Ophthalmologists with conjunctivitis: are they fit to work?

PURPOSE: To establish current opinion as to whether ophthalmologists with conjunctivitis are fit to work. METHODS: One hundred and sixty ophthalmology units in the United Kingdom were sent a postal survey enquiring about work practices when an ophthalmologist contracts conjunctivitis. RESULTS: One hundred and five replies were received. Twenty-nine per cent of respondents said the ophthalmologist should stay off work while 7% said he or she should continue as usual. There was no concordance as to whether viral or bacterial conjunctivitis posed a greater problem. There is evidence that ophthalmologists have been implicated in the spread of epidemics of viral conjunctivitis but also reports of ophthalmologists who have continued to work with no reported spread of infection. CONCLUSION: In view of the lack of consensus the authors are unable to recommend evidence-based clinical guidelines, but would suggest that use of modern diagnostic laboratory techniques may help in making the decision as to whether to continue at work or not.

Direct ophthalmoscopy versus slit lamp biomicroscopy in diagnosis of the acute red eye.

The causes of red eye range from trivial to life-threatening, and many general practitioners are uncertain of their ability to diagnose them with the aid of an ophthalmoscope. We tested the hypothesis that, in the assessment of a patient with red eye, a doctor using a slit lamp biomicroscope would not differ in diagnostic accuracy from a doctor using a direct ophthalmoscope. A cross-over study was conducted in 98 patients newly attending an eye casualty department. 71% of diagnoses agreed exactly, and all potentially sight-threatening lesions were either diagnosed correctly or managed appropriately by doctors using an ophthalmoscope. We conclude that the initial diagnosis and management of patients with an acute red eye is not prejudiced by the lack of a slit lamp biomicroscope.

Ocular pain: a casualty study. The spectrum and prevalence of pain in acute eye disease.

This study examined the prevalence and severity of ocular pain in eye casualty patients. All new patients presenting over a 1 month period were invited to indicate their pain level using a visual analogue scale. The results for 352 patients were analysed, and median pain levels calculated for 29 common diagnoses. Of those responding, 94% (= 47% of all new patients) had ocular pain at presentation. While many results were predictable, some diagnoses were associated with higher pain scores than expected. Junior ophthalmologists also were asked to indicate their perceptions of pain severity for the 29 diagnoses using the same visual analogue scale.

Communication and compliance in eye casualty.

PURPOSE: This study aimed to assess patients' perceptions and priorities when consulting doctors in eye casualty, to assess their satisfaction with eye casualty and to evaluate and improve patients' level of knowledge and understanding of their treatment. METHODS: A selected consecutive group of 130 patients presenting to eye casualty between 1 July and 15 September 1995 was interviewed by two of the authors prior to collecting their medication. A further group was interviewed again after collecting their medication from the hospital pharmacist. The hospital pharmacist reiterated treatment details when patients collected their medication. Interviews were conducted by means of a questionnaire. There was no inter- or intraobserver variation. Patients' priorities and perceptions were measured as percentages of the group. Patient satisfaction was measured both by a score on a standardised questionnaire and on a visual analogue scale. Patient recall of treatment details was scored as correct or incorrect. The score prior to and after seeing the pharmacist was compared in those patients who were interviewed after collecting their medication. RESULTS: Among the patients 30.8% considered themselves emergencies, 20.8% were referred and the remainder attended for non-urgent reasons. Eighty-three per cent (83.0%) were wholly satisfied with the consultation. The consultation scored an average of 8.3, SD 1.6, measured on a visual analogue scale of 0-10. When asked the most important aspects of the consultation 54.6% cited treatment, 25.4% reassurance and 20.0% diagnosis. Ninety-six per cent felt that their treatment had been adequately explained; however, 78.3% made errors when reporting their regimen. A significant improvement in patients' level of recall was found after they had received further information from the hospital pharmacist. CONCLUSIONS: Firstly, this study shows patients' perceptions and priorities when visiting eye casualty. Secondly, it demonstrates that patients are generally satisfied with their eye casualty attendance. Thirdly, many patients depart with poor understanding of their eye treatment regime which is likely to affect compliance. Communication between doctors and patients was enhanced by involvement of the hospital pharmacist. This strategy is applicable not only to an ophthalmic casualty unit but also to a wider range of settings and could provide a service standard for future audit.

Immunophenotyping in presumed ocular histoplasmosis like retinopathy.

Four cases of presumed ocular histoplasmosis like retinopathy are presented. A detailed immunological assessment was carried out on the patients and a control group: lymphocyte immunophenotyping; flow cytometric analysis; HLA typing and T cell receptor variable region (TCR V region) expression were assessed. Analysis of TCR V region expression revealed no significant preferential expression. HLA typing also failed to reveal any links. All lymphocyte markers analysed were unremarkable, with the exception of CD38 which was significantly raised compared with controls (p < 0.01). This finding was confirmed by the use of two different CD38-specific monoclonal antibodies. The raised CD38 in our cases was shown to be persistent when the patients were retested after an interval of several months. Significantly, this may correlate with poor T cell function, as in Common Variable Immunodeficiency, making these patients more susceptible to various stimuli.

Visual outcome of childhood anterior perforating eye injuries: prognostic indicators.

Ninety-six cases of anterior globe perforation in children less than 16 years old, requiring surgical repair, were reviewed. Seventy-three patients were male and 23 female, with a mean age of 9 years 4 months. Perforation involving just the cornea was associated with a good visual prognosis unless: it involved the visual axis, resulting in corneal scarring and/or significant astigmatism (> 3.0 DS); it involved greater than one-quarter of corneal diameter; or there was non-compliance with spectacles/patching in patients younger than 8 years old. Injuries involving the lens in those younger than 8 years were associated with a far worse prognosis due to the problems of correcting aphakia. Surgical delay and method of injury did not affect prognosis. Some patients fail to re-attend and greater patient/parent education prior to discharge is recommended.

The effect of pilocarpine on the glaucomatous visual field.

Patients with chronic open angle glaucoma are traditionally managed by medical therapy during the early stages of the disease. Pilocarpine is a well established topical agent, but suffers troublesome sequelae, the most apparent of which is pupillary constriction. This study assesses the effect of miosis (produced by one drop of 2% pilocarpine) on the static threshold perimetry of 20 subjects with chronic open angle glaucoma and documented visual field loss, using the 30-2 program of the Humphrey field analyser. Following miosis, the Statpac mean defect deteriorated by an average of -1.49 dB compared with baseline (p = 0.004). This dB deterioration is twice that reported in studies on younger normal subjects following miosis. The decrease in mean defect showed a positive correlation with the degree of pupillary constriction, the correlation being greater in those eyes with a miosed pupil diameter of 2 mm or less. There was no significant decrease in the other Statpac global indices following miosis. A parallel study using the fellow eye of the same glaucoma patients showed a high degree of intertest variability, but no significant learning or fatigue effect. We conclude that pilocarpine-induced miosis causes a significant deterioration in visual field in a population of patients with chronic open angle glaucoma: this factor should be considered when choosing therapy for glaucoma particularly in cases where field loss approaches the permitted legal minimum for driving.

More than meets the eye: a study of the time lost from work by patients who incurred injuries from corneal foreign bodies.

A prospective study was carried out to establish the time lost from work due to corneal foreign body injury. Data were collected over a 5 month period on a total of 504 patients attending a busy district hospital eye casualty department. The median time lost through injury was 4 hours and 148 patients (30%) took no time off work. Corneal foreign bodies are known to be painful injuries but in spite of this few patients take more than half a day off work.

Ofloxacin compared with chloramphenicol in the management of external ocular infection.

The safety and efficacy of 0.3% ofloxacin in treating bacterial ocular infections was compared with that of 0.5% chloramphenicol in a parallel-group, randomised clinical trial at five sites. Clinical and microbiological improvement rates were studied in 84 culture-positive patients. Patients with suspected bacterial ocular infections were evaluated for clinical improvement and were included in drug safety and comfort analyses. Clinical improvement did not differ significantly between drug treatments. All patients completing the study (79 assigned ofloxacin, and 74 chloramphenicol) showed clinical improvement. Clinical improvement in the culture-positive groups was 100% (41/41) after ofloxacin treatment, and 95% (41/43) after chloramphenicol treatment. Microbiological improvement rates were similar for the two drugs: 85% (33/39) improved with ofloxacin, and 88% (38/43) improved with chloramphenicol. Both drugs were well tolerated. Adverse reactions possibly due to the study medication occurred in 1% (1/89) of those who received ofloxacin, and in 4% (4/93) of those who received chloramphenicol.

Complete infarction of the eye complicating a choroidal malignant melanoma.

Infarction of malignant melanoma of the choroid has been previously reported, but infarction of the whole eye in association with infarction of melanoma is a rare event that has not been previously described. We present such a case and discuss the possible pathogenesis.

The cataract explosion: the changing pattern of diagnoses of patients attending an ophthalmic outpatient department.

An outpatient diagnostic index was used to analyse data relating to a sample of new patients attending the Southampton Eye Hospital in 1979 and 1986. Our main findings are an increased demand for cataract surgery by an increasingly aged population and a trend towards operating on cataracts at an earlier stage in their development. These and other results are discussed.

The structure of the lamina cribrosa of the human eye: an immunocytochemical and electron microscopical study.

The structure of the lamina cribrosa was studied by histological and immunocytochemical techniques and by scanning and transmission electron microscopy in four eyes removed surgically and in 21 normal eyes obtained from an eye bank. Dissection of the eyes emphasised the relatively fragile links between lamina and sclera. Reticulin staining of the fibrous trabeculae in the posterior (scleral) part of the lamina revealed a structure composed of interweaving skeins of collagen fibres frequently arranged tangentially around the canals, 40-220 microns in diameter, through which optic nerve axons pass. Immunocytochemistry for glial fibrillary acidic protein demonstrated the intimate web that astrocyte processes form around axons within the canals of the lamina and the close association of astrocyte processes and fibrous trabeculae in the posterior part of the lamina. Scanning electron microscopy clearly demonstrated anatomical relationships of the lamina cribrosa and the wide variation in the size of the canals in the lamina. Transmission electron microscopy confirmed the close association of astrocyte processes with axons demonstrated in the immunocytochemical preparations. The results of this study emphasise the complex relationships between astrocytic, neural and fibrous elements in the lamina cribrosa and how more information is required regarding the mechanical and metabolic properties of the astrocyte web and the fibrous trabeculae before the role of the lamina cribrosa in the pathogenesis of nerve damage in glaucoma can be fully assessed.

Problems encountered in recruiting patients to an ophthalmic drug trial.

Two clinical trials to assess the efficacy of two topical beta-blocker preparations involved the recruitment of 60 and 40 patients respectively. The greatest obstacle encountered in carrying out the trials was recruiting patients. This difficulty is reported in detail and comparisons are made with the experience of others who have met similar problems.