A multi-centre, prospective epidemiological surveillance study considering ophthalmic complications of functional endoscopic sinus surgery.

OBJECTIVES: This prospective, epidemiological British Ophthalmological Surveillance Unit study into ophthalmic complications of functional endoscopic sinus surgery aimed to determine the minimum incidence, presenting features and management throughout the UK. METHODS: Cases of ophthalmic complications of functional endoscopic sinus surgery, between February 2016 and February 2018, were identified through the British Ophthalmological Surveillance Unit reporting card system. Reporting ophthalmic consultants were sent an initial questionnaire, followed by a second questionnaire at six months. RESULTS: Twenty-six cases of ophthalmic complications of functional endoscopic sinus surgery were reported. The majority (16 cases (62 per cent)) had limitations of ocular motility at presentation. The most common final diagnosis was rectus muscle (33 per cent) and nasolacrimal duct trauma (27 per cent). Using national data, this study reports a minimum incidence of ophthalmic complications of functional endoscopic sinus surgery in the UK of 0.2 per cent over two years. CONCLUSION: In terms of ophthalmic complications, functional endoscopic sinus surgery is shown to be safe. Ophthalmic complications are rare, but when they do occur, they commonly result in rectus muscle trauma, often requiring surgical intervention.

Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome.

PurposeTo determine the frequency of patients suffering harm due to delay in ophthalmic care in the UK over a 12-month period.MethodsPatients with deterioration in vision in at least one eye of 3 lines of Snellen acuity or 15 letters on ETDRS chart or deterioration in visual field deviation of 3 decibels due to health service initiated delay in review or care were ascertained through the BOSU using prospective active surveillance involving all UK consultant ophthalmologists. Demographic details, diagnosis, cause and length of delay, and vision loss were then sought by questionnaire.Results238 cases reported between March 2015 and February 2016. 197/238 questionnaires were returned (83%). Twenty-eight reports were out of the study period or did not meet the case definition. Median age was 76 years (range: 1 to 98 years). Median delay was 22 weeks (range: 2 days to 5½ years). Seventy two per cent experienced permanent reduction in visual acuity, 23% permanent deterioration in visual field. Main diagnoses were Glaucoma 42%, Age-related Macular Degeneration (AMD) 23%, and Diabetic Retinopathy (DR) 16%. Eighteen patients were eligible for Severely Sight Impaired (SSI) or Sight Impaired (SI) registration. Main causes were delayed follow-up (76%), lost referral (7%), and delayed treatment (8%).ConclusionPatients are suffering preventable harm due to health service initiated delay leading to permanently reduced vision. This is occurring in patients of all ages, but most consistently in those with chronic conditions. Delayed follow-up or review is the cause in the majority of cases indicating a lack of capacity within the hospital eye service.

Acute corneal hydrops in keratoconus: a national prospective study of incidence and management.

PurposeTo determine incidence and management of acute corneal hydrops in the UK.MethodsWe used the BOSU report card system to survey cases of acute corneal hydrops in patients with keratoconus that occurred in the UK between November 2009 and December 2010. Ophthalmologists who reported a case were sent an initial questionnaire, with a follow-up questionnaire after 6 months. We collected information on the demographics, complications, changes in visual acuity, and management. The 2011 National Census was used as a source for population and ethnicity in the UK.ResultsThere were 73 incident cases of acute corneal hydrops, with a response to the initial questionnaire for 64 (88%) patients and follow-up data at 6 months for 57 (78%) patients. For the 64 confirmed cases the median (interquartile range) age of onset was 31.9 (23.2, 41.3) years and 48 (75%) of the cases occurred in males. A total of 42 (66%) patients were white, 14 (22%) were South Asian, and 7 (11%) were black. The proportion of South Asian and black patients with acute corneal hydrops was significantly higher than in the general population (P<0.001). The minimum estimated annual incidence of acute corneal hydrops in patients with keratoconus was estimated to be 1.43 (1.10, 1.83) per 1000. At 6 months following acute corneal hydrops a decision to proceed with keratoplasty had been made for 12 (20.3%) patients.ConclusionsThis is the first population-based estimate of the incidence of acute corneal hydrops in keratoconus.

Incidence of periorbital necrotising fasciitis in the UK population: a BOSU study.

BACKGROUND: Periorbital necrotising fasciitis (PNF) is a devastating infection of subcutaneous soft tissue and underlying fascia causing severe morbidity and even loss of life. Few case reports of PNF exist and there are no prospective epidemiological studies. METHODS: A prospective observational study was undertaken using the British Ophthalmological Surveillance Unit reporting system. Questionnaires were sent to reporting ophthalmologists in the UK seeking cases of PNF over a 2-year period. RESULTS: 30 new cases were confirmed. 16 of the reported cases followed a precipitating event, 9 cases followed trauma and 3 followed surgery. ß-haemolytic Streptococcus A was the causative organism identified in 76%, either alone or with concurrent infection, and antibiotic sensitivities are discussed. Systemic complications occurred in the majority of cases (66.6%), with sepsis and death occurring in 10%. Over 50% of surviving patients had subsequent morbidity, reduced acuity (<6/18) being common. CONCLUSION: PNF is a rare, dangerous condition. This study identified an incidence of 0.24 per 1,000,000 per annum in the UK. ß-haemolytic Streptococcus A is the most common causative organism. Mortality remains a potential outcome, and survivors suffer significant morbidity. Early intravenous antibiotic management with a consensus favouring penicillin and clindamycin combined with debridement.

Orbital cellulitis in Scotland: current incidence, aetiology, management and outcomes.

PURPOSE: Orbital cellulitis is a potentially blinding and life-threatening condition. There are little published data on the incidence of orbital cellulitis and little is known about the differences between children and adults affected. The purpose of this study was to identify the incidence, aetiology, management and outcome of orbital cellulitis in children and adults in Scotland. METHODS: This study was a 1-year prospective observational study using the Scottish Ophthalmic Surveillance Unit reporting system among Scottish ophthalmologists. RESULTS: The response rate from ophthalmologists was 66.4%. There were 15 children and 5 adults reported giving an incidence of 1.6 per 100 000 and 0.1 per 100 000 in children and adults, respectively. 47% of children had a preceding upper respiratory tract infection with 87% having radiological evidence of sinus disease. Within the adult group, there was preceding immunosuppression and trauma. Streptococcus (66%) and Haemophilus (46%) species were the most commonly isolated pathogens in children. Respiratory pathogens were less predictable in adults. All patients were treated with intravenous antibiotics. All children with orbital and subperiosteal abscesses had surgery; one adult with orbital abscess did not have surgery. There were two cases of series morbidity: one intracranial spread of infection and one evisceration. DISCUSSION: The incidence of orbital cellulitis is higher in children than in adults. In children, it commonly follows upper respiratory infection and sinus disease; however, in adults, preceding illness and trauma are more common. Respiratory pathogens are common in affected children. Intravenous antibiotics and surgical treatment of abscesses remain the preferred management.

Severe intraocular pressure rise following intravitreal triamcinolone: a national survey to estimate incidence and describe case profiles.

PURPOSE: The objective of this study is to estimate the incidence of steroid-induced severe intraocular pressure (IOP) rise following intravitreal triamcinolone acetonide (IVTA) injection and to describe case profiles of the patients affected within the United Kingdom. PATIENTS AND METHODS: A national survey was carried out to identify cases that had developed severe IOP rise requiring laser or surgery following IVTA through the British Ophthalmic Surveillance Unit. Respondents were mailed a questionnaire and with a follow-up questionnaire 1 year later, to ascertain characteristics of the patients identified. We also carried out a midpoint survey to ascertain national practice of IVTA at the time. RESULTS: There were 29 confirmed reports of severe IOP rise after IVTA in the 13-month period of surveillance. All the cases were unilateral and the mean time between the IVTA and the maximum recorded IOP was 16 weeks. Six of these patients had pre-existing glaucoma or ocular hypertension, and a further two were known to be 'steroid responders'. Using the adjusted denominators, obtained from our national survey, the estimated annual incidence would be between 3.6 and 9.5 per 1000 injections. CONCLUSIONS: These results confirm that severe IOP rise after IVTA is an uncommon but serious complication. Data obtained from this national study should aid clinicians in choosing the treatment best suited to their patients.

The incidence of serious eye injury in Scotland: a prospective study.

PURPOSE: Ocular trauma remains an important cause of visual morbidity worldwide. A previous population-based study in Scotland reported a 1-year cumulative incidence of 8.14 per 100 000 population. The purpose of this study was to identify any change in the incidence and pattern of serious ocular trauma in Scotland. METHODS: This study was a 1-year prospective observational study using the British Ophthalmological Surveillance Unit reporting scheme among Scottish ophthalmologists. Serious ocular trauma was defined as requiring hospital admission. Data were collected using two questionnaires for each patient 1 year apart. RESULTS: The response rate from ophthalmologists was 77.1%. There were 102 patients reported with complete data giving an incidence of 1.96 per 100 000 population, four times less than in 1992. In patients younger than 65 years, the age-adjusted incidence ratio (males/females) indicated a ninefold higher risk of trauma in males. In 25 patients (27.2%), the injured eye was blind (final visual acuities (FVA) <6/60), 24 being attributable to the eye injury. Standardised morbidity ratios suggested a threefold decrease in risk of poor visual outcome in 2009 compared with 1992. CONCLUSIONS: The incidence of serious ocular trauma has fallen; this study has shown hospital admission for serious eye injury in Scotland has decreased fourfold in 17 years. Young adult males continue to be at highest risk, which needs to be specifically addressed in future health-prevention strategies. This study also observed a reduction in visual loss from serious ocular injuries, although the reasons for this require further exploration.

The Incidence of Blindness Due to Idiopathic Intracranial Hypertension in the UK.

PURPOSE: To determine the incidence of blindness secondary to idiopathic intracranial hypertension (IIH) in the United Kingdom. METHODS: New cases of blindness occurring secondary to IIH were identified prospectively through the British Ophthalmological Surveillance Unit (BOSU) from October 2005 to November 2006. Only idiopathic cases of intracranial hypertension and those meeting the World Health Organisation`s definition of blindness were included. Cases that were already blind or had already been blind registered before the study period were excluded. RESULTS: There were 24 new cases of registerable blindness secondary to IIH reported during the 12 month period. Questionnaires were completed for 19 cases. Of these 19 cases, 3 were not truly idiopathic and 3 cases did not fulfil the strict criteria for blindness. One case was a duplicate report. There were 12 definite cases of blindness secondary to IIH giving a UK incidence of blindness secondary to IIH of 0.6-2% (assuming a UK population of 63.2 million and an incidence of IIH of 1-3/100,000). If the 5 cases reported as blind but without a completed questionnaire are assumed to be true cases then the incidence of blindness would be 1-3%. CONCLUSIONS: The results of this study suggest that approximately 1-2% of new cases of IIH are likely to become blind in a given year. This contrasts with rates of between 4-10% reported previously in hospital-based studies, but may be a more accurate figure for the population as a whole. Under-ascertainment and improving standards of care may also have contributed to the lower figure than previously reported.

Post-intravitreal anti-VEGF endophthalmitis in the United Kingdom: incidence, features, risk factors, and outcomes.

PURPOSE: To describe the incidence, features, management, and risk factors of post-intravitreal anti-VEGF endophthalmitis (PIAE) in patients undergoing treatment for exudative age-related macular degeneration in the United Kingdom. METHODS: Prospective observational case control study. Forty-seven cases of PIAE were identified through the British Ophthalmological Surveillance Unit from January 2009 to March 2010. Data collected at diagnosis and at 6 months follow-up included patient demographics, intravitreal injection details, pre- and post-injection management, visual acuity, clinical features and management of PIAE, causative organisms, and clinical outcomes. Details were compared with 200 control cases from 10 control centres to identify potential risk factors. RESULTS: Estimated PIAE was 0.025%. Culture-positive PIAE incidence was 0.015%. Mean age of presentation was 78 years. Mean number of intravitreal injections before PIAE was 5. Mean days to presentation was 5 (range 1-39). Positive microbiology culture was found in 59.6%. The majority of causative organisms were Gram positive (92.8%). Significant risk factors were failure to administer topical antibiotics immediately after the injection (P=0.001), blepharitis (P=0.006), subconjunctival anaesthesia (P=0.021), patient squeezing during the injection (P=0.021), and failure to administer topical antibiotics before anti-VEGF injection (P=0.05). DISCUSSION: The incidence of PIAE in the United Kingdom is comparable to other studies at a rate of 0.025%. The most common causative organisms were Gram positive. Measures to minimise the risk of PIAE include treatment of blepharitis before injection, avoidance of subconjunctival anaesthesia, topical antibiotic administration immediately after injection with consideration to administering topical antibiotics before injection.

Acute retinal necrosis in the United Kingdom: results of a prospective surveillance study.

BACKGROUND: To determine the incidence of acute retinal necrosis (ARN) in the United Kingdom and to describe the demographics, management, and visual outcome in these patients. METHODS: This was a prospective study carried out by the British Ophthalmological Surveillance Unit (BOSU) between September 2007 and October 2008. Initial and 6-month questionnaires were sent to UK ophthalmologists who reported cases of ARN via the monthly BOSU report card system. RESULTS: In all, 45 confirmed cases (52 eyes) of ARN were reported in the 14-month study period, giving a minimum incidence of 0.63 cases per million population per year. There were 20 females and 25 males. Age ranged from 10 to 94 years. Eight patients had a history of herpetic CNS disease. Aqueous sampling was carried out in 13 patients, vitreous in 27, and cerebrospinal fluid (CSF) in 4. Varicella-zoster virus followed by herpes simplex were the most common causative agents. Treatment in 76% of the cases was with intravenous antivirals; however, 24% received only oral antivirals. In all, 47% of patients had intravitreal antiviral therapy. Visual outcome at 6 months was <6/60 in 48% of the affected eyes. CONCLUSION: The minimum incidence of ARN in the UK is 0.63 cases per million. Patients with a history of herpetic CNS disease should be warned to immediately report any visual symptoms. There is increased use of oral and intravitreal antivirals in initial treatment.

A population-based study of Coats disease in the United Kingdom I: epidemiology and clinical features at diagnosis.

AIMS: coats disease is an uncommon form of retinal telangiectasis. Published case series mostly originate from tertiary referrals centres and may provide a skewed view of disease severity. We conducted a prospective population-based study of Coats disease in the United Kingdom to ascertain the incidence and provide a more representative picture. METHODS: the study was conducted through the British Ophthalmological Surveillance Unit. This first paper reports the features at presentation; gender, mode of presentation, visual acuity, anterior and posterior segment findings, amount of retinal exudation, and disease staging. RESULTS: a total of 55 eligible cases of Coats disease were identified giving an estimated population incidence of 0.09 per 100.000 of the population. All cases were unilateral and 85% were male. Mean age at presentation was 146 months (median 96 months). The mean age of diagnosis was markedly different with differing mechanisms of presentation. Cases presenting with leucocoria or strabismus presented early whereas subjective visual loss presented much later. A large proportion of eyes (44%) were blind at diagnosis. The great majority of eyes (71%) had 6 or fewer clock hours of retinal exudation. More severe forms/stages of Coats disease were more common in the youngest patients. CONCLUSIONS: compared with published studies of Coats disease, we have found milder disease severity at presentation. This is most likely because of the population-based nature of our study reflecting the full disease spectrum. A large proportion of eyes with Coats have poor visual acuity and disease severity is worse in younger patients.

Surveillance of traumatic optic neuropathy in the UK.

AIMS: The aim of this study is to provide epidemiological data on the incidence, aetiology, management, and visual outcome in traumatic optic neuropathy (TON) in the UK. METHODS: Patients with TON were identified prospectively by population-based active surveillance through the British Ophthalmic Surveillance Unit over a 2-year period with data obtained from an incident questionnaire and follow-up questionnaire sent to positive reporters. RESULTS: Incident and follow-up data were available on 121 and 97 (80%) patients, respectively. The minimum estimated incidence was 1.005 per million. Leading causes included falls (25.6%), road traffic accidents (RTAs) (21.5%), and assaults (20.7%). The median age was 31 years. There were 95 (78.5%) men. Presenting visual acuity (VA) was 6/60 or worse in 85 (70%) patients, with 43 patients (36%) with no perception of light. Associated injuries included 47 (39%) orbital wall fractures, 37 (31%) closed globe injuries, 23 (19%) ocular adnexal injuries, 23 (19%) skull fractures, and 18 (16%) intracranial bleeding. Sixty-five percent (75/116) received no acute treatment and 35% (41/116) received steroids and/or surgery. Of the treated group, 24% (8/33) and of the untreated group 20% (11/56) improved three lines or more of VA (P=0.61). Prompt ophthalmic examination (P=0.002), orbital fracture (P=0.046), high Glasgow Coma Scale (GCS) score (P=0.023), and poor initial VA (P=0.009) were associated with increased likelihood of treatment. Poor initial VA (P<0.001), orbital fracture (P=0.004), and significant head injury (P=0.038) were associated with poor visual outcome. CONCLUSIONS: This study suggested that young men were at greatest risk of TON. We detected a trend towards conservative management of this condition in the UK. TON was associated with significant ocular, orbital, and head injuries that highlighted the need for multidisciplinary management.

Surveillance of severe chemical corneal injuries in the UK.

AIM: To estimate the incidence of severe chemical corneal injuries in the UK and describe presenting clinical features and initial management. METHODS: All patients with severe chemical corneal injury in the UK from December 2005 to November 2006 inclusive were prospectively identified using the British Ophthalmological Surveillance Unit. Reporting ophthalmologists provided information regarding presentation and follow-up. RESULTS: Twelve cases were identified, giving a minimum estimated incidence in the UK of severe chemical corneal injury of 0.02 per 100,000. 66.7% of injuries were in males of working age, 50% occurred at work, and alkali was causative in 66.7%. Only one patient was wearing eye protection at the time of injury, 75% received immediate irrigation. Six patients required one or more surgical procedures, most commonly amniotic membrane graft. At 6 months' follow-up, the best-corrected visual acuity was 6/12 or better in five patients, and worse than 6/60 in two. CONCLUSION: The incidence of severe chemical corneal injury in the UK is low. The cases that occur can require extended hospital treatment, with substantial ocular morbidity and visual sequelae. Current enforcement of eye protection in the workplace in the UK has probably contributed to a reduced incidence of severe ocular burns.

Surveillance of intraocular foreign bodies in the UK.

AIMS: To estimate the incidence of penetrating injuries with retained intraocular foreign bodies (IOFBs) in the United Kingdom, and to provide epidemiological data on the aetiology, management, and visual outcome of such injuries. METHODS: Cases were identified prospectively by active surveillance through the British Ophthalmological Surveillance Unit reporting card system, for the 12-month period June 2004 to May 2005 inclusive. Questionnaire data were obtained from UK ophthalmologists at presentation and 6 months following presentation. RESULTS: Data were available on 97 patients at presentation and 95 patients at follow-up. The minimum estimated incidence of IOFBs in the United Kingdom identified in this study was 0.16 per 100 000. All patients were male. Hammering was the most common mechanism of injury, occurring in 62% of patients. The IOFB was found in the anterior segment in 24%, the posterior segment in 73%, and involved both segments in 3%. Endophthalmitis was diagnosed in 9% of patients. Best-corrected visual acuity of the injured eye at final follow-up was 6/12 or better in 67%, 6/18 to 6/60 in 11%, and worse than 6/60 in 22%. Prognostic factors for a poor visual outcome included poor visual acuity at presentation, prolapse of intraocular tissue, development of endophthalmitis, development of retinal detachment, and large size of IOFB. CONCLUSIONS: The incidence of IOFB in the United Kingdom appears to have reduced compared to previous studies. The majority of patients (67%) retain good visual acuity in the injured eye; however, a significant minority (22%) sustain long-term severe visual loss.

A British Ophthalmological Surveillance Unit study on serious ocular injuries from fireworks in the UK.

PURPOSE: We conducted a surveillance study to assess the nature, management, and visual outcomes of serious ocular injuries from fireworks in the UK. METHODS: New cases of serious ocular injuries from fireworks were prospectively ascertained through the monthly active surveillance system of the British Ophthalmological Surveillance Unit (BOSU). All ophthalmologists in the UK received a reporting card each month for a 2-year period commencing July 2004. They were asked to indicate any new cases of serious ocular injury from a firework, or to confirm that they had no new cases to report. Information on demographic detail, type of injury, management, and visual outcome was sought through an incident and 6-month follow-up questionnaire. RESULTS: Eighty-one per cent of the injuries occurred in October and November and 27% (13/47) of the patients were less than 18 years old. Twenty-six per cent (12/47) of patients had a penetrating injury, and ocular surgery was required in 53% (25/47) of cases. Eight patients (17%) required enucleation or evisceration and four (9%) required a cosmetic shell for phthisis. At 6-month follow-up, 53% (21/40) of cases had a visual acuity of 6/60 or worse. CONCLUSION: This prospective national survey confirms that firework injuries are an important cause of preventable visual disability particularly to young males. It is likely that such injuries occur year on year and as such represent an important public health concern in addition to the burden placed upon the health service.

Displacement of nuclear fragments into the vitreous complicating phacoemulsification surgery in the UK: clinical features, outcomes and management.

AIMS: To study the clinical features, management and outcomes of displacement of nuclear fragments into the vitreous (DNFV) complicating phacoemulsification in the UK. METHODS: Cases were collected prospectively between March 2003 and March 2004 inclusive by active surveillance through the British Ophthalmological Surveillance Unit. Details were obtained using incidence questionnaires and follow-up questionnaires after 6 months. The data used in this paper were obtained from the follow-up questionnaires. RESULTS: 610 cases were confirmed during the reporting period, for which 387 follow-up questionnaires were received. In 67% of cases, a best-corrected visual acuity of 6/12 or better was reported at final follow-up. The most common immediate sequelae of DNFV were intraocular inflammation (85%), corneal oedema (55%) and an intraocular pressure >30 mm Hg (34%). Pars plana vitreolensectomy was used in 97% of cases, and fragmatome ultrasound lensectomy was used in over half of these procedures. The median time from cataract surgery to pars plana vitrectomy for the removal of DNFV was 3 days, and most patients (68%) had vitrectomy within 1 week of the first procedure. An intraocular lens had been inserted at the time of the complicated cataract surgery (defined as a "primary IOL") in 40% of cases, and over three-quarters of these primary IOLs were subsequently removed (with or without a replacement IOL). Only 67% of eyes that had a primary IOL inserted after DNFV were pseudophakic at final follow-up, in contrast with 79% of eyes that were left aphakic after DNFV (p = 0.008). A best-corrected visual acuity of 6/60 or worse was reported in 14% of cases at final follow-up and was most commonly associated with persistent uveitis, corneal oedema, cystoid macular oedema, optic atrophy or retinal detachment. CONCLUSIONS: DNFV complicating cataract surgery was followed by a secondary procedure in 97% of cases. About three-quarters (77%) of "primary IOLs" inserted at the time of DNFV were subsequently removed or replaced, and eyes that had received a primary IOL had significantly less chance of being pseudophakic at final follow-up than eyes that had been left primarily aphakic at the time of the complicated cataract surgery. The delay before secondary intervention was shorter, fragmatome ultrasound lensectomy use was higher, and the retinal detachment rate was lower than in previous studies. Affected eyes still had a worse outcome in terms of visual acuity compared with eyes after uncomplicated cataract surgery.