The Risk of Sympathetic Ophthalmia after Vitreoretinal Surgery.

PURPOSE: To investigate the clinical course and outcomes of sympathetic ophthalmia (SO) and correlate these with the nature of the inciting event and the number of vitreoretinal (VR) procedures undergone by patients. DESIGN: A retrospective case review. SUBJECTS: All patients diagnosed with SO who had been treated or monitored at a single center over a 15-year period. METHODS: A search of the electronic patient record system at Moorfields Eye Hospital, London, over a 15-year period (between January 2000 and December 2015) was carried out using the search terms "sympathetic," "ophthalmia," and "ophthalmitis." Sixty-one patients with available records were identified, and data were collected from their complete electronic and paper records. MAIN OUTCOME MEASURES: The main outcome measures were best-corrected visual acuity at 1 year and at the end of follow-up and the number of VR surgical procedures preceding the diagnosis of SO. Data on patient age, sex, disease duration, ocular and systemic manifestations, ocular complications, retinal angiography, and treatment were also collected. RESULTS: There was a wide age range at presentation (2-84 years), and the length of follow-up ranged from 1 to 75 years. The first ocular event was trauma in 40 patients and surgery in 21 patients. Vitreoretinal surgery accounted for 13 of the 21 (62%) surgical first-event triggers. Twenty-three of 61 (38%) patients underwent VR surgery (1-7 operations) at some point before diagnosis. Surgical details were available for 15 patients, who had undergone a total of 25 VR procedures. Based on the surgical activity of the unit, the risk of developing SO after a single VR procedure was estimated to be 0.008%, rising to 6.67% with 7 procedures. A total of 23 (38%) patients experienced a decrease in acuity at the end of the follow-up period, vs. 9 (15%) patients experiencing an improvement and 18 (30%) remaining unchanged. CONCLUSIONS: We feel that the most significant finding in this study is the calculated risk of SO development after a single VR procedure, which was significantly lower in our cohort than that previously reported in the literature. This was seen to rise exponentially with additional procedures.

Understanding Visual Impairment and Its Impact on Patients: A Simulation-Based Training in Undergraduate Medical Education.

INTRODUCTION: Simulation activities are valuable teaching aids for understanding about living with visual impairment (VI). Our medical students used low-vision simulation spectacles (Sim-specs) to enable learning about VI. METHODS: Students made tea and filled dosette boxes using Sim-specs simulating central visual loss (age-related macular degeneration) and navigated using Sim-specs simulating peripheral visual loss (glaucoma). Facilitators recorded errors made for each task. Students completed questionnaires to grade the tasks' difficulty on a 4-point Likert-type scale. The students also participated in focus groups to discuss how their approach to working with patients may change following this training. RESULTS: In total, 252 out of 254 students participated. Central visual loss provided the greatest challenge when undertaking fine motor skilled activity (dosette box). Highest average number of errors made was for dosette box task (0.70 error), followed by navigation (0.59), then making tea task (0.34). Students scored the most difficult task on average as the dosette box task (3.23 Likert-type points), followed by navigation (2.97), then making tea task (2.63). Our students have shown learning in recognising the challenges of VI and have adapted their approach to patients. CONCLUSIONS: Simulation activities are valuable additions to the undergraduate curriculum. Such activities can potentially enable greater empathy for our visually impaired patients.

The Role of Chorioretinal Biopsy in the Diagnosis of Intraocular Lymphoma.

PURPOSE: To assess the clinical usefulness of chorioretinal biopsy in establishing a definitive diagnosis in intraocular lymphomas. DESIGN: Retrospective, noncomparative, consecutive diagnostic case series. METHODS: setting: Moorfields Eye Hospital, London, United Kingdom. PATIENTS: Twenty-nine consecutive patients presenting with severe uveitis that required an intraocular biopsy where underlying lymphoma was suspected. OBSERVATION PROCEDURE: A retrospective review of a 15-year period (1999-2014) was undertaken of all patients that have undergone chorioretinal biopsy for suspected lymphoma at Moorfields Eye Hospital, London, United Kingdom. Patients were identified on the hospital's computerized database. MAIN OUTCOME MEASURES: Effectiveness of chorioretinal biopsy in establishing a definitive diagnosis or in excluding malignancy. RESULTS: A specific histologic diagnosis was made in 17 cases (59%) while in 9 cases the biopsy combined with clinical data was effective in excluding malignancy. In the 3 remaining cases, no specific diagnosis was made. No intraoperative complications were reported. Postoperative complications other than cataract included 2 vitreous hemorrhages and 2 retinal detachments. Of the 17 cases with a histologic diagnosis, 15 were obtained in eyes with marked vitritis, as opposed to 2 with minimal vitritis. CONCLUSIONS: Chorioretinal biopsy provided a definitive diagnosis of lymphoma in 59% of cases and assisted in exclusion of a further 31% in this series. The level of vitritis appears to act as a strong index of likelihood in achieving a definitive histologic diagnosis.

Association of systemic lupus erythematosus with uveitis.

IMPORTANCE: Systemic lupus erythematosus (SLE) can be associated with uveitis. The reported prevalence of SLE in patients with uveitis varies from 0.1% to 4.8%. Accordingly, the positive predictive value of antinuclear antibody testing in diagnosing SLE in a patient with uveitis varies enormously. An accurate estimate of SLE prevalence in uveitis is needed to establish the value of routine antinuclear antibody testing in patients with uveitis. OBSERVATIONS: A literature review using the Medline database was performed to find studies reporting data on uveitis etiology from January 1, 1984, to March 20, 2015. Studies were included where there were sufficient data to draw conclusions on the prevalence of SLE as an etiological factor in uveitis. Data for 53 315 patients were reviewed and 63 studies from 30 countries were included. The prevalence of SLE as a cause of uveitis was estimated to be 0.47% (95% CI, 0.41%-0.53%). The positive predictive value of routine antinuclear antibody testing was 2.9% (95% CI, 2.65%-3.19%). CONCLUSIONS AND RELEVANCE: Systemic lupus erythematosus is a rare cause of uveitis. Routine antinuclear antibody testing has a low positive predictive value for SLE. These data suggest such testing should be reserved for patients where there is a higher pretest probability of SLE.

Bridging the gap: theory-based design of a microsurgical skills course for ophthalmology residents.

OBJECTIVE: Although theory-based schemes for course design are widely used in educational settings, making use of cognitive theory in the design of surgical skills courses in ophthalmology is rare. The primary aim of this study is to describe the application of instructional design, an established theory-based approach in course design, to the development of a surgical skills course for ophthalmology residents. The secondary aim of this study is to assess the educational effect of this theory-based course. DESIGN: A 1-day skills course was designed according to Gagné׳s events of instruction model, which was employed as a template for the instructional sequence of learning steps. Skills acquisition following the implementation of the model was measured with precourse and postcourse assessments. SETTING: Moorfields Eye Hospital organized the 1-day annual intermediate surgical skills course, which was hosted at the Royal College of Ophthalmologists' microsurgical skills laboratory. PARTICIPANTS: A total of 20 ophthalmology residents of Moorfields Eye Hospital participated in the study. RESULTS: A 1-day surgical skills course was formulated according to the instructional design principles outlined. The 4 objectives of the course (corneal suturing, corneal gluing, intravitreal injections, and eyelid suturing) were addressed in a parallel fashion as to allow for multiple objectives to be processed simultaneously, in the context of the instructional design sequence. Assessments demonstrated significant improvement in skills acquisition for the 4 course objectives. CONCLUSIONS: Instructional design is a valuable tool for planning effective surgical training courses as it is portable, allowing its application to a wide variety of outcomes and settings, and its terminology is simple and understandable to those working in clinical education.

Bringing together patient and specialists: the first Birdshot Day.

BACKGROUND: The importance of patient and public involvement (PPI) in healthcare decisions and research is increasingly recognised. This paper describes the aims, delivery, evaluation and impact of a 'Birdshot Day' organised for patients with birdshot uveitis, their carers and healthcare professionals. METHODS: Delivery of this event involved the close collaboration of patients with a large number of different healthcare professionals. The event's evaluation used established social research methods including qualitative questionnaires pre, post and 6 months following the event. The results were statistically analysed. RESULTS: Results indicated that this event significantly educated both patients and professionals. The sense of isolation felt by patients was reduced and networking was developed among all attendees. Patient priorities for research were recorded and invaluable insight into patients' needs for a better quality of life was gained. CONCLUSIONS: The first undertaking of this novel PPI event achieved all its aims. It became even clearer that fundamental questions remain about birdshot uveitis, including aetiology, pathogenesis, practical clinical issues and impact on quality of life. These questions can only be addressed in partnership with patients. To this end, patients and professionals came together under the banner 'Team Birdshot' and the National Birdshot Research Network was launched.

Toxoplasma gondii: an atypical presentation of toxoplasma as optic disc swelling and hemispherical retinal vein occlusion treated with intravitreal clindamycin.

BACKGROUND: To present a case of toxoplasmosis with an atypical presentation and treated successfully with intravitreal clindamycin. METHOD: A young Brazilian woman presented with panuveitis and disc swelling with associated hemispheric vascular occlusion in one eye. The presumed diagnosis was of a papillitis with vasculitis due to an unknown inflammatory condition. RESULTS: Following treatment with intravenous corticosteroids, macular star appeared 1 week after treatment. On the 2nd week, a focus of retinitis appeared, and the patient was started on antitoxoplasma treatment. This was poorly tolerated, and the patient was injected with intravitreal clindamycin. Inflammation eventually settled and an organized lesion typical of toxoplasma chorioretinitis was observed. CONCLUSION: We describe an unusual presentation and the detrimental effects of toxoplasmosis in an otherwise immunocompetent subject. As the patient was not tolerating systemic antitoxoplasma treatment, intravitreal injection was administered and proved to be effective and well tolerated.

Skills acquisition and assessment after a microsurgical skills course for ophthalmology residents.

OBJECTIVE: To assess the impact of a skills course on microsurgical skills acquisition and to investigate the validity of a video-based modified Objective Structured Assessment of Technical Skill (OSATS) assessment tool that has not previously been applied to ophthalmic surgery. DESIGN: Prospective longitudinal cohort study. PARTICIPANTS: Fourteen residents were recruited from 20 attendees at the Moorfields Eye Hospital microsurgical skills course for residents. METHODS: Each resident performed a standardized microsurgical task consisting of the placement of a 10-0 nylon corneal suture into a model eye using an operating microscope with standardized equipment in a standardized environment. Objective measurements were made using the Imperial College Surgical Assessment Device (ICSAD). This is a motion-tracking device returning 3 parameters for economy of movement: total path length, time, and number of individual hand movements. A concurrent video recording was made of each task by 2 independent observers who were masked to the time of the recording relative to the course and the identity of the resident. Video footage was marked in accordance with the OSATS video scoring template. MAIN OUTCOME MEASURES: Each resident had motion-tracking analysis performed during corneal suturing before and after the course (total path length, time, and number of individual hand movements), along with concurrent OSATS video scores. RESULTS: Skills improvement after the course was found to be statistically significant for all 3 ICSAD economy of movement parameters: path length, P = 0.001; hand movements, P = 0.012; and time, P = 0.009. Differences in the combined OSATS scores of the 2 raters before and after the course were found to be significant (P = 0.039). Interrater reliability of OSATS scorers was 0.78 (alpha Cronbach). Correlations between the OSATS scores and each of the ICSAD parameters were found to be significant (P<0.001). CONCLUSIONS: A video-based OSATS scoring system has significant correlation with the ICSAD motion-tracking parameters, demonstrating concurrent validity between the 2 assessment tools. These data also demonstrate that surgical skill, as measured by a validated motion-tracking system, is significantly improved after a 1-day microsurgical skills course. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Intraoperative use of intravitreal triamcinolone in uveitic eyes having cataract surgery: pilot study.

PURPOSE: To report the outcomes of cataract extraction with intraoperative intravitreal triamcinolone (IVTA) in eyes with a history of posterior uveitis. SETTING: Moorfields Eye Hospital Uveitis Service, London, United Kingdom. METHODS: Nineteen eyes of 17 patients with posterior uveitis thought to require systemic corticosteroid prophylaxis for cataract surgery were included. The use of systemic corticosteroids at the time of surgery would have been problematic in 7 of the patients, who had a history of systemic hypertension. Three of the 7 patients were also diabetic. All patients were not happy about using oral corticosteroids. RESULTS: Median visual acuity 1 day after surgery was 20/40 (range 20/20 to counting fingers). At final follow-up (mean 25.2 months; range 7 to 41 months), 17 eyes (89.5%) eyes achieved visual acuity of 20/40 or better; 2 eyes failed to achieve a final visual acuity of 20/40 or better, 1 as a result of optic atrophy and the other as a result of macular edema. No patient lost acuity and no eye developed macular edema within 4 months of surgery. Intraocular pressure elevation occurred after surgery in 3 eyes; all were controlled by topical medication that was discontinued after 3 months. One patient developed severe intraocular inflammation after surgery that resolved with intensive topical corticosteroid therapy within 1 week. CONCLUSIONS: Cataract extraction by phacoemulsification with concurrent IVTA appears a useful treatment option. Targeted delivery of corticosteroid is achieved without the risks of systemic corticosteroid prophylaxis. The incidence of postoperative macular edema was markedly reduced. Levels of visual acuity after cataract surgery, similar to those in eyes without uveitis, were achieved in eyes with posterior uveitis.

Protocol for the use of polymerase chain reaction in the detection of intraocular large B-cell lymphoma in ocular samples.

To determine the usefulness of polymerase chain reaction (PCR) analyses in the diagnosis of lymphoid infiltrate cells in ocular samples, PCR was performed using oligonucleotide primers specific for immunoglobulin heavy chain rearrangement at framework 2, framework 3, and t(14;18) translocation of the bcl-2 gene. These were used to successfully generate amplicons of 220 to 230 bp, 110 to 120 bp, and 175 to 200 bp, respectively. After PCR amplification, primers directed against the t(14;18) detected 10 pg of B-cell lymphoma DNA. PCR against Fr2 and Fr3 IgH rearrangement detected 10 fg and 10 pg in the seminested PCR, respectively. Conventional pathological methods were highly accurate at establishing the correct final diagnosis in formalin-fixed, paraffin-embedded samples but were much less sensitive and predictive in cytological specimens of intraocular fluid. A combination of the three PCR reactions was an equally successful diagnostic approach on paraffin-embedded samples, whereas single PCR reactions did not significantly improve diagnosis over histopathological diagnostic techniques. Thus, a combination of PCR reactions is useful in the detection of B-cell monoclonality, aids the differentiation between lymphomatous and inflammatory infiltrates, and is more powerful as a diagnostic method than single PCR or conventional cytopathology for lymphoid infiltrates in ocular fluid aspirates.

Scleritis.

Scleritis is typically a severe painful inflammatory process centered in the sclera that may involve the cornea, adjacent episclera, and underlying uvea; it poses a significant threat to vision. Careful clinical history taking, detailed ocular examination, appropriate investigation for ocular disease with or without underlying systemic disease, and timely intervention with the use of immunosuppressant drugs when necessary, has improved the long-term outcome for patients with this disease.

Use of PCR to diagnose Toxoplasma gondii chorioretinitis in eyes with severe vitritis.

Two cases are reported of intraocular inflammation in which severe vitritis hampered the fundal view, making an accurate clinical diagnosis impossible, and vitreous analysis using conventional techniques was unhelpful. PCR for Toxoplasma gondii was positive in both cases and provided the only way of confirming the diagnosis. Other ocular samples also underwent PCR for Toxoplasma DNA and the specificity of this approach is demonstrated.

Cystoid macular edema in uveitis.

Cystoid macular edema (CME) can cause profound visual loss and is one of the major causes of legal blindness in patients with uveitis. It can complicate virtually any type of acute or chronic, anterior or posterior uveitis. When mild and of short duration, CME may respond to treatment used to control the intraocular inflammation. However, patients may need more aggressive treatment with local and systemic steroid therapy and other immunosuppressive drugs. Unfortunately, CME may become refractory to all currently available therapies and result in severe visual loss.

The eye in systemic sepsis.

Metastatic or endogenous endophthalmitis (EE) is a serious consequence of systemic sepsis. It is defined as intraocular infection resulting from haematogenous spread of organisms in which the initial focus of infection is at a site distal to the eye. A red/sore eye in a patient with a known septic focus needs urgent attention as EE can be a major cause of visual loss. Early diagnosis and treatment are associated with better visual outcome. This article focuses on the two main causes of EE, namely bacterial and fungal infections, and also briefly mentions dissemination of cytomegalovirus to the eye in immunocompromised patients. Although conscious patients may notice an ocular problem, unconscious or very sick patients may not; vigilance by medical staff in looking for early signs of this is extremely important.