Orbital exenteration is a physically debilitating procedure that may be a necessity in the management of orbital malignancy. It requires a sensitive multidisciplinary approach, both preoperatively and postoperatively. Providing life expectancy information for patients during preoperative counselling is pertinent to informed consent and in addressing patients' expectations. A retrospective review from one tertiary care centre was undertaken for a cohort of patients who were exenterated for orbital malignancy between 1998 and 2010. The cases were identified using an International Classification of Diseases 10th Revision (ICD-10)-derived database and were analysed using Prism statistical software (V.5.04). Cause of death was ascertained by liaising with the general practitioner and the National Registrar Office for Births, Deaths, and Marriages, Southport, UK. In total, 41 men and 32 women were identified. Mean age was 72 years with 47 cases living and 26 deceased at the time of review. The overall 5-year survival rate in this study was 64%. Kaplan-Meier analysis for basal cell carcinoma (BCC) against non-BCC returned a p value of 0.0199, with an HR of 0.3927 (CI 0.1788 to 0.8626). Kaplan-Meier analysis for cleared against non-cleared margins returned a p value of 0.2890, with an HR of 0.6571(CI 0.3024 to 1.428). Our results represent the highest 5-year survival data to date. However, the overall prognosis for patients who undergo orbital exenteration for malignancy remains poor. We hypothesise that the causes are multi-factorial. We recommend a multidisciplinary approach to the care of these patients, involving head and neck teams, oncology and other appropriate specialties, to optimise outcomes for this vulnerable patient group.

Better screening with existing tests should be the priority

Background The specialty-registration of independent prescribing (IP) was introduced for optometrists in 2008, which extended their roles including into acute ophthalmic services (AOS). The present study is the first since IP's introduction to test concordance between IP optometrists and consultant ophthalmologists for diagnosis and management in AOS. Methods The study ran prospectively for two years at Manchester Royal Eye Hospital (MREH). Each participant was individually assessed by an IP optometrist and then by the reference standard of a consultant ophthalmologist; diagnosis and management were recorded on separate, masked proformas. IP optometrists were compared to the reference standard in stages. Cases of disagreement were arbitrated by an independent consultant ophthalmologist. Cases where disagreement persisted after arbitration underwent consensus-review. Agreement was measured with percentages, and where possible kappa (Κ), for: diagnosis, prescribing decision, immediate management (interventions during assessment) and onward management (review, refer or discharge). Results A total of 321 participants presented with 423 diagnoses. Agreement between all IP optometrists and the staged reference standard was: 'almost perfect' for diagnosis (Κ=0.882 ± 0.018), 'substantial' for prescribing decision (Κ=0.745 ± 0.034) and 'almost perfect' for onward management (0.822 ± 0.032). Percentageagreement between all IP optometrists and the staged reference standard per diagnosis was 82.0% (CI 78.1%-85.4%), and per participant using stepwise weighting was 85.7% (CI 81.4%-89.1%). Conclusion Clinical decision making in MREH's AOS by experienced, appropriately trained IP optometrists is concordant with consultant ophthalmologists. This is the first study to explore and validate IP optometrists' role in the high-risk field of AOS.