Can Applying a Risk Stratification System, Preoperatively, Reduce Intraoperative Complications during Phacoemulsification?

SIGNIFICANCE: Adopting a risk stratification system and appropriate listing of cases reduces the rates of intraoperative complications during phacoemulsification. Such listing would allow both safe surgery and enhance training, by ensuring an appropriately experienced surgeon is available to operate on a case or supervise and teach a junior surgeon. PURPOSE: To assess if the application of a simple, robust, validated preoperative scoring system can reduce the rates of intraoperative complications if patients are assigned to the appropriately experienced surgeon's list and surgical time is modified accordingly. METHODS: Prospective data collection. One thousand one hundred and thirty five (1135) consecutive patients undergoing phakoemulsification cataract surgery were assessed preoperatively according to weighted criteria. According to the points of risk they accumulated using this system, the patients were preoperatively allocated to one of the four risk groups. The total rate of intraoperative complications for each risk group as well as the rate of each reported complication for each risk group was calculated. RESULTS: The rate of intraoperative complications through the risk groups was 1 = 0.62%, 2 = 0.44%, 3 = 0.18%, and 4 = 0% (P = .005). Thirty-seven per cent 37% (n = 420) of all operations were performed on eyes of patients carrying at least one risk factor for intraoperative complications. The overall rate of any intraoperative complication was 1.2% (n = 14). There was a 0.4% (n = 5) rate of a posterior capsule tear with 2 of these cases with vitreous loss. CONCLUSIONS: Risk stratification, allowing adequate theatre time and appropriate surgical experience, can reduce the rates of intraoperative complications. The risk stratification system allows for better planning of surgical lists and could be used as a transition for those trainees deemed to have sufficient experience for the more 'challenging' cases under adequate supervision.

Incidence of symptomatic os trigonum among nonathletic patients with ankle sprain.

PURPOSE: Os trigonum syndrome is a rare condition, often affecting athletes. A paucity of data exists on the incidence of os trigonum syndrome in nonathletic population. The study aimed to determine the incidence and clinical characteristics of os trigonum syndrome in nonathletic patients with sprained ankles. METHODS: The sample consisted of 798 adolescent and adult patients that attended the emergency department or Foot and Ankle Clinic with acute ankle sprain. Lateral and/or oblique lateral radiographs of the feet were screened for the presence of os trigonum in relation to age and gender. A cohort of 163 patients with os trigonum was followed up prospectively over a 48-month period to correlate the presence of the os trigonum with patient symptomatology. RESULTS: Os trigonum was found in 20.4% (163/798) of sprained ankles. Patients aged 18-35 exhibited most os trigonum [42.3% (69/163)], with higher incidence in females. 5.5% (9/163) of the os trigonum patients developed an os trigonum syndrome after a standard treatment of an ankle sprain [3.8% (3/78) of males and 7.1% (6/85) of females]. Females aged between 18 and 35 years had higher incidence of os trigonum syndrome compared to males of a similar age. CONCLUSION: Os trigonum syndrome should be suspected in nonathletic patients with an ankle sprain unresponsive to standard treatment. About 1.1% of acute ankle sprain patients develop an os trigonum syndrome. This finding can help identify the source of a patient's symptoms, leading to an accurate diagnosis, appropriate treatment and reducing the potential chronic symptoms.

A corneal dendritic lesion with a skin eruption: eczema herpeticum, an important differential diagnosis.

Eczema herpeticum is a rare and potentially life-threatening viral infection. We present the case of a 54-year-old man who presented to the emergency eye clinic with a dendritic ulcer and a facial rash. An initial diagnosis of herpes zoster ophthalmicus was suspected. On follow-up, the rash had begun to rapidly disseminate and was no longer respecting dermatome boundaries. A diagnosis of eczema herpeticum was made and appropriate treatment started. This case highlights the importance of a comprehensive history and close inspection of skin lesions in patients with herpetic eye disease.

The use of toric intraocular lens to correct astigmatism at the time of cataract surgery.

BACKGROUND: To evaluate the visual and refractive outcomes of cataract surgery with toric intraocular lens (IOL) implantation at a teaching hospital of the United Kingdom. DESIGN: Prospective interventional case series. MATERIALS AND METHODS: This study compared the outcome of 3 groups of patients: Group 1 included 25 eyes with cataract and more than 2.5 diopters (D) of corneal astigmatism receiving a toric monofocal IOL; Group 2 had 18 patients with cataract and more than 2.5 D of astigmatism but receiving a non-toric monofocal IOL; while Group 3 had 25 patients with cataract and less than 1.5 D of astigmatism and receiving a non-toric monofocal IOL. Data collected included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, refraction and corneal keratometry. Postoperative examinations were scheduled at 1 and 6 weeks. RESULTS: Postoperatively the mean UDVA was LogMAR 0.27 ± 0.20 (equivalent snellen acuity of 20/37) in Group 1, 0.54 ± 0.22 (20/69) in Group 2 and 0.16 ± 0.20 (20/29) in Group 3. The mean CDVA was LogMAR 0.08 ± 0.13 (20/24) in Group 1, 0.23 ± 0.16 (20/34) in Group 2 and 0.04 ± 0.13 in Group 3 (20/22). The mean preoperative keratometric cylinder was 3.78 ± 1.0 D in Group 1, 3.41 ± 1.47 D in Group 2 and 0.97 ± 0.43D in Group 3; the mean postoperative subjective cylinder was 1.2 ± 0.68 D in Group 1, 3.23 ± 1.41 D in Group 2 and 0.95 ± 0.58 D in Group 3. The difference was statistically significant for the postoperative refractive cylinder values when comparing Group 1 to Group 2 (P = <0.0001) but the difference was insignificant between Group 1 and Group 3 (P = 0.23). CONCLUSION: Toric IOL implantation is an effective option to manage corneal astigmatism at the time of cataract surgery and to optimise visual outcomes for astigmatic patients when comparing to outcomes for their non-astigmatic counterparts.

Sutureless large incision cataract extraction: Indications and results from two teaching hospital eye departments in the United Kingdom.

OBJECTIVE: To highlight the role of Sutureless Large Incision Cataract Extraction (SLICE) in the United Kingdom for the treatment of cataracts at high risk for intra- or postoperative complications. SETTING: Two University Hospitals in the United Kingdom MATERIALS AND METHODS: Retrospective case note review of planned SLICE performed over a 12-month period. RESULTS: SLICE was performed on 11 eyes of 11 patients (mean age, 79 years) having preoperative vision of hand motions (10 eyes) with very dense or mobile cataracts and high risk for phacoemulsification. Mean follow up was 12 weeks, with no operative or postoperative complications. Nine patients (without ocular or systemic comorbidity) achieved best corrected vision of 0.3 LogMAR (20/40) or better. CONCLUSIONS: SLICE is safe and effective for dense or mobile cataracts and can play a role in patients where conventional phacoemulsification carries higher risks of complications.

Iatrogenic extreme corneal decompensation treated by sequential Descemet's Stripping Endothelial Keratoplasty surgeries six months apart.

Descemet's stripping endothelial keratoplasty (DSEK) is now the most common surgical procedure to treat endothelial dysfunction although it is known that endothelial cell survival is an issue of concern. We present a case whereby severe iatrogenic corneal decompensation caused by Descemet's membrane detachment following premature disconnection of an infusion tube at the end of a trans pars plana vitrectomy and epiretinal membrane peel was successfully treated with two staged DSEK procedures six months apart. The patient was counselled that due to the severity of his extreme corneal oedema more than one DSEK procedure may be needed and the procedure was planned from the outset as a two-stage procedure. There was a measurable decrease in corneal thickness and increase in visual acuity following both the first and second procedures, which may be due to reinvigoration of the endothelial cell count following each procedure. We suggest that repeating the DSEK procedure, even when the first operation has gone well and the graft appears healthy, may be beneficial in obtaining further improvement in cases of severe corneal oedema.

Intrastromal corneal ring segments for advanced keratoconus and cases with high keratometric asymmetry.

PURPOSE: To report the safety and efficacy of intrastromal corneal ring segment (ICRS) implantation to manage keratoconus. SETTING: Singleton Hospital Abertawe Bro Morgannwg University NHS Trust, Swansea, United Kingdom DESIGN: Case series. METHODS: Intacs SK ICRS were implanted manually for moderate to severe keratoconus and contact lens intolerance or ineffectiveness. Postoperative examinations were at 2 and 4 weeks; 3, 6, 9, and 12 months; and every 6 months thereafter. Outcome measures included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, refraction, corneal topography, and slitlamp examination. RESULTS: This study enrolled 31 eyes (29 patients; mean age 30 years). The mean UDVA was significantly better 12 months postoperatively (0.88 logMAR) than preoperatively (1.40 logMAR) (P=.001), as was the mean CDVA (0.29 logMAR versus 0.44 logMAR) (P=.04). The mean spherical equivalent was -6.57 diopters (D) preoperatively and -2.84 D at 12 months (P=.01). The mean keratometry (K) reading decreased from 52.07 D (range 45.9 to 63.1 D) to 46.15 D (range 39.2 to 52.9 D) for K1 (P<.0001) and from 57.9 D (range 52.5 to 69.7 D) to 51.2 D (range 46.8 to 58.3 D) for K2 (P<.0001). There were no intraoperative complications; however, 6 patients had segment extrusion. CONCLUSION: Implantation of ICRS was useful in managing keratoconus, producing up to 12.00 D of corneal flattening, which improved CDVA and allowed contact lens tolerance in all cases.

Prevalence of corneal astigmatism in patients having routine cataract surgery at a teaching hospital in the United Kingdom.

PURPOSE: To analyze and quantify the pattern of corneal astigmatism in patients awaiting cataract surgery and to establish the demand for toric intraocular lenses (IOLs) in a hospital unit. SETTING: Singleton Hospital Abertawe Bro Morgannwg University NHS Trust, Swansea, United Kingdom. DESIGN: Cross-sectional study. METHODS: Keratometric measurements of all patients attending the preassessment clinic over a 4-month period were prospectively collected and analyzed. RESULTS: The study comprised 1230 eyes of 746 patients with a mean age of 75.54 years ± 0.71 (SD). The corneal astigmatism was 0.50 diopter (D) or less in 301 eyes (24.47%), 1.50 D or less in 978 eyes (79.50%), more than 2.50 D in 57 eyes (4.61%), and 3.00 D or more in 24 eyes (1.93%). CONCLUSIONS: Of patients attending for routine cataract surgery at a single center, 497 (40.41%) had more than 1.00 D of astigmatism. The results can help hospitals analyze the demand for and cost of using toric IOLs in patients with corneal astigmatism. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Performance of the Sulcoflex piggyback intraocular lens in pseudophakic patients.

PURPOSE: To present our experience with a pseudophakic piggyback intraocular lens (IOL) (Sulcoflex; Rayner Intraocular Lenses Ltd) in five eyes of four patients. One patient desired increased spectacle independence after bilateral LASIK and refractive lens exchange with an accommodating IOL. The remaining three patients with residual refractive error desired increased spectacle independence following cataract surgery with a monofocal IOL. METHODS: Four eyes received a multifocal Sulcoflex IOL and one eye received a toric Sulcoflex IOL. RESULTS: All patients achieved uncorrected distance visual acuity (UDVA) of 0.1 logMAR (Snellen 20/25) or better and those who received the multifocal Sulcoflex achieved uncorrected near visual acuity (UNVA) of N6 (Jaeger 4) or better. CONCLUSIONS: The Sulcoflex IOL may be a safe and effective method for enhancing the refractive outcome in pseudophakic eyes, providing good UDVA and UNVA when using the multifocal platform.

Opacification of the intraocular lens implant following uneventful Descemet's stripping endothelial keratoplasty.

A 74 year old pseudophakic patient developed opacification of a pre-existing intraocular lens implant following Descemet's stripping endothelial keratoplasty which may have been triggered by the presence of air in the anterior chamber.

Intrastromal corneal ring segments for bilateral keratoconus in an 11-year-old boy.

UNLABELLED: We present the case of an 11-year-old boy who had bilateral implantation of intrastromal corneal ring segments for progressive keratoconus and poor vision. No intraoperative or postoperative complications were seen, and 1 year postoperatively, the patient maintained good spectacle-corrected vision. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Visual and refractive outcomes of LASIK with the SCHWIND ESIRIS and WaveLight ALLEGRETTO WAVE Eye-q excimer lasers: a prospective, contralateral study.

PURPOSE: To compare the safety, efficacy, and predictability of LASIK with the SCHWIND ESIRIS and WaveLight ALLEGRETTO WAVE Eye-Q excimer laser platforms. METHODS: This prospective study comprised 44 eyes of 22 consecutive patients who were treated with LASIK using the Moria M2 microkeratome. One eye was treated with the SCHWIND ESIRIS laser and the fellow eye treated with the WaveLight ALLEGRETTO WAVE Eye-Q laser. All eyes operated with the SCHWIND ESIRIS were treated with standard aspheric ablation, whereas the eyes operated with the WaveLight ALLEGRETTO WAVE Eye-Q received treatment with three different ablation types according to the common practice at our clinic. Outcome measures were uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, and proximity to target refraction at 6-month follow-up. RESULTS: At 6 months postoperative, mean decimal UCVA was 0.96+/-0.22 (range: 0.3 to 1.2) for ESIRIS eyes and 0.98+/-0.17 (range: 0.6 to 1.2) for ALLEGRETTO eyes (P=.57). Mean postoperative spherical equivalent refraction was -0.02+/-0.28 diopters (D) (range: -0.75 to +0.75 D) for ESIRIS eyes and 0.11+/-0.91 D (range: -1.00 to +3.88 D) for ALLEGRETTO eyes (P=.49). Of the ESIRIS eyes, 20/22 (91%) were within +/-1.00 D of target refraction and 20/22 (91%) were within +/-0.50 D of target refraction. Of the ALLEGRETTO eyes, 20/22 (91%) and 19/22 (86%) were within +/-1.00 D and +/-0.50 D, respectively, of target refraction. No patient lost > or =2 lines of BSCVA in either group. CONCLUSIONS: No differences were seen in safety and efficacy outcome parameters between the SCHWIND ESIRIS and WaveLight ALLEGRETTO WAVE Eye-Q excimer lasers when used according to a previously established treatment algorithm at our clinic in the treatment of refractive error.