Outcomes of screening for hydroxychloroquine retinopathy at the Manchester Royal Eye Hospital: 2 years' audit.

BACKGROUND: The Royal College of Ophthalmologists has produced guidelines for screening for hydroxychloroquine retinopathy. New imaging modalities had suggested an increased prevalence of retinopathy compared with previous reports. The aim of this study is to identify the real-life prevalence of hydroxychloroquine retinopathy in patients attending Manchester Royal Eye Hospital screening service over a 2-year period using The RCOphth diagnostic criteria. METHODS: Data were collected prospectively from all patients attending Manchester Royal Eye Hospital hydroxychloroquine screening service over the audit period. Results of Humphrey visual field tests, spectral-domain optical coherence tomography and fundus autofluorescence were collected as well as data on dose, indication, duration of treatment, and additional risk factors. Cases were identified as having definite, possible, or no retinopathy based on the 2018 RCOphth criteria. The data are not publicly available due to information that could compromise research participant privacy and confidentiality but are available upon request from the corresponding author. RESULTS: 910 patients attended for screening. 566 were identified as being at risk of retinopathy (543 had been on treatment >5 years, 10 had renal impairment, 12 were on doses of >5 mg/kg/day, and one was concurrently on tamoxifen). The prevalence of HCQ retinopathy was 10/910 (1.09%) of all those screened, and 1.76% of those at risk (10/566). Six patients of those deemed at risk were identified as having definite hydroxychloroquine retinopathy, while four had possible retinopathy. CONCLUSIONS: Our results show a prevalence of retinopathy largely consistent with reports from regional audits yet reveal a far lower estimate compared to previously reported figures.

Video Conferencing in the Intravitreal Injection Clinic in Response to the COVID-19 Pandemic.

PURPOSE: To share a useful intervention to minimize risk of COVID-19 infection to both healthcare workers and patients in the eye clinic. METHODS: We present our experience of virtual, within-clinic remote visual acuity assessment to reduce the risk of infection with COVID-19. RESULTS: Along with standard recommendations for personal protective equipment and hand hygiene to contain viral spread and treating only urgent cases, remote within-clinic visual acuity testing and consultations can be undertaken with minimal specialist equipment and appears to provide useful information whilst being acceptable to patients. CONCLUSION: Ophthalmology practice must adapt in order to combat COVID-19. This measure can easily be incorporated into daily practice to reduce both patient footfall within the department and close contact between patient and healthcare practitioners.

Oral medications for central serous chorioretinopathy: a literature review.

Central serous chorioretinopathy (CSCR) is characterised by acute or chronic neurosensory detachments of the retina, usually in the posterior pole, with or without associated detachments of retinal pigment epithelium. Although the condition often resolves spontaneously, chronic and recurrent cases can lead to significant visual loss in the working population and it is thus increasingly recognised as an important public health issue. The uncertainty regarding the underlying cause of CSCR has led to a wide range of therapies being tried for this condition including photodynamic therapy, laser photocoagulation, anti-VEGF injections and a multitude of oral agents. This article aims to review the current evidence for oral agents that have been used for treatment of CSCR. A systematic literature search was conducted for articles published between 1980 to July 2018. A total of 73 articles were included. These studied the following oral medications: eplerenone, spironolactone, beta blockers, H. pylori agents, omeprazole, rifampicin, methotrexate, aspirin, acetazolamide, mifepristone, melatonin, finasteride, ketoconazole, antioxidants and curcumin phospholipid. Although none of the studies showed robust evidence of efficacy, the mineralocorticoid receptor antagonists, particularly eplerenone, appear to demonstrate the highest quality evidence for use in this condition. The review aims to give the reader an overview of the current available evidence for oral medications used in the treatment of CSCR in order to provide an evidence-based discussion with the patient and guide through possible options for treatment.

Clinical utility of intravitreal fluocinolone acetonide (Iluvien®) implant in the management of patients with chronic diabetic macular edema: a review of the current literature.

The first-line therapy for patients with center-involving diabetic macular edema (DME) is with intravitreal anti-vascular endothelial growth factor (VEGF) agents, with or without adjunctive macular laser treatment. However, a significant proportion of patients have persistent and recurrent edema despite repeated anti-VEGF injections. The fluocinolone acetonide (FA) 190 µg intravitreal implant has been shown in pivotal clinical trials to be efficacious for the treatment of DME and has been approved in many countries for use in patients who have not responded to first-line therapy. In this report, we have collated the latest data from the increasing number of studies to illustrate the pattern of usage of the Iluvien FA implant for DME during the current anti-VEGF era. We have shown that there is now a wealth of published evidence from real-world studies to support the clinical utility of the FA implant in achieving further resolution of edema and improving visual acuity outcomes in this challenging group of patients.

Ocular surface effects of repeated application of povidone iodine in patients receiving frequent intravitreal injections.

BACKGROUND: The aim of this study was to investigate the patient reported symptoms and objective signs of tear film and ocular surface abnormalities experienced by patients undergoing repeated exposure to povidone iodine as a consequence of requiring frequent intravitreal injections for wet macular degeneration. METHODS: This was a prospective study of consecutive patients who had received recent povidone 5% solution for sterile preparation of intravitreal injection less than 3 months prior to inclusion with a total of at least 3 intravitreal injections for macular degeneration. Each patient had one study eye which was undergoing regular intravitreal injection and a fellow eye which was not undergoing any injections. Each patient underwent evaluations of various tear film parameters on a single occasion for both eyes. The primary outcome was severity of dry eye symptoms as measured by the Schein dry eye questionnaire. The secondary outcomes were tear film osmolarity and corneal punctate staining using the Oxford Grading Scale. RESULTS: A total of 90 patients were included in the study. 43.3% n = 39, were using ocular lubricating medication on a regular basis. A significantly greater proportion of study eyes had a Schein dry eye questionnaire score of 7 or higher; 12.2%, n = 11 amongst study eyes vs 4.4%, n = 4 amongst control, fellow eyes (p < 0.05). In terms of secondary outcomes, the study eyes had a slightly higher mean tear film osmolality compared to control, fellow eyes: 305.5 ± 1.7 in study eyes vs 302 ± 1.6 in control eyes although this difference was not statistically significant (p = 0.087). The study eyes had statistically significantly worse corneal staining as determined by the Oxford grading scale; 0.69 in study eyes vs 0.58 in control, fellow eyes (p = 0.02). CONCLUSION: Our results confirm the detrimental impact of repeated application of povidone iodine for intravitreal injection procedures on symptoms of dry eyes as experienced and reported by patients.

An analysis of ophthalmology trainees' perceptions of feedback for cataract surgery training.

OBJECTIVES: To determine whether feedback for cataract surgery is perceived to be given to trainee ophthalmologists, the way in which any feedback is given, and what the trainee perceives to be the effect of feedback on their performance. DESIGN: Cross-sectional qualitative study. PARTICIPANTS: Twelve trainee ophthalmologists at various levels of specialty training in the UK. METHODS: Semi-structured interviews were conducted via telephone or face to face. Interviews were transcribed and underwent thematic analysis using a qualitative software data package. MAIN OUTCOME MEASURES: The importance of feedback to the trainee and methods to improve the giving of feedback. RESULTS: Feedback was thought to be a useful tool for improving performance in cataract surgery by all participants. Emergent themes were the importance of specificity of feedback and having confidence in the supervisor. Participants suggested ways that the feedback given can be improved upon. An insight was gained into how the feedback has an effect on their performance. CONCLUSION: This study showed that trainees perceive the feedback they receive to be of high quality. Feedback enables the trainees to self-reflect and improve their surgical techniques.

Temporal artery biopsy for giant cell arteritis: retrospective audit.

OBJECTIVES: Temporal artery biopsy (TAB) is performed in suspected cases of sight-threatening giant cell arteritis (GCA). We aimed to determine the feasibility of TAB in patients who are suspected of having GCA. DESIGN, SETTING AND PARTICIPANTS: A retrospective audit of all patients undergoing TAB at a single teaching hospital between 2005 and 2011, identified from the histopathology database. MAIN OUTCOME MEASURES: (1) Clinical profile and biochemical criteria associated with positive histology. (2) Proportion of negative histology patients who were commenced on steroid therapy. RESULTS: One hundred and fifty-three TAB were performed (mean age 70.8 years, men:women = 3:2, 110 Caucasian: 43 Asian). Thirty-two biopsies were positive for GCA and 121 were negative. In total, 68 (61%) of 112 negative TAB patients were clinically diagnosed with GCA despite histological findings (P < 0.001). Nine out of 153 biopsies were non-arterial. Histologically positive TAB patients were of higher mean age (77.1 [95% CI 74.5-79.7] versus 69.1 [95% CI 66.7-71.6]; P < 0.001) and had a higher erythrocyte sedimentation rate (ESR) (60 [95% CI 46.1-73.9] versus 39.8 [95% CI 34.2-45.3]; P < 0.01)] than those with negative histology. CONCLUSIONS: Raised ESR and higher age may be the most useful indicators of GCA. Many histologically negative individuals were nevertheless clinically diagnosed and managed as GCA.

The role of feedback in improving the effectiveness of workplace based assessments: a systematic review.

BACKGROUND: With recent emphasis placed on workplace based assessment (WBA) as a method of formative performance assessment, there is limited evidence in the current literature regarding the role of feedback in improving the effectiveness of WBA. The aim of this systematic review was to elucidate the impact of feedback on the effectiveness of WBA in postgraduate medical training. METHODS: Searches were conducted using the following bibliographic databases to identify original published studies related to WBA and the role of feedback: Medline (1950-December 2010), Embase (1980-December 2010) and Journals@Ovid (English language only, 1996-December 2010). Studies which attempted to evaluate the role of feedback in WBA involving postgraduate doctors were included. RESULTS: 15 identified studies met the inclusion criteria and minimum quality threshold. They were heterogeneous in methodological design. 7 studies focused on multi source feedback, 3 studies were based on mini-clinical evaluation exercise, 2 looked at procedural based assessment, one study looked at workplace based assessments in general and 2 studies looked at a combination of 3 to 6 workplace based assessments. 7 studies originated from the United Kingdom. Others were from Canada, the United States and New Zealand. Study populations were doctors in various grades of training from a wide range of specialties including general practice, general medicine, general surgery, dermatology, paediatrics and anaesthetics. All studies were prospective in design, and non-comparative descriptive or observational studies using a variety of methods including questionnaires, one to one interviews and focus groups. CONCLUSIONS: The evidence base contains few high quality conclusive studies and more studies are required to provide further evidence for the effect of feedback from workplace based assessment on subsequent performance. There is, however, good evidence that if well implemented, feedback from workplace based assessments, particularly multisource feedback, leads to a perceived positive effect on practice.

Soft lens matter recurrence after congenital cataract surgery.

UNLABELLED: We report a case of soft lens matter recurrence 17 years after the original congenital cataract was removed. To our knowledge, this is the longest interval for soft lens matter to recur. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Anterior dislocation of a Morcher capsular tension ring.

We report the rare complication of anterior dislocation of a capsular tension ring (CTR) and a simple management option, with excellent results and no inflammatory or pressure-related sequelae.

Opportunities for learning in the surgical workplace and how they can be exploited: a practical guide.

Training times and the working week have been shortened but the amount needed to be learned remains the same. This article demonstrates how trainees in surgery can incorporate learning opportunities into their normal working day.

An unusual presentation of merkel cell carcinoma of the eyelid.

Merkel cell carcinoma is a rare primary neuroendocrine tumor occurring on any part of the body. It usually presents as a firm, nontender, violaceous, or purple nodule located on areas of the body that have been exposed to sunlight. A 68-year-old female presented with a rapidly growing lesion on the left lower eyelid from 6 weeks. Examination showed a 4 cm diameter, exophytic, ovoid skin lesion of the left lower lid. Wide local excision of this lesion was followed by adjuvant chemotherapy. Histological examination of therapeutic frozen section of the lesion and the presence of neuroendocrine marker and cytokeratin markers established the diagnosis of Merkel Cell carcinoma. The follow-up at 8 months was uneventful. Merkel cell carcinoma can have an unusual presentation of a large, exophytic, oval lesion resembling a basal cell carcinoma. Merkel cell carcinoma has predilection for rapid spread; hence, in a case of lid lesions, a suspicion for this diagnosis should be kept in mind.

Occult traumatic nasolacrimal duct obstruction causing anophthalmic socket contraction presenting 20 years later: a case report.

PURPOSE: To highlight undiagnosed nasolacrimal duct obstruction as a cause of multiple problems related to the anophthalmic socket and the importance of early diagnosis and treatment in their prevention. METHODS: Case report with high resolution digital clinical photography. RESULTS: A 43-year-old Asian gentleman sustained penetrating trauma to the right globe and midface in 1984. At the time, he underwent primary repair of the globe, followed by enucleation. Over the next ten years, he suffered a myriad of problems with recurrent entropion and trichiasis of upper and lower lids, a dry socket with an uncomfortable artificial eye and chronic mucoid discharge. Twenty years later he had a contracted socket with mucosal keratinization, cicatricial entropion of the eyelids, forniceal shortening and mucoid discharge. There was also nasolacrimal duct obstruction with an occult mucoceole. He underwent external dacrocystorhinostomy with correction of the entropions and anophthalmic socket refashioning. He remains symptom free twelve months following surgery. CONCLUSION: Contracted anophthalmic sockets can occur spontaneously or secondarily to a disease process. These may lead to changes in tear composition and have pro-inflammatory effects on the ocular surface. We hyphothesize that the chronic toxic tear film secondary to the mucocoele led to chronic conjunctivitis with cicatrisation over time and multiple structural lid & socket problems that ensued. This case highlights the importance of looking for occult causes of chronic cicatrization in the anophthalmic socket.