1

QUARTERLY BULLETIN OF THE ROYAL COLLEGE OF OPHTHALMOLOGISTS

College NEWS

Copy deadlinesWinter: 5 November 2014Spring: 5 February 2015Summer: 5 May 2015Autumn: 7 August 2015

Autumn 2014

2 Congress 2014 reports

4 Research opportunities in Malawi

5 Focus – Nystagmus

9 BOSU Bursaries

11 Global Ophthalmology Seminar report

14 An update on CORESS and case studies

17 Museum Piece – the founding of St Dunstan’s

18 Sustainability in Ophthalmology

Building report No. 7Things are really taking shape now that the heavy construction is complete. On a typical day there are 45 builders on site; work continues on the main circulation staircase, the central core areas and mechanical/electrical services installations to the open floor levels. The next stage will include installation of a feature staircase, a new lift and the completion of the roofing work so that the temporary roof and external scaffolding can be removed.

We have received £50,000 from the Lindbury Trust and £50,000 from the Monument Trust which, together with donations from members, brings the fundraising efforts to £454,000. The names of individuals giving £2,000 or

more with be displayed on the ground floor donors board.

Kathy Evans, Chief Executive

www.rcophth.ac.uk/giftaid

The beginnings of the central staircase

Articles and information to beconsidered for publication should besent to Liz Price, CommunicationsManager at liz.price@rcophth.ac.uk.

Advertising queries should be directed to Robert Sloan, 020 8882 7199, robertsloan@virginmedia.com.

Faruque Ganchi, Editor of Focus

NAME REGION END OF TERM

Mr Stephen Winder Yorkshire and Humberside (South) December 2014

Mr Ian Pearce Mersey December 2014

Regional Advisers are appointed by Council to act on behalf of the College. They must be:

• Fellows of the Royal College of Ophthalmologists registered with the College for Continuing Professional Development (CPD)

• NHS Consultants with an established or honorary contract in active practice. Advisers must stand down on retirement from their NHS post

A current list of Regional Advisors can be found in the Ophthalmic Directory, in the ‘For Trainees’ section on the website: www.rcophth.ac.uk/OphthalmicDirectory

Regional adviser posts

2 3

The second Glaucoma Day was organised and chaired by Pete Shah and myself and we aimed to provide an interesting day that would continue to appeal to everyone managing glaucoma, this wide spectrum to include consultants who see glaucoma in their general clinics, glaucoma subspecialists, trainees, SAS doctors, optometrists and other health professionals. This year was more popular than the inaugural year with 180 registrants fitting this profile. Interactive handsets and questions for the audience were aimed to encourage participation in sessions. The panel of distinguished international and UK speakers received excellent feedback and we were privileged to have Professor Weinreb as our keynote speaker this year.

The day had a practical theme based on “How I…” and was divided into four sessions. We started with “How I understand the patient’s perspective” with Mr Tony King explaining how he manages advanced disease, then Prof David Henson gave us practical tips on getting the best visual field performance and Prof David Crabb illustrated just how our patients’ visual field loss affects them. I brought the session to a close talking about the patients’ experience with medication and our education programme.

In the second session we learnt how to manage the comorbidity of ocular surface disease, the challenges of managing pigmentary glaucoma, how and when to perform SLT and how to manage blebitis with an algorithm for

understanding the inflamed bleb as Dr Freda Sii, Mr Tarun Sharma, Prof Pete Shah and Mr Joseph Abbott shared their expertise. Prof Robert Weinreb talked about how to, and the importance of being able to, detect high risk patients. He also gave us insight into the aetiology of disc haemorrhages showing how they occurred following a tear in the lamina cribrosa.

After lunch we tackled “the highs and lows of glaucoma management” discussing acute angle closure glaucoma, a systematic approach to managing high pressure (particularly after surgery) and then how to approach the patient with hypotony steered ably by Mr Mitch Menage, Miss Cecilia Fenerty and Mr Leon Au.

The day rounded off with a session looking at ‘tackling the bigger picture” which covered getting the best out of OCT by Mr Rustom Bativala, how to build trust with your patients from Prof Pete Shah, and before Mr Rupert Bourne looked at how to tackle glaucoma blindness with a worldwide viewpoint, Prof Robert Weinreb again shared his expert knowledge telling us how he manages glaucoma and his views on choosing a surgical approach.

Come and join us next year!

Fiona Spencer, Consultant Ophthalmologist, Manchester Royal Eye Hospital

Finding the right meeting to address your continuing professional development needs can be quite difficult in our time-challenged lives. If there were a meeting that you could attend and you were only allowed one day, what would you do? A short walk from Birmingham New Street station through the city centre took me to the ICC Birmingham which was the venue for the RCOphth Retina Day. Once inside it didn’t take too long before I ran into some like-minded friends who had the same idea. ‘Evie you are dressed as if you are going to a concert!’ Well they were right because that’s exactly how I felt. Retina Day was similar to attending an arena styled event.

Session one began with an overview of present and future management of wet AMD. It seems that for the moment, anti-VEGF therapy is here to stay as long term management for our patients. However, retinal gene therapy in the form of subretinal viral vectors may be the future. By the next lecture I learnt a new word; posology, which is concerned with the appropriate dosage of drugs. We were advised to check posology with OCT after two weeks in non-responders to anti-VEGF therapy. Professor Norbert Bornfield was one of several keynote speakers. He gave an update about the current status of radiotherapy for AMD. In conclusion, we were told that radiotherapy is invasive and in view of this there was no

Retina Day Report

Congress 2014 Reportjustification for its use as a primary agent in the management of AMD; Hmm! Our second keynote speaker was Professor Anat Loewenstein who summarised all the anti-VEGF trials in the management of retinal vein occlusion.

Session two focused on new developments in retinal imaging and management of the vitreomacular interface. The third keynote speaker, Professor Bart Leroy, told us that you need electrophysiology to do genetic eye disease properly. In this anti-VEGF era, it was good to hear about the benefits of TRP (targeted retinal photocoagulation) and sub-threshold laser. Clarification about the management of vitreomacular traction was also achieved in this session. Another keynote speaker, Professor Srinivas Sadda, talked about developments in wide-field imaging to the extent that I now must have wide-angled device in my department. This session ended with presentations of interesting and difficult retinal cases.

Session four was dedicated to diabetic macular oedema (DMO). Every lecture in this session was a well presented concoction of useful facts. Professor Ursula Schmidt-Erfurth summarised the session by telling us how we should manage DMO in 2014. The great debate followed and this was a lesson on how one must read the question properly. The debate topic was ‘Capacity issues in medical retina clinics would be sorted out by the introduction of non-medical staff (nurse)

injectors’. I, like the majority of the audience, voted in favour of this solution presented by Declan Flanagan. However, George Turner literally turned the audience opinion with his well thought argument against the proposal by pointing out that despite nurse injectors, the capacity issues around would remain....sorry Declan!

The last session of the day consisted of an elegant presentation by Professor Yusuke Oshima who showed videos of his small 27 gauge pars plana vitrectomies. Finally, Professor Barauch Kuppermann kept our attention to the last minute with an excellent overview of the role of inflammation in retinal vascular disease.

At the end of the day I had an overwhelming sense of achievement. I had been entertained by some of the world’s experts in retinal disease. Congratulations to Winfried Amoaku and Paulo Stanga for organising and chairing such a successful event. If next year you need an update of medical retina disease, and you only have one day to spare, I would definitely recommend Retina Day 2015. I can guarantee that you won’t be disappointed.

Evelyn Mensah, Consultant Eye Surgeon, Central Middlesex Hospital

Glaucoma Day Report

The 26th Annual Congress was well attended by all grades of ophthalmologists and allied health professionals. In addition to the regular programme there was an Allied Professions Day, a GP Day, a Laser Course and Training the Trainers session.

Tuesday started with the President’s session chaired by Prof Harminder Dua. There were excellent talks by Prof Weinreb on newer advances in imaging in glaucoma, Prof Nancy Newman discussed conditions affecting the visual pathway, Prof Donald Tan on the various lamellar corneal procedures, and Dr Bilyk on oculoplastic disorders.

The very popular retinal imaging course ran throughout the day. There were morning sessions on Corneal infections, Mitochondrial eye disorders, Tropical eye diseases and Incomitant Strabismus.

The afternoon session covered Macular oedema, Adnexal reconstruction, Systemic diseases and a very interesting session on translational research by Prof Paul Bishop; followed by the first Rapid Fire session chaired by Prof Andrew Dick.

The Barrie Jones Lecture was delivered by Prof Gullapalli Rao, founder and director of the L V Prasad Eye Hospital, India, who described his journey from India to the US, and back to India to set up a world class institution delivering affordable eye care. It was a truly inspirational story.

Wednesday started with the breakfast meeting sessions on medically unexplained visual loss, training and grand rounds. This was followed by stimulating sessions on Amblyopia, Glaucoma, FFA and measuring outcomes.

The Duke Elder Oration was delivered by Prof Richard Abbott, University of California, who spoke on global initiatives for improving patient safety and reducing medical

error. This was followed by sessions on Acquired optic neuropathies, Corneal transplantation, Emergency eye services and Uveitis.

Prof Rennie conducted the second rapid fire session which was followed by Prof Dua handing over the Presidency to Prof Carrie MacEwen. Prof John Marshall delivered the Bowman lecture in his inimitable style, sharing his observations on the relationship of light, ageing and the human eye.

Thursday started with breakfast meeting covering simulated ocular surgery, and the role of industry and private provision of care. This was followed by excellent sessions on paediatric cataracts, endophthalmitis, chronic eye diseases and retinal vascular disease.

Bill Aylward chaired the great debate. This was followed by Prof Neil Miller’s erudite Optic UK lecture on neuro-ophthalmic disorders. The concluding session comprised neuro-ophthalmology grand rounds, and sessions on cataract complications and infectious diseases of the eye.

Many thanks to all who have made this such a successful meeting, including the speakers, delegates, Optic UK and the excellent preparation and support from the RCOphth Scientific Department. A special thanks to Prof Tony Moore for his stewardship of the congress scientific programme over the years, and to Mr Parwez Hossain for his hard work as Honorary Program Secretary to the Congress. Prof Moore has now handed over the reins of the Scientific Committee to Mr Mike Burdon, and Mr Manoj Parulekar takes over from Mr Hossain.

We look forward to welcoming you to the Annual Congress 2015!

Manoj V Parulekar, Birmingham Children’s Hospital

4 5

THE ROYAL COLLEGE OF OPHTHALMOLOGISTS

FocusAn occasional update commissioned by the College.The views expressed are those of the authors.

5

Autumn 2014

Nystagmus is defined as rhythmic to-and-fro oscillation of one of both eyes. The incidence of nystagmus has been reported as 2.4 per 1000.1 If it occurs within the first few months of life it is termed infantile nystagmus (INS). INS can be further subdivided based on etiology into the following groups:2

1. Idiopathic infantile nystagmus (IIN). 2. Albinism. 3. Nystagmus associated with ocular disease. This includes aniridia (PAX6 mutations), congenital cataracts, optic nerve hypoplasia and retinal dystrophies such as achromatopsia and congenital stationary night blindness (CSNB). 4. Latent or manifest latent nystagmus (MLN). 5. Spasmus nutans.

If nystagmus occurs later in life it is termed acquired nystagmus. This can result from a variety of neurological diseases including multiple sclerosis (MS), diseases of the vestibular system, cerebrovascular accident, trauma, tumors and drug toxicity.

In addition to impaired vision, congenital and acquired nystagmus impact on many aspects of daily life such as cosmesis, difficulties with relationships and social interaction.3

Clinical AssessmentThe assessment of a patient with nystagmus involves recording a detailed history including family history, time of onset, symptoms such as blurred vision, oscillopsia and any associated neurological symptoms. Visual acuity (VA) is recorded monocularly and binocularly, both for distance and near, with and without spectacle correction. It is important to note any associated head postures during each test, particularly when the patient is exerting their maximal visual effort. When VA is tested without spectacles the abnormal head turn is often even larger as gaze is not limited by frames. An up-to-date refraction is carried out. An orthoptic assessment is performed detailing the presence of any squints and nystagmus form (amplitude, frequency, direction, conjugacy).

Slit lamp examination helps to determine the presence of iris transillumination defects (TID) (which can suggest a diagnosis of albinism), aniridia and cataract. Examination of family members for iris TID can also provide a diagnostic clue as this is a typical carrier feature in albinism.4 Dilated retinal examination is performed to document if there are any optic nerve or retina abnormalities such as optic nerve and foveal hypoplasia or abnormalities of pigmentation such as hypo-pigmentation in albinism.

InvestigationsThis initial assessment is the most important stage in diagnosing the etiology of the nystagmus and in directing any further investigations. This is summarised in Figure 1. If there is a clear history of onset in early infancy and no oscillopsia or other neurological symptoms are present then the etiology is most likely congenital infantile nystagmus. If however it is later onset or associated with oscillopsia or other neurological symptoms then it is most likely an acquired form of nystagmus. Eye movement recordings (EMR) can be used to distinguish between the different subtypes of nystagmus based on characteristic waveforms. Magnetic resonance imaging of the brain is essential if the nystagmus appears to be acquired in origin; if there are any associated neurological signs/symptoms or if the nystagmus appears atypical for congenital infantile nystagmus, for example disconjugate or vertical nystagmus.

The presence of iris TID on examination in conjunction with ocular and/or cutaneous hypo-pigmentation hints at a diagnosis of albinism. Optical coherence tomography (OCT) examination in albinism normally demonstrates typical foveal hypoplasia. In a normal OCT, the inner retinal layers which includes the ganglion cell layer, inner plexiform layer, inner nuclear layer and outer plexiform layer are absent from the central fovea. In typical foveal hypoplasia these inner retinal layers are present at the fovea. Visual evoked potentials (VEPs) can help to diagnose albinism based on the presence of crossed asymmetry. Normally, the right and left eyes have similar deflections at the same time point on VEP (i.e. they are symmetrical). In albinism the deflections may occur in opposite directions in each eye (i.e. they are asymmetrical).

Focus on Nystagmus

Helena Lee, Clinical Research Fellow and Irene Gottlob, Consultant Ophthalmologist

Ophthalmology Group, University of Leicester, Robert Kilpatrick Clinical Sciences Building,

Leicester Royal Infirmary, PO Box 65, Leicester. ig15@le.ac.uk

Join FMLM to professionalise medical leadership and management for better patient care. Doctors have a long and proud history of defining and expecting high clinical standards as well as establishing the necessary systems of training and development that have led to massive benefits for patients. In a recent article, Peter Lees, Medical Director at the Faculty announced: “It is now time to recognise the value that medical leadership can add to that history and support all doctors to equip themselves with the leadership skills necessary for their various roles in complex and challenging systems.”

As part of the effort to serve our membership, one of the key FMLM activities in 2014 will be seven regional conferences to engage members locally and provide an opportunity to learn from experts in management and leadership, share experience and know-how and network.

All doctors, dentists and medical and dental students are invited to participate in these events taking place across the UK between September and November 2014 and the annual national conference in February 2015. Regional and annual conference places are available at discounted rates for FMLM members and associates, visit www.fmlm.ac.uk/events/regional-conferences-2014

Your support is hugely important so please join FMLM’s 2000 strong membership, take advantage of the many member benefits and add your voice to ours! For more information about membership and the regional and national conferences, go to www.fmlm.ac.uk

Faculty of Medical Leadership and Management

Exciting ophthalmology research opportunities in Blantyre, MalawiBackgroundThe Department of Eye and Vision Science (DEVS) at the University of Liverpool has long standing links with the Liverpool School of Tropical Medicine, the Malawi-Liverpool-Wellcome Trust Clinical Research Programme and the Lions Sight First Eye Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi. Clinicians from Liverpool are currently undertaking Wellcome Trust funded research in diabetic retinopathy and malarial retinopathy in Blantyre.

Current opportunityThe Department of Eye and Vision Science is looking for talented clinicians interested in undertaking research in Malawi. We hope to find candidates to complete a 1 year period of research culminating in a successful application for a research training fellowship. Areas of research interest include diabetic retinopathy (service delivery in resource

poor settings), malarial retinopathy (retinal and cerebral vascular biology), cornea (microbial keratitis) and ocular oncology (ocular surface malignancies associated with infection). Opportunities also exist for laboratory based research in areas that DEVS is currently active.

This is an excellent opportunity for an ophthalmology trainee interested in developing research as an aspect of their career. This is ideal for someone wishing to undertake a higher degree although no commitment to a higher degree is required in the first instance. In partnership with the Malawi-Liverpool-Wellcome Trust Clinical Research Programme DEVS can provide a salary, flights and research expenses for successful applicants.

Contact detailsFurther information can be obtained by email from Dr Phil Burgess (pburgess@liverpool.ac.uk), Mr Nicholas Beare (nbeare@btinternet.com)

or Professor Simon Harding (sharding@liverpool.ac.uk). Dr Burgess will give a talk as part of the St Paul’s post graduate training programme in autumn 2014.

6 76

A close scrutiny of the motility examination can provide a diagnosis of IIN or MLN. IIN presents with typical horizontal conjugate nystagmus which does not change upon covering one eye. Normally no other abnormality other than nystagmus and squint are found. Binocular vision is often present. Testing for FRMD7 gene mutation which is known to cause IIN, should be considered as it can confirm X-linked IIN. In contrast to this, MLN is typically associated with a congenital squint syndrome, typical nystagmus which increases upon covering one eye and beats in the direction of the open or fixing eye. Binocular vision is absent. In both cases, slit lamp, fundus, OCT and electrophysiology examinations are all normal, although mild foveal hypoplasia can be present on OCT in cases of FRMD7 IIN. IIN and MLN can occur concurrently in the same patient. This can easily be seen on eye movement recordings.

Diagnosis of nystagmus associated with ocular disease is dependent on a thorough history and ocular examination. Some conditions associated with nystagmus such as congenital cataract and optic nerve hypoplasia may be immediately apparent on clinical examination. If a diagnosis of optic nerve hypoplasia is made, MRI screening for septo-optic dysplasia should be considered as this is known to be associated with this condition. PAX6 mutations are autosomal dominant and are often associated with a family history of the condition. Vertical nystagmus is a feature of PAX6 mutation. All parts of the eye may be affected and findings may include aniridia, cataract, optic nerve and foveal hypoplasia. OCT demonstrates typical foveal hypoplasia. VEP is normal.

Retinal conditions that are associated with nystagmus include retinal dystrophies such as achromatopsia and congenital stationary night blindness (CSNB). These conditions may present with horizontal or vertical conjugate or dysconjugate nystagmus, light sensitivity and problems with night vision or color vision. In achromatopsia, nystagmus is usually low amplitude and rapid and there is severe photophobia. The retinal examination can appear normal in the early stages of the diseases. In these cases the electroretinogram (ERG) is very useful in distinguishing between these conditions. In achromatopsia, the cone function is abnormal and this results in a flat response on photopic testing. In CSNB, the rod function is abnormal and this results in a negative deflection on scotopic testing. OCT studies in achromatopsia have demonstrated atypical foveal hypoplasia (where in addition to the abnormal continuation of the inner retinal layers, there are also abnormalities of the photoreceptor layer) which is almost always pathognomonic of achromatopsia.

Spasmus nutans consists of the triad of rapid pendular nystagmus, head nodding and abnormal head position. Clinically it resolves spontaneously within a few months to a year after onset. However, it is important to rule out optic nerve and chiasmal gliomas before labeling it as benign, as

these tumors have been found to be associated with spasmus nutans syndrome.

TreatmentTreatment for nystagmus includes optical, pharmacological and surgical options. Vision should be optimized with up-to-date spectacle corrections or contact lenses. Tinted glasses can be beneficial in photophobic patients. Contact lenses may be of benefit in those patients with high astigmatic refractive errors associated with head turns who cannot achieve their full visual potential with normal spectacles as their head postures do not allow them to look through the center of their lenses. Hard contact lenses as opposed to soft contact lenses should be used as these are more stable on the moving eye of a nystagmus patient. Prisms can be used to treat abnormal head turns, decrease squints or dampen nystagmus by increasing convergence.

There are a small number of randomized control trials relating to the pharmacological treatment of nystagmus. These include Memantine, Gabapentin and 3,4 Diaminopyridine (DAP). Gabapentin and Memantine can improve both infantile and acquired nystagmus in terms of EMR, VA and visual function scores. Memantine is efficacious in treating acquired nystagmus secondary to MS. DAP has been shown to be of benefit in both idiopathic and acquired down-beat nystagmus. There are also case reports that suggest other medications including: Baclofen, Clonazepam, topical Brinzolamide and Acetazolamide may also be effective.

Surgical treatment options include corrections for head turns (Kestenbaum-Anderson procedure) which involve large recessions and resections of the extra ocular muscles in order to shift the null point to the primary position. They can be done for horizontal, vertical and torsional head positions. This is beneficial in several ways. Firstly, in patients with astigmatic corrections it allows them to gain the full benefit of their spectacle correction in the primary position. Secondly, this treats the associated muscular neck pain that these patients often have as a result of their head posture. Finally, cosmesis is significantly improved in the primary position. Before considering surgery for abnormal head position, it is important to rule out periodic alternating nystagmus (PAN) preferably using EMR as this procedure may not be appropriate in PAN. Tenotomy of all four horizontal muscles has also been advocated to reduce nystagmus intensity.

SummaryA detailed history and examination can often direct the diagnosis of any associated conditions in nystagmus and focuses subsequent investigations. Additional investigations with OCT, eye movement recordings and electrodiagnostics are often needed for diagnosis. There are several management options available; including optical/refractive, pharmacological and surgical treatments.

References1. Sarvananthan N, Surendran M, Roberts EO, et al. The prevalence of nystagmus: the Leicestershire nystagmus survey. Invest Ophthalmol Vis Sci 2009;50:5201-6.2. Gottlob I. Nystagmus. Curr Opin Ophthalmol 2000;11:330-5.3. McLean RJ, Windridge KC, Gottlob I. Living with nystagmus: a qualitative study. The British journal of ophthalmology 2012;96:981-6.4. Charles SJ, Moore AT, Zhang Y, et al. Carrier detection in X linked ocular albinism using linked DNA polymorphisms. Br J Ophthalmol 1994;78:539-41.5. Lee H, Sheth V, Bibi M, et al. Potential of handheld optical coherence tomography to determine cause of infantile nystagmus in children by using foveal morphology.

Ophthalmology 2013;120:2714-24.

Further reference: a Diagnostic Algorithm for Nystagmus will be published on www.rcophth.ac.uk alongside this Focus feature.

8 9

Thanks to the kind support from The Red Trust and the Ross Foundation the British Ophthalmological Surveillance Unit (BOSU) is offering 3 research bursaries of £6000 to support ophthalmologists in training undertake an epidemiological study of a rare eye condition through the BOSU or the Scottish Ophthalmological Surveillance Unit (SOSU).

• The RED Trust BOSU Bursary- for an ophthalmologist in Training

• The Ross Foundation BOSU bursary for an ophthalmologist Training in Scotland (NB Eligible candidates may submit one application for both awards)

• The Ross Foundation SOSU study bursary for an ophthalmologist Training in Scotland

Suitable conditions for BOSU studies are a predicted annual incidence of >5

per million (300 cases per annum in the UK), but topics with an expected incidence of between 75 and 125 are best suited for these awards.

Suitable conditions for SOSU studies are a predicted annual incidence of >30 per million (150 cases per annum in Scotland).

These awards aim to enable the successful ophthalmologist to develop their research skills, promote the importance of rare disease surveillance and add to the body of knowledge of rare eye diseases and conditions

Applicants are advised to contact Barny Food, barny.foot@rcophth.ac.uk or 07808 581659 for assistance with preparation of applications. Closing date for applications for all bursaries is 10th October 2014.

BOSU Surveillance Study Bursaries for Ophthalmologists in Training 2014

High Holborn ReunionA Reunion Lunch will be held on Friday, October 24th 2014 for all those who were on the clinical staff at the High Holborn branch of Moorfields. The venue will again be The Medical Society of London, 11 Chandos Street, London, W1G 9EB. Those interested in attending should contact me at: t.ffytche@btinternet.com or by post to my home address: 1 Wellington Square, London, SW3 4NJ.

Tim ffytche, Honorary President, Moorfields Association

We need your updated email addressesWe are aware that our communications are not always getting through the IT systems in hospitals. It would help to have an alternative address. Whilst not fool-proof, a personal or alternative email address may help overcome this issue. Please send your preferred email address to Martin Reeves, Membership Co-ordinator, martin.reeves@rcophth.ac.uk

The College encourages Ophthalmologists of all grades to submit articles to Ophthalmopaedia. A monthly prize for the best article submitted is available (excluding consultants).

Articles will be published following review and acceptance by the editorial team. An article published on the RCOphth website may then be cited as a Royal College recognised publication for the author’s CV.

We are currently prioritising articles which pertain to either “Ophthalmic Conditions” or “Surgical Techniques”. Standardised Microsoft word templates are available.

To submit an article prospective authors are encouraged to follow these simple steps:

1. Register for the e-learning for healthcare website 2. Identify the topic they are interested in writing about after checking that it has not already been covered 3. Liaise with the editorial team before

commencing work on the article and refer to the guide for authors 4. Use one of the existing Microsoft word templates or discuss alternative templates with the editorial team 5. Submit the article to the editorial team for review

Online CoursesA new course in Corneal Surgery has been added and a course in Strabismus Surgery is in development. All Eye-Site courses are designed to support live practical courses.

Single sign-inMembers can now access e-learning for healthcare materials directly from the members’ area of the College website without having to separately sign in to Eye Site.

Please access the Eye-Site pages on the College website for more details.

Kasra Taherian – Chair E-learning Sub-committee & Editor - Ophthalmopaedia

E-learning update - Ophthalmopaedia

ObituariesWe note with regret the death of:

Professor Natalija Jaković, Serbia Mr Peter Hamilton, London, UK Mr John Alan McKelvey, Truro, UK

10 11

Global Ophthalmology SeminarJune 27th 2014The majority of the world’s blind people live in low-income countries. 37 million people in the world are blind, and 80% of this blindness is avoidable: either preventable or treatable. The Royal College hosted a Global Ophthalmology Seminar, where eminent speakers from the world of global ophthalmology told of their journey into this fascinating and critical, but hugely neglected part of ophthalmology.

The objectives of the seminar were to:

• Illustrate how UK ophthalmologists work in global ophthalmology, and how trainees and ophthalmologists can be involved

• Define global ophthalmology and highlight the huge burden of visual impairment in low-income settings.

• Discuss global health research and how it can guide practice and blindness prevention

• Demonstrate a number of appropriate techniques including sutureless extra-capsular cataract extraction and trachomatous trichiasis surgery that highlight the enormous scope for treating and preventing blindness

This dynamic and practical day was more about the ‘how’ than the ‘what’ of global blindness prevention.

The first speaker was Prof Rupert Bourne who presented work on the global burden of visual impairment and blindness. He further talked about the Universal Eye Health WHO global action plan for improved coordination, efficient monitoring, and focussed use of resources towards the most cost-effective interventions to prevent and cure eye diseases. He also elegantly described the enormous personal adventure and rewards of being involved in global ophthalmology.

Mr John Sandford–Smith MBE from Leicester narrated a fascinating account of his life’s eye care work in poor countries and hot climates. John also presented the audience with low-cost, high-tech, solar powered ‘Arclight’® ophthalmoscopes.

Mr John Buchan of Leeds, spoke of ‘Training, teaching and survival’. John worked for four years through the Christian Blind Mission (CBM) to lead a clinic in Sierra Leone. He showed that despite the enormous challenges, one can make a huge difference with careful needs based planning, empowering the local staff and a good strategy for sustaining care when you leave.

The President of the Royal College, Professor Carrie MacEwen, highlighted the role of the Royal College International Committee with reference to the College charter that pledges “to improve education and training to raise standards in ophthalmology worldwide by sharing knowledge and expertise”. It is hoped we can build on this and facilitate more UK ophthalmologists taking well-planned career or training breaks to work in global ophthalmology.

Dr Babar Qureshi, Director at CBM and co-chair of the International Agency for the Prevention of Blindness (IAPB) spoke on ‘Comprehensive Eye Care Everywhere’ using Pakistan as a model. This showed the importance of providing whole eye-care programmes and not just unsustainable single disease campaigns.

Dr Keith Waddell CBE from Ruharo Eye Hospital, Mbarara, gave an inspiring talk on his fifty years of working and living in Uganda. His work has facilitated the control of measles and leprosy as public health problems and set up a large, national ‘high-tech’ retinoblastoma programme but has also inaugurated the training of a whole generation of eye care workers.

An insight into the International Centre for Eye Health (ICEH) Vision 2020 LINKS Program, a toolkit for international collaboration of skills and expertise was given by Mr Nick Astbury. Dr Hendra Kusuma, a trainee from Indonesia was invited to recount the benefits of the UK LINKS Programme to his hospital and training programme.

Mr Saul Rajak described some of his work on management of trachoma in Ethiopia. Saul illustrated how simple programmatic research can be of enormous benefit to

CONTINUED ON PAGE 12...

12 13

blindness prevention programmes and gave some practical tips on how to set up global ophthalmology research.

How to leave and rejoin the UK ophthalmology training programme for a period in global ophthalmology, was the theme of the talk by Dr Karinya Lewis of Salisbury District Hospital. Karinya dropped in at the deep end working with CBM in South Sudan.

The final talk was given by Mr Will Dean, on ‘Sutureless cataract surgery in high volume settings’. Will had run an eye unit in Malawi and showed how with good management, good outreach and a good team a surgeon can do up to 50 high-quality sutureless ECCEs in a day. He also emphasised the necessity of monitoring quality and outcomes in these environments.

With over 50 delegates, feedback was exceptionally positive, with 100% stating they would recommend the seminar

Mr Zubin Saihan Moorfields Eye Hospital, LondonMiss Susmita Bala Queen’s Medical Centre Campus, NottinghamMiss Dania Al-Nuaimi Frimley Park Hospital, CaamberleyMr Sambath Tiroumal Southport and Ormskirk Hospital NHS Trust, SouthportMiss Sophie Jones King’s College Hospital, LondonMr Usman Saeed Epsom and St Helier NHS trust, CarshaltonMrs Sobha Joseph Heartlands & Solihull Hospital, BirminghamMiss Bita Manzouri Queen’s Hospital, RomfordMiss Ourania Frangouli Queen’s Hospital, RomfordMr Taha Ahmed Leighton Hospital, CreweMr Balasubramanian Ramasamy Arrowe Park Hospital, WirralMiss Kanchan Bhan Royal Manchester Eye Hospital, ManchesterMr Rajesh Bhardwaj Russells Hall Hospital, DudleyMr Muhammad Raja James Paget University Hospital, Great YarmouthMr Michael Bearn Royal Victoria Infirmary, Newcastle upon TyneMr Alan Connor Royal Victoria Infirmary, Newcastle upon TyneMr Krishnamoorthy Narayanan Royal Victoria Infirmary, Newcastle upon TyneMr Vikas Shankar Burnley General Hospital, BurnleyMr Hasan Usmani Burnley General Hospital, BurnleyMrs Sreekumari Pushpoth Ramakrishnan The James Cook University Hospital, MiddlesbroughMiss Fiona Cuthbertson The Countess of Chester NHS Foundation Trust, ChesterMr Neil Modi Dorset County Hospital, DorchesterMs Rebecca Ford Bristol Eye Hospital, BristolMr Robert Malcolm John Purbrick Sussex Eye Hospital, Brighton

Consultant appointmentsWe rely on medical personnel departments to confirm consultant appointments. Please contact aac@rcophth.ac.uk if you notice an error or omission.

CONTINUED FROM PAGE 11...

VISION 2020 UK LINKS ProgrammeVISION 2020 LINKS Programme, based at the International Centre for Eye Health, has over 25 LINKS between institutions in the UK and Africa.  The Programme continues to look for institutions in the UK wanting to become involved in LINKING with African Institutions awaiting a match.  If you think your eye department and your institution would be interested please contact marcia.zondervan@lshtm.ac.uk or write Marcia Zondervan, LSHTM/ICEH Keppel Street, London SW11 6QT or telephone 02079588335

to a colleague.

The conference was well attended by a range of cadres in the audience: 39% were consultants, 29% SAS ophthalmologists, and 16% ophthalmology trainees.

A huge amount of work continues in the global fight against avoidable blindness; and many UK ophthalmologists are involved on the front line, in research, in training, and in capacity building, fund-raising and advocacy. A great deal of enthusiasm exists among UK ophthalmologists and trainees to get involved. We hope to host the Global Ophthalmology Seminar every two years, supplementing continued forums and sessions on global blindness prevention at the annual College Congress.

Will Dean, Chair of OTG and Saul Rajak

14 15

FACTOID from the Quality and Safety GroupAccording to a recent issue of the British Journal of Ophthalmology http://bjo.bmj.com/content/98/1/141, a patient undergoing laser capsulotomy suffered macular burns reducing her vision from 6/18 to counting fingers. The dual mode laser had been set to selective laser trabeculoplasty instead of YAG.

“Learning from problems”The first ophthalmology case reports from CORESS: the Confidential Reporting System for SurgeryLearning the lessons from problems, mistakes and near-misses is essential to the development of a high-quality service. The RCOphth recently joined CORESS, the national system for disseminating lessons from these problems. We are pleased to publish here the first ‘ophthalmology CORESS case reports’.

We hope that these stories will encourage higher standards of care and better outcomes for our patients. If you’ve got a story you’d like to share, please file a very brief report via www.coress.org.uk. All reports are treated anonymously, and you’ll get a reporting certificate which is useful for your appraisal.

More importantly, patients can be reassured that ‘the incident has been reported to other eye doctors, so hopefully it won’t happen again’.

Published cases will also appear on the CORESS and RCOphth websites. Submitting to CORESS does not replace the requirement to report incidents via local/national patient safety reporting systems.

Account of Incidents Case 1 - Things can go wrong when a patient says ‘Yes’During an ophthalmology outpatient laser clinic, another patient came to my clinic room instead of the patient I had actually called. I think she must have mis-heard the name that I called. We discussed the scheduled treatment (laser iridotomy), she signed a consent form with the other patient’s sticker at the top, and I performed YAG laser iridotomies on her. Unfortunately, the patient I treated had been listed for selective laser trabeculoplasty, and so she ended up having the wrong laser procedure.

I did not check her date of birth, and the patient had answered “Yes” when I asked her if she was Mrs X. Soon afterwards, I realised what I had done. I immediately told the patient what had happened and notified this event to my Trust as a Serious Untoward Incident. Thankfully, no harm was done.

CORESS commentsThis case illustrates the dangers of ‘passive’ identification of patients. It is easy for a patient to mis-hear a question and then inadvertently agree with the clinician. This problem would not have occurred if the clinician had actively followed the principles of the WHO pre-operative checklist.

The patient should be asked ‘please tell me your name’, with similar open questions asking the patient to state their date of birth, address, planned procedure and side to be treated.

This principle applies to many other situations in medicine and surgery. Positive identification of patient, procedure (and side) is also vital for many other situations, including the ordering and interpretation of tests.

Case 2 - Gonioscopy: how wrong can you be?A man of 71 was referred to ophthalmology by his optometrist, with suspected narrow anterior chamber drainage angles. The optometrist was concerned that the patient was at risk of developing ‘acute glaucoma’ if nothing was done to prevent it. Gonioscopy was done by a trainee who was highly experienced with the Goldmann gonioscopic contact lens, but unfamiliar with the 4-mirror goniolens.

Using the 4-mirror lens, the trainee recorded that the angle was open, reassured the patient and discharged him. Two months later, the patient returned as an emergency with a painful red eye and blurred vision, due to Acute Primary Angle Closure (‘acute glaucoma’, with confirmed narrow angles). This required medical treatment, laser iridotomies, and eventual cataract surgery to control the pressure.

CORESS commentsThe 4-mirror gonio lens (e.g. Zeiss, Posner, Sussman) has a small central portion, making it easy to indent the cornea. Thus, pressing on the cornea with the 4-mirror lens will indent the central cornea, thereby opening up a narrow iridocorneal angle. This is the principle of indentation gonioscopy, which can give a lot of useful

additional information. However, this does mean that if one inadvertently presses when using the 4-mirror lens, the angle may appear open when it is in fact narrow.

Ophthalmologists should be aware of this potential pitfall. There are helpful training videos on-line. When learning this technique, it is probably safest to get a second opinion from an experienced colleague.

Case 3 - Lost surgical spongeA 68 year old patient with uncontrolled glaucoma underwent trabeculectomy surgery to the left eye, under local anaesthesia. Five small sponges, soaked in antimetabolite, were placed under the sub-Tenon’s space for 3 minutes, as per standard practice. At the end of the 3 minutes, two of the five pieces of sponge could not be retrieved - it was assumed that they had migrated backwards between Tenon’s capsule and the sclera. Repeated attempts at removal with forceps seemed to push the sponges further back, and eventually resulted in significant orbital haemorrhage. The sponges were finally removed by an orbital surgeon under general anaesthesia: one was found behind the macula, and the other had migrated to the tendon sheath of one of the rectus muscles. Thankfully, no harm came to the patient’s vision.

A colleague told us how to avoid this situation in future. ‘Lost sponge’ can be prevented by threading the sponges onto a suture beforehand, and tying it in a loop, like beads on a necklace. We use 6/0 or 5/0 nylon. This makes surgery quicker as well as safer. Sponges could still potentially come off the “necklace”, so they must still be counted in and out of the eye.

CORESS commentsThe sub-Tenon’s space is a potential space between the sclera and surrounding Tenon’s capsule, extending to the back of the globe and around the extra-ocular muscles. There are several other surgical ‘potential spaces’ in the body (eg pleural cavity, pericardium), and surgical sponges or other material could be lost in any cavity or potential cavity. As in this case, ‘blind’ attempts to remove a sponge may inadvertently push it further into the cavity.

Where possible, it is recommended that surgeons use sponges/swabs that are pre-attached to a handle, thread, ribbon, or other system to prevent them getting ‘lost’. For situations like this where pre-threaded sponges are not commercially available, we recommend that sponges are tied securely to a circular loop of thread before they are put in to the patient. All surgical swabs, sponges etc should be counted in, and counted out, of the patient.

Case 4 - Pre-operative surgical checklist (again)After a routine cataract operation, the patient was found to be myopic (needing strong spectacles) when the intention had been to aim for emmetropia (no distance glasses). Investigation of this incident revealed that another patient with the same name had recently also undergone cataract surgery in our unit. Pre-operative biometry had not been filed in the case-notes for our patient, so the biometry report had to be re-printed: this was done using the other patient’s data in error. The dates of birth of both patients, although not identical, contained similar numerals. This led to the wrong lens being inserted into a patient.

Two main factors contributed to this incident. Re-printing of the biometry was done without a careful confirmation of the patient’s identity- therefore the printout was done for a different patient, who happened to have the same name. During the pre-operative WHO check, the biometry printout was checked using one identifier only (patient name) and not date or birth or hospital number. Therefore, this error was not picked up in the pre-operative check.

CORESS commentsThis is another case which highlights the importance of checking patients’ identity at all stages of the medical process. Patients should be asked to state their name, date of birth, and address prior to any aspect of care. WHO pre-operative checks should ensure that all critical data (e.g. imaging, biometry, pre-operative examination findings) are of the correct patient.

16 17

Museum Piece

The Founding of St Dunstan’s in WW1The founder of St Dunstan’s, Sir Arthur Pearson, had two outstanding careers, one as a sighted person and the other when blind. Pearson is perhaps best known for the publishing empire he started but the subject of this piece, the founding of St Dunstan’s, was his second career.

Arthur Pearson was born in 1866 in Somerset. On leaving Winchester College at the age of 16, when the family money ran out, Pearson entered a writing competition for Tit-Bits and won the prize of £100 out of 3,000 competitors. He started work at the magazine in 1884 and duly became editor. This was the start of a dazzling career in writing and publishing. He founded Review of Reviews and Pearson’s Weekly in 1890, the first issue selling a staggering 250,000 copies.

However, at the age of 24, Pearson’s eyesight was beginning to fail but he continued to prosper in founding numerous magazines and newspapers, the most famous being the Daily Express in 1900. He then went on to establish the Evening Standard.

In 1908 Pearson was unsuccessfully operated on for glaucoma by Robert Doyne and in 1912 he had a retinal detachment. On consulting Professor Ernst Fuchs of Vienna he was told “you will soon be blind.”

In 1910 Pearson was created a baronet. Shortly before he became totally blind Pearson joined the council of the National Institute for the Blind (Royal NIB in 1953). He was appointed

Treasurer and its first President in 1914.

Otto Kahn, investment banker and philanthropist, who had bought St Dunstan’s Lodge in Regents Park (now the American Ambassador’s residence) in 1867, put it at Pearson’s disposal as a hostel for blind soldiers.

All those blinded in the war first went to the 2nd General Hospital, Chelsea to be assessed. This assessment was done by Major Arthur Ormond RAMC, a volunteer ophthalmologist from Guy’s Hospital who saw 1,008 blinded servicemen during the war. After this the servicemen, mainly soldiers, went to St Dunstan’s to learn how to cope with being blind. Practically every blinded serviceman during WW1 went through this organisation.

Arthur Lawson (later Sir), joined Pearson at St Dunstan’s and was to become an essential part of the organisation. Lawson was a consultant ophthalmologist at the Middlesex Hospital and at Moorfields. He attended to the ophthalmological needs of 824 service men during the period 1915-1920.

His book “War blindness at St Dunstan’s” published in 1922 is an account of the traumatic (407) and non-traumatic (417) causes of blindness he treated. He recounts how there were only a small number of cases of blindness caused by mustard gas. The conclusion he reached was that if it was severe enough to damage the eye it was severe enough to kill through inhalation. Box respirators were not issued until 1916. 417 servicemen lost their sight for reasons

other than those directly connected with wartime service, 127 of these through venereal disease syphilis.

If the College had been occupying Cornwall Terrace during WW1, staff would have witnessed the comings and goings of St Dunstaners, some of whom were taught typing and how to become masseurs at 2-4 Cornwall Terrace which St Dunstan’s had acquired. The boating lake was frequently used for recreation by the men, each boat having a volunteer lady coxswain. There were open air dances and St Dunstaners had their own orchestra. All the men were offered the chance to learn Braille.

By the end of the war there were 293 staff employed at St Dunstan’s. Many famous visitors, amongst them deaf and blind Helen Keller and Ernest Shackleton the explorer, visited St Dunstan’s.

Pearson tragically died in 1921, aged 55, as a result of a freak accident when he slipped in his bath and hit his head with fatal consequences. 1,200 blind St Dunstaners attended his funeral at Holy Trinity, Marylebone Road.

Arthur Pearson had been endowed with great intelligence and an exceptional capacity for organisation both of which he exploited to the full for the benefit of blind servicemen in WW1 and after. The wonderful work of St Dunstan’s continues today under its new name, Blind Veterans UK.

Richard Keeler, Honorary Curator

rkeeler@blueyonder.co.uk

Left to right: Sir Arnold Lawson; Sir Arthur Pearson and Sir Ernest Shackleton (courtesy of Blind Veterans UK); Typewriting class (courtesy Blind Veterans UK); Walking group in snow Regent’s Park (courtesy Blind Veterans UK)

18 19

Membership Survey – the results are in!Thank you to all members who responded to the first ever membership survey for the College. The 23.4% response rate to the survey has achieved the top end of the ‘standard’ industry norm of between 10 – 25%.We are really delighted that 177 members have offered help in testing the new website and we will be in contact with more information on how you can help.The initial findings will be presented to Council in the next few weeks and headlines will be published to members in October as part of the strategic planning process.Liz Price, Communications Manager

A sustainable health and care system has been defined as one which “works within the available environmental and social resources protecting and improving health now and for future generations.”

Today eye departments throughout the UK are struggling to improve health in a sustainable way. Challenges include the growing number of intravitreal injections, the burgeoning number of follow up appointments for patients with chronic eye diseases and providing effective training while complying with the European working time directive. Often there is no time for considerations about the future but locally and globally there is an increasing demand for eye services.

Many people suffer from preventable or treatable visual loss and there is a dearth of qualified practitioners who can apply today’s effective treatments more widely. Faced with such pressure on limited services it is important to consider how we can maximise efficiency and promote sustainable eye services for all. The American Academy of Ophthalmology

recently proposed five wasteful practices to be avoided for ‘the choosing wisely campaign’ (www.choosingwisely.org/doctor-patient-lists/american-academy-of-ophthalmology/)

The Royal College of Ophthalmologists is joining other members of the Academy of Medical Royal Colleges to assess how the aims of the Sustainable Development Strategy for the Health and Care System 2014 – 2020 can be realised. Measuring the sustainability of eye care requires an assessment of its financial, social and environmental impacts, the triple bottom line. Activities which can be considered examples of sustainable eye care include disease prevention and health promotion, patient education and empowerment, professional education and skill development, lean service delivery, low carbon alternatives to standard care and cost reduction, savings and quality improvement.

The College is currently setting up a working group on sustainability in order to address questions about the provision of sustainable eye care, to find examples of good practice and to contribute to an understanding of the issue of sustainability in ophthalmology.

If anyone is keen to get involved or to find out more please get in touch with Beth Barnes, Head of Professional Standards, beth.barnes@rcophth.ac.uk

Rachel Stancliffe, Dan Morris, John Somner and Andy Cassels-Brown

Sustainability in ophthalmology- benefits for patients and the planet

Natural Environment

Economic Vitality Hea

lthy

Commun

ities

SUSTAINABILITY

CongratulationsParul Desai, consultant in public health and ophthalmology at Moorfields Eye Hospital, is the first woman to be appointed to the prestigious role of Master of the Oxford Ophthalmological Congress. Parul said “It’s a wonderful honour and privilege to follow in the footsteps of an august body of people who have been masters before me.”

Dr Parwez Hossain has been appointed ‘Associate Professor in Ophthalmology’ at Southampton University. The University has offered this position to their staff who have strong portfolios in clinical research and teaching. Parwez said ‘ I am absolutely delighted to have been offered this role and look forward to the opportunities that this new post has to offer’.

Well doneCongratulations to Martin Reeves, Membership co-ordinator, who has passed both his accountancy exams taken in June.

20

DIARY DATES

The Royal College of Ophthalmologists, 17 Cornwall Terrace, London NW1 4QW Tel. 020 7935 0702 Fax. 020 7935 9838 www.rcophth.ac.uk

Seminar Calendar 2014All information about our 2014 seminars can be found atwww.rcophth.ac.uk/seminarcalendar or contact events@rcophth.ac.uk

Wednesday 24 September 2014Frontline Neuro-ophthalmologyVenue: University Hospitals BirminghamChairs: Mr Mike Burdon & Miss Susan Mollan

Tuesday 7 October 2014NIHR Master Class for Industry Supported ResearchVenue: Royal College of Ophthalmologists, LondonChairs: Professor Usha Chakravarthy & Mr Faruque Ghanchi

Wednesday 15 October 2014Paediatric RetinaVenue: Royal College of Obs & Gynae, LondonChair: Mr CK Patel

Tuesday 18 November 2014How to be a Research Active OphthalmologistVenue: Royal College of Ophthalmologists, LondonChair: Professor Andrew Lotery

Friday 21 November 2014Eyelid Surgery for the Tear FilmVenue: Royal College of Ophthalmologists, LondonChair: Mrs Carol Lane

Friday 5 December 2014Elizabeth Thomas SeminarVenue: East Midland Conference Centre, NottinghamChair: Mr Winfried Amoaku

19 – 21 May 2015The Annual Congress 2015Venue: The ACC, Liverpool

Courses at MoorfieldsPlease email courses@moorfields.nhs.uk or call 020 7253 3411 / 2248 for more information.

Friday 7 November 2014 A&E (1 day only) – course code 14/27Thistle Hotel Barbican, London

Monday 17 November 2014 Macular (5 days) – course code 14/17 Thistle Hotel Barbican, London

Wednesday 3 and Thursday 4 December 2014 (TBC) LASIK (2 days) – course code 14/19 Clinical Tutorial Complex, Moorfields Eye Hospital NHS Foundation Trust

Tuesday 17 to Saturday 21 March 2015 Clinical Electrophysiology of Vision (3 days, optional half day) – course code 15/04 Clinical Tutorial Complex, Moorfields Eye Hospital NHS Foundation Trust

Friday 30 January 2015 Paediatric nystagmus: a practical training day. £50 delegate fee including lunch and refreshments. This one day course organised by the Nystagmus Network charity is for ophthalmic and any other interested professionals.Marriott Hotel, Bristol City CentreFor further information email john.sanders@nystagmusnet.org, 029 2945 4242, www.nystagmusnet.org. Online booking is also available

Courses at The Royal College of Ophthalmologists.Please check on the website for availability and information for courses.

Wednesday 19 November 2014Oculoplastics CourseMs Sally Webber, Ms Ruth Manners

Monday 1 December 2014Medical Students Day - basic surgical skills course for medical students interested in ophthalmology.Mr Khalid El Ghazali, Ms Zanna Currie, Ms Teresa Anthony

Microsurgical Skills Courses Please check online or with the Education and Training Administrator on 020 7935 0702 or at skills.centre@rcophth.ac.uk for availability on courses as they do get booked up very quickly.

Moorfields Alumni Meeting – New venue for 2015Friday 13th February 2015Venue: One Wimpole Street W1G 0AE

Ophthalmic Trainees’ Annual Symposium Saturday 22 November 2014Venue: Royal College of Obstetricians and Gynaecologists. Visit www.rcophth.ac.uk/otgsymposium for the full programme

RCOphth Clinical Leads ForumThursday 20 November 2014Venue: The Royal College of Ophthalmologists. Visitwww.rcophth.ac.uk/clinicalleadsforum for more information.