Consultant Ophthalmologist Research Articles

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Correspondence: Dr. Manoj V. Parulekar, M.S., F.R.C.S., Consultant Ophthalmologist, Birmingham Children’s Hospital, Steelhouse La., Birmingham B4 6NH, U.K. ([email protected]) The author declares no financial or conflict of interest.

Development and Validation of a Standardized Tool for Reporting Retinal Findings in Abusive Head Trauma

To develop and validate a robust standardized reporting tool for describing retinal findings in children examined for suspected abusive head trauma. A prospective interobserver and intraobserver agreement study. An evidence-based assessment pro forma was developed, recording hemorrhages (location, layer, severity) and additional features. Eight consultant pediatric ophthalmologists and 7 ophthalmology residents assessed a series of 105 high-quality RetCam images of 21 eyes from abusive head trauma cases with varying degrees of retinal hemorrhage and associated findings. The pediatric ophthalmologists performed a repeat assessment of the randomized images. The images were observed simultaneously with standardized display settings. Interobserver and intraobserver agreement was assessed using free-marginal multirater kappa, intraclass correlation coefficients, and concordance coefficients. Almost-perfect interobserver agreement was observed for residents and pediatric ophthalmologists recording the presence and number of fundus hemorrhages (intraclass correlation coefficients 0.91 and 0.87, respectively) and the location of hemorrhages (concordance coefficients 0.86 and 0.85, respectively). Substantial agreement was observed by both groups regarding size of hemorrhage (concordance coefficients 0.73 and 0.76), moderate agreement for hemorrhage morphology (concordance coefficients 0.53 and 0.52), and other findings (concordance coefficients 0.48 and 0.59). Intraobserver agreement for pediatric ophthalmologists varied by question, ranging from substantial to perfect for the presence, number, location, size, and morphology of fundus hemorrhage. We have developed and validated a standardized clinical reporting tool for ophthalmic findings in suspected abusive head trauma, which has excellent interobserver and intraobserver agreement among consultant specialists and residents. We suggest that its use will improve standardized clinical reporting of such cases.

Agreement between specially trained and accredited optometrists and glaucoma specialist consultant ophthalmologists in their management of glaucoma patients.

Optometrists are becoming increasingly involved in the co-management of glaucoma patients as the burden on the Hospital Eye Service continues to escalate. The aim of this study was to assess the agreement between specially trained optometrists and glaucoma-specialist consultant ophthalmologists in their management of glaucoma patients. Four optometrists examined 23-25 patients each and the clinical findings, up to the point of dilation, were documented in the hospital records. The optometrist, and one of two consultant ophthalmologists, then independently examined and documented the optic-disc appearance before recording their decisions regarding the stability and management of the patient on a specially designed proforma. Percentage agreement was calculated together with kappa or weighted kappa statistics, where appropriate. Agreement between consultants and optometrists in evaluating glaucoma stability was 68.5% (kappa (κ)=0.42-0.50) for visual fields, 64.5% (weighted κ=0.17-0.31) for optic discs, and 84.5% (weighted κ=0.55-0.60) for intraocular pressures. Agreement regarding medical management was 96.5% (κ=0.73-0.81) and for other glaucoma management decisions, including timing of follow-up, referral to a consultant ophthalmologist, and discharge, was 72% (weighted κ=0.65). This agreement increased to 90% following a retrospective independent then consensus review between the two consultants and when qualified agreements were included. Of the 47 glaucoma and non-glaucoma queries generated during the study, 42 resulted in a change of management. Confirming the ability of optometrists to make appropriate decisions regarding the stability and management of glaucoma patients is essential if their involvement is to continue to develop to meet the demand of an aging population.

Practice Preferences for Glaucoma Drainage Device Implantation and Cyclodestruction in Australia and New Zealand

To evaluate the practice patterns in the use of glaucoma drainage devices (GDD) and cyclodestruction among consultant ophthalmologists in Australia and New Zealand. A 22-part questionnaire regarding GDD implantation and cyclodestruction practices was sent to all ophthalmologists registered with the Royal Australian and New Zealand College of Ophthalmologists in 2008 by post or e-mail. Sixty-six percent of 872 questionnaires were returned, of these, 14% were from glaucoma subspecialists. Ten percent of all respondents performed GDD implantations. Molteno drains were the most popular device (69%). The most commonly recognized indications for GDD implantation were a history of 2 failed trabeculectomies (85%), neovascular glaucoma (71%), iridocorneal endothelial syndrome (55%), and uveitic glaucoma (52%). Only a minority of surgeons used intraoperative mitomycin C (38%) or 5-fluorouracil (26%) when implanting GDD. Cyclodestruction had been performed by 20% of all respondents. External diode cyclophotocoagulation was the most preferred treatment mode (73%). Sixty-seven percent treated 180 degrees of the ciliary body during initial treatment. Fifty-five percent treated only the earlier untreated area during retreatment. Only 11% of surgeons who performed cyclodestruction agreed that the indications for cyclodestruction are expanding. A wide range of practice patterns for GDD implantation and cyclodestruction exist among Australian and New Zealand ophthalmologists. This likely reflects a paucity of good evidence to guide practice. The Australasian indications for GDD implantation were moderately different from the reported practice in America. Well-designed clinical trials are needed to better define the indications and best practice for these 2 important glaucoma treatment modalities.

United Kingdom national cataract training survey

A nationwide postal survey of all consultant ophthalmologists in the United Kingdom was conducted to determine attitudes and techniques of cataract surgery trainers, identify trainer-related factors that determine surgical opportunity, and ascertain whether trainers had received adequate training in how to teach surgery. The response rate was 43% (410/950). Seventy-nine percent of respondents were men; 46% worked in a university teaching hospital (UTH). University teaching hospital consultants provided more surgical opportunities to their trainees (P<.001). Surgical opportunity was directly correlated with number of vitreoretinal surgeons in the department independent of UTH status (P<.001). Eighty-three percent of trainers had received no formal training in how to teach surgery; only 12% of these expressed a desire to undertake such training. Further research is required to determine optimal methods for delivery of ophthalmic surgical training. No author has a financial or proprietary interest in any material or method mentioned.

Does optometrists’ self‐reported practice in glaucoma detection predict actual practice as determined by standardised patients?

Questionnaires are commonly used as a proxy measure of clinical practice; however their application in a variety of healthcare settings has found significant self-reporting bias. The aim of this study is to estimate the validity of self-reporting as a measure of optometrist case-finding practice for glaucoma and the appropriate referral of suspects. Two complementary approaches were used: (1) a sample of optometrists (N=34) on an ophthalmic list in West London were visited incognito by Standardised Patient (SP) volunteers aged over 54 who were trained to identify the components of a standard Sight Test. Optometrists from the same list were then invited to participate in a structured face-to-face interview regarding their case finding practice for glaucoma. The findings from the two sources were compared. (2) as part of a national glaucoma survey of optometrists, respondents (N=1264) were asked in a free text question for the information that they would include in a referral letter for suspect glaucoma. The responses were compared to the content of a sample of glaucoma referral letters (N=571) obtained from consultant ophthalmologists across the UK. In each case, the degree of correspondence ('match') between reported practice and actual practice was assessed by chi-square analysis. For the SP study there was incomplete correspondence between the questionnaire and SP reports in several areas e.g. questions relating to a complete history and symptoms, measurement of intra-ocular pressure and visual fields. Complete correspondence was found for questions asking about the routine assessment of ocular health and refraction. For the referral study, correspondence between survey findings and referral letters was obtained for IOP only. No correspondence was found for disc assessment, visual fields or family history of glaucoma. The overall findings from both studies indicate that self-reported clinical practice questionnaires overestimate routine tests undertaken by optometrists in practice. Although there was a good correspondence for mandatory tests, correspondence was poor for discretionary tests. These findings should be borne in mind in all questionnaire studies that report current practice in glaucoma case-finding.

Light and portable novel device for diabetic retinopathy screening

To validate the use of an economical portable multipurpose ophthalmic imaging device, EyeScan (Ophthalmic Imaging System, Sacramento, CA, USA), for diabetic retinopathy screening. Evaluation of a diagnostic device. One hundred thirty-six (272 eyes) were recruited from diabetic retinopathy screening clinic of Royal Perth Hospital, Western Australia, Australia. All patients underwent three-field (optic disc, macular and temporal view) mydriatic retinal digital still photography captured by EyeScan and FF450 plus (Carl Zeiss Meditec, North America) and were subsequently examined by a senior consultant ophthalmologist using the slit-lamp biomicroscopy (reference standard). All retinal images were interpreted by a consultant ophthalmologist and a medical officer. The sensitivity, specificity and kappa statistics of EyeScan and FF450 plus with reference to the slit-lamp examination findings by a senior consultant ophthalmologist. For detection of any grade of diabetic retinopathy, EyeScan had a sensitivity and specificity of 93 and 98%, respectively (ophthalmologist), and 92 and 95%, respectively (medical officer). In contrast, FF450 plus images had a sensitivity and specificity of 95 and 99%, respectively (ophthalmologist), and 92 and 96%, respectively (medical officer). The overall kappa statistics for diabetic retinopathy grading for EyeScan and FF450 plus were 0.93 and 0.95 for ophthalmologist and 0.88 and 0.90 for medical officer, respectively. Given that the EyeScan requires minimal training to use and has excellent diagnostic accuracy in screening for diabetic retinopathy, it could be potentially utilized by the primary eye care providers to widely screen for diabetic retinopathy in the community.

Peer Review Group for therapeutics prescribers

This day will be dedicated to teaching and promoting the latest developments in medical contact lens practice.We shall start with Dr Sarah Janikoun and a “Mini guide to contact lenses”, which takes a look at medical contact lens treatments. She will then discuss: “Is the problem the solution?” Dr Ursula Vogt will then examine the challenge of “Fitting irregular corneas” with contact lenses. During the workshop you will have the opportunity to handle lenses, and learn which lenses to use, when and for whom. Consultant ophthalmologist Andrena McElvanney will talk you through the very important subject of “Therapeutic contact lenses”. The morning session will conclude with an examination of “Coloured contact lenses”. This course gives you the opportunity to exchange views and engage in discussion in a friendly atmosphere with other ophthalmologists.

Sheila Maclean Ross

Sheila Maclean Ross was the daughter of Dr James Ross, consultant ophthalmologist at Carlisle. The day after she was born, her father wrote (to her older brother): “Her name is...

Initial experience of a nationwide ruthenium‐106 and iodine‐125 ocular brachytherapy service in Ireland

AbstractPurpose St. Lukes Hospital, Rathgar, Dublin 6, Ireland has recently implemented an Ocular Brachytherapy Service using both Ruthenium‐106 and Iodine‐125 plaques. This work will summarize the initial experience of the hospital in these treatment modalities and provide information on some of the challenges experienced by a new centre performing this technique. Outline plans for the future of the service will also be presented.Methods Between September 2010 and June 2011, twenty six patients received a plaque treatment at St. Lukes Hospital. Six of these were Iodine‐125 cases, while twenty used Ruthenium‐106. A multi‐disciplinary pre‐planning procedure using BEBIGs "Plaque Simulator" software identifies treatment durations. This group consists of a Physicist, Consultant Ophthalmologist and a Consultant Radiation Oncologist with the goal of fitting both plaque insertions &amp; removals into designated weekly theatre slots. Following this, a comprehensive plancheck analysis is performed. Post‐treatment, a delivered plan is generated by a Physicist and signed by the clinical team. A yearly delivery of Ruthenium plaques is scheduled; information is given on plaque types, number of uses and plans for Year Two. NPL calibrations were used as a second‐check in Year One with an in‐house method involving a stereotactic diode proposed for Year Two.Results Nine months into the program, tumour regression in the initial patients is already being observed. Procedures have been streamlined to satisfy designated theatre slots where possible and to maximise throughput of patients. A second‐check calculation procedure for Ruthenium plaques has been devised; however the long‐term plan proposes a greater proportion of Iodine treatments due to the timing flexibility this provides. The in‐house method of calibration shows promise, however further investigations are required before it is suitable for clinical use. This work is ongoing.Conclusion An Ocular Brachytherapy service has been successfully implemented in St Lukes Hospital that is providing both Ruthenium‐106 and Iodine‐125 treatments to patients across the Republic of Ireland. As the service matures and further intra‐departmental training takes place, the facility will be well prepared to handle both an increase in capacity and complexity while performing treatments to a high standard.

Endothelial Cell Survival and Graft Profile Analysis in Descemet Stripping Endothelial Keratoplasty

To report the results of descemet stripping endothelial keratoplasty (DSEK) for a single-surgeon, consecutive case series. All patients undergoing DSEK at our institution from 2006 to 2007 under the care of a single consultant ophthalmologist were enrolled. This was a nonrandomized, retrospective case series. Grafts were dissected manually using an artificial anterior chamber and a Morlet lamellar dissector. Data were collected for refractive error, visual acuity, endothelial cell density, graft thickness, and graft profile. Twenty-one eyes of 20 patients were included. The average age at surgery was 69 ± 11 years (range, 37-88 years). The main indication for DSEK was Fuchs endothelial dystrophy. The mean preoperative best spectacle-corrected visual acuity was 1.2 logarithm of the minimum angle of resolution, improving to 0.48 logarithm of the minimum angle of resolution postoperatively (P = 0.001). Endothelial cell density decreased postoperatively compared with preoperatively, but the rate of cell loss decreased over time. No significant correlation was observed between mean graft thickness and final visual acuity or between graft profile and refractive shift. DSEK is a positive alternative to PK in the treatment of endothelial dysfunction. Visual function improves and the associated refractive change is negligible. Complication rates are low, and graft survival over 2 years is high. Manual preparation of tissue provides grafts of suitable thickness and profile, and endothelial cell density decline is comparable with that of donor's tissue cut via microkeratome or after PK.

Retinal Video Recording: A New Way to Image and Diagnose Diabetic Retinopathy

To validate the use of retinal video recording for diabetic retinopathy screening by comparing with standard retinal photography and slit-lamp examination. Evaluation of a new diagnostic technique. One hundred patients. All fundus images were captured using standard retinal still photography (FF 450 plus; Carl Zeiss) and retinal video (EyeScan; Ophthalmic Imaging System, Sacramento, CA), followed by a gold standard slit-lamp biomicroscopy examination. All videos and still images were de-identified, randomized, and interpreted by 2 senior consultant ophthalmologists (M.L.T-K. and L.L.). Kappa statistics, sensitivity, and specificity for all the diabetic retinopathy signs and grades were calculated with reference to slit-lamp examination results as the gold standard. Sensitivity and specificity of video recording for detecting diabetic retinopathy signs and grades. The mean age (± standard deviation [SD]) of participants was 52.8 ± 15.1 years, mean duration of diabetes (± SD) was 13.7 ± 9.7 years, and the mean glycosylated hemoglobin level was 8.0 ± 1.7%. Compared with the gold standard slit-lamp examination results, the sensitivity and specificity of video recording for detecting the presence of any diabetic retinopathy was 93.8% and 99.2%, respectively (ophthalmologist 1), and 93.3% and 95.2%, respectively (ophthalmologist 2). In contrast, the sensitivity and specificity of retinal photography was 91.8% and 98.4%, respectively (ophthalmologist 1), and 92.1% and 96.8%, respectively (ophthalmologist 2), for detection of any diabetic retinopathy. Both imaging methods had 100% sensitivity and specificity in detecting sight-threatening diabetic retinopathy. For overall diabetic retinopathy grading by both ophthalmologists, the measurements of agreement (Cohen's κ coefficient) between the overall grading obtained from the retinal video versus slit-lamp examination and retinal photography versus slit-lamp examination were more than 0.90. Technical failure rate for retinal video recording and retinal photography were 7.0% and 5.5%, respectively. This study demonstrated that retinal video recording was equally as effective as retinal photography in the subjects evaluated in this study. It is a novel alternative diabetic retinopathy screening technique that not only offers primary eye care providers the opportunity to view numerous retinal fields within a short period but also is easy to learn by nonexperienced personnel with minimal training. Proprietary or commercial disclosure may be found after the references.

Attitudes of consultant ophthalmologists in the UK to initial management of glaucoma patients presenting with severe visual field loss: a national survey

Recent National Institute of Clinical Excellence guidance suggests primary surgery should be offered to patients presenting with glaucoma with severe visual field loss. We undertook a survey of UK consultant ophthalmologists to determine if this represents current practice and explore attitudes towards managing patients with advanced glaucoma at presentation. Questionnaire evaluation study. All consultant ophthalmologists currently practicing in the UK. A single-page questionnaire was posted to all consultants (n = 910) currently practicing in the UK along with a pre-paid return envelope. A second questionnaire was sent to non-responders (n = 459). Questionnaire responses. 626 responses were received representing 68.8% of the population surveyed. 152 (24%) volunteered a specialist interest in glaucoma. Consensus opinion for both glaucoma specialists (64.9%) and non-glaucoma specialists (62.4%) was to start with primary medical therapy, most commonly citing surgical risk as the primary reason (23% and 22%, respectively) for this approach. Most felt the highest intraocular pressure measurement during follow up (measured in clinic) was the most important variable for prevention of further visual loss (60% of glaucoma specialists and 55% of non-glaucoma specialists). Eighty-three per cent of all responders suggested they would change their practice if evidence supporting primary surgery as a safe and more effective approach existed. Recent National Institute of Clinical Excellence guidance does not reflect the current management approach of UK ophthalmologists. The primary concern was related to potential complications of surgery although most practitioners would be willing to change their practice if evidence existed supporting primary surgery in patients presenting with advanced glaucoma.

A Survey of the Management of Globe Perforation During Strabismus Surgery in the United Kingdom

Introduction: Globe perforation is a potentially devastating complication of strabismus surgery. The purpose of this study is to investigate the management of suspected globe perforation encountered during strabismus surgery in the United Kingdom.Methods: A postal survey of all consultant ophthalmologists in the United Kingdom was undertaken. The questionnaire solicited data on the management and outcomes of globe perforation encountered during strabismus surgery.Results: Five hundred and seventeen of 850 (60.8%) surgeons responded to the survey. Of these, 240 (46.4%) performed strabismus surgery, of whom 58.8% performed fewer than 50, 32.1% performed 50 to 100, and 8.3% performed more than 100 surgical procedures annually. Ninety-eight (40.8%) had suspected globe perforation during strabismus surgery, of whom 86 subsequently carried out dilated fundoscopy. There were 74 reported globe perforations. Fifty-four detailed treatment with cryopexy (50%), retinal laser (31.5%), both (9.3%), cautery (1.9%), and not reported (7.4%). In 27% of cases surgeons chose not to treat the perforation observed postoperatively. Thirty-five respondents prescribed additional antibiotics. Visual loss occurred in 6 cases, with 2 cases of endophthalmitis, 2 retinal detachments, 1 suprachoroidal hemorrhage, and 1 from a chorioretinal scar.Discussion: Complications leading to visual loss were infrequent. Of the surgeons reporting globe perforations, approximately three quarters chose to treat the injury and one quarter chose to observe without treatment. Cryotherapy was the most popular intervention. Further prospective study is required to elucidate optimal management strategies.

NICE – impact on glaucoma case detection

To investigate the impact of publication of the National Institute of Clinical Excellence (NICE) guidelines ('Glaucoma: diagnosis and management of chronic open angle glaucoma and ocular hypertension') in April 2009, on the referrals for suspect glaucoma to Moorfields Community Eye Clinic (MCEC) at Ealing Hospital. The clinical data from all optometrist initiated referrals for suspect glaucoma and ocular hypertension were scrutinised by a Consultant Ophthalmologist for a 2 month period, 6 months after the publication of the NICE guidance. Each was then categorised into the following groups: glaucoma positive; glaucoma suspect; glaucoma negative; ocular hypertension (OHT) requiring further follow up in clinic; ocular hypertension to be followed up by community optometrist; other. The positive predictive value (PPV) was then calculated and a historical comparison made with previous studies. A total of 110 new referrals were assessed during the collection period, which reflects a marked increase in numbers attending. However, there was no increase in absolute numbers of glaucoma and glaucoma suspects identified. The absolute numbers of ocular hypertensive patients rose. The PPV fell to 0.25, which is lower than found in previous studies. The rising number of new referrals and the unchanged absolute numbers of glaucoma and glaucoma suspects identified following publication of the NICE guidance, in addition to a lower PPV, makes us question what advantage in improved case detection this represents. Furthermore, is this a cost effective strategy? We believe the next step is to introduce a repeat review, with carefully considered clinical governance of any new scheme.

A consultant ophthalmologist

Anurag Garg speaks to Nigel Davies, who aims to reduce the number of people in the community struggling with their vision

Making sense of strabismus

Making Sense of Strabismus is a three day course run by eyelearn. Most of the tutors are staff from Alder Hey Children’s Hospital, and the course itself is based in Liverpool. I attended the inaugural Making Sense of Strabismus course, which is now held monthly. The literature states that the course is primarily aimed at ophthalmology trainees and optometrists, although there were one or two consultant ophthalmologists attending as well. It is most suited to specialty registrars at specialty training year 3-7 level. I did the course during the second year of specialty training, while I was working in paediatric …

Through a glass clearly: Nigel Davies

Nigel Davies is a consultant ophthalmologist Biography—Nigel Davies has an undergraduate physics degree from Oxford University and studied medicine at the Royal London Medical School. He undertook ophthalmic training in the North Thames region including Moorfields Eye Hospital and completed a PhD at Imperial College investigating visual dysfunction in diabetic eye disease. He is a consultant ophthalmologist and lead clinician at the Chelsea & Westminster Hospital Eye Unit. His areas of interest include problems with the retina caused by diabetes and other vascular diseases. Ophthalmology is a fantastic specialty, principally because it involves a bit of medicine and a bit of surgery. You spend half your time in theatre and the other half in clinic. You see everybody from premature babies to people who are over 100. On the whole, you can also do a lot to help people out—vision is our primary sense. It is also an interesting specialty . . . the visual system is a …

Quality of life of the most severely vision‐impaired

To explore the interaction between vision impairment, perceived quality of life loss and willingness to trade remaining life for vision gain. Community-based cross-sectional study. Legally blind or severely vision-impaired people selected randomly from the Association for the Blind of Western Australia register. Individuals were examined by consultant ophthalmologists and completed the Impact of Vision Impairment profile quality of life assessment and a Time Trade-Off evaluation. Vision-related utility values were calculated. The results were analysed using univariate and multivariate regression methods. IVI Rasch Logits and TTO utility values (TTO UV). 156 people volunteered to contribute to the study. The median age was 80 (19-97) years, and 56% were female. Being legally blind (logMAR > 1) (95% CI 1.1 to 5.2, P = 0.003), clinically depressed (95% CI -11.2 to -1.8, P = 0.007) or more than 40 years of age (95% CI 0.9 to 8.1, P = 0.015) significantly lowered overall impact of vision impairment scores. The emotional domain of impact of vision impairment was associated with willingness to trade part of remaining life. A 5-Logit increase in impact of vision impairment emotional score resulted in a 21% (95% CI 10 to 31) decrease in the odds of being likely to trade life for sight. The Australian definition of blindness compared with World Health Organisation or USA best separates those with perceived loss and appears useful in identifying vision loss-related morbidity. These results suggest that emotional health and lack of depression are important determinants for quality and value of life.

The UK National Cyclodiode Laser Survey

To evaluate current practice of transscleral diode laser cyclophotocoagulation (cyclodiode) laser treatment among consultant ophthalmologists in the United Kingdom. A 31-question survey was emailed to all practising consultant ophthalmologists who were members of the Royal College of Ophthalmologists. All non-responders were sent a postal version of the questionnaire. This paper looked at cyclodiode practice patterns and consisted of questions on demographic data, transillumination, and power settings, factors influencing practice, post-operative care, and repeat treatment. A total of 510 participants (53.6%) responded. A total of 180 (35.3%) responders reported performing cyclodiode laser treatment, of which 84 (46.7%) were glaucoma subspecialists (GSS). Initial median power settings used were 1500 mW and 2000 ms. The average number of applications delivered per sitting was 25.5 ± 1.2 applications for GSS vs 20.6 ± 2.0 for non-GSS in a seeing eye (P = 0.0013). In all, 65% routinely transilluminated the globe of which 78% were GSS and 52.3% were non-GSS (P = 0.0009). In all, 43% of the GSS vs 17% of the non-GSS lowered power settings in uveitic glaucoma (P = 0.013). In blind eyes, 30% of the GSS vs 12% of the non-GSS increased energy levels (P = 0.0014). In all, 60% of the responders performed cyclodiode at any visual acuity, whereas 22% performed combined cyclodiode and cataract surgery. This survey highlights a wide variation in the use of cyclodiode laser treatment amongst GSS and non-GSS. However, the most frequently used practice may not be the optimal practice. A more individualised parameter according to the condition of the eyes may optimise the outcome.