Evaluating referrals of flashing lights and floaters coming into secondary care from primary care.

CLINICAL RELEVANCE: Optometrists should look to take every opportunity to expand their knowledge, understanding and skills pertaining to vitreoretinal conditions. BACKGROUND: Despite the existence of acute eye care schemes and the up-skilling of optometrists, many units are still noticing large numbers of poor-quality referrals with high false positive rates. The authors pondered whether these schemes are effective. METHODS: At two different time points, a prospective analysis of patients took place, of all the flashing lights and floaters referrals coming into secondary care at the Royal Glamorgan Hospital, Wales, UK. The following data was captured: the exact source of the primary care referral, the diagnosis being queried, the secondary care diagnoses made and the secondary care management decisions. The accuracy of retinal break and Shafer's sign detection were also directly compared between primary care and secondary care using Cohen's Kappa Coefficient. RESULTS: For the 2018 period, n = 51 patients were included. For the 2022-23 period n = 100 patients were included. The majority of referrals during both periods were from optometrists (>80%) via the WECS pathway. The most common diagnoses being queried were retinal breaks (~50%), followed by retinal detachments (~20%). Interestingly up to 20% of patients seen in secondary care were diagnosed as normal examinations and ~ 20%. Over 1/3 of patients were discharged after their first visit to the EEC. Statistically significant differences were found between the accuracy of retinal tear and Shafer's identification between the primary and secondary care settings. CONCLUSION: A high number of false positive referrals are coming into secondary care from the WECS pathway and clear training and education needs have been identified.

Prevalence of peripapillary hyperreflective ovoid mass-like structures (PHOMS) in suspected papilloedema in children.

PURPOSE: Suspected papilloedema is a frequent cause of referral to paediatric ophthalmology clinics. Recent publications have described a new finding called peripapillary hyperreflective ovoid mass-like structures (PHOMS) that may cause pseudopapilloedema. We evaluated the optical coherence tomography (OCT) scans of the optic nerve in all children referred with suspected papilloedema for the presence of PHOMS and report their frequency. METHODS: The optic nerve OCT scans from children seen in our suspected papilloedema virtual clinic between August 2016 and March 2021 were evaluated for the presence of PHOMS by three assessors. A Fleiss' kappa statistic was calculated to test the agreement between the assessors for the presence of PHOMS. RESULTS: A total of 220 scans from 110 patients were evaluated during the study period. The mean patient age was 11.2 SD ± 3.4, (range 4.1-16.8). PHOMS were identified in at least one eye in 74 (67.3%) patients. Of these, 42 (56.8%) patients had bilateral and 32 (43.2%) had unilateral PHOMS. Excellent agreement between assessors for the presence of PHOMS (Fleiss' kappa 0.9865) was observed. PHOMS were common in association with other identified causes of pseudopapilloedema (81.25%) but were also common in papilloedema (66.67%) and otherwise normal discs (55.36%). CONCLUSIONS: Misdiagnosis of papilloedema can lead to unnecessary and invasive tests. PHOMS are found frequently within the paediatric population referred for suspected disc swelling. They appear to be an independent cause of pseudopapilloedema but are often seen in conjunction with true papilloedema and other causes of pseudopapilloedema.

Ophthalmic emergencies presenting to the emergency department at the University Hospital of Wales, Cardiff, UK.

BACKGROUND: Community-based optometry services are increasingly used as a primary resource for patients with acute eye problems. The Eye Health Examination Wales (EHEW) is an example of one such established scheme. The aim of the project was to show how the aforementioned pathway has affected the presentation of ocular conditions to a general emergency department and the eye casualty department at the same hospital. METHODS: Clinical data were collected prospectively over a one-month period. The records of 100 consecutive patients with ocular pathology presenting to a general emergency department were analysed. Numbers were also obtained for the number of patients seen under the EHEW scheme by community optometrists for the same period. The notes of patients referred to ophthalmology or back out to the community optometry scheme were followed to monitor for re-attendance in either setting. RESULTS: Eighty-five per cent of patients were walk-in cases. The most common diagnosis made in the emergency department was 'no abnormality found' in 37 per cent. Eighty per cent of all conditions were discharged from the emergency department. Fifteen per cent of all cases, mainly foreign body-related, were followed up in the emergency eye clinic and 10 per cent were sent to EHEW for follow-up. No cases re-presented to a hospital service at a later date. CONCLUSION: At least 37 per cent of emergency department cases could have been potentially avoided had the patient presented to the EHEW scheme. The pathway for patients to be sent from the emergency department to an EHEW optometrist does not appear to delay presentation to an ophthalmologist thereafter. Further promotion of the EHEW service is needed to change patient behaviours and reduce avoidable attendance to overstretched emergency departments.

In patients with a positive family history of familial adenomatous polyposis can the condition be diagnosed from the presence of congenital hypertrophy of the retinal pigment epithelium detected via an eye examination: A systematic review.

In classic familial adenomatous polyposis (FAP) adenomas become malignant. Congenital hypertrophy of the retinal pigment epithelium (CHRPE) is a retinal pigmented lesion and is the earliest and most common potential extraintestinal manifestation of FAP. This review aims to summarize and analyse all of the published data on CHRPE in patients with classic FAP and then ascertain whether these patients should undergo a relatively cheap and non-invasive dilated fundus examination to screen for CHRPE. Adhering to Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines our database search identified 102 relevant articles of which 13 were selected for further analysis. The percentage of FAP patients with CHRPE was found to be 80.00%, whereas the percentage of at-risk patients with CHRPE was 31.12%. Despite various statistically significant findings, CHRPE alone cannot be used as a surrogate for diagnosing FAP in those with a positive family history. The authors advocate a combined approach of eye examinations, colonoscopy and genetic testing.

Pulmonary embolism, frostbite and high-altitude retinopathy - a combination of life- and sight-threatening vascular complications at high altitude.

The effects of high altitude on the human vascular system are well described. This case demonstrates an interesting combination of vascular complications at high altitude which were both life- and sight-threatening. In May 2017, during an attempt on Mount Everest, a 58-year-old man was forced to descend from 8000 m because of adverse weather. He suffered significant frostbite of his right hand, later requiring termination of the distal phalanx of one of the affected digits. He also experienced increasing breathlessness and went on to develop pleuritic chest pain. A CT pulmonary angiogram performed upon return to sea level revealed multiple small sub-segmental pulmonary emboli. He was anticoagulated for three months and made a full recovery. The patient also reported visual loss in the left eye and on ophthalmic examination was found to have multiple retinal haemorrhages including a left macular haemorrhage, consistent with high altitude retinopathy. The retinal haemorrhages settled with conservative management. The vascular complications suffered by this patient demonstrate the potentially fatal changes that can occur at altitude. They also serve to act as a reminder for physicians, even at sea level of the potential complications in patients returning from high altitude.

Pre-Medical Students' View Points on Integrated Poster Presentations as a Tool for Learning Medical Science.

BACKGROUND: A poster presentation is an experiential learning activity that stimulates curiosity and interest among students. Moreover, it encourages exploration and integration of concepts and provides students with a novel way to demonstrate their understanding of scientific principles. This pilot projects aimed to analyse views of participants on the academic benefits and learning of medical sciences via poster presentations. METHODS: This cross-sectional study used the sequential exploratory type of mixed methods design in which quantitative data analysis was performed via survey-based questionnaires and qualitative study. For this purpose, we performed a thematic analysis of semi-structured interview questions that were administered to all participants using the self-interview technique. RESULTS: A majority of students were of the opinion that the process of making poster preparation acted as an opportunity to promote deep learning. Moreover, a majority expressed that making these presentations required teamwork, which gave them an insight into collaborative learning. CONCLUSION: Our study revealed that poster presentations, when used effectively as an assignment, can facilitate a learner's critical and reflective thinking and promoting active learning. Previous generic guidelines for making posters were found to be an important step that led to a systematic scientific approach amongst learners as well as for integrating basic science and medical knowledge.

Unilateral cancer-associated retinopathy: a case report.

We write to report a rare case of unilateral cancer-associated retinopathy previously undocumented in the literature. Cancer-associated retinopathy is an uncommon paraneoplastic syndrome. It is characterised by retinal antigen autoantibodies causing rod and cone dysfunction and abnormal electroretinography findings with consequent progressive visual loss.Our patient, known to have a primary cervical intraepithelial neoplasia, presented with unilateral blurred vision as well as a disturbance in colour and night vision. Electroretinography findings of reduced a and b waves in the right eye, together with a fundoscopic appearance of a mottled retinal pigment epithelium, attenuated blood vessels and optic disc pallor were consistent with unilateral cancer-associated retinopathy. Posterior subtenon injections of triamcinolone were administered to control active disease. With periocular steroid injections, at 4 years, our patient's visual acuity remained relatively stable and her condition persisted strictly unilaterally. Cancer-associated retinopathy may be the first presenting sign of an underlying malignancy or may indicate its recurrence. Moreover, in patients with a diagnosed gynaecological malignancy, visual symptoms could reflect cancer-associated retinopathy. In our patient visual symptoms came secondary to the diagnosis of cancer.