PurposeTo assess the diagnostic accuracy of the Edinburgh diplopia diagnostic algorithm.MethodsThis was a prospective study. Details of consecutive patients referred to ophthalmology clinics at Falkirk Community Hospital and Princess Alexandra Eye Pavilion, Edinburgh, with double vision were collected by the clinician first seeing the patient and passed to the investigators. The investigators then assessed the patient using the algorithm. An assessment of the degree of concordance between the 'algorithm assisted' diagnosis and the 'gold standard' diagnosis, made by a consultant ophthalmologist was then carried out. The accuracy of the pre-algorithm diagnosis made by the referrer was also noted.ResultsAll patients referred with diplopia were eligible for inclusion. Fifty-one patients were assessed; six were excluded. The pre-algorithm accuracy of referrers was 24% (10/41). The algorithm assisted diagnosis was correct 82% (37/45) of the time. It correctly diagnosed: cranial nerve (CN) III palsy in 6/6, CN IV palsy in 7/8, CN VI palsy in 12/12, internuclear ophthalmoplegia in 4/4, restrictive myopathy in 4/4, media opacity in 1/1, and blurred vision in 3/3. The algorithm assisted diagnosis was wrong in 18% (8/45) of the patients.ConclusionsThe baseline diagnostic accuracy of non-ophthalmologists rose from 24 to 82% when patients were assessed using the algorithm. The improvement in the diagnostic accuracy resulting from the use of the algorithm would, hopefully, result in more accurate triage of patients with diplopia that are referred to the hospital eye service. We hope we have demonstrated its potential as a learning tool for inexperienced clinicians.

Purpose To assess the diagnostic accuracy of the Edinburgh visual loss algorithm. Methods This was a prospective study. Patients referred to the Edinburgh Eye Pavilion with visual loss were assessed using the Edinburgh Visual Loss Algorithm by either a medical student, an inexperienced ophthalmology trainee or an optometrist in the Lothian Optometry Treat and Teach clinic. Accuracy of this 'algorithm-assisted' diagnosis was then compared with the 'gold-standard' diagnosis, made by an experienced ophthalmologist. Accuracy of the pre-algorithm diagnosis, made by the referrer, was also compared with the algorithm-assisted diagnosis. Results All patients referred with visual loss were eligible for inclusion. Seventy patients were assessed; two were excluded. Pre-algorithm accuracy of referral of patients with visual loss was 51% (30/59). Overall, the algorithm-assisted diagnosis was correct 84% (57/68) of the time. The algorithm correctly diagnosed: retina in 71% of cases (5/7), macula in 86% (25/29), peripheral retina in 100% (2/2), optic nerve in 71% (5/7), media opacity in 89% (16/18), post chiasmal in 100% (4/4), and refractive error in 0% (0/1). Accuracy of diagnosis was similar for each algorithm user; medical student 81%, inexperienced ophthalmology trainee 84% and optometrist 92%. Discussion The baseline diagnostic accuracy of clinicians who are inexperienced in ophthalmology rose from 51 to 84% when patients were assessed using the algorithm. This algorithm significantly improves the diagnostic accuracy of referrals to the hospital eye service, regardless of the user's previous ophthalmic experience. We hope we have demonstrated its potential as a learning tool for inexperienced clinicians.

There have been significant changes in the management of out of hours services in ophthalmology recently. The European Working Time Directive (EWTD) and economic measures have anecdotally reduced the availability of staff and facilities outside normal working hours, and there have been various responses to the provision of emergency surgical care. There are disparate attitudes to the optimum management of the emergency surgical case. We sought to establish a nationwide picture of the management of out of hours surgery. A questionnaire was distributed to every consultant ophthalmologist working in the NHS and registered with the Royal College of Ophthalmologists (n=947). Information was requested regarding departmental and personal policies, local facilities, and personal beliefs regarding emergency surgery. A total of 440 (46.5%) questionnaires were returned from 155 units; 18.7% of the units had no out of hours services or no operating facilities. Sixty-three percent of units reported a local policy regarding a time after which patients should not be taken to theatre. For 57%, this time began between 2100 hours and midnight. The most common reasons for not operating after a certain time were ‘belief that delay does not significantly affect the outcome’ (41.6%), ‘delayed access to theatre due to competition with other surgical specialities’ (40%), and ‘no specialist ophthalmic-theatre nursing input’ (32.7%). We report the first nationwide study on out of hours ophthalmological surgical working practices. This demonstrates variation in work patterns. It is significant to patients and ophthalmologists that there should be units in United Kingdom without full local facilities and staff.

AIMS:To analyse the outcome of small margin (up to 2 mm) excision of primary clinically well-defined periocular basal cell carcinomas (BCCs).METHODS:Retrospective evaluation of 90 well-demarcated primary BCCs having a minimum follow-up of 36 months. All patients underwent excision of the tumour with maximum margins of 2 mm. Resulting defects were, if possible, closed directly. Reconstruction of defects requiring flaps or grafts was delayed until receipt of the histological report which was obtained in all cases.RESULTS:One-stage excision and direct closure was performed in 67 patients (74.4%). In 23 patients (25.6%) reconstruction was delayed by 4 days to enable receipt of the histopathology report. Histological assessment confirmed complete excision after the first excision in 78 (86.7%) rising to 83 (92.2%) after two excisions. The mean follow-up was 47.5 (SD 9.1) months. Of the 12 cases with incompletely excised lesions, seven of the patients chose not to have any more surgery, and only one of these recurred. There were two other recurrences, and in both of them the lesion had initially been reported as completely excised. Overall the recurrence rate in our study was 3.3% (n = 3).CONCLUSIONS:Our recurrence rate compares well with published results following conventional excision of BCCs. In the absence of availability of Mohs surgery, well-demarcated nodular basal cell carcinomas can be safely excised using smaller margins than conventionally practised.

Aim: To assess the results of primary aponeurotic ptosis surgery among UK ophthalmic oculoplastic surgeons, from both the surgeon’s and patient’s perspective; also to inform and encourage good clinical practice by generating outcomes for individual surgeons, units and for benchmarking purposes. Methods: A prospective, web-based, non-comparative, interventional study was conducted over a period of 1 year commencing January 2005 and ending December 2005. The data-entry sheet for the preoperative, operative and postoperative data was completed and submitted online via the British Oculoplastic Surgery Society website. Surgical results were assessed objectively (by the surgeon) by measuring the upper lid margin reflex distance (uMRD) and the interlid difference in: MRD, lid show, skin crease and lid contour with the outcome graded as: success, partial success or failed. Surgical results were also assessed subjectively (by the patient) with the outcome graded as: completely satisfied, significantly improved, no change or worse than before the operation. Results: Three hundred and sixty-five patients undergoing primary aponeurotic ptosis repair, from 40 different consultant-led teams with a declared oculoplastic interest and expertise, originating from 27 units across the UK were entered into the study. Using objective criteria, success was achieved in 128/223 (57%) cases, with significantly greater degrees of success seen in patients with mild ptosis and for surgeons who performed ptosis surgery more frequently. Using subjective criteria, 184/282 (65%) of patients were completely satisfied, with a further 89/282 (32%) judging themselves significantly improved. The patients’ assessment of the surgery was less critical than that of the surgeons: 46/138 (33%) of patients who were completely satisfied and 37/72 (51%) of those who were significantly improved did not meet the criteria for a successful surgical outcome. The re-operation rate was 8/313 (2.6%). Conclusions: The authors have generated a valid series of surgical outcomes both for individuals, units and the UK as a whole, expressed in both objective and subjective terms for what we regard as the signature procedure for an oculoplastic surgeon: aponeurotic ptosis surgery. Individual results have been communicated to our members, which will allow them to compare their results with true peer-group-generated figures and will aid appraisal and ultimately revalidation.