College News Winter 2014

college news

QUARTERLY BULLETIN WINTER 2014

Farewell Cornwall Terrace Staff bid a fond farewell to Cornwall Terrace, which had been the home of the College since 1993. The beautiful building and surrounding area of Regent’s Park will be missed. Relocation to Stephenson Way, our brand new purpose-build head office went smoothly on Friday 28 November. Well done to all members of staff for their hard work in moving everything across and keeping up with the day job!

Focus Museum Piece Trainee Section PAGE 5 Management PAGE 10 David James PAGE 21 A NEW of unexplained vitreous Wood, South Africa’s section written by haemorrhage Father of Ophthalmology trainees, for trainees college news

Dear fellow members, I have thoroughly enjoyed the last six months as President, although they seem to have flown by! The Contents College has been a busy place with 2 Introduction - Carrie routine work, new challenges and MacEwen, President the anticipation and preparation for 3 Building Report the move to our new premises at 5 Focus - Management Stephenson Way. of unexplained vitreous haemorrhage The key goals and direction for the College over the next five years have been drawn up 8 Andrew Elkington The building at Cornwall Terrace has served us well but we now own flexible, beautifully based on feedback and I am delighted that 10 Wrong IOLs and designed and user-friendly office space with the draft strategic plan will be published on Never Events in a surgical skills training suite and space for our website in the new year. I encourage you Ophthalmology members to work or relax. I hope that everyone to review and comment on it. The new website, 12 Museum Piece - David will manage to find a reason to visit, and a to be launched in the new year has a fresh, James Wood, varied array of seminars in 2015 should attract contemporary design, engaging content and South Africa’s Father of Ophthalmology many members. will offer a more user friendly experience. There is an updated College Crest that is easier 20 NEW Trainee Section At the start of the long warm summer we sent to reproduce and recognise - you may have out the first membership survey which has 23 Diary Dates noticed this on the re-designed College News. helped to identify how the College is seen to The heritage crest will continue to be used on perform and what we could do better. The certificates. summary has been posted in the members’ Articles and information to be considered for publication area and it recognises that training, education, In 2015 I have plans to meet with as many should be sent to: examinations and guidelines are delivered members as possible in your home areas well, but that we could communicate more to hear what you would like your College Liz Price effectively with our members and be a better to do and to share more about how the Communications Manager [email protected] ‘voice’ for ophthalmology as a specialty. These College can support you and your work as points are well taken and the regular monthly an ophthalmologist. I would like to thank Copy deadlines: e-newsletter and proactive Twitter feed are everyone who has contributed to College work Spring: 13 March 2015 Summer: 12 June 2015 the first steps in better communication. There so freely over the past year: many come to Autumn: 18 September 2015 will also be a review of how we deliver policy London to work on committees, set exams and Winter: 4 December 2015 working and raising our profile. write guidelines, and even more represent the College externally on related organisations and Editor of Focus: The College had been successful in its bid to Mr Faruque Ghanchi locally as College Tutors, Regional Advisors and provide the system to collect and analyse data Council Representatives – the College is run on Advertising queries should for an English national cataract audit and to the enthusiasm and goodwill of members who be directed to: prepare a feasibility study of the analysis of the are keen to maintain the high standards in our Robert Sloan outcomes for glaucoma, retinal detachment specialty for the benefit of our patients. 020 8882 7199 and AMD. This project will provide data that [email protected] will have relevance for ophthalmic practise I wish you all a very happy festive period and Contact Details: in the entire UK. It is vital that our patients trust that you manage a pleasant and restful The Royal College of are our main concern, and recently we have break with your families and friends. Ophthalmologists highlighted that the pressure on space and 18 Stephenson Way personnel in eye departments is leading to London, NW1 2HD some return patients failing to be reviewed in T. 020 7935 0702 the clinically recommended times. Finding ways to reduce referrals and increase safe discharges are important, but the high return to new ratio in ophthalmology needs to be recognised and accommodated. Carrie MacEwen, President [email protected]

2 THE ROYAL COLLEGE OF OPHTHALMOLOGISTS QUARTERLY BULLETIN | WINTER 2014 New branding for the College As part of an overall review of its communications and profile, the College Heritage crest commissioned a piece of brand work which looked at how the College crest could be contemporised and made to stand out from all the other Royal Medical Colleges.

Like many colleges, universities and organisations with crests, many have simplified the design for ease of standout and use online and in print, particularly where a print version is small and many features are potentially lost in the reproduction.

Astwood Design agency was commissioned because of their experience in developing and working with similar organisations that had undergone a New crest brand review and because of their knowledge of heraldic and royal crests. Astwood worked with the College of Arms to ensure that any amends would not contravene the original Arms of the College granted to the College in 1993.

Design concepts were shown to council members and staff for final approval. The original crest will continue to be used for certificates of qualifications, but the new crest will be used on all other communication materials and channels, such as the new website.

Building Report 8 Revamped College News

Knight Harwood Limited handed the building over to the College at the beginning of November. The firm was a pleasure to work with and had a strong commitment to good quality workmanship; Bennetts Associates produced a strong design and Jackson Coles LLP ably managed the project.

It has been a challenging project; it has demanded a lot of staff time and the attentions of the Building Group. I would particularly like to thank Aziz You will have noticed the change in design Rajab-Ali, Head of Operational Support and Mark Merrill, Finance Director, for of College News and we hope you find it their continued efforts and Mike Hayward, Senior Vice President for his eye bright, professional and a great source of for detail. information about the work of the College and you, our members. It does feel like a new chapter for the College and I hope many members will come to visit. As part of our continued drive to improve communications, we are looking to Kathy Evans, Chief Executive reschedule College News to fit more closely [email protected] with activities and events taking place; with this in mind, our next College News will not be until April 2015.

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Clinical Excellence Awards to compete for a College nomination. A College nomination It’s not too soon to prepare for 2015! carries a College citation and guarantees that the application by-passes the first but not subsequent stages of the ACCEA selection process. It is not necessarily a good indicator We expect the results of the 2014 Round to be announced that an application will be successful as all applications are end March/early April 2015. It is possible that the May carefully scrutinised by several levels of ACCEA committees 2015 General Election may delay the announcement of a (which include lay members). The strong support of the 2015 Round. It is, however, anticipated that the scheme will employing Trust or Trusts is essential. continue and that, for 2015 at least, it will continue in its The College process is itself time-consuming, relying as it current scaled-back form. Both the Advisory Committee on does, on the work of the elected Regional Representatives or Clinical Excellence Awards (ACCEA) and the College would their deputies to score the applications and between them wish to encourage clinicians to seek awards and the following arrive at the College ranking. Thought is being given to points may help you decide whether or not to apply: ways to improve the system. The trend over the past couple • Only about 600 Awards are made under the Scheme across of years has shown that there is a significant “pinch-point” all specialties at the Silver Award stage and failure to achieve a College nomination does not reflect on the applicant but may • Awards are made for a period of 3 years and, if not be a reflection on the way the application form has been renewed, lapse which may well have an impact on salary/ completed (scorers can only score what is on the form). In pension. You may need to seek financial advice any event, the system is time-consuming and definitely not • Renewals are not a formality and applications need to perfect. Given the uncertainties of the coming year, those demonstrate at least the same level of performance as who are considering making an application are encouraged when the award was first made to prepare their forms now so that they can be revised at the appropriate time. • At Bronze level, if your work impacts on the local rather than the national arena, it may be more prudent to apply Advice on completion of forms is available at www.gov.uk/ for a Level 9 Local Award government/organisations/advisory-committee-on- clinical-excellence-awards but the most succinct advice The College is only allowed to make a very limited number of is to ensure that all parts of the form and domains are nominations and will continue to invite eligible consultants completed and display the correct dates for entries made.

Council Elections Looking out for a Keeler The College will be seeking nominations for representatives for the following Ophthalmic (B&L) regions in January 2015. These posts are for 3 years and are renewable once. In addition, nominations will also be sought for the post of Honorary Zoom Microscope Treasurer. This post is for 3 years and is renewable twice.

Member Role Region Eligible for a An important instrument is missing in second term the historical collection at the Museum Gillian Adams Council Member Moorfields Yes of Microsurgery at the State University of Timothy Dabbs Council Member Yorkshire Yes New York, USA. It is the Keeler Ophthalmic Saurabh Jain Council Member North East Thames Yes (B&L) Zoom Microscope manufactured Martin Leyland Council Member Oxford Yes in the 1960s and was the first motorized Fiona Spencer Council Member North West Yes zoom microscope in the world used in James Talks Council Member Northern Yes surgery. It was the result of a collaboration Nick Wilson-Holt Council Member South Western Yes between Dr Troutman and the Keeler Martin Murphy Council Member Northern Ireland No company in the early days of ophthalmic Peter McDonnell Honorary Treasurer Yes microsurgery.

Please contact [email protected] for more information on the roles or If you know of the location of one of these the nomination and election process. instruments Dr Troutman would be very pleased to hear from you. Elected President for ESCRS Richard Troutman MD, FACS, FRCOphth [email protected] Professor David Spalton has been elected as the next President of the European Society of Cataract and Refractive Surgeons.

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Illustrative Case A 56 year old non-diabetic, emmetropic, phakic female focus with no previous ocular history presented with a 1 day history of painless visual loss in the right eye. A dense vitreous haemorrhage was noted. The ultrasound scan Management of revealed no retinal detachment or obvious cause. The fellow eye was normal. When reviewed 4 weeks later a unexplained vitreous total RD with severe PVR (7 clock hours of posterior grade C) was found. Two vitreoretinal procedures failed to reattach the retina due to severe PVR. She consequently haemorrhage has long term silicone oil tamponade, a severely distorted Timothy Cochrane, Alistair Laidlaw, St Thomas’ Hospital, London macula and visual reduction to HM.

Unexplained fundus-obscuring vitreous Unexplained vitreous haemorrhage is high risk. haemorrhage represents a management dilemma. Sarrafizadeh et al4 retrospectively analysed the outcome of Traditional practice has been to observe with serial conservative management of patients with unexplained ultrasound scans, a vitrectomy being performed if dense vitreous haemorrhage. They included 36 eyes of 34 consecutive patients with fundus-obscuring unexplained the patient develops a retinal detachment. Retinal vitreous haemorrhage who underwent regular review and B-scan tears are the most important cause of unexplained ultrasound. No RDs were evident on ultrasonography at first vitreous haemorrhage. Such patients are at high risk presentation. Surgery was required in 78% of cases due to a retinal break being identified, an RD developing or failure of the of retinal detachment complicated by proliferative haemorrhage to clear. vitreoretinopathy (PVR) leading to poor anatomical 48% (14/29) of patients under 80 developed an RD, half of which 1 and visual outcome. This evidence based article were complicated by PVR. The visual outcome in this group was will argue that the default standard care of such poor. No patient over 80 developed an RD. In 76% (22/29) of patients should be urgent referral for vitrectomy. patients under 80 the cause of the haemorrhage was found to be a retinal tear. The mean final acuity in all patients (none of whom had macular pathology to explain the haemorrhage) was only Introduction equivalent to 6/18-1. Cases with anatomical success following non haemorrhagic RD usually have a much better visual outcome. Vitreous haemorrhage is a relatively common problem. In a population of 542,000 studied over 2.5 years Lindgren et al2 In another series Yeung et al1 retrospectively reported a 9 year found an incidence of 7 cases per 100,000 population per year (by series of RDs occurring in patients with vitreous haemorrhage. comparison retinal detachment (RD) has an incidence of 12 cases 33% of those with severe (fundus-obscuring) vitreous per 100,000 per year). The most common cause of spontaneous haemorrhage developed an RD complicated by PVR. vitreous haemorrhage is a partial or complete vitreous detachment (PVD) resulting in traction and tearing of new vessels It can be seen from these data above that rapid resolution of an such as proliferative diabetic retinopathy or branch vein occlusion. unexplained vitreous haemorrhage is rare, that a retinal tear is the most likely cause of such haemorrhages and that RD might be The second most common and arguably most important cause expected to occur up to 50% of conservatively managed cases. of spontaneous vitreous haemorrhage is a PVD resulting in a Further to this it is common for eyes that go on to detach to retinal tear and a torn normal retinal blood vessel. In the authors develop PVR. PVR is the single most likely predictor of failure of RD experience such tears are typically large and relatively posterior. surgery. The natural history of unexplained vitreous haemorrhage This second group have a high risk of preventable permanent is therefore far from benign with poor resulting visual outcome. visual loss secondary to RD. Referral for urgent vitrectomy is the safest approach. Aetiology of non-traumatic % vitreous haemorrhage There are no randomised trials or other direct comparison data on this subject. Tan et al5 and Dhingra et al6 have published data Abnormal new vessels with 45 PDR 32 which strongly suggest that an early vitrectomy will reduce the PVD or vitreous traction RVO 11 overall RD rate with a consequent considerable benefit in terms of sickle retinopathy 2 final visual outcome. Normal retinal vessels with 38 no tear 8 Tan et al5 report the results of 40 eyes undergoing immediate PVD flat tear 21 early vitrectomy for either dense unexplained vitreous RD 9 continued overleaf Macroaneurysm 2 AMD 2 Table 1 Adapted from Spraul et al3 collating figures for non- Other 13 traumatic vitreous haemorrhage from 6 studies2 from USA, UK Total 100 and Sweden (n=1487).

5 collegeFOCUS - THE ROYAL news COLLEGE OF OPHTHALMOLOGISTS QUARTERLY BULLETIN | WINTER 2014 haemorrhage (27/40, 69%), or cases where a tear was evident but patient had a history of treatment for proliferative diabetic intraocular haemorrhage precluded adequate visualisation and retinopathy, yet they were conservatively managed due to the treatment (13/40, 32%). None of the patients were diagnosed history or diabetes. with RD prior to surgery, but 2 were found to have an RD at the time of surgery. Tears were identified in 88% of the included eyes. Patients aged over 80 are most likely to develop a vitreous Only two eyes in this series (5%) developed a post-operative RD haemorrhage secondary to neovascular age-related macular and the median final post-operative visual acuity was equivalent degeneration or a retinal macroaneurysm. In this age group to 6/7.5. vitreous haemorrhage is less likely to be related to a posterior vitreous detachment. In neovascular AMD the haemorrhage may Dhingra et al6 published a series of 12 cases of that had be peripheral rather than sub macular, clues to this diagnosis are undergone early vitrectomy with fundus-obscuring vitreous the status of the macula in the fellow eye and or the presence of haemorrhage. 3/12 eyes showed evidence of an RD on a pre- peripheral reticular degeneration and/or eccentric disciform scars operative ultrasound. Retinal tears were found intra-operatively in or haemorrhages. Such eyes will usually have a central or pre 9 /12 eyes (75%). Mean visual acuity improved from HM to 6/12. equatorial sub retinal elevation evident on B Scan ultrasound of Two of the 12 eyes (17%) re-detached post op, both however the affected eye. achieved a final VA of 6/9 and no patients developed PVR. Conservative management is not justified by an ultrasound scan Inherent in a policy of early vitrectomy for unexplained vitreous which demonstrates an attached retina, no retinal tears and no haemorrhage is the fact that some patients will be found not other causative lesion. The sensitivity of ultrasound in detecting to have a retinal tear and therefore to have been at low risk of retinal tears is between 44 and 56%5,7. This means that half of development of a retinal detachment if left untreated. Such all retinal tears in eyes with unexplained vitreous haemorrhage patients cannot however be reliably identified pre-operatively. will be missed by ultrasound imaging, leaving these patients at Sarrafizadeh et al4 also reported that a vitrectomy was ongoing risk of a retinal detachment and long term visual loss if ultimately required in 78% of eyes in their series either due managed conservatively. Ultrasound is an unreliable tool for this to the development of a retinal detachment or failure of the purpose. The role of ultrasound is in detecting retinal detachment vitreous haemorrhage to clear, so conservative management at first presentation and identifying alternative causative lesions will only usually delay an intervention. The requirement for such as eccentric or sub macular vitreous haemorrhage. subsequent cataract surgery with its associated costs and potential complications in phakic patients should be recognised Evidence based approach but set against the high risk of permanent visual impairment in unoperated eyes. Early intervention is also not universally High risk patients are therefore adults under 80 with no effective in preventing a retinal detachment, however definite alternative cause of their dense vitreous haemorrhage. complication rates are low; 5% RD in above studies5,6 when Retinal tears are present in 75% or more of such patients. compared against the poor visual recovery and RD rates without There is an evidence base to justify a default management policy early intervention (39%4). in such patients of early vitrectomy. Visual outcomes are better with this approach because retinal detachments, complicated by Clinical Assessment of Patients Presenting With Vitreous PVR, are prevented. Haemorrhage

It is vital to establish whether vitreous haemorrhage is References unexplained and therefore high risk, or if there is a probable 1. Yeung, L. et al. Association between severity of vitreous haemorrhage cause which can be safely conservatively managed. and visual outcome in primary rhegmatogenous retinal detachment. Acta Ophthalmol. 86, 165–9 (2008). The only patients undergoing conservative management should be the elderly (over 80) or those in whom an 2. Lindgren, G., Sjödell, L. & Lindblom, B. A prospective study of dense spontaneous vitreous hemorrhage. Am. J. Ophthalmol. 119, 458–65 alternative aetiology such as pre-existing retinal (1995). neovascularisation or haemorrhagic age related macular 3. Spraul, C. W. & Grossniklaus, H. E. Vitreous Haemorrhage 98 review. degeneration is known to exist. Surv. Ophthalmol. 42, 3–39 (1997). Medical enquiry should ascertain whether there is a history 4. Sarrafizadeh, R., Hassan, T. S., Ruby, A. J. & Williams, G. A. Incidence of diabetic retinopathy requiring pan retinal laser, sickle of Retinal Detachment and Visual Outcome in Eyes Presenting with cell haemoglobinopathy or anticoagulation therapy. Drug Posterior Vitreous Separation and Dense Fundus-. Ophthalmology 108, interactions such as antibiotics with warfarin or advertent or 2273–2278 (2001). inadvertent dual anti platelet therapy (as in adding an non 5. Tan, H. S., Mura, M. & Bijl, H. M. Early vitrectomy for vitreous steroidal anti inflammatory to the medication of a patients hemorrhage associated with retinal tears. Am. J. Ophthalmol. 150, 529–533 (2010). already taking clopidogrel) may exacerbate spontaneous vitreous haemorrhage, however, an underlying cause is still required. 6. Dhingra, N., Pearce, I. & Wong, D. Early vitrectomy for fundus-obscuring dense vitreous haemorrhage from presumptive retinal tears. Graefes Relevant enquiry and examination of the fellow eye may reveal Arch. Clin. Exp. Ophthalmol. 245, 301–4 (2007). a history or signs of a known neovascular central or branch vein 7. Rabinowitz, R., Yagev, R., Shoham, a & Lifshitz, T. Comparison between occlusion, or prior laser for proliferative diabetic retinopathy. clinical and ultrasound findings in patients with vitreous hemorrhage. Eye (Lond). 18, 253–6 (2004). A history of diabetes alone is not a sufficient explanation for a vitreous haemorrhage: the authors have seen two diabetic patients who developed a total retinal detachment with PVR as a complication of an unexplained vitreous haemorrhage. Neither

6 college news Andrew Elkington by Tim ffytche

There can be few people who have done more to change the face of British Ophthalmology in the past twenty-five years than Andrew Elkington.

Born of a line of doctors stretching back into the 18th of the Royal Society of Medicine to become President of century, he had his medical education at Clare College the Ophthalmic Section in 1990 choosing for his inaugural Cambridge and St. Thomas’s and qualified in 1960. After lecture the alliterative title ‘Trials and Tribulations of several jobs, including obstetrics and general practice, his Training’. He continued to be involved in the College as first step on the ophthalmic ladder was an SHO post at it developed, taking the lead in various committees and Southampton Eye Hospital in 1966, he then moved to the proving to be an accomplished chairman and facilitator. He Westminster Hospital, then to Moorfields, then back to the was elected as its third President in 1994. Westminster and finally, with admirable symmetry, back again to Southampton where he became a Consultant in When the Southampton Eye was incorporated into the 1974 and later a Professor in 1990. General Hospital in 1994 Andrew was a key figure in launching the charity Gift of Sight which raised over a By his own admission he was not a pioneering surgeon, million pounds to equip a research area in the hospital. nor would he claim to have advanced the frontiers of It later helped fund a new Professorial Chair in 2002 and ophthalmic knowledge. His contribution to the specialty supports on-going research in the Unit - now one of the was more fundamental, his particular interests being most prestigious in the country. teaching and training. Many at Southampton recall the Friday afternoon tutorials which he ran; they were informal, After completing his three-year term as President of the inspirational, compelling and compulsory, and from them College, and having been awarded the CBE in 1996 for sprung a cohort of young ophthalmologists who went on to his services to medicine, he continued to move things become national and international figures. forward in many different fields – rationalising ophthalmic training for junior doctors throughout the UK, representing He published a number of papers, many on glaucoma, ophthalmology on the GMC, the Specialist Training a special interest of his, and on topics varying from Authority, the Criminal Injuries Compensation Board, eye injuries to the structure of the lamina cribrosa, promoting the new Royal College in the Academy of photogrammetry, screening, ocular therapeutics and the Medical Royal Colleges, chairing the British Council for the way eye clinics should be run. But it is through books that Prevention of Blindness and introducing fellowships for his teaching will be chiefly remembered – Clinical Optics, young eye doctors working in blindness prevention in the UK Ophthalmology for Nurses, Aids to Ophthalmology and and abroad. above all his series co-authored with Peng Khaw, the ABC of Eyes, serialised as twelve articles in the British Medical He will be remembered fondly by a generation of Journal - compulsory reading for all medical students, GPs ophthalmologists as a major influence in their training, and and those setting out on an ophthalmic career. by his colleagues for his warmth, his humanity, his lack of pomposity, his willingness to listen and his kindness. Not surprisingly he was drawn at an early stage into the Faculty of Ophthalmologists working on several committees, being an examiner - a benign one by repute, and later becoming its Honorary Secretary. He had a similar role when the College of Ophthalmologists was founded in 1988 and was an ideal person for it – calm, unflappable and open to new ideas. During this time he also rose through the ranks

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The Ophthalmology Clinical Research Training Fellowship Scheme Opens for Applications

The second series of Clinical Research Training Up to two fellowships may be made available per year and Fellowships, supported by the Medical are open to all UK-based ophthalmologists. The MRC will manage the assessment of the fellowships on behalf of The Research Council (MRC), The Royal College of RCOphth and Novartis, as part of the Clinical Research Training Ophthalmologists and Novartis Pharmaceuticals Fellowship programme. Ophthalmologists can apply for the Ltd, focusing on ophthalmology research fellowships via the MRC’s website. training within the United Kingdom, opened for The MRC’s Clinical Research Training Fellowships provide up to applications in November 2014. three years’ support for clinically qualified, active professionals to undertake specialised or further research training in the bio- The programme is the first example of a prestigious research medical sciences within the UK. fellowship involving a royal college, an industry partner and the MRC, and aims to develop research leaders of the future, The Clinical Research Training Fellowship programme has two address strategic research skills and support talented individuals rounds a year. Full details of forthcoming rounds are available at critical points in their career as they develop and establish here: www.mrc.ac.uk/funding/deadlines/fellowships- themselves. application-submission-deadlines/

Crucial dates for applications

Meeting/Interview Opening Date Closing Date Shortlisting Take Up Dates Dates

15 Nov 2014 14 Jan 2015 May 2015 24-25 Jun 2015 Aug 2015-Jan 2016

29 Jul 2015 9 Sep 2015 Feb 2016 2-3 Mar 2016 Apr 2016-Sep 2016

Ophthalmologists can apply for the fellowships via the Research For more information please visit the MRC website: Councils’ joint electronic submission system (Je-S): www.mrc.ac.uk/skills-careers/fellowships/clinical- http://je-s.rcuk.ac.uk/ fellowships/clinical-research-training-fellowship-crtf/

New Consultants Please see below for latest appointments following AAC’s that took place:

Mr Spyridon Mourtzoukos Queen Alexandra Hospital, Portsmouth Mr Michael Kouroupis Queen Elizabeth Hospital, Norfolk Dr Sonia Mall Hemel Hempstead General Hospital, Hertfordshire Dr Michael Karampelas Hemel Hempstead General Hospital, Hertfordshire Mr Edward Pringle King’s College Hospital, London Dr Tahrina Salam Torbay Hospital, Torbay Mr Peter Wishart Broomfield Hospital, Essex Mr Usman Mahmood Hull Royal Infirmary, Hull Dr Gurpal Toor Warwick Hospital, Warwick Miss Rupa Shenoy Colchester General Hospital, Colchester Dr Simon Ruben Southend University Hospital, Southend Mr Kamaljit Balaggan New Cross Hospital, Wolverhampton Mrs Neeta Ray-Chaudhuri Ashford & St Peters Hospital, Surrey Dr Amira Syliandes Royal Liverpool University Hospital, Liverpool Dr Clare Rogers Royal Liverpool University Hospital, Liverpool Mr Michael Bearn Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear Mr Alan Connor Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear Mr Krishnamoorthy Narayanan Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear Dr James Cameron University of Edinburgh

9 college news Wrong IOLs and Never Events in Ophthalmology

Mrs Melanie Hingorani Consultant Ophthalmologist, Clinical Director for Quality and Safety, Moorfields Eye Hospital NHS Foundation Trust Mr Declan Flanagan, Consultant Ophthalmologist, Medical Director, Moorfields Eye Hospital NHS Foundation Trust

There is now a large body of evidence it appears that many ophthalmologists have differing views on the appropriateness of inclusion of wrong intraocular lens (IOL) supporting the use of local and national insertion.

incident reporting, root cause analysis Of the 290 NEs reported to STEIS in 2012-3, 42 were wrong and consequent action (“learning from implants and, of these, 29 were wrong IOLs5. Cataract surgery 1 almost certainly carries a greater risk of inserting a wrong failure”) to improve care quality . implant than any other specialty. For every cataract procedure multiple elements of data must be measured accurately with The concept of Never Events emerged in Lord Darzi’s High delicate instruments requiring regular calibration. The patient Quality Care for All2 and a policy and framework for their use needs to be precisely positioned and cooperative. IOL planning in the NHS were introduced in 2009 by the National Patient and selection requires analysis of many factors about the Safety agency (NPSA)3. Never events are defined by NHS patient, the eye, their refractive desires and previous ocular England as serious, largely preventable patient safety incidents history as well as the use of complex formulae. Correct IOL that should not occur if the available preventative measures selection requires the clinician to assess and check multiple, have been implemented. Commissioners were asked to use the often small font, data fields on different sheets of paper or Never Events Framework when contracting with providers of screens. This, together with a huge number of permutations health care. of available lens types and powers, within a high volume list increases the risks far beyond that which one could expect with The criteria used to define a Never Event were: the Never Event a hip replacement or similar implant6. The introduction of toric may or does result in severe harm/death to patients and/or the lenses to correct astigmatism makes the risk of error even higher. public; there was evidence of occurrence in the past; national guidance and/or safety recommendations existed on how to prevent along with support for implementation; and occurrence can be easily defined, identified and measured on an ongoing ‘Many of these events may never be detected basis. The initial list included eight Never Events (NEs, table unless postoperative review is extremely 1) and, following a consultation after the first year’s data rigorous, particularly now that many patients collection, a longer core list of events was introduced in 20114. This included the following addition of particular relevance to have their postoperative care outside hospital ophthalmology: in the community.’ Surgical placement of the wrong implant or prosthesis where the implant/prosthesis placed in the patient is other than that specified in the operating plan either prior to or during How harmful is a wrong IOL to a patient? For many, especially the procedure. The incident is detected at any time after the if they have a visually undemanding lifestyle, there may be implant/prosthesis is placed in the patient and the patient little or no detectable harm or they may be somewhat more requires further surgery to replace the incorrect implant/ reliant on their spectacles. Many of these events may never prosthesis and/or suffers complications following the surgery. be detected unless postoperative review is extremely rigorous, particularly now that many patients have their postoperative care outside hospital in the community.

‘14.5% of reported Never Events in 2012-3 However, some cases will require intervention, such as refractive were wrong, and of, these 10% were surgery or a lens exchange, which carries little risk and the vast wrong IOLs5’ majority of patients are pleased with the outcome following IOL exchange. The NE framework was designed to prevent serious harm (and death), defined within the policy as Severe: Of the small number of NEs relevant to ophthalmology, there is Permanent harm is defined as permanent lessening of bodily little controversy over the inclusion of items wrong site surgery, functions, sensory, motor, physiologic or intellectual, directly retained foreign object post procedure, and misidentification related to the incident and not related to the natural course of patients which are clearly very high risk and avoidable with of the patient’s illness. For many, wrong IOLs do not fulfil this appropriate use of the WHO surgical safety checklist. However definition of severity.

10 THE ROYAL COLLEGE OF OPHTHALMOLOGISTS QUARTERLY BULLETIN | WINTER 2014

To address this, within the policy only wrong IOLs which References require further surgical intervention or develop complications 1. An organisation with a memory 2000. Available at http://www. are currently defined as NEs. This has had consequences for aagbi.org/sites/default/files/An%20organisation%20with%20a%20 some providers who have found themselves at odds with memory.pdf commissioners who feel that declarations ought to be made 2. Department of Health (2008). High quality care for all – NHS next for all wrong IOLs and also puts the provider in the difficult stage review final report situation of potentially feeling a reluctance to offer corrective Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/ input and persuade the patient against further intervention PublicationsPolicyAndGuidance/DH_085825 to avoid the NE label. However, the current new draft policy removes this distinction7. 3. National Patient Safety Agency (2009). Never Events Framework 2009/10 There are significant negative consequences of a declaration, Available at: www.nrls.npsa.nhs.uk/neverevents/ particularly for high volume cataract providers for whom it 4. The never events policy framework: An update to the never events may be very challenging to completely prevent events. The policy 2013/14. Available at: https://www.gov.uk/government/uploads/ Never Event framework clearly states the following: Failure to system/uploads/attachment_data/file/213046/never-events-policy- learn the lessons of a single never event or a prevented never framework-update-to-policy.pdf event could be perceived as organisational failure on grounds 5. Never events data summary for 2012/13. Available at: http://www. of patient safety for which Board leaders, particularly the Chief england.nhs.uk/wp-content/uploads/2013/12/nev-ev-data-sum-1213. Executive and Medical and Nurse Directors are accountable.4 pdf In addition, it states the NHS should not pay for care that is 6. Neily, J., Mills, P.D., Eldridge, N. et al. Incorrect Surgical procedures so substandard as to result in a never event. For this reason within and outside of the operating room: a follow–up report. Arch Commissioners should seek to withhold payment for the cost Surg 2011; 146: 1235–1239 of the episode of care in which a never event has occurred and 7. Never events policy framework review 2014. https://www.engage. any subsequent costs involved in treating the consequences of england.nhs.uk/consultation/never-events-policy-framework-review a never event. 8. Significant events in ophthalmology. Royal College Of Ophthalmolo- Classification of wrong IOL insertion as a NEVER event has gists. Available at: http://www.rcophth.ac.uk/revalidation/page.asp?sec tion=755§ionTitle=Significant+events+in+cataract+surgery undoubtedly raised awareness of the potential for error and led to better more robust procedures and improved working 9. Intraocular Lens Confusions: A Preventable “Never Event”—The practices in many eye units8,9. Withdrawing IOLs from the Royal Victorian Eye and Ear Hospital Protocol Intraocular Lens Confu- sions: A Preventable “Never Event”—The Royal Victorian Eye and definition of NEs has the potential to send the wrong message Ear Hospital Protocol. Zahmir E, Beresova-Creese K, Miln L. Survey of about the need to continually strive to prevent and to learn Ophthalmology 2012;57: 430-47. lessons following incidents.

NHS England is currently consulting on NEs and the College has responded. In the meantime, it is crucial that all cataract services have robust IOL selection procedures and that all members of the clinical team are aware of these procedures and adhere to them. It is also essential that all ophthalmologists continue to openly declare all NEVER events.

Table 1. Initial list of Never Events 2009 • Wrong site surgery • Retained instrument post-operation • Wrong route administration of chemotherapy • Misplaced naso or orogastric tube not detected prior to use • Inpatient suicide using non-collapsible rails • Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners • In-hospital maternal death from post-partum haemorrhage after elective caesarean section • Intravenous administration of mis-selected concentrated potassium chloride

11 college news

David James Wood - South Africa’s Museum Piece Father of Ophthalmology

David James Wood was the Father of a bigger house for their increasingly large family of six children. He converted rooms in the attic for his pathology laboratory where he Ophthalmology and the first medical did all his own eye sectioning and microphotography. In addition to specialist in South Africa. He was born in these talents he became a fine ophthalmic artist. 1865 at Earlston, Scotland and went to Wood was always interested in the organisation and conduct of the medical profession. He was the BMA’s Cape Town representative Edinburgh University to study medicine. acting as Secretary and finally President in the 1890s. In 1917 the BJO appointed him as their South African representative, a post he held until his death in 1937. Every year he would have an article He was taken on by Dr Douglas published in the journal. Argyle Robertson as a non- residential House Surgeon in the Wood became ophthalmic surgeon to the Robben Island Leper Eye Ward of Edinburgh Hospital. Institute and made his first inspection in 1913. He was unsparing Arthur Conan Doyle, James Barrie in his criticism of the cruel conditions under which the hand-cuffed (Peter Pan author) and Robert Louis lepers were compulsorily detained. He gave a report in the BJO in Stevenson were fellow students. 1921 on Ocular Leprosy. Wood wrote extensively. An unusual paper After nine months he moved to that made his international reputation was on “The Blindness of London to continue his training and John Milton” in which he diagnosed the cause of his blindness. was appointed a clinical assistant David James Wood, 1865-1937 Wood attended the Athlone School for the Blind and saw every at the Royal London Ophthalmic pupil, operating on some of them. During WWI his humanitarian Hospital (Moorfields). Here he worked under Marcus Gunn, John work extended to the treatment of all soldiers and sailors. In 1918 Couper, Edward Nettleship and Arthur Silcock with whom he spent Wood joined the medical faculty at the University of Cape Town two days a week training at St Mary’s Hospital in the pathology and offered his services as Honorary visiting ophthalmic surgeon. In laboratory, which was to hold him in good stead later in his career. 1919 he started a series of lectures and made a major contribution After eighteen months Wood was appointed Junior House Surgeon to the degree course. and then a Senior House Surgeon at Moorfields which at that David Wood was a man of many talents and interests. He was a time looked out on noisy and dirty Broad Street Station. The work gardener, cook and fine wood worker. In 1898 he owned one of was demanding and the pay poor. In his final year there was the first motor vehicles in South Africa and won the long distance no sunshine for forty consecutive days and he became ill with a Siddeley Cup in 1912. In 1937 he was invited to give the Doyne chest complaint. He was advised to leave the British climate and Memorial Lecture at the Oxford Ophthalmological Congress but from being an ophthalmologist he joined the Union Castle Mail died shortly before the meeting. His prepared lecture on “Night Steamship as a ship’s surgeon. blindness in Eye Diseases- suggestions and speculations” was given by his friend Dr Meyer.

‘At first patients were few and far between and to The annual DJ Wood Memorial Lecture was instigated to keep save money David Wood slept in the waiting room.’ alive the memory of the pioneering work and contribution to ophthalmology of this exceptional man. A biography of DJ Wood, published by his granddaughter, Dr Janet Hodgson and can be On the 28th October 1893 he sailed to Cape Town with £40 in his purchased directly. Please contact [email protected] pocket but most importantly some letters of commendation from senior ophthalmologists who described him as “brilliant”, with “an Richard Keeler, Honorary Museum Curator outstanding intellect” and “a person with a great future ahead [email protected] of him”.

Wood immediately set up practice as an ophthalmologist in Cape Town, the first specialist to do so in South Africa. At first patients were few and far between and to save money he slept in the waiting room. Soon the practice started to build and he had to work long hours. He administered to all in the community and gave his services free to those who could not pay.

In 1896 he was appointed part-time Honorary Ophthalmic Surgeon to the New Somerset Hospital. As his practice grew he and his DJ Wood with his daughter Slit Lamp painting by wife, Constance, who he had married in 1895, could afford to buy in one of his cars DJ Wood, BJO 1928

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JOHN LEE FELLOWSHIP 2015

This prestigious clinical research training fellowship, set up to honour the late John Lee, Opening Date to advance the science and practice of ophthalmology, will be awarded jointly by the > 15 Nov 2014 MRC and The Royal College of Ophthalmologists. Applicants must be a member of the Closing Date College, a UK trainee ophthalmologist and want to work towards a doctoral degree. > 14 Jan 2015

The fellowship will provide an opportunity for someone who aspires to a career as a Shortlisting clinician scientist or who wishes to strengthen their future clinical practice to undertake > May 2015 a period of clinical, epidemiological or laboratory based research related to eye disorders. For further details see www.rcophth.ac.uk/johnleefellowship, or contact Meeting/Interview Dates [email protected] > 24-25 June 2015

Applications must be made to the MRC. www.mrc.ac.uk/skills-careers/fellowships/ Take Up Dates > Aug 2015-Jan 2016 clinical-fellowships/jointly-funded-clinical-research-training-fellowship/

The first sitting of the Refraction Certificate examination was held at UNIMAS First sitting of Refraction in Kuching in June. The President, Carrie MacEwen, the Chairman of the Examinations Committee, Peter Tiffin, and the Senior Examiner for the Refraction Certificate Examination Certificate, Nick Hawksworth joined me in travelling to Kuching for the exam. in Kuching, Malaysia The week started with an examiners’ training session for our new, locally based examiners, Yee Fong Choong, Ken Fong and Chung Nen Chua. 24 candidates attended the examination, which was conducted over two days, with a pass rate of 62%.

On the final day of the visit, Professor MacEwen, Mr Hawksworth and Professor Chua delivered a teaching session for local trainees and examination candidates covering ‘Neurological Eye Movement Disorders’, ‘Dealing with Difficult Corneas’ and Ophthalmic Surgery on Malaysian Patients – The Perspective of a UK-Trained Ophthalmologist’.

‘Professor Chua and this team did a superb job in organising the examination! Our thanks also go to Professor Chua for his generous hospitality which included a trip to a local crocodile farm and many culinary delights. We look forward to returning in 2015!’

Part 2 FRCOphth Oral Examination - Letter of Intent between RCOphth and National University of Singapore

Following the examination in Kuching the Chairman of the Examinations Committee, Peter Tiffin, and I travelled to Singapore to meet with the Dean, Professor Yeoh Khay Guan, Director, Professor Chen Fun Fee, Senior Ophthalmic Consultant, Professor Chew Tec Kuan Paul, and other representatives from the Yong Loo Lin School of Medicine of the National University of Singapore (NUS) to discuss the proposal to hold the Part 2 FRCOphth Oral examination in Singapore from 2015.

Fruitful discussions were had culminating in the College and NUS signing a Letter of Intent to signify both parties’ willingness to continue negotiations in order to secure final agreement on the delivery of the Part 2 FRCOphth Oral Examination at NUS.

Emily Beet, Head of Examinations [email protected] 15 The moment you get the full picture to make the best decisions for your patients. This is the moment we work for.

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IOL master 700 Ad.indd 1 16/9/14 11:43:22 IOLMaster 700_Moment Ad_A4_template_140908_V6.indd 1 09.09.2014 09:52:06 THE ROYAL COLLEGE OF OPHTHALMOLOGISTS QUARTERLY BULLETIN | WINTER 2014 The moment you get the full picture to make the best decisions for your patients. Staff Joiners and Leavers This is the moment we work for. Keeler Awards George Hibdige, previously Deputy Head of Examinations Scholarship has been appointed as the Events Manager for the College and will be taking responsibility for delivering Congress in 2015. Mr. Manickam Muthiah (Nick) and Dr. Jasmina Cehajic- Kapetanovic have been jointly awarded the 2014 £30,000 George is looking forward to the new experiences this role Keeler Scholarship administered by The Royal College will bring, saying, “Following the success of Congress in of Ophthalmologists. The RCOphth Trustees made the 2014 I appear to have big shoes to fill, but I am looking forward to the challenge and hope Annual Congress 2015 unusual decision to award a shared Scholarship after the will be the best yet.” record number of applicants were shortlisted to only five from which a clear winner was impossible to choose. Moinul Mannan has recently joined the College as Professional Standards Coordinator, supporting the Nick will be travelling to Wisconsin to learn the latest Scientific and Professional Standards departments. techniques in ophthalmic imaging and to pursue some Moinul will be supporting Beth and George on organising research into 2-photon imaging for the early diagnosis of seminars, events and committee meetings. retinal diseases; Jasmina will be going to San Francisco to pursue research on intravitreal gene therapy for inherited Kam Khunkhune joined this year and is project manager retinal disorders for which there is currently no effective for the National Ophthalmology Audit project, he will be working directly with John Sparrow, Beth Barnes and treatment. Dr. Abbas Sotoudeh, M.D. of Keeler Ltd. stakeholders. Commented, ‘I am hugely excited about the prospect of supporting this year’s winners in their quest to acquire Following George’s change in role, Sophie Donovan has been skills and experience for UK ophthalmology and wish promoted to Deputy Head of Examinations. Sophie has them every success.’ worked in the Exams team for over eight years so brings a wealth of experience to her new role. Also, within the Exams Colin West, Keeler Ltd. team, Sheila Patel has left the College after eight years for [email protected] www.keeler.co.uk an external role. Sheila’s smile and sunny disposition will be missed by examiners and candidates alike. Martin Reeves has accepted a role with an accountancy firm after spending four years with the College as Melanie Corbett represents RCOphth Membership and Elections Co-ordinator and Carol Welch at the All Party Parliamentary Group has also left to pursue a different career path. We wish them all the best for the future. for Eye Health and Visual Impairment // CERTAINTY With MADE BY ZEISS SWEPT Source Biometry The All Party Parliamentary ™ Congratulations to Mr Jack Kanski - Group (APPG) for Eye Health awarded Peter Eustace medal and Visual Impairment met with representatives from The Royal College of Jack Kanski (who is a College Honorary Fellow) has been Ophthalmologists and the awarded the Peter Eustace medal for excellence in Education College of Optometrists The new IOLMaster 700 by the European Board of Ophthalmology. Mr Eustace, who to discuss the eye health Next generation biometry from ZEISS died in April 2014 has been described as “a giant of Irish and sector’s response to the European Ophthalmology who will be sorely missed” was a recent consultation from great advocate for Neuro-Ophthalmology. NHS England. ‘Improving We integrated SWEPT Source OCT technology into biometry eye health and reducing to create the first SWEPT Source Biometry device from ZEISS. The Admission Ceremony 2014 sight loss - a call to action’ • Detect unusual eye geometries on Monday 20 October. Melanie raised concerns about the • Detect poor fixation capacity issues facing eye service clinics today and the effect • Visually verify your measurement The Admission Ceremony for new Honorary Fellows, Fellows, this potentially has on the health and safety of patients. The Members, Diplomates and those who have passed the APPG, Chaired by Lord Low, was particularly interested to hear For fewer refractive surprises! Fellowship Assessment, took place on 5 September at the the recommendations from the College and we will be following Royal College of Obstetricians and Gynaecologists on a bright up with further information to the Group. and sunny afternoon. Professor John Forrester was made an Honorary Fellow and the citation by Professor Harminder Dua http://tinyurl.com/owcqnpc can be found on the news section of the website. www.zeiss.com/iolmaster700 Tel: 01223 401 450 [email protected] 17

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Congratulations to Paul Tesha and his team at the Lincoln Count Hospital who were one of three winners of the Macular Society Awards Clinical Service of the Year category. Awards were also presented to Geeta Menon and the macular team Muraine Punch at Frimley Park Hospital and Andrew Needham and his team Single-use at Eyecare Medical in Macclesfield. Adjustable Trephine DMEK made simple Paul commented on their award, ‘The AMD team at Lincoln County Hospital were pleased to receive the Clinic Service of the Year Award at the Macular Society Awards for Excellence 2014. This is a very prestigious national award and recognises all the hard work that the staff have put in to develop the NEW service to treat patients with macular disease which I believe has contributed to the reduction in the incidence of blindness Surgitrac I/A Systems in our county’ Paul Tesha and AMD team at Lincoln County Hospital

The Macular Society recognised Eyecare Medical’s exemplary HPMC patient care and passion to deliver a high quality NHS service. Single-use Telephone reviews with patients after treatment were also Co-axial Trypan Blue praised. Andrew Needham, Consultant Ophthalmologist, I/A Cannulas said: “We are delighted and very proud to have won this award. We particularly appreciate the fact that it was our Viscoelastics patients who nominated us. I would like to thank Macular Society for highlighting the work we do for the community.”

NEW Sarah-Lucie Watson, Consultant Ophthalmic Surgeon at the Royal Berkshire NHS Trust, won the Alan Alderman award for services to people with macular conditions.

For more on the awards, visit the Macular Society website. www.macularsociety.org Andrew Needham and Eyecare medical staff 1.6 mm diameter The Presbyopia Multifocal IOLs Solution CRG Update A key objective of the CRG is to finalise and agree our service Monofocal Toric IOLs Rejuvenates near vision specifications with NHS England for inclusion in contracts. It is unlikely that the current specifications on the CRG website are The progress of specialised commissioning has been likely to change significantly and should be used as a guide. frustratingly slow. A deficit of £800m was identified NEW NEW We are progressing the development of clinical commissioning in April and attention is now focussed on resolving policies for the use of Infliximab and Adalimumab for the this. The CRG is interested in hearing if there are treatment of Uveitis in children and adults. The policies specific cases where care is being compromised and are being considered by NHS England for prioritisation and we will raise these with NHS England. implementation in 2015/16. The CRG acts as a source of clinical advice and opinion for IFRs. Moria One use Plus There is still considerable debate as to the make-up of for DSAEK A new concept specialised services in the future. In some services there is likely Trusts will soon be commencing contract negotiations with NHS England commissioners and we would encourage lead clinicians in the treatment to be a consolidation of specialised centres, but no decisions A hands free have yet been made. The view remains that a network model to talk to their Trust’s contracting teams to ensure they are of Keratoconus automated system of delivery is the preferred option. The Dalton Review, set aware of local developments and needs. up by the Sec of State for Health is currently looking at root The CRG members are happy to talk to individual consultants. organisational reforms, which includes the network model Details of your local CRG senate area representative can be together with integrated care, networks, partnerships, chains found on the CRG’s NHS England website - www.england.nhs. and mergers (and acquisitions). The intention is to create uk/ourwork/d-com/spec-serv/crg/ good quality care with little or no variation but could see high performing Trusts sharing or taking over those performing less Alison Davis, Consultant Paedatric Ophthalmologist, Contact SD Healthcare Tel: +44 (0)161 776 7620 well. This could have an impact on who provides specialised Moorfields Eye Hospital; Chair of the Specialised services. Ophthalmology Clinical reference group for adults and www.sdhealthcare.com or Scan QR code to find out more paediatrics. 19 college news

Trainees Section

Welcome to the new section of College News, written by trainees and for trainees. Over the coming year, I aim to highlight some of the exciting opportunities available to you: international visits, out of programme experiences, skills courses, prizes etc. In addition to information on important issues relevant to training, more indulgent contributions are welcome: short stories, portrayals from the arts, interesting images (clinical or non-clinical) – anything that lends perspective. I hope you find the content informative, relevant, and even entertaining. If you have an idea you wish to contribute, an experience you consider valuable to training, or any comments, please contact me. Imran Yusuf, Editor [email protected]

College News Trainee Quiz Feature

You are in eye casualty when…

A 32-year-old female of Japanese descent presents with a two-day history of progressive, bilateral visual loss. She has no previous ophthalmic or medical history, although complains of a persistent headache and progressive hearing loss over the preceding five days. Visual acuity is 6/60 bilaterally. There is mild anterior chamber and vitreous activity, with fundal appearance similar in both eyes, as shown. There is no evidence of poliosis, vitiligo or alopecia. Initial investigations for secondary causes of uveitis are unremarkable. She is treated with high dose oral Prednisolone on a tapering course. At follow-up six weeks later, her vision and hearing are much improved.

What features are demonstrated on fundoscopy Answers are available on the Ophthalmopaedia at presentation? website, indexed under College News Quiz - accessible through www.rcophth.ac.uk What is the differential diagnosis of this appearance? TIPS: • Ophthalmopaedia is an online encyclopaedia and What is the most likely diagnosis in this patient? a useful resource.

What other signs might be present six months • Consider submitting an article for publication with after her acute presentation? your supervisor.

20 THE ROYAL COLLEGE OF OPHTHALMOLOGISTS QUARTERLY BULLETIN | WINTER 2014

The Shape of Training William H. Dean - Chair, Ophthalmic Trainees Group

What is the Shape of Training? The Shape of Training review was launched in 2013 by Broad-based training organizations responsible for medical training in the UK, “Appropriate organizations should put in place broad based chaired by Professor Sir David Greenaway. It set out to review specialty training” and reshape all post-graduate clinical training pathways. This is a difficult theme for ophthalmology and other single- entry run through training programmes. Would the entry Why was there a need for the Shape of Training review? point for ophthalmology training be amalgamated with The impetus behind the review was to ensure doctors are general surgery or general medicine? It may provide a great trained to the highest standards and are prepared to meet opportunity to align Medical Ophthalmology and Surgical changing patient and service needs. It aimed to offer a Ophthalmology. structure of postgraduate medical training that will be fit for purpose for years to come. Will the Shape of Training review affect my training? The timescale for implementation is potentially for the 2017 What were the recommendations of the review? starters, although the GMC would like trainees on the new There were 19 recommendations in total, ranging from curriculum with immediate effect. The recommendations may advancing the point of registration forward to qualification, take 7-10 years to fully implement. shortening training and increasing flexibility, changing the Certificate of Completion of Training to Certificate of Specialty What can trainees do voice opinion on the Shape of Training (CST), and introducing post-CST ‘credentialing’. Training Review? Currently the Colleges, the OTG, and other stakeholders How will the recommendations of the review apply to are involved in a number of workshops in response to the ophthalmology? review. If the Shape of Training proposals are indeed to It is unclear how some of the recommendations would be implemented, there will be a number of issues with far apply to ophthalmology, and some in particular are worth reaching implications in the future of ophthalmic specialist highlighting: training. Length of Training The OTG will be disseminating regular information via “Appropriate organisations must introduce processes… that communications with your local OTG representatives. I invite allow doctors to progress at an appropriate pace through you to actively participate in this process by engaging with training…” them and responding to communications. It is only through active involvement that we can bring together our ideas and Will this lead to a shortening of Ophthalmic Specialist address the challenges that the Shape of Training review Training? brings to Ophthalmic Specialist Training. Generalists / Comprehensive Consultants “Appropriate organisations… to make sure the postgraduate Where can I find out more? training structure is fit to deliver broader specialty training that www.shapeoftraining.co.uk includes generic capabilities…” www.rcophth.ac.uk - The OTG response to the review is Does this imply that more general ophthalmologists will be available to download trained and employed? Credentialing “Appropriate organisations… should develop credentialed programmes for some specialty and all subspecialty training…” Would training in certain ophthalmic sub-specialities be undertaken after Certificate of Specialty Training as part of credentialing? This may present an opportunity to more formally regulate current post-CCT fellowships.

21 college news

Successful COECSA Fellowship examination in Blantyre, Malawi

Sara Livesey, consultant ophthalmologist from Torbay Hospital and I made a special trip to Blantyre, Malawi on the 25 and 26 September to lead the examiners training course and support the second College of Ophthalmology of Eastern Central & Southern Africa (COECSA) Fellowship examination. The examination was well attended by 20 candidates from the COECSA countries mainly but some as far flung as Peru and Russia who were working in Kenya and Zambia respectively. All candidates must have completed at least three years of postgraduate ophthalmology training and have all passed a written assessment run by their local University; the standard of this examination ensures that successful candidates are considered competent to practice as an independent ophthalmologist in the eight countries which are part of COECSA. The examiners training course was also well attended by 25 examiners. The first day of the examination was the Objective Structured Clinical Examination (OSCE) which took place at the Lions Sight First Eye Unit of the Queen Elizabeth Central Hospital, Blantyre. The second examination day was the Structured Viva oral examination again held at the Eye Unit. The overall pass rate of 55% was much lower than in previous exams, which I believe is an indication of the exam becoming more robust as examiners become more experienced and confident in assessing. This has become an effective exam attracting an increasing number of candidates each year thanks to the leadership shown by Dr Millicent Kariuki and her successor Dr Muchai Gachago. There is an increasing pool of trained examiners and as the link with our College looks set to continue, I am sure the exam will go from strength to strength. A special thanks should also go to Dr Gerald Msukwa, the host examiner in Blantyre who made us feel so welcome. George Hibdige, Events Manager [email protected]