Recent Submissions

  • An Update Summary on the Learning Sciences Within an Ophthalmic Context.

    Khanna, Aishwarya
    Clinical reasoning, specifically diagnostic decision-making, has been a subject of fragmented literature since the 1970s, marked by diverse theories and conflicting perspectives. This article reviews the latest evidence in medical education, drawing from scientific literature, to offer ophthalmologists insights into optimal strategies for personal learning and the education of others. It explores the historical development of clinical reasoning theories, emphasising the challenges in understanding how doctors formulate diagnoses. The importance of clinical reasoning is underscored by its role in making accurate diagnoses and preventing diagnostic errors. The article delves into the dual process theory, distinguishing between type 1 and type 2 thinking and their implications for clinical decision-making. Cognitive load theory is introduced as a crucial aspect, highlighting the limited capacity of working memory and its impact on the diagnostic process. The zone of proximal development (ZPD) is explored as a framework for optimal learning environments, emphasising the importance of scaffolding and deliberate practice in skill development. The article discusses semantic competence, mental representation, and the interplay of different memory stores-semantic, episodic, and procedural-in enhancing diagnostic proficiency. Self-regulated learning (SRL) is introduced as a student-centric approach, emphasising goal setting, metacognition, and continuous improvement. Practical advice is provided for minimising cognitive errors in clinical reasoning, applying dual process theory, and considering cognitive load theory in teaching. The relevance of deliberate practice in ophthalmology, especially in a rapidly evolving field, is emphasised for continuous learning and staying updated with advancements. The article concludes by highlighting the importance of clinical supervisors in recognising and supporting trainees' self-regulated learning and understanding the principles of various teaching and learning theories. Ultimately, a profound comprehension of the science behind clinical reasoning is deemed fundamental for ophthalmologists to deliver high-quality, evidence-based care and foster critical thinking skills in the dynamic landscape of ophthalmology.
  • Optical coherence tomography angiography: a review of the current literature

    Khanna, Aishwarya
    This narrative review presents a comprehensive examination of optical coherence tomography angiography (OCTA), a non-invasive retinal vascular imaging technology, as reported in the existing literature. Building on the coherence tomography principles of standard OCT, OCTA further delineates the retinal vascular system, thus offering an advanced alternative to conventional dye-based imaging. OCTA provides high-resolution visualisation of both the superficial and deep capillary networks, an achievement previously unattainable. However, image quality may be compromised by factors such as motion artefacts or media opacities, potentially limiting the utility of OCTA in certain patient cohorts. Despite these limitations, OCTA has various potential clinical applications in managing retinal and choroidal vascular diseases. Still, given its considerable cost implications relative to current modalities, further research is warranted to justify its broader application in clinical practice.
  • Simplifying placement of bonded retainers

    Makwana, M; Murray, Alison
    The placement of bonded retainers can be daunting to the inexperienced clinician. The aim of the present article was to share a simple means of using everyday intermaxillay elastics to effortlessly secure the wire, allowing the clinician to easily complete placement of the bonded retainer. The challenge of manipulating the wire, etch, bond and composite simultaneously is thus alleviated! A step-by-step explanation is provided.
  • Revision Transoral Robotic Surgery for Early Stage HPV Positive Oropharyngeal Squamous Cell Carcinoma, it's Timing and Margins: Past and Present- a Prospective Single Centre Observational Study.

    Kumar, Sachin; Mortimore, Sean; Laugharne, David
    To review cohort of patients with HPV positive early stage oropharyngeal cancer that underwent revision trans oral robotic surgery for positive or close margin for evidence of residual disease, its impact on survival and discussion about clear margin. This is a prospective observational study. Our TORS revision rate was 20.6%. 91.7% did not need radiotherapy to primary site; mean recurrence free survival is 31 months and no mortality in this cohort due to the primary disease. There is no consensus on what is clear margin. The surgical margins are a surrogate marker for later recurrences or long-term survival and this is what guides our treatment but equally attempts should be made to preserve their function and not increase the morbidity.
  • Morbidity and Mortality Following Transoral Robotic Surgery, a Prospective Single Centre Study.

    Kumar, Sachin; Mettias, B; Laugharne, David; Mortimore, Sean
    To review complications including mortality after transoral robotic surgery (TORS) for both benign and malignant pathologies. This is a prospective observational study. Postoperative haemorrhage (8.7%) was the most common complication and 2 (1.7%) mortality were seen in this study. Airway complications and tracheostomy (1.7%), aspiration pneumonia (1.7%), swallowing problems and nasogastric feeding (7%), intra-operative pharyngocutaneous fistula (0.9%) and transient nasal regurgitation (3.5%) were also seen. The more tissue is removed the more is the risk of complication. Complications were mainly seen in the first year of starting the service of TORS and it is a reflection of the learning curve. However, secondary haemorrhage did not follow any pattern in our series. The postoperative haemorrhage was more common in patients with T2 oropharyngeal carcinoma. The mortality was seen in 2 patients (1.7%) with T2 oropharyngeal carcinoma due to postoperative haemorrhage. Higher T stage of oropharyngeal squamous cell carcinoma (OPSCC) needs bigger resection with resultant increase in morbidity.
  • Management of Retraction Pockets: historic and novel approaches.

    Spinos, Dimitrios; Mallick, Sameer; Judd, Owen
  • Frey's syndrome: A review of the physiology and possible role of neurotrophic factors.

    Judd, Owen
    OBJECTIVES: Frey's syndrome (FS) describes the phenomenon of gustatory sweating and is a cause of significant social embarrassment for sufferers. It has been attributed to aberrant growth of parasympathetic salivatory fibers in the auriculotemporal nerve toward overlying sweat glands. However, the exact mechanism behind this growth is unknown. This review aims to expand and elucidate the theory of aberrant regeneration in FS. METHODS: A review of the recent literature on nerve regeneration was conducted in order develop further insights into the etiology of both adult onset and pediatric FS. RESULTS: Neurturin, a neurotrophic factor released by both salivary and sweat glands, was identified as a possible key player in the etiology of FS. CONCLUSION: Further research into the role of neurturin could help to elucidate the pathogenic mechanisms underlying the condition and might reveal neurturin to be a potential target for pharmacological intervention. LEVEL OF EVIDENCE: NA (Basic Science Review).
  • Retinal Imaging in Infants

    Fung, THM (2021-01)
    Digital retinal imaging is at the core of a revolution that is continually improving the screening, diagnosis, documentation, monitoring, and treatment of infant retinal diseases. Historically, imaging the retina of infants had been limited and difficult to obtain. Recent advances in photographic instrumentation have significantly improved the ability to obtain high-quality multimodal images of the infant retina. These include color fundus photography with different camera angles, ultrasonography, fundus fluorescein angiography, optical coherence tomography, and optical coherence tomography angiography. We provide a summary of the current literature on retinal imaging in infants and highlight areas where further research is required.
  • The Use of Interlocking Polyetheretherketone Patient-Specific Facial Implants in the Treatment of Facial Deformities. A Retrospective Review of Ten Patients

    Thomas, Mathew (2020-12)
    Purpose: Polyetheretherketone (PEEK) is a versatile biocompatible material with a wide variety of clinical applications. Multiple-piece 3-dimensionally milled interlocking PEEK patient-specific implants are used in cases with restricted access or around vital structures. The interlocking joints reduce the number of fixation screws required by converting the multiple segments into one single implant. Stability of such joints is of paramount importance to prevent complications such as infection and implant extrusion. This retrospective study evaluates the clinical outcomes in the use of multiple-piece 3-dimensionally milled interlocking PEEK patient-specific implants as a treatment for various congenital and acquired facial deformities. Methods: Patients' records and clinical interviews were retrospectively reviewed. Results: A total of 10 patients were included; 6 of them (60%) were men. A planning cone beam scan (90%) or computed tomography scan (10%) were obtained following a standard protocol. All treatments were performed by a single surgeon, following a standardized approach. The follow-up time ranged from 11 to 61 months (mean = 37.1 months), No implant exposure, extrusion or removal were reported. Three patients (30%) have experienced complications. Recurrent edema was observed in 1 patient (10%), another patient (10%) experienced bilateral mental nerve paresthesia, and the third patient (10%) had recurrent sinusitis, which was successfully treated with functional endoscopic sinus surgery without removing the implant. Conclusion: Within the limitation of this study, 3-dimensionally milled interlocking PEEK patient-specific implants are safe, predictable, potentially save operative time, and readily adjustable. Extra stability and antislippage mechanism can be achieved by using the interlocking joint. Further studies on a larger cohort of patients is needed to confirm these results.
  • What still presents urgently to ENT during a pandemic? Experience of an ENT rapid access clinic during the coronavirus disease 2019 pandemic

    Stubington, TJ; Morrison, B; Sevilla, C; Judd, Owen (2021-01)
    Objectives: This study sought to determine the conditions that still present to ENT despite government advice to avoid unnecessary travel. It also assessed the impact of social distancing on pathologies presenting to ENT and reviewed the usefulness of telephone consultations in semi-urgent presentations. Method: A retrospective review was conducted of 97 instances of patient care carried out in the rapid access ENT clinic at a large district general hospital. Results: Otitis externa and foreign bodies represented 25 per cent and 13 per cent of consultations respectively. Tonsillitis and peritonsillar abscess were uncommon, representing 6 per cent of total consultations. Telephone appointments represented only 28 per cent of total consultations; however, they appeared to reduce the number of physical appointments required. Conclusion: Otitis externa and foreign bodies continue to be common during the pandemic. Social distancing measures reduced the number of tonsillitis and quinsy presentations. Telephone consultations are effective for certain urgent presentations to ENT, most noticeably nasal trauma and follow up of non-serious pathologies.
  • Food bolus and oesophageal foreign body: a summary of the evidence and proposed management process

    Stubington, TJ (2021-01)
    Purpose: Food bolus and oesophageal foreign bodies are a common presentation that may be managed by otolaryngologists, gastroenterologists, acute medicine physicians and accident and emergency. The condition is highly variable with presentations ranging from well patients whose obstruction spontaneously passes to peri-arrest with severe aspiration or impending airway compromise. Management of this condition is heterogeneous and often depends on the specialty the patient is originally admitted under. There exist European and American guidelines from the perspective of gastroenterology, but there are no UK-based guidelines and limited consideration of the role of the otolaryngologists and rigid oesophagoscopy. Methods: An extensive literature search was carried out to generate conclusions on key management questions for food bolus and oesophageal foreign bodies. This was then summarised into both a written summary of the evidence and a graphical decision tree. Results: This paper is a review article and presents conclusions regarding management options for food bolus and oesophageal foreign bodies. Conclusion: This article considers the current evidence surrounding investigation and management of oesophageal food bolus and foreign body. It draws conclusions regarding presentation, investigation and subsequent operative treatment. As part of this process, we propose a graphical decision tree to assist in management decisions.
  • Quantification of aerosol production during phacoemulsification and pars plana vitrectomy

    Fung, THM; Kuet, Mong-Loon; Poostchi, Ali; Pegg, Kate; Patel, MK; Gandhewar, Ravikiran (2020-11)
  • A multicentre audit to assess the effectiveness of the British Orthodontic Society 'Hold that Smile' retainer videos

    Murray, Alison (2020-03)
    Introduction: Retention is a crucial part of orthodontic treatment; however, patients often do not wear their retainers as advised. The British Orthodontic Society developed the 'Hold that Smile' campaign in 2017, to improve patient knowledge about retention. Information is provided in two formats: a cartoon and a conventional film. Objective: To assess whether patients find the 'Hold that Smile' videos useful and whether they improved patients' intended retainer wear. The gold standard was that 90% of patients should intend to wear their retainers in the long term after watching the videos. Design: National multicentre audit. Setting: Nine units in the UK. Methods: Patients aged ⩾ 10 years, in fixed appliances or retention, watched the retainer videos and then completed a questionnaire that was designed specifically for this audit. Each unit collected data for approximately 30 patients. Results: Data were collected for 278 patients in total. The average age was 17.9 years; 64.4% of patients were female and 35.6% were male. Most patients (86.3%) watched both videos and, of these, 44.1% preferred the film, 31.3% preferred the cartoon and 24.6% had no preference. The majority of patients (81.3%) felt that the film provided them with new information, compared with a lower percentage (48.5%) for the cartoon. More patients said they would recommend the film (76.3%) compared with the cartoon (63.3%). Before watching the videos, 77.0% of patients felt they knew about long-term retainer wear and 74.3% of those intended to wear their retainers in the long term. After watching the videos, 96.4% of all patients thought they would now wear their retainers long term. Conclusion: After watching the videos, there was a notable increase in the number of patients planning to wear their retainers long term and the gold standard was met. Therefore, these videos may be beneficial in improving understanding and compliance with retention.
  • Current perspectives on the surgical management of mandibular third molars in the United Kingdom: the need for further research

    Chiu, Geoff (2020-04)
    This survey of expert opinion regarding the management of mandibular third molar (M3M) impaction and its clinical sequelae was circulated to all members of the British Association of Oral and Maxillofacial Surgeons (BAOMS). It was completed by 289 clinicians who reported treating 60003 patients annually. Respondents included 199 (69%) specialists and 58 (20%) primary care clinicians. Most (99%) of the clinicians treated at least one M3M with complete surgical removal (CSR) annually. Only 69% performed one or more coronectomies (COR). Advocates of coronectomy reported lower rates of inferior alveolar nerve (IAN) injury, but IAN, lingual nerve, and adjacent second molar damage were rare, occurring in less than 0.5% of cases, with small differences between the COR and CSR groups. Although these differences are not statistically significant, they are likely to be clinically important. Also, the COR group would have comprised mainly high-risk teeth, while the CSR group would include many teeth at low risk of complications. This might have skewed the results. Those clinicians performing no coronectomies cited three main reasons for being low adopters of COR: the lack of irrefutable evidence to support its benefit, the increased need for a second operation, and more non-IAN complications. Although COR may prevent permanent IAN damage in high-risk cases, this paper highlights clinicians' views that there is a gap in evidence and knowledge to support COR. As a result, 47% of the clinicians surveyed recommended, and were prepared to participate in, further studies to determine the effectiveness and safety of COR.
  • A simple computerised technique for estimating resting lip position and symmetry

    Klimach, Stefan (2020-10)
    The angle between the commisure-commisure and the endocantus-commisure lines (CCE angle) is approximately equal to the contralateral angle. A computerised technique for assessing the gross symmetry and position of the lips by comparing left- and right-sided CCE angles was developed. This study established (1) the repeatability of computerized CCE angle measurement; (2) mean CCE angle magnitudes in healthy controls and suggest a "normal" reference range. Two authors independently measured CCE angles on frontal repose facial photographs of 104 volunteers on three separate occasions using facial analysis software. Twenty right-sided hemifaces with the largest CCE differences were then mirrored in the sagittal plane to produce symmetrical photographs. Measurements were repeated by a single author. There was high agreement of angle measurements between authors (inter-rater ICC of 0.89) and within each authors' repeated measurements (intra-raters ICCs of 0.85 and 0.77). Differences in the mean right and left-sided CCE angles in controls were small but statistically significant (82.4° and 81.7°, respectively, mean absolute difference 2.2 ± 1.7°, p < 0.05). The mean absolute differences had a skewed distribution. The 2.5th and 97.5th centiles were therefore set as limits of the range of asymmetries which could be regarded as "normal" (95% reference range, or 95% reference interval): 0.2°-6.2°. Measurements of opposing CCE angles in symmetrical mirrored images were similar (82.4° versus 82.3°, mean absolute difference 0.6°, p > 0.05). In conclusion, computerised CCE angle measurement is highly repeatable and may be a useful tool with which to assess gross resting lip symmetry.
  • Covid-19: face masks can be devastating for people with hearing loss but alternatives are available.

    Poostchi, Ali; Kuet, Mong-Loon; Richardson, PS; Patel, MK (2020-08)
    Chodosh and colleagues and Grote and Izagaren highlight an important matter but overlook the use of face shields, hoods, and other clear barriers that decrease disease transmission, facilitate lip reading, and reduce muffling. Face shields are also easier to manufacture, clean, and reuse. They protect the user’s eyes and are more acceptable than masks in a paediatric setting. The suggestion to adopt masks with clear windows is premature given the lack of evidence that they are more effective than face shields. Using a laser particle counter, we found that face masks and Perspex barriers had similar efficacy in reducing airborne and droplet transmission across a slit lamp. When a higher level of protection is required, clear ventilated hoods can be used and these have been successfully trialled with a view to widespread adoption. The authors have identified a salient problem to which cost effective and viable solutions are available and can be readily applied.
  • Novel technique using surgical scrub sponges to protect the nose and face during prone ventilation for coronavirus disease 2019.

    Stubington, TJ; Mansuri, MS (2020-07)
    Background: Coronavirus disease 2019 is an international pandemic. One of the features is acute respiratory distress syndrome, and proning has been identified as beneficial for a subset of patients. However, proning is associated with pressure-related side effects, including injury to the nose and face. Method: This paper describes a pressure-relieving technique using surgical scrub sponges. This technique was derived based on previous methods used in patients following rhinectomy. Conclusion: The increased use of prone ventilation has resulted in a number of referrals to the ENT team with concerns regarding nasal pressure damage. The described technique, which is straightforward and uses readily available materials, has proven effective in relieving pressure in a small number of patients.
  • Efficacy of slit lamp breath shields

    Poostchi, Ali; Kuet, Mong-Loon; Pegg, Kate; Richardson, PS; Patel, MK (2020-05)
    The use of enlarged breath shields has been suggested as part of a wide range of infection control measures implemented during the COVID-19 pandemic. Breath shields have long been a standard feature of slit lamps and act as a physical barrier between the examiner and subject but there is an absence of evidence on their effectiveness in reducing droplet transmission and respiratory infections.

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