trials comprising of 1281 patients were identified for analysis. Our data comparison showed a significantly lower intraoperative pain perception in patient groups using supplementary intracameral lidocaine, although the difference was small. No significant difference was demonstrated between the groups receiving topical anaesthesia alone and topical combined with intracameral anaesthesia in terms of the need for supplemental anaesthesia, intraoperative adverse events or corneal toxicity. AUTHORS' CONCLUSIONS: The use of intracameral unpreserved 1% lidocaine is an effective and safe adjunct to topical anaesthesia for phacoemulsification cataract surgery.

Reliability of ophthalmic accident and emergency referrals: a new role for the emergency nurse practitioner?

BACKGROUND AND OBJECTIVES: Annual attendances at the accident and emergency (A&E) department of St Bartholomew's and The Royal London NHS Trust exceed 100,000 people of which 6% are ophthalmic. This study evaluated the accuracy of eye referrals from A&E senior house officers (SHOs) and emergency nurse practitioners (ENPs) and the impact any inaccuracies may have had on out of hours work. METHODS: Over a four week period a record of all referrals from the A&E department was made. The doctor receiving the referral made a note of clinical variables as reported by the referring clinician. When the patient was subsequently reviewed by an ophthalmologist, a record was again made of these findings. Any discrepancies were recorded. RESULTS: A total of 67 patients were recruited. ENPs were found to be consistently more accurate than SHOs in every aspect of the assessment, most notably in visual acuity (p = 0.0029), and provisional diagnosis (p = 0.012). Furthermore, had the examination findings been accurate, 58% of all SHO referrals seen after hours would have been triaged to the next available clinic but only 10% of ENP referrals could have been seen at the next clinic session (p = 0.027). CONCLUSION: This study found ENPs to be more accurate than A&E SHOs in history taking, recording visual acuity, describing ocular anatomy, and making provisional diagnoses. A significant reduction in out of hours ophthalmic workload may be achieved in the authors' unit if ENPs were to see all eye emergencies.

Microbial keratitis in ITU staff: an occupational hazard?

Microbial keratitis is a potentially blinding corneal infection; the infection may progress rapidly if untreated and result in corneal perforation. The breakdown of the innate ocular defences is known to predispose to corneal infection. We present three cases of microbial keratitis in intensive therapy unit (ITU) staff each of whom had compromised corneal immunity. Anaesthetists and nurses regularly perform high-risk procedures, such as tracheal suctioning, which have been known to cause ocular infections by aerosol inoculation. We suggest that although the absolute risk of infection is low, susceptible individuals may be at increased risk of corneal infection from exposure to potentially pathogenic organisms in such environments. We stress the need for ITU staff, particularly those who wear contact lenses, to wear eye protection when performing procedures likely to cause infected aerosols.