John F. Salmon

The National Survey of Trabeculectomy. III. Early and late complications.

Purposeu2003There is a considerable body of literature relating to trabeculectomy, however there are no data representative of the national experience of trabeculectomy in the United Kingdom (UK). The Department of Health funded a national survey of trabeculectomy to establish current practice patterns and the outcome of trabeculectomy in the National Health Service (NHS). In this paper we present the reported complications of first-time trabeculectomy from a nationally representative cohort of patients with chronic open angle glaucoma.Methodsu2003Cross-sectional study of consultant ophthalmologists performing trabeculectomy in the NHS. Participants recruited their four most recent consecutive first-time trabeculectomy cases with chronic open angle glaucoma according to study eligibility criteria and data were collected by self-administered questionnaire. Follow-up: one year post-trabeculectomy. Main outcome measures: occurrence of early and late complications.Resultsu2003Clinical outcome data were available for 1240 (85.3%) of cases. Early complications were reported in 578 (46.6%) cases and late complications in 512 (42.3%) cases. Some cases had more than one complication. The most frequent early complications were hyphaema (n = 304, 24.6%), shallow anterior chamber (n = 296, 23.9%), hypotony (n = 296, 24.3%), wound leak (n = 216, 17.8%) and choroidal detachment (n = 175, 14.1%). The most frequent late complications were cataract (n = 251, 20.2%), visual loss (n = 230, 18.8%) and encapsulated bleb (n = 42, 3.4%). The occurrence of most complications was not associated with a consultant’s specialist interest, level of activity, type of hospital or region. Encapsulated bleb was reported more frequently in a university hospital setting.Conclusionsu2003The complication rates reported in this paper represent the national experience of first-time trabeculectomy for open angle glaucoma in the UK. These are similar to previous published studies and highlight in particular, the impact of trabeculectomy on visual acuity in the first year following surgery. This survey provides valid and clinically relevant data on the complications of trabeculectomy for the production of guidelines and standards for audit at regional, local and individual level.

The National Survey of Trabeculectomy. II. Variations in operative technique and outcome

Purpose There is a considerable body of literature relating to trabeculectomy; however, there are no data representative of the national experience of trabeculectomy in the United Kingdom (UK). The Department of Health funded a national survey of trabeculectomy to establish current practice patterns and the outcome of trabeculectomy in the National Health Service (NHS). In this paper we report variations in surgical technique and the national success rate of trabeculectomy.Methods A cross-sectional survey was carried out of consultant ophthalmologists performing trabeculectomy in the NHS. Participants recruited their four most recent consecutive first-time trabeculectomy cases according to study eligibility criteria and data were collected by self-administered questionnaire. Follow-up: 1 year post-trabeculectomy. Main outcome measure of success: final intraocular pressure (IOP) less than two-thirds the pre-operative IOP. Secondary outcome measures of success: final IOP less than 21 mmHg and visual field stability. Success was further defined as unqualified (excluding patients on anti-glaucoma medications at final follow-up) or qualified (including patients on anti-glaucoma medications at final follow-up). The relationship between variables characterising consultants practice and main outcome measure was examined by chi-square test.Results Clinical outcome data were available for 1240 (85.3%) cases. There were wide variations in operative technique. The mean post-operative IOP was 14.4 mmHg (95% CI 14.2-14.7), which is a mean reduction of 11.8 mmHg (95% CI 11.4-12.2). An unqualified success, in terms of the main outcome measure, was achieved in 66.6% of patients and a qualified success in 71.0% of cases. An unqualified success, in terms of a final IOP less than 21 mmHg, was achieved in 84.0% of cases and a qualified success in 92.0%. Visual fields were stable in 84.2%. Outcome was not related to consultants specialist interest, level of activity, type of hospital or region.Conclusions The success rates reported in this paper represent the national experience of first-time trabeculectomy for open angle glaucoma in the UK. The national success rate at 1 year compares favourably with many studies in the literature. This survey provides valid and clinically relevant measures of success for the production of guidelines and standards for audit at regional, local and individual level and a baseline for the comparison of new therapies.

The Dimensions of Eyes with Chronic Angle-closure Glaucoma.

The measurement of eyes with primary angle-closure glaucoma has been comprehensively documented in people of European ethnic origin. In comparison, few biometric studies have examined the relationship of one intraocular structure to another in people of Oriental or African ethnic background with primary angle-closure glaucoma. To determine the ocular characteristics of people with this ethnic background suffering from chronic angleclosure glacoma, both eyes of 46 patients with chronic angle-closure glaucoma were measured by contact A-scan ultrasonography, and the measurements were compared with those found in two groups of 23 matched normals. The correlation between the measurements obtained in the right and left eyes in each group was statistically significant (p < 0.001). Although the mean axial length was less (22.43 mm vs. 23.17 and 23.25 mm, p = 0.0001), the mean anterior chamber depth shallower (2.48 mm vs. 2.80 and 2.81 mm, p < 0.001). and the mean relative lens position more anterior in eyes with chronic angle-closure glaucoma compared with normal, the mean lens thickness in all three groups was similar (4.73 mm). These measurements are significantly different from those reported in other ethnic groups. In comparison with the previously reported findings in Europeans, an anterior lens position without significant lens enlargement is responsible for the crowded anterior segment in our patients with chronic angle-closure glaucoma.

Motteno Tube Implantation for Neovascular Glaucoma

Background: The Molteno implant has been shown to be useful in the treatment of neovascular glaucoma. However, a wide range of success rates has been reported. This is related to the use of differing criteria for success, varying periods of follow-up, and difficulty in quantifying the preoperative condition of the eye. Methods: The authors studied the long-term results of the Molteno single-plate implant in 60 eyes with neovascular glaucoma using Kaplan-Meier life-table analysis. Age, visual acuity, underlying retinal diseases, and preoperative retinal ablation treatment were evaluated to establish factors influencing the surgical outcome. The criteria for success included a postoperative intraocular pressure (lOP} of less than or equal to 21 mmHg and maintenance of vision. Results: The success rate was 62.1% at 1 year, 52.9% at 2 years, 43.1% at 3 years, 30.8% at 4 years, and 1 0.3% at 5 years. The main causes for failure were loss of light perception in 48% of eyes (29/60}, progression to phthisis bulbi in 18% (11 /60}, and encapsulation of the filtering bleb in 10% (6/60}. The long-term surgical outcome was significantly better in patients older than 55 years of age (P = 0.048} and in those with a preoperative visual acuity equal to or better than 6/60 (P = 0.019}. Eyes with neovascular glaucoma secondary to diabetic retinopathy had a better prognosis than those with a central retinal vein occlusion (P = 0.003}. Conclusion: Although the lOP can be significantly reduced after Molteno implantation, this study suggests that in severely compromised eyes with neovascular glaucoma the main advantage of Molteno implantation is pain relief and avoidance of enucleation. Ophthalmology 1993;100:897-902

The national survey of trabeculectomy. I. Sample and methods

Purpose The National Survey of Trabeculectomy was designed to evaluate current practices of glaucoma surgery in the United Kingdom and to determine the success and complication rates of trabeculectomy on a national basis. This paper reports the survey methods, levels of consultant activity, waiting times, indications for surgery and the demographic and clinical characteristics of the patient sample.Methods Consultant ophthalmologists performing trabeculectomy in the United Kingdom were studied. Four consecutive patients undergoing trabeculectomy under each consultant prior to 18 June 1996 were retrospectively sampled. Patients were followed prospectively and evaluated 6 and 12 months after surgery. Data were collected by self-administered postal questionnaires. To determine the effects of selection and reporting bias a validation study of 14 randomly selected units was also conducted.Results Three hundred and eighty-two consultants recruited 1454 eligible patients for analysis. The mean age of patients was 69.2 years (standard deviation 10.9) and 51.7% were male. The underlying diagnosis was primary open angle glaucoma in 89.2%, pseudoexfoliation glaucoma in 5.4%, normal tension glaucoma in 3.8% and pigmentary glaucoma in 1.6%. There was advanced visual field damage in 50.5% of the cohort by the time of listing. The main indications for surgery were failure of medication to control intraocular pressure in 57.1%, progressive visual field loss in 26.5% and progressive optic disc damage in 4.8%. Primary surgery was undertaken in 4.8% of patients. In 80% trabeculectomy was performed within 3 months of listing. However, almost a third of consultants considered individual patients waiting time too long. Validation studies confirmed that systematic bias did not operate in the selection of patients for the survey or in the reporting of outcomes.Conclusion The findings of this survey are representative of current practices of trabeculectomy by consultants throughout the United Kingdom and show considerable variation in practice. Failure to control intraocular pressure with topical medications was the main indication for surgery. Advanced glaucomatous visual field damage was present at the time of surgery in half the sample. Though most patients were operated on within 3 months of listing, almost a third of consultants considered the wait unacceptably long.

Post-traumatic angle recession glaucoma: a risk factor for bleb failure after trabeculectomy.

In order to determine if post-traumatic angle recession is a risk factor for failure of glaucoma filtering surgery independent of age or race, the surgical results of trabeculectomy performed in 35 consecutive patients with angle recession glaucoma were compared with those of 35 matched patients with primary open angle glaucoma. A postoperative intraocular pressure of < or = 21 mm Hg (with or without glaucoma medication) was found in 15 of the 35 (43%) patients with angle recession glaucoma compared with 26 of the 35 (74%) patients with primary open angle glaucoma. The long term success of trabeculectomy was significantly worse in angle recession glaucoma when the results were analysed using Kaplan-Meier survival curves. Bleb failure occurred a mean period of 3.1 (SD 1.2) months after trabeculectomy in angle recession glaucoma compared with 9.4 (5) months in primary open angle glaucoma (p < or = 0.001). The finding that posttraumatic angle recession is a risk factor for failure of trabeculectomy, supports the use of antimetabolite therapy to suppress fibrosis after trabeculectomy in these patients.

Recurrent posterior scleritis and orbital myositis as extra-intestinal manifestations of Crohn's disease: Case report and systematic literature review

BACKGROUNDnOcular episcleritis and uveitis are well-recognised extra-intestinal manifestations of Crohns disease. Orbital myositis is rare: to our knowledge it has been associated with Crohns disease in thirteen cases. Posterior scleritis, orbital myositis and Crohns disease have been reported as coexisting in only two cases.nnnMETHODS AND RESULTSnWe describe a third case, that of a 31-year old female with Crohns colitis for 8xa0years, complicated by enteropathic arthritis and pyoderma gangrenosum. She presented with intense and intractable periorbital pain, particularly at night and worse on eye movements. B-scan ultrasonography confirmed posterior scleritis and treatment with high dose oral steroids (up to 60xa0mg prednisolone) was initially effective, but subsequently failed to control the inflammation. There was only a partial response to infliximab. Five months after presentation, diplopia developed, with failure of abduction of the left eye. MRI scan of the orbits confirmed orbital myositis involving the left lateral and medial rectus muscles. Pulsed intravenous methylprednisolone and six cycles of intravenous cyclophosphamide over a three month period resulted in complete resolution of inflammatory symptoms.nnnCONCLUSIONSnThis case highlights a rare combination of ocular abnormality secondary to Crohns disease and reports successful resolution with aggressive immunosuppressive therapy.

Direct ophthalmoscopy should be taught to undergraduate medical students—yes

The place of ophthalmology in the undergraduate medical curriculum is slowly fading—with certainty, and yet without objection. Over the past 30 years, the duration of the ophthalmology placement has dwindled in the United States,1 the United Kingdom,2 and elsewhere.3 The inescapable truth is that without renewed activism from ophthalmologists interested in the education of tomorrows doctors,1 the ophthalmology clerkship—exposed by poor representation from ophthalmologists on medical school committees—may soon disappear entirely.1, 2, 3 The likely outcome is a generation of clinicians who lack confidence and competence in basic ophthalmic examination,1 the management of simple eye complaints, and the safe triaging of patients under their care who develop serious ophthalmic disease.4 n nSkills in direct ophthalmoscopy among undergraduates have declined in parallel.5 Medical students lack confidence in direct ophthalmoscopy,6 and often request additional training to improve their performance.7 Several challenges exist for ophthalmologists and others involved in training of direct ophthalmoscopy: (1) reduced exposure to ophthalmology clinics where direct ophthalmoscopy is traditionally taught; (2) ownership of direct ophthalmoscopes in the United Kingdom has fallen since 1986 following withdrawal of grants traditionally used to fund them;8 (3) there is no clear consensus as to the standard of proficiency in direct ophthalmoscopy a medical student should satisfy;1, 9 (4) direct ophthalmoscopy is poorly represented in undergraduate examinations2—an influential determinant of student learning behaviour. n nWith crisis comes opportunity, and approaches have been suggested to address these challenges:1, 10 to identify and prioritize essential ophthalmic clinical skills; to advocate for ophthalmology clerkships in the undergraduate curriculum; to integrate ophthalmology in the teaching of all basic sciences and allied clinical disciplines; and to innovate to create opportunities for clinical training in ophthalmology for undergraduates.10 One cannot advocate direct ophthalmoscopy without supporting undergraduate ophthalmology training around it: fundal findings are interpreted in the context of other elicited clinical signs, synthesized with relevant clinical knowledge to accurately triage or manage a patients ocular complaint. n nIt is common for patients with ophthalmic symptoms to present to primary care, minor injury units, and emergency departments.11 Immediate access to an ophthalmologist for clinical assessment is not universal. Non-specialist clinicians have a duty of care to perform a competent basic ophthalmic examination—of which direct ophthalmoscopy may be an essential component—to safely assess or triage a patient.11, 12 Omission of the components of a basic ophthalmic examination may be medico-legally indefensible, yet is common.4 n nDirect ophthalmoscopy adds a valuable weapon to the diagnostic armamentarium of a clinician. The identification of spontaneous venous pulsation may exclude raised intracranial pressure and prevent the need for acute neuroimaging in a child with meningococcal meningitis.13 The detection of papilloedema may be life-saving—potentially indicating a cerebral space occupying lesion or accelerated hypertension.14 Concealed systemic disorders may be elucidated on direct ophthalmoscopy, for example, endocarditis or cytomegalovirus retinitis—obviating the need for invasive investigations. Abusive head trauma may be supported by the finding of bilateral retinal haemorrhages on direct ophthalmoscopy in an infant with unexplained encephalopathy.15 n nDirect ophthalmoscopy may accurately distinguish causes of acute, painless visual loss into those requiring immediate treatment or referral (such as central retinal artery occlusion) from those which may be referred non-urgently (central retinal vein occlusion). Timely diagnosis of retinal artery occlusion could permit reversal of sight loss or prevent an impending stroke through identification of an embolic source. Swift recognition of leukocoria on direct ophthalmoscopy may improve visual outcome in congenital cataract or eye-saving in cases of retinoblastoma. n nTo deprive medical students of a valuable clinical skill will leave them exposed in such contexts, and may endanger their patients.12 The cost of its omission is the additional time, investigation, anxiety, and travel required of a patient to arrive at a diagnosis—or worse—failure to make a diagnosis at all. Medical school committees would consider it unthinkable to omit training in cardiac auscultation simply because it is a difficult clinical skill. They would challenge any assertions that it is specialist skill undertaken only by cardiologists, or that an echocardiogram may safely circumvent it. Put simply, it is bad medicine to omit direct ophthalmoscopy in such contexts. Accordingly, the relegation of direct ophthalmoscopy from the undergraduate medical curriculum may be considered negligent. n nTechnological advances may, in time, supersede the direct ophthalmoscope. The pan-ophthalmoscope circumvents the technical skill of direct ophthalmoscopy, but not the interpretation of the retinal image. Non-mydriatic digital fundus cameras promises accurate remote diagnosis by ophthalmologists using images captured by non-specialists at the point of care16 (emergency departments, primary care). It requires investment and training, and few ophthalmic units have established it. It is unlikely to be available in the foreseeable future in the developing world. n nThe imperative for ophthalmologists to protect the teaching of direct ophthalmoscopy transcends the diagnostic value of the clinical skill itself. It strikes at the quintessence of the real issue of ophthalmology in the undergraduate curriculum: influential non-specialists contend—largely unchallenged—that the responsibility for ophthalmic assessment, diagnosis and treatment rests exclusively with the ophthalmologist. Defending the place of direct ophthalmoscopy in the undergraduate curriculum emphasizes our opposition to the global relegation of ophthalmology, and underlines a clear message: basic skills in ophthalmic assessment are mandatory. Students are required to learn them, doctors to practice and teach them, and patients to receive them. To forfeit direct ophthalmoscopy is to concede to this erroneous notion of diminished responsibility for ophthalmic health by non-specialists. Ophthalmologists are on occasion witnesses to mistakes in referral or assessment by non-specialists—errors whose root cause is the inadequate training at the undergraduate level, and where an irretrievable attitude of passivity to ophthalmology is ingrained. As ophthalmologists we are advocates for ophthalmic health. We must take action locally, regionally, and nationally to preserve direct ophthalmoscopy—and ophthalmology—in the undergraduate medical curriculum for the benefit of our future patients.1, 12 n nIt is in the interests of the Royal College of Ophthalmologists to support it. Why? ‘Ut Omnes Videant: so that all may see.

Anaphylactic response to topical fluorescein 2% eye drops: a case report

IntroductionThe intravenous use of fluorescein 10% during retinal angiography can cause severe systemic reactions including, on rare occasions, anaphylaxis. Fluorescein 2% eye drops are used extensively for clinical examination and diagnosis, but to the best of our knowledge, they have only been reported as being responsible for a systemic anaphylactic response on two previous occasions.Case presentationWe report the case of a 51-year-old woman who developed an anaphylactic reaction when she was administered fluorescein sodium 2% eye drops after cataract surgery. This was the second time she had been exposed to fluorescein. She had brittle asthma and a history of anaphylaxis following exposure to a variety of drug and food allergens. She was successfully resuscitated and recovered completely over a period of two days.ConclusionsFluorescein 2% drops are universally used in general practice, ophthalmology, optometry, and casualty departments. Our case report reveals the potential for this benign eye drop to cause a life-threatening systemic reaction and emphasises the importance of considering this consequence when administering topical fluorescein 2% to a patient with a history of anaphylaxis to other allergens.

Ten‐year outcomes in newly diagnosed glaucoma patients: mortality and visual function

Objectives: To determine the mortality within ten years of diagnosis of chronic open angle glaucoma and the visual field progression amongst survivors of a group of patients who were followed for 10 years. Patients and methods: Of the 436 patients seen in a glaucoma case-finding clinic between July 1994 and December 1995 a diagnosis of chronic open angle glaucoma was made in 65. Ten years after diagnosis the outcome of the 57 patients who were treated at the Oxford Eye Hospital was determined. The causes of death were obtained from the general practitioner records and from the official death certificates. The probability of death was analysed using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. The visual outcome was analysed at the 10-year follow up visit. Findings: Seventeen patients (29.8%) died during the 10-year period, including nine from cardiovascular disease. The mean (SD) age at presentation of those that died was 76.4 years (9.7) compared with 69.5 years (10.9) for survivors (pu200a=u200a0.029). Using a nine-stage grading system, 42 eyes (52.5%) did not deteriorate, 30 eyes (37.5%) deteriorated by one stage, seven eyes (8.75%) two stages and one eye (1.25%) three stages over the 10-year period. The average time to first deterioration by one stage was 8.51 years (CI 7.92 to 9.10). The mean (SD) intraocular pressure was 25.6 mmHg (5.8 mmHg) on presentation and 15.7 mmHg (3.0 mmHg) at the end of 10 years. Conclusion: Approximately two thirds of patients will still be under care 10 years after presentation. In older, white patients with glaucoma the overall goal of preventing visual handicap is achievable for most patients 10 years after diagnosis.