Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 11, techniques and complications of local anesthesia for cataract surgery in the United Kingdom.

PURPOSE: To describe variation in local anesthesia techniques and complications over a 10-year period for cataract surgery in the United Kingdom. SETTING: Reporting centers to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD). DESIGN: Retrospective cross-sectional register-based study. METHODS: Data from the RCOphth NOD were used. Eligible for analysis were 1 195 882 cataract operations performed using local anesthesia between April 1, 2010, and March 31, 2020, in 80 centers. RESULTS: Overall, topical anesthesia alone was used in 152 321 operations (12.7%), combined topical and intracameral in 522 849 (43.7%), sub-Tenon in 461 175 (38.6%), and peribulbar/retrobulbar in 59 537 (5.0%). In National Health Service (NHS) institutions, 48.3% of operations were topical with/without intracameral vs 88.7% in independent sector treatment centers (ISTCs). 45.9% were sub-Tenon in NHS vs 9.6% in ISTCs. 5.8% were peribulbar/retrobulbar in NHS vs 1.7% in ISTCs. Anesthetic complication rates decreased from 2.7% in the 2010 NHS year to 1.5% in the 2019 NHS year (overall, 2.1% for NHS; 0.2% for ISTCs). Overall anesthetic complication rates were 0.3%, 0.3%, 3.5%, and 3.1% for topical alone, combined topical/intracameral, sub-Tenon, and peribulbar/retrobulbar, respectively. Complication rates were higher for sharp-needle anesthesia (peribulbar/retrobulbar) in patients taking warfarin rather than direct oral anticoagulants (4.8% vs 3.1%; P = .024). Considerable variation was observed between centers on anesthetic choices and anesthetic complication rates. CONCLUSIONS: Combined topical and intracameral is the most common choice of anesthesia for cataract surgery in the United Kingdom and is associated with lower anesthetic-related complication rates than sub-Tenon and peribulbar/retrobulbar anesthesia. Variation in the anesthetic choice exists between centers and between NHS and ISTC sectors.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of Cataract Surgery: Report 12, Risk factors for suprachoroidal haemorrhage during cataract surgery.

OBJECTIVE: To establish the incidence of acute intraoperative suprachoroidal haemorrhage (AISH) during cataract surgery and identify the risk factors for this complication. METHODS: Data from the Royal College of Ophthalmologists' National Ophthalmology Database was analysed. During the 11-year study period, from 01/04/2010 to 31/03/2021, 709 083 operations performed on 498 170 patients from 65 centres were eligible for inclusion. RESULTS: AISH occurred in 0.03% (204/709 083, approximately 1 in 3 500) of eligible cataract operations performed during the study period. Posterior capsule rupture was the risk factor most strongly associated with AISH (OR: 17.6, 95% CI: 12.4-24.9, p < 0.001). Other ocular risk factors identified were raised intraocular pressure (IOP) preoperatively (OR: 3.7, 95% CI: 2.5-5.5, p < 0.001), glaucoma (OR: 1.7, 95% CI: 1.2-2.4, p = 0.004). Risk increased with age and patients aged over 90 years were at greatest risk (OR: 6.7, 95% CI: 3.5-12.8, p < 0.001). The addition of intracameral anaesthetic when performing surgery under topical anaesthetic appears to be protective (OR: 0.5, 95% CI: 0.3-0.8, p = 0.003), compared to topical anaesthetic alone. There was a 16-fold increase in the incidence of vision loss when AISH occurred. CONCLUSIONS: The risk of AISH during modern cataract surgery is approximately 1 in 3 500 and is associated with a significant increase in the risk of vision loss should it occur. Posterior capsule rupture is the risk factor most strongly associated with AISH. Preoperative IOP control is a modifiable risk factor. The use of intracameral anaesthesia may reduce the risk of AISH.

Effect of cataract surgery training on operating room productivity: How long trainees take.

PURPOSE: To determine the effect of specialty training on cataract operation times and operating room efficiency. SETTING: Manchester Royal Eye Hospital, Manchester, United Kingdom. DESIGN: Retrospective consecutive case series. METHODS: Specialty training and consultant case times with preparation times were recorded between August 2014 and May 2015. Cases with posterior capsule rupture requiring anterior vitrectomy or iris hook insertion were analyzed. RESULTS: The study reviewed 1904 cases (906 consultant cases, 797 specialty training cases). Trainees' case time was significantly longer than consultants' (mean 24.25 minutes ± 12.36 [SD] versus 19.59 ± 10.05 minutes) (P < .0001). The difference between the 1- to 3-year trainees' mean surgical time and 4- to 7-year trainees' mean surgical time was statistically significant (P < .0001). Mean case time decreased from 27.63 ± 12.57 minutes (1- to 3-year trainees) to 22.55 ± 11.90 minutes (4- to 7-year trainees). The mean posterior capsule rupture rate was 2.76% for trainees and 1.77% for consultants. When posterior capsule rupture occurred, the mean surgical time increased to 49.81 ± 18.69 minutes for the consultant group and 67.00 ± 26.26 minutes for the trainee group (P = .024). When iris hooks were required, the mean case time was 26.41 ± 11.28 minutes and 34.11 ± 15.06 minutes, respectively (P = .026). CONCLUSIONS: Specialty training cases had a longer duration than consultant cases, although the mean surgical time decreased with increased trainee experience. After 3 years of training, trainees did not have a significant effect on operating room efficiency. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Severe vernal keratoconjunctivitis successfully treated with subcutaneous omalizumab.

A 12-year-old boy with severe mixed limbal and palpebral vernal keratoconjunctivitis experienced persistent ocular symptoms despite treatment with topical corticosteroids or cyclosporine. Signs and symptoms resolved completely with monthly subcutaneous omalizumab, an immunomodulating biologic agent. To our knowledge, this is the first report of its use as a monotherapy agent to treat vernal keratoconjunctivitis.

Manchester iStent study: early results from a prospective UK case series.

BACKGROUND: To evaluate the 6-month efficacy and safety of the iStent microtrabecular bypass stent in patients with open-angle glaucoma. DESIGN: A prospective, uncontrolled, interventional case series. PARTICIPANTS: Forty-four eyes with open-angle glaucoma were reported. METHODS: All subjects underwent ab interno implantation of a single iStent together with (n = 40) or without (n = 4) cataract surgery. MAIN OUTCOME MEASURES: Patients were assessed at postoperative week 1, months 1 and 3, and quarterly, thereafter. Data collected included visual acuity, intraocular pressure measurement using Goldmann tonometry, number of glaucoma medications, and number and type of complications. RESULTS: The mean age of the sample was 76.8 years. The mean duration since glaucoma diagnosis was 5.3 years (standard deviation 2.9 years). The mean visual acuity was 0.53 logMAR at baseline that improved to 0.23 at 6 months postoperatively. The mean baseline intraocular pressure was 21.1 mmHg, and this decreased significantly to 16.7 mmHg at 6 months (P < 0.01). The mean number of drops prescribed preoperatively was 2.3, which decreased to 0.6 at 6 months (P < 0.01). Sixty-six per cent of patients were drop-free at 6 months. One patient developed an hyphaema following surgery; no other adverse events were recorded. CONCLUSIONS: The iStent proved to be a safe and effective treatment for patients with open-angle glaucoma over our 6-month follow up period. Insertion resulted in a significant decrease in intraocular pressure as well as the number of topical antiglaucoma medications required for adequate intraocular pressure control.

Use of intravitreal bevacizumab in a patient with a Von Hippel-Lindau-associated retinal haemangioblastoma of the optic nerve head: a case report.

INTRODUCTION: The optimum management of a capillary haemangioblastoma affecting the optic nerve head is not clear. A number of treatment modalities have been used to treat the tumours and their consequences. Ocular haemangioblastomas express high levels of vascular endothelial growth factor and levels have been correlated with tumour growth and activity. Treatment with vascular endothelial growth factor inhibitors would therefore seem a logical approach. CASE PRESENTATION: We describe a 23-year-old man with an exophytic capillary haemangioblastoma of the optic nerve head that was treated with intravitreal bevacizumab injections. CONCLUSION: Unfortunately, treatment with intravitreal bevacizumab on three occasions had no effect on either tumour size or exudation in this patient.