Transcript Unsual presentation of intraorbital foreign body

Vitreo-retinal Evidence in Practice Group, Department of
Ophthalmology, University Hospital.
When the evidence base is low, is the clinical
librarian compromised? Making the role
work for the patient.
Jacqueline Verschuere
Clinical Librarian Conference, York, June 2007
The evidence in practice:
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Clinical Guidance from Official Bodies
Systematic Reviews
Randomised Controlled Trials
Critical appraisal
Grade 4 evidence
Expert Opinion
Clinical decision making
ACTING ON THE EVIDENCE
Case 1: Oculoplastics EPG
Lynval Jones,Mr Bhandari, Andria Johnson, JV
Consultant: Mr
Ahluwalia
• Pre-operative management of patients on
aspirin: to withdraw or continue: the
evidence.
• Specific to Oculoplastics – Survey (92%rr)
Parkin B & Manners R. (2000) Aspirin and warfarin
therapy in oculoplastic surgery. Br J Ophthalmol.
84:1426-7.
Discussion
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Minimum period for stopping aspirin
Risk: Actual complication verses perceived complication
Benefit
Follow up data
Adapted from: Parkin,B. &
Manners, R. (2000) Aspirin and
warfarin therapy in oculoplastic
surgery.
Br J Ophthalmol ;84:1426-7
Non Oculoplastic
Specialists
Oculoplastic
Specialists
Stop Aspirin
Stop Aspirin
Ectropion repair
Entropion repair
Ptosis procedures
DCR
21%
20%
35%
57%
40%
40%
57%
78%
Clinical decision May 2005:
• Not to stop aspirin for patients undergoing:
– Entropion/ectropion, lateral tarsal strip, lateral canthal
sling
– Ptosis repair
– Excision of lid lesions
– Excision of xanthelasmata
– Electrolysis
– Brow lift procedures
– Insertion of gold weights
– Tarsorrahaphy
Clinical decision May 2005:
• May be discontinued if no absolute contraindication:
– Orbital surgery
– Enucleation/evisceration
– Lid reconstruction following BCC
– Dacryocystorrhinostomy
Revision of clinical management
May 2006:
• Absolute contraindications relaxed to relative
• Encouraged by audit of no complications and no
change in surgical outcome
• Impact
– patient
– service
– take home message
Case 2: Eye Casualty
Osama Makhzoum, Eli Pradhan, Mr Ahluwalia, Moh’d El’Ashrey,
JV
• 89 yr old lady presented to the eye casualty with
a history of right eye injury after a fall on a
bush, with a stick penetrating the right orbital
area.
• Clinical teams involved:
– A&E
– VitreoRetinal
– Radiology
- Maxofacial
- Oculoplastics
- VR/O-EPGs
Management
• The patient was admitted for removal of the
foreign body and EUA.
• X-ray to the skull and orbits.
• CTscan was ordered but done the second day.
• Swabs were taken for fungal and bacterial
• Blood tests ordered.
• ECG.
• Fragments of foreign body removed, wound
cleaned with normal saline
• Repair of lid and conjuctival laceration
Management
• Discussion with Radiologists, the presence of FB was
doubtful.
 Referral to Max Fax team, was put on the theatre list but
decided not to operate as they ruled out orbital floor
fracture.
• Discharged on 16/02/07, with VA 6/36
• Weekly Review in main Clinic
• Signs of improvement with small but continued discharge
• Discussion wooden FB, CL advised
Discussion
• MRI scans are better at demonstrating wooden
FB, and should be performed if there is this
possibility of wooden FB(1).
• A retained orbital wooden foreign body can
cause early and late complications and is
known to have potential to migrate intracranially.
• A team approach may be the best technique to
ensure complete removal(4).
Discussion
• Surgical removal is indicated for all organic IntraOrbital FBs(IOrbFBs).
• Inorganic IOrbFBs should be removed if causing
complications or if located anteriorly after
discussion of potential surgical complications with
the patients.
• However, if posteriorly located inorganic Iofbs to
be left alone unless causing significant orbital
complications(5).
Discussion
• It depends on
• degree of wood hydration
• location of the wood
• the extent of the collateral inflammation(1,2).
• It can misinterpreted as air (2, 3).
Further Management
• Debate about presence of foreign body as the
size of lesion in MRI is seen less than in CT
• Clinically there is improvement following initial
removal and systemic antibiotic therapy, with the
decrease in proptosis and regaining of EOMs
which was completely lost at the time of
admission.
• Finally decided to re-explore
Multiple
fragmented wooden body (28 pieces), lying close to Optic nerve
Take home message
• Intra-orbital wooden foreign bodies can be
difficult to detect
• Radiographic studies and CT may fail to
identify their presence.
References:
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1.Green B.E.KraftSP,Carter KD et al. Intraorbital wood : Detection by
Magnetic resonance imaging. Ophthalmology 1990;97608-611.
2.Roberts CF,Leehey PJ 3rd. Intraorbital wooden foreign body mimicking
air at CT. Radiology 1992;185:507-508.
3.Adesanya-O-O,Dawkins-Denise-M. Intraorbital wooden foreign body (
IOFB) mimicking air at CT. Emergency Radiology; 31 January 2007
(epub:31 1 2007), ISSN:1070-3004.
4.Liu-Don,Al-Shail-Essam. Retained orbital wooden foreign body: surgical
technique and rationale. Ophthalmology; Feb2002,Vol. 109,no.2, p3939,ISSN:0161-6420.
5.Fulcher et al. Clinical Features and Management of Intraorbital Foreign
Bodies. Ophthalmology; Vol 109, Nov 3, March 2002.
Case 3: Medical Retina EPG
Dr Yannis Athanasiadis, Amritpal Chaggar, Annette Ryman, JV, JDs
Consultant: Mr
Pagliarini
http://www.guardian.co.uk/frontpage/story/0,,1799832,00.html
Is intravitreal Avastin a safe and effective treatment
for patients with wet age related macular
degeneration?
• Avastin is unlicensed for use in AMD
• 4 published case series and 12 unpublished conference
case series.
• Use of this evidence for the benefit of patients
– Overall change in practice
– Individual patient care
1. Drug lifts blindness threat for thousands. The Times, 05
October 2006, p1.
2. Specialists seek trials of cheaper drug to prevent blindness.
The Guardian, 05 October 2006, p4.
3. Wonder drug that could beat blindness. Daily Mail, 05
October 2006, p5.
4. Threat to jabs that can save eyesight. Daily Express, 05
October 2006, p35.
5. Scientists hail cure for most common cause of blindness.
The Independent, 05 October 2006, p8.
6. Jab cure for blind. The Sun, 05 October 2006, p29.
Is Ranibizumab (Lucentis®) for the treatment of wet
age-related macular degeneration?
• Lucentis is licensed in Europe Jan 2007 – awaiting
NICE appraisal
• 3 published RCTs, 23 located ongoing studies
• Use of this evidence for the benefit of patients
– Overall change in practice
– Individual patient care
Impact on patient care
TAKE HOME MESSAGE:
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Never assume low base evidence equates to
‘not enough evidence’ to either change routine
practice or impact on individual patient
management.
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The work of the CL can be a pivotal point in
the delivery of quality patient care
Contact Details
• Jacqueline Verschuere
– [email protected]
– 02476 96 8838