PurposeTo determine if the reason(s) stated by the optometrist affect the positive predictive value (PPV) of referrals for suspected glaucoma.MethodsOptometrist referrals in Portsmouth are streamlined though the Glaucoma Referral Refinement Scheme (GRRS). We retrospectively analysed 100 ‘positive’ and 100 ‘negative’ referrals to the GRRS. Positives: those referred on to a secondary care glaucoma clinic; negatives: those discharged from the GRRS. Reason(s) for referral were determined and classified: intraocular pressure (IOP) optic disc changes (OD), visual field defect (VF), shallow anterior chamber depth (ACD). Since negative referrals to GRRS are four times more prevalent than positives, we calculated a ‘corrected’ PPV for each reason by multiplying the number of negatives by 4.ResultsThe overall PPV was 0.16. 70.4% cases were referred for a single reason (47.2% IOP, 12.2% OD, 8.8% VF, 2.4% ACD); the PPV was 0.11 for IOP and for OD, 0.05 for VF, 0.17 for ACD. 26.2% were referred for two reasons; the PPV was 0.47 for IOP + OD, 0.21 for OD + VF and 0.14 for IOP + VF. 4.2% were referred for IOP + OD + VF with a PPV of 0.62. Positive family history of glaucoma (21.4% referrals) did not increase PPV. The GRRS increased the PPV to 0.8.ConclusionsThe majority of patients are referred for a single reason, yet the chance of a positive diagnosis is low. Accuracy is increased when IOP is reported in combination with OD, but VF adds little value as a second parameter. The highest PPV is found when all three reasons are stated (IOP + OD + VF). The proportion of referrals for IOP alone is similar to that found prior to the NICE guidelines. However, the PPV is considerably lower; 0.11 compared to 0.3–0.4 found in previous studies. In the NICE era, refinement schemes play an important role in reducing false positive referrals.
PurposeTo determine if the reason(s) stated by the optometrist affect the positive predictive value (PPV) of referrals for suspected glaucoma.MethodsOptometrist referrals in Portsmouth are streamlined though the Glaucoma Referral Refinement Scheme (GRRS). We retrospectively analysed 100 ‘positive’ and 100 ‘negative’ referrals to the GRRS. Positives: those referred on to a secondary care glaucoma clinic; negatives: those discharged from the GRRS. Reason(s) for referral were determined and classified: intraocular pressure (IOP) optic disc changes (OD), visual field defect (VF), shallow anterior chamber depth (ACD). Since negative referrals to GRRS are four times more prevalent than positives, we calculated a ‘corrected’ PPV for each reason by multiplying the number of negatives by 4.ResultsThe overall PPV was 0.16. 70.4% cases were referred for a single reason (47.2% IOP, 12.2% OD, 8.8% VF, 2.4% ACD); the PPV was 0.11 for IOP and for OD, 0.05 for VF, 0.17 for ACD. 26.2% were referred for two reasons; the PPV was 0.47 for IOP + OD, 0.21 for OD + VF and 0.14 for IOP + VF. 4.2% were referred for IOP + OD + VF with a PPV of 0.62. Positive family history of glaucoma (21.4% referrals) did not increase PPV. The GRRS increased the PPV to 0.8.ConclusionsThe majority of patients are referred for a single reason, yet the chance of a positive diagnosis is low. Accuracy is increased when IOP is reported in combination with OD, but VF adds little value as a second parameter. The highest PPV is found when all three reasons are stated (IOP + OD + VF). The proportion of referrals for IOP alone is similar to that found prior to the NICE guidelines. However, the PPV is considerably lower; 0.11 compared to 0.3–0.4 found in previous studies. In the NICE era, refinement schemes play an important role in reducing false positive referrals.
PurposeThe England screening service classification of diabetic retinopathy has strict, quality assured criteria to identify potential diabetic maculopathy termed ‘M1’. All new M1 cases identified by the screening service are referred to a hospital service. We aimed to evaluate the effectiveness of the England National Diabetic Eye Screening R1M1 classification of diabetic maculopathy as a criteria for secondary care referral in Portsmouth, UK.MethodsRetrospective audit of all patients referred to Portsmouth Hospitals NHS Trust with R1M1 pathology from April 2013 to January 2014. The total number of referrals received for this period was noted as well as the number of patients followed up in subsequent care pathways. Follow‐up data on those who remained under hospital care is presented for three years.ResultsA total of 306 diabetic patients were referred to Portsmouth Hospitals NHS Trust for R1M1 pathology over a 10 month period. At the first hospital appointment 135 (44%) had no fluid present on macular SD OCT and were either referred back to screening if the M1 features had resolved (65) or followed up with retinal images (70). 115 (38%) patients were considered to require further follow‐up in secondary care. Of those patients remaining in secondary care 70 remained in active follow up 3 years later.ConclusionsThese results would suggest that 44% of those with M1 features have no evidence of diabetic maculopathy on OCT at the initial hospital appointment and were discharged to community screening. Follow‐up for over three years in a secondary care setting is required by 23%. Secondary service could be better utilised by streamlining referrals either by refining the R1M1 classification or developing community based OCT service.
PurposeDespite advances in optical coherence tomography (OCT), clinicians have few prognostic indicators. We chose anomalous features found in OCTs, and retrospectively analysed OCT images for subsequent progression in visual acuity (VA), OCT results and interventions required over 22–24 months.MethodsPutative risk factors were grouped into sets based on similar putative aetiology: sub‐retinal fluid and large cysts, hyperreflective dots, partial/total disorganisation of retinal inner layers (DRIL) and photoreceptor disruption, epiretinal membranes, vitreomacular traction, vitreomacular adhesion. Eyes were stratified according to how many of these groups of features they displayed (0–4) and were all treated as per protocol and clinical need.ResultsIncreasing risk factors correlated with increasing initial OCT central retinal thickness (CRT) (387 vs. 555) and volume (9.99 vs. 11.28), and poorer initial visual acuity (0.41 vs. 0.60) on presentation.Whilst final CRT results showed no significant differences between the groups (325–248 nm), and no significant differences between numbers of injections performed (6.8 vs. 7.35), more features correlated with poorer VA, both absolute and relative to baseline, irrespective of whether there had been previous treatment.ConclusionsThese features are better prognostic indicators than OCT measurements alone.
PurposeTo report risk factors and visual outcomes of cataract surgery complicated by posterior capsule rupture (PCR) at Portsmouth Hospital over an 11 year period (2004–2015)MethodsA search of all cataract surgery complicated by PCR was performed on our Electronic Patient Record (EPR). Clinical data was extracted from the EPR, patient case notes and clinical letters. Only patients with a minimum of 3 months VA recorded were included.ResultsIn total 366 patients were identified. The mean number of cataract operations performed per year was 3,832 giving an overall PCR rate of 0.98%. Of the cases affected the average age was 74 years and 56% were female. The most common risk factors were dense cataract (15%), high myopia (8%) and previous vitrectomy (6%). Thirty five percent of PCR cases occurred during a trainee surgical list. Initial mean best corrected VA in all patients was 0.68, 0.62 at 3 months and 0.46 at 1 year. The mean length of follow up was 35 months and the mean VA was 0.36 at the final visit.ConclusionsPCR rate at Portsmouth is almost half the national rate. We found in our cohort of patients, previous vitrectomy was a common risk factor which was not reflected in the Royal College of Ophthalmologists’ National Database. Over a third of PCR occurred during trainee lists, emphasising the need for risk stratification preoperatively to identify difficult cases.
PurposeTo report the functional and anatomical outcomes of using intravitreal ranibizumab (IR) for patients with ischaemic diabetic maculopathy (IDM).MethodsRetrospective analysis of 11 consecutive patients treated with IR for IDM from Nov 2008 to May 2015. The number of injections, fluorescein fundus angiography (FFA) results, visual acuity (VA) and central retinal thickness (CRT) prior to commencing IR were recorded. VA was assessed with logMAR.ResultsThree eyes were excluded as one had a history of vein occlusion, one was amblyopic and the other patient had multiple vitreous haemorrhages and vitrectomy.There were equal numbers of females and males, the average age was 67 (34–82 years) and patients had on average 5 (range 3–11) injections of IR. Average length of follow up was 13 months (5–18 months). On FFA 4 patients had enlargement of foveal avascular zone (FAZ), 1 patient had fragmentation of FAZ, 1 patient had deregulation of FAZ and 1 patient had an increase in FAZ. The average initial VA was +0.9 (+0.3 to +1.78) and the average final VA was +1.05 (+0.6 to +1.78). The average change between initial and final VA was +0.15. Initial average CRT was 558 (306–785) reducing to an average of 447 (197–892) at the final follow up. The average CRT reduction was 111 between initial and final CRT.ConclusionsAnatomical thickness appears to be reduced with IR injections, but without improvement in visual acuity. No adverse complications were noted with this regimen.
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