What a difference a year makes: Dr Stuart Guthrie’s

What a difference a year makes

In his shortlisted essay for the John Henahan Prize 2021, Dr Stuart Guthrie says the changes that are lasting and beneficial in daily clinical practice will help to improve patient care, safety and ophthalmology training

Lifting the next set of case notes from an ever-expanding pile I look up at a sea of faces gazing at me in anticipation. A moment later I am responsible for a reverberation of disappointment as I call the “wrong” name. Sighs, groans and at times the occasional quietly muttered expletive lilt in the warm clammy afternoon air. Even the soothing tones of Marvin Gaye’s ‘Sexual healing’ from Smooth FM do little to abate the growing sense of frustration from the tightly packed ocularly challenged throng.

The lucky chosen one lifts themselves from their hard plastic chair slowly, joints stiffened and gluteus maximus numbed by hours of stasis. A quick rub of the knees and a shake of the legs and the assault course to my consultation room begins. Prams, hurried medical personnel and small sugar laden children attempt to scupper the poor chap’s attempt at his quest for a resolution in his ophthalmic complaint.

He makes it to my door physically unscathed but clearly in a degree of psychological distress. “Thank you so much for waiting today sir, it’s a been terribly busy clinic, please take a seat.” Comes my unconscious response for nearly every patient seen.

“What has brought you to the emergency clinic today Mr Anderson?”. The gentleman opens his mouth to begin when there is a knock at the door. A nurse pops her head in “Sorry to interrupt, I can’t cannulate the patient you requested an FFA on”. I attempt a reply but my mobile beginnings to loudly ring the classically awful Motorola ringtone. I nod apologetically to both nurse and patient.

“Hello, Dr Guthrie on call ophthalmology, how can I help?” another automated response comes.

“Afternoon, this is Dr Rashid, I’ve got a lady down in ED with fixed pupil, cloudy cornea and nausea and vomiting... think it may be angle closure. Would you be able to take a look?” Like watching the nucleus sink down through the posterior capsule into the ever welcoming vitreous, an impending sense of doom enters my already fragile mind.

“Yes, of course.” I say weakly.

I hang up and smile maintaining my professional façade. However, it is broken shortly when a most unwelcome guest makes his feelings known “grrrrrrrrrrr…. gggrrrrr”. Ah but of course, the familiar low growl of peristalsis attempting to evacuate an empty gastrointestinal tract. Thoughts of a missed lunch must be pushed to one side or alas, these patients, and I, will never leave this department. ......

“Stuart…..Stuart? wakey wakey!” I suddenly find myself in the same clinic, gazing absentmindedly out into the empty waiting area. “That’s your first patient in, Room 2. And put your mask over your nose you dafty.”

I turn back to my computer and finish replying to the email of a local optician who had sent in some photos for review of Mr. Anderson. Marginal keratitis I think. “Barn door” I mutter under my breath. I provide an appropriate management plan and click reply.

I rise, shake my stiff legs and enter my new automated routine. Wash hands, don gloves and apron, and take lens.

At that point, a text message alert pings from my phone requesting a video consultation from ED. Frustratingly, having just “donned”, I must, as they now say in common medical vernacular “doff”.

I accept the invitation and a familiar face now engulfs my display in crystal clear pixelated form.

“Dr Rashid! how can I help you today?”

“Good afternoon, I have a patient here with an abrasion, but the pupil looks a bit funny. He had a nasty fall yesterday.” Dr Rashid mounts the tablet on to the slit lamp adapter and focuses on the area of interest.

“I am afraid that’s a penetrating eye injury, Dr Rashid. The iris is peaking out of a small corneal wound”

I then immediately coordinate an appropriate management plan with ED and liaise with theatre staff and my seniors.

My concentration is temporarily broken by the TV blaring to the patient-

...I take great hope in how we humans do what we have always done in response to crises. Adapt and become more creative, finding new solutions to new problems

less waiting room. Statistics flash upon the screen dramatically. “Death count 25,345, Tested positive 50,678,” accompanied by aerial footage of mass graves outside New York. Sometimes I think I am in some awful dream. Not being able to see friends or family. Loved ones passing away with no one to comfort them. How life can seemingly change so quickly.

However, I take great hope in how we humans do what we have always done in response to crises. Adapt and become more creative, finding new solutions to new problems.

There is no doubt daily clinical practice has changed and will continue to change. But the changes that are lasting and beneficial will stay with us improving patient care, safety, and ophthalmology training for the future... and hopefully allow me to finally enjoy lunch. Stuart Guthrie is an ST4 Ophthalmology specialist registrar at Queen Margaret Hospital, Dunfermline, Scotland

Endothelial keratoplasty

Good long- to medium-term graft survival and visual outcomes with DSEK and DMEK. Roibeard Ó hÉineacháin reports

Descemet’s stripping endothelial keratoplasty (DSEK) and Descemet’s membrane endothelial keratoplasty (DMEK) appear to provide good visual acuity over the medium to long term, according to studies presented at the 25th ESCRS Winter Meeting.

In a single-centre retrospective consecutive series study, eyes undergoing DSEK had 10-year graft survival of 79%, said Lana Fu FRCOphth, King’s College Hospital NHS Foundation Trust, London, UK.

“DSEK remains a viable treatment option, especially in complex eyes with comorbidity,” Dr Fu added.

The study involved 356 eyes of 263 patients who underwent DSEK from January 2006 to January 2020 and had a median follow-up of 6.0 years (range: 0.5-14 years).The patients had a mean age of 72 years (range 35-95 years). The indications for surgery included Fuchs’ endothelial dystrophy (FED) in 59%, pseudophakic bullous keratopathy (PBK) in 25%, and previous graft failure in 5%.

Ten surgeons performed the procedures using a standardised protocol. In all eyes they prepared the donor buttons manually using the Melles technique. In the first year of the study they inserted the donor tissue with a forceps, but switched to using the Busin glide in 2007 and the Tan EndoGlide in 2010 .

Dr Fu noted that 189 (53%) eyes had low visual potential preoperatively due to ocular co-morbidities, glaucoma, age-related macular degeneration, optic neuropathy and retinal detachment surgery.

Cumulative graft survival of all eyes, including those with complex co-morbidities, was 85% at five years and 79% at 10 years, Dr Fu pointed out. Among eyes with glaucoma, the cumulative graft survival was 52% at five years and 35% at 10 years, among eyes with PBK it was 89% at five years and 62% at 10 years and among eyes with FED it was 97% at five years and 92% at 10 years.

The endothelial cell loss of all grafts was 46.5% at one year, 54.9% at three years, 59.21% at five years and 75.65% at 10 years. After exclusion of the failed grafts there was no statistically significant increase in central corneal thickness, she noted.

Complications included interface fluid, which occurred in 52 (14.6%) eyes, and re-bubbling was performed in 29 eyes (8.1%). There were also 70 (19.7%) rejection episodes, half of which occurred in eyes that had preoperative glaucoma. Graft failure occurred in 50 (14%) eyes, of which 27 underwent repeat transplants.

GOOD VISION MAINTAINED FOR FIVE YEARS AFTER DMEK Another retrospective study, presented at the ESCRS meeting by Nikolaos Kappos MD, suggested that eyes undergoing DMEK maintain normal visual acuity levels for five postoperative years despite some loss of transparency.

The study involved 60 eyes of 51 patients who underwent DMEK at the Philipps University of Marburg, Germany. The patients had a mean age of 67 years and their indications were FED in 53 (88%) cases and BK in seven (12%) cases. None included in the analysis had undergone previous corneal surgery, complicated perioperative course, vision-limiting ocular comorbidity and/or incomplete follow-up data, said Dr Kappos, National and Kapodistrian University of Athens, Athens, Greece.

The primary outcome in the study was corneal densitometry, a measure of light scatter as determined with the Pentacam

DSEK remains a viable treatment option, especially in complex eyes with comorbidity

Lana Fu FRCOphth

Light scattering constitutes a significant parameter in the evaluation of the corneal optical performance since back scatter interferes with its transparency

HR (Oculus). Secondary outcomes were best corrected visual acuity, endothelial cell density measured with the Topcon SP2000P and central corneal thickness measured with the Pentacam HR.

“Light scattering constitutes a significant parameter in the evaluation of the corneal optical performance since back scatter interferes with its transparency. The rotating Scheimpflug camera in the clinical settings enables the objective quantification backscatter in greyscale units (GSU) in different layers and zones,” Dr Kappos said.

The study showed that mean corneal density decreased significantly in the central and paracentral zone for up to two years but increased slightly between the second and fifth year, although it remained significantly lower than the preoperative value (21 GSU vs 33 GSU, respectively). In the mid-peripheral zone there was no change in corneal density postoperatively for up to two years, but there was a considerable increase between the second and fifth years, reaching levels higher than preoperative values.

Similarly, mean central corneal thickness decreased significantly from 686μm preoperatively to 527μm at three months but by two years had increased to 542μm and by five years had increased to 557μm. Mean endothelial cell density decreased by 60% from 2,500 cells/mm2 prior to implantation to 1,000 cells/mm2 at five years. Nonetheless, visual acuity improved from 0.3 (Snellen decimal) preoperatively to 0.8 (Snellen decimal) at six months and remained stable thereafter.

“Despite a slight corneal density increase at all layers of all corneal zones from the second to the fifth postoperative year, the excellent visual outcome was maintained throughout five years’ follow-up. Thus, DMEK seems to treat effectively corneal endothelial disease in the long term,” Dr Kappos concluded.