Second-eye cataract surgery in elderly women: a cost-utility analysis conducted alongside a randomized controlled trial.

AIM: The aim of this study was to evaluate the cost-effectiveness of second-eye cataract surgery for older women with minimal visual dysfunction in the eye to be operated on from a Health and Personal Social Services perspective, compared to waiting list controls who had already undergone first-eye cataract surgery. METHODS: A cost-utility analysis was undertaken alongside a randomized controlled trial of second-eye cataract surgery in secondary care ophthalmology clinics. A total of 239 women over 70 years old with one unoperated cataract were randomized to cataract surgery (expedited, approximately 4 weeks) or control (routine surgery, 12 months wait). Outcomes were measured in terms of quality-adjusted life years (QALYs), with health-related quality of life estimated using the EuroQol EQ-5D. RESULTS: The operated group had costs which were, on average, pound646 more than the control group (95% confidence interval, pound16-1276, P<0.04) and had a mean QALY gain of 0.015 (95% confidence interval, -0.039 to 0.068, P=0.59) per patient over 1 year. Therefore, the incremental cost-utility ratio was pound44,263 over the 1-year trial period. In an analysis modelling costs and benefits over patients' expected lifetime, the incremental cost per QALY was pound17,299, under conservative assumptions. CONCLUSIONS: Second-eye cataract surgery is not likely to be cost-effective in the short term for those with mild visual dysfunction pre-operation. In the long term, second-eye cataract surgery appears to be cost-effective unless carer costs are included.

Preliminary results from the use of the novel Interactive binocular treatment (I-BiT) system, in the treatment of strabismic and anisometropic amblyopia.

BACKGROUND: We have developed a novel application of adapted virtual reality (VR) technology, for the binocular treatment of amblyopia. We describe the use of the system in six children. METHODS: Subjects consisted of three conventional treatment 'failures' and three conventional treatment 'refusers', with a mean age of 6.25 years (5.42-7.75 years). Treatment consisted of watching video clips and playing interactive games with specifically designed software to allow streamed binocular image presentation. RESULTS: Initial vision in the amblyopic eye ranged from 6/12 to 6/120 and post-treatment 6/7.5 to 6/24-1. Total treatment time was a mean of 4.4 h. Five out of six children have shown an improvement in their vision (average increase of 10 letters), including those who had previously failed to comply with conventional occlusion. CONCLUSIONS: Improvements in vision were demonstrable within a short period of time, in some children after 1 h of treatment. This system is an exciting and promising application of VR technology as a new treatment for amblyopia.

Modified virtual reality technology for treatment of amblyopia.

PURPOSE: The conventional patching/occlusion treatment for amblyopia sometimes gives disappointing results for a number of reasons: it is unpopular, prolonged, frequently resulting in poor or noncompliance, and also disrupts fusion. The aim of this research was to develop a novel virtual-reality (VR)-based display system that facilitates the treatment of amblyopia with both eyes stimulated simultaneously. METHODS: We have adopted a multidisciplinary approach, combining VR expertise with a team of ophthalmologists and orthoptists to develop the Interactive Binocular Treatment (I-BiT) system. This system incorporates adapted VR technology and specially written software providing interactive 2D and 3D games and videos to the patient via a stereo (binocular) display, and a control screen for the clinician. RESULTS: We developed a prototype research system designed for treatment of amblyopia in children. CONCLUSIONS: The result is a novel way to treat amblyopia, which allows binocular treatment. It is interactive, and as it is partially software based, can be adapted to suit the age/ability, and needs of the patient. This means that the treatment can be made captivating and enjoyable. Further research is on-going to determine the efficacy of this new modality in the treatment of amblyopia.

Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial.

BACKGROUND/AIM: A third of elderly people fall each year. Poor vision is associated with increased risk of falls. The authors aimed to determine if first eye cataract surgery reduces the risk of falling, and to measure associated health gain. METHODS: 306 women aged over 70, with cataract, were randomised to expedited (approximately 4 weeks) or routine (12 months wait) surgery. Falls were ascertained by diary, with follow up every 3 months. Health status was measured after 6 months. RESULTS: Visual function improved in the operated group (corrected binocular acuity improved by 0.25 logMAR units; 8% had acuity worse than 6/12 compared with 37% of controls). Over 12 months of follow up, 76 (49%) operated participants fell at least once, and 28 (18%) fell more than once. 69 (45%) unoperated participants fell at least once, 38 (25%) fell more than once. Rate of falling was reduced by 34% in the operated group (rate ratio 0.66, 95% confidence interval 0.45 to 0.96, p = 0.03). Activity, anxiety, depression, confidence, visual disability, and handicap all improved in the operated group compared with the control group. Four participants in the operated group had fractures (3%), compared with 12 (8%) in the control group (p = 0.04). CONCLUSION: First eye cataract surgery reduces the rate of falling, and risk of fractures and improves visual function and general health status.

Visual outcome of malignant hypertension in young people.

A retrospective review was carried out of patients under 16 years old with malignant hypertension, who had been referred to a teaching hospital ophthalmology department because of reduced visual acuity. Four patients (three girls, one boy) were seen between 1994 and 2000 with a mean age at presentation of 11.5 years (range 9-15). In the short term, visual acuity improved after control of blood pressure in all four patients. However, in the long term, two patients were registered blind one to two years after presentation, one because of a choroidal neovascular membrane developing at the macula, and the other because of progressive optic neuropathy. Both of these patients had a longer duration of symptoms before diagnosis, worse visual acuity, and higher blood pressure at presentation when compared with the patients who made a good visual recovery. These observations suggest that early diagnosis of malignant hypertension in children is essential in reducing the likelihood of permanent severe visual damage.

Hydrated salts of 3,5-dihydroxybenzoic acid with organic diamines: hydrogen-bonded supramolecular structures in two and three dimensions.

The trigonally trisubstituted acid 3,5-dihydroxybenzoic acid forms hydrated salt-type adducts with organic diamines. In 1,4-diazabicyclo[2.2.2]octane-3,5-dihydroxybenzoic acid-water (1/1/1) (1), where Z' = 2 in P2(1)/c, the constitution is [HN(CH(2)CH(2))(3)N](+).[(HO)(2)C(6)H(3)COO](-).H(2)O: the anions and the water molecules are linked by six O-H.O hydrogen bonds to form two-dimensional sheets and each cation is linked to a single sheet by one O-H.N and one N-H.O hydrogen bond. Piperazine-3,5-dihydroxybenzoic acid-water (1/2/4) (2) and 1,2-diaminoethane-3,5-dihydroxybenzoic acid-water (1/2/2) (3) are also both salts with constitutions [H(2)N(CH(2)CH(2))(2)NH(2)](2+).2[(HO)(2)C(6)H(3)COO](-).4H(2)O and [H(3)NCH(2)CH(2)NH(3)](2+).2[(HO)(2)C(6)H(3)COO](-).2H(2)O, respectively. Both (2) and (3) have supramolecular structures which are three-dimensional: in (2) the anions and the water molecules are linked by six O-H.O hydrogen bonds to form a three-dimensional framework enclosing large centrosymmetric voids, which contain the cations that are linked to the framework by two N-H.O hydrogen bonds; in (3) the construction of the three-dimensional framework requires the participation of cations, anions and water molecules, which are linked together by four O-H.O and three N-H.O hydrogen bonds.

Randomised controlled trial of anterior-chamber intraocular lenses.

BACKGROUND: There are an estimated 16 million people blind in both eyes with cataracts. Most live in rural areas of developing countries where surgical resources are scarce. There is no consensus on the most appropriate type of intraocular lens in situations where high-volume low-cost surgery is required. This study was undertaken to evaluate the safety of multiflex open-loop anterior-chamber lenses (ACIOLs). METHODS: 2000 people attending Lahan Eye Hospital, southern Nepal, with bilateral cataracts reducing vision to 6/36 or less were randomly allocated to receive standard surgery--intracapsular extraction (ICCE) with aphakic correction--or ICCE with an ACIOL in their first operated eye. The primary outcome was a visual acuity of less than 6/60 in the operated eye at 1 year follow-up. Visual acuity was measured for 91% of the cohort at 1 year. The sample size was estimated to detect a doubling in poor visual outcome from an estimated rate of 4% in the standard surgery (control) group. FINDINGS: The median (range) time taken to do the surgery was 6.0 (3.0-17.2) min for the ACIOL group and 4.1 (2.4-10.3) min for the control group. 1 year after surgery, 5.0% of the ACIOL group and 5.4% of controls had functional vision less than 6/60 (OR 0.93 [0.60-1.43], p = 0.71). The causes of poor vision in the ACIOL and control groups were: correctable refractive error (22 and 29), uveitis/secondary glaucoma (13 and two), endophthalmitis (four and seven), pre-existing eye disease (four and five), retinal detachment (none and four), cystoid macular oedema (two and none), corneal ulcer (one and one), and corneal decompensation (none and one). INTERPRETATION: This study provides evidence that, in rural areas of developing countries, multiflex open-loop ACIOLs can be implanted safely by experienced ophthalmologists after routine ICCE, avoiding the disadvantages of aphakic spectacle correction. Further follow-up is planned.

Management of fixed divergent squint in third nerve palsy using traction sutures.

BACKGROUND: Long-standing fixed divergent squint is a difficult management problem, presenting marked cosmetic and functional symptoms in the patient, and a significant challenge for the squint surgeon to overcome. METHODS: We describe use of through-the-lid traction sutures in 24 consecutive patients with fixed divergent squint secondary to long-standing third nerve palsy. Very large recessions of the lateral rectus were combined with large resections of the medial rectus and traction sutures placed through the insertions of the superior and inferior rectus were brought out through the extreme medial fornices and skin of the upper and lower lids. Sutures were tied over tarsorrhaphy bolsters and left in situ for six weeks. RESULTS: After removal of the traction sutures, the eye maintained a good cosmetic position in all but two cases. Postoperative motility was extremely limited or absent. Complications were limited to transient skin ulceration in two cases. CONCLUSIONS: Supramaximal horizontal recess-resect procedure combined with adducting traction sutures left in situ for six weeks in a safe and effective procedure to restore the eye to the centre of the palpebral fissure.

Extracapsular cataract extraction in proliferative diabetic retinopathy.

PURPOSE: To establish the visual prognosis, prevalence of complications, and optimal strategy for management of proliferative diabetic retinopathy (PDR) in isolated extracapsular cataract extraction (ECCE). METHOD: This is a retrospective review of 56 patients with PDR who underwent ECCE with lens implantation. Results were compared with 64 patients with background diabetic retinopathy (BDR) operated on during the same time period. RESULTS: Final visual acuity (67% > or = 20/40) was better in BDR eyes compared with PDR eyes (21% > or = 20/40; P < 0.001). In eyes without maculopathy, 94% with BDR achieved a final visual acuity of at least 20/40 compared with 52% with quiescent proliferative retinopathy (P < 0.001). Final visual acuity in eyes with maculopathy was better in BDR eyes (36% > or = 20/40) than in PDR eyes (5% > or = 20/40) (P < 0.02). No patient with active proliferative or preproliferative retinopathy achieved a final visual acuity of more than 20/80. Postoperative deterioration of retinopathy occurred in 50% of patients with active proliferative retinopathy compared with 10% with quiescent proliferative retinopathy (P < 0.01) and 3% with BDR (P < 0.001). Immediate postoperative fibrinous anterior uveitis, which prevented early panretinal photocoagulation, developed in over half the patients with active proliferative retinopathy. CONCLUSIONS: Final visual acuity after cataract extraction in diabetic patients with proliferative retinopathy is generally poor; however, in patients with quiescent proliferative retinopathy and no maculopathy, visual acuity may be good. Active proliferative retinopathy at the time of surgery is a poor prognostic indicator for final visual acuity and is associated with postoperative deterioration of retinopathy and fibrinous uveitis, which may preclude immediate postoperative panretinal photocoagulation.

Extracapsular cataract extraction in diabetics with rubeosis iridis.

We reviewed thirteen operated eyes (twelve diabetic patients) with rubeosis iridis who underwent extracapsular cataract extraction and intraocular lens implantation. Prior to surgery five had active proliferative retinopathy (APR), and eight had non-proliferative retinopathy (NPR), either quiescent proliferative retinopathy (QPR) or background retinopathy (BR). No case with APR was visually improved by surgery. Three cases with NPR achieved a visual acuity of 6/12. After surgery, vitreous haemorrhage or progression of proliferative retinopathy occurred in three cases with APR. Early postoperative fibrinous uveitis was severe in eyes with APR, resulting in permanent fibrin membrane formation in four. We suggest a significant prognostic indicator in diabetic cataract extraction with rubeosis iridis is the status of the underlying retinopathy. With NPR, postoperative visual acuity may be good and early postoperative complications less severe. In the presence of APR the visual outcome is poor, progression of retinopathy likely and early postoperative fibrinous uveitis may be severe enough to prevent postoperative panretinal photocoagulation. Maximum preoperative panretinal ablation is essential in these cases.

Vaso-occlusive retinopathy in the primary anti-phospholipid antibody syndrome.

We report two patients with contrasting patterns of retinal vascular occlusion associated with the primary anti-phospholipid antibody syndrome. The immuno-pathological features and clinical associations are discussed. This condition is of interest to ophthalmologists because of its association with thrombosis in the eye, brain and elsewhere and because it provides new insights into the pathogenesis of retinal vascular disease in young patients.