Building a Culture of Safety in Ophthalmology.

Patient safety focused on a reduction in both procedural and diagnostic error is the number one concern of the United States healthcare system in the 21st century. The American Board of Ophthalmology has a longstanding interest in patient safety, and in 2015, teamed with the American Academy of Ophthalmology to convene all ophthalmology subspecialties and other prominent national organizations to address patient safety in ophthalmology. This article reviews the topic and highlights concerns for ophthalmologists.

Bacterial endogenous endophthalmitis in Vietnam: a randomized controlled trial comparing vitrectomy with silicone oil versus vitrectomy alone.

BACKGROUND/AIMS: To compare treatment outcomes with and without silicone oil tamponade in patients undergoing pars plana vitrectomy (PPV) for severe endogenous bacterial endophthalmitis (BEE). METHODS: One hundred and eight consecutive patients with severe BEE (defined by the absence of pupil red reflex at presentation and/or dense vitreous opacity on ultrasound and no improvement after 24-36 hours of medical treatment) were randomly assigned to two treatment groups: Group 1, standard PPV with intravitreal antibiotics; and Group 2, PPV with intravitreal antibiotics and silicone tamponade. Overall success was defined as: a visual acuity ≥ count fingers at 1 meter, with an attached retina, and no intraocular oil. RESULTS: Fifty three patients were randomized to Group 1 and 55 patients to Group 2. The mean age of study subjects was 32 years and baseline clinical characteristics were similar in both groups. At the final follow-up visit at 9 months, the overall success rate of Group 2 (67.3%) was significantly better than Group 1 (43.4%; P=0.01). There were also fewer devastating complications (such as inoperable retinal detachment, phthisis bulbi) in Group 2 compared with Group 1 (21.8% versus 43.4%; P=0.01). CONCLUSION: The outcome at 9 months of patients with BEE treated by vitrectomy with silicone oil was better than those treated by vitrectomy alone.

Review for disease of the year: differential diagnosis of ocular sarcoidosis.

Sarcoid is characterized by the heterogeneity of its clinical expression as well as the silent nature and nonspecificity of many of its clinical findings. Diagnosis is often difficult due to its ability to mimic other diseases. In the absence of a highly specific confirmatory test, one must be cognizant of the features that distinguish these simulating conditions from sarcoidosis. Establishing an appropriate differential for patients suspected of having sarcoid requires one to consider the entire clinical presentation, the presence or absence of risk factors for masquerading disorders, patterns of resolution or progression, and response to treatment. This paper provides an overview of ocular conditions that may share part of the spectrum of clinical manifestations associated with sarcoid.

Development of evidence-based clinical practice guidelines for diabetes: the Department of Veterans Affairs/Department of Defense guidelines initiative.

OBJECTIVE: To describe the Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guidelines for diabetes and contrast selected recommendations with those of the American Diabetes Association (ADA). RESEARCH DESIGN AND METHODS: We summarize the general structure of the VA/DoD Guidelines and describe the rationale for recommendations issued in 2003 for glycemic control, management of hypertension, and retinopathy screening. We compare the synthesis of evidence and resulting recommendations for these content areas with the 2004 American Diabetes Association Clinical Practice Recommendations. RESULTS: The VA/DoD Guidelines and the ADA Clinical Practice Recommendations reported similar strength of evidence findings by content area, but clinical recommendations varied. The VA/DoD Guidelines and practice recommendations emphasize the use of data on absolute risk reduction from available published randomized clinical trials rather than relative risk reduction from observational analyses. The VA/DoD Guidelines employ an algorithm-based methodology to guide clinicians through a risk-stratified approach to managing individual patients rather than promoting a single standard for most or all patients without explicit consideration of competing comorbidities. CONCLUSIONS: The VA/DoD Guidelines are intended to guide diabetes care by providing Internet-ready, evidence-based annotations in algorithmic form to help clinicians set and revise individual treatment goals for their patients.

Progression of visual field loss in untreated glaucoma patients and glaucoma suspects in St. Lucia, West Indies.

PURPOSE: A 1986-1987 survey found 8.8% prevalence of open-angle glaucoma in the black population of St. Lucia, West Indies. This follow-up study assessed visual field loss progression in untreated glaucoma patients and glaucoma suspects 10 years later. DESIGN: Cohort study. METHODS: Subjects were 205 glaucoma patients and suspects; 1987 data included age, sex, visual acuity, and visual fields measured by automated threshold perimetry (Humphrey C 30-2 test), and 1997 data included intraocular pressure, visual acuity, and visual fields measured by the same test. Exclusion criteria included field unreliability, field improvement due to vision improvement, nonglaucomatous vision deterioration, glaucoma treatment since 1988, and scoring of a visual field as end stage in 1987. Visual fields were scored by algorithms for the Advanced Glaucoma Intervention Study (AGIS) and Collaborative Initial Glaucoma Treatment Study (CIGTS). RESULTS: By AGIS criteria, 55% of 146 right eyes and 52% of 141 left eyes showed progression of visual field loss. In linear regressions, progression severity was unassociated with sex, intraocular pressure, or baseline visual field score, but was positively associated with age (P <.001, right; P =.002, left). The cumulative probability of reaching end stage in 10 years in at least one eye was approximately 16% by AGIS criteria. By CIGTS criteria, 73% of 146 right eyes and 72% of 141 left eyes progressed. CONCLUSIONS: These data provide a unique opportunity to study progression of untreated glaucoma. The percentage of eyes showing visual field loss progression and the percentage reaching end stage were considerably higher than in studies of visual field progression in treated eyes.

Evaluating headaches

Headache is a common affliction and one of the most frequent causes of referral to opthmalmologists. Multiple intra- and extra-cranial disturbances may be responsible for severe head pain and the many structures contained within the head make diagnostic confusion common. Ocular causes of head pain include trauma, inflammation, ocular hypertension, painful neuropathies and asthenopic symptoms. Other than trauma, inflammation is the most common cause of orbital pain but ischaemia and painful neuropathies are not uncommon. In addition, disease involving the para-nasal sinuses is often referred to the eye or orbit. Ocular tumours are infrequent causes of head pain and when pain is present it is usually associated with secondary glaucoma or inflammation. Similarly, pain is uncommon in otherwise silent orbital tumours, but lachrymal gland lesions may be painful in the absence of other outward signs of abnormality. When faced with the patient with unexplained head pain, the opthalmologist must first establish if an ocular cause is present. If none is found, a systematic work-up should be initiated and the patient referred to the appropriate specialist. (AU)

Systemic acidosis associated with diamox [abstract]

Glaucoma is an optic neuropathy defined by the presence of characteristic morphological alterations to the optic nerve head and suggestive visual field abnormalities. The aetiology of primary open angel glaucoma remains elusive but intraocular pressure is presumably the most important risk factor in all forms of glaucoma. In addition, the intraocular pressure remains the only modifiable risk factor, and current glaucoma therapy focusses on addressing the variable. A variety of drugs is available to reduce the intraocular pressure and they work by reducing aqueous production, increasing aqueous overflow or both. Although generally safe, these medications can be associated with local and systemic side effects. Topical beta blockers and systemic carbonic anhydrase inhibitors are notable for their effects on multiple organ systems and their potential for severe toxity. As with most medications, their safe use requires knowledge of the patient's health status, an awareness of specific contraindications to their use, sensitivity to the effects of ageing on drug metabolism, familarity with drugs which may cause adverse interaction and due diligence in the detection of insidious long-term effects. An illustrative case of marked acid-base imbalance associated with carbonic anhydrase inhibitor use is presented. (AU)

Ethics and the Itinerant Surgeon

Itinerancy as it relates to health care is a well established practice. In most cases it serves to extend the reach of limited resources to ensure at least a minimum level of care to the largest number of individuals. Non-indigenous itinerant practitioners play an important role where skilled providers are in extremely short supply or non-existent. However, these providers face significant ethical challenges and must practise according to the same general principles that guide the practice of medicine in any setting. Technical competence, communication and consent, utilisation of accepted therapies and appropriate follow-up and delegation of responsibility are essential components of medical and surgical care regardless of practice setting, and remain the responsibilty of the physican.(AU)

Thyroid associated opththalmopathy

Hyperthyroidism refers to a group of disorders characterized by over-production of thyroid hormone by the thyroid gland. Of these disorders, toxic diffuse goiter or Graves' disease is most frequently associated with ocular complications. Graves' disease is an auto-immune process that has a predilection for middle-aged women. Thyroid opththalmopathy may reflect increased sympathetic tone and/or an infiltrative immune mediated process. Lid retraction, proptosis, chemosis, injection and ocular discomfort are relatively benign signs of thyroid eye disease, but may cause significant emotional and functional disturbances. More advanced disease characterized by keratopathy, motility restriction, and optic nerve compression represent greater threats to ocular function and may require intensive therapy. Thyroid management, systemic steroids, local irradiation and surgery represent the cornerstones of management for thyroid associated ophthalmopathy. Ocular therapy should be used judiciously as the disease is associated with a good functional and cosmetic outcome for most individual. However, those with sight threatening diesease or severe cosmetic alterations should be treated agressively and, preferably, before fibrosis leads to permanent orbital abnormalities.(AU)

National survey of the prevalence and risk factors of glaucoma in St. Lucia, West Indies. Part I. Prevalence findings

Although blacks appear to be at higher risk for blindness from glaucoma, there is little information available on the epidemiology of this disease in this population. Using a cluster sampling technique with systematic allocation of clusters, the authors conducted a national survey of black individuals 30 years of age and older in St. Lucia. A total of 1679 individuals underwent a screening examination that included visual acuity, intraocular pressure (IOP) measurement, and cup/disc (C/D) evaluation. Every third person had a screening field on the Humphrey field analyzer. Individuals with either elevated IOP, abnormal C/D ratio, or an abnormal screening visual field were referred for a definitive examination and threshold visual fields. A total of 520 people were referred. Identified by stringent criteria for the diagnosis of glaucoma, which required reliable threshold visual fields abnormal by the mirror image method, 147 individuals had glaucoma for a prevalence of 8.8 percent in the 30 years of age and older population. (AU)