Retinal dialysis: are we missing diagnostic opportunities?

AIMS

To review medical records of those patients managed by our department for retinal dialysis, and establish whether the initial assessment had been adequate to make the diagnosis. That is, to establish if an adequate initial assessment had been performed that would reasonably exclude the likelihood of retinal dialysis and other trauma-related sequelae such as angle recession.

METHODS

A retrospective review was made of all patients managed for retinal dialysis at Sussex Eye Hospital between 20 March 1997 and 20 September 2002 (66 months). In addition to general demographic data, surgical management and outcome, patient files were reviewed for history of trauma, prior ophthalmic review, and whether such review included documentation of peripheral retinal examination and gonioscopy.

RESULTS

A total of 580 primary procedures were performed for retinal detachment during the review period, of which 32 eyes of 29 patients underwent surgery for retinal dialysis (6%). There were 21 male and eight female patients, with a history of trauma obtained in 55% (17 eyes, 16 patients). Of the 16 patients with prior trauma, nine had undergone prior ophthalmic review at the time or soon after their trauma; however, only 2 (22%) had documented evidence of indented peripheral retinal examination. Only one (3%) patient in the whole series had documented gonioscopy.

CONCLUSIONS

Patients with history of trauma often present at the time or soon after their injury (eg hyphaema, orbital fractures). Thus, an opportunity exists to screen patients for known sequelae of trauma such as retinal dialysis and angle recession. It was disappointing to learn that this opportunity was not always being utilized, with some patients consequently developing macula-off retinal detachments and potential for reduced visual outcome.

Vitreous haemorrhage without obvious cause: national survey of management practices

AIM

We undertook a national survey to establish the management of dense vitreous haemorrhage without obvious cause.

METHODS DESIGN

Cross-sectional anonymous self-reporting survey of ophthalmic practitioners within three target groups: vitreoretinal specialists (VRS), nonvitreoretinal specialists (NVRS), and associate specialists (AS).

INTERVENTION

Presentation of the hypothetical scenario of a patient presenting with recent onset (fresh) vitreous haemorrhage with no retinal view and no apparent cause on history taken at presentation.

OUTCOME MEASURES

The relative importance assigned by respondents to eight examination techniques at presentation. The proportion of respondents stating that they would review patients and perform B-scan examination at or prior to 2 weeks after presentation. The stated time to surgical intervention by VRS, and the time to referral by NVRS and AS.

RESULTS

VRS ranked B-scan examination higher than AS (P<0.001). A total of 98.1% of VRS indicated that they would next review patients within 2 weeks of presentation, this figure fell to 86.5% for NVRS and 47% for AS (P<0.001). A 98.1% of VRS indicated that they would next perform B-scan ultrasound within 2 weeks of presentation, this figure fell to 88.9% for NVRS and 70.6% for AS (P<0.001). The mean time to surgical intervention by VRS was 9.5 weeks without retinal tear demonstrated on B-scan, 1.7 weeks with retinal tear demonstrated on B-scan and 1 week with retinal detachment demonstrated on B-scan. The mean time to referral by NVRS was 6.7 weeks and by AS was 11.9 weeks.

CONCLUSIONS

Vitreoretinal specialists considered B-scan the most important examination tool, and typically perform B-scan early and frequently after presentation. Non-VR ophthalmologists (particularly associate specialists) review patients and perform B-scan ultrasound later and less often than vitreoretinal specialists. We recommend early referral to VR specialists, as reported referral even in uncomplicated cases would often be outside the timeframe within which VR specialists would typically choose to operate.

Undergraduate ophthalmology education survey of New Zealand ophthalmologists, general practitioners and optometrists

AIM

To determine what New Zealand ophthalmologists, general practitioners and optometrists consider important ophthalmic topic areas requiring emphasis in the medical undergraduate curriculum.

METHOD

A total of 793 questionnaires related to the content and teaching of undergraduate ophthalmology were sent to ophthalmologists, general practitioners and optometrists. Results were analysed separately for the three respondent groups and as a whole.

RESULTS

Four hundred and fourteen questionnaires were returned (52% return rate). Overall responses of the three participant groups were similar and agreed favourably with the current curriculum. The ability to measure visual acuity (97%) and pupillary reflexes (93%), perform ophthalmoscopy (92%), and assess visual fields (68%) were regarded as 'important or essential' by the majority of respondents. Only 53% of respondents consider the ability to diagnose chronic open angle glaucoma as important. The respondents stressed the importance of the diagnosis of predominantly anterior segment disease contrasting with the traditional bias towards the teaching of ophthalmoscopy and posterior segment disease. The majority of respondents stressed the importance of graduating medical students being able to treat bacterial and allergic conjunctivitis, styes, blepharitis, corneal abrasion, and corneal and conjunctival foreign bodies, areas present but not normally emphasized in current curricula.

CONCLUSION

The findings of this study provided additional data to facilitate curriculum design and illustrated the value of an integrated problem-based learning approach in ophthalmology undergraduate teaching.

X-ray turns a blind eye to ferrous metal

The case is reported of a 31-year-old man with a retained metallic intraocular foreign body (IOFB) in the left eye who underwent magnetic resonance imaging (MRI) for investigation of a subsequent unrelated brachial plexus injury Despite the patient providing good history of IOFB, the decision to proceed with MRI was based on screening orbit X-ray which was reported as normal. A review of published reports regarding screening recommendations for MRI for patients with IOFB is provided. A minimum recommendation is for prescreening questionnaire; belief of the patient history is critical. If there is any doubt after history and examination by an ophthalmologist, then computed tomography imaging of the orbits is recommended. Whether screening by plain X-ray imaging is worthwhile is debatable as the sensitivity and specificity of this modality is poor.

Upside-down orbitopathy: unilateral orbital dependent-tissue oedema causing total visual loss

The case is reported of a 24-year-old man who was involved in a road traffic accident and became trapped upside down with the right side of his face being the most dependent part of his body. Marked hemifacial tissue oedema was associated with right acute compressive orbitopathy and vascular compromise. Acute dysfunction of al orbital nerves was found on examination. Such neuropathy is usually related to the consequences of direct trauma, fractures or haemorrhage; however, computed tomography scanning demonstrated no evidence of orbital fracture or haemorrhage. Immediate anterior surgical orbital decompression was performed in the emergency room in addition to high dose intravenous steroids. Dependent orbtal tissue oedema is proposed as a mechanism of compressive orbitopathy with consequent ischaemic damage to all orbital nerves, total visual loss and complete ophthalmoparesis. Good recovery of other orbital nerves has occurred and the globe has reperfused. Despite intervention, no visual function has returned.

Cyanoacrylate glue for corneal perforations: a description of a surgical technique and a review of the literature

The effective early application of a cyanoacrylate glue corneal patch can aid in the management of small corneal perforations, corneal melts and wound leaks. Their use gives improved visual outcomes with reduced enucleation rates (6% vs 19%). It may also avoid the need for tectonic penetrating keratoplasty. Cyanoacrylate glue prevents re-epithelialization into the zone of damaged and naked stroma and prevents the development of the critical setting for collagenase production that leads to stromal melting. Cyanoacrylates also have significant bacteriostatic activity against gram-positive organisms. We describe a simple and easily reproducible method of cyanoacrylate corneal patch application, with neglible risk of inadvertent glue complications. It has the further advantage of a smooth corneal surface rather than an irregular surface as often occurs with direct application methods. With corneal application, the major concern is toxicity of cyanoacrylates through direct contact with the corneal endothelium and lens. Fibrin glues may be less toxic; however, they are not as readily available. The longer alkyl chains of currently available cyanoacrylate glues (e.g. Histoacryl) slows degradation significantly, limiting accumulation of histotoxic by-products to amounts that can be effectively eliminated by tissues. Vigilance in monitoring for infection/corneal infiltrate is necessary at all times, especially when the glue has been present for more than 6 weeks. Corneal patching with cyanoacrylate glue is a temporizing procedure only, buying time to allow healing secondary to medical treatment of the underlying condition, or allowing surgery to be elective and under more optimal conditions once inflammation has been reduced and the integrity of the globe restored.