Systemic corticosteroid use in UK Uveitis practice: results from the ocular inflammation steroid toxicity risk (OSTRICH) study

OBJECTIVES

To ascertain adherence to an international consensus target of ≤7.5 mg/day of prednisolone for maintenance systemic corticosteroid (CS) prescribing in uveitis and report the frequency of courses of high-dose systemic CS in the UK.

METHODS

We conducted a national, multicentre audit of systemic CS prescribing for uveitis at 11 UK sites between November 2018 and March 2019. High-dose CS was defined as (1) maintenance >7.5 mg prednisolone for >3 consecutive months, or (2) >1 course ≥40 mg oral CS or ≥500 mg intravenous (IV) methylprednisolone in the past 12 months. Case notes of patients exceeding threshold CS doses were reviewed by an independent uveitis specialist and judged as avoidable or not, based upon a scoring matrix.

RESULTS

Of 667 eligible patients, 285 (42.7%) were treated with oral or IV CS over the preceding 12 months; 96 (33.7%) of these exceeded the threshold for high-dose CS. Twenty-five percent of prescribing in patients on excess CS was judged avoidable; attributed to either prescribing long-term CS without evidence of consideration of alternative strategies, prescribing error or miscommunication. More patients received immunomodulatory therapy (IMT) in the group treated with CS above threshold than below threshold (p < 0.001) but there was no significant difference in doses of IMT.

CONCLUSION

33% of patients had been prescribed excessive corticosteroid when compared to the reference standard. An analysis of decision-making suggests there may be opportunity to reduce excess CS prescribing in 25% of these patients.

Ponatinib Inducing a Panuveitis with Choroidal Effusions and Neurosensory Retinal Detachment in a Patient with Chronic Myeloid Leukaemia

CASE SUMMARY

We present the case of a 50 year old male patient being treated for chronic myeloid leukemia by the tyrosine kinase inhibitor, Ponatinib. After 3 months of treatment, he developed a sight-threatening granulomatous panuveitis in both eyes, with choroidal effusions and neurosensory retinal detachments. Except for a positive interferon-gamma release assay suggesting previous Tuberculosis exposure, all uveitis investigations were normal. Discontinuation of the suspected causative drug led to resolution of signs and a consequent improvement in visual acuity.

CONCLUSION

Ponatinib use may be associated with with a uveitic phenotype that is reminiscent of Harada's disease. We compare and contrast this rare ocular phenomenon with Vogt-Koyanagi-Harada syndrome and discuss a possible immunological basis.

Unilateral acute maculopathy associated with adult onset hand, foot and mouth disease: case report and review of literature

Background

Acute maculopathy is a rare condition of unknown aetiology and Coxsackie virus is known to be associated with this macular chorioretinitis.

Findings

We report a case of acute unilateral maculopathy in a 35-year-old woman with concurrent hand foot and mouth disease. Furthermore, we display multimodal imaging (colour fundus photographs, autofluorescence, spectral domain ocular coherence tomography, fluorescein angiography and indocyanine green angiography) charting the course of the disease. The source of the virus was thought to be the patient's child. Empirical treatment with oral corticosteroids was commenced and the inflammation resolved, leaving a residual macular scar.

Conclusions

We present this case combined with the review of literature of adult onset Coxsackie-virus-associated retinitis. This case reiterates the fact that Coxsackie virus is an uncommon but important consideration in the differential diagnosis of chorioretinitis and posterior uveitis with atypical retinopathy.

"Cryoanalgesic preparation" before local anaesthetic injection for lid surgery

INTRODUCTION

Lid surgery under local anaesthetic is commonplace in ophthalmic practise. The most distressing part of the surgery for the patient is often the injection of local anaesthetic into the sensitive lid skin. Various methods like pre-injection warming of the anaesthetic agent, buffering pH levels, varying agents used, and using thinner gauge needles have been tried to reduce pain levels. Cooling of tissue is known to have anaesthetic properties and has been proposed as a substitute to injection of local anaesthetic in certain surgical procedures. In this study we use the anaesthetic property of cooling, as a pre local anaesthetic injection procedure ("Cryo-preparation"). The anaesthetic injection induced discomfort with and without "cryo-preparation" was then assessed.

METHODS

Thirty-nine patients aged 13-85 years (mean = 50, s.d. = 19) were randomly allocated and assessed. Twenty-two patients underwent local lid anaesthetic infiltration with "cryo-preparation," and 17 without. Pain monitoring was performed subjectively and objectively by scoring systems. Results were analysed using unpaired two tailed t-test on Microsoft Excel.

RESULTS

Significant reduction in injection pain with cryo-preparation (24.6% reduction in score) was achieved (statistically significant p = 0.039). Surgical anaesthesia was complete in all cases.

CONCLUSION

The study shows that "cryopreparation" by local ice application immediately prior to local anaesthetic injection reduces the sensitivity to the injection by a significant 24.6%. Thus while all the advantages of good analgesia are obtained from the injection, the distressing discomfort is reduced. This study serves as a pilot, in demonstrating a novel method of pain control for lid surgery.

Risk management strategies following analysis of cataract negligence claims

INTRODUCTION

Clinical governance and risk management is very important in today's clinical practice. Cataract surgery is one of the most common procedures performed in the NHS, with around 200,000 operations per year. In order to help minimise the frequency of negligence claims, we performed a collaborative study to analyse claims relating to cataract surgery, dealt with by the defence organisations of England, Scotland, Wales, and Northern Ireland.

MATERIALS AND METHODS

All claims dealt with by the Medical Defence Union, the Medical Protection Society, and the Medical and Dental Defence Union of Scotland from January 1990 to December 1999, were analysed by three ophthalmologists with at least 5 years' speciality experience. Recurrent themes were identified and claims were grouped by major causative factor. The findings were discussed by a panel compromising the authors in conjunction with the defence unions and risk management strategies were designed.

RESULTS

There were 96 claims within the 10- year period analysed. Of these, the largest group (52) pertained to claims that related to accepted complications of cataract surgery. The remainder comprised two groups: 'Medical Errors' (anaesthetic, surgeon, and biometry) and 'Other Claims' comprising subjective complaints, pain and poor visual outcome. A total of 16 claims had been settled by May 2002, 45 are ongoing and 35 have closed without settlement.

CONCLUSIONS

The majority of claims pertained to well-recognised complications of cataract surgery. If these risks are adequately explained to the patient before surgery and if the care provided reaches a standard acceptable to a responsible body of professional opinion, all such claims should be defensible. Good visual outcome does not protect against litigation.

Repeatability of ocular blood flow pneumotonometry

PURPOSE

To establish the repeatability of ocular blood flow (OBF) pneumotonometry and its agreement with Goldmann tonometry.

DESIGN

Instrument evaluation study.

PARTICIPANTS

Ten female healthcare professionals.

METHODS

Intraocular pressure (IOP) was measured by one experienced ophthalmologist in both eyes of 10 healthy female subjects on 10 different occasions at the same time of day. The two methods were performed by alternate allocation, and laterality was chosen by random order. Repeatability coefficients and agreement plots were calculated by using the Bland-Altman method.

MAIN OUTCOME MEASURES

Intraocular pressure repeatability coefficients.

RESULTS

Mean IOPs were 15.6 mmHg (right) and 15.1 mmHg (left) by OBF pneumotonometry and 12.6 mmHg (right) and 12.4 mmHg (left) by Goldmann tonometry (P < 0.001). The repeatability coefficients were 7.06 (right) and 7.66 (left) for the OBF pneumotonometer and 4.81 (right) and 3.87 (left) for the Goldmann tonometer. With regard to agreement, the OBF pneumotonometer read significantly higher than did the Goldmann tonometer. The mean bias for the right eye was 2.92 (95% limits of agreement, -4.37 to 10.20), and for the left eye it was 2.68 (95% limits of agreement, -3.93 to 9.28).

CONCLUSIONS

In our group of healthy females, the repeatability of the OBF pneumotonometer was worse than that of the Goldmann tonometer. This casts doubt on the value of the OBF pneumotonometer as a tool for measuring IOP. The agreement plots indicate that the OBF pneumotonometer may produce significant numbers of false-positive results in screening programs.