Confidence of Emergency Department doctors in managing ophthalmic emergencies: a systematic review.

BACKGROUND: Eye emergencies constitute a significant portion of attendances to general Emergency Departments (EDs) in the UK, therefore it is important to assess the confidence of doctors who work in this setting in managing these potentially sight- and life-threatening presentations. This systematic review aims to assess the confidence of UK doctors working in general EDs in managing ophthalmic emergencies. METHODS: MEDLINE (Ovid), EMBASE (Ovid), ProQuest Central and Web of Science databases and grey literature were searched from inception to 1 October 2022 for publications that (1) featured doctors working in UK general EDs, (2) assessed doctors' confidence in managing ophthalmic emergencies, (3) contained original data, (4) were full-text, and (5) written in English. Methodological quality was assessed using the AXIS tool. RESULTS: 462 articles were screened, and 7 papers included for data extraction, which collectively assessed the confidence of 956 doctors working in EDs in managing ophthalmic emergencies. There was a widespread lack of confidence amongst foundation doctors, which has worsened over time. Most doctors lacked confidence in performing funduscopy and using the slit-lamp, and considered formal ophthalmology training received in EDs to be inadequate. CONCLUSIONS: Evidence suggests a lack of confidence amongst foundation doctors in managing ophthalmic emergencies. High-quality evidence investigating the confidence amongst more experienced Emergency Medicine (EM) physicians was lacking. It is important to assess why foundation doctors feel so ill-prepared to manage eye emergencies and develop further ophthalmic training for doctors working in EDs. Further investigation exploring the confidence of EM trainees and consultants is required.

Impact of an email advice service on filtering and refining ophthalmology referrals in England.

PURPOSE: The growing capacity-demand imbalance has necessitated the accelerated digital transformation of eye care services. The role of Oxford Eye Hospital's (OEH) email advice service has become even more relevant in the post-Covid era. We sought to evaluate its impact on referrals to secondary care. METHODS: The consultant-led OEH email advice service primarily targets primary eye care personnel (optometrists and GPs) requiring clinical advice on patient referral. Emails received between September and November 2020 were analysed for demographic data, contents, characteristics, and outcomes. Thematic analysis was performed. A user feedback survey was conducted. RESULTS: A total of 828 emails were received over the 3-month study period (mean 9.1/day). They were predominantly from optometrists (77.9%) and general practitioners (16.1%). Of the 81.0% (671) relating to clinical advice, over half (54.8%) included images from a variety of modalities, and following review, over half (55.5%) were deemed suitable for management in the community, while 36.5% were referred directly to appropriate subspecialty clinics. Only 8.1% required urgent assessment in eye casualty. Thematic analysis showed that this service was most useful for retinal lesions, optical coherence tomography abnormalities, and borderline abnormal optic discs. No adverse events were identified. User feedback was very positive. CONCLUSION: A secure email advice service is a safe and low-maintenance modality that provides direct and efficient two-way communication between primary and secondary eye care professionals. It allows rapid response to clinical queries, referral filtering and refinement, and streamlining of patient referral pathways. Users (predominantly optometrists) were overwhelmingly positive about its usefulness in clinical practice.

Outcome measures in childhood glaucoma: a systematic review of randomized controlled trials.

PURPOSE: To synthesize the outcome measures used by randomized controlled trials (RCTs) for childhood glaucoma. METHODS: MEDLINE, EMBASE, and Scopus were searched from inception to February 17, 2023. Randomized controlled trials and observational studies related to childhood glaucoma were included. Primary and secondary outcomes were extracted and the data was used to generate a literature review. RESULTS: This review identified 42 unique reports pertaining to childhood glaucomas. Most of the studies originated from Egypt, India, and the USA. Intraocular pressure (IOP) outcomes were the most frequent outcomes studied, followed by clinical outcomes and safety outcomes. Clinical outcomes were the most common secondary outcomes studied, followed by IOP outcomes and safety outcomes. CONCLUSIONS: This systematic review found heterogenous outcomes with IOP outcomes as the most studied primary outcome. As the remaining outcomes were not consistently utilized, this review highlights the need for a consensus on studies of pediatric glaucoma.

Refractory iatrogenic pigmentary glaucoma secondary to cosmetic laser treatment: A case report.

PURPOSE: To report a case of bilateral iatrogenic pigmentary glaucoma secondary to cosmetic iris-lightening laser treatment. CASE REPORT: A 39-year-old patient presented with bilateral iatrogenic pigmentary glaucoma. She had elevated intraocular pressures (IOPs), scattered iris pitting, and intense angle pigmentation secondary to the cosmetic laser treatment she underwent 4 weeks prior to presentation. Her IOPs were refractory to maximal medical treatment and she subsequently underwent trabeculectomy. CONCLUSION: The true scale of complications related to cosmetic laser treatments is as yet unknown. Robust clinical investigations into its safety profile, including long-term data, are required. Prospective patients should consider this with great care. Clinicians should be aware of the potential risks of this procedure, as early recognition of cosmetic laser-induced pigmentary glaucoma may avert further sequelae.

Colobomatous macrophthalmia with microcornea syndrome maps to the 2p23-p16 region.

Colobomatous macrophthalmia with microcornea syndrome (OMIM 602499) is a rare, autosomal dominant malformation characterized by microcornea, uveal coloboma, axial enlargement of the globe, and myopia. Using what is currently the largest described pedigree and candidate localization approach, we first excluded the candidate genes PAX2, PAX3, PAX6, and PAX9. Subsequently, the chromosome 14q24 region containing the CHX10, SIX1, and SIX4 genes were also excluded. Positive LOD scores were obtained with the DNA markers selected from the 2p23-p16 region. A maximum pairwise LOD score of 3.61 (Theta = 0) was noted with the DNA marker D2S1788. Haplotype analysis positioned the locus between DNA markers D2S2263 and D2S1352 within a 22 Mb physical interval. This region contains major candidate genes, such as SIX2, SIX3, and CYP1B1; however, mutation analysis did not identify a causative mutation in these genes. Macrophthalmia, colobomatous, with microcornea (MACOM) is proposed as the gene symbol for this malformation linked to 2p23-p16.

Eye birth defects in humans may be caused by a recessively-inherited genetic predisposition to the effects of maternal vitamin A deficiency during pregnancy.

Congenital malformations of the eye can cause blindness in children. They occur throughout the world and in most cases the aetiology is unknown. Linkage studies have largely been unsuccessful and the risk to siblings is generally low. Epidemiological and laboratory evidence support a hypothesis that there may be genetic (recessive) predisposition to the teratogenetic effects of mild to moderate maternal vitamin A deficiency (VAD) during pregnancy. This may explain the higher prevalence of congenital eye anomalies in a part of Asian countries, where maternal VAD is common and consanguineous marriages are popular. Other congenital malformations commonly found in association with ocular coloboma (e.g. oesophageal fistulae and heart defects in CHARGE association) may also be VAD related. Mutations in a gene involved in the cellular access to vitamin A that normally protects the tissue or embryo from natural variation in dietary vitamin A intake, could render that individual intolerant of conditions of VAD. An interaction of this kind could also explain a proportion of "sporadic" cases in locations where VAD is uncommon. If this interaction is shown to be true, there are public health implications for the prevention of blindness due to congenital eye malformations. The hypotheses proposed above are reminiscent of the research leading to the discovery that folic acid supplementation could prevent neural tube defects. However, this form of intervention would be much more difficult with vitamin A, which is itself a powerful teratogen if present in excess.

Environmental risk factors in congenital malformations of the eye.

Developmental eye defects such as coloboma are a significant cause of visual morbidity in children, and are more common in India than elsewhere. The possible role of environmental factors in the aetiology of these conditions was investigated by studying birth order, symptoms of vitamin A deficiency (night blindness), drug use and maternal illness in pregnancy, rubella antibodies and exposure to agricultural chemicals. Through hospital records and community-based rehabilitation programmes in Andhra Pradesh, children with colobomata were recruited from schools for the blind. Eighty-three mothers of affected children were interviewed. The results showed that 43% of parents were consanguineous, that 19% had a positive family history and that the frequency of coloboma was highest in second-born children. Eleven (16%) mothers had a history of night blindness while pregnant with the affected child; seven (8%) took medication during the 1st trimester, abortifacients in two cases; three reported fever in the 1st trimester; and 11 (13%) reported exposure to agricultural chemicals.

Congenital hydrocephalus associated with congenital glaucoma and natal teeth.

We report the first described association of natal teeth with congenital hydrocephalus and congenital glaucoma, anterior segment dysgenesis with non-attachment of the retina. The clinical findings support a diagnosis of Walker-Warburg syndrome. The forkhead 7 transcription factor gene is proposed as a candidate gene for this syndrome.