The cataract national data set electronic multi-centre audit of 55,567 operations: case-mix adjusted surgeon's outcomes for posterior capsule rupture

Aims

To develop a methodology for case-mix adjustment of surgical outcomes for individual cataract surgeons using electronically collected multi-centre data conforming to the cataract national data set (CND).

Methods

Routinely collected anonymised data were remotely extracted from electronic patient record (EPR) systems in 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were carried out to risk adjust outcomes for posterior capsule rupture rates for individual surgeons, with stratification by surgical grade.

Results

A total of 406 surgeons from 12 NHS Trusts submitted data on 55 567 cataract operations between November 2001 and July 2006 (86% from January 2004). In all, 283 surgeons contributed data on >25 cases, providing 54 319 operations suitable for detailed analysis. Case-mix adjusted results of individual surgeons are presented as funnel plots for all surgeons together, and separately for three different grades of surgeon. Plots include 95 and 99.8% confidence limits around the case-mix adjusted outcomes for detection of surgical outliers.

Conclusions

Routinely collected electronic data conforming to the CND provides sufficient detail for case-mix adjustment of cataract surgical outcomes. The validation of these risk indicators should be carried out using fresh data to confirm the validity of the risk model. Once validated this model should provide an equitable approach for peer-to-peer comparisons in the context of revalidation.     

The Cataract National Dataset electronic multi-centre audit of 55,567 operations: risk indicators for monocular visual acuity outcomes

Aims

To report risk factors for visual acuity (VA) improvement and harm following cataract surgery using electronically collected multi-centre data conforming to the Cataract National Dataset (CND).

Methods

Routinely collected anonymised data were remotely extracted from the electronic patient record systems of 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were performed to identify risk indicators for: (1) a good acuity outcome (VA 6/12 or better), (2) the pre- to postoperative change in VA, and (3) VA loss (doubling or worse of the visual angle).

Results

In all, 406 surgeons from 12 NHS Trusts submitted data on 55 567 cataract operations. Preoperative VA was known for 55 528 (99.9%) and postoperative VA outcome for 40 758 (73.3%) operations. Important adverse preoperative risk indicators found in at least 2 of the 3 analyses included older age (3), short axial length (3), any ocular comorbidity (3), age-related macular degeneration (2), diabetic retinopathy (3), amblyopia (2), corneal pathology (2), previous vitrectomy (2), and posterior capsule rupture (PCR) during surgery (3). PCR was the only potentially modifiable adverse risk indicator and was powerfully associated with VA loss (OR=5.74).

Conclusion

Routinely collected electronic data conforming to the CND provide sufficient detail for identification and quantification of preoperative risk indicators for VA outcomes of cataract surgery. The majority of risk indicators are intrinsic to the patient or their eye, with a notable exception being PCR during surgery.     

Vitreous surgery for macular hole-related retinal detachment after phacoemulsification cataract extraction: 10-year retrospective review

Purpose

To evaluate the visual and anatomical results of surgery for macular hole-related retinal detachment (MHRD) after phacoemulsification cataract extraction.

Methods

Data for all patients who underwent surgery for MHRD after phacoemulsification cataract extraction from 1 December 1998 to 30 September 2008 in one hospital were evaluated. Patient characteristics, best-corrected visual acuity (VA) preoperatively and at last examination, surgical technique, anatomical success, and follow-up period were extracted and analysed statistically.

Results

A total of 13 625 eyes of 10 076 patients who had phacoemulsification cataract surgery were included. In the follow-up period, 10 cases of MHRD in nine patients were observed, of which seven eyes had high myopia. The mean axial length was 30.97±1.36 mm (29.19, 32.97) and mean myopia was−19.35±1.93 (−7.5,−3.5) dioptres. Overall anatomical success was achieved in 90% (9 out of 10 eyes). There was no statistically significant difference (P=0.240) between the logarithm of the MAR VA before the phacoemulsification cataract extraction and after MHRD surgical repair. VA increased in three eyes but decreased in the other seven after MHRD surgery.

Conclusions

As a primary procedure, vitreous surgery combined with other necessary adjunct procedures such as membrane peeling and retinal tamponade seems to be successful in achieving anatomical success. However, VA improvement is dependent on the type of macular lesion and not the surgical procedure.     

Surgical checklist for cataract surgery: progress with the initiative by the Royal College of Ophthalmologists to improve patient safety

Purpose

The World Health Organisation (WHO) identified patient safety in surgery as an important public health matter and advised the adoption of a universal peri-operative surgical checklist. An adapted version of the WHO checklist has been mandatory in the National Health Service since 2010. Wrong intraocular lens (IOL) implantation is a particular safety concern in ophthalmology. The Royal College of Ophthalmologists launched a bespoke checklist for cataract surgery in 2010 to reduce the likelihood of preventable errors. We sought to ascertain the use of checklists in cataract surgery in 2012.

Patients and methods

A survey of members of the Royal College of Ophthalmologists seeking views on the use of checklists in cataract surgery. Four hundred and sixty-nine completed responses were received (18% response rate).

Results

Respondents worked in England (75%), Scotland (11%), Wales (5%), Northern Ireland (2%), the Republic of Ireland (1%), and overseas (6%). Ninety-four per cent of respondents support the use of a checklist for cataract surgery and 85% say that they always use a checklist before cataract surgery. Sixty-seven per cent of cataract surgeons stated they undertake a pre-operative team brief. Thirty-six per cent use a cataract surgery checklist developed locally, 18% use the college''s bespoke cataract surgery checklist, 39% use a generic surgical checklist, and 4% reported that they do not use a checklist.

Conclusion

Ninety-three per cent of cataract surgeons responding to the questionnaire report using a surgical checklist and 67% use a team brief. However, only 54% use a checklist, which addresses the selection of the correct intraocular implant. We recommend wider adoption of checklists, which address risks relevant to cataract surgery, in particular the possibility of selection of an incorrect IOL.     

Lens retrodots and vacuoles and their associations with the prevalence and incidence of age-related cataract

Aim

To assess the prevalence of retrodots and vacuoles and their associations with the prevalence and long-term incidence of age-related cataract in an older Australian cohort.

Methods

Of 3654 baseline participants of the Blue Mountains Eye Study aged 49+ years (1992–1994), 2335 and 1952 were re-examined after 5 and 10 years, respectively. Lens photographs were graded for cataract, retrodots, and vacuoles. Eye-specific data were used to assess the associations between retrodots or vacuoles at baseline and the prevalence and 10-year incidence of nuclear, cortical, and posterior subcapsular (PSC) cataract and cataract surgery.

Results

At baseline, retrodots were present in 142 persons (4%) and vacuoles in 1333 persons (40%). Prevalence of both lens features increased with increasing age (Pfor trend <0.0001). After adjusting for age and gender, vacuoles were associated with prevalent PSC cataract at baseline (odds ratio (OR), 1.60, 95% confidence interval (CI), 1.25–2.05). After adjusting for age, gender, smoking, hypertension, diabetes, education, and use of inhaled/oral steroids, baseline retrodots were associated with an increased incidence of cataract surgery (OR 2.90, 95% CI 1.71–4.91), while 3+ vacuoles at baseline were associated with an increased risk of PSC cataract (OR 3.56, 95% CI 2.13–5.95) and cataract surgery (OR 1.84, 95% CI 1.22–2.77).

Discussion

Lens retrodots and vacuoles were found to be positively associated with 10-year incidence of cataract surgery, and vacuoles associated with PSC cataract, a finding suggestive of shared risk factors or pathogenesis between these two lens features and the development of PSC cataract.     

Cataract extraction and patient vision-related quality of life: a cohort study

Aims

Cataract surgery is one of the most common surgeries performed, but its overuse has been reported. The threshold for cataract surgery has become increasingly lenient; therefore, the selection process and surgical need has been questioned. The aim of this study was to evaluate the changes associated with cataract surgery in patient-reported vision-related quality of life (VR-QoL).

Methods

A prospective cohort study was conducted. Consecutive patients referred to cataract clinics in an NHS unit in Scotland were identified. Those listed for surgery were invited to complete a validated questionnaire (TyPE) to measure VR-QoL pre- and post-operatively. TyPE has five different domains (near vision, distance vision, daytime driving, night-time driving, and glare) and a global score of vision. The influence of pre-operative visual acuity (VA) levels, vision, and lens status of the fellow eye on changes in VR-QoL were explored.

Results

A total of 320 listed patients were approached, of whom 36 were excluded. Among the 284 enrolled patients, 229 (81%) returned the questionnaire after surgery. Results revealed that the mean overall vision improved, as reported by patients. Improvements were also seen in all sub-domains of the questionnaire.

Conclusion

The majority of patients appear to have improvement in patient-reported VR-QoL, including those with good pre-operative VA and previous surgery to the fellow eye. VA thresholds may not capture the effects of the quality of life on patients. This information can assist clinicians to make more informed decisions when debating over the benefits of listing a patient for cataract extraction.     

The UK National Cyclodiode Laser Survey

Purpose

To evaluate current practice of transscleral diode laser cyclophotocoagulation (cyclodiode) laser treatment among consultant ophthalmologists in the United Kingdom.

Methods

A 31-question survey was emailed to all practising consultant ophthalmologists who were members of the Royal College of Ophthalmologists. All non-responders were sent a postal version of the questionnaire. This paper looked at cyclodiode practice patterns and consisted of questions on demographic data, transillumination, and power settings, factors influencing practice, post-operative care, and repeat treatment.

Results

A total of 510 participants (53.6%) responded. A total of 180 (35.3%) responders reported performing cyclodiode laser treatment, of which 84 (46.7%) were glaucoma subspecialists (GSS). Initial median power settings used were 1500 mW and 2000 ms. The average number of applications delivered per sitting was 25.5±1.2 applications for GSS vs20.6±2.0 for non-GSS in a seeing eye (P=0.0013). In all, 65% routinely transilluminated the globe of which 78% were GSS and 52.3% were non-GSS (P=0.0009). In all, 43% of the GSS vs17% of the non-GSS lowered power settings in uveitic glaucoma (P=0.013). In blind eyes, 30% of the GSS vs12% of the non-GSS increased energy levels (P=0.0014). In all, 60% of the responders performed cyclodiode at any visual acuity, whereas 22% performed combined cyclodiode and cataract surgery.

Conclusions

This survey highlights a wide variation in the use of cyclodiode laser treatment amongst GSS and non-GSS. However, the most frequently used practice may not be the optimal practice. A more individualised parameter according to the condition of the eyes may optimise the outcome.     

Survival of bacteria on the ocular surface following double application of povidone-iodine before cataract surgery

Aims

This study assessed the effectiveness of one vs two applications of povidone-iodine in decontaminating the eye before cataract surgery.

Methods

This was a prospective, interventional study of 52 patients having elective unilateral phacoemulsification cataract surgery in a tertiary care centre. Each patient had two applications of povidone-iodine before phacoemulsification cataract surgery, separated by 10 min. Conjunctival swabs were taken before and after each application and cultured in 5% CO₂ and anaerobically. Statistical analysis was performed using McNemar''s test for correlated proportions.

Results

In all, 15 of 52 (29%) patients had positive cultures before the first application and 21 of 52 (40%) patients had positive cultures after it. This was not statistically significant (P=0.239). A total of 25 of 52 (48%) patients were culture positive before the second application. This was not statistically significantly different from 10 min earlier (P=0.423). Six of 52 (12%) patients were positive after the second application (P<0.001).

Conclusions

We conclude that the initial application of povidone-iodine was not effective in decontaminating the eye. Recontamination did not take place between applications. The difference in the proportion of patients with positive results before and after the second application of povidone-iodine was statistically significant. We infer from this that double application of povidone-iodine before cataract surgery is advisable.     

The accuracy of accredited glaucoma optometrists in the diagnosis and treatment recommendation for glaucoma

Aim

To compare the diagnostic performance of accredited glaucoma optometrists (AGO) for both the diagnosis of glaucoma and the decision to treat with that of routine hospital eye care, against a reference standard of expert opinion (a consultant ophthalmologist with a special interest in glaucoma).

Methods

A directly comparative, masked, performance study was undertaken in Grampian, Scotland. Of 165 people invited to participate, 100 (61%) were examined. People suspected of having glaucoma underwent, within one month, a full ophthalmic assessment in both a newly established community optometry led glaucoma management scheme and a consultant led hospital eye service.

Results

Agreement between the AGO and the consultant ophthalmologist in diagnosing glaucoma was substantial (89%; κ = 0.703, SE = 0.083). Agreement over the need for treatment was also substantial (88%; κ = 0.716, SE = 0.076). The agreement between the trainee ophthalmologists and the consultant ophthalmologist in the diagnosis of glaucoma and treatment recommendation was moderate (83%, κ = 0.541, SE = 0.098, SE = 0.98; and 81%, κ = 0.553, SE = 0.90, respectively). The diagnostic accuracy of the optometrists in detecting glaucoma in this population was high for specificity (0.93 (95% confidence interval, 0.85 to 0.97)) but lower for sensitivity (0.76 (0.57 to 0.89)). Performance was similar when accuracy was assessed for treatment recommendation (sensitivity 0.73 (0.57 to 0.85); specificity 0.96 (0.88 to 0.99)). The differences in sensitivity and specificity between AGO and junior ophthalmologist were not statistically significant.

Conclusions

Community optometrists trained in glaucoma provided satisfactory decisions regarding diagnosis and initiation of treatment for glaucoma. With such additional training in glaucoma, optometrists are at least as accurate as junior ophthalmologists but some cases of glaucoma are missed.     

Ocular manifestations of Alport syndrome

AIM： To analyze the clinical manifestation of Alport syndrome, especially the ocular features. METHODS: The physical, ophthalmologic and audiologic examination results of thirty-two patients with Alport syndrome were analyzed retrospectively. RESULTS: Thirty (93.7%) patients had some family history. All patients had renal disease: eighteen (56.3%) patients with chronic renal failure, four (12.5%) patients with renal insufficiency, and the other ten (31.3%) patients with hematuria. Twenty (62.5%) patients had sensorineural deafness. Thirteen (40.6%) patients had ocular deformity, five (15.7%) patients had typical ocular changes: three patients with anterior lenticonus, and two patients with macular flecks. CONCLUSION: Ocular anomalies are not requisite for the diagnosis of Alport syndrome. But its typical ocular features should be recognized by the ophthalmologists which supports the diagnosis.     

Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial

Aim

To evaluate the cost‐effectiveness of first eye cataract surgery compared with no surgery from a health service and personal social services perspective.

Methods

An economic evaluation undertaken alongside a randomised controlled trial of first eye cataract surgery in secondary care ophthalmology clinics. A sample of 306 women over 70 years old with bilateral cataracts was randomised to cataract surgery (expedited, approximately four weeks) or control (routine, 12 months wait); 75% of participants had baseline acuity of 6/12 or better. Outcomes included falls and the EuroQol EQ‐5D.

Results

The operated group cost a mean £2004 (bootstrapped) more than the control group over one year (95% confidence interval (CI), £1363 to £2833) (p<0.001), but experienced on average 0.456 fewer falls, an incremental cost per fall prevented of £4390. The bootstrapped mean gain in quality adjusted life years (QALYs) per patient was 0.056 (95% CI, 0.006 to 0.108) (p<0.001). The incremental cost–utility ratio was £35 704, above the currently accepted UK threshold level of willingness to pay per QALY of £30 000. However, in an analysis modelling costs and benefits over patients'' expected lifetime, the incremental cost per QALY was £13 172, under conservative assumptions.

Conclusions

First eye cataract surgery, while cost‐ineffective over the trial period, was probably cost‐effective over the participants'' remaining lifetime.     

The incidence of serious eye injury in Scotland: a prospective study

Purpose

Ocular trauma remains an important cause of visual morbidity worldwide. A previous population-based study in Scotland reported a 1-year cumulative incidence of 8.14 per 100 000 population. The purpose of this study was to identify any change in the incidence and pattern of serious ocular trauma in Scotland.

Methods

This study was a 1-year prospective observational study using the British Ophthalmological Surveillance Unit reporting scheme among Scottish ophthalmologists. Serious ocular trauma was defined as requiring hospital admission. Data were collected using two questionnaires for each patient 1 year apart.

Results

The response rate from ophthalmologists was 77.1%. There were 102 patients reported with complete data giving an incidence of 1.96 per 100 000 population, four times less than in 1992. In patients younger than 65 years, the age-adjusted incidence ratio (males/females) indicated a ninefold higher risk of trauma in males. In 25 patients (27.2%), the injured eye was blind (final visual acuities (FVA) <6/60), 24 being attributable to the eye injury. Standardised morbidity ratios suggested a threefold decrease in risk of poor visual outcome in 2009 compared with 1992.

Conclusions

The incidence of serious ocular trauma has fallen; this study has shown hospital admission for serious eye injury in Scotland has decreased fourfold in 17 years. Young adult males continue to be at highest risk, which needs to be specifically addressed in future health-prevention strategies. This study also observed a reduction in visual loss from serious ocular injuries, although the reasons for this require further exploration.     

Factors associated with strabismus after cataract extraction and primary intraocular lens implantation in congenital cataracts

AIM: To evaluate factors associated with the development of strabismus after cataract extraction and primary intraocular lens implantation.METHODS: The medical records of 122 patients, aged 1.5mo to 9y, who had undergone cataract extraction with primary intraocular lens implantation between January 1993 and August 2011 were reviewed. Fourteen patients (17 eyes) with strabismus before cataract surgery were excluded. Patients were divided into those with congenital bilateral cataracts (64 patients, 128 eyes) and those with unilateral cataracts (44 patients, 44 eyes). The associations between the development of strabismus and age at cataract surgery, pre- and post-cataract extraction corrected distance visual acuity (CDVA), interocular CDVA difference, nystagmus, surgical method, and secondary cataract were evaluated.RESULTS: Factors significantly associated with the development of strabismus included age at cataract surgery (≤1y), preoperative mean CDVA ≤20/100, presence of nystagmus in the bilateral cataract group and postoperative interocular CDVA difference ＞20/70 in the unilateral group. Postoperative CDVA ≤20/100 and preservation of posterior capsule, and presence of secondary cataract were significant factors in both groups.CONCLUSION: Children with congenital cataracts should be monitored carefully after cataract surgery for the development of strabismus, especially when they underwent surgery at age ≤1y, and they have nystagmus, large postoperative interocular CDVA difference, poor preoperative and postoperative CDVA, preservation of the posterior capsule, or secondary cataract.     

Rapid assessment of avoidable blindness in Negros Island and Antique District, Philippines

Objectives

To conduct rapid assessments of avoidable blindness to estimate the magnitude and causes of blindness in people aged ⩾50 years in Negros Island and Antique district, Philippines.

Methods

Clusters of 50 people aged ⩾50 years were sampled with probability proportionate to size. Households within clusters were selected through compact segment sampling. Visual acuity (VA) was measured with a tumbling “E” chart. Ophthalmologists examined people with VA<6/18 in either eye.

Results

In Negros, 2774 of 3649 enumerated subjects were examined (76.0%) and 3177 of 3842 enumerated subjects in Antique (82.7%). The prevalence of blindness (presenting VA<3/60 in better eye) was 2.6% (95% CI = 2.0 to 3.2%) in Negros and 3.0% (2.4 to 3.6%) in Antique. The leading cause of blindness was untreated cataract, and was refractive error for visual impairment (VA<6/18 to ⩾6/60). Most of the cases of blindness (67% in Negros, 82% in Antique) and visual impairment (94% in Negros, 95% in Antique) were avoidable (ie, operated and unoperated cataract, refractive error and corneal scar). In Negros, 23% of eyes had a poor outcome after cataract surgery, and 13% in Antique.

Conclusions

The prevalence of blindness in two areas in the Philippines was relatively low. Since most cases were avoidable, further reductions are possible.The World Health Organization (WHO) estimated that there were 161 million visually impaired people and 37 million blind people in the world in 2002.¹ These estimates were derived from surveys in only 55 countries, most of which were carried out at the district or regional rather than the national level.² There is an urgent need for more up‐to‐date and accurate surveys, particularly in South East Asia, because of its enormous population size.The WHO estimates for the area, which includes the Philippines, suggest that the prevalence of blindness is 1.0% in all ages and 6.3% in the population aged ⩾50 years.¹ This is about twice as high as the estimates obtained from the 2002 Philippines national survey, which reported a prevalence of blindness overall of 0.58%, and 2.8% for people aged ⩾50 years.³ The national survey showed a reduction from an earlier national survey conducted in the Philippines in 1995 which reported an all‐age prevalence of blindness of 0.76%.⁴ Unfortunately, these surveys do not provide sufficient detail to allow programme planners to estimate the prevalence of blindness at the district level; nor do they provide data about the availability and quality of cataract surgical services.Negros Island in the Philippines includes the provinces of Negros Occidental and Negros Oriental, which has a total population of approximately 4 million.⁵ There are 14 ophthalmologists in Negros who conduct regular cataract surgery to give a cataract surgical rate (CSR) of approximately 1000 surgeries per million people per year (personal communication). Antique district is on Panay Island and has a population of approximately 0.53 million. There is only one ophthalmologist who regularly conducts surgeries and another who refers cases to IloIlo, the capital of the island. Consequently, the CSR in Antique is lower at about 600 operations per million people per year (personal communication). The national survey estimated that the all‐age prevalence of blindness in both areas was approximately 0.5–0.6%.³The aim of this study was to conduct a Rapid Assessment of Avoidable Blindness in Negros Island (excluding the two major cities of Bacolod and Dumaguete) and in Antique district, the Philippines, to estimate the prevalence and cause of blindness in people aged 50 years and over and to evaluate the availability and quality of the cataract surgical services.^6,7     

Optic disc classification by the Heidelberg Retina Tomograph and by physicians with varying experience of glaucoma

Purpose

To compare the diagnostic accuracy of the Heidelberg Retina Tomograph''s (HRT) Moorfields regression analysis (MRA) and glaucoma probability score (GPS) with that of subjective grading of optic disc photographs performed by ophthalmologists with varying experience of glaucoma and by ophthalmology residents.

Methods

Digitized disc photographs and HRT images from 97 glaucoma patients with visual field defects and 138 healthy individuals were classified as either within normal limits (WNL), borderline (BL), or outside normal limits (ONL). Sensitivity and specificity were compared for MRA, GPS, and the physicians. Analyses were also made according to disc size and for advanced visual field loss.

Results

Forty-five physicians participated. When BL results were regarded as normal, sensitivity was significantly higher (P<5%) for both MRA and GPS compared with the average physician, 87%, 79%, and 62%, respectively. Specificity ranged from 86% for MRA to 97% for general ophthalmologists, but the differences were not significant. In eyes with small discs, sensitivity was 75% for MRA, 60% for the average doctor, and 25% for GPS; in eyes with large discs, sensitivity was 100% for both GPS and MRA, but only 68% for physicians.

Conclusion

Our results suggest that sensitivity of MRA is superior to that of the average physician, but not that of glaucoma experts. MRA correctly classified all eyes with advanced glaucoma and showed the best sensitivity in eyes with small optic discs.     

Deep sclerectomy with mitomycin C in eyes with failed glaucoma surgery and pseudophakia

Purpose

To report outcomes of deep sclerectomy (DS) with intraoperative mitomycin C (MMC) application in eyes with previous failed glaucoma surgery (GS) and/or cataract extraction (CE).

Patients and methods

Single-surgeon case series of 82 eyes of 82 patients undergoing DS with MMC. The patients had previous CE with IOL and/or conjunctival GS and treated intraocular pressure (IOP) >18 mm Hg. MMC (0.2 mg/ml) was applied for 2–3 min before scleral flap dissection. Complete success was defined as IOP between 6 and 21 mm Hg or a reduction of 20% from baseline without medications. Reoperation for glaucoma or related complications, or loss of light perception vision was considered as failure.

Results

Mean follow-up was 57.7±22.4 months with 78% of patients completing the 3-year follow-up. Mean IOP decreased from 24.0 mm Hg (22.3–25.6, 95% confidence intervals) to 13.4 mm Hg (12.0–14.2) at 3 years after surgery (P<0.001). There was a significant decrease in the number of glaucoma medications from 2.0±1 preoperatively, to 0.3±0.7, 3 years after surgery. Kaplan–Meier cumulative success rates were 85.6% at 1 year, 80.0% at 2 years, and 76% at 3 years. At 3 years, IOP was maintained <19 and 15 mm Hg in 83 and 70% of eyes, respectively. Fourteen eyes (17.1%) had complications. Delayed hypotony (IOP <6 mm Hg) was the commonest complication in five eyes (6.1%).

Conclusion

DS with MMC appears to be a safe and effective surgical procedure for eyes with previous intraocular surgery.     

Late in-the-bag intraocular lens dislocation requiring explantation: risk factors and outcomes

Purpose

To study the predisposing factors for late in-the-bag intraocular lens (IOL) dislocation and to analyze the outcomes after explantation surgery.

Methods

In this retrospective multicentre study, 61 eyes were enrolled. The main inclusion criterion was in-the-bag spontaneous IOL dislocation after uneventful phacoemulsification cataract extraction. Only eyes with serious dislocation that required IOL explantation were eligible. Follow-up after explantation surgery of at least 3 months was required. Exclusion criteria were complicated cataract surgery, out-of-the-bag IOL dislocation, and dislocations that occurred in the first year after the cataract surgery. The main outcome measures were predisposing factors for dislocation, interval between cataract surgery and dislocation, surgical treatment at the time of explantation, preoperative and postoperative corrected distance visual acuity (CDVA), and postoperative complications.

Results

High myopia was detected in 12 cases (19.7%) and it was the main predisposing factor. Mean time interval from cataract surgery to dislocation was 7.5 (SD 5.2) years. The dislocated in-the-bag IOL was replaced with a scleral fixated IOL (36.1%), angle-supported anterior chamber IOL (31.1%), sulcus repositioning (18%), or posterior chamber iris sutured IOL (4.9%). Finally, 9.8% of the patients were left aphakic. Mean CDVA improved significantly after surgery (P=0.005). Final CDVA of 20/40 or better was achieved in 29 cases (47.5%).

Conclusions

High myopia was the main risk factor for late in-the-bag IOL dislocation. Surgical treatment significantly improved the CDVA in our sample and was associated with a low complication rate.     

Effects of corneal thickness on the intraocular penetration of travoprost 0.004%

Purpose

To determine whether the intraocular penetration of travoprost 0.004% is affected by central corneal thickness.

Methods

Sixty-four patients who were scheduled for cataract surgery without any other ophthalmologic pathology of significance were enroled in this study. At 120 min before surgery, one drop of travoprost 0.004% was instilled in the eye to be operated on. At the start of surgery, a sample of aqueous humour was extracted to subsequently determine its AL-5848 concentration. These concentrations were compared among three groups of patients established according to central corneal thickness measurements obtained by ultrasound pachymetry.

Results

Mean AL-5848 concentrations were 3.27±2.03 ng/ml in Group I (CCT<511 microns), 3.27±2.44 ng/ml in Group II (CCT≥511 and ≤574 microns), and 2.73±2.15 ng/ml in Group III (CCT>574 microns), indicating no significant differences among the groups.

Conclusions

We were unable to demonstrate the greater or lesser penetration of travoprost depending on corneal thickness, which could explain differences in patient responses to this drug.     

Transcranial surgery through pterional approach for removal of cranio-orbital tumors by an interdisciplinary team of nurosurgeons and ophthalmologists

AIM

To investigate the specialty of transcranial surgery through pterional approach for removal of cranio-orbital tumors, introduce the ophthalmological experiences of entering the orbit to reduce the incidence rate of associated complications of this operation.

METHODS

We performed a retrospective analysis of a series of 37 cases involving patients who underwent transcranial surgery through pterional approach for treatment of cranio-orbital tumors in our department in the past 8 years. Pterion approach craniotomy was performed to all patients. After removing tumors in the skull by the neurosurgeon, ophthalmologist removed tumors in orbit. We took measures below to decrease complications, including grounding optic canal through an abrasive drilling when necessary, hanging various extraocular muscles to be exposed for protection, refrigerating by refrigeration heads to remove tumors, at last sewing up orbit septum after surgery.

RESULTS

Tumors were removed completely in 32 cases, and incomplete in 5 cases due to extensive invasion into the cavernous sinus or sphenoid sinus. Of all the cases, benign tumors were demonstrated in 28 cases (75.6%, 28/37) and malignant in 9(24.3%, 9/37). The most common lesion type was meningioma in 11 cases (29.7%, 11/37). Extraocular muscles (EOM) impairment, occurring in 21 cases (56.7%, 21/37), was the most frequent postoperative complication. The most serious consequence was vision loss occurred in 4 cases (10.8%, 4/37). Other complications, such as 11 cases of transient blepharoptosis 29.7% (11/37), 5 cases of mydriasis in 13.5% (5/7); 2 cases of cerebrospinal rhinorrhea in 5.4% (2/37).

CONCLUSION

Cranio-orbital tumors can be removed completely using transcranial approach, and the pterional approach offers excellent exposure. Cooperation of interdisciplinary team of neurosurgeons and ophthalmologists conduces to full use of respective professional advantages. The experience of ophthalmic operation technology can decrease occurrence of ocular complications after surgery.     

Plaque radiotherapy treatment with ruthenium-106 for iris malignant melanoma

Purpose

To report the results of ruthenium-106 plaque radiotherapy for iris malignant melanoma.

Methods

A retrospective study of 15 patients with pure iris melanoma treated with ruthenium-106 plaque radiotherapy from June 1998 to June 2006. The main outcome measures were tumour control and ocular complications.

Results

Of the 15 patients, 8 had biopsy-proven melanoma (6 incisional and 2 excisional biopsies). In the remaining seven patients enlargement of the lesion was documented. The median follow-up was 96 months (ranging from 14 months to 12 years). Common radiation-related complications included cataract in 9 (60%) patients, dry eyes in 3 (20%) patients and elevated intraocular pressure in 4 (27%) patients. Vision was preserved in 80% of patients. Local tumour control was obtained in all patients.

Conclusions

Ruthenium-106 plaque radiotherapy is an effective treatment for primary malignant iris melanoma, resulting in excellent local control with preservation of vision. Main complications included cataract, dry eyes, and glaucoma.