IMPORTANCE:Primary repair of open globe injury (OGI) is typically undertaken urgently. Imaging plays an important role in the preoperative assessment, including detection of an OGI and presence of an intraocular foreign body (IOFB). Evidence is lacking on the utility of preoperative imaging in diagnosing OGI and IOFB. OBJECTIVE:The primary objective is to assess the role of pre-operative imaging in OGI. Studies including patients who had sustained an OGI and reporting the findings of radiologic imaging in pre-operative assessment of OGI were eligible for inclusion. DATA SOURCES:A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, searching the Cochrane Central Register of Controlled Trials, PubMed, Medline and ClinicalTrials.gov. STUDY SELECTION:Prospective and retrospective studies reporting preoperative imaging assessment after OGI were included with no restriction on language or start date up until 15 December 2023. DATA EXTRACTION AND SYNTHESIS:Eleven studies, 10 retrospective and 1 prospective, with a total of 1126 patients were included, of which 8 assessed computed tomography (CT) detection of OGI and 3 assessed ultrasound for the detection of IOFB. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) tool. MAIN OUTCOMES AND MEASURES:Sensitivity of CT detection for OGI compared with clinical examination by an ophthalmologist and IOFB detection using intraoperative examination findings as gold standard. Preoperative B Scan ultrasonography (US) sensitivity for IOFB detection compared with CT. RESULTS:CT was 74% sensitive (95% CI 66.4% to 80.0%) and 93% specific (95% CI 88.2% to 95.4%) in OGI detection compared with clinical diagnosis. CT findings associated with OGI included scleral deformity, altered anterior chamber (AC) depth, lens abnormality and vitreous haemorrhage. CT was 69% sensitive (95% CI 51.4% to 82.0%) for IOFB detection using intraoperative examination findings as the gold standard.Preoperative B Scan US was not examined for OGI detection but had 86% sensitivity for IOFB detection (95% CI 77% to 92%) compared with the gold standard of CT, but safety with respect to pressure on the globe extruding intraocular contents was not studied. CONCLUSIONS AND RELEVANCE:CT had moderate sensitivity but high specificity for OGI detection, and therefore cannot replace clinical assessment by an ophthalmologist. A negative CT does not exclude an IOFB.

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PURPOSE:When severe retinal and corneal injury occur together, a temporary keratoprosthesis (TKP) is often a last resort to allow posterior segment visualization to enable vitreoretinal surgery, followed by a penetrating keratoplasty (PKP) which can restore corneal clarity in a single operation. We aimed to assess visual outcomes following combined PKP and vitreoretinal surgery with the use of a TKP for cases of ocular trauma. DESIGN:A systematic literature review was performed following PRISMA guidelines (PROSPERO registration number: CRD42023423518). METHODS:CENTRAL, MEDLINE, Embase, ISRCTN registry, and ClinicalTrials.gov were searched from inception to 27 April 2023. Randomized and nonrandomized studies assessing visual outcomes after combined vitreoretinal surgery and PKP with the use of a TKP after ocular trauma were eligible for inclusion. Outcomes included change in best corrected visual acuity, corneal graft survival and retinal reattachment at final follow up. Proportional meta-analysis was used to estimate the overall rate of the primary outcomes. Risk of bias for nonrandomized studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. RESULTS:A total of 19 studies met inclusion criteria reporting a total of 352 eyes. All studies were retrospective and nonrandomized with follow up times ranging from 6 to 91 months, with at least 79% of outcomes reported after 6 months. After combined surgery the rate of corneal graft survival was 52% (95% CI 0.41-0.62; I2 60%) successful retinal attachment was 79% (95% CI 0.73-0.84; I2 0%). and improved visual acuity, when compared to no change or decrease in visual acuity, was 45% (95% CI 0.32-0.59; I2 66%). CONCLUSION:Patients with severe injury affecting the anterior and posterior segments have very limited treatment options. This systematic review found that when combined vitreoretinal surgery and PKP with a TKP are performed, approximately half of corneal grafts survive, anatomically successful retinal reattachment is likely, and a similar proportion of patients benefit in terms of improved visual acuity, compared to their preoperative function. This systematic review of the available literature may help inform surgeons of the benefits of using a TKP for cases of ocular trauma.

Open globe injuries are a significant global cause of visual loss, including unilateral and bilateral blindness. Prognosis is predicted by injury severity, with lower presenting visual acuity and more posterior injuries associated with poor visual outcomes, although even the most severely injured eyes with no perception of light vision may regain some visual function. In addition to severity of the primary injury, the secondary injuries and complications causing poor outcomes include proliferative vitreoretinopathy (PVR) and endophthalmitis. Endophthalmitis is common after open globe injury, affecting up to 16.5% of patients. Systemic antibiotic prophylaxis is commonly used, with a limited evidence base, while intraocular antibiotics are less commonly used but have stronger supporting evidence of efficacy. Endophthalmitis rates are also reduced by prompt primary repair, which may also support recovery of visual acuity. PVR is not prevented or treated by any pharmacologic interventions in current clinical practice, but the incidence of post-traumatic PVR may be reduced by early vitrectomy within the first 4-7 days after injury. Ocular trauma training is often limited in Western ophthalmic surgical training programmes, and patients with ocular trauma often require the input of multiple subspecialists. In this context, it is important that patients have an overview and coordination of the different aspects of their care, with ownership by one lead clinician.

TOPIC:The timing of primary repair of open-globe injury is variable in major trauma centers worldwide, and consensus on optimal timing is lacking. CLINICAL RELEVANCE:Surgery is the mainstay of open-globe injury management, and appropriate timing of surgical repair may minimize the risk of potentially blinding complications such as endophthalmitis, thereby optimizing visual outcomes. METHODS:A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (International Prospective Register of Systematic Reviews identifier, CRD42023442972). The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and ISRCTN registries and ClinicalTrials.gov were searched from inception through October 29, 2023. Prospective and retrospective nonrandomized studies of patients with open-globe injury with a minimum of 1 month of follow-up after primary repair were included. Primary outcomes included visual acuity at last follow-up and the proportion of patients with endophthalmitis. Certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS:Fifteen studies met inclusion criteria, reporting a total of 8497 eyes. The most common injury types were penetrating and intraocular foreign body (IOFB). Meta-analysis found that primary repair less than 24 hours after open-globe injury was associated with 0.30 odds of endophthalmitis compared with primary repair conducted more than 24 hours after trauma (odds ratio, 0.39; 95% confidence interval [CI], 0.19-0.79; I2 = 95%; P = 0.01). No significant difference was found in reported visual outcomes between patients whose open-globe injuries were repaired more than, compared with less than, 24 hours after trauma (odds ratio, 0.89; 95% CI, 0.61-1.29; I2 = 70%; P = 0.52). All included studies were retrospective and nonrandomized, demonstrating an overall low certainty of evidence on GRADE assessment. DISCUSSION:Only retrospective data exist around the effect of timing of open-globe repair, resulting in low certainty of the available evidence. However, this review of current evidence, predominantly including penetrating and IOFB injuries, suggests that primary repair performed less than 24 hours after open-globe injury is associated with a reduced endophthalmitis rate compared with longer delays, consistent with delay to primary repair increasing endophthalmitis risk. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Background Standard treatment for tuberculosis (TB) in children and adults includes an initial two-month course of ethambutol, a drug that in rare cases can cause optic neuropathy and irreversible vision loss. There is a lack of clear guidance on what vision assessments are needed before and during treatment with ethambutol, with the Royal College of Ophthalmologists, National Institute for Health and Care Excellence, British National Formulary and British Thoracic Society offering different guidance. We aimed to assess how vision is routinely tested in patients treated with ethambutol in TB services across England. Methods An online survey developed by Public Health England was sent to all TB services in England in 2018 to assess current practice and inform the development of best practice recommendations for visual assessment of patients treated with ethambutol for TB. Results Sixty-six TB professionals from across England responded, a response rate of 54%. The results showed variations in practice, including when to omit ethambutol from treatment, the timing and frequency of visual assessment, the type of visual assessment, referral processes and management of visual changes. Conclusion This national survey highlights the need for clear guidelines on the testing of vision for patients taking ethambutol at recommended doses, before and during treatment. We suggest a pragmatic approach to visual assessment to reduce variation in practice, proposing a stepwise pathway for patients on standard TB treatment for local adaptation.

Eye health is an integral part of well-being that may be at increased risk when health service delivery is affected by sudden-onset disasters, complex humanitarian events, or conflict in resource-scarce environments. This study proposes a design plan for a mobile eye hospital to support health systems between the initial emergency response and recovery of health infrastructure in resource-scarce environments of low- and middle-income countries. The facility benefits from high mobility and modularity, it can be assembled and operated by minimal personnel, and easily expanded as necessary. It has capacity to host high-volume ophthalmological services without the logistical complexity of large-scale emergency medical team responses or military operations. The design provides a medium-term service that can either operate from a fixed location or be redeployed in-country with ease. Mobile eye hospitals may provide a useful facility for local governments suffering damaged health systems, or as a way to complement current eye health provision. The design may also be used by charitable nongovernmental organizations during an initial emergency response, with the ability to quickly deploy to a target location and establish eye services.

In 2020, COVID-19 caused widespread disruption to all aspects of medical care, including cancer screening procedures, elective surgeries and outpatient face-to-face appointments. As we emerge from this pandemic, we must plan for the inevitable increased service demand of non-COVID-19 conditions that have been neglected. One potential solution is to select appropriate services for delivery by qualified primary care physicians and increase their involvement in telemedicine services. Disruption to surgical procedures has caused a reduction in the detection rates of colorectal cancers (1,2), pri-marily screened through elective gastroscopies. Delayed screening procedures combined with the neoplastic nature of tumours results in diagnosis at more advanced stages, with a less favourable prog-nosis and the potential to cause severe problems for health care systems. An increase in emergency presentations of cancer at advanced stages requiring surgical intervention (e.g. colostomy), the long-term additional management this creates, and the strain on screening services are just some of the consequences (1). Moving appropriate elective procedures (e.g. gastroscopy, minor skin surgery) to primary care and equipping GPs with necessary training is a potential solution to help reduce the demands on the health care system. Guidelines for the requirements of primary care centres to perform minor surgeries have been published, indicating adequate infrastructure (3).

We present a rare case of tuberculous mastoiditis in a 2-month-old infant. The patient presented with facial nerve palsy, fever and otorrhoea and was subsequently confirmed to have a Mycobacterium tuberculosis infection. Mastoiditis was confirmed with a CT scan of the head, and gastric aspirate analysis with the Xpert MTB/RIF assay (Cepheid, USA) rapidly confirmed tuberculosis (TB), allowing prompt initiation of anti-TB therapy. The patient is now recovering, with the initial facial nerve palsy resolved.

Editor – The future of medical education is online and as the world restructures in the midst of this pandemic there is opportunity for this future to be expedited. As a group of medical students from the UK, we have seen great variation in the content of online education provided by medical schools, in lieu of normal teaching, to cater for students currently isolating at home. With the likelihood that online courses will become increasingly integrated into …

Stimes GT, Girotto JE. Applying pharmacodynamics and antimicrobial stewardship to pediatric preseptal and orbital cellulitis. Paediatr Drugs. 2019;21:427–38. Article Google Scholar Georgakopoulos CD, Eliopoulou MI, Stasinos S, Exarchou A, Pharmakakis N, Varvarigou A. Periorbital and orbital cellulitis: a 10-year review of hospitalised children. Eur J Ophthalmol. 2010;20:1066–72. Article Google Scholar Tsirouki T, Dastiridou AI, Ibanez Flores N, Castellar Cerpa J, Moschos MM, Brazitikos P, et al. Orbital cellulitis. Surv Ophthalmol. 2018;63:543–53. Article Google Scholar Amin N, Syed I, Osborne S. Assessment and management of orbital cellulitis. Br J Hosp Med. 2016;77:216–20. Article Google Scholar Wong SJ, Levi J. Management of pediatric orbital cellulitis: a systematic review. Int J Pediatr Otorhinolaryngol. 2018;110:123–9. Article Google Scholar Markham JL, Hall M, Bettenhausen JL, Myers AL, Puls HT, McCulloh RJ. Variation in care and clinical outcomes in children hospitalized with orbital cellulitis. Hosp Pediatr. 2018;8:28–35. Article Google Scholar European Centre for Disease Prevention and Control. Surveillance Atlas of Infectious Diseases. European Centre for Disease Prevention and Control; 2020. http://atlas.ecdc.europa.eu/public/index.aspx. Accessed 28 Jun 2020. Paediatric Formulary Committee. BNF for children 2016–2017. London, UK: BMJ Group, Pharmaceutical Press, and RCPCH Publications; 2016. Mathur S, Jackson C, Urus H, Ziarko I, Goodbun M, Hsia Y, et al. A comparison of five paediatric dosing guidelines for antibiotics. Bull World Health Organ. 2020;98:406–12F. Article Google Scholar McMullan BJ, Andresen D, Blyth CC, Avent ML, Bowen AC, Britton PN, et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: a systematic review and guidelines. Lancet Infect Dis. 2016;16:e139–52. Article Google Scholar World Health Organization. Global action plan on antimicrobial resistance. World Health Organization; 2015. https://www.who.int/antimicrobial-resistance/publications/global-action-plan/en/. Accessed 28 Jun 2020. Sharland M, Butler K, Cant A, Dagan R, Davies G, de Groot R, et al. editors. Manual of childhood infections: the blue book. 4th ed. Oxford, UK: Oxford University Press; 2016. The Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: periorbital and orbital cellulitis. The Royal Children’s Hospital Melbourne; 2019. https://www.rch.org.au/clinicalguide/guideline_index/Periorbital_and_orbital_cellulitis/. Accessed 28 Jun 2020. National Centre for Disease Control. National treatment guidelines for antimicrobial use in infectious diseases. Version 1.0. National Centre for Disease Control; 2016. http://pbhealth.gov.in/AMR_guideline7001495889.pdf. Accessed 28 Jun 2020. Jackson TL, editor. Moorfields manual of ophthalmology. 2nd ed. London, UK: JP Medical Ltd; 2016. ENT UK. Orbital cellulitis management guidelines—for adults & paeds. ENT UK; 2017. https://www.entuk.org/sites/default/files/files/ENT%20UK%20Revised%20Orbital%20Cellulitis%20Flow%20Chart%202017.pdf. Accessed 28 Jun 2020. Horizon Strategic Partners. MicroGuide. Horizon Strategic Partners; 2020. http://www.microguide.eu. Accessed 28 Jun 2020. Brighton and Sussex University Hospitals NHS Trust. Management of pre-septal and orbital cellulitis. Brighton and Sussex University Hospitals NHS Trust; 2014. https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2019/03/Paediatric-Guidelines-Pre-septal-and-orbital-cellulitis-2014.pdf. Accessed 28 Jun 2020. Gloucestershire Hospitals NHS Foundation Trust. Orbital cellulitis/peri-orbital cellulitis (paediatric). Gloucestershire Hospitals NHS Foundation Trust; 2017. https://www.gloshospitals.nhs.uk/gps/antimicrobial-resources/paediatric-antibiotic-treatment-guidelines-site-infection/orbital-peri-orbital-cellulitis-paediatric/. Accessed 28 Jun 2020. Northern Care Alliance NHS Group. Antibiotics guidelines: paediatric prescribing guidelines. Northern Care Alliance NHS Group; 2018. https://www.srft.nhs.uk/EasysiteWeb/getresource.axd?AssetID=21914t 2018. https://www.networks.nhs.uk/nhs-networks/north-west-paediatric-allergy-immunology-infection/documents/antimicrobial-paediatric-guidelines-15-11-2018/view. Accessed 28 Jun 2020. University Hospitals of Leicester NHS Trust. Management of children with preseptal and orbital cellulitis. University Hospitals of Leicester NHS Trust; 2017. https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Preseptal%20and%20Orbital%20Cellulitis%20UHL%20Childrens%20Hospital%20Guideline.pdf. Accessed 28 Jun 2020. Brady MT, Jackson MA, Kimberlin DW, Long SS, editors. Red book: 2018–2021 report of the committee on infectious diseases. 31st ed. Itasca, USA: American Academy of Pediatrics; 2018. World Health Organization. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses. 2nd ed. World Health Organization; 2013. https://www.who.int/maternal_child_adolescent/documents/child_hospital_care/en/. Accessed 28 Jun 2020. Download references University of Nottingham School of Medicine, Nottingham, UK David McMaster University Hospital Southampton NHS Foundation Trust, Southampton, UK Sanjay Patel The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK Catherine Marsh You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar Correspondence to David McMaster. The authors declare that they have no conflict of interest. Publisher’s note Springer...

Dear Editor, The coronavirus disease 2019 (COVID-19) has led to unexpected disruption to medical education in the UK. Medical schools are fast tracking final year medical students, giving provision...

As a group of medical students from the United Kingdom (UK), we currently find ourselves in a period of uncertainty as the continuing coronavirus disease 2019 (COVID-19) pandemic has caused widespread disruption to medical education. Our medical schools, like many others, have cancelled clinical placements, formal teaching, examinations and international elective programmes. Despite these challenges, we believe that the unprecedented COVID-19 pandemic is generating opportunities for both professional development and innovation in medical education. Social distancing is the most effective preventative strategy for COVID-19, but for many medical students this creates a gap where previously there were clinical attachments, a seemingly infinite syllabus and looming examinations. This unplanned interruption offers a unique opportunity for professional development, which may otherwise be missed, with the chance to consolidate learning, reflect on personal career plans and engage in academic research. Reflection helps us to process experiences and is a powerful way to facilitate learning. With over 60 specialties, and often limited exposure during medical school, choosing a career path in medicine can be daunting. There are many advantages in having a specialty interest when at medical school, and during this period it may be useful for those still unsure to reflect on past experiences and to consider their academic interests and what factors they value most in their careers. This unplanned interruption offers a unique opportunity for professional development, which may otherwise be missed, … Learning to critically evaluate research to inform future evidence-based practice is an essential skill that medical students must develop and, unsurprisingly, time constraints are often the greatest barrier to involvement in research.1 The General Medical Council recommends keeping up to date with current research in an individual's area of interest through independent study and by conducting literature searches and reviews. During the COVID-19 pandemic there will be barriers to engaging in laboratory- and hospital-based research; however, there is great value in performing systematic reviews of the literature and in taking part in qualitative research projects that may be conducted remotely, all of which will improve skills and strengthen applications to future training posts. We already know many fellow medical students engaging in reviews, video teaching, app development and even online language courses during self-isolation. Medical schools are rapidly trying to adapt their methods of teaching and assessment to accommodate the nationwide lockdown. During the severe acute respiratory syndrome (SARS) epidemic of 2003, Chinese medical schools cancelled clinical teaching and examinations. This led to the implementation of novel online problem-based learning that was so successful it was subsequently integrated into the curriculum.2 Similar to then, online teaching will play a key role in the continuation of the curriculum during the COVID-19 pandemic, with highly reproducible content accessible to students at home. During this rapid restructuring there are opportunities to strengthen engagement by involving students in the planning and execution of learning resources. Evidence shows that involving students as stakeholders in their education adds value and fosters intrinsic motivation, which strongly correlates with self-efficacy and academic performance.3 We encourage medical schools to actively engage with students to call on their ingenuity and to develop these resources, which may benefit medical education in the long term and motivate future educators. … there are opportunities to strengthen engagement by involving students in the planning and execution of learning resources The COVID-19 pandemic is catalysing an enduring transformation in medicine, with advances in telemedicine, disease surveillance and artificial intelligence, which have already been used to triage infected patients. We are experiencing an unparalleled boom in cross-industry cooperation to combat this virus, bringing together pharmaceutical, biomedical, data analytic and computational drug discovery companies with a singular goal. In the UK, we have seen airplane manufacturers, carmakers and Formula One teams repurpose their production lines to build ventilators to cope with rising demand. Johns Hopkins University has developed an interactive web-based dashboard to track COVID-19 in real time, and researchers at King's College London have created a COVID-19 symptom tracker app with more than 1.5 million downloads.4 Disruptive events, such as economic recessions and pandemics, can advance innovation, and there are opportunities here for resourceful initiatives in medical education. Students at Harvard Medical School have already created a rapidly updating COVID-19 curriculum, with the latest research and developments, that is benefiting many clinicians.5 In summary, as medical students affected by this global disruption, we see a rare opportunity for professional development in an otherwise heavily structured degree. In addition, innovation driven by medical students during this viral pandemic may accelerate the continuing transformation away from traditional teaching methods in medical education. Analysing the effects of this change, and professional development during the COVID-19 pandemic will have a lasting benefit for medical and scientific communities, and a long-lasting impact on future clinicians' practice.

BACKGROUND:In the UK there is limited coverage of antimicrobial stewardship across postgraduate curricula and evidence that final year medical students have insufficient and inconsistent antimicrobial stewardship teaching. A national undergraduate curriculum for antimicrobial resistance and stewardship is required to standardize an adequate level of understanding for all future doctors. OBJECTIVES:To provide a UK national consensus on competencies for antimicrobial resistance and stewardship for undergraduate medical education. METHODS:Using the modified Delphi method over two online survey rounds, an expert panel comprising leads for infection teaching from 25 UK medical schools reviewed competency descriptors for antimicrobial resistance and stewardship education. RESULTS:There was a response rate of 100% with all 28 experts who agreed to take part completing both survey rounds. Following the first-round survey, of the initial 55 descriptors, 43 reached consensus (78%). The second-round survey included the 12 descriptors from the first round in which agreement had not been reached, four amended descriptors and 12 new descriptors following qualitative feedback from the panel members. Following the second-round survey, a total of 58 consensus-based competency descriptors within six overarching domains were identified. CONCLUSIONS:The consensus-based competency descriptors defined here can be used to inform standards, design curricula, develop assessment tools and direct UK undergraduate medical education.