Royal College Of Ophthalmologists Research Articles

Anticoagulant therapy is not a risk factor for choroidal haemorrhage

Dear Editor, Jin et al. report the experience of the management of delayed supra-choroidal haemorrhage (DSCH) [1]. Table 1 in their paper lays out the risk factors, procedures, and outcomes, but does not mention usage of anticoagulation and antiplatelet aggregation agents. Based on one patient who is stated to have been on Warfarin, they go on to conclude that Warfarin usage is a major risk factor for DSCH, and also recommend cessation of warfarin for 4 days to allow resynthesis of coagulation factors, and cessation of other antiplatelet agents (such as clopidogrel and ticlopidine) for 2 weeks. We think it is important to point out that clear corneal phacoemulsification under topical anaesthesia can be safely done without stopping warfarin or antiplatelet agents [2, 3]. The American Academy of Ophthalmology’s Preferred Practice Pattern on this subject also states that anticoagulation with warfarin does not significantly increase the risk of choroidal haemorrhage [4,] as was also shown by the British National Cataract Dataset report [5]; and the UK Royal College of Ophthalmologists also does not recommend stopping anticoagulation or antiplatelet agents for cataract surgery, as doing so may increase the risk of stroke and death. [6] We would therefore like to emphasise that stopping anticoagulation or antiplatelet agents for routine phacoemulsification is against available evidence and guidelines, and therefore should not be done, although it is sensible to check that the INR is in the desired therapeutic range as set by the treating physician, and the surgery should be done under topical anaesthesia by an ophthalmologist used to doing the operation with this technique; if need be, sub-Tenon anaesthesia may be used.

An evaluation of cataract surgery clinical practice guidelines

PurposeThis study used the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument to evaluate the methodological quality of clinical practice guidelines (CPG) published by the American Academy of...

Nurse-led intravitreal injection clinics: defining the ophthalmic nurse's scope of practice and educational needs

This article critically explores ophthalmic nurses’ scope of practice and educational needs when undertaking the intravitreal injection. This topic has been more widely discussed since The Royal College of Ophthalmologists recommended that injections of anti-vascular endothelial growth factor (anti-VEGF) medicines can be administered by non-medical health professionals ( Kirkby, 2013 ). The increasing pressure on eye departments to deliver intravitreal therapy in a timely manner for thousands of new and existing patients led to the consideration of the development of nurse-led intravitreal injection clinics ( Kirkby, 2013 ). An in-depth critical review of the literature demonstrates excellent outcomes and patient satisfaction from nurse-led treatments. When undertaking this advanced role, it is therefore important that nurses are given the opportunity to adhere to the Nursing and Midwifery Council's code (2008) and the Royal College of Nursing's ophthalmic nurse competencies (2012) to clearly define their scope of practice and educational needs. This article will offer ophthalmic nurses and stakeholders a discussion on the ophthalmic nurse's scope of practice, and how investing in nurse training will result in highly skilled ophthalmic nurses who are equipped to deliver a well-rounded service that results in benefits to patient care and cost-effective service delivery.

St John Eye Hospital, Jerusalem: an optometrist's experience

With the help of the Royal College of Ophthalmologists, in August 2013, Joanna Dilley, a qualified optometrist and a 4th-year medical student at Barts and The London Medical School was lucky enough to have the opportunity to visit the infamous St John Eye Hospital in the unsettled city of Jerusalem, Israel. This hospital is dedicated to providing access to eye care for many, including Palestinians living in the occupied Palestinian territory. In this article, Joanna reviews her experience and provides a snapshot of the day-to-day challenges faced by staff and patients at this inspiring hospital.

Abusive head trauma and the eye in infancy

A child suspected of having an abusive head trauma (AHT) is referred by paediatricians to an ophthalmologist for evaluation. The incidence of abusive head injury in children is highest in infancy and less frequently seen in children over 3 years of age. Retinal haemorrhages (RHs) have a high positive predictive rate for abusive head injury. In the presence of head injury without any plausible medical explanation the description of the retinal findings help in distinguishing between abusive injury and other causes. It is incumbent on the ophthalmologist to be familiar with the clinical presentation, the differential diagnosis, and controversies associated with attributing the presence or absence of retinal findings to abusive head injury in children. The guidance was developed by a guideline working party (GWP) from the Royal College of Ophthalmologists (RCO) and the Royal College of Paediatrics and Child Health (RCPCH). It brings together previous publications of the RCO1, 2, 3 and an update of the literature since these publications. The publication is a summary of the updates of the full version of the document, with its appendices available on the websites of the RCO (www.rcophth.ac.uk) and the RCPCH (www.rcpch.ac.uk).

The UK Sight Loss and Vision Priority Setting Partnership (SLV‐PSP): Vision research questions prioritised by patients and health care professionals

AbstractPurpose The SLV‐PSP process aims to identify research priorities that can be used to inform decisions of funding bodies and enhance the case for additional research funding.Methods People were asked to submit questions about prevention, diagnosis and treatment of sight loss and eye conditions that are most important to them. The survey was available online, by phone, post and alternative formats (Braille and audio). The partner organisations were Fight for Sight, the College of Optometrists, NIHR Biomedical Research Centre for Ophthalmology, The Royal College of Ophthalmologists and Vision 2020. Over 30 charitable and professional organisations promoted the survey.Results 2,200 people responded generating 4,461 questions. 65% of respondents had sight loss or an eye condition. 17% were healthcare professionals (ophthalmologists, optometrists, orthoptists, ophthalmic nurses, opticians, social care/ rehabilitation). The questions were allocated to 12 eye disease categories before subsequent prioritisation of the top 10 at 12 workshops (questions at http://fightforsight.org.uk/sightlosspsp). The categories were ARMD, cataract, corneal and external, glaucoma, inherited retinal, neuro‐ophthalmology, ocular cancer, ocular inflammatory, refractive error and ocular motility and vitreoretinal/ocular trauma.Conclusion Analysis of demographic data for respondents indicates that the sample is generally representative of the UK population. The number and diversity of conditions represented in responses is distributed across the major conditions and fits projected population incidence.

Ophthalmic histopathology samples – are we sending enough?

AbstractPurpose To ascertain the range of histopathological diagnoses made from tissues removed during ophthalmic surgical procedures over two years from one NHS Trust. During this period, joint recommendations were published by the Royal College of Pathologists (RCPath) and the Royal College of Ophthalmologists (RCOphth) in the United Kingdom, regarding the referral of ophthalmic pathology specimens, stating that in order to avoid delayed or missed diagnoses, with certain exceptions, all tissues obtained from ophthalmic surgical procedures should be sent for histopathological examination. This policy was implemented locally from January 2011.Methods This was a retrospective case note review of the ophthalmic histopathology specimens sent between January 2010 and December 2011, at the Mid Essex Hospital Services NHS Trust. Patient demographics and histopathological diagnoses were determined for each.Results Over the two‐year period, 268 specimens were sent for ophthalmic histopathological examination. In 2010, 112 samples were sent, with 18 malignancies detected (16.1%). In 2011, 156 samples were sent, with 30 malignancies identified (19.2%). The most common diagnosis was basal cell carcinoma, comprising 43/48 malignancies (89.6%).Conclusion Since the local implementation of the joint guidelines from the RCPath and RCOphth, there was an increase in the number of ophthalmic histopathology specimens sent within this Trust, with a 3.1% increase in the number of malignancies detected. We believe that this improvement in detection of ocular malignancies justifies the increased burden on the histopathology service from the ophthalmology unit within this Trust.

Refractive outcomes in anterior chamber intraocular lenses

To the Editor,The 2008 United Kingdom Royal College of Oph-thalmologists’ (RCOphth) Cataract Surgery Guide-lines included, for the first time, a biometricbenchmark of achieving a final spherical equivalent(SE) within ±1 dioptre (D) of the target in 85 % ofcases [1]. This was based on a prospective analysis of4,806 eyes with in-the-bag lens implantation, with83.4 and 53.6 % within ±1 and ±0.5 D of predictedSE, respectively [2].We retrospectively applied this benchmark to anauditofrefractiveoutcomesforanteriorchamberlenses(ACIOL). Data were available in 52 eyes implantedwith 122UV lenses (Bausch & Lomb Inc., New York,NY,USA),a polymethylmethacrylate open-loop angle-supported design available in two lengths: 12.5 mm(S122UV) and 13.75 mm (L122UV). The manufac-turer’s A-constant of 115.8 was used in all cases.Subjective refractions were performed in 41 (79 %) of52 eyes, with the remainder by auto-refraction. Finalrefraction following suture removal revealed 71.2 %within ±1Dand40.4%within±0.5 D of target SE.Mean difference between target and achieved SE was0.37 D (range -1.77 to 2.54, SD 0.89); no differenceswere observed between refraction methods (p = 0.31,t test) or the two lens lengths (p = 0.44, t test), norwhether the lens was implanted as a primary orsecondary procedure (p = 0.41, t test). Weak correla-tion between increasing anterior chamber depth andgreater hypermetropic error was demonstrated (Pear-son’s correlation, r = 0.23). Raw data were submittedto the Users Group for Laser Interference Biometry(ULIB) website, providing an optimized A-constant of115.1 for use with the SRK/T formula (http://www.augenklinik.uni-wuerzburg.de/ulib/c1.htm).Comparative published outcomes predominantlyinvolve extracapsular extractions, although none pro-vide SE outcomes in the same RCOphth format:98 % ± 3D[3], 86 % ± 2D[4] and mean SE -0.73[5]. The largest series of 83 ACIOLs between 1991and 2005 (method of surgery not stated), reported amean refractive outcome of -0.8 D ± 1.67 [6].While RCOphth guidelines are not explicitly lim-ited to in-the-bag implantation, with the routine use ofoptical biometry, modern lens calculation formulaeand A-constant optimization there is no reason whyrefractive benchmarks should not be applied toanterior chamber implantation. While the inherentlimitations of this small retrospective audit areacknowledged, our data suggest that refractive out-comes with ACIOLs can be judged by the samebiometric standards.

SAT0453 Have We Got the Eyes Right? An Audit of Referral Patterns to Opthalmology in JIA

BackgroundUveitis is a complication of Juvenile Idiopathic Arthitis (JIA) and can lead to chronic visual impairment. Each type of JIA has a different prevalence. Oligoarticular onset JIA has a high...

Interventions for improving adherence to ocular hypotensive therapy

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.

The Ophthalmology Specialty Group and the National Institute for Health Research: the first 6 years

The Ophthalmology Specialty Group and the National Institute for Health Research: the first 6 years

Out of hours ophthalmic surgery: a UK national survey

There have been significant changes in the management of out of hours services in ophthalmology recently. The European Working Time Directive (EWTD) and economic measures have anecdotally reduced the availability of staff and facilities outside normal working hours, and there have been various responses to the provision of emergency surgical care. There are disparate attitudes to the optimum management of the emergency surgical case. We sought to establish a nationwide picture of the management of out of hours surgery. A questionnaire was distributed to every consultant ophthalmologist working in the NHS and registered with the Royal College of Ophthalmologists (n=947). Information was requested regarding departmental and personal policies, local facilities, and personal beliefs regarding emergency surgery. A total of 440 (46.5%) questionnaires were returned from 155 units; 18.7% of the units had no out of hours services or no operating facilities. Sixty-three percent of units reported a local policy regarding a time after which patients should not be taken to theatre. For 57%, this time began between 2100 hours and midnight. The most common reasons for not operating after a certain time were 'belief that delay does not significantly affect the outcome' (41.6%), 'delayed access to theatre due to competition with other surgical specialities' (40%), and 'no specialist ophthalmic-theatre nursing input' (32.7%). We report the first nationwide study on out of hours ophthalmological surgical working practices. This demonstrates variation in work patterns. It is significant to patients and ophthalmologists that there should be units in United Kingdom without full local facilities and staff.

The Royal College of Ophthalmologists' clinical guidelines for diabetic retinopathy: a summary.

The Royal College of Ophthalmologists’ clinical guidelines for diabetic retinopathy: a summary

Comparison of optometrist glaucoma referrals against published guidelines

To examine if community optometrists follow published guidelines for referral of patients with suspect glaucoma to the hospital eye service. A retrospective audit of new optometrist-initiated referrals to the Glaucoma Service at Moorfields Eye Hospital, London was performed. Clinical data from referral letters recorded included evidence of intraocular pressure (IOP) measurement and tonometer used. Referral letter information was compared to 2009 guidelines published jointly by the College of Optometrists and Royal College of Ophthalmologists on referring glaucoma suspect patients. A total of 289 new patients were seen in the Glaucoma Service over a 6week period from 4th January 2011; a 100% hospital record retrieval rate was obtained. Of these, 114 (39%) were optometrists initiated referrals. Optometrist letters were available for 105 patients. IOP measurements were recorded in 102 (97%); most practitioners used non-contact tonometry (NCT; n=69; 68%). Practitioners recorded <4NCT readings per eye (4 readings: n=3, 4%; 3 readings: n=42, 61%; 2 readings: n=6, 9%; 1 reading: n=18, 26%). Seventy-seven patients (73%) reported with raised IOP as the main referral reason; of these, 33 (43%) were referred with raised IOP in isolation. NCT was the instrument used in the majority of these raised IOP cases (n=56; 73%). In cases where raised IOP in isolation was the referral reason, 24 (73%) were recorded using NCT; 10 (30%) provided repeat IOP measurement data in the letter. One hundred and two (97%) referred patients attended the hospital appointment. Thirty (29%) were deemed not to have glaucoma, with the remainder diagnosed with ocular hypertension (n=25; 25%), glaucoma suspect/glaucoma (n=35, 34%) or narrow angles requiring intervention (n=12, 12%). Thirty of the 33 patients referred with raised IOP in isolation attended their hospital visit. Ten (33%) of these patients were subsequently discharged. Six (20%) patients had IOP within normal limits when measured with applanation tonometry; all of these patients were kept within the service. Community optometrists using NCT for measurement should be reminded of the guidelines on number of readings to take and also the value of repeating NCT measures when appropriate. This may help to increase the accuracy of glaucoma suspect referrals to hospital eye service.

Cannula detachment during cataract surgery: results of a survey

ObjectiveTo ascertain whether cannula displacement during cataract surgery with the use of the Luer lock is a common and recognized complication. MethodsA questionnaire was sent to attending physicians on the Royal College of Ophthalmologists U.K. register inquiring about episodes of cannula displacement and complications. ResultsDespite the use of Luer locks, 60 cases of cannula detachment were reported; 196 respondents experienced this complication, and the most common cause of cannula detachment was stromal hydration (50%). Hydrodissection and viscoelastic were experienced by 18% and 17%, respectively. No severe damage resulted in most cases (76 cases), but some serious complications were reported: retinal damage (9%) and vitreous loss (17%). ConclusionsWe recommend that surgeons test the union carefully themselves and then test the system by squirting outside the eye. Additionally, we recommend that a new cannula be used for each stage of the procedure. The viscoelastic cannula, in particular, should not be used for any other purpose.

Local anaesthesia for ophthalmic surgery—new guidelines from the Royal College of Anaesthetists and the Royal College of Ophthalmologists

Local anaesthesia for ophthalmic surgery—new guidelines from the Royal College of Anaesthetists and the Royal College of Ophthalmologists

Survey of perioperative prostaglandin analogue administration during cataract surgery in Greece

Fifteen years after the introduction of the first prostaglandin analogue eye drop (PAE) as a topical intraocular pressure-lowering medication, the literature regarding PAE perioperative use in cataract surgery and potential harmful effects for the patient remains controversial. Anecdotal reports as well as case series have associated its preoperative or continued postoperative use with the occurrence of cystoid macular oedema (CMO) [1–3], while other authors only report this as a rare phenomenon and the causative relationship is debated [4, 5]. Neither the recently updated Royal College of Ophthalmologists ‘Cataract Surgery Guidelines’ (September 2010) nor the latest printing of the American Academy of Ophthalmology Preferred Practice Pattern ‘Cataract in the Adult Eye’ in 2006 provide any guidance with regards to perioperatively withholding PAE or not. We aimed to assess the current preferences of Greek surgeons on this matter and discuss their approach. A random sample of 100 members of the Greek Society of Cataract and Refractive Surgeons was selected using a computerised random number generator and were then contacted by telephone. The questions asked were: (i) Do you stop PAE when you undertake cataract surgery, and if yes, (ii) routinely or under what circumstances, and (iii) how long for before and after the operation. Responses were recorded anonymously and analysed by a blinded evaluator. Eighty-two of the 100 surgeons who were telephoned confirmed being active cataract surgeons and agreed to answer the questionnaire. Sixty-five (65/82; 80 %) replied that they discontinue PAE perioperatively, of whom fifty-three (53/82; 65 %) do so routinely. One-third of all responders (27/82; 33 %) discontinue PAE for a month postoperatively, while 15 % (12/82) do so for a variable time depending on perioperative complications or the individual circumstances of the case. Twenty-eight percent (23/82) additionally discontinue PAE treatment preoperatively from 1 to 30 days (Fig. 1). A mean complication rate of 1.5 % for clinically detectable CMO following cataract extraction with intraocular lens implantation has been reported [6] and, to date, it has not been investigated if this rate increases when using perioperative PAE. CMO has been causally associated with topical PAE treatment in different circumstances: phakic, aphakic and pseudophakic eyes [2], or with intact or ruptured posterior capsule [1–3]; hence the aetiopathogenic mechanism is hypothesised but not yet fully elucidated. It appears that some eyes present an increased susceptibility to develop CMO, possibly associated with pre-existing abnormalities of the blood–retinal barrier [1, 2]. A. Mataftsi (&) K. T. Tsaousis I. T. Tsinopoulos S. A. Dimitrakos II Department of Ophthalmology, General Hospital of ‘‘Papageorgiou’’, Aristotle University of Thessaloniki, Periferiaki Odos Thessalonikis, N. Efkarpia, 56403 Thessaloniki, Greece e-mail: mataftsi@doctors.org.uk

Consent for cataract surgery training: a national trainers’ survey

To evaluate current trainers' attitudes and practices for informing patients about the trainee participation in cataract surgery within the United Kingdom. An anonymous online survey was distributed to current cataract surgery trainers via all Royal College of Ophthalmologists' tutors within the United Kingdom. Trainers were asked specific questions about their current consent practice regarding trainee participation in the cataract surgery. Questions also targeted experiences of patient complaints about training. One hundred and twenty-three trainers completed the survey. Ninety-three percent (n=114) of responders were consultants and 7% (n=8) were non-consultant career-grade doctors or other grades. A total of 34% (n=42) of responders stated that consent was usually taken by themselves or the trainee assigned to the list, whereas 26% (n=32) always took consent themselves. Sixty percent of responders (n=74) stated that consent is taken on the day of surgery; 59% (n=73) indicated consent is taken where listing takes place. Thirty-three percent (n=41) of trainers indicated that they had experienced patient dissatisfaction or complaints. Surgical complications, length of surgery, and discussions during surgery were the leading causes of complaints. Thirty-nine percent (n=48) would operate themselves if patients requested no trainee participation. There is a wide variety in the current practice of disclosure and level of information given regarding trainee participation in surgery. This will influence patients' expectations, experiences, and satisfaction.

Distribution of glial fibrillary acidic protein accumulation after retinal tack insertion for intraocular fixation of epiretinal implants

surface of the globe. This dissection was similarly continued until past the level of the fornices. The fatty tissue and Tenon’s capsule behind the conjunctiva were then divided until the anterior and posterior planes met, as demonstrated in Fig. 1I. It was found that it was easier to perform this dissection from the anterior plane using scissors to cut down onto the globe, taking care to do so beyond the fornices, so as not to breach the conjunctiva. This was completed circumferentially allowing the conjunctiva to be excised as a whole specimen. Eye sockets were reconstructed using cotton wool and plastic eye shields that hold the eyelids in a closed position in accordance with the guidance standards of the Royal College of Ophthalmologists (2008) with good aesthetic results. Using this technique, whole conjunctival tissue was successfully obtained from 16 human cadaveric donors (32 eyes). Conjunctival tissue was subsequently wax embedded, sectioned and examined histologically confirming the presence of tarsal to limbal conjunctiva (Fig. 1J). Conjunctival epithelial cells were also harvested using trypsin disaggregation and co-cultured on an inactivated J23T3 mouse fibroblast feeder layer. Cultured cells were fixed in methanol and immunofluorescently stained for the conjunctival marker cytokeratin 19 (R. M. K. Stewart unpublished data). We have developed a technique to retrieve whole human cadaveric conjunctiva. This will further enable future ex vivo and in vitro analyses of the whole human conjunctiva, which require a continuum of conjunctival tissue. This is of particular benefit to studies assessing the distribution and characterization of conjunctival stem cells to aid propagation and transplantation; similarly for inflammatory cells and vasculature to improve knowledge of ocular surface immunity and potential for therapeutic agents.

Retinal imaging interpretation course

The retinal imaging interpretation course is ideal for all junior trainees in ophthalmology, including foundation doctors, who are preparing for examinations for fellowship of the Royal College of Ophthalmologists (FRCOphth) and those interested in learning about current trends in ophthalmic diagnostic imaging. During foundation year 2. I have a very keen interest in ophthalmology, and while I was preparing for the FRCOphth part 1 exam I believed that this course would help me to build on my basic knowledge of imaging techniques of the retina. The course aimed to cover the basic concepts of the main imaging techniques and gave the opportunity to test my knowledge with cases and quizzes, which was exactly what I wanted. I had heard that the course …