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1

Evidence Search and Synthesis NHS Education for Scotland

Summary V 0.3

Title

Effective management of optometry emergencies presenting in a community optometry

setting.

This document summarises current evidence on managing optometry emergencies in a

community setting by identifying existing systematic reviews and indicates where systematic

reviews are lacking.

1 Key Messages

Include key messages from all your questions and sub-questions here

• We found no reviews on triaging optometry emergencies

• When we then searched for four conditions considered emergencies we only found reviews

on medical or surgical interventions and none on organisation of services.

3 Background

NES Optometry directorate conducted research to establish priority areas for guidance and

educational support within the profession. At the end of 2013 a survey went out to canvass

opinions from optometrists. Their responses indicated a need for guidance for dealing with

emergencies in the community setting. The TRIADS team in NES were asked to review

guidance for the highest priority topic within emergencies, Flashes and Floaters. NHS

Education for Scotland, Knowledge Services Group were asked for a summary of systematic

reviews and guidance for other emergency conditions.

The question relates to patients presenting to community optometry as emergency cases.

An emergency case is described as any walk-in patient with any condition who has no prior

arranged appointment.

This question is important for a number of reasons. In 2006 there was a change in the

optometrists contract. Everyone in Scotland is now entitled to regular NHS eye exam, and

there is a new emphasis on community optometry as the first port of call for all eye

conditions, all NHS funded. There is an emphasis is on emergency care in the community

and a number of A&E departments are now closed to walk-in patients with eye conditions.

Additional legislation was also enacted due to the changes in the contract – some

optometrists became independent prescribers (so patients don’t need to go anywhere else

to be prescribed any necessary medication as part of their treatment). There are currently

about 85 prescribing optometrists in Scotland. Treating emergencies in the high street

clinics can cause problems as there are often no gaps in the planned appointments.

2

There are a number of local pathways and guidelines for emergency optometry but there is

no consistent pathway as all local set-ups are different.

4 Question(s)

The original question was:

“How can walk-in patients with any type or seriousness of eye condition, who present to

community optometry as emergency cases, be effectively managed and treated?”

5 Scope of this summary

Initially KSG searched for triaging and treatment of emergencies without success and

following discussion with enquirer agreed to focus on emergency management of a limited

number of conditions.

The precise scope is described in the table below.

What the authors of this evidence summary searched for

Expectations Improving identification of eye emergencies in community setting

Client group People presenting with emergency eye conditions of

• Closed angle glaucoma

• Chemical burn or trauma

• Scleritis

• Microbial keratitis

Location Community settings

Impact/improvement Appropriate treatment or referral to GPs or secondary care

Professionals Community optometrists

Service Community optometry clinics

We searched for studies during March -April 2015 for the time period 2010-2015. For details of

search strategy see Appendix 1.

6. Results

No systematic reviews addressing triage for optometry emergencies were identified though

we found one UK case study of a pilot trial of tele-ophthalmology services (see reference 8)

referenced in NHS England consultation document ‘Urgent and Emergency Care Review -

Evidence Base Engagement Document’ June 2013.

We found 15 documents offering clinical guidance but none of these were explicitly

informed by research evidence except a SIGN guidance which did not address emergency

care (see Appendix 3).

We found 7 reviews of medical or surgical care relating to:

3

• Chemical burn x3

• Closed angle glaucoma x1

• Keratitis x 3

• Scleritis - none

These are summarised below.

Reviews summary table

Chemical burns and

injury

Periorbital infections after

Dermabond closure of traumatic

lacerations in three children. (1)

Review of 14 case studies

Chemical burns and

injury

Medical interventions for traumatic

hyphema (2)

Cochrane Database of

Systematic Reviews on The

Cochrane Library

Chemical burns and

injury

Amniotic membrane transplantation

for acute ocular burns (3)



Cochrane Library

Closed angle

glaucoma

Medication-induced acute angle

closure attack (4)

These include 36 case

reports, four review

articles, three prospective

non-controlled studies, and

one prospective controlled

trial.

Keratitis Topical corticosteroids as adjunctive

therapy for bacterial keratitis (5)

4 RCTs

Keratitis Medical interventions for

acanthamoeba keratitis (6)



Cochrane Library

Keratitis Topical antibiotics for the

management of bacterial keratitis: an

evidence-based review of high quality

randomised controlled trials (7)

Reports use of The

Cochrane Handbook

16 trials

Reviews – details included findings

4

Chemical burns and injury

Citation Periorbital infections after Dermabond closure of traumatic lacerations in

three children.

O'Day Denis M; Li Chun, Alexander Pauline T; Mawn Louise A; (2012)

Periorbital infections after Dermabond closure of traumatic lacerations in three

children.. Journal of AAPOS : the official publication of the American

Association for Pediatric Ophthalmology and Strabismus / American

Association for Pediatric Ophthalmology and Strabismus. 16(2): 168-72.

URL http://www.jaapos.org/article/S1091-8531(12)00104-8/abstract

Quality of

review

Only original case reports involving tissue adhesive wound closure and

traumatic laceration that reported the presence or absence of infection.

Date of last search Nov 2010 Date published April 2012

Details reviews 24 Case studies

Authors' comments on quality of studies - Only included original case studies

Conclusions of effectiveness based on statistical meta-analysis

Relevance

of review

Review addresses a sub-question - Chemical burns and injury

Findings

of review

Authors recommendations match the change in guidance - “Dermabond

Advance,” (www.dermabond.com), and the revised instructions for use state

that “Adhesive should only be used after wounds have been thoroughly and

adequately cleaned and debrided in accordance with standard surgical

practice.”

Citation Medical interventions for traumatic hyphema Gharaibeh Almutez, Savage Howard I; Scherer Roberta W; Goldberg Morton F;

Lindsley Kristina (2013). Medical interventions for traumatic hyphema

Cochrane Database of Systematic Reviews. (12): .

URL http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005431.pub3/abstract

Quality of

review

Published in Cochrane Database of Systematic Reviews on The Cochrane

Library Date of last search Aug 2013 Date published Dec 2013

20 randomized and seven quasi-randomized studies with 2643 participants

Authors' comments on quality of studies -Use of Cochrane Guidance


5

Relevance

of review

Address sub question - Chemical burns and injury

List countries of included studies Studies took place in a number of different countries: three in China; two each

in Iran, Sweden, and South Africa; one each in Denmark, Israel, and Malaysia;

and the remainder in Canada and the US Findings

of review

Antifibrinolytic drugs are often used to treat traumatic hyphema and are thought

to be effective, because they delay absorption of blood clots until complete

healing of the damaged blood vessels takes place. This review found that

antifibrinolytics did not affect final vision, but did appear to reduce the risk of

secondary bleeding. However, patients taking one of the antifibrinolytics,

aminocaproic acid, appeared to have more nausea and vomiting compared with

control patients. Two other antifibrinolytics, tranexamic acid and

aminomethylbenzoic acid, also reduced the risk of secondary hemorrhage, but

there was limited information about side effects. It was unclear whether these

medications reduced complications of secondary hemorrhage, because these

events did not occur often in the studies. Other medications evaluated in trials

included corticosteroids, either taken internally or applied as eyedrops;

estrogens; and other kinds of eyedrops. Nondrug interventions included wearing

a patch on one or both eyes, moderate activity versus bed rest, and elevation of

the head versus laying flat. Because the number of participants and events were

small, the evidence for a beneficial effect of any of these interventions is

inconclusive.

Summary of findings Authors' conclusions Traumatic hyphema in the absence of other intraocular

injuries uncommonly leads to permanent loss of vision. Complications resulting

from secondary hemorrhage could lead to permanent impairment of vision,

especially in patients with sickle cell trait/disease. We found no evidence to show

an effect on visual acuity by any of the interventions evaluated in this review.

Although evidence was limited, it appears that patients with traumatic hyphema

who receive aminocaproic acid or tranexamic acid are less likely to experience

secondary hemorrhaging. However, hyphema in patients treated with

aminocaproic acid take longer to clear.

Topic Chemical burns and injury

Citation Amniotic membrane transplantation for acute ocular burns

Gerry Clare, Hanif Suleman, Catey Bunce, Harminder Dua (2012) Amniotic

membrane transplantation for acute ocular burns. Cochrane Database of

Systematic Reviews. 9(9): CD009379.


Quality of

review


Library

6

Date of last search - June 2012 Date published -Sept 2012

Details -88studies identified, 87 rejected , 1 used

Authors' comments on quality of studies A subset of patients from one RCT (Tandon 2011) met the inclusion criteria for

this review. Due to the paucity of adequate RCTs, we could not conduct a meta-

analysis; instead, we have analysed the data on the subset of RCT participants.

The RCT data were provided by the study authors.


Relevance

of review

Addresses sub question - Chemical burns and injury

Findings

of review

Conclusive evidence supporting the treatment of acute ocular surface burns with

AMT is lacking. Heterogeneity of disease presentation, variations in treatment,

undefined criteria for treatment success and failure, and non-uniform outcome

measures are some of the factors complicating the search for clear evidence

regarding this treatment.

Closed angle glaucoma

Citation Medication-induced acute angle closure attack

Gangwani Rita A; (2012) Medication-induced acute angle closure attack. Hong

Kong medical journal = Xianggang yi xue za zhi / Hong Kong Academy of

Medicine. 18(2): 139-45.

URL http://www.hkmj.org/abstracts/v18n2/139.htm

Quality of

review

A PubMed search of literature up to August 2011 was conducted using the

following key words: “acute angle closure glaucoma”, “iatrogenic”, and

“drugs”. A total of 86 articles were retrieved. Only those concerning acute

angle closure attack triggered by local or systemic drug administration were

included. During article selection, prospective studies had a higher ranking

than retrospective studies, and case reports were also included. For articles on

the same or related topics, those published at later or more recent dates were

selected. In all, 44 articles were included and formed the basis of this review.

These include 36 case reports, four review articles, three prospective non-

controlled studies, and one prospective controlled trial. Other references were

also cited for the background and related information of this review article.

These included seven prospective non-controlled studies, one prospective

controlled trial, three retrospective case series, and five review articles.

Date of last search - August 2011 Date published -2012

44 studies included

7

Conclusions of effectiveness not based on statistical meta-analysis

Relevance

of review

Addresses a sub-question - Closed angle glaucoma and relates to adverse effects

of drugs only

Findings

of review

Since acute angle closure attack is a potentially blinding eye disease, it is

extremely important to be vigilant and aware of ophthalmic and systemic

medications that can lead to such attacks in predisposed subjects and to

diagnose the condition when it occurs. The standard of the evidence is poor and

not systematically reported with no mention on the types or standards of trials

incorporated

Keratitis

Citation Topical corticosteroids as adjunctive therapy for bacterial keratitis

Herretes Samantha, Wang Xue, Reyes Johann MG; (2014). Topical

corticosteroids as adjunctive therapy for bacterial keratitis. Cochrane Database

of Systematic Reviews. (10): .


Quality of

review

Date of last search - July 2014 Date published - Oct 2014

Includes 4 RCTs

Authors' comments on quality of studies -Generally, the quality of the evidence

based on the four studies we identified was moderate due to the proportions of

participants who were not included in the final study analyses and the

inconsistency of outcomes assessed across the four studies. In addition, three

studies enrolled too few participants (30 to 42) to reach scientifically valid

conclusions.

Conclusions of effectiveness not based on statistical meta-analysis

Relevance

of review

Review addresses a sub question - Keratitis

List countries of included studies - USA, Canada, India, and South Africa, and

included a total of 612 eyes of 611 participants Findings

of review

There is inadequate evidence as to the effectiveness and safety of adjunctive

topical corticosteroids compared with no topical corticosteroids in improving

visual acuity, infiltrate/scar size, or adverse events among participants with

bacterial keratitis. Current evidence does not support a strong effect of

corticosteroid, but may be due to insufficient power to detect a treatment effect.

8

None of the four studies reported an important difference between topical

corticosteroid therapy and placebo or control treatment for reduction in ulcer

size, change in visual acuity, adverse events, or quality of life. One study

reported that healing or cure time in the steroid group was slower than the

placebo group (for every 100 people cured in the control group, only 47 were

cured in the steroid group during the same time period), but the largest study did

not report any difference (for every 100 people cured in the control group, 92

were cured in the steroid group during the same time interval). For adverse

events, none of the studies found a difference between the two groups, except

that one study reported that more eyes in the control group developed

intraocular pressure (IOP) elevation. We did not find any information on

economic outcomes.

Citation Medical interventions for acanthamoeba keratitis

Alkharashi Majed, Lindsley Kristina, Law Hua Andrew; Sikder Shameema

(2015) Medical interventions for acanthamoeba keratitis Cochrane Database of

Systematic Reviews. (2): .


Quality of

review


Library

Date of last search Jan 2015 Date published 2015 Only 1 trial included

Authors' comments on quality of studies - was well-designed and had low risk of

bias overall


Relevance

of review

Addresses a sub-question - keratitis

List countries of included studies - no restrictions but only 1 trial found which is

a UK study Findings

of review

One study about a very specific aspect of the condition

Results from the one included study yielded no difference with respect to

outcomes reported between chlorhexidine and PHMB. However, the sample size

was inadequate to detect clinically meaningful differences between the two

groups as indicated by the wide confidence intervals of effect estimates.

9

Citation Topical antibiotics for the management of bacterial keratitis: an evidence-based

review of high quality randomised controlled trials.

McDonald EM, Ram FS, Patel DV, McGhee CN (2014) Topical antibiotics for

the management of bacterial keratitis: an evidence-based review of high quality

randomised controlled trials.. The British journal of ophthalmology. 98(11):

1470-7.

URL http://bjo.bmj.com/content/98/11/1470.full

Quality of

review

Reports use of The Cochrane Handbook Date of last search -March 2013 Date published -Nov 2014

16 trials included

Authors' comments on quality of studies -The remaining 16 trials,16–31

involving 1823 participants, were included as described in our Preferred

Reporting of Systematic Reviews and Meta-Analysis (PRISMA) statement

(figure 1). Two reviewers (EM and FR) were in full agreement regarding trial

selection. Characteristics of included trials are reported in online

supplementary table S1.


Relevance

of review

Review addresses sub question - keratitis

Findings

of review

Results of this review suggest no evidence of difference in comparative

effectiveness between fluoroquinolones and aminoglycoside-cephalosporin

treatment options in the management of BK. There were differences in safety

profile, however. Fluoroquinolones decreased the risk of ocular discomfort and

chemical conjunctivitis while ciprofloxacin increased the risk of white corneal

precipitate compared with aminoglycoside-cephalosporin.

7. Narrative summary

The evidence found does not help with the question about triaging nor is there any strong evidence

for emergency treatment of the four conditions. The guidelines identified did not include

information about the evidence base used to develop the guidelines, with the exception of SIGN

guidelines which is included in the table for information only as it does not deal explicitly with

emergencies.

8. References

10

1. O'Day Denis M; Li Chun, Alexander Pauline T; Mawn Louise A; (2012) Periorbital

infections after Dermabond closure of traumatic lacerations in three children.. Journal

of AAPOS : the official publication of the American Association for Pediatric

Ophthalmology and Strabismus / American Association for Pediatric Ophthalmology

and Strabismus. 16(2): 168-72.

2. Gharaibeh Almutez, Savage Howard I; Scherer Roberta W; Goldberg Morton F;

Lindsley Kristina (2013). Medical interventions for traumatic hyphema Cochrane

Database of Systematic Reviews. (12): .

3. Gerry Clare, Hanif Suleman, Catey Bunce, Harminder Dua (2012) Amniotic

membrane transplantation for acute ocular burns. Cochrane Database of Systematic

Reviews. 9(9): CD009379.

4. Gangwani Rita A; (2012) Medication-induced acute angle closure attack. Hong Kong

medical journal = Xianggang yi xue za zhi / Hong Kong Academy of Medicine. 18(2):

139-45.

5. Herretes Samantha, Wang Xue, Reyes Johann MG; (2014). Topical corticosteroids as

adjunctive therapy for bacterial keratitis. Cochrane Database of Systematic Reviews.

(10): .

6. Alkharashi Majed, Lindsley Kristina, Law Hua Andrew; Sikder Shameema (2015)

Medical interventions for acanthamoeba keratitis Cochrane Database of Systematic

Reviews. (2): .

7. McDonald EM, Ram FS, Patel DV, McGhee CN (2014) Topical antibiotics for the

management of bacterial keratitis: an evidence-based review of high quality

randomised controlled trials.. The British journal of ophthalmology. 98(11): 1470-7.

8. Kulshrestha M (2010) A pilot trial of tele-ophthalmology services in north Wales.

Journal of Telemedicine and Telecare. 16(4): 196.

Date this summary was last updated: April 2015

Suggested citation for this evidence summary:

For further information please contact:

Annette Thain [email protected]

This summary along with others in the series are available electronically at: xxx

11

Appendix 1

Search strings

Search strings

1. Emergency treatment of 4 conditions

Emergenc* or Urgent or Acute or Serious or Trauma*

AND

Closed angle glaucoma or Angle-closure glaucoma or “Closed drainage of eye”

OR

Chemical burn and (Eye or Ocular or Opthal* or Optom*)

OR

Scleritis or sclera* inflammation

OR

keratitis and (microbial or bacterial or fung* or acanthamoeba )

2. Triaging

((Eye or Ocular or Opthal* or Optom* or vision) and (Emergenc* or Urgent or Acute or Serious or

Trauma*)) and (Triag* or Referr*)

Sources searched

1 www.thecochranelibrary.com

2 www.epistemonikos.org

3 www.mcmasterhealthforum.org/hse/

4 http://www.nihr.ac.uk/research/

5 http://srdr.ahrq.gov/

6 http://www.cardiff.ac.uk/insrv/libraries/sure/sysnet/atozreviews.html

7 http://www.healthevidence.org/

8 Medline Systematic review and 2012 filters

9 Royal college optometrists http://www.college-optometrists.org/

http://www.college-

optometrists.org/filemanager/root/site_assets/guidance/urgent_eye_care_template_25_11_13.

pdf =uploaded to EPPI

10 Royal college ophthalmologists http://www.rcophth.ac.uk/

11 Joint college guidance eg

http://www.locsu.co.uk/uploads/enhanced_pathways_2013/joint_colleges_glaucoma_guid

ance.pdf

12 Canadian and other colleges

13 Local guidance eg Lanarkshire LENS , GG&C

14 Evidence based practice in optometry – Australian 2012-13 https://www.eboptometry.com/

15 http://www.optometrists.asn.au/for-optometrists/guidelines/optometry-australia.aspx

16 American Optometric Association http://www.aoa.org/

17 Quality in Optometry http://www.qualityinoptometry.co.uk/

18 ECOO Guidelines for Optometric & Optical Services 22 June 2013 http://www.ecoo.info/wp-

12

content/uploads/2013/07/Guidelines-for-Optometric-and-Optical-Services-in-Europe.pdf

19 Guideline Central – optometry

https://www.guidelinecentral.com/summaries/specialties/optometry/

20 International Council of Ophthalmology

http://www.icoph.org/enhancing_eyecare/international_clinical_guidelines.html

Dynamed

21 http://emedicine.medscape.com/emergency_medicine - guidance for ophthalmology

conditions – best practice in diagnosis and treatment

22 http://www.pathways.scot.nhs.uk/ophthalmology.htm

From 2005 – states 4 conditions investigating should be treated in secondary care as sight

threatening

Search process

56 Papers identified, uploaded to EPPI Reviewer and screened on title and abstract

22 Items excluded on date, language, country or scope

34 screened on full text

Items excluded if not relating to

• early signs and symptoms

• risk to sight if delay in diagnosis

• emergency care

15 guidance documents excluded but listed in Appendix 3

1 case study relating to triaging noted in references

13

Appendix 2

Reviews with abstracts


Citation Periorbital infections after Dermabond closure of traumatic lacerations in three children.

O'Day Denis M; Li Chun, Alexander Pauline T; Mawn Louise A; (2012) Periorbital infections after Dermabond closure

of traumatic lacerations in three children.. Journal of AAPOS : the official publication of the American Association for

Pediatric Ophthalmology and Strabismus / American Association for Pediatric Ophthalmology and Strabismus. 16(2):

168-72.

URL http://www.jaapos.org/article/S1091-8531(12)00104-8/abstract

Abstract Abstract: PURPOSE: To report the occurrence of periorbital infections in 3 children treated with the tissue adhesive 2-

octyl cyanoacrylate (Dermabond) after traumatic periorbital laceration., METHODS: We retrospectively reviewed the

records of consecutive patients referred to Vanderbilt Children's Hospital for the treatment of periorbital infections to

identify cases associated with the use of Dermabond. The clinical features and outcomes of each case were reviewed.

We performed a meta-analysis of published cases to identify any association of tissue adhesive with wound infection

rate., RESULTS: The review identified 3 patients, all of whom were younger than 3 years of age and developed

cellulitis within 24 hours of wound closure. Broad-spectrum intravenous antibiotic therapy was started in less than 3

hours in all cases. Cultures were obtained in 2 of the 3 cases; both grew Streptococcus pyogenes. Two cases required

surgical intervention, including one with necrotizing fasciitis. In the meta-analysis, the wound infection rate was 1.8% in

tissue adhesive closure and 0.3% in standard wound closure (odds ratio 6.0; 95% confidence interval 0.7-50.3, P =

0.06)., CONCLUSIONS: The development of periorbital cellulitis after the closure of periorbital lacerations with

Dermabond should alert the physician to the possibility of periorbital infection, including necrotizing fasciitis. The

literature review suggests a trend toward an increased infection rate with tissue adhesive closure. We propose that

ineffective wound sterilization before tissue adhesive wound closure may be a contributing factor.Copyright © 2012

American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.

14


Citation Medical interventions for traumatic hyphema Gharaibeh Almutez, Savage Howard I; Scherer Roberta W; Goldberg Morton F; Lindsley Kristina (2013). Medical

interventions for traumatic hyphema Cochrane Database of Systematic Reviews. (12): .


Abstarct Abstract: Background: Traumatic hyphema is the entry of blood into the anterior chamber (the space between the

cornea and iris) subsequent to a blow or a projectile striking the eye. Hyphema uncommonly causes permanent loss of

vision. Associated trauma (e.g. corneal staining, traumatic cataract, angle recession glaucoma, optic atrophy, etc.) may

seriously affect vision. Such complications may lead to permanent impairment of vision. Patients with sickle cell

trait/disease may be particularly susceptible to increases of elevated intraocular pressure. If rebleeding occurs, the rates

and severity of complications increase.Objectives: To assess the effectiveness of various medical interventions in the

management of traumatic hyphema.Search methods: We searched CENTRAL (which contains the Cochrane Eyes and

Vision Group Trials Register) (The Cochrane Library 2013, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and

Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2013), EMBASE

(January 1980 to August 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com),

ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP)

(www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We

last searched the electronic databases on 30 August 2013.Selection criteria: Two authors independently assessed the

titles and abstracts of all reports identified by the electronic and manual searches. In this review, we included

randomized and quasi-randomized trials that compared various medical interventions versus other medical interventions

or control groups for the treatment of traumatic hyphema following closed globe trauma. We applied no restrictions

regarding age, gender, severity of the closed globe trauma, or level of visual acuity at the time of enrolment.Data

collection and analysis: Two authors independently extracted the data for the primary and secondary outcomes. We

entered and analyzed data using Review Manager 5. We performed meta-analyses using a fixed-effect model and

reported dichotomous outcomes as odds ratios and continuous outcomes as mean differences.Main results: We included

20 randomized and seven quasi-randomized studies with 2643 participants in this review. Interventions included

antifibrinolytic agents (oral and systemic aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid),

15

corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine,

monocular versus bilateral patching, elevation of the head, and bed rest. No intervention had a significant effect on

visual acuity whether measured at two weeks or less after the trauma or at longer time periods. The number of days for

the primary hyphema to resolve appeared to be longer with the use of aminocaproic acid compared with no use, but was

not altered by any other intervention.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (odds ratio

(OR) 0.25, 95% confidence interval (CI) 0.11 to 0.57), but a sensitivity analysis omitting studies not using an intention-

to-treat (ITT) analysis reduced the strength of the evidence (OR 0.41, 95% CI 0.16 to 1.09). We obtained similar results

for topical aminocaproic acid (OR 0.42, 95% CI 0.16 to 1.10). We found tranexamic acid had a significant effect in

reducing the rate of secondary hemorrhage (OR 0.25, 95% CI 0.13 to 0.49), as did aminomethylbenzoic acid as reported

in one study (OR 0.07, 95% CI 0.01 to 0.32). The evidence to support an associated reduction in the risk of

complications from secondary hemorrhage (i.e. corneal bloodstaining, peripheral anterior synechiae, elevated intraocular

pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of

aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo.

We found no difference in the number of adverse events with the use of systemic versus topical aminocaproic acid or

with standard versus lower drug dose. The available evidence on usage of corticosteroids, cycloplegics, or aspirin in

traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no difference

in effect between a single versus binocular patch or ambulation versus complete bed rest on the risk of secondary

hemorrhage or time to rebleed.Authors' conclusions: Traumatic hyphema in the absence of other intraocular injuries

uncommonly leads to permanent loss of vision. Complications resulting from secondary hemorrhage could lead to

permanent impairment of vision, especially in patients with sickle cell trait/disease. We found no evidence to show an

effect on visual acuity by any of the interventions evaluated in this review. Although evidence was limited, it appears

that patients with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience

secondary hemorrhaging. However, hyphema in patients treated with aminocaproic acid take longer to clear.Other than

the possible benefits of antifibrinolytic usage to reduce the rate of secondary hemorrhage, the decision to use

corticosteroids, cycloplegics, or nondrug interventions (such as binocular patching, bed rest, or head elevation) should

remain individualized because no solid scientific evidence supports a benefit. As these multiple interventions are rarely

used in isolation, further research to assess the additive effect of these interventions might be of value.


16

Citation Amniotic membrane transplantation for acute ocular burns

Gerry Clare, Hanif Suleman, Catey Bunce, Harminder Dua (2012) Amniotic membrane transplantation for acute ocular

burns. Cochrane Database of Systematic Reviews. 9(9): CD009379.


Abstract Abstract: BACKGROUND: Ocular surface burns can be caused by chemicals (alkalis and acids) or by direct heat.

Amniotic membrane transplantation (AMT) performed in the acute phase (day 0 to day 7) of an ocular surface burn is

reported to relieve pain, accelerate healing and reduce scarring and blood vessel formation. The surgery involves

applying a patch of amniotic membrane (AM) over the entire ocular surface up to the eyelid margins. OBJECTIVES: To

assess the effects of AMT on the eyes of people having suffered acute ocular surface burns. SEARCH METHODS: We

searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library

2012, Issue 6), MEDLINE (January 1946 to June 2012), EMBASE (January 1980 to June 2012), Latin American and

Caribbean Literature on Health Sciences (LILACS) (January 1982 to June 2012), the metaRegister of Controlled Trials

(mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical

Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the

electronic searches for trials. We last searched the electronic databases on 11 June 2012. SELECTION CRITERIA: We

included randomised trials of medical therapy and AMT applied in the first seven days after an ocular surface burn

compared to medical therapy alone. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the

risk of bias of included studies and extracted relevant data. We contacted trial investigators for missing information. We

summarised data using risk ratios (RRs) and mean differences (MDs) as appropriate. MAIN RESULTS: We included

one RCT of 100 participants with ocular burns that were randomised to treatment with AMT and medical therapy or

medical therapy alone. A subset of patients (n = 68) who were treated within the first seven days of the injury met the

inclusion criteria and were included in the analysis. The remaining 32 eyes were excluded. The included subset

consisted of 36 moderate (Dua classification II-III) and 32 severe (Dua classification IV-VI) ocular burns from alkali,

acid and thermal injuries. In the moderate category, 13/20 control eyes and 14/16 treatment eyes had complete

epithelialisation by 21 days. The RR of failure of epithelialisation by day 21 was 0.18 in the treatment group (95%

confidence interval (CI) 0.02 to 1.31; P = 0.09). Mean LogMAR final visual acuities were 0.06 (standard deviation (SD)

0.10) in the treatment group and 0.38 (SD 0.52) in the control group, representing a MD of -0.32 (95% CI -0.05 to -

0.59). In the severe category, 1/17 treatment and 1/15 control eyes were epithelialised by day 21. The RR of failure of

epithelialisation in the treatment group was 1.01 (95% CI 0.84 to 1.21; P = 0.93). Final visual acuity was 1.77 (SD 1.31)

in the treated eyes and 1.64 (SD 1.48) in the control group (MD 0.13; 95% CI -0.88 to 1.14). The risks of performance

17

and detection biases were high, because treating personnel and outcome assessors could not be masked to treatment.

There was also a high risk of bias in the visual outcomes of the moderate category, since mean visual acuity was

significantly worse at presentation in the control eyes. This reduced confidence in the study findings. AUTHORS'

CONCLUSIONS: Conclusive evidence supporting the treatment of acute ocular surface burns with AMT is lacking.

Heterogeneity of disease presentation, variations in treatment, undefined criteria for treatment success and failure, and

non-uniform outcome measures are some of the factors complicating the search for clear evidence regarding this

treatment.

Topic Closed angle glaucoma

Citation Medication-induced acute angle closure attack

Gangwani Rita A; (2012) Medication-induced acute angle closure attack. Hong Kong medical journal = Xianggang yi

xue za zhi / Hong Kong Academy of Medicine. 18(2): 139-45.

URL http://www.hkmj.org/abstracts/v18n2/139.htm

Abstract Abstract: OBJECTIVE: To review acute angle closure attacks induced by local and systemic medications., DATA

SOURCES: PubMed literature searches up to August 2011., STUDY SELECTION: The following key words were used

for the search: "drug", "iatrogenic", "acute angle closure glaucoma"., DATA EXTRACTION: A total of 86 articles were

retrieved using the key words. Only those concerning acute angle closure attack triggered by local or systemic drug

administration were included. For articles on the same or related topics, those published at later or more recent dates

were selected. As a result, 44 articles were included and formed the basis of this review., DATA SYNTHESIS: An acute

attack of angle closure can be triggered by dilatation of the pupil, by anatomical changes in the ciliary body and iris, or

by movement of the iris-lens diaphragm. Local and systemic medications that cause these changes have the potential to

precipitate an attack of acute angle closure. The risk is higher in subjects who are predisposed to the development of

angle closure. Many pharmaceutical agents including ophthalmic eyedrops and systemic drugs prescribed by general

practitioners and various specialists (in psychiatry, otorhinolaryngology, ophthalmology, medicine, and anaesthesia) can

precipitate an acute angle closure attack. The medications include: anti-histamines, anti-epileptics, antiparkinsonian

agents, antispasmolytic drugs, mydriatic agents, sympathetic agents, and botulinum toxin., CONCLUSION: Since acute

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angle closure attack is a potentially blinding eye disease, it is extremely important to be vigilant and aware of

ophthalmic and systemic medications that can lead to such attacks in predisposed subjects and to diagnose the condition

when it occurs.

Topic Keratitis

Citation Topical corticosteroids as adjunctive therapy for bacterial keratitis

Herretes Samantha, Wang Xue, Reyes Johann MG; (2014). Topical corticosteroids as adjunctive therapy for bacterial

keratitis. Cochrane Database of Systematic Reviews. (10): .


Abstract Abstract: Background: Bacterial keratitis is a serious ocular infectious disease that can lead to severe visual disability.

Risk factors for bacterial corneal infection include contact lens wear, ocular surface disease, corneal trauma, and

previous ocular or eyelid surgery. Topical antibiotics constitute the mainstay of treatment in cases of bacterial keratitis,

whereas the use of topical corticosteroids as an adjunctive therapy to antibiotics remains controversial. Topical

corticosteroids are usually used to control inflammation using the smallest amount of the drug. Their use requires

optimal timing, concomitant antibiotics, and careful follow-up.Objectives: The objective of the review was to assess the

effectiveness and safety of corticosteroids as adjunctive therapy for bacterial keratitis. Secondary objectives included

evaluation of health economic outcomes and quality of life outcomes.Search methods: We searched CENTRAL (which

contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-

Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2014),

EMBASE (January 1980 to July 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS)

(January 1982 to July 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com),

ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials

Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the

electronic searches for trials. We last searched the electronic databases on 14 July 2014. We also searched the Science

19

Citation Index to identify additional studies that had cited the only trial included in the original version of this review,

reference lists of included trials, earlier reviews, and the American Academy of Ophthalmology guidelines. We also

contacted experts to identify any unpublished and ongoing randomized trials.Selection criteria: We included randomized

controlled trials (RCTs) that had evaluated adjunctive therapy with topical corticosteroids in people with bacterial

keratitis who were being treated with antibiotics.Data collection and analysis: We used the standard methodological

procedures expected by The Cochrane Collaboration.Main results: We found four RCTs that met the inclusion criteria of

this review. The total number of included participants was 611 (612 eyes), ranging from 30 to 500 participants per trial.

One trial was included in the previous version of the review, and we identified three additional trials through the

updated searches in July 2014. One of the three smaller trials was a pilot study of the largest study: the Steroids for

Corneal Ulcers Trial (SCUT). All trials compared the treatment of bacterial keratitis with topical corticosteroid and

without topical corticosteroid and had follow-up periods ranging from two months to one year. These trials were

conducted in the USA, Canada, India, and South Africa.All trials reported data on visual acuity ranging from three

weeks to one year, and none of them found any important difference between the corticosteroid group and the control

group. The pilot study of the SCUT reported that time to re-epithelialization in the steroid group was 53% slower than

the placebo group after adjusting for baseline epithelial defect size (hazard ratio (HR) 0.47; 95% confidence interval

(CI) 0.23 to 0.94). However, the SCUT did not find any important difference in time to re-epithelialization (HR 0.92;

95% CI 0.76 to 1.11). For adverse events, none of the three small trials found any important difference between the two

treatment groups. The investigators of the largest trial reported that more patients in the control group developed

intraocular pressure (IOP) elevation (risk ratio (RR) 0.20; 95% CI 0.04 to 0.90). One trial reported quality of life and

concluded that there was no difference between the two groups (data not available). We did not find any reports

regarding economic outcomes.Although the four trials were generally of good methodological design, all trials had

considerable losses to follow-up (10% or more) in the final analyses. Further, three of the four trials were underpowered

to detect treatment effect differences between groups and inconsistency in outcome measurements precluded meta-

analyses for most outcomes relevant to this review.Authors' conclusions: There is inadequate evidence as to the

effectiveness and safety of adjunctive topical corticosteroids compared with no topical corticosteroids in improving

visual acuity, infiltrate/scar size, or adverse events among participants with bacterial keratitis. Current evidence does not

support a strong effect of corticosteroid, but may be due to insufficient power to detect a treatment effect.

20

Topic Keratitis

Citation Medical interventions for acanthamoeba keratitis

Alkharashi Majed, Lindsley Kristina, Law Hua Andrew; Sikder Shameema (2015) Medical interventions for

acanthamoeba keratitis Cochrane Database of Systematic Reviews. (2): .


Abstract Abstract: Background: Acanthamoeba are microscopic, free-living, single-celled organisms which can infect the eye

and lead to Acanthamoeba keratitis (AK). AK can result in loss of vision in the infected eye or loss of eye itself;

however, there are no formal guidelines or standards of care for the treatment of AK.Objectives: To evaluate the relative

effectiveness and safety of medical therapy for the treatment of AK.Search methods: We searched CENTRAL (which

contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 1), Ovid MEDLINE, Ovid MEDLINE In-

Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January

2015), EMBASE (January 1980 to January 2015), PubMed (1948 to January 2015), Latin American and Caribbean

Health Sciences Literature Database (LILACS) (1982 to January 2015), the metaRegister of Controlled Trials (mRCT)

(www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO)

International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or

language restrictions in the electronic search for trials. We last searched the electronic databases on 9 January

2015.Selection criteria: We included randomized controlled trials (RCTs) of medical therapy for AK, regardless of the

participants? age, sex, or etiology of disease. We included studies that compared either anti-amoeba therapy (drugs used

alone or in combination with other medical therapies) with no anti-amoeba therapy or one anti-amoeba therapy with

another anti-amoeba therapy.Data collection and analysis: Two authors independently screened search results and full-

text reports, assessed risk of bias, and abstracted data. We used standard methodological procedures as set forth by the

Cochrane Collaboration.Main results: We included one RCT (56 eyes of 55 participants) in this review. The study

compared two types of topical biguanides for the treatment of AK: chlorhexidine 0.02% and polyhexamethylene

biguanide (PHMB) 0.02%. All participants were contact lens wearers with a median age of 31 years. Treatment duration

ranged from 51 to 145 days. The study, conducted in the UK, was well-designed and had low risk of bias

overall.Outcome data were available for 51 (91%) of 56 eyes. Follow-up times for outcome measurements in the study

were not reported. Resolution of infection, defined as control of ocular inflammation, relief of pain and photosensitivity,

and recovery of vision, was 86% in the chlorhexidine group compared with 78% in the PHMB group (relative risk (RR)

1.10, 95% confidence intervals (CI) 0.84 to 1.42). In the chlorhexidine group, 20 of 28 eyes (71%) had better visual

acuity compared with 13 of 23 eyes (57%) in the PHMB group at final follow-up (RR 1.26, 95% CI 0.82 to 1.94). Five

21

participants required therapeutic keratoplasty: 2 in the chlorhexidine group compared with 3 in the PHMB group (RR

0.55, 95% CI 0.10 to 3.00). No serious adverse event related to drug toxicity was observed in the study.Authors'

conclusions: There is insufficient evidence to evaluate the relative effectiveness and safety of medical therapy for the

treatment of AK. Results from the one included study yielded no difference with respect to outcomes reported between

chlorhexidine and PHMB. However, the sample size was inadequate to detect clinically meaningful differences between

the two groups as indicated by the wide confidence intervals of effect estimates.

Topic Keratitis

Citation Topical antibiotics for the management of bacterial keratitis: an evidence-based review of high quality randomised

controlled trials.

McDonald EM, Ram FS, Patel DV, McGhee CN (2014) Topical antibiotics for the management of bacterial keratitis: an

evidence-based review of high quality randomised controlled trials.. The British journal of ophthalmology. 98(11):

1470-7.

URL http://bjo.bmj.com/content/98/11/1470.full

Abstract Abstract: BACKGROUND: Severe bacterial keratitis (BK) typically requires intensive antimicrobial therapy. Empiric

therapy is usually with a topical fluoroquinolone or fortified aminoglycoside-cephalosporin combination. Trials to date

have not reached any consensus as to which antibiotic regimen most effectively treats BK. METHODS: A systematic

review and meta-analysis using Cochrane methodology was undertaken to evaluate the effectiveness of topical

antibiotics in the management of BK. Outcomes included treatment success, time to cure, serious complications of

infection and adverse effects. RESULTS: A comprehensive search for trials resulted in 27 956 abstracts for review. This

eventually resulted in 16 high quality trials involving 1823 participants included in the review. Treatment success, time

to cure and serious complications of infection were comparable among all antibiotic treatments included in the review.

Furthermore, there was no evidence of difference in the risk of corneal perforation with any included antibiotics or

antibiotic classes. Fluoroquinolones significantly reduced risk of ocular discomfort and chemical conjunctivitis but

22

increased the risk of white precipitate formation compared with aminoglycoside-cephalosporin. Fortified tobramycin-

cefazolin was approximately three times more likely to cause ocular discomfort than other topical antibiotics.

CONCLUSIONS: Results of this review suggest no evidence of difference in comparative effectiveness between

fluoroquinolones and aminoglycoside-cephalosporin treatment options in the management of BK. There were

differences in safety profile, however. Fluoroquinolones decreased the risk of ocular discomfort and chemical

conjunctivitis while ciprofloxacin increased the risk of white corneal precipitate compared with aminoglycoside-

cephalosporin.

Topic General emergency

Citation A pilot trial of tele-ophthalmology services in north Wales

Kulshrestha M (2010) A pilot trial of tele-ophthalmology services in north Wales. Journal of Telemedicine and

Telecare. 16(4): 196.

URL http://jtt.sagepub.com/content/16/4/196.abstract

Abstract Abstract: We identified the need for a tele-ophthalmology service at the Tywyn hospital in Wales. During a two-year

period, 22 emergency patients were managed by telemedicine, thereby reducing the need for ambulance transfer. We

expect that there will be increased use of tele-ophthalmology in north Wales as the technology improves and the

equipment becomes easier to use.

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Appendix 3

Guidelines identified by

Although we found 15 documents offering clinical guidance none of these were explicitly informed by research evidence.

Burns and injury

Commissioning better eye care

The College of Optometrists and The Royal College of Ophthalmology

www.college-optometrists.org/filemanager/root/site_assets/guidance/urgent_eye_care_template_25_11_13.pdf

2013

Burns and injury

Trauma Chemical The College of Optometrists http://www.college-optometrists.org/en/utilities/document-summary.cfm/docid/137E793D-D7F2-49F1-8F17936C435E820F

2011


Glaucoma (primary angle closure) (PACG)

The College of Optometrists http://www.college-optometrists.org/en/utilities/document-summary.cfm/docid/A292CCFD-42BE-4A3B-9B663C886D463F00

2013


Commissioning better eye care: Glaucoma

The College of Optometrists and The Royal College of Ophthalmo

http://www.locsu.co.uk/uploads/enhanced_pathways_2013/joint_colleges_glaucoma_guidance.pdf

2013


Care of the Patient with Primary Angle Closure Glaucoma (QRG-5).

American Optometric Association

http://www.aoa.org/documents/optometrists/QRG-5.pdf

2001

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ICO International Clinical Guideline, Primary Angle Closure (Initial evaluation and therapy).

International Council of Ophthalmology

http://www.icoph.org/resources/resources_detail/90/ICO-International-Clinical-Guideline-Primary-Angle-Closure-Initial-evaluation-and-therapy.html

2011


Glaucoma referral and safe discharge A national clinical guideline

SIGN 144 • Glaucoma referral and safe discharge

http://sign.ac.uk/pdf/SIGN144.pdf 2015

General emergency

NHS England Review of Urgent and Emergency Care Services JOINT RESPONSE

The College of Optometrists http://www.college-optometrists.org/en/utilities/document-summary.cfm/docid/AB07CFBF-26A7-4A23-9316DBA9FA17E885

2013

General emergency

Emergency Eye Care The Royal College of Ophthalmologists

https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013_PROF_203_EmergencyEyeCare.pdf

2014

General emergency

Emergency Eye Care The College of Optometrists and The Royal College of Ophthalmo

http://www.college-optometrists.org/filemanager/root/site_assets/guidance/urgent_eye_care_template_25_11_13.pdf

2013

General emergency

ICO Emergency Ophthalmology Handbook for Junior Residents and Medical Students


http://www.icoph.org/resources/153/ICO-Emergency-Ophthalmology-Handbook-for-Junior-Residents-and-Medical-Students.html

(2010

Keratitis Microbial keratitis (bacterial, fungal)

The College of Optometrists http://www.college-optometrists.org/en/utilities/document-

2013

25

summary.cfm/docid/B5A5F28A-AC2A-4B8F-918345D87DE1ADA9

Keratitis ICO International Clinical

Guideline Bacterial Keratitis (Initial evaluation).


http://www.icoph.org/resources/resources_detail/74/ICO-International-Clinical-Guideline-Bacterial-Keratitis-Initial-evaluation-.html

2011

Keratitis ICO International Clinical Guideline, Bacterial Keratitis (Management recommendations).


http://www.icoph.org/resources/resources_detail/75/ICO-International-Clinical-Guideline-Bacterial-Keratitis-Management-recommendations--.html

2011

Scleritis Scleritis. The College of Optometrists http://www.college-optometrists.org/en/utilities/document-summary.cfm/docid/205F6E8F-A882-4697-8B2D281F476F850D

2011

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