The Next Trial

EricBarnes • 12 August 2019

 

The last week was eventful as the previous one. To the degree that I’m writing the blog before the main mayhem arrives.

The main theme of this blog is – make the most of your good health, things can be so much worse!

A train journey to visit my good and previously very fit birding friend (age 61) on a South London Neurosurgical ward focussed my attention on how short and unpredictable life is. One day you are producing a lovely painting in preparation for the Bird Fair and the next month,  you are in a coma. Make the most of each day, all of us are only given a limited number.

Boarding the 18:00 electric train from Newcastle to Kings Cross was supposed to make the trip comfortable and hassle free. Unfortunately, our train didn’t pull into King’s Cross till 7 hours and 50 minutes later; the power cut that affected the south east melted down the network and meant we had to board a diesel run train to complete the journey.

The positive aspect of the trip was that I got to read a couple of journals.

One of the most interesting papers showed evidence that exercise not only reduces the risk of dementia but also the risk of glaucoma. I was interested to see a further debate on ‘phasing’ – the regular measuring of intra-ocular pressure in patients with glaucoma throughout the day to detect pressure spikes.This was normal clinical practice 20 years ago,and it seems to be getting a revival.

3 glaucoma trials – ZAP, EAGLE and LIGHT were discussed. The outcomes suggesting that in acute angle closure glaucoma, laser treatment to the unaffected eye was of no benefit within the first 3 years of the trial but showed moderate benefit at 6 years. EAGLE showed that early lens removal was the preferred treatment for patients presenting with high pressures with narrow angle glaucoma. LIGHT looked at Selective laser Trabeculoplasty (SLT) followed by medical treatment versus conventional medical treatment alone. It seems that SLT is the preferred initial management of patients with open angle glaucoma or ocular hypertension.

Other advances include the recent trials on Bimatoprost implants adequately controlling intraocular pressure for 4 months in 90% of patients and 70% of patients for 6 months.

Disappointingly the Eye News cataract survey did not shed any light on the number of respondents involved.These were the most interesting results from their survey. 

In all 3 questions , my practice was in line with the majority of ophthalmologists. Surprisingly the majority of opinion was really not anything as weighted as one might imagine.

Q1. What do you use for pre-op prep if the is allergic to iodine?

88% of doctors used Chlorhexidine as the next best thing. I do too but I have always been extra concerned about the risk of endophthalmitis ( infection inside the eye) post operatively , as Chlorhexidine is inferior to Betadine ( an iodine based prep cleaning solution) at preventing endophthalmitis. I was particularly interested in the 6.5 % of respondents who didn’t believe in a Betadine allergy. Clearly an area for greater focus if this is true.

Q2. Assuming the other eye reaches the driving visual threshold, how long do you tell patients not to drive for after cataract surgery?

I am with the 30% of ophthalmologists who would let patients drive the next day if the patient didn’t have significant imbalance between the 2 eyes but there was a wide spread of opinions including 5% who wanted new glasses made up first , and 18% suggesting they shouldn’t drive for 2 weeks post op.

Q3. Assuming the other eye does not reach the driving visual threshold , when do you tell patients they are fit to drive after cataract surgery?

Once again I was with the majority. The 52% said as soon as the patient can read a number plate at 20 metres in the operated eye. 25% wanted patients to wait 2-4 weeks and 13% wanted the patient to be reviewed by an optician or in the clinic prior to being deemed fit.

Lastly but not least, an Editorial from the American Academy of Ophthalmologists about Dry Eye Disease (DED).This article highlights what has been blatantly apparent to doctors treating these patients – the patient reported symptoms are not proportional to the signs the ophthalmologist sees.Sometimes the symptoms are far worse than the signs we see and sometimes the signs are far worse than the symptoms experienced.They have suggested that the pathology is in the corneal nerves and our current treatment may only be helpful because they protect corneal nerves and improve their function. This concept opens up new ways in managing patient with DED and avenues for understanding ,assessing and hopefully addressing these common and sometimes disabling symptoms.

struggle-to-bring-down-the-waiting-list

The Times They Are a Changing

by Eric Barnes • 11 January 2023
Since my last blog 2 years ago we have experienced turbulent times, in the NHS. Once the restrictions were lifted, we found ourselves in a sea of cataracts. Clinics were emotional rollercoasters with several clinics in succession studded with patients so poorly sighted that they could not see the consultation chair. Thankfully, they all managed to leave the RVI with better vision on their return home! Such is the miracle of modern cataract surgery. When the chips are down, the NHS steps up to the mark to help the most needy. I wish I’d managed to record the joy of a patient shouting that he could see,as I was typing up the operating notes! The waiting list for surgery was terrible after the pandemic and all my general clinics were converted to Action for Cataract clinics, which I run with a team of able staff. The waiting list is being whittled down but difficult times lie ahead for the future of cataract surgery locally. With the struggle to bring down the waiting list has come outside competitors, eager to take NHS money for their own profit. Their strategy is simple, encourage the opticians to refer patients to them with a monetary incentive for their referral, cherry pick the straight forward cases that can be turned over quickly, send all the technically difficult cases to the NHS, and send all the complications of their surgery to the Emergency Eye Department! Interestingly, they seem to have a much lower threshold for proceeding with cataract surgery based on the referrals I see. They clearly feel they are doing something reasonable and positive but at the coal face, something difficult to measure is happening. We now have less money for the NHS to invest in the NHS, and fewer technically straight forward cataracts for training the future consultants. In addition, they are taking the hard working nurses and doctors for weekend locum work , which impacts on the hours they can do in the NHS. Sometimes these staff are leaving the NHS altogether to work for the private providers. Reducing the already depleted number of trained nurses for the service. Not a good recipe for a better NHS in a few years time. Almost all the NHS cataract work has now moved to the Newcastle Westgate Cataract Centre, which is opposite the main car park at the old Newcastle General Hospital. We have the capacity to do about 50 cataracts a day. Even if for some reason ,we only staffed it for 40 weeks a year, that would allow us to do 10000 cataracts a year. Pre-pandemic and independent providers, the region would do around 8000- 8500 cataracts a year, with a waiting list of roughly 12-18 weeks from referral. The crux of the problem now is staffing, partly because the independent providers are poaching our trained staff. The NHS seem powerless to defend themselves against this threat. On a brighter note, there are a group of patients who are still getting a decent service from the NHS. The patients with tumours round their eyelids, infected tear drainage systems and patients troubled by misdirected lashes on to the front of their eye will get priority surgery, as their conditions can’t wait without potential permanent detriment to their vision.. Unfortunately, that means if you have a stable non sight threatening problem, you might feel like you are waiting forever for your turn. That is definitely not the case, but the waiting times are painfully long under the current conditions.
Eye-Surgery-Newcastle-Nuffield-Hospital

NHS and Newcastle Nuffield Hospital

by Eric Barnes • 26 July 2020
During this pandemic, it has been come apparent that the NHS will not be able to push as many patients through their facilities like they used to. This is to do with creating the space for people to socially distance. To address this, the government have essentially rented space in local private hospitals to increase the number of patients we can see and operate on. The Newcastle Nuffield Hospital have been very accommodating and offer excellent facilities in the out patient department and theatres.  There are strict rules for seeing patients and stricter rules when going for surgery. Out patient attendance is possible at the Royal Victoria Infirmary and the Newcastle Nuffield Hospital after a risk assessment is made. Hospitals do not want to see patients with a high temperature, a new continuous cough or those who have recently lost their sense of taste or smell (all symptoms of Covid 19).  For patients who have routine, non-sight threatening conditions like cataracts, they need to meet the following criteria:  1. They must not have any symptoms of Covid 19 within the last 14 days 2. They must have not been in close contact with anyone who is suspected or proven to have Covid 19  Patients who are listed for surgery must self isolate /shield for 14 days prior to surgery and attend for a SARS CoV2 swab test around 72 hours prior to their operation. This is to confirm that they have not got Covid 19. Should they develop symptoms of Covid 19 or a positive swab test, their surgery will have to be deferred.  These strict rules are designed to make the hospital environment as save and Coronavirus free as possible. Despite these strict rules, I managed to operate on 21 cataracts this week, 2 tumour reconstructions, 1 dacryocystorhinostomy and a couple of lid malposition repairs!  It is particularly important to keep Coronavirus away from patients who require a general anaesthetic. General anaesthesia (but not local anaesthesia, which is how we do all our cataracts and most of our lid and tumour work) greatly increases the seriousness of Covid 19.  As mentioned in my last blog, the death rate from Covid 19 rises with increasing age. What is somewhat surprising, is that a general anaesthetic greatly increases the death rate from Covid 19 if you catch it around the time of your surgery. Regardless of age, the anaesthetists quote that the chance of dying from Covid 19 is 1 in 5, if you catch it around the time of surgery. This of course means we currently avoid general anaesthesia, unless absolutely necessary.  
Coronavirus-Impact-on-Ophthalmology

Coronavirus Impact on Ophthalmology

by Eric Barnes • 27 June 2020
During the current Coronavirus pandemic, we are responding to Government guidance and making changes to the way we offer Ophthalmology services. We will protect you by limiting travel, hospital visits wherever possible and avoiding crowds in our waiting rooms. We are committed to maintaining a safe service for all of our patients. The pandemic has affected all of us, ophthalmologists and ENT surgeons have been unexpectedly on the front lines. Alarmingly 3 consultant ophthalmologists at the Wuhan Central Hospital where the outbreak of Covid 19 was first identified have died. Patients can get conjunctivitis as part of the spectrum of symptoms in Covid 19 and ophthalmologists need to get close to their patients to examine their eyes. The government have been in a tough place and I am sure there is no real solution to our current situation. We will have to accept that most of us will get Covid 19 or wait for a vaccine, which is likely to be at least a year and of unknown effectiveness and longevity. The risk of severe problems from SARS Co V2 is linked strongly to age. The mortality statistics are frightening 4.5%, 9% and 12.5% for the 60,70 and 80 year old age groups. The only other option is shielding yourself from everyone else. My top tips for trying to avoid this highly infectious virus revolve around how the virus is spread. I believe it is largely spread by inhalation. So, my key things to avoid doing are: 1. Breathing other people’s air. a. Try to avoid places with poor air circulation. If on a bus or metro, open the windows to improve ventilation. b. Avoid talking face to face with people. c. Avoid being down wind from people if at all possible. This is particularly important when being overtaken by runners or cyclists. Their ‘cloud’ of exhaled air is greater than for pedestrians. d. Of course, keep your distance from people. e. Avoid gatherings particularly those that involve chanting or singing 2. Avoid people who are coughing like they have the plague! Hold you breath and move rapidly away from these people. 3. Besides public transport, most people’s greatest risk will be shopping for essential groceries. Ordering on-line is safest. If you don’t want to do this, minimise your interaction with people when out. 4. There is some evidence that the virus can survive on objects. Everything you touch outside your home is potentially a problem. The simple message is to avoid touching your face with your hands and wash your hands with soap and water when you come in doors. Be sensible and this will keep you safe. I hope you find some reassurance in the fact that most of us will be fine. Currently, telephone or video consultations can be made. I resumed NHS cataract operations at the beginning of June and we are doing our best to get through the backlog of about 4500 cataracts. We have been unable to assess any of the new cataract referrals since the lock down began but this should change shortly. It looks like we are in for some difficult times but rest assured we are all trying our best to tackle the backlog.
Catching-Up

Catching Up

by EricBarnes • 26 December 2019
Compliments of the Season! Finally, the wheel of work has come to a brief halt. So much has happened since my last blog. I bring news of developments from the largest Ophthalmology conference on earth, the American Academy of Ophthalmology – 12000 ophthalmologists plus 8000 exhibitors and ancillary staff! Highlights included new technology.These 2 Apps […] The post Catching Up appeared first on Eric Barnes | Newcastle Eye Surgeon.

Taking it seriously

by EricBarnes • 6 September 2019
I’ve always worked on the basis that medicine can’t always explain patients symptoms but that is usually because we don’t fully understand the nuances of the human body.I always recall one of mentors telling me about a heavy metal fan who came to outpatients complaining that everytime he started to ‘head bang’ he could feel […] The post Taking it seriously appeared first on Eric Barnes | Newcastle Eye Surgeon.

Trauma in the Garden

by EricBarnes • 25 August 2019
Sometimes the smallest of tasks can result in disaster. Always be extra careful in the garden. I have a particular bug bear with garden canes. They can be blinding. Classically someone bends down quickly to pull out a weed, the cane falls into a blind spot and the next thing you know you are irreversibly […] The post Trauma in the Garden appeared first on Eric Barnes | Newcastle Eye Surgeon.

Another busy week in the life of a jobing ophthalmic surgeon

by Eric Barnes • 7 August 2019
I’ve seen so many interesting cases in the last 4 days, I scarcely know where to start. Today I saw a case that highlights my mantra. ‘The treatment depends on the diagnosis and the diagnosis depends on the history, examination and special investigations’. In a nutshell , despite seeing 3 other senior eye surgeons and […] The post Another busy week in the life of a jobing ophthalmic surgeon appeared first on Eric Barnes | Newcastle Eye Surgeon.
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