Background Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9–61% of true cases. Objective To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. Design Prospective multicentre cohort study. Setting Secondary care. Participants A total of 381 patients referred with newly suspected GCA. Main outcome measures Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. Results We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician’s assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). Limitations There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. Conclusion We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. Future work Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. Funding The National Institute for Health Research Health Technology Assessment programme.

Results Clinical 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. ConclusionsThe 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 concept of an “organizing model” of trade unionism has shaped union strategies for revitalization in a number of countries in recent years. This article examines the transfer of “organizing unionism” to the UK in two ways. It presents findings from a survey of unions to identify the extent to which the organizing model is influencing national recruitment policy and presents case studies of three union campaigns which have drawn upon the organizing model, in an attempt to assess its strengths and weaknesses in a UK context. The survey results indicate only limited take‐up of the organizing model, though there is a group of vanguard unions which have embraced it with enthusiasm. The case studies demonstrate some success in applying the model, though identify employer resistance and internal opposition as significant constraints.

Primary angle closure glaucoma (PACG) is a major cause of blindness worldwide. We conducted a genome-wide association study (GWAS) followed by replication in a combined total of 10,503 PACG cases and 29,567 controls drawn from 24 countries across Asia, Australia, Europe, North America, and South America. We observed significant evidence of disease association at five new genetic loci upon meta-analysis of all patient collections. These loci are at EPDR1 rs3816415 (odds ratio (OR) = 1.24, P = 5.94 × 10(-15)), CHAT rs1258267 (OR = 1.22, P = 2.85 × 10(-16)), GLIS3 rs736893 (OR = 1.18, P = 1.43 × 10(-14)), FERMT2 rs7494379 (OR = 1.14, P = 3.43 × 10(-11)), and DPM2-FAM102A rs3739821 (OR = 1.15, P = 8.32 × 10(-12)). We also confirmed significant association at three previously described loci (P < 5 × 10(-8) for each sentinel SNP at PLEKHA7, COL11A1, and PCMTD1-ST18), providing new insights into the biology of PACG.

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Aim: To compare the long term mean intraocular pressure (IOP) reduction after non-augmented single site phacotrabeculectomy with that after trabeculectomy and to determine the relation between preoperative IOP and IOP reduction. Methods: A group of 44 consecutive patients with chronic open angle glaucoma who underwent phacotrabeculectomy were matched to a trabeculectomy control group and the results of surgery were compared. Linear regression analysis of preoperative IOP and IOP reduction was undertaken.Results: The mean IOP reduction was significantly less in the phacotrabeculectomy group (6.7 (SD 2.1) mm Hg) than in the trabeculectomy group (11.0 (1.4) mm Hg) (p=0.0017). There was a significant difference in surgical success between the groups. The preoperative IOP was significantly related to the postoperative reduction in IOP in both groups (p<0.001). Conclusions: In elderly white patients with chronic open angle glaucoma, phacotrabeculectomy is not as effective as trabeculectomy in reducing IOP. In both procedures the magnitude of IOP reduction is proportional to the preoperative IOP. I n recent years, there has been a widespread shift towards the use of combined phacotrabeculectomy as the surgical treatment of choice for coexisting cataract and glaucoma. 1 Despite its popularity, the efficacy of this operation compared to trabeculectomy remains unclear and published follow up periods are generally short, rarely exceeding a year.2-8 In addition, the relation between the preoperative IOP and IOP reduction after phacotrabeculectomy has not been previously reported.In this retrospective study, the long term efficacy of single site phacotrabeculectomy without intraoperative antimetabolites is compared to that of trabeculectomy in a matched group of patients and the relation between preoperative IOP and the magnitude of IOP reduction is examined. PATIENTS AND METHODSFrom September 1996 to July 2000, 44 consecutive patients with chronic open angle glaucoma (COAG) at low risk of bleb failure, underwent combined phacotrabeculectomy without antimetabolites by a single surgeon (JFS). The results of surgery were retrospectively analysed. All patients with COAG who underwent trabeculectomy without antimetabolites during the same period by the same surgeon were identified, and 44 were matched to the phacotrabeculectomy group with respect to age, sex, race, and preoperative IOP. All patients were followed for at least 12 months, with an average follow up of 29 (SD 3.4) months in both groups.Phacotrabeculectomy was performed using a fornix based, superior, one site approach. Phacoemulsification was undertaken through a 3.2 mm incision and a foldable three piece silicone IOL was placed into the capsular bag. The scleral tunnel was incised at its lateral borders to create a scleral flap and a punch was used to create an internal sclerectomy. A peripheral iridectomy was then undertaken and the scleral flap and conjunctiva were sutured with 10-0 nylon. Postoperative drops consisted of topical chloramphenicol and dexamethasone...

Malignant glaucoma is a rare form of glaucoma that typically follows surgery in patients with primary angle closure and primary angle-closure glaucoma. In this paper, the clinical features, classification, pathogenesis, and principles of management are discussed. Despite a high prevalence of primary angle closure glaucoma in South-East Asia, the vast majority of cases of malignant glaucoma are reported in White populations. This may reflect differing mechanisms of angle closure in White and Asian patients, which somehow reduces the likelihood of an aberrant relationship developing between the lens, ciliary body, anterior hyaloid, and vitreous structures within the eye. Although the exact underlying pathogenic mechanism remains unclear, the prognosis is good with modern medical, laser, and surgical treatment modalities.

Trabeculectomy. II. Variations in operative technique and outcome Abstract