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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
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The evidence in practice

• Clinical Guidance from Official Bodies
• Systematic Reviews
• Randomised Controlled Trials
• Critical appraisal
• Grade 4 evidence
• Expert Opinion
• Clinical decision making
• ACTING ON THE EVIDENCE

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Case 1 Oculoplastics EPGLynval 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 (92rr)
• Parkin B Manners R. (2000) Aspirin and
  warfarin therapy in oculoplastic surgery. Br J
  Ophthalmol. 841426-7.

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Discussion

• 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 841426-7 Non Oculoplastic Specialists Oculoplastic Specialists
Adapted from Parkin,B. Manners, R. (2000) Aspirin and warfarin therapy in oculoplastic surgery. Br J Ophthalmol 841426-7 Stop Aspirin Stop Aspirin
Ectropion repair 21 40
Entropion repair 20 40
Ptosis procedures 35 57
DCR 57 78
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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

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Clinical decision May 2005

• May be discontinued if no absolute
  contraindication
• Orbital surgery
• Enucleation/evisceration
• Lid reconstruction following BCC
• Dacryocystorrhinostomy

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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

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Case 2 Eye CasualtyOsama Makhzoum, Eli Pradhan,
Mr Ahluwalia, Mohd ElAshrey, 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
• AE - Maxofacial
• VitreoRetinal - Oculoplastics
• Radiology - VR/O-EPGs

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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

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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

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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 intra-cranially.
• A team approach may be the best technique to
  ensure complete removal(4).

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Discussion

• Surgical removal is indicated for all organic
  Intra-Orbital 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).

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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).

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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

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• Multiple fragmented wooden body (28 pieces),
  lying close to Optic nerve

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Take home message

• Intra-orbital wooden foreign bodies can be
  difficult to detect
• Radiographic studies and CT may fail to identify
  their presence.

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References

• 1.Green B.E.KraftSP,Carter KD et al. Intraorbital
  wood Detection by Magnetic resonance imaging.
  Ophthalmology 199097608-611.
• 2.Roberts CF,Leehey PJ 3rd. Intraorbital wooden
  foreign body mimicking air at CT. Radiology
  1992185507-508.
• 3.Adesanya-O-O,Dawkins-Denise-M. Intraorbital
  wooden foreign body ( IOFB) mimicking air at CT.
  Emergency Radiology 31 January 2007 (epub31 1
  2007), ISSN1070-3004.
• 4.Liu-Don,Al-Shail-Essam. Retained orbital wooden
  foreign body surgical technique and rationale.
  Ophthalmology Feb2002,Vol. 109,no.2,
  p393-9,ISSN0161-6420.
• 5.Fulcher et al. Clinical Features and Management
  of Intraorbital Foreign Bodies. Ophthalmology
  Vol 109, Nov 3, March 2002.

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Case 3 Medical Retina EPGDr Yannis
Athanasiadis, Amritpal Chaggar, Annette Ryman,
JV, JDs Consultant Mr
Pagliarini
http//www.guardian.co.uk/frontpage/story/0,,17998
32,00.html
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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

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• 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.

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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

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Impact on patient care
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TAKE HOME MESSAGE

• Never assume low base evidence equates to not
  enough evidence to either change routine
  practice or impact on individual patient
  management.
• The work of the CL can be a pivotal point in the
  delivery of quality patient care

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Contact Details

• Jacqueline Verschuere
• jacqueline.verschuere_at_uhcw.nhs.uk
• 02476 96 8838