Evaluation of Nd:YAG Laser Capsulotomy Rates in a Real-Life Population.

OBJECTIVE: The objective of this study was to assess the rate of posterior capsule opacification (PCO), under "real-life" conditions, as measured by rates of Nd:YAG laser intervention, rather than from a controlled study from which patients with conditions predisposing to PCO have been excluded. METHODS AND ANALYSIS: This was a retrospective, multicenter study in an unselected consecutive cohort of patients undergoing surgery for senile cataract. Patients aged 18 years and older, previously implanted with the CT LUCIA 611P IOL, were contacted at 12, 18 and 24 months to ascertain if they had received Nd:YAG laser treatment. There was an additional assessment at 36 months at the Austrian centre. RESULTS: A total of 200 patients were recruited at two centers. Laser capsulotomy rates were 4.5% at 1 year and 10% by year 2 and 12% by year 3. Three Nd:YAG capsulotomies, carried out at other external centers, were performed for reasons other than PCO, including astigmatism, epiretinal membrane and ARMD. If these patients are excluded, the true rate of Nd:YAG carried out for PCO at 1 year was 3.5% and at 2 years was 8.5%. CONCLUSION: It is critical to ensure that Nd:YAG capsulotomies are being performed only for the correct clinical reason. Carrying out unnecessary procedures places the patient at risk of adverse events, is a cost to the healthcare system, and is likely to have no direct visual benefit for the patient. In PCO studies, it should be a requirement to document the fibrosis grade to confirm that Nd:YAG capsulotomy was correctly indicated.

Visual impairment certification due to diabetic retinopathy in North and Eastern Devon.

PURPOSE: To determine certifications of visual impairment (CVIs) due to diabetic retinopathy (DR) in a region that has operated diabetic screening since 1992. METHODS: A retrospective review of all CVIs due to DR was conducted, with mid-year population estimates and a diabetes prevalence model used to determine the annual incidence of certification from 2010 to 2013. For 2013, CVIs due to DR were also compared to all CVIs in the region. RESULTS: The total number of certifications due to DR was 75; 52 were sight impaired (SI) and 23 severely sight impaired (SSI) certifications; 25% of patients had type 1, and 75% had type 2 diabetes mellitus. The mean age at time of CVI was 65.5 years. The mean duration of known diabetes was 22.0 years. The incidence of CVI due to DR ranged from 30.8 to 77.4 per million population per year between 2010 and 2013. The incidence of CVI in the diabetic population was estimated at 0.47 to 1.21 per 1000 patients per year with diabetes for 2010-2013. In 2013, DR was a main or contributing cause in 4.3% of all CVIs, but did not contribute to any SSI certifications in the working age population. CONCLUSION: The incidence of CVI due to DR was comparable to that reported in other regions. Nationwide, DR was the second most common cause of blindness in working age adults, but did not contribute to any SSI certifications in our population. Our results are consistent with the success of a long-standing retinal screening programme.

A prospective and nationwide study investigating endophthalmitis following pars plana vitrectomy: clinical presentation, microbiology, management and outcome.

BACKGROUND/AIMS: This is the first prospective and nationwide study aiming to provide epidemiological data relating to presentation, microbiology, management and outcome of endophthalmitis following vitrectomy. METHODS: Two years of prospective and nationwide surveillance for cases of presumed infectious endophthalmitis within 6 weeks of pars plana vitrectomy was completed. The study obtained case reports via the established British Ophthalmological Surveillance Unit (BOSU) system. RESULTS: Thirty-seven cases were reported and 28 met the diagnostic criteria for presumed infectious endophthalmitis following vitrectomy. Mean age was 61 years and 67% were male. Nineteen cases were 23/25 gauge and 9 cases were 20 gauge. Mean time from surgery to endophthalmitis was 5 days. Blurred vision (85.2%), pain (77.8%) and a hypopyon (77.8%) were the commonest presenting symptoms and signs. Seventeen cases (60.7%) had a positive culture. Culture-positive endophthalmitis, relative to culture-negative endophthalmitis, was no different with respect to time to presentation, symptoms, signs or outcome. Outcome was poor, with 29.6% of eyes being eviscerated or having no perception of light or perception of light. CONCLUSIONS: This study helps surgeons promptly identify cases of endophthalmitis following vitrectomy and informs them about the various management options currently used and the likely outcome of this devastating complication.

Inadvertent dexamethasone implant injection into the lens body management.

PURPOSE: Dexamethasone intravitreal implant is an approved preparation in the treatment of macular edema. The most common adverse reactions are increased intraocular pressure and cataract but the inadvertent injection of the dexamethasone implant into the capsular bag is an extremely rare event. METHODS: We present a case of a 78-year-old man treated for persistence of cystoid macular edema (CME) with Ozurdex intravitreal implant in which the procedure was complicated by the injection of the dexamethasone implant into the lens body and discuss the management. RESULTS: The patient underwent phacoemulsification of the lens, replacement of the Ozurdex, and implant of a 3-piece lens in the posterior chamber. CONCLUSIONS: The injection of an intravitreal dexamethasone implant (Ozurdex) into the lens body is an extremely rare complication that can be effectively and successfully managed with the surgical extraction of the implant from the lens body and implant of a 3-piece intraocular lens in the sulcus.

A prospective and nationwide study investigating endophthalmitis following pars plana vitrectomy: incidence and risk factors.

BACKGROUND/AIMS: This is the first nationwide prospective study to investigate the incidence and risk factors of endophthalmitis following pars plana vitrectomy (PPV). METHODS: This was a prospective, nationwide case-control study. Cases of presumed infectious endophthalmitis within 6 weeks of PPV were reported via the established British Ophthalmological Surveillance Unit. The surveillance period was 2 years. Controls (patients who had PPV but no endophthalmitis) were recruited from nine randomly selected UK centres. RESULTS: 37 reports were received and 28 cases met the diagnostic criteria for presumed infectious endophthalmitis following PPV. The incidence of endophthalmitis following PPV was 28 cases per 48 433 PPVs (1 in 1730 with a 95% CI of 1 in 1263 to 1 in 2747). 272 controls were randomly recruited from nine UK centres. Smaller gauge port sizes were not found to be a risk. Immunosuppression (OR 19.0, p=0.001) and preoperative topical steroids (OR 131.4, p<0.001) increased the endophthalmitis risk. Operating for retinal detachment was associated with a reduced risk of endophthalmitis (OR 0.10, p=0.005). CONCLUSIONS: Endophthalmitis following PPV is rare. Operating with smaller gauge port sizes does not increase the risk of endophthalmitis.

Sudden apparent worsening of diabetic retinopathy leading to a diagnosis of chronic myeloid leukaemia.

A 65-year-old woman with well-controlled type 2 diabetes presented with a sudden decrease in visual acuity bilaterally (right eye 6/60, left eye 6/18).

Cost implications, deprivation and geodemographic segmentation analysis of non-attenders (DNA) in an established diabetic retinopathy screening programme.

AIM: To ascertain the relationship between socioeconomic status and non attendance alongside the role of geodemographic analysis in identifying reasons for non attendance. To also ascertain the financial implications of non attendance on the service. METHODS: Retrospective analysis of DNA patients between April 2009 and March 2010. Cost to the service was calculated based on Devon Primary Care Trust tariffs. Deprivation Analysis was based on the Indices of Multiple Deprivation 2007 for England. Geodemographic analysis was done using a commercially available software (MOSAIC Public Sector, Experian Information Solutions Inc.). RESULTS: 22,651 patients were invited for screening with 20,514 screened and 2137 (9.4%) DNA's. Of these, 1757 (82.2%) were DNA 1's while 380 (17.7%) were DNA 2's. Mean age of screened patients was 68 (SD ±14.2), DNA 1's was 62 (SD ±17.3) and DNA 2's was 57 (SD ±18.7).1269 (59%) of DNA's were males and 868 (41%) were females. Cost to the service as calculated by lost earnings from missed appointments came to £78,259. Deprivation analysis showed increasing non attendance rates with increasing deprivation. Geodemographic segmentation analysis revealed that the lowest DNA rates were seen in successful professionals and active retired communities and the highest rates were seen in areas of social housing. CONCLUSIONS: The study demonstrates an association between non attendance and socioeconomic deprivation. The use of geodemographic analysis programmes can help identify groups that do not respond to traditional postal reminders. More focused and customised strategies can then be developed for these groups to eliminate nonattendance.

Vitrectomy with membrane peeling for vasocentric idiopathic epiretinal membranes.

PURPOSE: To report the clinical course and outcome of surgery for idiopathic epiretinal membranes (ERMs) centered on retinal blood vessels. METHODS: Retrospective observational case series review of the case records of 15 patients with idiopathic ERMs overlying retinal blood vessels, of whom 9 underwent vitrectomy with membrane peeling. The patients attended two eye departments under the care of four vitreoretinal surgeons with a total of more than 50 years of surgical experience. RESULTS: The patients were aged 12-74 years (mean = 34.3 years). Difficulties were experienced in achieving vitreoretinal and membranoretinal separation in the 9 eyes undergoing vitreous microsurgery. Recurrent ERM formation occurred in 8 of these eyes (89%) of which 6 underwent revision vitrectomy. Visual improvement was achieved in 55% of patients. Mean follow-up was 2.5 years. CONCLUSIONS: The authors describe a subgroup of patients with idiopathic ERMs in which the membrane is centered over a large retinal vessel. This occurs predominantly but not exclusively in a young age group. Surgical removal is characterized by a high recurrence rate.

Phacovitrectomy for primary retinal detachment repair in presbyopes.

PURPOSE: To review the results of phacovitrectomy for primary retinal detachment repair in presbyopes. METHODS: The outcome and complications of surgery were examined in a retrospective case series of 93 presbyopic patients who underwent phacoemulsification and vitrectomy for primary rhegmatogenous retinal detachment. RESULTS: Eighty-two patients (88.2%) had reattachment with a single procedure. The final reattachment rate with further procedures was 97.8%. Two patients (2.2%) in whom final reattachment did not occur declined further surgery after the primary repair. All redetachments were due to proliferative vitreoretinopathy. The median Snellen converted logMAR visual acuity improved from 1.00 preoperatively to 0.30 postoperatively (P < 0.001, Wilcoxon test). Postoperative complications included transient intraocular pressure rise (29%), fibrinous uveitis (16.2%), and iris/intraocular lens capture (8.6%). One of the eight patients with iris/intraocular lens capture required surgical reintervention. All cases of fibrinous uveitis and intraocular pressure rise resolved within a few days with medical treatment. Posterior capsular opacification occurred in 23 patients (24.7%). CONCLUSION: Combined surgery with phacoemulsification, lens extraction, and vitrectomy offers significant advantages to both patient and surgeon in the management of primary retinal detachment. We believe that it should be considered for presbyopes even in the absence of significant lens opacity. Fibrinous uveitis and intraocular pressure rise may occur in a few patients in the immediate postoperative period but are transient and resolve with medical treatment. Further prospective studies are required, in particular to examine the rate of postoperative proliferative vitreoretinopathy, which may be higher than with vitrectomy alone.

Effect of Honan balloon compression on peribulbar anesthesia adequacy in cataract surgery.

PURPOSE: To ascertain whether a Honan balloon is necessary to produce effective peribulbar anesthesia in routine cataract surgery by evaluating its effect on intraocular pressure (IOP), surgeon assessment of the anesthesia's effectiveness, and patients' analgesic experience. SETTING: West of England Eye Unit, Royal Devon and Exeter Hospital, England. METHOD: Fifty eyes of 50 patients having routine phacoemulsification cataract extraction and intraocular lens implantation were randomized to have 10-minute ocular compression with the Honan balloon or no compression after peribulbar anesthesia. A single investigator gave all the peribulbar injections using a standard technique. The IOP was measured immediately before and 10 minutes after the injections. Two surgeons who were blinded to the randomization process performed the surgeries and completed an assessment questionnaire on various aspects of the peribulbar block. The patients also scored their level of analgesia during surgery. RESULTS: In the 26 patients who had Honan balloon compression, there was a significant reduction in IOP (mean 6.2 mm Hg; P <.05). In the 24 patients with no balloon compression, there were no significant changes in IOP 10 minutes after the peribulbar injections. There was no statistically significant difference in the surgeons' scores in any aspect of the peribulbar anesthesia (P >.05). All patients experienced a good level of analgesia. CONCLUSIONS: There was a significant reduction in IOP after Honan balloon ocular compression. However, there was no significant increase in IOP without balloon compression. The use of a Honan balloon did not appear to make a significant difference in the effectiveness of the peribulbar anesthesia to the surgeons or patients.