A Quality Improvement Project of Acute Red Eye Consultations in Primary Care: Improving the Identification of Red Flags

Aim The acute red eye or conjunctival injection is the most common ophthalmic presentation in primary care. The aim of this audit was to improve red eye consultations by increasing the number of red flag features documented in the history of patients. Method The National Institute of Clinical Excellence (NICE) Clinical Knowledge Summary (CKS) outlines red flag features, which should be documented for an acute red eye consultation. Two interventions were implemented to attempt to improve consultations. The first involved creating a template in the Egton Medical Information Systems. The second involved training doctors in the recognition of red flag features and identifying sight-threatening conditions. Red eye consultations and red flag features documented were recorded in the two months before and after the interventions. Results All documentation of red flag features assessed in this project increased post intervention. However, lateralisation, visual changes, and eye pain were commonly asked prior to the intervention and did not show a statistically significant difference. They showed an increase from 90% (19/21) to 100% (19/19), 71% (15/21) to 84% (16/19), and 67% (14/21) to 79% (15/19), respectively. After the interventions, significant increases in asking about headaches (14% (3/21) to 74% (14/19), pupil changes (5% (1/19) to 58% (11/19)), and method of injury (high velocity 10% (2/21) to 84% (16/19), foreign body 14% (3/21) to 84% (16/19), chemical 10% (2/21) to 84% (16/19) were observed (p<0.05). Photophobia inquiries also significantly increased (14% (3/19) to 79% (15/19), P<0.05). Conclusion  The number of red flag features identified and documented for acute red eye consultations increased with the introduction of an online template and a teaching session.

Pneumatic Retinopexy Versus Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment: Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

This study aims to compare the outcomes of pneumatic retinopexy (PnR) versus pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD).

MATERIALS AND METHODS

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. An electronic search was conducted identifying six comparative studies of PnR versus PPV for RRD enrolling 1,061 patients. The primary outcome was visual acuity (VA). Anatomical success and complications were the secondary outcomes.

RESULTS

No statistically significant difference was observed in VA between the groups. There was a statistically significant difference in the odds of re-attachment favoring PPV over PnR (odds ratio [OR] = 0.29, P < 0.00001). No statistically significant difference was found in final anatomical success (OR = 1.00, P = 1.00) and the development of cataracts (OR = 0.34, P = 0.61). Other complications, including retinal tears and postoperative proliferative vitreoretinopathy, were more frequently reported in the PnR group.

CONCLUSION

PPV has a higher rate of primary reattachment compared to PnR for treating RRD with comparable final anatomical success, complications, and VA outcomes. [Ophthalmic Surg Lasers Imaging Retina 2023;54:xx-xx.].

Mycophenolate versus Methotrexate in Non-infectious Ocular Inflammatory Disease: A Systematic Review and Meta-Analysis

PURPOSE

To compare the outcomes of mycophenolate mofetil (MMF) versus methotrexate (MTX) in non-infectious ocular inflammatory disease (NIOID).

METHODS

The study was performed as per the PRISMA Guidelines. A search identified all studies comparing MMF versus MTX in NIOID. Treatment result and side effects were primary outcomes.

RESULTS

Four studies enrolling 905 patients were identified. There was no significant difference between MMF and MTX groups in overall treatment success (OR = 0.97, P = .96), treatment failure (OR = 0.86, P = .85). MTX showed a significantly improved effect in cases involving posterior uveitis and panuveitis (OR = 0.41, P = .003). In addition, MTX was associated with a faster median time to treatment success and had less side effects when compared to MTX, however this was not significant. For secondary outcomes, no significant difference was found in visual acuity and resolution of macular oedema.

CONCLUSION

MMF is comparable to MTX in the treatment of NIOID.

Mohs Micrographic Surgery Versus Standard Excision for Basal Cell Carcinoma in the Head and Neck: Systematic Review and Meta-Analysis

The objective of this study was to quantitatively compare outcomes between standard excision (SE) and Mohs micrographic surgery (MMS) for basal cell carcinoma (BCC). A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic databases was conducted to identify all randomised controlled trials (RCTs) and observational studies comparing the outcomes of SE versus MMS for BCC. The primary outcome was the recurrence rate for primary and recurrent BCC. The secondary outcomes included the cost of treatment, aesthetic results, the rate of incomplete excision, and the surgical defect size post excision. Five studies enrolling 2060 lesions were identified. There was a statistically significant difference between MMS and SE groups in terms of recurrence rate for primary BCCs (odds ratio (OR) = 0.44, confidence interval (CI) = 0.16 to 0.97, P = 0.04) and recurrent BCCs (OR = 0.33, CI = 0.12 to 0.97, P = 0.04). For secondary outcomes, MMS had improved results compared with SE, except for mean cost. In conclusion, both primary and secondary BCCs treated with MMS have a reduced recurrence rate and defect size thus simplifying reconstruction. However, due to higher costs and operative time attributed to MMS, it should be reserved for high-risk BCCs.

Chest CT versus RT-PCR for the detection of COVID-19: systematic review and meta-analysis of comparative studies

OBJECTIVES

To compare the performance of chest computed tomography (CT) scan versus reverse transcription polymerase chain reaction (RT-PCR) as the reference standard in the initial diagnostic assessment of coronavirus disease 2019 (COVID-19) patients.

DESIGN

A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A search of electronic information was conducted using the following databases: MEDLINE, EMBASE, EMCARE, CINAHL and the Cochrane Central Register of Controlled Trials.

SETTING

Studies that compared the diagnostic performance within the same patient cohort of chest CT scan versus RT-PCR in COVID-19 suspected patients.

PARTICIPANTS

Thirteen non-randomised studies enrolling 4092 patients were identified.

MAIN OUTCOME MEASURES

Sensitivity, specificity and accuracy were primary outcome measures. Secondary outcomes included other test performance characteristics and discrepant findings between both investigations.

RESULTS

Chest CT had a median sensitivity, specificity and accuracy of 0.91 (range 0.82-0.98), 0.775 (0.25-1.00) and 0.87 (0.68-0.99), respectively, with RT-PCR as the reference. Importantly, early small, China-based studies tended to favour chest CT versus later larger, non-China studies.

CONCLUSIONS

A relatively high false positive rate can be expected with chest CT. It is possible it may still be useful to provide circumstantial evidence, however, in some patients with a suspicious clinical presentation of COVID-19 and negative initial Severe Acute Respiratory Syndrome Coronavirus 2 RT-PCR tests, but more evidence is required in this context. In acute cardiorespiratory presentations, negative CT scan and RT-PCR tests is likely to be reassuring.

Functional cognitive disorder: what is it and what to do about it?

To err is human, and it is normal to make minor cognitive errors from time to time. Some people experience persistent subjective cognitive difficulties that cause distress and functional impairment, with no underlying structural, neurodegenerative, toxic or metabolic cause. This is considered a form of functional disorder. In this article, we review functional cognitive disorder and outline its core clinical features. Patients with this are typically of working age and have a source of psychological distress, such as chronic pain, work stress or family difficulties. Its distinction from incipient dementia is difficult and usually requires interval follow-up. Pointers towards possible dementia include abnormal neuroimaging or loss of insight. Many patients accept a functional cognitive disorder diagnosis and willingly engage with psychological therapies but there is no defined optimal treatment. Functional cognitive disorder is common but under-studied; future research priorities include the development of clear diagnostic criteria and robust trials of therapeutic strategies.