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.

Brow ptosis: are we measuring the right thing? The impact of surgery and the correlation of objective and subjective measures with postoperative improvement in quality-of-life.

INTRODUCTION: To assess the effect of brow ptosis on visual function and quality-of-life (QoL), and to determine what measures are associated with post-surgical change in functional status. METHODS: Prospective longitudinal study. Fifteen consecutive patients undergoing brow-lift surgery from February 2009 to August 2010. MAIN OUTCOME MEASURES: pre- and post-operative eyelid position (ie, distance mm from corneal reflex to upper skin fold (FRD1), lowest brow hair to lower limbus (LLB), centre of lower lid to upper lid skin fold (LLF)) and number of points missing in 'superior' and 'superior plus elsewhere' Humphrey 120-point visual field, as well as a Quality-of-life and Visual Function questionnaire before and after brow lift surgery. RESULTS: The strongest correlation between pre-op functional index score and any pre-op objective measure was visual fields (r=-0.46, P<0.085). There was a mean 36-point increase in functional index score after brow lift surgery (P<0.001).Self-reported preoperative functional impairment was the only outcome measure significantly (and strongly) associated with post-surgical improvement in functional status (r=-0.833, P<0.001). CONCLUSIONS: Surgical repair of brow ptosis results in a measurable increase in health-related QoL. The preoperative QoL score is the best predictor of postoperative improvement in QoL. The best available objective preoperative parameter for indicating postoperative QoL improvement is visual fields. These two measures should be used to better predict successful surgical outcomes.

Long-term visual and retinopathy outcomes in a predominately type 2 diabetic patient population undergoing early vitrectomy and endolaser for severe vitreous haemorrhage.

PURPOSE: To evaluate the long-term visual outcome of type 2 diabetic patients receiving early vitrectomy and endolaser for severe vitreous haemorrhage (VH). MATERIALS AND METHODS: Retrospective case note review of 88 eyes (69 type 2 diabetics and 19 type 1 diabetics) of 80 patients who underwent vitrectomy and endolaser within 6 months of VH. Post-operative and most recent VA, in addition to long-term retinopathy grading, were analysed. A subset of patients fulfilling the criteria for the Diabetic Retinopathy Vitrectomy Study was compared with this study. RESULTS: Mean pre-operative visual acuity (VA) in the type 2 group was 0.64 logMAR, with 1 eye showing perception light (PL), 10 eyes detecting hand movements (HMs), and 7 eyes counting fingers (CFs). At the 2-week post-operative visit, the mean VA had improved to 0.46 logMAR, with two eyes showing PL, two eyes detecting HM, and one eye CF (P=0.0002); at the last review, mean VA score was 0.36 logMAR, with three eyes showing PL and four eyes detecting HM (P=0.0008). Mean pre-operative VA in the type 1 group was 0.47 logMAR, with one eye showing PL, one eye detecting HM, and two eyes CF. At the 2-week post-operative visit, the mean VA had improved to 0.37 logMAR, with one eye showing PL (P=0.002), and at the latest review, the mean VA was 0.20 logMAR (P=0.027). CONCLUSION: Our study shows that type 2 DM patients can observe improvement in VA and stabilisation of their proliferative retinopathy after early vitrectomy and endolaser for vitreous haemorrahage, which is maintained after long-term follow-up.

Aqualase for cataract extraction.

PURPOSE: To report our experience of using Aqualase technology for cataract extraction. METHODS: In total, 33 patients (20 females; mean age 71.4 years) underwent cataract surgery using Aqualase through a 3.2-mm corneal incision. Grade of nucleus, nuclear removal technique, and intraoperative complications were noted. Clinical parameters from postoperative visits were collected. RESULTS: Aqualase is capable of removing cataracts up to nuclear sclerosis 2+ (out of 4) with relative ease. Nuclei graded 2+ or greater were technically more difficult and conversion to ultrasound phacoemulsification was required in one case. Two posterior capsule ruptures occurred: one during nucleus removal (contact with the tip while aspirating without Aqualase) and one unrelated to Aqualase during aspiration of cortex. Of 25 patients seen on the first postoperative day, 22 had a clear cornea. A total of 96% patients without preoperative comorbidity achieved 6/9 or better postoperatively. One patient had transient postoperative uveitis. CONCLUSIONS: Removal of softer cataracts with Aqualase has the theoretical advantage over phacoemulsification, by carrying less risk to the posterior capsule, since the handpiece has a smooth polymer tip that has no mechanical motion inside the eye. However, the tip should not be considered entirely capsule-friendly, as rupture is possible with the foot-pedal in position two (aspiration only). Although certain adjustments to the technique are required, the method is similar enough to phacoemulsification to ensure a brief learning curve. With increasingly firm cataracts, Aqualase becomes less effective and ultrasound phacoemulsification is still superior for such cases, in our experience.

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.

Cerebral malaria versus bacterial meningitis in children with impaired consciousness.

Cerebral malaria (CM) and acute bacterial meningitis (ABM) are the two common causes of impaired consciousness in children presenting to hospital in sub-Sahara Africa. Since the clinical features of the two diseases may be very similar, treatment is often guided by the initial laboratory findings. However, no detailed studies have examined the extent to which the laboratory findings in these two diseases may overlap. We reviewed data from 555 children with impaired consciousness admitted to Kilifi District Hospital, Kenya. Strictly defined groups were established based on the malaria slide, cerebrospinal fluid (CSF) leucocyte count and the results of blood and CSF culture and CSF bacterial antigen testing. Our data suggests significant overlap in the initial CSF findings between CM and ABM. The absolute minimum proportions of children with impaired consciousness and malaria parasitaemia who also had definite bacterial meningitis were 4% of all children and 14% of children under 1 year of age. The estimated maximum proportion of all children with impaired consciousness and malaria parasitaemia in whom the diagnosis was dual or unclear was at least 13%. The finding of malaria parasites in the blood of an unconscious child in sub-Saharan Africa is not sufficient to establish a diagnosis of cerebral malaria, and acute bacterial meningitis must be actively excluded in all cases.